Private Cancer: Cancers of the Prostate, Testicles and Ovaries

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Private CancerCancers of the Prostate,
Testicles and Ovaries

• Paolo Aquino
• Internal Medicine/Pediatrics
• November 2005

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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

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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 11

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Testicular Cancer

• Risk factors
• Cryptorchidism
• Family history of testicular cancer
• Infertility
• HIV
• Isochromosome 12p

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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

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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

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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

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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

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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

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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

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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 gt 5 cm

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Testicular Cancer

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

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Testicular Cancer

• Staging
• Tumor markers

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Testicular Cancer
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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 lt 1000 ng/mL, Beta-hCG lt5000mIU/mL, LDH lt1.5x
  upper limit of normal

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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

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Testicular Cancer

• Prognosis
• Poor prognosis (14) 5-year survival48
• NSGCT Stage IIIC
• Mediastinal primary
• Visceral metastases
• AFP gt 10,000 ng/mL, beta-hCG gt 50,000mIU/mL, or
  LDH gt 10x upper limit of normal

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Testicular Cancer

• Considerations
• Semen cryopreservation
• Association with impaired spermatogenesis
• No association with congenital abnormalities

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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

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Prostate Cancer

• Risk factors
• Age
• Family history
• ? High fat diet
• ? High testosterone level

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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

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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

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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

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Prostate Cancer

• Diagnosis
• Serum PSA lt4 ng/mL
• 43 of those 50 years and older with prostate
  cancer had serum PSAlt4 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 PSAlt 4 ng/mL

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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 gt10 ng/mL
• Biopsy uniformly recommended
• Chance of finding prostate cancer over 50
• Many cancers at this stage will no longer be
  organ-confined

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Prostate Cancer

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

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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

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Prostate Cancer

• Screening
• Life expectancy gt 10 years
• Age 40-50 annual DRE only
• Over age 50 annual DRE serum PSA

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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

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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

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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

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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 gt 10 ng/mL
• Clinical stage T2 or greater
• Design of treatment portals for external beam
  radiation therapy

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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

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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

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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

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Ovarian Cancer

• Presentation
• Most present with advanced disease
• Abdominal distension
• Nausea
• Anorexia
• Early satiety
• Dyspnea

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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
• Trousseaus syndrome

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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

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Ovarian Cancer

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

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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

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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

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Ovarian Cancer

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

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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

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Ovarian Cancer

• Diagnosis
• Exclusion of an extraovarian primary
• Gastric
• Colorectal
• Appendiceal
• Breast
• Endometrial

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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

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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

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Review

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

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Review

• Answer B- Smoking

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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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Review

• Answer E

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Review

• A 72-year-old man with a history of localized
  prostate cancer presents to his physician with
  pain in his ribs. He underwent a radical
  prostatectomy 4 years earlier but was lost to
  follow-up. A bone scan demonstrates diffuse
  skeletal metastases his serum PSA level is 97
  ng/mL. The best next step in management is
• A) Treat with strontium-89 to relieve the
  patients pain
• B) Perform a rib biopsy to rule out other
  malignancies
• C) Perform an orchiectomy
• D) Treat with flutamide alone
• E) Perform a needle biopsy of the prostatectomy
  site to confirm recurrent disease.

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Review

• Answer C- Perform an orchiectomy
• This patient presents with unequivocal metastatic
  disease pain, widespread osteoblastic
  metastases and a highly elevated PSA. Further
  biopsies are unnecessary. Treatment with
  strontium-89, although effective, is toxic and
  should be considered only after hormone therapy
  has failed. Monotherapy with flutamide is
  associated with poor survival compared with the
  combination of flutamide and leuprolide.