U rogenital Neoplasms

Urogenital Neoplasms

Liping Xie

Department of Urology, First Affiliated Hospital, School of Medicine, Zhejiang University

Renal Cell Carcinoma (RCC)

• RCC accounts for 2% to 3% of all adult malignant , 85% of all primary malignant renal tumors, is the most lethal of the urologic cancers

• Renal cell carcinoma (RCC) affects 38,000 individuals in the U.S. yearly, and 11,900 patients die of this disease

• RCC occurs most commonly in 5th~6th decade, male-female ratio 1.6:1


Etiology


• Majority of RCC occurs sporadically• Tobacco smoking contributes to 24-30% of RCC cases

- Tobacco results in a 2-fold increased risk • Occupational exposure to cadmium, asbestos, petroleum• Obesity• Chronic phenacetin or aspirin use • Acquired polycystic kidney disease due to dialysis results

in 30% increase risk

• 2-4% of RCC associated with inherited disorder * Von Hippel-Lindau disease

- familial cancer syndrome of retinal angiomas, CNS hemangioblastomas, pheochromocytomas and clear cell RCC.

* Hereditary papillary renal cancer

- Multiple, bilateral papillary renal tumors , C-met oncogene on ch 7

* Birt-Hogg-Duke syndrome

- Fibrofolliculomas, lung cysts, and RCC, Mutation in BHD gene ch 17p


Etiology

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.


Clinical Findings

Symptoms & Signs Renal tumors are increasingly detected incidentally

by CT or ultrasound

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


Clinical Findings

B. Paraneoplastic Syndromes• Erythrocytosis, hypercalcemia, hypertension

C. Lab Findings• anemia, hematuria (60%), ESR↑


Clinical Findings

B. Paraneoplastic Syndromes• Erythrocytosis, hypercalcemia, hypertension

C. Lab Findings• anemia, hematuria (60%), ESR↑


Clinical Findings

D. Imaging• Ultrasonography• Intravenous Urography (IVU): • CT scanning: more sensitive, mass+renal

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

• Renal Angiography• MRI: to evaluate collecting system and IVC

involvement


Diagnosis

• No screening for the general population• No bio-marker available• Radiographic evaluation


IVU of right RCC


CT Scan of Left RCC


RCC invading renal vein

Righ Cystic RCC

CT scan with 3D reconstruction


Neovascularity in Renal Angiography

associated with RCC

A, Magnetic resonance scan of kidneys without administration of gadolinium suggests anterior right

renal mass.

B, After intravenous administration of gadolinium-labeled

diethylenetriaminepentaacetic acid, MRI shows enhancement of this mass

indicative of malignancy.


Tissue Diagnosis

• Tissue diagnosis obtained from nephrectomy or biopsy


Papillary (chromophilic) renal cell carcinoma extending into the collecting

system with histological findings

Tumor Staging (Robson System)


Tumor Staging (International TNM Staging System)


Tumor Staging


Differential Diagnosis

• Benign renal tumors

-Angiomyolipoma


• Renal Pelvis Cancer

Treatment

A. Localized disease:• Surgical removal---only potentially curative therapy

• Radical Nephrectomy (en bloc removal of the kidney and Gerota’s fascia including ipsilateral adrenal, proximal ureter, regional lymphadenectomy



Laparoscopic Radical NephrectomyHand-Assisted Laparoscopic

Radical Nephrectomy

TreatmentA. Localized disease:• Partial Nephrectomy(nephron-sparing surgery, NSS )

--polar tumor

--tumor size<4cm

--bilateral RCC

--solitary kidney


Laparoscopic NSS

TreatmentA. Localized disease:• Percutaneous/

Laparoscopic Radiofrequency Ablation or Cryoablation


Laparoscopic Cryoablation

Treatment

B. Disseminated disease:• nephrectomy--- reducing tumor burden• radiation--- radioresistant tumor, metastases 2/3

effective• chemotherapy--- <10% effective• immunotherapy--- IL-2/interferon-alpha, 30% response

rate• molecular therapy---eg. sorafenib


Prognosis

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

Bladder Cancer

The second most common cancer of the genitourinary system (most common in China)

The male-female is 2.7:1

The peak incidence is in persons from 50-70 years

Bladder Cancer

Industrial toxins Cigarette smoking Genetic events Other risk factors

cyclophosphamide, alkylating agents,

radiotherapy of pelvis.

Bladder Cancer

Etiology

Pathology

Histopathlogy 1.transitional cell carcinoma 90% 2.squamous cell carcinoma 7-8% 3.adenocarcinoma 1-2% 4.other types Grading Grade 1 mild anaplasia Grade 2 moderate anaplasia Grage 3 marked anaplasia

Bladder Cancer

Clinical Findings

A. Symptoms:• Painless Hematuria 85~90%• Irritative voiding symptoms

B. Signs:• The majority of patients have no pertinent

physical signs.

Bladder Cancer

Clinical Findings

C. Lab tests:• Urine test——hematuria• Urinary cytology——depend on grade and

volume of the tumor• Other markers: BTA, NMP22, telomerase

Bladder Cancer

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

Bladder Cancer

Diagnosis

Ultrasonography can be used as screening method to detect bladder tumors and upper urinary tract obstruction.

both CT and MRI are used to characterize the extent of bladder wall invasion and detect enlarged pelvic lymph node.

Bladder Cancer

Diagnosis

Cystoscopy

the diagnosis of bladder cancer depends on cystoscopy.

cystoscopy can provide good information on the extent of the tumour.

suspicous areas can be biopsied.

Bladder Cancer

Ultrasonography of Bladder Ca (Arrow Head)

Bladder Cancer

IVU of Bladder Tumor

CT scan of bladder Ca

Bladder Cancer

Bladder Cancer

Cystoscopy of bladder Ca

Bladder Cancer

TNM Tumor Staging

Bladder Cancer

TNM Tumor Staging

Treatment Superficial bladder cancer (Ta,T1,Tis) transurethral resection intravesical chemotherapy or immnotherapy(BCG) cystoscopic surveillance

Bladder Cancer

Treatment

Invasive bladder cancer (T2-T4) partial cyctectomy solitary, inflitrating tumors localized along the posterior lateral

wall or dome of the bladder. radical cystectomy 1.muscle-invasive bladder cancer T2-T4a, N0-NX, M0. 2.high-risk superficial

tumours (T1G3, BCG-resistant Tis) 3.extensive papillary disease Urinary diversion after radical cystectomy

Bladder Cancer

partial cyctectomy

Bladder Cancer

Bladder Cancer

Radical Cystectomy

Treatment

Radiotherapy Modern 3D-radiotherapy is a reasonable treatment option in

patients who wish to preserve their bladder

Chemothery

chemothery for metastatic disease.

adjuvant chemotherapy

Neoadjuvant chemotherapy

Bladder Cancer

Prostate Cancer

• The most common cancer diagnosed and is the second leading cause of cancer death in American men

• the incidence of prostate cancer is continuously increasing each year in china

• The incidence increases with advancing age

Prostate Cancer

Risk factor

• Age• Genetic influences

Race － African Americans are at a higher risk than whites

• Positive family history • High dietary fat intake • Hormonal factors

androgen dependence Others

Prostate Cancer

Pathology

• Over 95% of the cancers of the prostate are adenocarcinomas.

• Prostatic intraepithelial neoplasia (PIN)

high grade (HGPIN)

low grade (LGPIN)

Prostate Cancer

Prostate Cancer

Mostly arise from the peripheral zone of the

gland

Grading

• the Gleason system is widely used for its best clinical correlation

Prostate Cancer

Staging

Prostate Cancer

• Stage I small foci of carcinoma in resection for benign disease

• Stage II disease confined to prostate• Stage III extracapsular extension• Stage IV regional lymph node metastases or distant

metastases

The TNM staging system

Prostate Cancer

Clinical Findings

A. Symptoms• Early stage: asymptomatic• Locally advanced/metastatic disease—

obstructive or irritative voiding complaints, bone pain, paresthesias and weakness of lower extremities

Prostate Cancer

Clinical Findings

B. Signs: • Digital rectal examination—induration

Prostate Cancer

Clinical Findings

C. Tumor markers

Prostate Specific Antigen (PSA)

• < 4 ng/ml normal

• 4 ~ 10 ng/ml Grey Zone

• > 10 ng/ml highly suspect of PCa

Prostate Cancer

Clinical Findings

D. Imaging• Ultrasonography － hypoechoic lesion

Transrectal ultrasonography (TRUS)• CT, MRI• Bone scan

Prostate Cancer

Clinical Findings

E. Prostate biopsy• The golden standard

Prostate Cancer

MRI of prostate cancer

Prostate Cancer

Bone scan

Prostate Cancer

Treatment

A. Localized disease• Watchful waiting, older patients with samll,

well-differentiated cancer• Radical prostatectomy, patients with a life

expectency > 10 years• Radiation

Prostate Cancer

Radical ProstatectomyProstate Cancer

Prostate Cancer

Treatment

B. Locally advanced/metastatic diseases• Endocrine therapy—androgen blockade :

orchiectomy

antiandrogen agent

LHRH agonist• Radiation• Chemotherapy

Prostate Cancer

Further Reading

Renal Pelvis Cancer / Tumor of Ureter

Penile Cancer

Testicular Cancer

Further Reading

Thank you for your attention !

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U rogenital Neoplasms