Neoplasms of Genitourinary System 泌尿系肿瘤

1. Neoplasms of Genitourinary System泌尿系肿瘤

2. Adenocarcinoma of the Kidney （ Renal Cell Carcinoma, RCC, 肾细胞癌）

3. RCC • In US(1999), 30,000 new cases diagnosed, 11,900 deaths from this disease • RCC accounts for 3% of adult cancers, 85% of all primary malignant renal tumors • RCC occurs most commonly in 5th~6th decade, male-female ratio 2:1

4. Etiology • Cause: unknown • Risk Factors: • cigarette smoking, • exposure to asbestos （石棉）and tanning（鞣革）products

5. Etiology • RCC occurs in 2 forms: • --inherited（遗传）：chromosome translocation, Von Hippel-Lindau disease • --sporadic（散发）

6. Pathology • RCC originates from the proximal renal tubular epithelium. • Types: • Clear cell type • Granular cell type • Mixed cell type • RCC is most often a mixed adenocarcinoma（腺癌）.

7. Tumor Staging (Robson System) • I: Tumor is confined within the kidney parenchyma. • II: Tumor involves the perinephric fat but confined within Gerota’s fascia (including the adrenal). • IIIA: Tumor involves the main renal vein/inferior vena cava.

8. Tumor Staging (Robson System) • IIIB: Tumor involves regional LN. • IIIC: Tumor involves both local vessels and LN. • IVA: Tumor involves adjacent organs other than the adrenal. • IVB: Distant metastases.

9. Clinical Findings • Symptoms & Signs • A. Classical triad——gross hematuria, flank pain, palpable mass (only in 10~15% advanced cases) • Symptoms secondary to metastatic disease: dysnea & cough, seizure & headache, bone pain • Renal tumors are increasingly detected incidentally by CT or ultrasound

10. Clinical Findings • B. Paraneoplastic Syndromes: • erythrocytosis（红细胞增多症）, hypercalcemia（高钙血症）, hypertension • C. Lab Findings: • anemia, hematuria(60%), ESR↑,

11. Clinical Findings • D. X-ray Findings: • *Ultrasonography • *Intravenous Urography (IVU): 75% accurate (used alone), calcification • *CT scanning: more sensitive, mass +renal hilum, perinephric space and vena cava, adrenals, regional LN and adjacent organs • *Renal Angiography

12. IVU of right RCC

13. CT scan of right RCC

14. CT scan of left RCC

15. RCC invading renal vein

16. Left cystic RCC

17. Left cystic RCC

18. Differential Diagnosis • Benign renal tumors: • Angiomyolipoma （血管平滑肌脂肪瘤, 错构瘤)

19. Treatment • 1. Localized disease: • Surgical removal---only potentially curative therapy • Radical Nephrectomy (en bloc removal of the kidney and Gerota’s fascia including ipsilateral adrenal, proximal ½ ureter, regional lymphadenectomy (淋巴结清扫)

20. Treatment • 2.Disseminated disease: • nephrectomy--- reducing tumor burden • radiation--- radioresistant tumor, metastases 2/3 effective • chemotherapy--- <10% effective • immunotherapy--- IL-2/interferon-alpha, 30% response rate

21. Prognosis • Stage 5-year survival rate • I 88~100% • II 60% • III 15~20% • IV 0~20%

22. Renal Pelvic Cancer 肾盂癌

23. Incidence: rare, 3% of all urothelial cancers • Pathology: • transitional cell 90% • squamous cell 10%

24. Clinical Findings • A. Symptoms & Signs • gross hematuria 70~90% • flank pain 8~50% • B. Lab Findings: • hematuria, cytology (40% positive), tumor markers (BTA, NMP22)

25. Clinical Findings • C. Imaging • IVU---intraluminal filling defect, unilateral nonvisualization of the collecting system, hydronephrosis • US, CT & MRI • Ureteropyeloscopy (肾盂输尿管镜)

26. IVU of right pelvic Ca

27. CT scan of right pelvic Ca

28. CT of right pelvic Ca

29. Treatment • Standard therapy---nephroureterectomy (肾输尿管全长切除) • removal of the entire distal ureter with a small cuff of bladder

30. Bladder Carcinoma 膀胱癌

31. Bladder Ca • The second most common cancer of the genitourinary system, male-female ratio 2.7:1 • Initiators/Promoters: • cigarette smoking • occupational exposure • genetic events

32. Staging: TNM System

33. Histopathology（组织病理学） • Transitional cell carcinoma（移行细胞癌）90% • Nontransitional cell carcinoma: adenocarcinoma, squamous cell Ca, undifferentiated Ca

34. Clinical Findings • A. Symptoms: • hematuria 85~90% • irritative voiding symptoms • B. Signs: • Majority of patients have no pertinent physical signs.

35. Clinical Findings • C. Lab tests: • urine test——hematuria • urinary cytology——depend on grade and volume of the tumor • other markers: BTA, NMP22, telomerase（端粒酶）

36. Clinical Findings • D. Imaging: • Ultrasonography—screen • IVU—evaluation of upper urinary tract • CT/MRI—assessment of the depth of infiltration and pelvic LN enlargement • E. Cystoscopy（膀胱镜）

37. Ultrasonography of Bladder Ca

38. IVU of Bladder Tumor

39. CT scan of bladder Ca

40. Bladder Ca under cystoscopy

41. Treatment • 1. Surgery • TUR (Trans-Urethral Resection) • Partial Cystectomy （膀胱部分切除） • Radical Cystectomy（根治性膀胱全切除） • 2. Radiotherapy

42. TUR of Bladder Tumor (TURBT)

43. After TUR

44. Treatment • 3. Intravesical Chemotherapy（膀胱内化疗） • molecular response • weight rate • Mitomycin C 329 39~78% • Thiotepa 189 up to 55% • Doxorubicin 580 mean 38% • BCG 36~71%

45. Carcinoma of the ProstateCaP 前列腺癌

46. CaP • The most common cancer in American men • Increases rapidly with age • 95% are adenocarcinoma

47. Clinical Findings • A. Symptoms • early stage: asymptomatic（无症状） • locally advanced/metastatic disease—obstructive or irritative voiding complaints, bone pain, paresthesias（感觉异常）and weakness of lower extremities • B. Signs: DRE—induration（硬结）

48. Clinical Findings • C. Tumor markers • PSA（前列腺特异抗原）Prostate Specific Antigen • < 4 ng/ml normal • 4 ~ 20 ng/ml Grey Zone • > 20 ng/ml highly suspect of PCa

49. Clinical Findings • D. Prostate biopsy（活检） • golden standard • E. Imaging • TRUS, MRI, Bone scan

50. Treatment • 1. Localized disease • (optimal form in great debating) • Watchful waiting • Radical prostatectomy（根治性前列腺切除） • Radiation—external beam