Genitourinary Cancers

Genitourinary Cancers



Bladder Cancer



Mary Collins



DEFINITION


Bladder cancer is the fourth most common cancer in men and the ninth most common cancer in women. Alterations in deoxyribonucleic acid from viruses, chemical carcinogens, or exposure to other chemical agents will influence who has bladder cancer. Bladder cancer is often described as a field-change disease, which involves the urothelium from the renal pelvis to the urethra. Metastasis occurs through the lymphatic system to the regional lymph nodes. Bladder cancer may also metastasize to the bones, liver, and lungs.



INCIDENCE


Bladder cancer is the second most common urologic malignancy. It is estimated more than 67,160 Americans will be diagnosed with bladder cancer in 2007 and more than 13,750 will die from this disease. Bladder cancer occurs twice as frequently in men than in women. The average age at diagnosis is between 65 and 70 years.



ETIOLOGY AND RISK FACTORS


Risk factors include the following:



• Increasing age (>65 years)


• White race and male sex


• Cigarette smoking


˚ At least 50% of bladder cancer in men is attributed to cigarette smoking. Men and women who smoke have two to three times the risk for development of bladder cancer compared with nonsmokers.

• Exposure to industrial chemicals


˚ Most bladder carcinogens are aromatic amines. Individuals working in the rubber, paint, leather, petroleum, and printing industry are at an increased risk for development of bladder cancer.

˚ Other occupations that involve organic chemicals such as rope making and dry cleaning and barbers and beauticians may also be at increased risk.

• Patients with indwelling catheters, chronic urinary infections, and renal calculi may be prone to development of the disease.


• Cyclophosphamide administered over an extended period of time, in particular to patients with upper tract bladder outlet obstruction, has been reported to increase the incidence of bladder cancer.



SIGNS AND SYMPTOMS




• Frequency


• Dysuria


• Urgency


• Altered stream



Advanced disease




• Palpable mass


• Bone pain


• Flank/rectal/pelvic pain



DIAGNOSTIC WORKUP


Diagnostic workup includes a urine specimen for cytologic study, which may include saline solution irrigation of the bladder (bladder washings) for more accurate results and an excretory urogram (intravenous pyelogram). Definitive diagnosis is made with cystoscopy and biopsy. To rule out advanced disease, chest x-ray films, computed tomography scans, bone scans, and magnetic resonance imaging may be ordered.



HISTOLOGY


Approximately 90% of all bladder cancers are transitional cell or urothelial carcinomas. Squamous cell carcinoma accounts for 3% to 7% and adenocarcinoma represents 2% of malignant bladder tumors. Bladder cancer is typically divided into two groups: superficial or muscle invasive. Superficial bladder cancer, T1, Tis or Ta, is usually low grade and noninvasive, whereas muscle invasive disease, T2 to T4 tends to be more aggressive and invades the muscularis propria. The degree of cellular differentiation determines histological tumor grade. A grade 1 tumor is well differentiated, grade 2 is moderately differentiated, and grade 3 to 4 is poorly differentiated or undifferentiated.



CLINICAL STAGING


Information obtained before definitive treatment may be included for clinical staging. Two staging systems are used for bladder cancer: the Jewett Marshall system and the TNM (tumor, node, metastasis) system based on the American Joint Committee for Cancer Staging. The TNM system is the most accurate and is also the preferred system (see table at right). Histologic grade (G) is the grading system for bladder cancer (see box at right).




Clinical Staging: Bladder Cancer

image image



Histologic Grading System




GX: Grade cannot be assessed


G1: Well differentiated


G2: Moderately differentiated


G3-4: Poorly differentiated or undifferentiated


From American Joint Committee on Cancer. (2002). AJCC cancer staging manual (6th Ed.). Chicago: American Joint Committee on Cancer.



TREATMENT



Medical Treatment


Often for high-grade lesions or lesions suspected of recurring, intravesical therapy may be warranted. Immunotherapy such as Bacille Calmette-Guérin (BCG) or chemotherapy is used to decrease recurrence, prevent progression, and eradicate the residual disease after transurethral resection. Intravesical BCG is the standard treatment for superficial bladder cancer. Treatment with BCG is weekly for 6 weeks, and maintenance therapy is usually monthly or every 3 months. Subcutaneous interferon may be used in patients who have failed BCG. Interferon response rates have been reported at 20% to 43%. Interferon may also be effective in preventing recurrence of superficial disease. Intravesical chemotherapy is generally given for low-grade disease. Mitomycin, doxorubicin, or thiotepa is recommended to be administered at surgery or at least within 6 hours of resection. The role of gene therapy for superficial bladder cancer is currently being investigated.



Radiation Therapy


The role of radiation therapy is limited in bladder cancer. Clinical trials indicate a high recurrence rate of 90% within 5 years when used for Ta disease. Higher grade lesions (grades 3 and 4) have been reported to have better response rates. Patients who are not candidates for surgery may be offered radiation therapy.



Surgery


Transurethral resection of the bladder followed by observation is generally all that is required for superficial low-grade tumors. Cystectomy for superficial disease is recommended in patients who have failed intravesical therapy or who have persistent recurrent disease. Radical cystectomy remains the gold standard for muscle-invasive bladder cancer without metastatic disease. This procedure includes removal of bilateral pelvic lymph nodes, bladder, the prostate gland, and seminal vesicles in men and the uterus, fallopian tubes, ovaries, bladder, urethra, and a segment of the interior vaginal wall in women. After surgical removal of the bladder, patients will require either an ileal conduit or a continent urinary diversion such as a Kock pouch or an Indiana pouch.



Chemotherapy


Systemic chemotherapy may be given neoadjuvantly to downstage a tumor before surgery or as adjuvant therapy after cystectomy for muscle-invasive lesions or metastatic disease. In advanced disease, methotrexate, vincristine, doxorubicin, and cisplatin (MVAC) have achieved reported response rates from 40-65% with median survival rates of approximately 1 year. Newer agents such as paclitaxel, docetaxel, and gemcitabine have also produced similar response rates with less toxicity.



PROGNOSIS


The incidence and mortality rates of bladder cancer have continued to decline over the last several years. Radical cystectomy results in the lowest recurrence rate for invasive disease, although high-grade lesions (grade 3) progress in at least 50% of patients. Patients who fail the initial treatment for muscle-invasive disease are predicted to die of their disease within 3 years of diagnosis. The prognosis is poor for metastatic disease.



PREVENTION


Avoiding tobacco and limiting exposure to environmental carcinogens may decrease the risk for development of bladder cancer.



BIBLIOGRAPHY



Green F.L., Page D.L., Fleming I.D., et al. AJCC cancer staging manual, 6th ed. New York: Springer-Verlag, 2002.


Grossfield G., Carroll P. Urothelial carcinoma: cancers of the bladder, ureter and renal pelvis. In: Tanagho E., McAninch J. Smith’s general urology. 6th ed. New York: McGraw-Hill; 2004:324–345.


Jemal A., Siegel R., Ward E., et al. Cancer statistics, 2007. CA: A Cancer Journal for Clinicians. 2007;57:43–66.


Lamm D.L., McGee W., Hale K. Bladder cancer: current optimal intravesical treatment. Urologic Nursing. 2005;25:323–333.


Malkowicz S. Management of superficial bladder cancer. In: Walsh P.C., Retik A.B., Vaughan E.D., et al. Campbell’s urology. 8th ed. Philadelphia: W. B. Saunders; 2002:2785–2802.


Nieder A.M., Brausi M., Lamm D., et al. Management of stage 1 tumors of the bladder: international consensus panel. Urology. 2005;66(6A Suppl):108–125. In M. Soloway (Ed)


Raghavan D., Skinner E. Genitourinary cancer in the elderly. Seminars in Oncology. 2004;31:249–263.


Schoenberg M. Management of invasive and metastatic bladder cancer. In: Walsh P.C., Retik A.B., Vaughan E.D., et al. Campbell’s urology. 8th ed. Philadelphia: W. B. Saunders; 2002:2803–2817.


Shipley W., Kaufman D., McDougal W., et al. Cancer of the bladder, urether, and renal pelvis. In: DeVita V., Hellman S., Rosenberg S. Cancer principles and practice. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:1168–1192.


Skinner D., Stein J., Ross R., et al. Cancer of the bladder. In: Gillenwater J.Y., Grayhack J.T., Howards S.S., et al. Adult and pediatric urology. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2002:1298–1362.


Wood L., Clabrese D. Bladder and renal cancers. In: Yarbro C., Frogge M., Goodman M. Cancer nursing. 6th ed. Boston: Jones & Bartlett; 2005:1005–1021.



Penile Cancer



Patty Woods Bunch, Mary Collins



DEFINITION


Carcinoma of the penis is an uncommon malignancy in the United States. Ninety-five percent of cancers of the penis are squamous cell carcinoma that may evolve from the prepuce, glans, or shaft of the penis. Metastasis occurs primarily in regional lymph nodes (femoral, inguinal, pelvic, iliac) and rarely spreads to distant sites such as lung, liver, bone, or brain.



INCIDENCE


Carcinoma of the penis comprises less that 1% of all malignancies in men. Approximately one to two cases per 100,000 occur annually. The peak incidence is in the sixth and seventh decades of life. It is estimated there will be 1,280 men diagnosed in the United States with penile cancer in 2007 and 290 will die of the disease. Although the incidence is low in North America and Europe, penile malignancies are higher in Africa, South America, and Asian countries.



ETIOLOGY AND RISK FACTORS


The etiology of penile carcinoma is controversial. Risk factors include the following:



• Increasing age—most diagnoses are made after 60 years of age.


• The presence of a foreskin. It is rare to find cancer of the penis in a man who was circumcised at birth


• Phimosis (tightness of the foreskin that prevents retraction)


˚ 25% to 75% of men with penile cancer have had phimosis

• Exposure to human papillomavirus (HPV)


• Multiple sex partners


• Prior history of sexually transmitted diseases, including human immunodeficiency virus


• Poor personal hygiene practices


• Tobacco use


• Psoriasis patients treated with ultraviolet radiation in combination with oral 8-methoxypsoralen


• Premalignant lesions associated with squamous cell carcinoma of the penis include the following:


˚ Balanitis xerotica obliterans

˚ Cutaneous horn

˚ Giant condyloma

˚ Bowenoid papulosis


SIGNS AND SYMPTOMS


The presenting penile lesions may be quite variable, ranging from a small papule or pustule that does not heal to a large exophytic, fungating lesion. These lesions occur most commonly on the glans (48%) and prepuce (21%) and less commonly on the coronal sulcus and penile shaft. These lesions are usually painless. A reddish rash or persistent, foul-smelling discharge under the foreskin may also be present.



DIAGNOSTIC WORKUP


The following diagnostic tools are crucial in the diagnosis and staging of penile cancer:



• Complete physical examination


• Biopsy from the penile lesion


• Imaging such as ultrasonography, computed tomographic scan, and magnetic resonance imaging



HISTOLOGY


Ninety-five percent of penile cancers are squamous cell carcinoma. Squamous cell carcinoma is graded according to Broders’ classification: well, moderately, and poorly differentiated. The distinction as to degree of differentiation is an important predictor for risk of metastatic disease to the groin and even more powerful when combined with the depth of tumor invasion. The remaining 5% of malignancies include the sarcomas, melanoma, basal cell carcinoma, and lymphoma.



CLINICAL STAGING


No universal staging system has been established for penile cancer, but the AJCC TNM system is preferred. Combining the TNM system with differentiation gives the predictive ability for regional nodal involvement (see table below).



TREATMENT


Because the incidence is so rare, treatment management decisions may be difficult. Depending on the stage of the disease at diagnosis, the following treatments may be used:



• Small superficial tumors: Mohs’ micrographic surgery, laser beam therapy, radiation therapy, and in some cases, topical fluorouracil


• Tumors involving only the prepuce: circumcision


• Invasive tumors: partial or total penectomy


• Advanced stages: single-agent or combination chemotherapy


• Approximately half of the patients with penile cancer present with lymphadenopathy.


˚ Frequently this is the result of inflammation and a course of antibiotics is recommended.

˚ If the lymphadenopathy does not resolve after the antibiotics, patients should have a biopsy and treatment.



Clinical Staging: Penile Cancer

image

Other than 5-fluorouracil, which has been used to treat superficial penile cancer, chemotherapy has had a limited role. Cisplatin, bleomycin, and methotrexate have been the only drugs used with modest activity.



• Combination therapy of surgery, chemotherapy, and radiation has been used with some encouraging results in patients with advanced disease.



PROGNOSIS


Prognosis is primarily related to the presence or absence of inguinal node metastasis. The prognosis is worse if lymph node involvement is present. Untreated patients with inguinal metastases rarely survive 2 years. In patients with clinically palpable adenopathy and histologically proven metastases, 20% to 50% are alive 5 years after inguinal lymphadenectomy. An 82% to 88% 5-year survival rate has been reported when only one to three lymph nodes are involved.



PREVENTION




• Good genital hygiene in men who have not been circumcised


• Avoiding sexual practices likely to result in HPV or HIV infection


• Avoid tobacco use



BIBLIOGRAPHY



Brosman S.A. Penile cancer. Retrieved on June 13, 2006 from http://www.emedicine.com/med/topic3046.htm, 2006.


Green F.L., Page D.L., Fleming I.D., et al. AJCC cancer staging manual, 6th Ed. New York: Springer-Verlag, 2002.


Jemal A., Siegel R., Ward E., et al. Cancer statistics, 2007. CA: A Cancer Journal for Clinicians. 2007;57:43–66.


Misra S., Chaturvedi A., Misra N. Penile carcinoma: a challenge for the developing world. The Lancet. 2004;5:240–247.


Presti J. Genital tumors. In: Tanagho E., McAninch J. Smith’s general urology. 6th Ed. New York: McGraw-Hill; 2004:386–399.


Razdan S., Gomella L. Cancer of the urethra and pelvis. In: DeVita V., Hellman S., Rosenberg S. Cancer principles and practice. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:1260–1267.


Sanchez-Ortiz R., Pettaway C. National history, management, and surveillance of recurrent squamous cell penile carcinoma: a risk-based approach. Urological Clinics of North America. 2003;30:853–867.


Stotts R.C. Cancers of the prostate, penis, and testicles: epidemiology, prevention, and treatment. Nursing Clinics of North America. 2004;39:327–340.


Vogelzang N.J., Scardina P.T., Shipley W.U., et al. Comprehensive textbook of genitourinary oncology. In: Vogelzang N.J., Scardino P.T., Shipley W.U., et al. Penile cancer: clinical signs and symptoms. Philadelphia: Lippincott Williams & Wilkins; 2006:805–830.

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Mar 1, 2017 | Posted by in NURSING | Comments Off on Genitourinary Cancers

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