1. 1. Genitourinary Tumors BY PROF/ GOUDA ELLABBAN
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5. 5. RENAL CELL CARCINOMA (Hypernephroma,Adenocarcinoma) 85 % of all primary kidney neoplasms 3% of all adult malignancies more than 40% of patients with RCC have died from their cancer The incidence of RCC has increased since 1997( more prevalent use of ultrasonography and CT scan for the evaluation of a variety of abdominal or gastrointestinal complaints Male to femal ratio is 2:1 The tumor is not encapsulated Calcification is present in 7% of cases
6. 6. Etiology: Tobacco use has been incriminated as an etiologic agent !!!!!!! Occupational and industrial carcinogens has no relationship. Von Hippel-Lindau disease 30 % of pts have RCC ( 50% metastatic) Often bilateral and multifocal In younger patients, M = F Tuberous sclerosis Angiomyolipomas in 40-80% RCC Long-term dialysis Developed cystic changes with associated carcinoma Chromosome 3 Deletions and translocation involving short arm Suppressor cancer gene
7. 7. Clinical presentation: The classic triad of flank pain, gross hematuria, and palpable abdominal mass is now rarely found Hematuria ( micro, gross) in 60% Flank Or Abdominal pain in 50% Palpable mass in 30-40% more than 50% of RCCs are now detected incidentally Paraneoplastic syndromes in 20% of patients with RCC Hepatic dysfunction Fever Hypertionsion ( renin production) Hypercalcemia (PTH-like protien) Erethrocytosis (Erythropoiten) Symptoms secondary to metastasis
8. 8. Investigation: Plain X-ray Enlarged kidney shadow IVP A space-occupying lesion ( calyceal distortion) Ultrasonography An echogenic mass in the renal parenchyma Ct scan A mass with an attenuation density value of +30 to +70 hounsfield MRI, Renal arteriography
9. 9. In general, any renal mass that enhances with intravenous contrast on CT scanning should be considered a renal cell carcinoma (RCC) until proved otherwise Figure 751. A, Computed tomographic (CT) scan without contrast shows solid, left upper pole renal mass measuring 31 Hounsfield units. B, After contrast administration, CT scan shows that the mass enhances to 58 Hounsfield units. This mass was excised and found to be a renal cell carcinoma
10. 10. Renal pseudotumors may be due to a hypertrophied column of Bertin, renal dysmorphism, or an unusually shaped kidney. In this situation, the diagnosis of a pseudotumor can be confirmed by isotope renography with technetium dimercaptosuccinic acid or glucoheptonate Figure 752. A, Computed tomographic scan with contrast shows isodense hilar mass in solitary right kidney. B, Right renal arteriography shows no neovascularity. C, Glucoheptonate isotope renal scan shows increased density of mass indicative of hypertrophied column of Bertin. Copyright
11. 11. approximately 20% to 25% of RCCs are angiographically avascular Fine-needle aspiration or biopsy is of limited value in the evaluation of renal masses high incidence of false-negative biopsies in patients with renal malignancy The primary indication for needle aspiration or biopsy of a renal mass is when a renal abscess or infected cyst is suspected or when RCC must be differentiated from metastatic malignancy or renal lymphoma.
12. 12. Figure 754. Bosniaks class II cysts. A, Computed tomographic (CT) scan without contrast shows calcium in wall of right renal cyst. B, CT scan with contrast in another patient shows right renal cyst with thin internal septation.
13. 13. Figure 755. Bosniaks class II hyperdense cyst. A, Computed tomographic (CT) scan without contrast shows small, smooth-walled, high-density right renal cyst. B, CT scan after contrast administration shows no enhancement of the cyst.
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20. 20. Treatments: Radical nephrectomy Laparoscopic Radical nephrectomy ***** Nephron sparing surgery A solitory metastatic focus in the lung is locally excised Immunotherapy Interferon & interleukin-2 for metastases Renal cell ca is radio-resistant, &chemo-resistant
21. 21. CARCINOMA OF THE RENAL PELVIS, CALYCES AND URETER Urothelial tumors arise from the epithelial lining of the urinary tract (calyces, renal pelvis, ureter and urinary bladder) Incidence Pelvic tumors account for 7% of renal tumors, and 5% of urothelial tumors. Pelvic tumors: ureteric tumors = 4:1 Male: female ratio = 2.1 Peak age incidence: 65 years
22. 22. Etiology Smoking Chronic infection Abuse of analgesic medications ( phenacetin) Occupational and industrial carcinogens has relationship. Pathology Transitional cell carcinoma (TCC) (95%) Squamous cell carcinoma (about 5%) Chronic bilharzial ureteritis Recurrent calcular disease Adenocarcinoma: very rare (< 1%)
23. 23. Metastases: Direct extension Mucosal extension (seeding) Lymphatic extension Vascular extension Staging: Stage 0: confined to the urothelium Stage A: suburothelial invasion Stage B: muscle invasion Stage C: peri-ureteral fat invasion Stage D: invasion of adjacent organs, lymph nodes Clinical findings Symptoms: total painless hematuria is the most common
24. 24. Investigations: Intravenous urography Urine cytology Cystoscopy & ureteroscopy Treatment: Nephro-ureterectomy (simple nephrectomy + ipsilateral ureterectomy)
25. 25. CARCINOMA OF THE URINARY BLADDER Incidence The commonest neoplasm affecting the urinary tract. Male: female ratio = 3:1 Etiology 1. Chronic bilharzial cystitis 2. Cigarette smoking 3. Occupational exposure 4. Ectopia vesicae: rare.
26. 26. Staging: Stage 0 :tumor confined to urothelium Stage A :suburothelial invasion Stage B1 :superficial muscle invasion Stage B2 :deep muscle invasion Stage C :perivesical fat invasion Stage D1 : invasion of adjacent pelvic organs Stage D2 : distant metastases.
27. 27. Methods of Staging: Bimanual examination of the bladder under anasthesia Ultrasonography Transurethral biopsy CT scan Chest X-ray Liver function test
28. 28. Pathology: Transitional cell carcinoma(TCC) 90% Squamous cell carcinoma 2-15% Adenocarcinoma 0.5-2% Grading: Grade 1 : well-differentiated Grade 2 : moderately-differentiated Grade 3 : poorly-differentiated
29. 29. Clinical presentation: Total painless hematuria Burning and frequency Obstructive urinary symptoms Hydronephrosis renal pain Investigations: Urine cytology IVP Cystoscopy
30. 30. Treatments: stages 0 and A papillary tumors: Transurethral resection of the tumor Intravesical immunotherapy Follow-up cystoscopy carcinoma in situ: Transurethral resection and fulguration, BCG therapy Radical cystectomy !!!!! Stage B tumors and beyond: Radical cystectomy Stage C & D Radiotherapy Chemotherapy
31. 31. Prostate cancer Rare before the age of 50 Hereditary factors Tumor staging Stage A: no palpable lesion by DRE. A1: focal A2: diffuse Stage B B1: small, discrete nodules B2: large, or multiple nodules Stage C C1: seminal vesicles not involved; tumor