Download Pathogenesis, pathology, clinical features, diagnosis and treatment of

Bladder cancer
 M:F = 2:1
 many known urinary carcinogens, cmoking is responsible for ≥ 50% of new cases
 chronic irritation (e.g. in schistosomiasis, with bladder calculi) predisposes to bladder cancer
Pathology
 transitional cell carcinoma is the most common type may range from a superficial well differentiated papillary tumor to a highly invasive,
poorly differentiated tumor at presentation
 squamous cell carcinoma is less frequent and is usually associated with parasitic infection or chronic irritation of the mucosa
 adenocarcinoma may occur as a primary tumor, and metastasis from a bowel carcinoma should be ruled out
Symptoms, Signs, and Dx
 microscopic hematuria may be the earliest sign
 pyuria, dysuria, burning and frequency are also common at presentation
 pelvic pain occurs with advanced disease
 mass may be palpable on bimanual exam
 urinary cytology is frequently positive for tumor cells
 Dx is by cystoscopy and transurethral biopsy or resection
 Bimanual exam under anesthesia and pelvic CT, US, and MRI may help in staging
Px and Rx
 Pts w/ superficial malignancies, death from bladder cancer is very rare
 Pts w/ deeply invasive lesions of bladder musculature, survival is poor (50% at 5 year)
 Adjuvant chemotherapy may improve these odds (above)
 Squamous cell carcinoma of the bladder has a poor prognosis because it is usually highly infiltrative and presents at a more advanced state
 Superficial malignancies (including superficial invasion of bladder musculature) can be completely removed by transurethral resection and
fulguration
 ↓ recurrency via adjuvant chemo: mitomycin C, doxorubicin, bladder instillation ?
 tumors that invade deeply into or through the bladder wall usually require partial or radical cystectomy (necessitates concomitant urinary
diversion)
 radiotherapy in combination with chemo is the alternative and may be curative
 orthotopic neobladder, continent cutaneous diversion are becoming more common instead of traditional urinary diversion
 metastatic malignancies require chemo
Prostate Cancer
 adenocarcinoma of the prostate is the most common malignancy in men > 50y of age
 incidence increases with each decade of life
 sarcoma of the prostate is rare, and occurs primarily in children
 undifferentiated prostate cancer, squamous cell carcinoma, and ductal transitional carcinoma also occur and respond poorly to usu measures of
control
 hormonal influences on the above mentioned
 prostate ca is usu glandular, similar histologically to normal postate
 small cell proliferation and large nucleoli are characteristic
 grading is based on architectural patterns and is commonly reported as the gleason score (2-10)
Symptoms, Signs, and Dx
 slowly progressive disease and may cause no symptoms
 in late disease, symptoms of bladder outlet obstruction, ureteral obstruction, and hematuria may occur
 metastases to the pelvis, ribs and vertebral bodies may cause bone pain
 locally advanced prostate cancer may exhibit extension of induration to the seminal vesicles and fixation of the gland laterally
 prostate cancer should be suspected from DRE, elevated levels of serum PSA, or from transrectal ultrasound (TRUS)
 Dx requires histo confirmation by needle biopsy (can be done w/o anesthesia
 Involvement of perineural lymphatics, is diagnostic
 Although PSA levels decline after treatment and rise with recurrence, PSA is the most sensitive marker for monitoring cancer progression and
response to therapy
 BUT, PSA is moderately elevated in 30-50% of pts with benign prostatic hyperplasia
 PSA levels depend on tumor volume
 New assays that determine free vs bound PSA may ↓ the frequency of biopsies
 Stony hard induration or a nodule of the prostate on DRE suggests malignancy and must be differentiated from granulomatous prostatitis,
prostatic calculi, and other unusual prostatic diseases.
 However, a normal prostate on DRE dn exclude carcinoma
Prognosis and Rx
 Potential for cure depends on factors: stage, grade, and pretreatment PSA level
 Low grade, organ confined tumors have excellent Px
 Some older pts with localized prostate ca, particularly well differentiated, may req no Rx (watchful waiting)
 Radical prostatectomy or radiotherapy. Prostatectomy favored in younger pts as complications are less frequent
 An asymptomatic pt with a locally advanced tumor or mets, may benefit from hormonal ther (you want to ↓ test)
 Bilateral orchiectomy or medical castration with LHRH also ↓ testosterone