Neoplasms of Genitourinary System

泌尿系肿瘤

Adenocarcinoma of the Kidney

（ Renal Cell Carcinoma, RCC, 肾细胞癌）

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

Etiology

• Cause: unknown

• Risk Factors:

• cigarette smoking,

• exposure to asbestos （石棉） and tanning （鞣革） products

Etiology

• RCC occurs in 2 forms:

• --inherited （遗传）： chromosome translocation, Von Hippel-Lindau disease

• --sporadic （散发）

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） .

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.

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.

Clinical Findings

• Symptoms & Signs• A. Classical triad——gross hematuria, flan

k 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

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↑,

Clinical Findings

• D. X-ray Findings:• *Ultrasonography• *Intravenous Urography (IVU): 75% accur

ate (used alone), calcification• *CT scanning: more sensitive, mass +ren

al hilum, perinephric space and vena cava, adrenals, regional LN and adjacent organs

• *Renal Angiography

IVU of right RCC

CT scan of right RCC

CT scan of left RCC

RCC invading renal vein

Left cystic RCC

Left cystic RCC

Differential Diagnosis

• Benign renal tumors:

• Angiomyolipoma （血管平滑肌脂肪瘤 , 错构瘤 )

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 )

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

Prognosis

• Stage 5-year survival rate

• I 88~100%

• II 60%

• III 15~20%

• IV 0~20%

Renal Pelvic Cancer

肾盂癌

• Incidence: rare, 3% of all urothelial cancers

• Pathology:

• transitional cell 90%

• squamous cell 10%

Clinical Findings

• A. Symptoms & Signs

• gross hematuria 70~90%

• flank pain 8~50%

• B. Lab Findings:

• hematuria, cytology (40% positive), tumor markers (BTA, NMP22)

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 )

IVU of right pelvic Ca

CT scan of right pelvic Ca

CT of right pelvic Ca

Treatment

• Standard therapy---nephroureterectomy ( 肾输尿管全长切除 )

• removal of the entire distal ureter with a small cuff of bladder

Bladder Carcinoma

膀胱癌

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

Staging: TNM System

Histopathology （组织病理学）• Transitional cell carcinoma （移行细胞

癌） 90%

• Nontransitional cell carcinoma: adenocarcinoma, squamous cell Ca, undifferentiated Ca

Clinical Findings

• A. Symptoms:

• hematuria 85~90%

• irritative voiding symptoms

• B. Signs:

• Majority of patients have no pertinent physical signs.

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）

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）

Ultrasonography of Bladder Ca

IVU of Bladder Tumor

CT scan of bladder Ca

Bladder Ca under cystoscopy

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

TUR of Bladder Tumor (TURBT)

After TUR

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%

Carcinoma of the ProstateCaP

前列腺癌

CaP

• The most common cancer in American men

• Increases rapidly with age

• 95% are adenocarcinoma

Clinical Findings

• A. Symptoms

• early stage: asymptomatic （无症状）• locally advanced/metastatic disease—ob

structive or irritative voiding complaints, bone pain, paresthesias （感觉异常） and weakness of lower extremities

• B. Signs: DRE—induration （硬结）

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

Clinical Findings

• D. Prostate biopsy （活检）• golden standard

• E. Imaging

• TRUS, MRI, Bone scan

Treatment

• 1. Localized disease

• (optimal form in great debating)

• Watchful waiting

• Radical prostatectomy （根治性前列腺切除）

• Radiation—external beam

Treatment

• 2. Locally advanced/metastatic diseases

• Endocrine therapy—complete androgen blockade : orchiectomy 睾丸切除 +antiandrogen agent (flutamide, 氟他胺 ) or LHRH agonist （类似物）

• Radiation

Thanks for your attention!