145 GU Neoplasms. Only the pieces you need to pass.

Hello and welcome to the Physician Assistant Exam Review Podcast. My name is Brian Wallace. I’m the host and creator here and today we’re going to be covering GU neoplasms.

All right, so we’re moving through the genitourinary system and we are making some headway. We’ve got three sessions left, this one and then two more the way that I see it. Well, one of the things I want you to notice as we go through the material here is that we’re not just focused on the content. No, no, no. We do far more than that. We’re focusing on how you see the content. We’re focusing on how you see the exams.

We do that so that you can study in a way that makes it so the material is there for you on test day. Everything we do is with the idea that you’re gearing up toward exams. Because like it or not, that’s the way that the system works. So, pay attention as we go through the material. And one thing I want to share is that as you go through GU neoplasms, the good news here is that you don’t really have to learn about treatments.

Now, why don’t you have to learn about treatments? What’s the issue? Well, it should be kind of obvious. Treatments plans for GU neoplasms are going to be radiation, chemotherapy, and surgery. You’re not going to get much else, right? So you’re not going to have to know the chemotherapy agents. They’re going to have to know anything more about radiation than that they need radiation.

Same thing with surgery. I started looking into surgeries and you start to find all the details about what type of surgery, muscle sparing versus taking the muscle and so on and so forth. But you don’t have to know any of that. You just have to know they’re getting surgery. That’s it. Same thing when we do musculoskeletal. You don’t need to know how to do a rotator cuff repair.

You don’t need to know how to do a total knee replacement. You just need to know what a rotator cuff tear looks like, how it presents, what imaging you get. Well, it’s the same thing here.

Now, if that line of thinking interests you, That’s the kind of thing we dive really deep into in the 33 Days to Pass the PANCE program. But I know that the next session isn’t until February 2026. And I’ve had a lot of people reaching out asking about it. And that’s kind of far away for some of you. The other thing is I know some of you feel like you can’t commit to the full 33 Days. That you might pay the money, sign up, and then not do the course. And that definitely happens.

We encourage you. We have the coaches there checking in on you, but I get that feeling. So one thing I’m doing to solve both of those problems is for Black Friday, for the first time, I’m releasing a PA student reboot program. It’s going to be three short sessions designed to give you the biggest impact I can give you in the shortest amount of time to reboot your studying, your approach to test taking, and your peak performance and anxiety management as it pertains to tests and exams. To get you ready for the next big exam. So that’ll be released on Black Friday. What I’m going to do is only make it available that weekend because we’re going to start the following Tuesday night.

Don’t worry, you don’t have to be there live. I’ll record everything. It’s better if you’re there live, but you don’t have to be. And it’s going to be three short sessions. But it’s only going to be, registration’s only going to be available Black Friday through Cyber Monday. And Black Friday’s going to be the lowest price you can possibly get, the lowest I’m ever going to do it. And then that’ll go up over the weekend.

So if you want to get in on that, and you want to see your scores go up, your anxiety go down, your amount of free time go up, your amount of sleep go up, all of those things, we’re going to see what we can do for you. But go to physicianassistantexamreview.com/blackfriday to get all that. Cool.

All right, let’s jump into today’s discussion on GU and neoplasms. We’ll start with our priming questions.

All right, you’ve got a painless testicular mass in a 25-year-old. What should your next step be? What’s the most important risk factor for bladder cancer? What’s the most important risk factor for bladder cancer? Which tumor type keeps AFP normal, seminoma or non-seminoma? Which tumor type keeps AFP normal? Seminoma or non-seminoma?

Penile cancer is most strongly associated with what viral infection? Penile cancer is most strongly associated with what viral infection? PSA may be elevated in prostate cancer, but also in what benign condition? PSA may be elevated in prostate cancer, but also in what benign condition?

All right, so hold on to those. Those are going to be like scaffolding, so you have places or hooks, places where you can store this information in your brain as we move through. We’re going to start with bladder cancer. This is a malignancy of the bladder urothelium. Most are urothelial. I’ve been out of school a little while, not exactly a pathologist these days. I always thought of this as transitional cell carcinoma.

That was what stood out to me. This is strongly linked to smoking and occupational chemical exposure. Most common presenting symptom is painless, gross hematuria. Risk factors are cigarette smoking, occupational exposure, like we just said, dyes, rubber, leather, chronic cystitis, or long-term catheter use can also be a risk factor. Cyclophosphamide therapy, which is a chemotherapy agent, is a risk factor for this because it causes hemorrhagic cystitis. Your clinical presentation, painless gross hematuria. So, you’re going to see the patients are going to come in complaining of blood in their urine.

Irritated voiding symptoms like frequency, urgency, dysuria, flank pain if there’s an obstruction, may or may not be present, but something to think about. Your question stem here is likely going to have something like an older smoker with new painless hematuria and no fever, right? That’s going to help us separate this out from our infectious causes. So keep that in mind. For diagnosis, you’re going to do urinalysis and see the hematuria. You can do urine cytology, which may show malignant urothelial cells. Cystoscopy with biopsy, this is your test of choice.

This is going to be diagnostic. You’re going to stick a scope in or have a urologist stick a scope in, look inside the bladder, and get a biopsy of the lesion. You can also do a CT urogram to look for upper urinary tract issues if needed. So treatment here is going to be referred to a urologist, right, for that cystoscopy and get a biopsy. Advanced disease may require surgery. And then you’re going to want to do ongoing surveillance because there’s a high recurrence rate. So here we have for our exam keys, which is a new section we’ve been doing for this, are an older male plus smoker plus painless hematuria equals bladder cancer until proven otherwise.

Diagnosis does require a cystoscopy with a biopsy and most are that transitional cell. Beautiful.

All right. Penile cancer is next. This is a rare malignancy of the penis, most commonly squamous cell carcinoma. Here’s one of the keys, though. It’s strongly associated with HPV infection and poor genital hygiene. Occurs more often in uncircumcised men and those with chronic foreskin inflammation. So our risk factors, kind of a little bit repeating here.

HPV infection, lack of circumcision, phimosis or chronic balanitis, smoking, HIV infection or immunosuppression. Clinical presentation. Persistent painless penile lesion, ulcer, red patch or fungating mass. It may have a foul odor, discharge or bleeding. You can get an inguinal lymphadenopathy in advanced disease. The question stem here is likely going to say something like an uncircumcised man with a non-healing painless penile ulcer or growth. For diagnosis, you’re going to see that physical exam.

You’re going to see that ulcer or that lesion. A biopsy is going to be next. And then you may do imaging for staging and lymph node evaluation. Treatment. Once again, we have referred to urology for biopsy and management. It may require a local excision and topical therapies. You could do a partial or total penectomy for advanced disease.

And our exam keys here are persistent painless penile lesion in an uncircumcised man. Think penile cancer first here, right? Most are squamous cell. Diagnosis is a biopsy. And our risk factors are that chronic foreskin inflammation.

Next, we have prostate cancer. This is most common non-skin cancer in men. It’s usually adenocarcinoma arising in the peripheral zone, and it’s often asymptomatic until late disease. Risk factors are increasing age, African-American race, family history, especially if you have a first-degree relative, and then a BRCA1 and BRCA2 mutations. Clinical presentation here, it’s usually asymptomatic because you’re not getting any symptoms early on, right? It may develop obstructive urinary symptoms, so you get a weak stream or hesitancy in later stages because that prostate has actually grown so large it’s compressing the urethra.

Now, in later stages, you get bone pain because of metastasis, especially spine or pelvis. I know someone who’s struggling with this now and they’re having trouble walking because the pain in their bones is so painful. That pain is so painful because the pain is so much. Here, your question stem is likely to describe an older man with an abnormal PSA on screening and no symptoms. That’s going to be more typical in your question stem. Could you get someone with bone pain and metastasis? Yes, absolutely.

That’s probably what you may see in your clinic, depending on what type of clinic you run. But your question stem is probably not going to have that. For diagnosis, it’s going to be a PSA, which is going to be elevated in most cases, but can also rise with prostatitis, BPH, or recent ejaculation. Digital rectal exam, you can feel a hard nodular asymmetric prostate, so you can actually feel perhaps those tumors. Diagnosis is confirmed with a transrectal ultrasound guided biopsy. And then you can move to a bone scan or CT if you’re looking for metastasis. Treatment, again, we’re going to refer to urology for biopsy confirmation and management.

Options include active surveillance. We can just watch it because some prostate cancer, and especially in older men, is so slow growing, it’s okay to watch, but others are more malignant. You can do radiation therapy. You can do a prostatectomy. And then there are also medications which are androgen blockers, especially for metastasis, that can slow down and alleviate some of the symptoms. Our exam keys here. An elevated PSA plus abnormal digital rectal exam is evaluated for prostate cancer.

Most cases are asymptomatic at diagnosis. That hard nodular prostate distinguishes it from that soft boggy prostate of prostatitis. And bone pain suggests metastatic spread.

All right, that moves us right through. Our next one for today is testicular cancer, but that’s going to be the end. There really isn’t a whole lot to this section. In fact, I think our next two sections are going to be a little bit shorter in nature. I don’t want to go too deep, spend too long, because I know it’s a lot to hold on to. So for testicular cancer, it’s a malignancy of the germ cells within the testis. It’s most commonly a solid tumor.

I’m sorry, it is the most common solid tumor in men 15 to 35. There are two main types, seminoma and non-seminoma. Let me just say for one second here that seminoma is a primitive germ cell. That’s where it’s coming from, so it’s slower growing, you get a normal AFP, and radiosensitive. Non-seminoma germ cell tumor is from a differentiated germ cell, so it’s more aggressive. AFP and HCG can often be elevated. They don’t have to be.

It could be one or the other, but they’re often elevated. And again, that non-seminomatous germ cell tumor is the one that’s more aggressive. The seminoma one has a slower growing, and the AFP is usually normal. Risk factors are cryptorchidism, family history, prior testicular cancer, Caucasian race, and Klinefelter syndrome. Clinical presentation, painless unilateral testicular mass. Heaviness or dull ache in the scrotum or lower abdomen. Gynecomastia, possible with hCG-producing tumors.

So, our question stem here would likely describe a young man with firm, painless testicular lump that does not transilluminate, because this is a solid. This is not a cystic mass. This is a solid mass, so it will not transilluminate. So, how are we going to diagnose this? What do you think? Before I get into it, just stop and think for a second. What’s going to be a good test to look for testicular cancer?

The ultrasound is going to be the winner here. You’re looking for a solid hypoechoic mass. Our tumor markers could be next. AFP, beta-HCG, LDH. Again, seminoma AFP would be normal. Non-seminoma would be AFP and or HCG could be elevated. We can follow that with a CT of the abdomen and pelvis, maybe even the chest staging after orchiectomy.

Here you’re not going to do a biopsy because there’s a risk of seeding the tumor and changing the lymphatic spread. So we’re going to be careful that we’re not going to biopsy so we’re just going to ultrasound and then go to surgery. Radical inguinal orchiectomy is diagnostic and therapeutic. So again, treatment, radical inguinal orchiectomy for all suspected cases. Seminoma, you can do radiation or chemotherapy based on the stage. On a non-seminoma, you’re going to do chemotherapy, possible retroperitoneal lymph node biopsies and dissections. And then there’s an excellent cure rate, even with metastasis for these.

Our exam keys, young men with painless testicular mass is testicular cancer till proven otherwise. Ultrasound is first, never biopsy these. A seminoma is radio-sensitive, normal AFP, non-seminoma AFP and HCG may be elevated, and it’s much more aggressive. No matter what, we’re doing a radical inguinal orchiectomy.

All right, we breezed through GU neoplasms. There’s a lot in there, but it’s not that much. I mean, like I said, you saw how all of the treatments are the same. Everything is the same. It’s really just refer to, refer to urology, biopsy. Except know the difference like in the testicular cancer. We’re not going to get a biopsy.

Know that it’s ultrasound. So know those diagnostics, but that’s the part that you need to know. That’s the part you need to know. Know that the non-seminoma is more aggressive, right? Know that the AFP is elevated in non-seminoma. I think that’s valuable because it’s so easy to test. It’s so easy to look for.

All right, our study tip for today. One thing I want to talk about, I’ve discussed this a lot with some faculty members. I talk a lot about active versus passive studying. And one of the big pushbacks I get, when I ask students to do more active studying, they’re worried about making mistakes. They’re worried about getting things wrong. So, when I say something like draw a diagram from memory, they’re like, what if I get it wrong? What if I hold on to that information?

Or if I say, why don’t you teach the material to your house plant or to your spouse, or to your partner, or to your roommate? They’re like, yeah, but what if I explain it wrong? What if I’m missing something? What if I forget something? What if I say something wrong? Won’t I remember it longer? And the answer is no.

The answer is emphatically no. You get so much more out of trying than you ever will out of not trying. Reading the right words that are correct every time out of a review book, not nearly as helpful as trying to drudge the information up out of your brain, even if it’s some of it’s wrong. That’s why we do practice questions. The ones I get wrong are the ones I remember.

Now, if no one ever points out your mistake, I get where you’re coming from, but then it wouldn’t matter anyway. So, in some things, it’s good to have someone check your work so they can say, oh, you got this one wrong. Oh, you left this blank. You didn’t label this part of the diagram. Or, oh, you labeled this wrong. Let me move it over here. Someone to look over that is great.

And that’ll make you hold on to it even longer. That’s not a problem. That’s not an error in studying. That is studying. I can’t stress that enough. I know it’s a concern. It was a concern for me when I was in school and it’s a concern when I talk to students now all the time.

Don’t let that bother you. Don’t let the fear of a mistake stop you from doing the work. That’s such good advice in general, but it’s great advice here. Practice, practice, practice. It’s what’s going to make it stick. Again, reading over a book because they have everything right isn’t going to help you. Fumbling along, making mistakes, screwing things up, and then putting the pieces back together is how we learn.

It’s so, so important. So, feel free to go to the whiteboard and do brain dumps and then review that brain dump and see what it looks like afterwards. Have a friend look at it. That’s how studying works. That’s how retention works. It works through pulling the information up. You know, I’ve seen studies that actually show that doing test questions before a lecture on the material that you’re about to learn improves long-term retention, even though obviously you’re going to get everything wrong.

But you’re building out the scaffolding, just like we do with the priming questions. I’m not asking you to get them right. We’re building them out on purpose. We’re building out those structures in your brain is what we’re doing. We’re not concerned with right or wrong, but I know we get so hung up on right or wrong. It’s one of the reasons why I don’t like doing practice questions on tutor mode because we get so hung up. Did I get it right or did I get it wrong?

It’s important to get them right. I understand that, right? And it seems silly for me to say it doesn’t matter. But that’s not the only thing. That’s not the only thing that matters. It’s also not relevant when you’re studying. You’re not expected to get everything right.

That’s okay. All right, let’s finish up with our priming questions. These should be pretty easy now. Painless testicular mass in a 25 year old. What should be your next step? Ultrasound. Scrotal ultrasound.

Most important risk factor for bladder cancer. This always stood out to me. I don’t know why this always was an easy one for me. Cigarette smoking. Which tumor type keeps AFP normal? Seminoma or non-seminoma? Seminoma.

Penile cancer is most strongly associated with what viral infection? HPV. PSA may be elevated in prostate cancer, but also in what benign condition? I don’t think I mentioned this in the notes, and we’ll get to it next week, I think, but it’s benign prostatic hyperplasia is going to be the other thing that can raise a PSA. Speaking of next week, we’re going to be wrapping up or getting near the end of GU. We’re going to cover the very exciting topics of penile disorders. We may do BPH and see how that goes.

Real quick before we sign off for today, I do want to remind you that on Black Friday, so next, not this coming Friday, but next Friday, I’m going to be releasing for the very first time, and perhaps the only time, the Physician Assistant Student Reboot Program. It’s going to be three short sessions where we’re going to hit it hard. We’re going to give you as much as we possibly can in an effort to get your, to reboot your studying. If you’re struggling there, if you find that you’re doing work but not making good progress, We’re going to reboot your test taking and give you some new approaches to that and ways to think about it so that if you aren’t getting the scores you think you deserve for the work you’re putting in, we’re going to solve that. And then lastly, we’re going to work on mindset and anxiety levels. Because if you’re not showing up to your exam, if it’s not you, if you’re blanking out, if you’re panicking, if your heart rate’s up to 112 and you can’t get the information out of your head onto the paper, well, all the rest of it doesn’t even matter. So we’re going to spend three days on those sessions.

We’re going to bang through it. Again, if you can’t make the live, don’t worry about it. I’m going to do them live because it’s so much more fun. But if you can’t make the live, it’s okay. If you can’t make the live, I’m going to have everything recorded for you. So it’ll be there and available.

All right. You can find out more about that at physicianassistantexamreview.com/blackfriday. You’re going to get the best possible pricing. The best price I’m ever going to offer on this will be on Friday. I’ll make it available through Monday, but then we get started on Tuesday. So that’ll close out as well.

All right. That’s it for me. I’ll talk to you soon. Talk to you next week. And for now, good luck on your exams. Let me know how they go. Take care.

We’ll see you next week. We’ll see you next time.