A 68-year-old man comes to the office due to intermittent, painless blood in his urine. He has no other symptoms. The patient uses transdermal testosterone for chronic hypogonadism and erectile dysfunction. He has smoked a pack of cigarettes daily for 40 years; he drinks 2 shots of vodka every day and 2 glasses of wine once a week. He works as an operations manager for a large beverage company and frequently travels to Mexico. Vital signs are within normal limits. Abdominal examination shows no abnormalities. On digital rectal examination, the prostate is smooth with no nodules. Urinalysis is positive for 50 red blood cells/hpf; there are no casts or dysmorphic blood cells. Urine cytology is positive for malignant cells. Renal ultrasonogram reveals normal kidneys. Which of the following is a major risk factor for this patient's current condition?

Question

A 68-year-old man comes to the office due to intermittent, painless blood in his urine.  He has no other symptoms.  The patient uses transdermal testosterone for chronic hypogonadism and erectile dysfunction.  He has smoked a pack of cigarettes daily for 40 years; he drinks 2 shots of vodka every day and 2 glasses of wine once a week.  He works as an operations manager for a large beverage company and frequently travels to Mexico.  Vital signs are within normal limits.  Abdominal examination shows no abnormalities.  On digital rectal examination, the prostate is smooth with no nodules.  Urinalysis is positive for >50 red blood cells/hpf; there are no casts or dysmorphic blood cells.  Urine cytology is positive for malignant cells.  Renal ultrasonogram reveals normal kidneys.  Which of the following is a major risk factor for this patient's current condition?

Quizplus · Accepted Answer

11ec160b_3a2e_8093_9249_3b4973a714d1_MD0001_00 This patient has intermittent, painless hematuria. His positive urine cytology and negative imaging of the upper urinary tract suggest a urothelial (transitional cell) cancer in the bladder. The lesions in urothelial cancer can be visualized on cystoscopy as erythematous flat, nodular, or papillary lesions. On biopsy, the malignant cells are pleomorphic with hyperchromatic nuclei, an increased nucleus/cytoplasm ratio, disrupted orientation and polarity (in relation to the basal membrane), and frequent mitotic figures. Depth of invasion is important for staging; invasion into the muscular layer is associated with a poor prognosis. Urothelial cancer is most common in patients age >60, with men affected more than women. Major risk factors include cigarette smoking and occupational exposure to rubber, plastics, or aromatic amine-containing dyes (eg, used in textile and leather processing). Cyclophosphamide therapy (eg, for lymphoma, autoimmune disorders) also increases the risk. (Choice A) Heavy alcohol intake is associated with increased risk of squamous cell carcinoma of the upper gastrointestinal tract (mouth, throat, esophagus) and hepatocellular carcinoma. The risk for bladder cancer is not significantly increased. (Choice B) The carcinogens implicated in urothelial cancer are not commonly encountered in the food and beverage industry. (Choice C) Testosterone therapy increases the risk for prostate cancer, which is often asymptomatic or discovered on evaluation for lower urinary tract voiding symptoms (eg, decreased force of stream, nocturia). Painless hematuria without voiding symptoms is more suggestive of bladder cancer. (Choice E) Schistosoma haematobium is a trematode endemic to Africa and the Middle East that causes chronic infection in the bladder and increases the risk for a variety of bladder malignancies (including transitional cell and squamous cell carcinoma). This organism is not common in Mexico. Educational objective: Major risk factors for urothelial cancer of the bladder include age >60, cigarette smoking, and occupational exposure to rubber, plastics, or aromatic amine-containing dyes. Cyclophosphamide therapy also increases the risk. __________ References: Epidemiology and risk factors of urothelial bladder cancer. (http://www.ncbi.nlm.nih.gov/pubmed/22877502)

A 68-Year-Old Man Comes to the Office Due to Intermittent