Prostate cancer: diagnosis and management strategy
A 60-year-old male presenting with frequent urination, hesitancy, and a feeling of incomplete bladder emptying against the background of chronic cystitis requires a sequential workup. The first step is cystoscopy to evaluate the condition of the urinary bladder. If prostate pathology is suspected, pelvic MRI is ordered; imaging of the prostate and the urinary bladder is performed separately because the contrast agent accumulates differently in these organs.
If signs of a malignant tumor are detected, a prostate biopsy is performed. A mandatory first step when prostate cancer is suspected is a blood test for PSA—in the discussed case, the level was 175 ng/mL, which clearly indicated an oncological process.
- In the presence of bone pain unresponsive to neurological treatment, it is advisable to perform an osteoscintigraphy to rule out metastatic involvement.
- For a solitary symptomatic bone metastasis, radiation therapy is applied to the lesion to destroy it and reduce symptoms.
- In a young patient with a single metastasis, docetaxel chemotherapy (approximately 6 cycles) is possible, followed by response assessment and irradiation of regional areas and the prostate upon a complete response.
Concomitant cancer: prostate and urinary bladder cancer
In a 59-year-old male presenting with dysuria, an enlarged nodular prostate on digital rectal examination, and bone pattern changes in the pubic and ischial bones on X-ray, the algorithm includes determining PSA, followed by MRI. If bone structure changes are identified on the X-ray, a confirmatory study (bone scan or CT) is mandatory, as radiography has insufficient diagnostic accuracy and cannot reliably differentiate metastases from osteoporosis or the sequelae of old fractures.
If a filling defect with irregular contours is detected on a cystogram, cystoscopy with biopsy is necessary to verify the process. In the discussed case, concomitant ulcerating urinary bladder cancer was identified. The strategy for managing two concurrent tumors depends on the histological type and depth of invasion:
- Combined irradiation of the prostate and urinary bladder is possible only if there is a squamous cell component in the urinary bladder tumor, as squamous cell carcinoma responds better to radiation therapy, unlike the more typical transitional cell carcinoma.
- For superficial bladder lesions, transurethral resection (TUR) is performed, while radiation therapy to the prostate is temporarily deferred to avoid additional bladder injury.
- A combination of LHRH analogue hormone therapy for the prostate and chemotherapy (approx. 6 cycles) for the bladder is permissible—simultaneous treatment of two cancer locations is not contraindicated.
Renal cell carcinoma: from incidental finding to metastatic disease
A 52-year-old female presenting with acute flank pain, hematuria, weakness, loss of appetite, and a 5 kg weight loss over 3 months, with a positive Pasternatsky sign and a palpable supraclavicular lymph node, undergoes abdominal CT. A 10x7 cm right kidney mass invading the pelvicalyceal system was revealed, along with liver lesions and an affected lymph node—signs of a metastatic process.
If metastasis is suspected, a biopsy is preferred over nephrectomy: clear cell renal cell carcinoma is histologically confirmed. Supraclavicular lymph node biopsy is mandatory to rule out a second primary tumor (e.g., breast cancer metastasis). Treatment is combined: if resectable, cytoreductive nephrectomy is possible, but systemic therapy (targeted therapy or immunotherapy) is required in any case due to the presence of distant metastases.
In contrast to this case, a 45-year-old female with an incidental left renal mass 2 cm in diameter discovered on ultrasound was found on CT to have a lesion with smooth, clear margins and minimal central contrast enhancement—angiomyolipoma, a benign tumor that does not require removal if small and asymptomatic.
Non-oncological pathology in the practice of an oncourologist
It is important to be able to differentiate oncological and non-oncological causes of similar symptoms. A 55-year-old female with hematuria, flank pain, and a positive right costovertebral angle tenderness sign showed no renal mass on ultrasound, but a calculus was found between the renal pelvis and ureter—the cause of hematuria and pain is urolithiasis, a non-oncological disease requiring urological monitoring.
A 34-year-old male working in aniline dye manufacturing, presenting with frequent urination and lower abdominal pain, with microhematuria (8 red blood cells per high-power field), has a history of aniline dye contact, which is a well-known risk factor for urinary bladder cancer. Cystoscopy revealed cauliflower-like lesions, and MRI showed invasion into the perivesical tissue. Histologically confirmed transitional cell carcinoma with invasion into the muscular layer. The strategy in a young, functionally preserved patient involves neoadjuvant therapy followed by an attempt at organ-sparing surgical treatment and reservoir creation to preserve quality of life.
Rare localizations and primary metastatic tumors
Penile cancer is a rare pathology, predominantly squamous cell in histology, occurring mainly in elderly men. Squamous cell carcinoma of this site responds poorly to chemotherapy; surgical removal (partial or total) and mandatory evaluation of inguinal lymph nodes are preferred due to the high risk of regional metastasis.
Special attention should be given to situations where a tumor of one location invades a neighboring organ—for example, rectal adenocarcinoma invading the prostate. Treatment in such cases is determined by the primary tumor location, and in cases of extensive disease spread, treatment begins with neoadjuvant chemotherapy to reduce tumor volume prior to the surgical stage.
It is fundamentally important to distinguish between the following concepts:
- Primary metastatic tumor: the location of the primary lesion that has already given distant metastases is known.
- Tumor of unknown primary origin: only metastases are detected without an established primary site; gastrointestinal origin is often suspected.
In both cases, the patient does not go untreated: morphological verification of an accessible lesion is performed, and therapy covering the most likely sites is selected. Treatment continues until disease progression or intolerable toxicity develops, even after multiple prior lines of therapy.
Key points
- When prostate cancer is suspected, the first mandatory investigation is a blood test for PSA.
- Pelvic MRI in men requires separate evaluation of the prostate and urinary bladder due to different contrast uptake kinetics.
- Bone pain unresponsive to neurological treatment requires ruling out metastatic disease using bone scintigraphy.
- Solitary symptomatic bone metastases are subject to local irradiation; with a favorable response, radical treatment is possible.
- The coexistence of two oncological diseases does not preclude combined treatment for each location.
- Any suspicious lesion (lymph node, mass) must be morphologically verified to rule out a second primary tumor.
- Renal angiomyolipoma is a benign incidental finding that does not require intervention if small.
- Contact with aniline dyes is a significant occupational risk factor for urinary bladder cancer.