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Private Cancer: Cancers of the Prostate, Testicles and Ovaries

Private Cancer: Cancers of the Prostate, Testicles and Ovaries. Paolo Aquino Internal Medicine/Pediatrics November 2005. Testicular Cancer. Epidemiology Most common solid malignancy for males 14-35 Accounts for 1% of all cancers in men One of the most curable solid neoplasms

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Private Cancer: Cancers of the Prostate, Testicles and Ovaries

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  1. Private Cancer:Cancers of the Prostate, Testicles and Ovaries Paolo Aquino Internal Medicine/Pediatrics November 2005

  2. Testicular Cancer • Epidemiology • Most common solid malignancy for males 14-35 • Accounts for 1% of all cancers in men • One of the most curable solid neoplasms • Prior to late 1970s, accounted for 11% of cancer deaths for men 25-34 with 5-yr survival of 64% • Currently 390 annual deaths from testicular cancer with a 5-year survival of 95%

  3. Testicular Cancer • Epidemiology • Cell types • May consist of single predominant histologic pattern or mix of multiple histologic types • Two broad categories: • Pure seminoma • Non-seminomatous germ cell tumors (NSGCTs) • Ratio 1:1

  4. Testicular Cancer • Risk factors • Cryptorchidism • Family history of testicular cancer • Infertility • HIV • Isochromosome 12p

  5. Testicular Cancer • Presentation • Nodule or painless swelling of one testicle • Dull ache or heavy sensation in lower abdomen, perianal region or scrotum • 10% will present as acute pain • Increased hCG production • Gynecomastia • Hyperthyroidism

  6. Testicular Cancer • Presentation • 10% will present with metastatic symptoms • Neck mass • Cough/dyspnea • Anorexia, nausea, vomiting, GI bleed • Bone pain • Nervous system • Lower extremity swelling • Paraneoplastic limbic encephalitis

  7. Testicular Cancer • Diagnosis • Bimanual examination of scrotal contents • Any solid, firm mass within the testis is testicular cancer until proven otherwise • Differential: torsion, epidydimitis, hydrocele, epididymo-orchitis, varicocele, hernia, hematoma, spermatocele, syphilitic gumma

  8. Testicular Cancer • Diagnosis • Imaging • Scrotal ultrasound • High resolution CT of abdomen and pelvis • Chest x-ray vs. CT • Serum tumor markers • Alpha fetoprotein • Beta-hCG • LDH

  9. Testicular Cancer • Diagnosis • Radical inguinal orchiectomy • Histologic evaluation • Local tumor control • Retroperitoneal lymph node dissection • Only reliable method to identify nodal micrometastases • Gold standard for accurate pathologic staging of the retroperitoneum

  10. Testicular Cancer • Staging • Tumor • 0= no tumor • is= carcinoma in-situ • 1= limited to tunica albuginea without vascular or lymphatic invasion • 2= limited to tunica vaginalis with vascular or lymphatic invasion • 3= invades the spermatic cord • 4= invades the scrotum

  11. Testicular Cancer • Staging • Lymph nodes • 0= no regional lymph node metastases • 1= lymph nodes less than 2 cm • 2= lymph nodes 2-5 cm • 3= lymph node > 5 cm

  12. Testicular Cancer • Staging • Metastases • 0= no metastasis • 1a= nonregional nodal or pulmonary metastasis • 1b= distant metastasis other than nonregional lymph nodes and lungs

  13. Testicular Cancer • Staging • Tumor markers

  14. Testicular Cancer

  15. Testicular Cancer • Prognosis • Good prognosis (60%): 5-year survival= 91% • Seminoma: Stage I- IIIA/B • No visceral metastases • Normal AFP • NSGCT: Stage I-IIIA • Testicular or retroperitoneal primary tumors • No visceral metastases • AFP < 1000 ng/mL, Beta-hCG <5000mIU/mL, LDH <1.5x upper limit of normal

  16. Testicular Cancer • Prognosis • Intermediate prognosis (26%): 5-year survival= 79% • Seminoma: Stage IIIC • Testicular or retroperitoneal primary • Visceral metastases • Normal serum AFP • NSGCT: Stage IIIB • Testicular or retroperitoneal primary • No visceral metastases • AFP 1,000-10,000 ng/mL, beta-hCG 5,000-50,000mIU/mL or LDH 1.5-10x upper limit of normal

  17. Testicular Cancer • Prognosis • Poor prognosis (14%): 5-year survival=48% • NSGCT: Stage IIIC • Mediastinal primary • Visceral metastases • AFP > 10,000 ng/mL, beta-hCG > 50,000mIU/mL, or LDH > 10x upper limit of normal

  18. Testicular Cancer • Considerations • Semen cryopreservation • Association with impaired spermatogenesis • No association with congenital abnormalities

  19. Prostate Cancer • Epidemiology • 2nd most common cancer in American men (non-melanoma skin cancer= #1) • Estimated 230,000 cases in 2005 with 30,000 deaths • Increased detection rates • 1.5% annual increase in incidence since 1995

  20. Prostate Cancer • Risk factors • Age • Family history • ? High fat diet • ? High testosterone level

  21. Prostate Cancer • Presentation • Usually asymptomatic • Elevated serum PSA • Asymmetric areas of induration • Frank nodules • Urinary urgency, frequency, hesitancy, nocturia • Erectile dysfunction • Hematuria • Hematospermia • Metastatic disease: bone pain, spinal cord compression

  22. Prostate Cancer • Diagnosis • Digital rectal examination • Evaluates posterior and lateral prostate gland • PPV 5-30% • PPV increases with respect to PSA concentration • Any induration, asymmetry or nodularity require further diagnostic studies

  23. Prostate Cancer • Diagnosis • Serum PSA • Causes of elevation • Benign prostatic hypertrophy • Prostate cancer • Prostatitis • Trauma • Malignant prostate tissue generates more PSA than normal or hyperplastic tissue • Disruption of prostate-blood barrier increases serum concentration of PSA

  24. Prostate Cancer • Diagnosis • Serum PSA <4 ng/mL • 43% of those 50 years and older with prostate cancer had serum PSA<4 ng/mL • 21% of cancers diagnosed without PSA had a serum PSA of 2.6-3.9 ng/mL • Higher likelihood of finding organ-confined disease with serum PSA< 4 ng/mL

  25. Prostate Cancer • Diagnosis • Serum PSA 4-10 ng/mL • Biopsy advised regardless of DRE findings • One in five biopsies done with serum PSA 4-10 ng/mL will be positive • Serum PSA >10 ng/mL • Biopsy uniformly recommended • Chance of finding prostate cancer over 50% • Many cancers at this stage will no longer be organ-confined

  26. Prostate Cancer • Diagnosis • Recommendations for prostate biopsy • Suspected by DRE • Serum PSA as low as 2.6 ng/mL • PSA velocity > 0.75 ng/mL per year • Confirmation of elevated PSA advised prior to proceeding with prostate biopsy

  27. Prostate Cancer • Diagnosis • Biopsy • Gold standard • Any suspicious area + 6 tissue cores from base, midzone, and apical areas bilaterally • Higher cancer detection rates with more biopsies • Complications • Hematospermia, hematuria • Fever • Rectal bleeding • No clinical data support spread of cancer due to biopsy

  28. Prostate Cancer • Screening • Life expectancy > 10 years • Age 40-50: annual DRE only • Over age 50: annual DRE + serum PSA

  29. Prostate Cancer • Staging • Determining correct stage is critical • Major complications associated with therapies • Risks justified if treatment has reasonable chance of achieving a cure • Primary goals • Rule out disease outside of prostate gland • Assess likelihood of finding potentially resectable, organ-confined disease

  30. Prostate Cancer • Staging • Clinical staging- frequently underestimates extent of tumor found at surgery • T1= not palpable, not visible on TRUS • T2= palpable, confined to gland • T3= protrudes beyond the prostate capsule • T4= fixed, extended well beyond the prostate

  31. Prostate Cancer • Staging • Gleason grade • Analysis of tumor histology • Graded 1-5 based upon differentiation and architecture • Combined Gleason score of primary and secondary score • 2-4= low-grade • 5-7= moderately differentiated • 8-10= poorly differentiated

  32. Prostate Cancer • Staging • Radionuclide bone scan • Not indicated for • Clincal T2 cancer or less • Gleason score less than or equal to 6 • Serum PSA less than 10 ng/mL • CT scan indications • Gleason score greater than 6 • Serum PSA > 10 ng/mL • Clinical stage T2 or greater • Design of treatment portals for external beam radiation therapy

  33. Prostate Cancer • Treatment • Hormone therapy • LHRH agonists: leuprolide, goserelin • Testosterone antagonists: flutamide, blcalutamide • Orchiectomy • Androgen-independent prostate cancer (AIPC) • Most with metastatic disease will become refractory to hormonal therapy

  34. Ovarian Cancer • Epidemiology • 2nd most common gynecologic malignancy • Most common cause of death for gynecologic cancer • 4th most common cause of cancer related death for females in the United States • 90% are epithelial cell tumors

  35. Ovarian Cancer • Presentation • Most diagnosed between 40 & 65 • Early disease has vague symptoms • Lower abdominal discomfort, pressure • Gas, bloating, constipation • Irregular menstrual cycles • Low back pain • Fatigue, nausea, indigestion • Urinary frequency • dyspareunia

  36. Ovarian Cancer • Presentation • Most present with advanced disease • Abdominal distension • Nausea • Anorexia • Early satiety • Dyspnea

  37. Ovarian Cancer • Presentation • Symptoms more typical for ovarian cancer • Develop over shorter period of time • Multiple symptoms • Greater frequency and severity • Paraneoplastic phenomena • Humoral hypercalcemia of malignancy • Subacute cerebellar degeneration • Leser-Trelat sign • Trousseau’s syndrome

  38. Ovarian Cancer • Presentation • Pelvic exam • Solid, irregular, fixed pelvic mass • Upper abdominal mass • Ascites • Differential diagnosis • Benign neoplasms- endometriomas, fibroids • Functional ovarian cysts • TOA • Non- gynecologic masses • Metastases • Ectopic pregnancy

  39. Ovarian Cancer • Risk factors • Increased risk • Family history • BRCA-1 or BRCA-2 positive • Nulliparity • Frequent miscarriages • Medications that induce ovulation

  40. Ovarian Cancer • Risk factors • Decreased risk • Oral contraceptive use • Breast feeding • Early age of first pregnancy • Tubal ligation • Early menarche • 10% decrease in risk with each pregnancy

  41. Ovarian Cancer • Diagnosis • Pelvic examination • Ultrasound • Characteristics against malignancy • Cystic • Unilateral • Less than 8 cm • Smooth internal and external contours • Threshold for surgical intervention is lower for postmenopausal women

  42. Ovarian Cancer • Diagnosis • Tumor markers • CA 125 • > 65U/mL in 80 percent of women with ovarian cancer • Not specific • Endometrial cancer • Pancreatic cancer • Endometriosis • Fibroids • PID • Menstrual variation

  43. Ovarian Cancer • Diagnosis • Tumor markers • CA 125 • More useful in postmenopausal women • PPV 97% • Baseline measurement useful for following treatment • Alpha fetoprotein for endodermal sinus tumor • LDH for dysgerminoma • Beta-hCG for nongestational choriocarcinoma

  44. Ovarian Cancer • Diagnosis • Exclusion of an extraovarian primary • Gastric • Colorectal • Appendiceal • Breast • Endometrial

  45. Ovarian Cancer • Diagnosis • Histopathology • Papillary serous ~75% • Simulates lining of fallopian tube • Mucinous ~10% • Resembles endocervical epithelium • Endometroid ~10% • Resembles endometrial cancer • Rare- clear cell, transitional cell

  46. Ovarian Cancer • Staging • Surgery is necessary • Occult metastases not uncommon • More advanced disease noted in 29% of patients thought to have stage I disease, 43% of patients thought to have stage II

  47. Review • Which of the following is NOT an identified risk factor for testicular cancer? • A) HIV • B) Smoking • C) Cryptorchidism • D) Infertility

  48. Review • Answer: B- Smoking

  49. Review • Which of the following statements about ovarian cancer is false? • A) Among gynecologic cancers it is the most common cause of death • B) Typically presents as advanced disease • C) Tubal ligation is associated with decreased risk for ovarian cancer • D) Surgery is necessary for accurate staging • E) Elevated serum CA-125 is specific for ovarian cancer

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