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Berczi Csaba Department of Urology
Juhász Balázs Department of Oncology
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The most common urological tumor
The 2nd cause of the mortality in males with
malignancies in USA
3500-4000 new cases, 1200 deaths in
Hungary
Asymptomatic
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PSA measurement
Rectal digital examination
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Prostata biopsy
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Histology of the biopsy – Gleason grade and
score
Staging
Local staging: rectal US, CT, MRI ( endorectal
MRI )
Distant metastasis: bone scintigraphy
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Organ-confined prostata cancer
◦ No distant metastasis
◦ Inside the prostatic capsule
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Locally advanced or metastatic prostata
cancer
◦ Wait and see:
◦ Stage T1a – (TUR resected tissue ≤ 5%)
◦ Gleason score ≤ 6
◦ Over 70 years
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Organ confined prostata cancer
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Wait and see
Radical prostatectomy
Radiation therapy
Neoadjuvant TAB + radical prostatectomy or
irradiation
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Radical prostatectomy
◦ Remove the total prostata gland with the vesicula
seminalis
◦ Types: open surgery:
retropubic
perineal
laparoscopy
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External irradiation
◦ Target
 Prostata + vesicula seminalis + pelvic minor
 Prostata + vesicula seminalis
 Prostata
◦ 45-80 Gy
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Brachyterapy
◦ UH/CT guided
◦ izotop
3 dimensional conformal radiotherapy (3DCRT)
2. kép
4. kép
5. kép
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Permanent („seed”)
implantation
◦ Low-dose (LDR)
◦ I-125, Pd-103 izotop
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„after-loading”
technique
◦ High dose (HDR)
◦ Ir-192 izotop
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Locally advanced or metastatic prostata
cancer
Hormonal therapy (TAB, MAB, CAB)
Chemotherapy
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TAB
◦ LH-RH analog +
antiandrogen
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LH-RH analogs
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Buserelin ( Suprefact)
Goserelin (Zoladex)
Leuprorelin ( Lucrin, Eligard)
Triptorelin ( Decapeptyl, Dipherelin)
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Oestrogen
◦ Not used
◦ Cardiovascular complications
30-40 %
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Antiandrogens
◦ Steroid
 cyproteron acetat (Androcur)
◦ Non steroid:
 flutamid (Fugerel,Flutamid)
 nilutamin (Anandron)
 bicalutamid (Casodex, Calumid)
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Chemoterapy:
Indications:
◦ Hormon resistant tumor
◦ Anaplastic cancer
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Drogs:
◦ Estracyt
◦ vinblastin, etoposide, cisplastin, mitoxantron
◦ docetaxel (Taxotere)
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The 2nd most common urological tumor
◦ Morbidity 2600, mortality 820
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Symptoms:
◦ Haematuria
◦ Abdominal pain
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Diagnosis:
◦ US
◦ Iv. urography
◦ Cystoscopy
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Superficial (Ta,T1): 75-85 %
located only for the mucosa or the
submucosa, no infiltration of the muscalar
layer.
Infiltrate the muscular layer or metastatic (
15-25 %).
30% of the superficial tumors in time will
infiltrate the muscular layer.
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Surgery
◦ TUR ( superficial tumor )
◦ Cystectomy (tumors with muscular infiltration)
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Chemoterapy
Irradiation
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Adjuvant treatment of superficial tumors
(Ta,T1)
◦ Within 6 hours after the operation - 1 dose.
◦ Bladder instillatio - 1 year.
Decrease the occurrance of the recurrant
tumors, but did not decrease the
progression.
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Adjuvant treatment of superficial tumors
(Ta,T1)
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Mitomicin C
Epirubicin
Doxirubicin
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BCG
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Locally advanced or metastatic tumors
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Adjuvant chemoterapy:
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M-VAC
CISCA
gemcitabine+cisplatin
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gemcitabine + cisplatin vs. M-VAC
5 years follow-up
Overall 5-yeras survival:
OR:
Toxicity caused mortality:
86.
10 vs. 18 %
54 vs. 53 %
0 vs. 3 %
Lehmann J - 2003 Urologe A. 2003.42(8):1074-
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gemcitabine + cisplatin vs. M-VAC
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Similar response rate.
Similar time to the progression.
Similar overall survival.
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But the toxicicy is favourable with GC.
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von der Maase H - Semin Oncol. 2001. 28(2 Suppl 7):11-4.
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Gemcitabine:
OR:26%, CR:9%
Paclitaxel :
OR:42% , CR:27%
Docetaxel :
OR:31%, CR:15%
Gemcitabine + Cisplatin:
OR: 41-57%, CR:15-22%
Paclitaxel + Cisplatin:
OR:50%, CR:8%
Docetaxel + Cisplatin:
OR:58%,CR:19%
Paclitaxel + Carboplatin:
OR: 14%–65%, CR:0-40%
Paclitaxel + Ifosfamide:
OR:30%, CR:18%
Gemcitabine + Paclitaxel:
OR: 69%, CR: 41%
Gemcitabine + Docetaxel:
OR:18%
Gemcitabine + Paclitaxel + Cisplatin:OR:78%, CR:28%
Gemcitabine + Paclitaxel + Carboplatin : OR:68%, CR:32%
Paclitaxel + Cisplatin +Ifosfamide:
OR:79%, CR:32%
Galsky - The Oncologist 2005:10: 792-798.
von der Maase H.: Semin Oncol. 2002.29(1 Suppl 3):3-14.
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Metastasis occurs in 50 % after cystectomy.
The 5-years survival is 35-55 % after
cystectomy.
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The 5-years survival is better ( 5 % ) with
neoadjuvant chemotherapy ( cisplatin
based).
The 3-years survival is better (9%) with
adjuvant chemotherapy ( cisplatin based)
Conclusion: surgical factors ( margin pozitiv
status, lymph node status) have more
pronounced influence on the survival than
the perioperative chemotherapy.
Winquist -Can J Urol. 2006.13 Suppl 1:77-80.
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The results of the 5-years follow-up
proved that gemcitabine+cisplatin
treatment is effective in locally
advanced or metastatic bladder
cancer.
The effectivity of gemcitabine
+cisplatin and MVAC is similar but
the toxicity is favourable with
gemcitabine+cisplatin.
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Symptoms:
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Haematuria
Pain
Palpable mass
25 % of the tumors are diagnosed incidentally)
Diagnosis:
◦ US
◦ CT, MRI
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Treatment:
◦ Surgery
◦ Chemotherapy
◦ Irradiation (?)
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Treatment of the organ confined and locally
advanced tumors:
Radical nephrectomy ( Robson 1969.)
◦ Early ligation of renal vessels
◦ Removing the kidney and the surrounding tissues
within the Gerota fascia
◦ Adrenalectomy
◦ Lymph node block dissection
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Treatment of the organ confined and locally
advanced tumors:
Nephron-sparing surgery
Aim:
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Indication:
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◦ Oncologically radical tumorectomy
◦ Preserving the renal function
◦ Bilateral renal cancer
◦ Solitarí kidney
◦ Small tumor ( ≤ 4 cm)
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Treatment of the organ confined and locally
advanced tumors:
Postoperative treatment:
◦ Immunochemotherapy- depending on histology
◦ Irradiation (?)
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Treatment of the metastatic tumors:
Chemotherapy alone
Nephrectomy and postoperative
chemotherapy
Neoadjuvant chemotherapy and after that
nephrectomy
Supportive treatment
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Treatment of the metastatic tumors:
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Nephrectomy
Advantages:
◦ Decreasing the tumor mass
◦ Prevention the possible complications (haematuria)
◦ Sponataneus regression of the metastasis can
occurr
◦ psychotic effect
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Treatment of the metastatic tumors:
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Chemotherapy
◦ Chemotherapy: 5-FU, VBL
◦ Immunotherapy: Interferon-α2, Interleukin-2
◦ Targeted therapy:
 Thyrosine kinase inhibitor: sunitinib (Sutent), sorafenib
(Nexavar)
 M-TOR inhibitor: temsirolimus (Torisel), everolimus
(Affinitor)
 Monoclonal antibody (Mab) against VEGF: bevacizumab
(Avastin)
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Symptoms:
◦ Palpable nodule in the testis
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Diagnosis
◦ Palpation
◦ US of the testis
◦ Tumormarkers ( AFP, bHCG)
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Treatment
Semicastration
The further therapy depends on the
histological result and the staging
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After the semicastration:
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Wait and see
Chemotherapy
Irradiation
RLA
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2 main group
Seminoma:
◦ Sensitive for radiation and sensitive for
chemotherapy
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Non seminoma:
◦ Sensitive only for chemotherapy
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Rare
Diagnosis
◦ You can see
◦ Biopsy
 Squamosus cell cancer
 HPV 16, 18
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Treatment
◦ Surgery
◦ Chemotherapy?
◦ Irradiation