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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