UROLOGICAL CANCERS. Helen Forristal Cancer Nurse Co-ordinator Urology Denise Murray Clinical Nurse Specialist St.Vincent s University Hospital

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1 UROLOGICAL CANCERS Helen Forristal Cancer Nurse Co-ordinator Urology Denise Murray Clinical Nurse Specialist St.Vincent s University Hospital

2 (a) Kidney37% F Kidney 63% M Ureteric 4% F Ureteric 7% M Bladder 29% F Bladder 71% M LOCATION OF UROLOGICAL TUMOURS (b) Prostate 90% Testicular 2-4% (seen in men aged years) Urethral and penile 1%

3 TRYING TO ACHIEVE. Key Performance Indicators (Targets!!!) - National Cancer Control Programme Way forward Health Promotion/prevention Fast easy access Information & support Nurse Specialist MDT & Communication All treatment options- patient informed choice Continued support follow up Palliative care support at home

4 PROSTATE CANCER

5 Bladder Prostate Gland Urethra Penis

6 Anatomy of the prostate Bladder Urethra Penis Seminal vesicle Ejaculatory duct Testis Prostate

7 INCIDENCE Most common cancer in men. Most common form of cancer death in men in the Ireland ,100 and 2,600 respectively in the year age group 2,900 new cases are registered in Ireland each year respectively in men aged 55

8 RISKS Racial - higher incidence in Afro Caribbean black Americans. Environmental low risk in Chinese people but if move to America >risk. If 2 immediate family members with CAP 10% >risk Diet some suggestive risk with high fat & red meat intake. Lower risk with higher intake of tomatoes.

9 SIGNS & SYMPTOMS Asymptomatic Elevated PSA Lower Urinary Tract Symptoms Poor stream Hesitancy Urgency Frequency Nocturia

10 Haematuria -Incontinence Impotence - Haemospermia Rectal pain Acute Retention of Urine -uraemia Anuria (obstructed ureters) Bone pain pathological fracture Spinal Cord Compression

11 DIAGNOSTIC TESTS Prostatic Specific Antigen Digital Rectal Examination TRUS Biopsy Bone Scan CT Scan MRI Prostate

12 DRE

13 TRUS guided biopsy Prostate

14 STAGING T.N.M T1-T4 Gleason grade Histology Adenocarcinoma Small Cell carcinoma TCC

15 Staging of prostatic carcinoma: T0; one or more foci of impalpable carcinoma, usually a chance finding following TURP: T1, one or more small tumours with no deformity of the capsule; T2, tumour confined to the prostate but deforming the capsule; T3, tumour extending beyond the capsule and/or invading the seminal vesicles; T4, tumour infiltrating other pelvic organs or the pelvic wall.

16 TREATMENTS ACTIVE SURVEILLANCE RADICAL SURGERY RADICAL CONFORMAL RADIOTHERAPY BRACHYTHERAPY HORMONE THERAPY

17 Radical prostatectomy Retropubic: antegrade retrograde Seminal vesicle Perineal Prostate

18 Technique The patient is treated using an anterior and two opposing lateral wedged fields. rectum bladder

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20 LHRH analogues

21 Local Extension Haematuria Dysuria Impotence Loin Pain Lethargy

22 Distant Mets Bone Pain Sciatica Lethargy Wt loss and cachexia

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24 METASTATIC DISEASE MANAGEMENT BONE PAIN Radiotherapy Strontium Zometa ROU Catheterise RENAL FAILURE Nephrostomy tube Internalisation with stenting Radiotherapy SYMPTOM CONTROL Cancer Nurse Specialists Palliative Care Team

25 OTHER SCREENING PSA Test? 20% Patients with CAP have normal PSA If raised have you got CAP? Maybe? Men entitled to Informed Choice (prostate cancer Programme 2000) PSA test following counselling If PSA above age related criteria then seen in 2/52 wait

26 BLADDER CANCER

27 INCIDENCE 466 cancers of bladder cancer th most common cancer in Ireland. There has been a fall in the percentage of Stage 1 cancers from 32%-23%. Small increase in Stage 3 and 4 Bladder cancers. The percentage of unstaged cancers remains quite high, at over 40%. Most common in industrialised areas 3:1 male to female ratio Peak incidence aged 65 years No evidence of familial link cont

28 CAUSES Cigarette Smoking Occupational exposure Dye-rubber-coal/gas-sewage-Pest control-hairdressers Dietary factors Caffeine artificial sweeteners Drugs Phentacin-cylclophosphamide Radiation Cervical - Thyroid Chronic infection/inflammation Catheters - schistosomiasis Chromosomal changes

29 SIGNS & SYMPTOMS Painless Haematuria 20-30% - often ignored by patient- treated as UTI by GP Microscopic haematuria screening Irritative Symptoms Recurrent UTI cystoscopy Systemic symptoms Metastatic disease ureteric obstruction-weight loss-bladder outflow obstruction-anorexia-bone pain-pulmonary mets

30 DIAGNOSTIC TESTS History & physical examination Urinalysis C&S Cytology One Stop Haematuria Clinic Fast easy access KUB ultrasound Flexible cystoscopy IVU if required TURBT CT & chest x-ray

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32 monitoring of bladder cancer : Imaging techniques such as a Urogram, Ultrasound, a CT scan or an MRI scan

33 GRADING TNM GRADE 1 Least degree of anaplasia GRADE 2 GRADE 3 Most severe degree of anaplasia G3,pT2 ANAPLASIA Loss of typical cell characteristics or differentiation that can occur.

34 TREATMENTS SUPERFICIAL DISEASE TURBT Photodynamic therapy Intravesical chemotherapy MMC Epirubicin Doxirubicin Immunotherapy BCG

35 CONT. ORGAN CONFINED DISEASE-muscle invasive Poor prognosis years Radiotherapy Radical cystectomy With conduit With continent diversion - mitroffanof With neobladder Urinary diversion-rectal bladder uncommon these days

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37 Technique The patient is treated using an anterior and two opposing lateral wedged fields. rectum bladder

38 METASTATIC DISEASE Poor prognosis 95% will die within one year Look to improve quality of life Analgesia Blood transfusions UTI Catheterisation/management of incontinence Palliative RT for haematuria/bone pain Palliative systemic chemo Palliative cystectomy?treat renal failure

39 HEALTH PROMOTION Raise public awareness re: haematuria Smoking! Occupational screening in high risk groups Educate health professionals to refer early

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41 RENAL CANCER

42 200,000 new kidney cancers worldwide in Europe 63,300; 26,400 deaths ; 2008 USA 54,390; 13,010 deaths 12 th most common cancer in Ireland; 3% of adult malignancies In Ireland, statistically significant increases have occurred over the period in Renal cancer ,485-64% male; 36% female females (63) & 125 males females & 198 males females (58) & 227 males ( National Cancer Registry) The incidence of RCC increases after the age 40 yrs with only 5% presenting before then. Rate of incidental RCC increasing due to increased use of diagnostic imaging % % Int Urol Nephrol (2009)

43 RISK FACTORS-CAUSES Not fully understood Smoking 1/3 rd of cases linked Occupational chemical exposure, asbestos, lead, cadmium, organic solvents Obesity Kidney dialysis Inherited disease

44 SIGNS & SYMPTOMS Asymptomatic found incidentally Haematuria Loin pain or swelling Fever Weight loss Anaemia Hypertension Varicocele

45 DIAGNOSTIC TESTS Many found incidentally - Palpable X-ray imaging Investigation for haematuria - urine cytologycystoscopy - ureteroscopy KUB ultrasound IVU CT

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47 TREATMENTS Nephrectomy Nephroureterectomy Radiotherapy post-op/palliative Immunotherapy post op/palliative Interleukin 2-metastatic renal cell ca-activates T lymphocytes to fight Ca injections flu like symptoms. Interferon alpha- acts directly on cell growth and multiplicationinjection 3x week flu like symptoms Multi-targeted Receptor Tyrosine Kinase inhibitor e.g. Sunitinib Clinical Trials

48 METASTATIC DISEASE Hormone therapy Progesterone Solitary mets also operated on: Partial lobectomy Surgery for bone Mets Immunotherapy Interluekin -Interferon Trials Vaccines Anti-angiogenesis drugs thalidomide- block blood supply to tumour Combination therapy-chemo alone poor results 5 FU Interluekin Interferon Encouraging results cont

49 Cont. Symptom Control Pain Bone Mets Lung mets

50 Health Promotion Public awareness Smoking Diet Haematuria Educate health professionals Raised awareness disease management

51 TESTICULAR CANCER

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53 PRESENTATION

54 INCIDENCE Highest rates in affluent white populations Most common Cancer in men aged years. 10 per year approximately in How many Ireland. Incidence has doubled in the last 20 years. Environmental? Contraceptive pill exposure? 50% seek medical advice when already spread EARLY DETECTION nearly 100% cure rate

55 RISK FACTORS Risks: Late or undescended testicle (even if corrected) Brother/father had testicular Ca Previous Ca on other side Trauma/Viral infections?

56 SIGNS & SYMPTOMS Painless lump in testicle A change in consistency Scrotal ache/dragging sensation Enlarged testicle Gynaecomastia Back ache pulmonary symptoms lymph nodes (all due to metastatic disease)

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58 epididymis testicle scrotum

59 DIAGNOSTIC TESTS History HIS STORY Examination Torch Tumour Markers Ultrasound Abdomen and Scrotum Chest x-ray CT Thorax/Abdomen/Pelvis

60 STAGING Seminoma germ cell tumour Aged Teratoma non-germ cell tumour Mixed 15% Stage 1 confined to testis Stage 2 spread to lymph nodes in abdomen and pelvis Stage 3 mediastinal and /or supraclavicular nodes Stage 4 distant mets

61 TREATMENTS - TERATOMA Orchidectomy 5% have CIS in other testicle? Bx Depending on staging post op markers. Surveillance 20-30% will relapse 80% in first year. Chemotherapy 2-4 courses Sperm banking

62 TREATMENTS-SEMINOMA Orchidectomy Surveillance Radiotherapy Chemotherapy if mixed

63 METATSTATIC DISEASE Chemo prior to surgery Retroperitoneal Lymph node dissection High dose chemo & peripheral stem cell or autologous bone marrow transplantation Lobectomy

64 HEALTH PROMOTION Raise awareness Testicular Self Examination GP/School nurse aware of boys with undescended testicles Target men's groups? screening

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66 TSE

67 PENILE CANCER

68 INCIDENCE/RISK FACTORS 2% of all male tumours Circumcision at birth offers complete immunity Rare in Europe/USA More Common in SE Asia/Africa/India More common in men over age of 60 years Increased risk with irritation balanitis & infection with penile wart virus

69 Signs & symptoms Growth or sore on the penis Glans 48% Prepuce 21% Glans & Prepuce 9% Coronal sulcas 6% Shaft 2% Discharge/bleeding Lymphatic spread - to superficial inguinal nodes 58% of patients

70 Risk Factors Poor standard genital hygiene and phimosis Presence of smegma harbours bacteria chronic inflammation

71 Painless ulcer, sore, red patch Signs & Symptoms Phimosis Contd

72 Signs & Symptoms Small lesions on the penis which gradually extends involving the entire glans, shaft and corpora

73 Papillary/nodul ar growth Signs & Symptoms Pain and bleeding from penis (may occur with advance disease) Contd

74 Diagnostic tests History Physical examination 44-90% patients have phimosis Circumcision & biopsy CT scan chest x-ray Lymph node biopsy

75 Staging/Pathology Squamous cell carcinoma 95% Malignant melanoma Basal cell carcinoma Other lesions at low risk of developing Erythroplasia of queyrat Bownes disease Pre-malignant lesions Balanitis Xerotica obliterans (BXO) Cutaneous Horn of the penis Bowenoid papulosis of the penis

76 TNM Tx Primary cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ Ta Non-invasive verrucous carcinoma T1 Invades subepithelial connective tissue T2 invades corpus spongiosum or cavernosum T3 invades urethra or prostate T4 invades other adjacent structures

77 TREATMENTS Surgery at a designated Cancer centre. Circumcision Laser Surgery Topical chemotherapy Wide local excision Partial amputation & reconstruction using skin grafts Total amputation excision of lymph nodes. Consider Body image Radiotherapy Chemotherapy

78 Metastatic disease Bladder prostate rectum Extensive surgery Radiotherapy Psychological support Symptom control Pain Lymphodema Urinary stricture etc

79 Health Promotion Raise men's awareness. Personal hygiene STD s Present early! 5 year survival rate of 52% 66% negative lymph nodes 27% positive nodes

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81 Consider Effects of incontinence Effects of altered body image Effects of impotence Effects on relationships Chronic tumours

82 ANYTHING ELSE?

83 THANK YOU