Urogenital cancers

Cancers of the genitourinary system

Prostate cancer
Prostate cancer is the most common non-skin cancer diagnosed in men. Risk factors
include increasing age and, less commonly, a family history of the disease. By far the most
common pathological subtype is adenocarcinoma; grading is by the Gleason system;
numbered from 1-5 (from well differentiated glandular structures to anaplastic) and the
scoring of the two most common histological growth patterns is added together, i.e. 4+3 =
7. Grading is a strong predictor of prognosis. PSA is not recommended as a screening test
for asymptomatic men as it results in over-diagnosis of many cases where survival would
not be altered.

When localised, prostate cancer can be cured by surgery or radiation, but “watchful
waiting” (observation) is a realistic management option, particularly when patients are
elderly or have other co-morbidities, or the discovered tumour is low grade.

In a proportion of men, prostate cancer recurs, sometimes years after definitive therapy. At
that stage, androgen deprivation, bilateral orchidectomy or LHRH (Leutinising Hormone
Releasing Hormones) agonists are usually the first treatment options entertained. This is
not curative, however, and around 3 years later on average, men develop rising PSA levels
again, denoting castrate-resistant disease. Treatment options at that stage include
chemotherapy and newer hormonal drugs targeting androgen receptors and androgen
scavenging pathways. Complications of androgen deprivation therapy include
osteoporosis, lack of libido, mood changes and metabolic syndrome, amongst others.
Complications of prostatic surgery and radiation include impotence, incontinence and
proctitis.

Bladder cancer
More correctly called urothelial carcinoma because the epithelium lining the bladder, ureter
and the renal pelvis is the same, “bladder cancer” increases in incidence with age,
smoking and exposure to dyes. The most common presenting symptom is painless, frank
haematuria. Patients presenting with haematuria require

evaluation, including a cystoscopy. The large majority of bladder cancer is superficial, and
can be managed by evaluation, including a cystoscopy. The large majority of bladder
cancer is superficial, and can be managed by local surgical techniques (e.g. resection,
fulguration), assisted with intravesical drug therapy such as instillation of chemotherapy or
BCG to control the disease. There is a small but real risk of disease progression to muscle
invasive disease. In this instance, cystectomy or radiotherapy can be considered. For
muscle invasive disease requiring cystectomy, neo-adjuvant chemotherapy improves
survival by 5%. Chemotherapy for metastatic disease improves survival and can help
maintain quality of life.

Renal cancer
Most kidney cancers are now diagnosed incidentally, from imaging performed for other
reasons. Clear cell carcinoma is the most common subtype. The disease is often silent
clinically until cancers reach a size large enough to cause problems (e.g. haematuria, pain,
inferior vena cava infiltration) or after it metastasises. For small cancers in anatomically
favourable locations (e.g. upper or lower pole of the kidney), resection is curative;
however, loss of nephrons leading to long term renal impairment has shifted thinking and
careful observation with regular CT scans is increasingly employed in these situations,
since some renal cancers grow very slowly. The prognosis for patients with metastatic
disease is variable but has increased dramatically in recent years with the introduction of
tyrosine kinase inhibitors and other targeted therapies. Patients who have solitary
metastases may be considered for resection.

Germ cell cancer

Typically presenting in young men as a lump in the testis, germ cell (reproductive cell)
tumours include a wide variety of histological subtypes (e.g. embryonal carcinoma,
teratoma, yolk sac tumour and seminoma).

Management of germ cell tumours generally follows that of pure seminoma or non-
seminoma; each is similar, but not exactly the same. An inguinal orchidectomy is
necessary for tissue diagnosis as well as management of the primary site. If there is no
evidence of metastatic disease on staging investigations (CT chest abdomen pelvis,
normalizing beta HCG, alpha fetoprotein and LDH), most patients are now placed on
surveillance (clinical, markers and CT scans) with systemic chemotherapy reserved for
recurrence with cure rates approaching 100% In the past, seminomas were managed by
para-aortic radiation with the long term risk of second tumours.

In the setting of metastatic disease, combination chemotherapy can still cure over 90% of
patients, suggesting exquisite sensitivity of germ cell tumours to chemotherapy.

Important points
Given the risk of interstitial lung disease from bleomycin, monitoring of lung function is
important. It is better to avoid high-flow oxygen supplementation for some time; the
duration of which is debatable.

Since the risk of infertility is high after chemotherapy, all men should be offered semen
cryopreservation.