Cancer of the Penis

- Penile cancer occurs in men older than 60 and represents about 0.5 % of malignancies in men. - Since most penile cancer occur in uncircumsized men, it has been suggested that the etiology of this cancer maybe the irritative effect of smegma and poor hygiene.

Benign Tumor :

1. Condyloma Acuminatum
- Benign epithelial proliferation caused by HPV, especially types 6 & 11. - Sexual contact is the most common mode of transmission. - It occurs most frequently after puberty; presence in a prepubertal child should arouse suspicion of sexual abuse. - Gross morphology is that of sessile or pedunculated papillary excresence, often the coronal sulcus or inner surface of the prepuce

Malignant tumors :

1. Erythroplasia of Queyrat
- A form of epithelial dysplasia, which may range from a mild cellular changes to carcinoma in situ ( Bowens disease); it is usually found on the glans penis & prepuce.
- Bowens disease, the malignant cell are well confined to the basement membrane with no evidence of invasion. Transmission to invasive SCC occurs in 10% of cases.

- The lesions appear as well- defined, reddish shiny plaques.

2. Squamous Cell Carcinoma

- Prevalence is high in regions where circumcision is not routinely practice. Most cases occur between ages 40 and 70. - Potential causes include carcinogens within smegma accumulating under the foreskin and HPV types 16 & 18. - SCC typically present as epithelial thickening on the glans or inner surface of the prepuce, progressing to ulceroinfiltrative or exophytic growth eroding the penile tip, shaft or both.

SQUAMOUS CELL CA

Clinical Features :

- SCC of the penis is most common in uncircumsized men & presents as an ulcerated, painful lesion that bleeds easily.

Prevention :

- Circumcision in infancy almost eliminates the possibility of penile cancer because chronic irritation & inflammation of the glans penis predispose to penile tumors. In uncircumsized men , personal hygiene is an important preventive measure.

Penile Biopsy

Medical Management 1. Excision smaller lesion involving only the skin. a. Partial Penectomy - About 40% of patient can then participate in sexual intercourse & stand for urination . - The shaft of the penis can still respond to sexual arousal with an erection & has the sensory capacity for orgasm & ejaculation.

b. Total Penectomy - Indicated when the tumor is not amenable to to conservative treatment. - After a total penectomy, patient may still experience orgasm with stimulation of the perineum & scrotal area.

2. Topical Chemotherapy - 5 Fluorouracil cream 3. Radiation therapy - Treatment of small SCC of the penis or for palliation in advanced tumors or lymph node metastasis.

Cancer of the Vagina

- Usually result from metastasized choriocarcinoma or from CA of the cervix or adjacent organs ( e.g. uterus, vulva, bladder or rectum) . - Risk factors : 1. Previous cervical CA 2. In utero exposure to Diethylstilbestrol (DES) 3. Previous vaginal or vulvar CA 4. Previous radiation therapy 5. Hx of HPV

Clinical manifestations :

- Patient often do not have symptoms but may report : 1. Slight bleeding after intercourse 2. Spontaneous bleeding 3. Vaginal discharge 4. Pain 5. Urinary or rectal symptoms

Colposcopy Vaginal CA

Biopsy - Vagina

Staging of Vaginal CA

Medical Management 1. Local excision 2. Topical Chemotherapy - 5 Fluorouracil cream ( applied w/ tampon or diaphragm) 3. Laser therapy - For early vaginal & vulvar cancer

4. Radiation therapy - External beam radiation to the pelvis 5. Radical node dissection

6. Water soluble lubricants

Liver Cancer

Primary Liver CA

- Hepatocellular CA (HCC) is usually non resectable bec. of rapid growth & metastasis. - Cirrhosis, chronic infection w/ hepatitis B & C and exposure to certain chemical toxins have been implicated as causes of HCC. - Cigarette smoking been identified as a risk factor esp.when combined w/ alcohol use. - Aflatoxin, a metabolite of the fungus Aspergillus flavus, may be a risk factor for HCC.

HEPATITIS

Liver Metastasis - Malignant tumors are likely to reach the liver eventually, by way of the portal system or lymphatic channels or by direct extension from an abdominal tumor.

Clinical Manifestations
Pain, continuous dull ache in RUQ epigastrium or back. Weight loss, loss of strength, anorexia ,anemia Liver enlarged & irregular on palpitation Jaundice (larger bile duct occluded by pressure of malignant nodule mass) . Ascites- if such nodules obstruct portal vein or if tumor tissue seeded in the peritoneal cavity.

Assessment & Diagnostic Findings

1. History & PE 2. Radiography (X-RAY) 3. Laboratories (blood tests) - Inc. Serum bilirubin - Inc. Alkaline phosphatase - Inc. AST - Inc. Lactic dehydrogenase (LDH) - Leukocytosis - Erythrocytosis - Hypercalcemia

4. Liver biopsy 5. Cholangiography 6. Selective hepatic angiography 7. Percutaneous needle biopsy 8. Peritoneoscopy 9. Laparoscopy 10. UTZ 11. CT scan 12. MRI

Staging of Liver Cancer

Medical Management 1. Radiation Therapy 2. Chemotherapy 3. Percutaneous Biliary drainage 4. Surgical Management a. Lobectomy b. Cryosurgery-efficacy still being evaluated c. Liver transplant

Cancer of the Pancreas

- Cigarette smoking, exposure to industrial chemicals or toxins in the environment & a diet rich in fat, meat, or both are assoc. w/ pancreatic CA. - Can also be a site of metastasis from other tumors. - 75% of pancreatic CA originate in the head of the pancreas.

- Tumor of the Head of the Pancreas -tumor in this region of the pancreas obstruct the CBD where the duct passes through the head of the pancreas to join the pancreatic duct & empty at the ampulla of Vater into the duodenum.

Clinical Manifestations
- Pain, jaundice or both- (90% of the px) with weight loss (classic sign of pancreatic cancer) - do not appear until the disease is far advanced - Rapid, profound & progressive weight loss - Vague upper abdominal pain radiates as a boring pain in the midback (relieve by sitting up & leaning forward) - Ascites

 Onset of Sx of insulin deficiency - (impt. sign) - glucosuria - hyperglycemia - abnormal glucose intolerance (DM is an early sign of pancreatic CA) Meals aggravate epigastric pain

Assessment & Diagnostic Findings

1. MRI 2. CT SCAN 3. ERCP 4. Percutaneous FNAB 5. Percutaneous transhepatic cholangiography 6. Angiography 7. Laparoscopy

Staging of Pancreatic Cancer

Medical Management 1. Surgery a. Pancreatoduodenectomy (Whipple procedure) 2. Adjuvant chemotherapy & radiation therapy (5-FU based chemotherapy)

Colorectal Cancer

Pathophysiology : Cancer of the colon & rectum is predominantly(95%) adenocarcinoma (i.e. arising from the epithelial lining of the intestine) May start as a benign polyp but may become malignant, invade & destroy normal tissues & extend into the surrounding structures. Cancer cells may break away from the primary tumor & spread to the other parts of the body (most often to liver).

Colorectal Cancer
Clinical Manifestations Most common presenting Sx is change in bowel habits Passage of blood in the stool (2nd most common Sx) Unexplained anemia Anorexia Weight loss

 Fatigue Sx most commonly associated with Right side lesion are dull abd.pain & melena Sx most commonly associated with Left side lesion are those associated with obstruction (constipation & bright red blood in the stool) Tenesmus (ineffective painful straining at stool) Feeling of incomplete evacuation after bowel movement Alternating constipation & diarrhea Rectal pain

Risk Factors
Increasing age Family history of the colon CA or adenomatous polyps History of inflammatory bowel disease High fat, high protein, low fiber Genital CA or Breast CA (in women)

Assessment & Diagnostics Findings

1. Fecal occult blood testing 2. Barium Enema 3. Proctosigmoidoscopy 4. Colonoscopy 5. Sigmoidoscopy with biopsy or cytology smears 6. Carcinoembryonic antigen (CEA studies)

Sclerotherapy

Staging of Colorectal CA

Medical Management
1. Surgery a. Segmental resection w/ anastomosis b. Abdominoperineal resection with permanent sigmoid colostomy c. Temporary colostomy d. Permanent colostomy or ileostomy e. Construction of a coloanal reservoir (colonic J pouch)

2. Radiation therapy 3. Chemotherapy 4. Adjuvant therapy

Gastric CA

Pathophysiology : Most gastric are adenocarcinoma & can occur in any portion of the stomach. The tumor infiltrates the sorrounding mucosa, penetrates the wall of the stomach & adjacent organ & structures. Liver, pancreas, esophagus & duodenum are often affected at the time of diagnosis. Metastasis through a lymph node to the peritoneal cavity occurs later in the dse.

Clinical Manifestations

Gastric CA

Asymptomatic at an early stage Most gastric tumors begin on lesser curvature Sx of progressive disease: ADWACAN 1. Anorexia 2. Dyspepsia (indigestion) 3. Weight loss 4. Abdominal pain 5. Constipation 6. Anemia 7. Nausea & vomiting

Assessment & Diagnostic Findings

1. Endoscopy for biopsy & cytologic washings 2. Barium x-ray examination of the upper GI 3. CT Scan 4. Bone Scan 5. Liver Scan

Staging of Gastric CA

Medical Management

1. Surgery a. Radical subtotal gastrectomy b. Total gastrectomy c. Chemotherapy d. Radiation therapy

LAPAROSCOPIC SLEEVE GASTRECTOMY

Gastrectomy - Before and After

Bladder CA

 Predominant cause of bladder CA today is cigarette smoking. Cancers arising from the prostate, colon,rectum in males & from the lower gynecologic tract in females may metastasize to the bladder.

Bladder CA
Clinical Manifestations (VIAP) Visible, painless hematuria- most common sx of bladder CA Infection of urinary tract- common SX producing urgency, frequency & dysuria Any alteration in voiding or change in the urine Pelvic or back pain

Risk Factors

Cigarette smoking Environmental carcinogens Recurrent or chronic bacterial infection of the urinary tract Bladder stones High urinary pH High cholesterol intake Pelvic radiation therapy CA arising from the prostates colon and rectum in males

Assessment & Diagnostic Findings

1. 2. 3. 4. 5. 6. 7. Cystoscopy mainstay diagnosis Excretory Urography CT Scan UTZ Bimanual examination Biopsies of the tumor & adjacent mucosa. Cytologic examination of fresh urine & saline bladder washings.

EXCRETORY UROGRAPHY or IVP

Staging of Bladder CA

Medical Management
1. Surgery a. Transurethral resection or fulguration (cauterization) b. Cystectomy 2. Pharmacologic Therapy

RADICAL CYSTECTOMY

2. Pharmacologic Therapy

a. Chemotherapy with a combination of methotrexate, 5Fluorouracil,Vinblastine, Doxorubicin and Cisplastin b. Topical chemotherapy - antineoplastic instilled into the bladder c. Intravesical BCG effective in tx of carcinoma in situ 3. Radiation Therapy

Skin CA

- Is the most successfully treated type of cancer. - Exposure to the sun is the leading cause of skin cancer - The increased in skin CA probably reflects changing lifestyle & emphasis on sunbathing & related activities in light of changes in the environment, such as holes in the earths ozone layer.

Risk Factors for Skin CA:

1. Fair-skinned 2. People who sustain sunburn 3. Long time sun exposure (farmers, fisherman, construction workers) 4. Exposure to chem. pollutants (industrial workers in arsenic, nitrates, coal & etc ) 5. Sun damaged skin (elderly people) 6. Chronic skin irritations 7. Immunosuppression 8.Genetic factors

Basal cell CA (BCC) & Squamous cell CA (SCC) are the most common types of skin CA 1. BCC is the most common type -BCC usually begins as a small, waxy nodule w/ rolled, translucent pearly borders telangiectatic vessels may be present. As it grows, it undergoes central ulceration & sometimes crusting.

2. SCC is a malignant proliferation arising from the epidermis. -The lesions may be primary, arising on the skin & mucous membrane, or they may develop from a precancerous condition such as actinic keratosis (ie, lesions occuring in sun-exposed areas); leukoplakia (ie, pre malignant lesion of the mucous membrane) or scarred or ulcerated lesions. -SCC appears as a rough thickened, scally tumor that may be asymptomatic or may involve bleeding. -Exposed areas, esp. of the upper extremities and of the face, lower lip, ears, nose & forehead are common sites.

BASAL CELL CANCER

Malignant Melanoma - a typical melanocytes (ie, pigment cells) are present in the epidermis & the dermis (sometimes subcu taneous cells). - most lethal of all skin CA. - the cause is unknown but UV rays are strongly suspected, based on indirect evidence such as the inc. incidence of melanoma in countries near equator.

Several Forms: 1. Superficial spreading melanoma - most common form of melanoma. - usually affects middle aged people & occurs most frequently on the trunk & lower extremities. - lesion tends to be circular, w/ irregular outer portions, the margins of the lesion maybe flat or elevated & palpable.

2. Lentigo maligna melanomas - slowly evolving, pigmented lesions that occur on exposed skin areas, esp. the dorsum of the hand, the head & neck in elderly people.

3. Nodular Melanoma - spherical, blue-berry like nodule w/a relatively uniform, blue-black color. - dome shape w/ smooth surface. - invades directly into adjacent dermis & therefore has a poorer prognosis. 4. Acral Lentiginous Melanoma - occurs in areas not excessively exposed to sunlight and where hair follicles are absent. - found on the palms, on the soles, in the nails & in mucous membrane in darkskinned people.

Skin CA
Medical Management 1. Surgery
a. Mohs Micrographic Surgery - BCC & SCC b. Electrosurgery c. Cryosurgery 2. Radiation Therapy

SURGICAL REMOVAL SKIN CA

Mohs Surgery Skin graft

ELECTROSURGERY SKIN CA

CRYOSURGERY SKIN CA

CRYOSURGERY - SKIN

Cancer of the Kidney

CA of the KIDNEY
-most common type of renal tumor is renal cell or renal adenoCA-85 % of all kidney tumors -tobacco use is the most important risk factor

Major Types of Renal Cell CA:

1.Clear Cell CA -most common type; accounting 70-80% of primary renal CA -composed of cell w/ clear to granular cytoplasm 1.Papillary CA 2.Chromophobe renal CA

- Most common type of renal tumor is renal cell or renal adenoCA -85 % of all kidney tumors. - Tobacco use is the most important risk factor.

Major Types of Renal Cell CA:

1.Clear Cell CA - most common type; accounting 70-80% of primary renal CA. - composed of cell w/ clear to granular cytoplasm 2. Papillary CA 3. Chromophobe renal CA

Clinical Manifestations - Produce no Sx, discovered on routine physical exam as a palpable abdominal mass. - Classic triad of SSx:
(occurs only in 10%)

1. Hematuria 2. Pain 3. Mass in the flank

 Usual sign that first calls attention to the tumor is painless hematuria . Dull pain in the back from the pressure produced by compression of the ureter, extension of the tumor to perineal area or hemorrhage into the kidney tissue .

- Colicky pains occur if a clot or mass of tumor cells passes down the ureter . - Sx from metastasis may be the first mainfestations of renal tumor & may include: - Unexplaned weight loss - increasing weakness - anemia

Risk Factors
Gender: affects men more than women Tobacco use Occuptional exposure to industrial chemicals such as petroleum products, heavy metals & asbestos . Obesity Unopposed estrogen therapy Polycystic kidney disease

Assessment & Diagnostic Findings

1. 2. 3. 4. 5. 6. Intravenous Urography Cystoscopic exam Nephrotomograms Renal angiograms UTZ CT Scan

Staging of Renal CA

Medical Management

1. Surgery a. Radical nephrectomy 2. Radiation therapy, hormonal therapy, chemotherapy along w/ surgery 3. Pharmacology Therapy

Primary Brain Cancers

 A localized intracranial lesion that occupies space w/in the skull . Primary brain tumors originate from cells & structures w/in the brain. Secondary or metastatic brain tumors develop from structures outside the brain & occur in 20-40% of all px w/ CA. Brain tumors rarely metastasize outside the CNS, but metastatic lesions to the brain occur more commonly from lung, breast, lower GIT, pancreas, kidney & skin (melanomas) .

 Pathophysiology : Brain tumor classified into several groups : -Those arising from the coverings of the brain (e.g dural meningioma) -Those developing in or on the cranial nerve (e.g acoustic neuroma) -Those originating w/in brain tissue (e.g gliomas)
- Metastatic lesion originating elsewhere in the body

 Clinical manifestations
A.) Increased ICP - Symptoms of increase ICP result from a gradual compression of the brain by the enlarging tumor. - As the tumor grows, compensatory adjustments may occur through compression of intracranial veins, reduction of CSF volume, a modest decrease of cerebral blood flow & reduction on of intracellular & extracellular brain tissue mass .

 When these compensatory mechanism fail, the px develops signs & symptoms of increased ICP.

Three most common signs of inc. ICP

1. Headache - Most common early in the AM & is made worse by coughing, straining or sudden movement. - Headache describe as deep or expanding or dull. Frontal tumor - usually produce a bilateral frontal headache .

Pituitary gland tumors - produce pain radiating between the two temples (bitemporal). Cerebellar tumor - headache may be located in the suboccipital region at the back of the head. 2. Vomiting - usually due to irritation of the vagal centers in the medulla. If the vomiting is of forceful type, it is described as a projectile vomiting.

3. Visual disturbances - Papilledema (edema of the optic nerve) is present in 70% to 75% of patients and is associated with visual disturbances such as decreased visual activity, diplopia & visual field deficits.
B.) Localized Symptoms The most common focal or localized symptoms are hemiparesis, seizures and mental status changes.

Medical Management
1. Radiation Therapy 2. Brachytherapy 3. Surgery

Assessment & Diagnostics Findings

1. 2. 3. 4. 5. 6. CT Scan MRI Position Emission Tomography (PET) Scan Cerebral angiography Electroencephalogram (EEG) Cytologic studies of the CSF