U rogenital Neoplasms PROF. DR. METE KİLCİLER - PowerPoint Presentation

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Urogenital Neoplasms

PROF. DR. METE KİLCİLER DEPARTMENT OF UROLOGY, SCHOOL OF MEDICINE, BAHÇEŞEHİR UNIVERSITY

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Renal Cell Carcinoma

(RCC)

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

Renal Cell Carcinoma (RCC)

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EtiologyMajority 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, petroleumObesity

Chronic

phenacetin

or aspirin use

Acquired polycystic kidney disease due to dialysis results in 30% increase risk

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

disease Hereditary papillary renal cancer Birt-Hogg-Duke syndrome

Etiology

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PathologyRCC originates from the proximal renal tubular

epithelium.Types: Clear cell type Granular cell type Mixed cell typeRCC is most often a mixed adenocarcinoma.

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Clinical FindingsSymptoms & Signs Renal tumors are increasingly detected incidentally by CT or ultrasound

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

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Clinical FindingsParaneoplastic Syndromes Erythrocytosis,

hypercalcemia, hypertensionLab Findings

Anemia

H

ematuria

(60%), ESR

↑

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Clinical FindingsD. ImagingUltrasonographyIntravenous

Urography (IVU): CT scanning:Renal AngiographyMRI

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Diagnosis No screening for the general populationNo bio-marker availableRadiographic evaluation

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IVU of right RCC

CT Scan of Left RCC

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RCC invading renal vein

Righ Cystic RCC

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CT scan with 3D reconstruction

Neovascularity in Renal Angiographyassociated with RCC

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Tissue Diagnosis Tissue diagnosis obtained from nephrectomy or biopsy

Papillary (chromophilic) renal cell carcinoma extending into the collecting system

with histological findings

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Tumor Staging (Robson System)

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Tumor Staging (International TNM Staging System)

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Tumor Staging

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TreatmentA. Localized disease:Surgical removal---only potentially curative therapyRadical Nephrectomy

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

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Laparoscopic Radical

NephrectomyHand-Assisted Laparoscopic Radical Nephrectomy

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TreatmentA. Localized disease:Partial Nephrectomy (

nephron-sparing surgery, NSS ) --polar tumor --tumor size<4cm --bilateral RCC --solitary kidney

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TreatmentA. Localized disease:Percutaneous Laparoscopic Cryoablation

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TreatmentB. Disseminated disease:nephrectomy--- reducing tumor burdenradiation--- radioresistant

tumor, chemotherapy--- chemoresistant tumor

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Bladder Cancer (TCC)

https://youtu.be/CFoGfUuq8Hg

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The second most common cancer of the genitourinary systemThe male-female is 2.7:1

The peak incidence is in persons from 50-70 years

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Cigarette smoking (most common)Industrial toxins

Genetic eventsOther risk factors cyclophosphamide, alkylating agents,

radiotherapy of pelvis.

Etiology

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Pathology Histopathlogy transitional cell carcinoma 90%

squamous cell carcinoma 7-8% adenocarcinoma 1-2% other types

Grading

Grade 1 mild

anaplasia

Grade 2 moderate

anaplasia

Grage

3 marked

anaplasia

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Clinical FindingsA. Symptoms:Painless Hematuria 85-90%

Irritative voiding symptomsB. Signs:The majority of patients have no physical signs.

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Clinical FindingsC. Lab tests:Urine test——hematuriaUrinary cytology——depend on grade and volume of the tumor

Other markers: BTA, NMP22, telomerase

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Clinical FindingsD. Imaging:Ultrasonography—screenIVU—evaluation of upper urinary tractCT/MRI—assessment of the depth of infiltration and pelvic LN enlargement

E. Cystoscopy

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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.

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Diagnosis Cystoscopy cystoscopy

is the gold stantard to detect

the

bladder

cancer

cystoscopy

can provide good information on the extent of the

tumour

.

suspicous

areas can be biopsied.

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CT scan of bladder Ca

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Cystoscopy of bladder Ca

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TNM Tumor Staging

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Treatment Superficial bladder cancer (Ta,T1,Tis) transurethral resection

intravesical chemotherapy or immnotherapy(BCG) cystoscopic controls

in

every

three

months

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TreatmentInvasive bladder cancer (T2-T4)Partial

cyctectomy solitary, inflitrating tumors localized along the posterior lateral wall or dome of the bladder.R

adical

cystectomy

1

.

muscle-invasive bladder cancer T2-T4

2.high-risk superficial

tumours

3.extensive papillary disease

Urinary diversion after radical

cystectomy

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partial cyctectomy

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Radical Cystectomy

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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

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Prostate Cancer

https://youtu.be/CFoGfUuq8Hg

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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 yearThe incidence increases with advancing age

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Risk factorAgeGenetic influences Race－African Americans are at a higher risk than whites

Positive family history High dietary fat intake Hormonal factors

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Pathology Over 95% of the cancers of the prostate are adenocarcinomasProstatic intraepithelial

neoplasia (PIN) high grade (HGPIN) low grade (LGPIN)

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Mostly arise from the peripheral zone of the gland

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Gradingthe Gleason system

is widely used for its best clinical correlation

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Staging Stage I small foci of carcinoma in resection for benign diseaseStage II disease confined to prostate

Stage III extracapsular extensionStage IV regional lymph node metastases or distant metastases

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Clinical FindingsA. SymptomsEarly stage: asymptomaticLocally advanced/metastatic

disease obstructive or irritative voiding complaints, bone pain,

paresthesias

and weakness of lower extremities

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Clinical FindingsB. Signs: Digital rectal examination—induration

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Prostate Cancer

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Clinical FindingsC. Tumor markersProstate Specific Antigen (PSA)

< 4 ng/ml normal 4 - 10 ng/ml Grey Zone > 10

ng

/ml

highly

suspect of

PCa

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Clinical FindingsD. ImagingUltrasonography－hypoechoic

lesion Transrectal ultrasonography (TRUS)CT, MRIBone scan

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TRUS Biopsy - The golden standard

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MRI of prostate cancer

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Methastasis at the bone scan

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TreatmentA. Localized diseaseWatchful waiting, older patients with small

, well-differentiated cancerRadical prostatectomy, patients with a life expectency > 10 yearsRadiation

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Radical Prostatectomy

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TreatmentB. Locally advanced/metastatic diseasesEndocrine therapy—androgen blockade : orchiectomy

antiandrogen agent LHRH agonistRadiationChemotherapy

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Testicular Cancer

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Testicular CancerTypically occurs in young healthy Men.Very good cure rates Even for Metastatic Disease!

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Testicular Cancer

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Testicular Cancer

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Germ Cell Testicular CancerSeminomaNon-Seminoma

Embryonal CarcinomaTeratomaTeratocarcinoma (Teratoma +Embryonal Carcinoma)

Choriocarcinoma

Yolk Sac

Tumour

(typically infants)

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Testicular Cancer

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Non-Germ Cell Testicular CancerLeydig Cell TumorSertoli Cell Tumor

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Testicular Cancer

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Secondary Testicular CancerLymphomaLeukemia

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Testicular CancerPresentationTypically painless intratesticular mass discovered on self examinationAge 15

– 40

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Testicular CancerInvestigationsLabsB-HCGProduced by

choriocarcinoma & in some SeminomasAlpha-fetoproteinProduced by Yolk Sac, Embryonal Carcinoma & Teratocarcinoma

LDH

Correlates with tumor volume

Imaging

Scrotal U/S

CT

Abdo

and Pelvis: assess for retroperitoneal

mets

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Testicular CancerTreatment:Radical OrchiectomyALWAYS Inguinal approach

NEVER scrotal approachPLUS…

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US Findings

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RPLNLarge retroperitonealmass in patient withright testicular

NSGCT

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Lymphatic Spread: RPLND

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WAG 2002UBC Phase IV UrologyTesticular cancer

Age 15 – 35 yrsHistory of cryptorchidism or previous testicular cancerPainlessDoes not transilluminate

Feels hard and irregular

Constitutional symptoms (weight loss)

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Self - ExaminationSelf – examination should

be taught to young menThey need to be shown the difference between the testicle and the epididymisThey need to report any

hard or suspicious lesions

immediately

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Penile Cancer

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Squamous cell carcinoma. > 95% Mesenchymal tumors. < 3% e.g Kaposi sarcoma, angiosarcoma etc Malign

ant Melanoma. Basal cell carcinoma. Metastasis.

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Etiology Circumcission practice.Hygiene standards.Phimosis.No. of sexual partners.HPV infection.Exposure to tobacco products.

gonorrhea, syphillisalcohol intake.

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Prevention Routine neonatal circumcission.Good hygiene practice.Avoid HPV infection and tobacco.

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Natural HistoryBegins as small lesion, papillary , exophytic

or flat, ulcerative.Flat and ulcerative lesions >5cm and extending >75%Distant metastasis uncommon 10%Death within 2 years for most untreated cases.

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Presentation Symptoms weight loss, fatigue, weakness, hemorrhage, pain.Signs penile lesion.

rarely nodal mass, ulceration, suppuration.

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Diagnosis Primary lesion.Regional lymph nodes.Distant metastasis. Physical examination.Ultrasound.MRI.CT.Cavernosography

.Lymphangiography.

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Diagnosis Histological diagnosis is absolutely necessary prior to treatment decision.

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TNM staging system

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Treatment of Penile lesion Penile intraepithelial neoplasiaPenis preserving strategyLaser therapy.Local excision.5 FU cream.

Cryotherapy.Photodynamic therapy.5% topical imiquimod.

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Treatment of Penile lesionLocal recurrenceSecond conservative procedure.Partial / total amputation.External beam radiotherapy / brachytherapy for lesions < 4cm diameter.