PROSTATE CANCER

AND UROTHELIAL
CARCINOMA

I Wayan Yudiana
Urology Departement, Medical Faculty of
Udayana University
Sanglah General Hospital
 PROSTATE
CANCER
❖ The incidence varies widely between different geographical areas
❖ Most common urologic malignancy, with bladder cancer
❖ Predictable malignancy with natural history or journey
❖ Coley & colleagues : CaP is age dependent 🡪
• 50-59 yo : 15%
• 60-69 yo : 22%
• 70-79 yo : 39%
• > 80 yo : 60-70%
NCCN Guidelines Version 1.2021; EAU Guidelines 2020
EPIDEMIOLOGY
…

Globacan 2020
 EPIDEMIOLOGY
…
❖ Indonesia 🡪 No complete data
1. Globocan 2020. Indonesian Fact Sheet.
2. Chen R et al. Prostate Cancer in Asia : A Collaborative Report. Asian J Urol 2014;1:15-29.

❖ More than 50% patients presenting at

metastatic stage in indonesia
Top 5 male cancer ❖ Localized cases are low
incidence in Indonesia
 RISK
FACTORS…
• Familial / genetic factors / etnic / racial background
• Exogenous / environmental factors / occupational exposure
• Dietary factors (alcohol, fat)
• Metabolic syndrome (diabetes, cholesterol, obesity)
• Hormone states (testosteron)
• Cigarette smoking Infection and inflammatory factors
• Sexual activity ???
NCCN Guidelines Version 1.2021; EAU Guidelines 2020
 CHEMOPREVENTIO
N…
• 5α-reductase inhibitor
• Anti-oxidant (Se and Vit E)
• Soy (isoflavone)
• Lycophen
• Green tea
• Statin

NCCN Guidelines Version 1.2021; EAU Guidelines 2020

ANATOMY…

Champbell-Walsh-Wein Urology 12th ed 2016

 DIAGNOSTIC AND
STAGING…
❖ Anamnesis (symptoms)
❖ Physical examination (sign)
❖ Diagnostic tool (Lab, Ro”)
✔ Serum tumor marker

Histo-pathology :
✔ Cell type : acinar adenocarcinoma (95 %)
✔ GS : Gleason score
 SYMPTOMS AND
SIGN…
❖ Symptoms : asymptomatic, LUTS & metastase
❖ Sign :
DRE 🡪 screening
✔ prostate enlargment, asymmetric
✔ hard / solid, nodule
✔ mobile / fixed,
✔ direct invasion to rectum & seminal vesicle
Metastase
 SYMPTOMS AND
SIGN…
❖ Symptoms and sign of metastase :
Bone metastase 🡪 SRE
✔ bone pain
✔ pathologic fracture
✔ spinal cord compression
✔ hipercalsemia malignancy
Visceral metastase (liver, lung,
non-regional)

NCCN Guidelines Version 1.2021; EAU Guidelines 2020

 LABORATORIUM…

❖ Tumor marker :
✔ PSA (blood)
✔ PCA3 (urine)
❖ Renal function test :
✔ Disease complication
✔ Treatment preferred
❖ Testosterone
EAU Guidelines 2020
 PSA (Prostate Specific Antigen)…

❖ Organ marker, not specific for cancer

❖ Detecting, staging, monitoring
❖ Elevated PSA levels are :
✔ Prostate cancer
✔ BPH / enlargement of prostate
✔ Prostatitis
✔ Prostate manipulation or instrumentation
EAU Guidelines 2020
 PSA (Prostate Specific Antigen)…

❖ Serum half-life : 2 - 3 days

❖ PSA derivatives :
✔ PSA ratio (free to total PSA)
✔ PSA density
✔ PSA velocity
✔ Age-adjusted PSA
❖ Cut of points : 4 ng/mL (2,5 - 4 ng/mL)
EAU Guidelines 2020
 RADIOLOGY
…
❖ TRUS (trans-rectal ultrasonography) 🡪 prostate biopsy
❖ TAUS
❖ Chest X ray (AP / lateral)
❖ Bone survey / scanning
❖ CT-Scan
❖ mp-MRI
❖ psma PET-CT
NCCN Guidelines Version 1.2021; EAU Guidelines 2020
 Prostate biopsy…
❖ Gold standar 🡪 10 - 32 core biopsy
❖ Transrectal or transperineal
❖ Guided TRUS or MRI
❖ Indicated :
✔ Abnormality finding of DRE
✔ Abnormality of PSA value or derived
✔ Chronic inflammation (HGPIN, ASAP, PIA)
❖ Morbiditas :
▪ Microhematuria, hematospermia, sepsis
STAGING…
 PROSTATE CANCER
JOURNEY…

Newly diagnosed
mCSPC

Primary progressive
mCSPC
Localised or locally
Biochemical Terminal
advanced prostate mCRPC
recurrence disease (death)
cancer

nmCRPC

Adapted from: Scher HI et al. J Clin Oncol. 2016;34(12):1402-1418; Mottet, N, et al. (2017). EAU - ESTRO -
ESUR - SIOG Guidelines on Prostate Cancer. Available from: http://uroweb.org/guideline/prostate-cancer/
(Access Date: August 2017)
 TREATMENT…

❖ Curative :
✔ Radical prostatectomy
✔ EBRT
❖ Paliative :
✔ EBRT, Bracytherapy
✔ Hormonal therapy (medical and surgical castration)
✔ Chemotherapy
❖ Surveillance
NCCN Guidelines Version 1.2021; EAU Guidelines 2020
 TREATMENT…

Terapi 🡪 Indonesia :
✔ Orkhidektomi : 307 (31%)
✔ Obat hormonal : 182 (18%)
✔ Prostatektomi rad : 89 (9%)
✔ Radioterapi : 63 (6%)
✔ Sisanya adalah pemantauan aktif,
kemoterapi dan kombinasi

InaSOU Meeting 2011; PNPK Kanker

Prostat 2015
 UROTHELIAL CANCER
Cancer of Bladder, Ureter and Renal Pelvis

❖ UTUC (Upper-Urinary Tract Urothelial Carsinoma)

❖ Lower-Urinary Tract Urothelial Carcinoma (Bladder Cancer)

 EPIDEMIOLOGY…

❖ Urothelial carcinomas (UCs) : 4th most common tumors

❖ Location : lower (bladder or urethra; 90-95%) and upper (pelviocaliceal
cavities or ureter; 5-10%)
❖ UTUC can be developing to bladder cancer (30-50%) and
contralateral UTUC (2-4%)
❖ Conversely, bladder cancer can be up-spreading and developing to
UTUC approximately < 2%

NCCN Guidelines Version 1.2021; EAU Guidelines 2020

Globacan 2020
 HISTOPATHOLOGY
…
❖ Epithelial
• Urothelial carcinoma (Transitional cell carcinoma/TCC) 90-95%
• Non-urothelial carcinoma (5-10%)
✔ Squamous cell carcinoma (5%)
✔ Adenocarcinoma (<2%)
✔ Undifferentiated carcinoma (<2%)
❖ Non-epithelial
• Pheochromocytoma, lymphoma, mesenchymal tumors
 RISK FACTORS…

❖ Exposure of carcinogens : naphthylamine, benzidine,

aminobiphenyl, nitrobiphenyl, aromatic amines
• Cigarette smoking
• Occupational or chemical exposure (dye, printing, rubber, petroleum,
leather, etc)

A latency period of 15 to 30 years from first exposure to carcinogens to

diagnosis of a tumor is common
NCCN Guidelines Version 1.2021; EAU Guidelines 2020
 RISK FACTORS…

❖ Chronic infection-inflammation-irritation :
• Chronic urinary tract infections
• Schistosomiasis
• Giant urinary calculi / stone and foreign bodies
• Cyclophosphamide
• Iradiation
• Fistula, urachal persistent, bladder extropia

NCCN Guidelines Version 1.2021; EAU Guidelines 2020

 WORK UP
DIAGNOSTIC…

❖ Anamnesis
❖ Physical examination
❖ Diagnostic tool :
✔ Lab & tumor marker
✔ Radiologic
 TUMOR MARKERs…

❖ Urinary cytology :
• A voided urine specimen or ureteral/bladder washing while
endoscopic procedure
• Classifications by G. Papanicolaou 🡪 5 class (normal cell, atypical
cell, not pathognomonic abnormal cell, suspicious cancer cell,
cancer cell)
• Low sensitivity (30-60%) and high specificity (95-100%)
 UTUC

o Hematuria (70-90%)
o Flank pain (8-50%)
o Flank mass (10-20%)
o Constitutional symptoms (anorexia, weight loss, lethargy)
o Metastatic symptoms
 UTUC
o Laboratory finding :
✔ Urinalysis
✔ Urine cytology 🡪 barbotage or ureteral brush
o Imaging :
✔ USG, IVU or CT urography
✔ Uretero-renoscopy/URS (rigid or flexible) 🡪 RPG and biopsy
o Histopatology : biopsy of renal pelvis or ureter
IMAGING…
 UTUC
Principal of treatmet :
• Based on stage, grade, location, and
multifocal tumors.
• Renal function and preserving therapy.
• Pelvis renalis and multifocal of ureter :
nefro-ureterctomy and excision of a
bladder cuff
• Unifokal of ureter : ureterectomy and
reconstruction (end-to-end anastomosis,
re-implantation)
EAU Guidelines 2020
UTUC CASE…
 BLADDER CANCER

▪ Painless intermittent hematuria (85-90%)

▪ Irritative voiding symptoms
▪ Metastasis sign and symptoms
▪ Bimanual palpation and digital rectal examination
 DIAGNOSTIC
TOOL…

▪ Laboratory findings :
✔ Urinalysis
✔ RFT
✔ Tumor marker : urinary cytology, BTA, NMP22, UroVysion test
▪ Imaging :
✔ USG, IVP/IVU
✔ CT Urography
✔ MRI
CT UROGRAPHY
IVP / IVU
 DIAGNOSTIC
TOOL…
▪ Urethro-cystoscopy + biopsy/TUR-BT
✔ Tumor growth pattern (sessile, papiler,
mixed)
✔ Location on bladder wall
✔ Number of tumors (unifocal or
multifocal)
✔ Size of tumors
✔ Presence of CIS
 HISTOPATOLOGY…

•Histopatology result from biopsy or TUR-BT :

✔ Cell cancer type (TCC, SCC, AdenoCa, etc)
✔ Grading (PUNLMP, LG, HG, CIS)
✔ Depth with muscle component or staging (NMIBC or MIBC)
✔ Trigone, bladder neck and prostatic urethra
 STAGING AND
CLASSIFICATION…

❖ NMIBC

❖ MIBC

EAU Guidelines 2020

 BLADDER CANCER

Principle of treatment :

❖ NMIBC 🡪 local treatment : intravesical therapy

❖ MIBC 🡪 radical cystectomy, bladder sparing treatment

Multi-modality treatment / approach

 TREATMENT…

❖ Intravesical treatment for NMIBC

• TUR-BT (Trans-Urethral Resection of Bladder Tumor)
• Immunotherapy instillation: BCG
• Chemotherapy : Mitomycin, Doxorubicin/Epirubicin, Gemcitabine
✔ Induction and maintenance dose 🡪 surveillance
✔ Recurrence and progression rate 🡪 re-treatment or
progressive treatment (cystectomy)
 TREATMENT…

❖ Treatment for MIBC

• Surgery : TUR-BT, partial cystectomy, radical cystectomy (male),
anterior pelvic exenteration (female) with urinary diversion

▪ Orthothopic neo-bladder
• Chemotherapy : cisplatin-based ▪ Cutaneous urinary diversion
✔ Continence
• Radiotherapy (EBRT) : 60-70 gray
✔ Incontinence
BLADDER CA
CASE…

Urology Sanglah MR
Google search “ileal conduit”
Thank You