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Urologic Oncology

Cancer of the prostate, kidneys, bladder, and testis

Prostate Cancer

What is prostate cancer?

Prostate cancer is the most common non-skin cancer in the United States with around 186,000 new cases in 2008 and it is the second leading cause of cancer death in men behind lung cancer. However, if detected early, prostate cancer can be cured with appropriate treatment. The cause of prostate cancer is unknown but there is a hereditary component.

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How is prostate cancer diagnosed?

There are two components to prostate cancer screening. One is a digital rectal examination where the physician places a finger into the rectum to feel the prostate for any suspicious areas of firmness, irregularity, or nodules. The second part of screening is a blood test called the prostate specific antigen or PSA. PSA is protein made in the prostate that typically increases when cancer is present. PSA can be elevated for other reasons such as prostate enlargement or infection, but an elevated PSA often will prompt the urologist to recommend a biopsy.

A prostate biopsy is the only way to definitively diagnose prostate cancer. During a biopsy, a small ultrasound probe is placed into the rectum and the prostate is measured and evaluated for any suspicious areas. Next, a local anesthetic is administered and then 12 needle biopsies are taken and sent to the pathologist to evaluate for cancer. While a biopsy is a very accurate test, it only takes a sampling of the prostate so sometimes may miss an area of cancer so occasional repeat biopsies are necessary.

Once a diagnosis of prostate cancer is made on biopsy, several additional tests may be necessary based on the pathology and the PSA level. Abdominal imaging with a CT scan or MRI is often utilized to look for any enlarged lymph nodes or any evidence that the cancer has spread outside the prostate. A bone scan to look for spread of cancer into the bones is also frequently obtained.

What is the Gleason score?

The Gleason score is how prostate cancer is graded. When the pathologist looks at the biopsy and finds cancer, a score is assigned on a 1 to 5 scale with a 1 being the least aggressive and 5 the most aggressive. The two most common cell patterns are then added together to get the Gleason score. While the score can theoretically range from 2-10, pathologists do not really call prostate tissue cancerous unless the score is at least a 6. Therefore, for all practical purposes, a Gleason 6 is low-risk, Gleason 7 is moderate, and Gleason score 8-10 are aggressive and high risk cancers.

How is prostate cancer treated?

For localized prostate cancer, meaning that the cancer is confined to the prostate based on all available information, there are multiple treatment options. One is referred to as active surveillance means that the PSA level is followed and occasional repeat biopsies are performed and if there is evidence that the cancer is progressing then more definitive treatment is performed.

Another option for localized cancer is radical prostatectomy which can be performed with the aid of the daVinci Surgical System (intuitivesurgical.com). During a prostatectomy, the prostate is completely removed and the bladder and urethra are then sutured back together. This allows the pathologist to examine the entire prostate to make sure that all the cancer has been removed and also allows a verification of the Gleason score.

Another option for the treatment of localized prostate cancer is radiation. Radiation can either be administered with small implanted radioactive seeds (brachytherapy) or external beam radiation therapy. Modern radiation therapy utilizes ultrasound and CT imaging to make very detailed treatment plans to treat the prostate with minimal radiation exposure to the surrounding structures.

Another treatment for prostate cancer is cryosurgery during which a special probe is placed into the prostate to freeze the tumor cells, but this treatment is not as well proven for primary treatment and is currently used mostly for recurrence of cancer after radiation therapy.

Due to screening with the PSA blood test, most prostate cancer cases discovered today are localized to the prostate and have not spread to other parts of the body. If prostate cancer does extend outside the prostate, hormonal therapy is often initiated. This includes injections and/or oral medications that help to reduce testosterone levels or block the effects of testosterone in the body. The growth and proliferation of prostate cancer cells are usually testosterone dependent so decreasing or blocking testosterone, the prostate cancer can be controlled, often for many years. Hormonal ablation does cause several side effects such as decreased libido, hot flushes, and osteoporosis which is why hormonal therapy is not typically utilized as primary treatment. In very advanced cases of metastatic prostate cancer, chemotherapy may be used to help control the progression of the disease.

 

Kidney Cancer

What is kidney cancer?

The majority of kidney tumors are now found incidentally due to the increase in the use of ultrasound, CT scans, and MRI scans to evaluate other medical problems. The majority of kidney cancer cases are renal cell carcinomas or RCC and develop from the outer portion of the kidney, also known as the cortex. There are about 30,000 new cases diagnosed per year and there are several different types of renal cell carcinoma, but for the most part all present and are treated in the same way. Another type of tumor that can occur in the kidney is called urothelial carcinoma and this is the same type of tumor cell that causes bladder cancer.

How is kidney cancer diagnosed?

As mentioned previously, the majority of kidney tumors are diagnosed incidentally on imaging studies done for another reason. On these studies, an abnormal appearing solid mass or an unusual kidney cyst is identified. Many people develop cysts in the kidney as they age, and the majority are benign and just simple sacs filled with fluid. If a cyst has multiple strands of tissue on the inside, or septations, it may be cancerous.

The best test to diagnose a kidney tumor is to obtain a CT scan or MRI both without and then with intravenous contrast. If the mass gets brighter (enhances) with the contrast, there is a high likelihood that the mass is a cancer. Most small kidney tumors do not cause symptoms but large tumors , or tumors that have spread, can cause pain, bleeding, fatigue, weight loss, and abnormalities with calcium levels. Most renal cell carcinomas do not cause blood in the urine but urothelial cancers typically do cause blood in the urine and this is how many are discovered.

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How is kidney cancer treated?

The majority of incidentally found kidney tumors can be cured with surgery. At Specialized Urologic Consultants, we offer state of the art laparoscopic and robotic surgery for the removal of kidney tumors.

Depending on the size and location of the tumor, a partial nephrectomy can be performed. During this procedure, the tumor is removed along with a margin of normal kidney but the remainder of the kidney is spared to help preserve as much kidney function as possible. This can be done open, laparoscopically, or with the daVinci robotic system.

 

For larger tumors or tumors in a difficult location, a laparoscopic or robotic radical nephrectomy can be performed which removes the entire kidney.

In cases of urothelial cancers of the kidney or ureter, a laparoscopic nephroureterectomy can be performed. This is similar to a nephrectomy but the entire ureter is also removed, all the way down to the bladder.

Depending on tumor location, some renal cell cancers can be ablated either with heat or freezing. For tumors that are less than 3-4 cm, special probes can be placed into the mass under ultrasound or CT guidance and then ablated with heat, called radiofrequency ablation or RFA, or frozen which is called cryoablation.

 

Kidney cancers that have not spread outside the kidney to surrounding organs or other parts of the body can be difficult to manage. We work closely with our medical oncology colleagues in the management of metastatic kidney cancer as a special type of chemotherapy known as immunotherapy, is often required. Several newer medications called tyrosine kinase inhibitors have been developed in recent years have also shown effectiveness in treating advanced renal cell carcinoma.

Surveillance after the treatment of kidney cancer depends on the stage of the cancer but often includes routine blood work, chest x-rays, and intermittent abdominal imaging with CT scans or MRI’s.

Bladder Cancer

What is Bladder Cancer?

Bladder cancer, also known as urothelial cancer, is currently the 6th most common cancer in the United States with an estimated 68,000 new cases in 2008. It is more likely to occur in men than women and usually occurs after the age of 55. According to the American Cancer Society, the chances of a man getting the disease is about 1 in 27 and for a woman is about 1 in 85. Bladder cancer develops in the cells that line the inside of the bladder, also known as urothelial cells. This type of cell also lines the ureters and the inner portion of the kidney known as the collecting system and urothelial cancer can occur anywhere in the urinary tract. However, the bladder is by far the most common location.

What are the symptoms?

The classic presentation of bladder cancer is blood in the urine (hematuria) without any accompanying pain. This is often diagnosed on a routine urinalysis which prompts a work-up to find the cause of the hematuria. Other symptoms that can occur depending on the type, size, and location of the tumor include urinary frequency, urinary urgency, and dysuria (pain or burning with urination)

How is bladder cancer diagnosed?

Bladder cancer is typically diagnosed during the evaluation of blood in the urine (hematuria). This evaluation includes a cystoscopy, which is an office procedure during which a small scope is placed into the bladder, and some type of imaging of the urinary tract such as a CT scan, MRI, or ultrasound. Often, a bladder tumor will be visualized on the images of the bladder as a mass growing out from the bladder wall. Once a suspected bladder tumor is identified during cystoscopy, a biopsy is required to confirm the diagnosis and stage the tumor.

How is bladder cancer staged?

Bladder cancer is staged with a combination of a biopsy and abdominal imaging. At the time of biopsy, the entire tumor is resected (if possible) with a procedure known as a transurethral resection of bladder tumor or TURBT. An attempt is made to not only remove the entire tumor, but to sample some of the muscle in the bladder wall at the base of the tumor. If the tumor is only on the bladder surface and does not invade the lining or lamina propria, it is a stage Ta tumor. If the tumor invades into the lining layer but not into the muscle of the bladder, it is referred to as a stage T1 tumor. Invasion into the bladder muscle is a stage T2 and when the tumor extends to surrounding structures or there are metastases, it becomes a T3 or T4. In addition to the stage, the pathologist will also report a tumor grade. Low grade bladder cancers are less likely to progress or spread whereas high grade tumors are more aggressive and need to be monitored more closely.

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How is bladder cancer treated?

The majority of bladder cancers do not invade into the muscle of the bladder and can be managed with transurethral resection (TURBT). Tumors that invade into the bladder lining, are high grade, or are in multiple locations, may require intravesical therapy after surgery to help prevent recurrence or progression of the cancer. Bladder cancers that invade into the bladder muscle, usually require a larger operation called a cystectomy where the entire bladder is removed. During a cystectomy, the urine is diverted using a segment of small intestine which is used to create a conduit to the skin (urostomy) or the bowel can be made into a new bladder (neobladder). For more advanced bladder cancer, chemotherapy may also be required.

How is bladder cancer followed?

One of the most important aspects in managing bladder cancer is surveillance. Bladder cancer has a high rate of recurrence and can also occur anywhere else in the urinary tract so patients require lifelong monitoring to prevent and treat any recurrences. This is accomplished with periodic urine testing, imaging, and cystoscopy.

 

Testis Cancer

Testis cancer is a rare type of cancer that mainly affects young men. It is typically diagnosed by a lump found on the testicle which may or may not be painful. The best test to determine if a lump on the testicle may be cancer is an ultrasound and if there is a suspicious mass, blood tests called tumor markers are sent and then the typical recommendation is to surgically remove the testicle (radical orchiectomy).

Your urologist will also likely order a CT scan to make sure there is no spread of disease. Then depending on the pathology of the tumor, the options are chemotherapy, radiation treatment, or in many cases, surveillance with CT scan every 6-12 months.