Urologic Oncology

Introduction

Urologic oncology is the sub-specialty within urology that encompasses the evaluation and treatment of cancers. These include cancers of the male genito-urinary tract (i.e., kidney, renal pelvis, ureter, bladder, prostate, urethra, penis) and female urinary tract (i.e., kidney, renal pelvis, ureter, bladder, urethra) and adrenal glands in both male and female.

Our physicians offer highly specialized care in a supportive environment with attention to quality of life issues. Today, more than ever, the patient with a newly diagnosed cancer will have many therapeutic options. Depending upon the type of cancer, minimally invasive surgery may be the most appropriate option.

Prostate Cancer

Prostate cancer is the most common solid organ tumor in men in the United States.  The rate of newly diagnosed prostate cancers has increased over the past 30 years, with a dramatic rise in incidence seen in the late 1980's following the introduction of serum PSA testing as part of prostate cancer screening.

The most appropriate treatment recommendation for men found to have prostate cancer is based upon the stage (extent of disease) at the time of diagnosis (i.e., cancer localized to prostate versus spread to other areas).  Important variables to assess stage include: 

• Serum PSA
• Biopsy Gleason Score
• Prostate MRI
• CT SCAN
• Bone Scan

This information allows the physician to most accurately discuss the available treatment options.  Patients will want to discuss the options of robotic prostatectomy, dose escalated IMRT external beam radiation therapy, prostate brachytherapy (seed implant) and surveillance alone.

1) Cancer Facts ans Figures. American Cacner Society. 2002; 5.

2) Reis LAG, Kosary CL, Hankey BF, et al., editors. SEER Cnacer Statistics Review, 1973-1995. Bethesda (MD): National Cancer Institute; 1998 NIH Publication No:98-2789.

3) Farkas A, Schneider D, Perrotti M, et al: National trends in the epidemiology of prostate cancer, 1973 to 1994: Evidence for the effectiveness of prostate-specific antigen screening. Urology 1998; 52:444-448.

4) Perrotti M, Moran ME: Robotic prostatectomy outcomes. Urol Oncol 2005; 23:341-345.

Bladder Cancer

Each year in the United States, approximately 54,000 new cases of bladder cancer are diagnosed. Bladder cancer is the fourth most common cancer in men, and eighth most common cancer in women. A number of factors have been associated with the development of bladder cancer. The most important is cigarette smoking. The etiology of bladder is considered to be multi-factorial.

The majority of bladder cancers are diagnosed as a result of evaluation of hematuria (blood in the urine). Some patients will present with frequency, dysuria and urgency. This symptoms can mimic a urinary tract infection. Patients with hematuria or unexplained urinary symptoms should be evaluated for the presence of bladder cancer. Evaluation will often include a urinary cytology cancer cell check, kidney x-ray examination, and cystoscopy. Cystoscopy is the examination of the bladder using a small, flexible, fiberoptic endoscope.

The vast majority of bladder cancers are transitional cell carcinomas of differing grade and stage. Other types of cancers that occur in the bladder are squamous cell, adenocarcinoma and sarcoma (i.e., leiomyosarcoma). At the time of initial diagnosis, most cases (75%) of bladder cancer are superficial in nature and localized to the bladder. The remaining are more extensive at presentation. Patients usually undergo a procedure called "transurethral resection of bladder tumor". This allows removal of bladder cancer specimen using specialized operative endoscopes in the operating room. Pathologic information gained from this initial procedure in addition to radiographic studies will allow the treating physician to initiate a discussion regarding the most appropriate treatment options and any necessary additional therapy. Treatment efforts are directed at bladder preservation, reduction of the recurrence rate, and in cases of need for extensive surgery, bladder replacement options.

1) Landis SH, Murray T, Bolden S, Wingo PA: Cancer statistics, 1999. CA Cancer J Clin 1999; 49:8-31.

2) Messing EM, Catalona W: Urothelial tumors of the urinary tract. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbells's Urology: Urothelial tumors of the urinary tract, 7th ed, vol3. Phila. W.B. Saunders,1998;2327-2410.

Kidney Cancer

There are approximately 30,000 new cases of kidney cancer each year in the United States. The vast majority of kidney cancers arise in the renal cortex and are adenocarcinomas (renal cell carcinoma, hypernephroma). Approximately 80 to 85% of kidney adenocarcinomas are clear cell type, 10% are papillary, and the remainder are comprised of chromophobe and oncocytoma. Kidney tumors arising in the renal pelvis or collecting system are most often of the transitional cell carcinoma cell type.

Incidence rates of renal cancer have been rising in part due to an increase in discovery of small asymtomatic tumors during radiographic imaging for unrelated reasons. Less well understood, however, has been an upward trend in the detection of tumors at more advanced stages.

Clinical cancer stage will guide the most appropriate recommendation for therapy. In cases of cancer localized to the kidney the recommended treatment is surgical. Options may include removal of the entire kidney, or an approach where the cancer and surrounding rim of kidney is removed and the remaining kidney left intact. This is referred to as partial nephrectomy, segmental nephrectomy or nephron-sparing surgery.  There is increasing evidence that small kidney cancers can safely be managed with partial nephrectomy and renal preservation, and this procedure is now frequently performed by our physicians. 

The kidney tumor may be removed through a standard open surgical incision, or in some cases laparoscopically utilizing minimally invasive techniques. In more advanced cases of renal cancer, either regional or distant, a multidisciplinary team is required to develop the most appropriate treatment plan. Such patients will benefit from presentation at a multidisciplinary working conference at which time all available options can be explored.

1) Landis SH, Murray T, Bolden S, Wingo PA: Cancer statistics. 1998. CA Cancer J Clin 1998; 48:6-29.

2) Devesa SS, Silverman DT, McLaughlin JK, et al: Comparison of the descriptive epidemiology of urinary tract cancers. Cancer Causes Control 1990; 1:133-141.

3) Chow WH, Devesa SS, Warren JL, Fraumeni JF: Kidney cancer incidence trends in the United States. JAMA 1999; 281:1628-1631.

4) Perrotti M, Badger WJ, McLeod D, et al: Does laparoscopy beget the underuse of partial nephrectomy for T1 renal masses? Competing treatment decision pathways influence utilization. J Endourol 2007; 21:1223-1228. 

Testis Cancer

Testicular cancer is a rare malignancy with approximately 7000 new cases per year in the United States. Testis cancer is most common in males between the ages of 15 and 45 years. In men between 45 and 60 years incidence declines, and a new peak develops in men over the age of 60.

Approximately 90% to 95% of testis tumors are germ cell tumors, with the remainder being lymphoma and additional rare tumor types. Of the germ cell tumors, 60% are seminomas and the remainder are non-seminomatous in cell type histology. The tumor type is assigned by examining the excised testis tumor. Assessment of the extent of disease (staging) involves physical examination, measurement of serum tumor markers (AFP, HCG, LDH), and radiologic evaluation (CXR, CT scanning). Treatment following removal of the primary testicular tumor will depend upon tumor histologic subtype and stage, and may involve systemic chemotherapy, retroperitoneal surgery, radiation therapy, or close surveillance alone.

Landis SH, Murray T, Bolden S, Wingo PA: Cancer statistics, 1998. CA Cancer J Clin 1998; 48:6-29.

Sogani PC, Perrotti M, Herr HW, Fair WR, Thaler HT, Bosl G: Clinical stage I testis cancer: Long term outcome of patients on surveillance. J Urol. 1998;159:855-858.

Perrotti M, Ankem M, Bancilla A, et al: Prospective metastatic risk assignment in clinical stage I nonseminomatous germ cell testis cancer: a single institution pilot study. Urol Oncol 2004; 22:174-177.