Pattern of urological malignancies in 2010 – an audit from a tertiary referral centre

Cancer is a major public health problem worldwide. Among various types of malignancies, genitourinary malignancies, except testicular cancer are notorious for causing high mortality and morbidity. Currently, 1 in 4 deaths in the United States is due to cancer. In USA, prostate cancer is the commonest cancer in men and accounts for the second commonest cause for the cancer death in men (1). Patterns of these cancers are variable according to time, region, and ethnic groups. We conducted an audit on the incidence of urological malignancies in a single urological unitat the National Hospital of Sri Lanka.

In this study, bladder cancer was the commonest urological malignancy accounting for 42.10% of all the cases.Their median age was 67.5 years (range 50 -90) and the male to female ratio was 3.7:1 (Table 1).Three fourth of them had painless or painful macroscopic haematuria at presentation (Table 2).More than half of the patients had their serum PSA >60 ng/l.

Site of malignancy
All nine cases of renal cell carcinoma were clear cell variety except one being chromophobe.Their mean age at presentation was 57.4 years (53-72) and male to female ratio was 9 to 1.Six patients had macroscopic haematuria at presentation while two cases were detected incidentally.According to the TNM classification, there were 3,4 and 2 of pT1, pT2 and pT3a respectively. No

Table 4. Clinicopathological presentation of prostate carcinoma
There was one testicular cancer in a 20-year old man which presented as a testicular mass and it was classic seminoma stage 1.
Out of two penile cancers, one presented as phimosis while the other was detected during follow up for benign penile lesion.Both were histologically well differentiated and pathological stages were pT2 and pT1a.

Discussion
According to the 2010 cancer statistics, the commonest noncutaneous malignancy in USA men is carcinoma of the prostate accounting for 25% of all cancers and is the second commonest cause of cancer death i.e. 11% of all cancer death.Urinary bladder cancer, kidney and renal pelvis cancers are the 4th and 7th leading cancers in men respectively.Kidney and renal pelvis malignancy is the commonest urological malignancy in female and is the 8th leading cancer (1).According to the cancer statistic data 2005, prostate cancer, being 8th leading cancer (5% of all cancers), is the only urological malignancy included among the first ten leading cancers in Sri Lanka (2).
In our study, number of Pca was slightly less than that of bladder cancer.As the PSA based screen detected Pca is not included, actual number of Pca would be much greater.
In USA, Pca incidence in 2005 was 170 per 100000 population (3,4).In Sri Lanka it was 3.1 in the same year (2).Worldwide, it is the fourth commonest male malignancy with great variation between countries and ethnic groups, Asia having the lowest incidence rate (1.9 cases per 100000 populationper year in Tianjin, China) while African-American having the highest (172 cases per 100000 populationper year) (5).Reason for such diversity would be due to access to and quality of health, accuracy of cancer registries and penetrance of PSA screening, environmental and genetic predisposition.Over the five year commencing from 2001 to 2005, Pca incidence has fluctuated in Sri Lanka (250,297,259,273,303 respectively) (2).In our study, all cases were advanced stage at diagnosis.Three patients presented with distantmetastases (one with hemiparesis following brain metastases and two with vertebral metastases).Two patients presented with unilateral lower limb lymphoedema indicating regional lymph node involvement.
The number of bladder cancers is slightly higher than that of prostate cancers in our study (32 vs 31).Similar study performed in the same unit for two year period from January 1994 to December 1995 shows higher incidence of bladder cancer (88 vs 62) (6).According to the Sri Lanka Cancer Registry, incidence of bladder cancer is much lower than that of prostate cancer (2) (Table 7).This difference is due to the fact that bladder cancer is a lmost exclusively ma naged by the urological surgeons at the start of the treatment while other cancers such as cancer of the prostate and kidney are predominantly managed by the general surgeons in Sri Lanka (6).
At presentation, approximately 75-85% of all patients with bladder cancer have non-muscle invasive disease, an almost similar finding (75%) in our study also (7).However, the largest bladder cancer study performed in Sri Lanka shows that muscle invasive disease at presentation is seen in nearly half of the patients (8).

Table 1 . Age and sex distribution
PATTERN OF UROLOGICAL MALIGNANCIES IN 2010

Table 3 . Histological type, grade and pathological stage
*Moderately differentiated

Table 2 . Clinical presentation of bladder cancer and number of patients
Histological type, grade and pathological stage of bladder cancers are shown in Table3.Out of 23 cases of nonmuscle invasive transitional cell carcinoma (TCC), 14 were low grade.All muscle invasive cancer in this study were high grade.There were two pure squamous cell carcinoma, one TCC with squamous differentiation and one sarcomatoid tumour in the study.Prostate carcinoma was the second commonest malignancy.The median age at presentation was 70.7 years (54-84).While the commonest presentation was lower urinary tract symptoms (18 cases) acute urine retention was the second commonest (5 cases).All patients with prostate carcinoma presented with locally advance disease except three patients who presented with symptoms of distant metastases.Histologically all were small acinar type adenocarcinoma except one case of papillary TCC.The Gleason sum score was 8 or more in 20 patients (64.5%).