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Kidney Cancer

Incidence

Kidney cancer affects men about twice as often as women. Most people who contract this disease are over the age of 50.

Causes

The exact causes of kidney cancer are not well understood. Kidney cancer is not contagious; no one can "catch" any type of cancer from another person.

Scientists have learned that smoking is a major risk factor for kidney cancer. Smokers are twice as likely to get this disease as nonsmokers. Several studies also suggest that the risk of developing kidney cancer may be higher than average among people with certain jobs. Groups with increased risk include coke oven workers and those who work with asbestos. Research also shows that being overweight can increase the chance of getting some types of cancer. Kidney cancer may be one of them.

Symptoms

The most common symptom of kidney cancer is the presence of blood in the urine. It may be present one day and not the next. Another symptom of kidney cancer is a lump or mass that can be felt in the kidney area. The tumor may cause a dull ache or pain in the back or side.

Investigation

To diagnose kidney cancer, the patient's personal and family medical history is taken and a thorough physical examination is conducted. In addition to checking temperature, pulse, blood pressure, and other general signs of health, the doctor usually orders blood and urine tests and one or more of the below mentioned exams :

Ultrasound
Intravenous Urogram(IVU)
CT or CAT scan

Magnetic Resonance Imaging (MRI)
Arteriogram
Nephrotomogram

Hypervascular Mass in the right kidney as seen on a Renal Angiogram.

hypervascular hypernephroma



Treatment

If these tests suggest that a tumor is present, it is important to know the extent, or stage, of the disease. Because kidney cancer can spread to the bones, lungs, liver, or brain, staging procedures may include special x-rays and tests to check these organs.

Treatment for kidney cancer depends on the location and size of the tumor and whether the cancer has spread to other organs. Kidney cancer is treated with surgery, embolization, or hormone therapy, biological therapy, or chemotherapy, which are forms of systemic therapy and rarely Radiation therapy.

Surgery

Most kidney cancer patients have surgery, an operation called Radical Nephrectomy. In some cases, the surgeon removes the whole kidney(palliative Nephrectomy) or just the part of the kidney that contains the tumor(partial nephrectomy). More often, the surgeon removes the whole kidney along with the adrenal gland and the fat around the kidney. Also, nearby lymph nodes may be removed because they are one of the first places where kidney cancer spreads. Finding cancer cells in the lymph nodes means there may be cancer elsewhere in the body.

Radical Nephrectomy is major surgery. For a few days after the operation, most patients need medicine to relieve pain. Discomfort may make it difficult to breathe deeply, and patients have to do special coughing and breathing exercises to keep their lungs clear. Patients may need IV (intravenous) feedings and fluids for several days before and after the operation. Nurses will keep track of the amount of fluid the patient takes in and the amount of urine produced. The remaining kidney takes over the work of the one that was removed.

Embolization

In embolization, a substance is injected to clog the renal blood vessels. The tumor shrinks because it does not get the blood supply it needs to grow. In some cases, embolization makes surgery easier. When surgery is not possible, this treatment may help reduce pain and bleeding.

Embolization can cause pain, fever, nausea, or vomiting. These problems are treated with medicine. Often, patients also require intravenous fluids.

Hormone Therapy

Some kidney cancers may be treated with hormones to control the growth of cancer cells. Some hormones are taken by mouth; others are given by injection. Patients do not need to be in the hospital for their treatment. This kind of treatment helps a small number of patients with advanced kidney cancer, especially when the disease has spread to the lungs.

The side effects of hormone therapy are usually mild. Progesterone is the hormone most often used to treat kidney cancer. Drugs containing progesterone generally cause few side effects, though some patients may retain fluid and gain weight.

Biological Therapy

Biological therapy is a new way of treating kidney cancer. This treatment attempts to improve the way the body's immune system fights disease. Interleukin-2 and interferon are two forms of biological therapy being studied to treat advanced kidney cancer. Doctors are also exploring the benefits of using biological therapy after surgery for early stage kidney cancer. This additional treatment is called adjuvant therapy. Doctors are trying to find out whether adjuvant biological therapy can prevent the cancer from recurring by killing undetected cancer cells that may remain in the body. Most patients having biological therapy must stay in the hospital so that the effects of their treatment can be monitored.

The side effects caused by biological therapies vary with the type of treatment. Often, these treatments cause flu-like symptoms such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Sometimes, patients develop a rash with dry, itching skin. Patients often feel very tired after treatment. In addition, interleukin-2 can cause the patient to retain fluid. These problems can be severe, and most patients need to stay in the hospital during treatment.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. Chemotherapy has not been very effective against kidney cancer, but researchers are studying new drugs and new drug combinations that may prove to be useful.

Bladder Cancer

Incidence

Bladder Cancer is cancer affecting the urinary bladder. Bladder cancer is a fairly common form of cancer and men are affected two to three times more than women. Most bladder cancers occur after the age of 55. The disease is not contagious. No one can "catch" bladder cancer from another person.

Causes

Research shows that smoking is a major risk factor. Workers in some occupations are at higher risk of developing bladder cancer because of exposure to carcinogens (cancer causing substances) in the workplace. These workers include people in the rubber, chemical, and leather industries, as well as hairstylists, machinists, metal workers, printers, painters, textile workers, and truck drivers.

Symptoms

The most common warning sign of bladder cancer is blood in the urine. Depending on the amount of blood present, the color of the urine can range from faintly rusty to deep red. Pain during urination can also be a sign of bladder cancer. A need to urinate often or urgently may be another warning sign. Often, bladder tumors cause no symptoms.

When symptoms do occur, they are not sure signs of cancer. They may also be caused by infections, benign tumors, bladder stones, or other problems. It is important to see a doctor to determine the cause of the symptoms.

Diagnosis

carcinoma_of_urinary_bladder_1.jpg carcinoma_of_urinary_bladder_1.jpg
Carcinoma of Urinary Bladder

To diagnose bladder cancer, a personal and family medical history is taken and a thorough physical examination is conducted. Often, the doctor orders an Ultrasonograpy or x-ray called an IntraVenous Urogram (IVU). A biopsy is needed to make a definite diagnosis of bladder cancer.

Treatment

  1. Treatment for bladder cancer depends on a number of factors. These are

  2. How quickly the cancer is growing,

  3. The number, size, and location of the tumors,

  4. Whether the cancer has spread to other organs

  5. The patient's age and general health.

Before treatment begins, it is important to know exactly where the cancer is located and whether it has spread from its original location. Staging procedures include a complete physical exam and additional blood tests and scans such as CT scan, Ultrasound or MRI .

Early (superficial) bladder cancer in which, the tumors are found superficially in the  bladder wall, generally can be treated using the cystoscope in a procedure called transurethral resection of the bladder tumour (TUR-BT). The entire tumour can be removed cystoscopically.

When several tumors are present in the bladder or when there is a risk that the cancer will recur, TURBT may be followed by treatment with drugs. The doctor may put a solution containing the Bacillus Calmette-Guerin (BCG), a form of biological therapy, directly into the bladder. Chemotherapy (anticancer drugs) may also be inserted directly into the bladder. Radiation therapy (also called radiotherapy) may be needed when the cancer cannot be removed with TUR because it involves a larger area of the bladder.

When the cancer involves much of the surface of the bladder or has grown into the bladder wall infiltrating into the bladder muscles, standard treatment is to remove the entire bladder. This surgery is called a Radical Cystectomy. In this operation, the surgeon removes the bladder as well as nearby organs. In women, this operation includes removing the uterus, fallopian tubes, ovaries, and part of the vagina. In men, the prostate and seminal vesicles are removed.

When cancer involves the pelvis or has spread to other parts of the body, chemotherapy may be required.

The methods used to treat bladder cancer are very powerful. Side effects depend on the type of treatment used and on the part of the body being treated.




Side Effects

When the bladder is removed, the patient needs a new way to store and pass urine. A newer method uses part of the small intestine to make a new storage pouch (called a continent reservoir) inside the body. The urine collects there and does not empty into a bag. Instead, the patient learns to use a tube (catheter) to drain the urine through a stoma. Other methods are being developed that connect a pouch made from the small intestine to a remaining part of the urethra. When this procedure is possible, a stoma and bag are not necessary because urine leaves the body through the urethra.

 Radical Cystectomy causes infertility in both men and women. This operation can also lead to sexual problems. In the past, nearly all men were impotent following this procedure, but improvements in surgery have made it possible to prevent this in many men. In women, the vagina may be narrower or shallower, and intercourse may be difficult.

During radiation therapy, patients may become very tired as the treatment continues. Resting as much as possible is important. Radiation treatment to the lower abdomen may cause nausea, vomiting, or diarrhea. Usually, certain foods or medications can ease these problems. Radiation therapy can also cause problems with fertility and can make sexual intercourse uncomfortable.

 Chemotherapy causes side effects because it damages not only cancer cells but other rapidly growing cells as well. The side effects of chemotherapy depend on the specific drugs that are given. In addition, each patient reacts differently. Chemotherapy commonly affects blood-forming cells and cells that line the digestive tract. As a result, patients may have side effects such as a lowered resistance to infection, loss of appetite, loss of hair, nausea and vomiting, less energy, and mouth sores. These are short-term side effects that usually end after treatment stops. When drugs are put directly into the bladder, these side effects may be limited. However, it is common for the bladder to be irritated.

Prostate Cancer

Introduction

prostate gland digital rectal exam

Each year, more than 120,000 new cases of prostate cancer occurs in USA and more than 30,000 deaths are caused annually by this disease. Approximately, one out of every 10 men will develop this form of cancer – it is second only to lung cancer as the leading cause of death in men – and the likelihood of developing it increases with age.  An estimated 232,090 cases of prostate cancer will be diagnosed in U.S. men in 2005.

Every man over the age of 50 should know that he is at risk for prostate cancer. African Americans have the highest risk of developing this disease. Having a father or brother with prostate cancer also greatly increases a man’s likelihood of developing it. In addition, studies have shown that a diet high in fat may contribute to the development of this cancer.

Most prostate cancers begin in the outer part of the prostate. The cancer must grow fairly large before it presses on the urethra and interferes with the urination. In the early stages, prostate cancer is curable. With prompt treatment the percentage of men who survive longer than 10 years is roughly equal to that of men who have never had prostate cancer.

If prostate cancer is allowed to develop without treatment, it may spread to other organs, causing disability and sometimes death. Advanced prostate cancer is more likely to cause symptoms, which may lead a man to see a doctor for diagnosis. Unfortunately, by the time prostate cancer has reached this stage, it is less responsive to treatment.

If the results of DRE suggest the presence of cancer, your urologist may recommend that other test be performed which help detect prostate cancer or indicate the extent of the cancer’s growth. To confirm the presence of cancer, the urologist may perform a biopsy obtaining a small sample of the suspected cancer for examination under a microscope by a pathologist.

If a diagnosis of prostate cancer is made, the urologist will generally recommend treatment. How prostate cancer is treated depends upon the stages of cancer, the aggressive nature of the cancer, the age of the patient, the patient’s overall health and side effects of different treatments. Because so many different options exists, the treatment of prostate cancer should be carefully weighed by you and your urologist.  One of the treatment options, no matte what the stage is “watchful waiting”.

Since the prostate cancer grows slowly, symptoms may not appear for years. Men generally develop this disease late in life, so a period of watchful waiting (period of observation) may be a choice. But studies have shown that after the age of 40, there is no fixed rule for cancer of prostate to develop.

Various treatment options are employed: these include surgery, radiation therapy, hormonal therapy and occasionally chemotherapy. The urologist will advise on the treatment most appropriate for each particular case depending upon the stage of disease.

Pathophysiology

Prostate cancer occurs when cells within the prostate grow uncontrollably, creating small tumors. Most cells in the body are constantly dividing, maturing, and then dying in a tightly controlled process.  Unlike normal cells, the growth of cancer cells is no longer well regulated. Instead of dying, as they should, cancers cells outlive normal cells and continue to form new, abnormal cells. The term “primary tumor” refers to the original tumor; secondary tumors are caused when the original cancer spreads to other locations in the body.  Prostate cancer typically is comprised of multiple very small, primary tumors within the prostate.  At this stage, the disease is often curable (rates of 90% or better) with standard interventions such as surgery or radiation that aim to remove or kill all cancerous cells in the prostate.  Unfortunately, at this stage the cancer produces few or no symptoms and can be difficult to detect.

prostate_cancer_metastatic

Metastatic prostate cancer

 If untreated and allowed to grow, the cells from these tumors can spread in a process called metastasis.  In this process, prostate cancer cells are transported through the lymphatic system and the bloodstream to other parts of the body, where they lodge and grow secondary tumors.  Once the cancer has spread beyond the prostate, cure rates drop dramatically

Causes & Risk Factors

 The major known risk factors for prostate cancer are

  • Age
    The chance of having prostate cancer increases rapidly after age 50.  In fact, about 80% of all prostate cancers are diagnosed in men over the age of 65.

  • no

  • Family history:
    Approximately 25% of men with prostate cancer have a history of the disease within their family.

  • It is believed that only 9% of all prostate cancers are purely hereditary.

  • Obesity:
    Recent studies have shown that men who are overweight or obese are at significantly higher risk for developing prostate cancer.




Prevention

Some risk factors – such as race, family history or age -cannot be modified, while others, especially diet and weight, can be controlled. 
The Prostate Cancer Foundation suggests that men wanting to reduce their risk of prostate cancer

  • Eat fewer red meats and high-fat dairy products,

  • Eat five or more servings of vegetables and fruits each day,

  • Exercise regularly and

  • Maintain a normal weight




Screening & Diagnosis

Screening for prostate cancer can be performed quickly and easily in a physician’s office using two simple tests:

  1. The Prostate Specific Antigen (PSA) blood test, and the
  2. Digital Rectal Exam (DRE).


PSA

A PSA level above 4.0 ng per milliliter of serum may trigger a prostate biopsy to search for cancer.

The Digital Rectal Exam
Normal Tenderness> symmetrical_enlargement>
Normal Tenderness Symmetrical Enlargement (BPH)
Asymmetry Induction Nodularity
Asymmetry Induction Nodularity

The digital rectal exam should be performed along with the PSA test.  A physician who will insert a gloved finger into the rectum to feel the peripheral zone of the prostate where most prostate cancers occur performs the DRE.  The physician will be checking for hardness of the prostate or for irregular shapes or bumps extending from the prostate – all of which may indicate a problem.  The DRE is particularly useful because the PSA test may miss up to 25% of cancers, and the DRE may catch some of these.

Symptoms

Often, early stages of prostate cancer do not cause symptoms.  However, in some cases, men with prostate cancer may experience any of these problems:


Treatment of prostate cancer in early stage:

In early stages, when the prostate cancer is localized (confined to prostate), treatment options generally would include:

1.Prostatectomy:

This is surgical removal of the prostate gland. The idea is to remove the cancerous growth of the prostate by removing the entire prostate gland.

    • Side effect include

      • Impotence

      • Incontinence

2.Radiation therapy:

This therapy helps to shrink the tumor by:

    • Directing radiation from outside the body directly on the tumor within prostate.
    • Implanting tiny radioactive seeds directly into prostate.

Radiation has its own complication but with proper planning and linear accelerator, side effects can be minimized.

Radical retropubic prostatectomy and radical perineal prostatectomy are the two most common types of radical prostatectomy procedures. The entire prostate gland, attached seminal vesicles, and some nearby tissue are removed during these surgeries.

  • A radical retropubic prostatectomy involves a surgical cut in the lower abdomen. The surgeon can then remove the cancer through this skin incision. The entire prostate and attached seminal vesicles are removed, along with a small part of the bladder next to the prostate.

  • If necessary, a pelvic lymphadenectomy is performed to remove nearby pelvic lymph nodes

  • Recent developments in surgery have led to a newer version of this technique, called nerve-sparing radical retropubic prostatectomy. This allows the surgeon to identify the nerves on either side of the prostate so that they can be left alone, if possible. In general, there is a lower risk of certain adverse effects if the nerve-sparing technique can be used.

  • Radical perineal prostatectomy is similar to radical retro pubic prostatectomy except that the cancer is removed through an incision in the perineum. A surgical cut is made in the area between the scrotum and the anus. The entire prostate is removed along with any nearby cancer.

Laparoscopic Robotic


Advantages:

 Prostatectomy is a one-time procedure that may optimally treat prostate cancer in its early stages and may help extend life in the later stages. Surgery avoids some of the problems seen with radiation therapy. These problems are discussed in the next section.



Disadvantages:

Prostatectomy is a major operation that requires hospitalization and can produce side effects. The possible side effects include impotence, urinary incontinence, and narrowing of the urethra that can make urination difficult.
Although impotence can occur in a large number of patients, the chance of impotence is lower with the newer nerve-sparing technique. Urinary incontinence occurs in only a small percentage of patients.

3.Radiation therapy:

Radiation therapy uses high-energy x-ray to kill cancer cells. There are two methods of radiotherapy

    • Radiation may come from out side the prostate (external radiation).
      As treatment begins cancer cells are damaged and later die. Some normal cells are damaged too. More cancer cells die with more treatment. Cells continue to die for 12-18 months after treatment.
      • During each dose of external beam radiotherapy, radiation comes from a machine outside your body is beamed into the cancer. Each dose damages more and more cancerous cells.
      • Your radiation oncologist designs your treatment plan based on the cancer’s grade, stage and your overall health.
      • Radiation therapist positions patients on tablet o help protect normal cells. Radiation is aimed at the tumor from different angle.
      • Each treatment last few minutes. Treatment occurs once a day, 5 days a week for 5-7 weeks.

Risk and complications:

  • Mild to moderate diarrhea.
  • Darkening and drying of skin in the treatment area.
  • Some loss of pubic hair.
  • Fatigue.
  • Bloating / Gas pain.
  • Frequent urination, possibly with burning.
  • Irritation or inflammation of rectum with diarrhea Urgent needs to pass stool or rectal discomfort.
  • Erectile dysfunction
  • Bleeding or scaring of the bladder and or rectum.
    • Radiation comes from material placed inside the prostate (interstitial brachytherapy).
      targeting cells from inside the prostate. During interstitial brachytherapy, “seeds” (tiny plastic tubes containing radioactive material) are implanted into your prostate through needles using the perineal approach. This occurs when you are under anesthesia. The seeds releases decreasing amount of radiation for about a year. The implant can be temporary or permanent. Healthy tissue near the seeds may also be affected. This may cause some side effect
  • Frequent urination, possibly with a burning feeling.
  • Erectile dysfunction.
  • Bleeding and inflammation of bladder and rectum.
  • Incontinence.

Treatment of advanced prostate cancer:

Advanced cancer of the prostate may not be present with the symptoms. The aim of treating advanced prostate cancer is to slow further growth of the disease, even before the symptoms begin.

Hormonal therapy is usually used for the slowing the spread of cancer

All male hormones “feed” prostate cancer. Hence, the idea is to shut off the supply of testosterone to prostate. This would prevent or slow down the spread of prostate cancer. This testosterone is manufactured in testis.

Partial Hormonal Therapy

Modern drugs provide various ways to reduce the flow of testosterone, the primary source of tumor growth. The following  are the examples of partial hormonal therapy:

Estrogen:

Estrogen (DES), a female hormone is used in the treatment of prostate cancer. In men, intake of estrogen leads to fall of testosterone. However, its use is not widely accepted due to many side effects. It is usually prescribed as a single dose per day but it may cause nausea, vomiting, breast tenderness or enlargement, serious heart or blood vessel problems (such as stroke, clots, and fluid retention) and lower sex drive.

Orchidetcomy:

It means surgical removal of testicles, it is also known as surgical castration. In the absence of testis, the main source of male hormones, testosterone, is absent. This slows the growth of the tumor. Side effects may include impotence and hot flashes. The surgery can be performed as a day care.

Medical Castration: Testosterone production from testicles can also be blocked by medicines. Medical castration shuts off the supply of testosterone by the testicle and achieves almost the same results as surgical castration. Medical castration involves monthly injection of Lupron Depot (Leuprolide) or Zoladex (Goserelin). These medications are also known as LHRH agonists. A LHRH agonist help reduce the amout of testosterone similar to surgical procedure. Side effects usually include hot flashes, impotence, breast enlargement and tenderness, loss of sex drive and nausea.

Complete Hormonal Therapy

Although testicles are the main source of male hormones, they are not the only one. The adrenal glands also make male hormones.

While castration stops the testicles from making testosterone, a drug called Flutamide can help prevent the male hormone produced by the adrenal glands from reaching the prostate. Flutamide is referred to as an antiandrogen.

The combination of LHRH agonist (Lupron or Zoladex), or castration plus Flutamide are called complete hormonal therapy. Complete hormonal theapy virtually shuts off the body’s supply of male hormones and slows the growth of the tumor.

 

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