The bladder is an organ meant to store urine until it is time to be expelled from the body through the urethra. The lining of this organ is named urothelium, so cancer of the bladder is often referred to as urothelial carcinoma (or sometimes more traditionally called transitional cell carcinoma).
Signs and Symptoms
Symptoms of bladder cancer such as frequency of urination, urgency of urination, and dysuria (painful urination) are common to many conditions. A slow, intermittent stream, as well as pelvic and flank (kidney) pain, can also be associated. Hematuria (blood in the urine) is a hallmark sign of bladder cancer; most patients with bladder tumors discover them this way.
- Smoking – the most common cause of bladder cancer
- Chronic cystitis – inflammation of the bladder for long periods of time
- Chemical exposures – certain industrial chemicals increase the chance of bladder cancer
- Phenactin – previously common analgesic
- Radiation – exposure to the pelvis; often to treat other malignancies
- Age – the elderly are more prone to this cancer
- Imaging – CT scan with intravenous dye usually of abdomen and pelvis
- Cystoscopy – a small camera inserted in the urethra to inspect the bladder
- Urinary markers – multiple urinary markers exist to aid in diagnosis and/or management. FISH (fluorescent in-situ hybridization), cytology, NMP-22, BTA are a few of the common ones used
- Ultimately, if you are found to have a bladder mass or tumor, a TURBT (transurethral resection of bladder tumor) is performed for formal diagnostic and pathologic analysis
Once formally diagnosed, CT (likely already performed), chest x-ray, physical exam, and blood studies such as LFT’s (liver function tests) are performed to stage the cancer.
- Stage 1 – confined to the lining of the bladder (often termed non-muscle invasive)
- Stage 2 – disease has entered the muscular lining of the bladder (detrusor)
- Stage 3 – disease is in the local tissue surrounding the bladder
- Stage 4 – disease is found in distinct areas from the bladder
- Ta – noninvasive papillary tumor
- Tis – carcinoma in situ
- T1 – involves subepithelial connective tissue
- T2a – invades superficial muscle, inner half
- T2b – invades superficial muscle, outer half
- T3a – microscopic perivesical invasion (outside bladder)
- T3b – macroscopic, palpable extravesical mass and/or extension
- T4a – involves prostate, uterus, vagina
- T4b – involves pelvic wall, abdominal wall, other structures
- Surgery is the hallmark of treatment for bladder cancer depending its Stage and Grade, especially with focus on whether or not there is muscle invasion.
- TURBT – repeated surveillance in the office with re-resection if needed is often recommended for non-muscle invasive, low grade, low volume tumors. Often at the original diagnostic TURBT, a chemotherapeutic agent, Mitomycin C, is administered to the bladder, and sometimes a chemical called BCG is instilled in the office for treatment.
- Partial Cystectomy – if the area is isolated especially near the dome of the bladder, removing just the section of involved bladder is an option
- Radical Cystectomy – the standard of care for muscle invasive disease, this surgery removes the entire bladder, sometimes urethra, and pelvic lymph nodes. The urine has to be re-routed in some fashion. Multiple options exist for urinary management; neo-bladder (new bladder), ileal conduit, continent stoma etc are options you can discuss with your Urologist
- Radiation – often used in conjunction with chemotherapy of the patient can tolerate chemo this method is often used in lieu of surgery for those who are not surgical candidates
- Chemotherapy – often used either as treatment before or after surgery; this adjunct treatment may also be used in conjunction with radiation
Penile cancer is rare in the United States, but is aggressive and can have devastating psychological effects. African-American males are affected twice as often as Caucasian males. The peak incidence is age seventy-five, and is rare before age forty.
Men typically present with a mass of the penis which requires biopsy. Confirmation of cancer then can often require more aggressive surgical therapy and chemotherapy
233,000 new cases of prostate cancer are expected to be diagnosed each year, which makes this the most common cancer in men with the exception of skin cancer. Of those diagnosed, there are expected to be almost 25,000 deaths due to prostate cancer. While prostate cancer screening remains a controversial subject in the medical field, we believe that early detection of clinically significant prostate cancers can meaningfully impact patient outcomes.
- Age – the older we get, the greater the chance of developing prostate cancers, although in the elderly these cancers are often indolent
- Ethnicity – African American heritage tends to lend itself toward early and more aggressive diagnosis.
- Family history– having a first relative such as a father or brother diagnosed with prostate cancer increases risk of being diagnosed significantly.
There are no significant symptoms that indicate prostate cancer so screening (while controversial) has been used and has been shown to decrease mortality. Enlarged prostate (BPH) often causes urinary symptoms which many people confuse with concerns for cancer. Because there are no symptoms until later stages of disease, you should talk with your healthcare provider about the risks and benefits of screening in order to make an informed decision.
The Digital Rectal Exam (DRE) and a blood test called Prostate Specific Antigen (PSA) are the screening methods used and if indicated lead to a biopsy of the prostate for diagnostic purposes. If prostate cancer is found then imaging such as a CT scan and/or bone scan may be in order to help plan treatments.
Many treatments are available which can make deciding on a treatment quite confusing. The decision is usually based on age, health status, aggressiveness of disease based on biopsy, lifestyle etc.
- Surgery – a radical prostatectomy is the technical name for removal of the entire prostate gland often with a lymph node dissection. Our Urologic surgeons perform many of these each year; it remains the “gold standard”of prostate cancer treatment.
- Expectant management – also referred to as watchful waiting or active surveillance, it is often suggested for less aggressive character tumors.
- Radiation – several forms are possibilities:
- Brachytherapy – insertion of radioactive pellets into the prostate
- External Beam Radiation – traditional radiation delivered over 8 weeks
- Proton Beam – newer method similar to external beam
- Cyberknife – traditional radiation with slightly different delivery
- Cryotherapy – freezing of the prostate gland to kill tumor cells.
- Hormonal therapy – manipulation of testosterone to cause regression or slow the process.
- Chemotherapy – usually later in the treatment process after failure of more traditional approaches.
- High Intensity Focused Ultrasound – not available in the United States; still multiple concerns over true cancer control this method continues to be researched.
We have several options available for advanced prostate cancer including Xgeva, Xtandi, Zytiga, Provenge, and Xofigo.
RENAL CELL (KIDNEY) CANCER
Cancer of the kidney affected approximately 65,000 Americans last year and caused around 14,000 deaths. This tumor historically presented late, but with imaging being used more common in general most are picked up earlier and are more easily treated. The rate of detection has been increasing by about 2% over the past ten years.
Smoking and obesity seem to be significant risk factors and there are some familial inheritance patterns that are associated with von Hippel-Lindau being the most common familial association. Increasing age and renal cystic disease associated with renal failure are also common factors in people with renal masses.
Hematuria (blood in the urine) is the most common symptom. A palpable abdominal mass and pain are also historically associated symptoms. Other tumor effects such as weight loss, swelling and blood count abnormalities may be present. Most renal cancers currently diagnosed are asymptomatic and are found incidentally with imaging obtained working up other problems
Imaging remains the gold standard of diagnosis. A CT scan with contrast has a very high rate of accuracy as an initial diagnostic endeavor. MRIs and Ultrasounds are also common modalities that are used. Staging is based mainly on imaging.
- Surgery remains the hallmark of treatment for kidney cancer. These tumors are generally not very responsive to chemotherapy and/or radiation although these other methods are used at times. There are newer oral chemotherapy agents that have show some promise but are generally not used as first-line treatment. Unless there is extensive disease these surgical procedures are able to be performed by minimally invasive techniques.
- Radical Nephrectomy is the removal of the entire kidney, partial ureter and the surrounding fat and lymph tissue.
- Partial Nephrectomy is the removal of the tumor only, leaving as much of the normal kidney intact as possible.
- Cyrotherapy is a procedure where the tumor is frozen to destroy the mass.
- Radiofrequency ablation has been used at some centers, but has some issues and is not often used on kidney masses.
Testicular cancer is not overly common and is mainly a concern of men that are younger between 15 and 35 years of age generally. Detected early, testicular cancer has an excellent prognosis and self-exams are the main form of detection.
- Undescended testicle – a history of undescended testicle increase one's risk
- Genetic disorders causing changes in sexual development
- Family or personal history
- Painless mass or swelling of the testicle
- Testicular pain
- Heavy feeling to testicle
- Physical examination
- Scrotal Ultrasound – based on imaging combined with exam and history, most masses in the testicle can confidently be determined likely to be cancerous or not
- Testicular cancer markers will be drawn
- Orchiectomy – removal of the testicle surgically is performed for definitive diagnosis
Testicular cancers are grouped into two categories: non-seminomatous and seminoma. Treatment depends of the type of tumor and imaging studies (CT scan, chest X-ray, etc.) and marker status both pre and post-operative. Modalities of treatment consist of possible further surgery to remove the lymph nodes associated, radiation and/or chemotherapy.