urological neoplasms Flashcards
What are the benign renal neoplasms?
ADENOMA
- pea-like cortical adenoma
- has malignant potential
ANGIOMA
- may cause profuse hematuria in young adults
- difficult to find bleeding source without renal angiography
ANGIOMYOLIPOMA
- v high malignant potential
What are the malignant renal neoplasms?
- Wilm’s tumor (nephroblastoma)
- Renal adenocarcinoma
- Transitional cell carcinoma
- squamous cell carcinoma
a rapidly growing tumor in one pole of the kidney that is smooth, soft, fleshy, pinkish white in color & has hemorrhagic areas discovered in the first 5 years of life is?
WILM’S TUMOR (nephroblastoma)
- large palpable abdominal mass
Micro
- malignant primitive glomeruli & primitive tubules with epithelial & connective tissue cells exist side by side
- spreads through blood into lungs
What are the clinical features of Wilm’s tumor?
ABDOMINAL MASS - FEVER - HEMATURIA
mass
- smooth, mobile, firm or hard, lobular, located in loin, moves with RESPIRATION
- bimanually palpable
- ballotable
- dullness in renal angle with resonant band in front
fever -> tumor necrosis
hematuria -> grave sign signifying rupture of tumor into renal pelvis
How is Wilm’s tumor diagnosed & treated?
Diagnosis
- ultrasound
- CT
- IVU
- renal angiography
- x-ray -> egg shell peripheral calcification
Treatment
- Unilateral tumor -> neoadjuvant chemotherapy followed by nephrectomy
- Bilateral tumors -> partial nephrectomy if POLAR
- > bilateral nephrectomy with renal transplantation
large tumors irregular in shape with central hemorrhage & necrosis located in upper pole commonly affecting women causing total hematuria is?
Adenocarcinoma (hypernephroma, renal cell carcinoma)
- yellowish or dull white, semi transparent cut surface
spread
- direct -> to surrounding structures
- hematogenous -> grows in renal vein -> reach the lungs -> cannonball secondary deposits
- lymphatics (LATE) -> para-aortic nodes & beyond
What are the clinical features of adenocarcinoma?
Hematuria
- painless
- profuse
- total hematuria
Pain
- clot colic
- dragging discomfort in loin or patient may detect a mass
Secondary rapidly developing varicocele
- left side
Pyrexia after nephrectomy -> metastases
What are the investigations used to diagnose adenocarcinoma?
US -> most important
CT or MRI -> confirmation
Angiography -> massive hematuria
How is adenocarcinoma treated?
NEPHRECTOMY
- ligate renal vessels to decrease risk of hemorrhage
- removal of large neoplasm is curative
What are the clinical features of papillary transitional cell tumors of the renal pelvis?
- multifocal & metastasize
- multiple ureteric tumors predispose the whole urothelium to metaplasia
- hematuria is most common
- hydronephrosis
How is transitional cell tumors of renal pelvis treated?
nephroureterectomy + life-long follow up using cystoscope
ureter must be disconnected with a cuff of bladder wall
What is the cause of transitional cell carcinoma of the bladder?
- cigarette smoking
- genetic -> activation of RAS & c-erbB-1 & 2 - inactivation of p53, p21, p16 & RB
- occupational exposure to urothelial carcinogens
most commonly in lateral wall then trigone
What is the classification of transitional cell carcinoma of the bladder?
NON-MUSCLE INVASIVE
MUSCLE INVASIVE
CARCINOMA IN SITU (least complex - cystectomy)
- primary CIS -> CIS alone
- Concomitant CIS -> occurs in association with a new tumor
- Secondary CIS -> in patient who had a previous tumor
Which tumor of the bladder is always associated with muscle invasion?
squamous cell carcinoma of the bladder
- most commonly where bilharzia is endemic
Which tumor of the bladder arises at the site of urachal remnant + ectopia vesica?
Adenocarcinoma of the bladder
- treated by partial cystectomy
What are the clinical features of transitional cell carcinoma of the bladder?
Hematuria
- painless
- gross
- increases at the end of the stream
- may give clots & cause clot colic
LUTS
- frequency
- dysuria
Pain
- infiltration of muscle
- constant pain in the pelvis -> extravesical spread
- suprapubic pain -> nerve involvement
What investigations are used to diagnose transitional cell carcinoma of the bladder?
URINE -> cytology for malignant cells is highly specific
CYSTOURETHROSCOPY -> guide for biopsy in patients with hematuria
all patients with painless hematuria
1- US scanning
2- CT (local staging) or MRI (local & lymphatic staging)
3- IVU -> irregular filling defect -> hydroureter or hydronephrosis
How should non muscle invasive transitional cell carcinoma of the bladder be treated?
NON MUSCLE INVASIVE
endoscopic surgery
- resected in layers using resectoscope & base is sent for histological examination
- small pinch biopsies are taken near to & distant from primary lesion when CIS is suspected
- exclude muscle invasion
- INTRAVESICAL MITOMYCIN before catheter removal to decrease risk of recurrence
- follow up is mandatory
- if recurrence is detected -> intravesical & systemic chemotherapy could be used
How should muscle invasive transitional cell carcinoma of the bladder be treated?
SURGICAL
- radical cystectomy + pelvic lymphadenectomy + urine diversion -> main line
- partial cystectomy -> in adenocarcinoma
CHEMOTHERAPY
- intravesical mitomycin
- systemic CT
RADIOTHERAPY
- could be used as primary curative line to preserve function of the bladder
- 2 types -> interstitial RT & deep external bean RT
What are the indications for urinary diversion?
TEMPORARY -> to relieve distal obstruction
- urinary catheter -> urine retention
- supra-pubic catheter -> prolonged catheterization
- nephrostomy tube -> if internal stent is not feasible
PERMANENT -> if bladder is removed or lost normal neurological control
- > incurable fistula
- > irremovable obstruction
What are the types of permanent urinary diversion?
EXTERNAL
ileal conduit
- ureters are implanted into a short, isolated segment of ileum
- conduit diverts urine downwards to cutaneous stoma for collection in a ileostomy bag
INTERNAL
colon & rectum
- anal sphincter must be competent
- could cause -> recurrent UTI
-> in the long term cancer can develop at long standing ureterocolic junctions
-> working overload on the kidney
bladder reconstruction
- ileum, ileum & caecum or sigmoid colon could be used
- results are good after radical cystectomy in younger patients
- only indicated when urethra can be preserved
What are the complications of internal diversion?
- stricture
- reflux of urine
- risk of malignancy
- resorption of solutes
- malabsorption
PATIENT MUST EMPTY RECTUM OR RESERVOIR 3 HOURLY BY DAY TO AVOID COMPLICATIONS
What is the most common malignant tumor in men over the age of 55 is?
CARCINOMA OF THE PROSTATE (adenocarcinoma)
- most commonly affects the peripheral zone
How does the carcinoma of the prostate spread?
LOCAL -> seminal vesicles, the bladder neck & trigone, & the distal sphincter
BLOOD -> to bone (esp pelvic bones & lower lumbar vertebrae) -> osteosclerotic lesions
LYMPHATIC -> Virchow’s node
How is prostatic cancer staged?
T1 incidentally discovered T1a -> involving <5% T1b -> involving > 5% T1c -> raised PSA
T2
local palpable nodule
T2a -> involving 1 lobe
T2b -> involving both lobes
T3
invasion of the capsule
T3a -> uni or bilateral extension
T3b -> seminal vesicle extension
T4
extra-prostatic invasion
- fixed or invading adjacent structures OTHER than seminal vesicles
What are the clinical features of prostate cancer?
- asymptomatic -> most common
- advanced disease gives rise to symptoms
- > bladder neck obstruction
- > pelvic pain & hematuria
- > bone pain, malaise, arthritis, anemia, or pancytopenia
- > renal failure
Rectal Examination
- detect nodules within the prostate
- advanced disease
- irregular induration -> stony hard
- non tender enlargement with obliteration of the median sulcus
What laboratory investigations should be done in suspected prostate cancer?
Prostate-specific antigen
- PSA > 10 is suggestive of cancer
- PSA > 35 is almost diagnostic of advanced cancer
CBC
- anemia -> extensive bone marrow invasion OR secondary to renal failure
Liver Function Tests
- alkaline phosphatase may be raised in hepatic involvement or secondaries in bone
What radiological investigations should be done in suspected prostate cancer?
XRAY
- metastases in lung fields or ribs
- sclerotic & osteolytic metastasis in lumbar vertebrae & pelvic bone -> characteristic
MRI -> most accurate method for staging local disease
TRUS -> to guide biopsy
BONE SCAN
- if PSA is >10 nmol/mL or if biopsy shows high-grade cancer
How is early prostatic cancer treated?
T1a, T1b, T1c, & T2
- managed by active surveillance
or
- radical prostatectomy -> localized disease T1 & T2 in men with life expectancy of >10 years
- radiotherapy -> external beam (T1 & 2)
-> brachytherapy (T1)
How is advanced prostatic cancer treated?
androgen ablation
- bilateral orchidectomy -> used for T3 & T4
- medical castration -> Stilbestrol
-> LHRH agonists (monthly or 3 monthly depot injection)
-> cyproterone acetate
radiotherapy -> bone metastasis
T3 in good general condition -> radical prostatectomy
What are the risk factors for testicular tumors?
- undescended testis
- history of contralateral testicular tumor
- Klinefelter’s syndrome
What is the most common testicular tumor?
SEMINOMA
spreads through lymphatics
- para-aortic LNs
- inguinal LNs in case of scrotal wall infiltration
What are the types of non-seminomatous germ cell tumors (NSGCT)?
Embryonal Carcinoma -> highly malignant -> invades cord structures
Yolk Sac Tumour -> secrete alpha fetoprotein (AFP)
Choriocarcinoma -> secretes human chorionic gonadotrophin (HCG) -> highly metastatic
Teratoma -> component derived from ectoderm, endoderm, & mesoderm
What are the types of interstitial cell tumours?
LEYDIG CELL TUMOR -> masculinizes
SERTOLI CELL TUMOR -> feminises
What are the stages of testicular tumors?
Stage I -> confined to testis
Stage II -> lymph nodes below diaphragm are affected
Stage III -> lymph nodes above diaphragm affected
Stage IV -> non-lymphatic metastatic disease (lungs)
What are the clinical features of testicular tumors?
- painless testicular lump
- sensation of heaviness
- pain
- manifestations of metastasis
- intratesticular solid mass
- lax secondary hydrocele
- epididymis becomes more difficult to feel when its flattened or incorporated in the growth
What investigations should be done for any testicular mass?
SCROTAL US
metastatic workup -> in confirmed cases -> staging (MRI)
Tumor markers
- LDH in seminoma
- AFP in NSGCT
used to reassess after orchidectomy to indicate if all tumor tissue has been removed
What is the treatment for testicular tumors?
SCROTAL EXPLORATION & ORCHIDECTOMY -> inguinal incision
+
adjuvant treatment (post-orchidectomy radiotherapy or chemotherapy)
Stage I
- Seminomas -> adjuvant radiotherapy to para-aortic nodes
- NSGCT -> chemotherapy
Stage II-IV
- combination chemotherapy -> seminoma II-IV & NSGCT
- retroperitoneal lymph node dissection in some cases of NSGCT
