tumor urologi.ppt [Read-Only]ocw.usu.ac.id/course/download/1110000119-genitourinary...prostate ca ±70% are superficial, 10 –20% will progress to muscle invasive disease Chance of

GENITOURINARY CANCER

Urology Division, Surgery Department

Medical Faculty,

University of Sumatera Utara

BENIGN TUMORS

� Adenoma

� Oncocytoma

� AngiomyolipomaAngiomyolipoma

� Leiomyoma

� Lipoma

� Hemangioma

1. Renal adenoma

� The most common benign renal parenchymal

lesion

� Small, well-diff glandular tumors of the

renal cortexrenal cortex

� Asymptomatic

� Should be treated of an early renal cancer

and the patient should be evaluated and

treated appropriately

2. Renal oncocytoma

� 3 – 5% of renal tumor, �: �= 2 : 1

� Gross hematuria & flank pain in < 20%

� Radical nephrectomy is the safest method of

treatment unless other factors argue for a treatment unless other factors argue for a

conservative approach

3. Angiomyolipoma (Renal hamartoma)

� Composed of fat, muscle & blood vessels

� Rare, 4 : 1 �

� Acute flank pain or shock due to spontaneous

renal or retroperitoneal hemorrhagerenal or retroperitoneal hemorrhage

� Asymptomatic tumors < 4 cm � followed

closely with serial imaging

� Symptomatic tumors or > 4 cm � selective

embolization or tumor enucleation by partial

nephrectomy

MALIGNANT TUMORS

� The most common type of renal tumor is

renal cell carcinoma

� 80 – 85% of all renal cancers

� Survival is based on tumor stage� Survival is based on tumor stage

� Other types of kidney tumors include

metastatic lesions, sarcomas,

juxtaglomerular tumors and lymphomas

ADENOCARCINOMA OF THE KIDNEY

(RENAL CELL CARCINOMA)

� 3% of adult cancer

� �: � = 2 : 1, 5th – 6th decades of life

� racial distribution is equal

� more common in urban settings� more common in urban settings

� = hypernephroma = clear cell carcinoma = alveolar carcinoma

� Etiology is unknwon

� Risk factor : Cigarret smoking � strongest

Obesity

Acquired renal cystic disease

GRADING & STAGING

� Fuhrman system (I – IV)� most often used

� General classification system :

- Robson system

- TNM system- TNM system

CLINICAL PRESENTATION

� Symptom & sign �

Classic triad : hematuria

flank pain

palpable masspalpable mass

� General symptom : weight loss, fever,

anemia, night sweats

� Presenting symptoms associated with the primary tumor :

- hematuria

- mass - typically appreciated with lower

pole masses in thin patientspole masses in thin patients

- varicocele : typically on left side, will not

decompress when patient is supine

- edema, and lower extremity varices

associated with vena cava obstruction

� Presenting symptoms associated with metastases :

- bone pain

- neurological symptom

- ascites

Paraneoplastic syndrome �� Paraneoplastic syndrome �

- erythrocytosis (1 – 5%)

- hypercalcemia

- hepatic dysfunction

- amyloidosis

- anemia

Initial evaluation

� Physical examination

� Laboratory studies

- CBC

- serum electrolytes- serum electrolytes

- LFT

� Imaging for staging

IMAGING EVALUATION

� Intravenous excretory urography

� Renal sonography

� CT

� MRI� MRI

� Angiography

� Radionuclide imaging

TREATMENT FOR LOCALIZED DISEASE

� Radical nephrectomy is gold standard

� Partial nephrectomy

� Energy ablative techniques� Energy ablative techniques

TREATMENT FOR METASTATIC RCC

� ∼ 30% of newly diagnosed cases of RCC are metastatic

� Associated with extremely poor survival

� Common sites : lung, bone, liver, brain, ipsilateral or contralateral kidneyor contralateral kidney

� Generally chemotherapy-resistant

� Disseminated disease

- surgery

- radiation therapy

- hormonal therapy

- radioimmunotherapy

- biologic response modifier

PROGNOSIS

� related to the stage at presentation

� 5-yr survival rate for T1 � 88 – 100%

T2 & T3a � 60%T2 & T3a � 60%

T3b � 15 – 20%

with metastatic � 0 – 20%

NEPHROBLASTOMA (WILMS TUMOR)

� The most common solid renal tumor of

childhood; 5% of childhood cancer

� 3rd year of life, no sex predilection

� Commonly unicentric, occur in either kidney � Commonly unicentric, occur in either kidney

with equal frequency

� Metastatic is present at diagnosis in 10 –

15%, with lungs (85-95%) and liver (10-15%)

the most common sites

Clinical findings

� ¾ present with palpable abdominal mass,

smooth and rarely crossing midline

� Abdominal pain, anorexia, nausea &

vomiting, fever, hematuriavomiting, fever, hematuria

� Hypertension (25-60%)

� DD : hydronephrosis

cystic kidneys

treatment

� Surgical

� Radiation

- radiosensitive

- its use complicated by potential growth

disturbances, recognized cardiac, pulmonary & disturbances, recognized cardiac, pulmonary &

hepatic toxicities

� Chemotherapy- chemosensitive neoplasm

- actinomycin D, vincristine, doxorubucin,

cyclophosphamide, etoposide, cisplatin

SARCOMA OF THE KIDNEY

� Rare, 1-3% of all malignant renal neoplasm

� 5th decade, alight male predominance

� Flank or abdominal pain, weight loss

� Leiomyosarcoma (50%), fibrosarcoma, � Leiomyosarcoma (50%), fibrosarcoma,

liposarcoma,hemangiopericytomas,

osteogenic sarcoma, malignant schwannomas

� Radical nephrectomy for localized disease

LYMPHOMA

� Primary renal lymphoma are extremely rare

� Kidney may be involved by either direct

extension or hematogenous spread

� Suspect lymphoma if the mass appears � Suspect lymphoma if the mass appears

infiltrating or multifocal, there is diffuse

adenopathy

� Biopsy warranted if lymphoma suspected

CARCINOMA OF THE BLADDER

� 2nd most common urologic malignancy after

prostate ca

� ± 70% are superficial, 10 – 20% will progress to

muscle invasive diseasemuscle invasive disease

� Chance of tumor recurrence is ± 70 – 80%

� Environmental exposures are strongly

associated

� The most common histologic diagnosis is TCC

etiologi

� Industrial carcinogens � aniline dyes, naphtylamin

� Tobacco exposure

� Chemotherapeutic agent

� Schistosomiasis� Schistosomiasis

� Pelvic irradiation

� Chronic irritation & infection

� Phenacetin

� Baldder exstrophy

� Coffee � not strong

� Saccharin � in experimental animal

Epidemiology

� Age � 6th – 8th decades

� Race � twice in American men

� Gender � �: �= 3 : 1Gender � �: �= 3 : 1

� Genetics

� Demography � higher in US compared to

Japan

Symptom

� Gross, painless hematuria

- most common (85% cases)

- intermittence is not a reason to exclude an

evaluationevaluation

- indicates cancer until proven otherwise

� Irritative voiding symptom � frequency, dysuria, urgency (frequently associated with CIS)

� Bladder filling defect on urography

� Unanticipated finding on cystoscopy

Diagnosis

� History & physical examination

� Urine culture

� Urine cytology � highly specific

Flow cytometry� Flow cytometry

� Tumor markers

� Upper tract imaging

� Cystoscopy

Pathology

� Epithelial dysplasia

� Carcinoma in situ

� Superficial TCC � 70%

� Muscle invasive TCC� Muscle invasive TCC

� Squamous cell ca

� Adenoca

� Sarcoma of the bladder

� Small cell carcinoma

treatment

� Superficial bladder cancer

1. TURBT � - initial & standard therapy

2. Laser photocoagulation � less dyscomfort,

minimal bleedingminimal bleeding

3. Intravesical therapy

- weekly treatment

- mitomycin C, adriamycin, thiotepa, BCG, interferons

� Muscle invasive TCC

1. radical cystectomy

2. partial cystectomy

3. radiation therapy3. radiation therapy

4. TUR

5. combined

6. adjuvant therapy

7. metastatic disease � MTX, vinblastine,

adriamycin

8. palliative therapy