Urologic Tumor

7/27/2019 Urologic Tumor

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BPH

Benign prostatic hyperplasia


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BPH develop in periurethral transitional zone ***

3 zones of prostate

1. periurethral transitional zone

2. central zone

3. peripheral zone


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Incidenceautopsy -> BPH

20% of 41-50 yr

50% of 51-60 yr>90% of >80 yr

LUTS symptom

25% of 55 yr50% of 75 yr

*****BPH is diagnosis in men > 50 year old


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Pathology

- increase in cell number

- nodular growth pattern that is compose of

stroma** and epithelium(gland)**

(stroma is compose of collagen and smooth muscle)


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gland stroma BPH


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Pathophysiology

1.Bladder outlet obstruction

stroma -> dynamic obstruction

glandular -> mechanical obstruction

2.Bladder M. :

-> detrussor instability,comliance,contractility


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Clinical= lower urinary tract symptom

obstructive symptom :**

hesitancy, straining,poor stream, intermittency,

terminal dribbling,

incomplete emtying sensation

irritative symptom : frequency, urgency, nocturia


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Clinical (complication)

1. urinary retention

2. UTI

3. hematuria

4. vesical calculi formation

5. renal deterioration


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Differential diagnosis

1. phimosis

2. meatal stenosis

3. urethral stricture

4. prostate cancer***

5. bladder cancer

6. other : dysfunctional bladder, parkinsonism,

spinal cord injury, prostatitis, multiple sclerosis


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History -> International prostatic symptom score (IPSS)

Sense of incomplete emptying 05

Frequency 0

5

Urgency 05

Straining 05

Poor stream 05

Intermittency 0

5

Nocturia 05

Diagnosis


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History -> International prostatic symptom score (IPSS)

Total score 035

Mild symptoms 07

Moderate symptoms 819

Severe symptoms 20 - 35


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Physical examination

abdomen

digital rectal exam (DRE)

genitalia

Investigation

PSA (normal < 4 ng/ml)

BUN/Cr

UAplain KUB


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Treatment

1. watchful waiting (mild symptom)

2. medical Tx ***

A. 1-blocker** : relieve dynamic obstruction

doxazosin, alfuzosin,

tamsulosin (selective 1a-blocker)

B. 5-reductase inhibitor**

Testosterone(T) ----- dihydrotestosterone(DHT)

5-reductase


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3. surgical treatment

A. TUR-P***(gold standard Tx)

B. TUI-P* (for small prostate)

C. open prostatectomy**- suprapubic prostatectomy

- retropubic prostatectomy

other

: thermotherapy (microwave), laser, transurethral needleablation, high intensity focused ultrasound, urethral stent


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TUR-P : transurethral resection of prostate


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Retropubic prostatectomy


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Transitional Cell Carcinoma (TCC)

TCC of upper tract (renal pelvis and ureter)

TCC of bladder


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Etiology

cigarette***

occupational expose: aromatic amine,aniline dye, benzidine

cyclophosphamide***(cytoxan)


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Occupation (increase risk)

- textile worker

- dye worker

- tyre rubber and cable worker- petrol worker

- leather worker

- shoe manufacturer and cleaners

- painter

- chemical worker


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Normal bladder TCC


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TCC of urinary tract

1.carcinogen***

2.seeding***

3.multifoci***

4.field change***


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TCC of upper tract

Risk of other tumors

65-70% of ureteric tumors occur in distal 1/3

of ureter

50% multicentricity of ureteric CA

1% risk of bilateral upper TCC


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TCC of the upper tract

Risk of other tumors

2-4% risk of contralateral upper TCC

30-50% risk of developing bladder CAwhen have upper TCC

5% of bladder CA pt have upper TCC


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Clinical

hematuria***(most common) 60-80%

flank pain


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Bleeding from upper tract


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Investigation

- urine cytology (if + of malignant cell = high grade)

- IVU = filling defect

- cystoscopy and retrograde pyelography- ureterorenoscopy (URS)

- CT scan


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IVP


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TNM Classification (1997)T-Primary tumor

Tx = 1ry tumor cannot be assessed

T0 = no evidence of 1ry tumor

Ta = non-invasive papillary ca

Tis = carcinoma in situ

T1 = tumor invades subepithelial connective tissue

T2 = tumor invades the muscularis


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T3 = (renal pelvis): tumor invades beyond muscularis into

peripelvic fat or renal parenchyma

T3 = (ureter):tumor invades beyond muscularis into

periureteric fat

T4 = tumor invades adjacent organs or through kidney

into perinephric fat


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N-Regional Lymph Nodes

Nx = regional lymphnodes cannot be

assessed

N0 = no regional lymphnodes metas.

N1 = metas. in a single LN


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M-Distant Metastases

Mx = Distant metastases cannot be assessed M0 = no distant metas.

M1 = Distant metastases present


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TCC of the upper tract

Overall 5-year Survival

Stage 5-yr. survival

T1 or lower = 90-100% T2 lesion = 40-80%

T3 lesion = 15-30%

Metastatic = 5%


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Treatment

1. nephroureterectomy (with bladder cuff excision) :

TCC of renal pelvis, high grade TCC of ureter

2. endoscopic management

ureteroscopic resection

percutaneous nephroscopic resection

: for T1-2, grade1-2 of ureter

3. segmental ureterectomy


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Endoscopic treatment


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TCC of bladder

Carcinoma of bladder

> 90% = TCC**

5% = squamous cell CA

associated with chronic irritation

Schistosoma haematobium

1-2% = adenocarcinoma (urachal remnant)


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EPIDEMIOLOGY

6.2 % of all adult malignancy in male (4th)

2.5 % of all adult malignancy in female (8th

)

Male : female = 2.5 : 1

Any age : -> median age 69 years old in male and 71 years old in

female


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Papillary tumor


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Primary tumor (T)

Tis carcinoma in istu

Ta noninvasive papillary carcinoma

T1 tumor invades subepithelial connective tissueT2a tumor invades superficial muscle (inner half)

T3 tumor invades deep muscle or perivesical fat

T3a tumor invades invades deep muscle (outer half)

T3b tumor invades perivesical fat

T4 tumor invades adjacent organ


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Tis

Ta

T1

T2

Superficial cancer(non muscle invasion)

Muscle invasive cancer


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Finding

superficial cancer muscle invasive CA

Pedunculated, narrow base

Papillary lesionVelvet -> = CIS

Solid tumorSessile tumor


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Clinical

- painless hematuria** (most common)-> should be regarded as indicative of a CA bladder

until proven otherwise

- urinary retention


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Investigation

- urine cytology

- IVP- cystourethroscopy


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Treatment

1st -> TUR-BT

2nd pathology

I. superficial cancer -> BCG** intravesical

-> Mitomycin-C intravesical

-> follow up cystoscopy, IVP

Superficial cancer

Invasive cancer


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II. Invasive cancer (> T2)

CT scan Radical cystectomy+ileal conduit+neobladder

Localise T2

>T3

metastasis Chemo therapy

Palliative radiation


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Testicular tumor

Germ cell tumor > 95%**

Non germ cell tumor 5%


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Epidemiology

most common neoplasm in young adult(20-35 yr)***

2-3 / 100,000

Testicular cancer is the most curable urological malignant tumor **


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Pathophysiology

~95% = germ cell tumor

Germ cell tumor

1. seminoma ~45%

2.nonseminoma

20-30%

Embryonal cell carcinoma

teratoma

ChoriocarcinomaYolk sac tumor

40% = mixed germ cell tumor

Non germ cell tumor -> the most are benign tumor


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Clinical

- painless scrotal mass

- abdominal mass (tumor of intra-abdominal testis)


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Cause/risk factorcryptorchidism***

gonadal dysgenesis (intersex who has Y chromosom)

Spreadinglymphatic -> para-aortic LN

-> paracaval LN

hematogenous (lung, liver) * choriocarcinoma


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Tumor marker

-hCG (choriocarcinoma)

-FP (embryonal cell carcinoma, yolk sac tumor)

LDH

Seminoma - rarely elevate -hCG (10%)

- never elevate -FP


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Treatment

1st radical orchiectomy

(transinguinal orchiectomy)

2nd staging CT scan, CXR, tumor marker

Seminoma/regional spread -> radiation regional LN

Nonseminama/regional spread -> retroperitonealnode dissection

Advanced disease -> chemo therapy


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wilms tumor

Arising from embronic nephrogenic tissue

Ussually discovered during the first 4 yrs. of life

Clinical

- abdominal mass- deterioration well being

- pyrexia

- hematuria


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Metastatic

lung ,liver,bone

Imagingultrasonography

CT

= solid tumor in the kidney


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Treatment

nephrectomy ,followed by radiation + chemo Tx

partial nephrectomy :in patient with bilateral disease


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Renal tumors

Benign = incidental finding

e.g.. Cyst, adenoma, angiomyolipoma

Malignancy

e.g.. renal cell carcinoma, transitional cell carcinoma, metastasisfrom other cancer


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RENAL CELL CARCINOMA

Adenocarcinoma, Renal carcinoma, Grawitzs

tumour, Hypernephroma, Nephrocarcinoma, Clear

cell carcinoma


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Renal cell carcinoma

RCC; clear cell CA; hypernephroma

Incidence = 3% of all adult CA

Age = 4th-6th decades

Male: Female ratio = 2:1 Origin: commonly proximal convoluted tubular

epithelium


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Common site of metas:

Lung 75%, Bone 20%, Liver 18%

LN : hilar ,para-aortic

Prone to grow into renal vein**


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Presentation

Pain

Hematuria ~50% of pts. flank mass, usually incidental finding

Classical triad:

pain + hematuria + flank mass**

present in


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Presentationparaneoplastic syndrome

- fever,wt loss, liver dysfunction

- erythrocytosis (erythropoietin)

- hypercalcemia (calcitonin),(bone met.X)

- nonmetastatic hepatic dysfuntion- hypertension (renin)

drowsiness -> hypercalcemia

bone pain -> bone met.

leg edema -> IVC involvement

varicocele -> renal vein involvement


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Investigation

- IVP- U/S (confirm cystic or solid tumor)

- CT


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Tx = tumor cannot be assessed

T0 = no evidence of 1ry tumor T1 = tumor < 7cm limited to kidney

T2 = tumor > 7cm limited to kidney

T3 = tumor extends into major veins or invades adrenal gland orperinephric tissues, but not beyond Gerota's fascia


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T3a = tumor directly invades adrenal gland or perinephric

tissues, but not beyond Gerota's fascia

T3b = tumor grossly extends into renal vein (includes segmental

branches) or vena cava or its

wall below diaphragm

T3c = tumor grossly extends into vena cava or its wall above

diaphragm T4 = tumor invades beyond Gerota's fascia


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N-Regional Lymph Nodes

Nx = regional lymphnodes cannot be

assessed

N0 = no regional lymphnodes metas.

N1 = lymphnodes metas. in a single

regional lymphnode

N2 = metas. in more than a single

regional lymphnode


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M-Distant Metastases

Mx = Distant metastases cannot be

assessed M0 = no distant metas.

M1 = Distant metastases present


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Treatment1.localized tumor

1. radical nephrectomy (standard Tx)

2. partial nephrectomy (tumor


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Left renal tumor


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Carcinoma of prostate


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3 zone

1.transitional zone

2.central zone

3.peripheral zone


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Usually originate in the peripheral zone***

Common malignant tumor in the USA

Uncommon in Japan and China

Incidence increase with age


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Pathology

- adenocarcinoma

- grading system: Gleason pattern(1-5) -> ->

Gleason sum (2-10)


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Spreading

- direct invasion : seminal vesicle ,bladder neck,

sphincter

- lymphatic invasion : pelvic LN- vascular invasion : bone*** -> pelvic bone ,lower

lumbar vertebrae

*** osteoblastic lesion 75%


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Bony metastasis


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Clinical

early = symptomless

incidental found following TUR-P ,DRE

advance = symptom

BOO ,urinary retention

pelvic pain

hematuriabone pain

renal failure


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Diagnosishistory and PE (DRE -> nodule ,stony hard consistency)

PSA > 4 ng/ml = abnormal

biopsy : transperineum

transrectal ultrasound guide biopsy (TRUS-BX)

CT, MRI : staging

CXR, bone scan : metastasis


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Treatment

1. Early disease : found incidentally -> active surveillance

2. Localize disease + life expectancy >10yr

- radical prostatectomy

- external beam radiation

- brachytherapy


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Laparoscopic surgery


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Robotic radical prostatectomy


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3. Advanced disease :**androgen ablation

- bilateral orchiectomy

- medical crastation = GnRH agonist

- palliative radiotherapy

-> relive bone pain

-> prevent met. bone fracture

S ll f i


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Squamous cell of penis


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Relative uncommon 50-80 yr

Etiology

- phimosis ***

- poor hygiene

- HPV infection


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Precancerous lesion

- leukoplakia

- long standing wart

- Pagets disease (erythroplasia of Querat)


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Pathology = squamous cell carcinoma

Lesion :

- flat

- infiltartive ,ulcerative- fungating

Location :

- glan 48%- prepuce 21%, coronal sulcus 6%


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Clinical

- phimosis

- foul bloody discharge

- penile mass : ulcerative ,fungating

- inguinal LN enlargement


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Treatment

1. partial penectomy

2. total penectomy

3. ilioinguinal lymphadenectomy( control LN met.)

**radiation ,chemo Tx -> poor response


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Partial penectomy


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Total penectomy

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Urologic Tumor