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Urologic malignancy
This document provides a comprehensive overview of urologic malignancies, focusing on various types such as renal, bladder, prostate, and penile cancers. It details classifications, clinical features, diagnostic workups, and treatment modalities for each cancer type, highlighting statistical data on incidence, prognosis, and therapeutic approaches including surgery, chemotherapy, and immunotherapy. The document emphasizes the importance of early detection and different staging systems used to assess the extent of these malignancies.
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Urologic malignancy
- 1.
- 2. General Outline ofPresentation Urological Malignancies : • Renal • Bladder • Penis • Prostate • Testicular
- 3.
- 4. Classification of Neoplasmsof The Kidney Benign neoplasms • Adenoma • Angioma • Angiomyolipoma Malignant neoplasms • Wilms’ tumour (nephroblastoma in children) • Grawitz’s tumour (adenocarcinoma, hypernephroma) • Transitional cell carcinoma of the renal pelvis and collecting system • Squamous cell carcinoma of the renal pelvis
- 5. Renal Cell Carcinoma •Grawitz’s/Hypernephroma/Adenocarcinoma • The most common neoplasm of the kidney (75% incidence), arises from renal tubular cells. • Male predominance (1.6:1.0 M:F) • Highest incidence between age 50-70 • Majority of RCC occurs sporadically • Highest incidence in Scandinavia and North America, lowest in Africa
- 6. Pathology • Surface –white to yellowish • Semi transparent • Areas of haemorrhage and necrosis
- 7.
- 8. Clinical Features -1 •Asymptomatic in the beginning • Triad of loin pain, loin mass, haematuria (10%) and usually indicate advanced disease • Haematuria is common complaint • Dragging discomfort in the loin • Mass • Rapidly developing varicocele
- 9. Clinical Features -2 •Paraneoplastic syndrome : hypercalcemia, erthrocytosis, non metastasis hepatic dysfunction (Stauffer syndrome) • Metastasis symptoms : Bone pain , chronic cough, hemoptysis
- 10.
- 11. Clinical Features -3 Atypicalsymptoms : Persistent pyrexia (37.8–38.9ºC) with no evidence of infection Cachexia Anaemia. Polycythaemia Raised ESR Nephrotic syndrome
- 12. Recommended Initial Test TESTREASON Renal Function Test Assess remaining renal function Full Blood Count Polycythemia, Anaemia ESR Increased in renal cell carcinoma Serum calcium Hypercalcaemia (paraneoplastic syndrome) Coagulation Profile Pre-surgery investigation Liver Function Test Impaired in metastases or paraneoplastic syndrome, ALP increase in bone metastasis Chest x-ray Canon ball appearance (metastasis)
- 13. Staging of disease TESTREASON Transabdominal Ultrasound Origin of mass, cystic/solid, sign of metastasis in liver and lymph nodes enlargement Contrast CT Abdomen TNM Staging MRI Abdomen If renal function is impaired to permit contrast Transesophageal Echocardiogram If suspected spread of tumour from inferior vena cava involving right atrium Excretory Urography Able to access renal function and any filling defect indicating presence of mass PET Scan Most sensitive but not widely available
- 14. Robson Modification Ofthe Flocks & Kadesky Staging of RCC
- 15.
- 17. Chest x-ray • Lung Metastasis •Canonball appearance
- 18. Intravenous urogram •Hypernephroma of theleft kidney •Displacement of the upper pole calyces by the mass.
- 19. Arteriogram •Vascular ‘blush’ due tometastasis in the femur from a Grawitz’s tumour
- 20.
- 21. Principles of Treatment •Radiotherapy, Chemotherapy – minimal respond • Surgical • Immunotherapy – Cytokine IL-2, Chemokines
- 22. Surgical • Surgical removalof affected kidney - partial or complete nephrectomy • 2 types of approach Loin Transabdominal • Vascular control by first ligation of renal artery and then ligation of renal vein
- 23. Indications 1. Bilateral RCC 2.RCC in a solitary functioning kidney 3. Unilateral RCC with contralateral kidney under threat of its future function 4. Tumour less than 4cms with normal opposite kidney. 5. Five year survival rate 75% to 85% 6. Local tumour recurrence of 10% is reported. Other Approaches 1. Radio frequency ablations 2. Cryoablation Nephron Sparing Surgery
- 24. • Gold standardtreatment for localized RCC with contralateral normal kidney, adequate surgical margin. • Principles of Surgery- Early ligation of renal artery and vein , removal of kidney including Gerota’s fascia, removal of ipsilateral adrenal gland, regional lymphadenectomy from crus of diaphragm to aortic bifurcation. Radical nephrectomy
- 26. Prognosis • In operablecases, 70% of patients are well after three years and 60% after five years. • Worse prognosis – - Macroscopic involvement of the renal vein or its tributaries - Invasion beyond the capsule - Lymphatic involvement
- 27. Transitional Cell Carcinomaof Kidney • Less common • May invade the renal parenchyma, be multifocal and metastasize. • Multiple ureteric tumours are thought to arise from a field change that predisposes the whole urothelium to metaplasia rather than seeding down the ureter. • Carcinogen is chemical or viral is uncertain
- 29. Diagnostic Work Up •Clinical - Haematuria • Investigations : Presence of malignant cells in the urine may indicate well or poorly differentiated. Obtain cells from the tumour by sampling using a brush or catheter Intravenous urography Retrograde pyelography
- 31. Treatment • Conventional surgical- nephroureterectomy. • Conservative resection - well-differentiated upper urinary tract transitional tumours
- 32. Squamous Cell Carcinomaof Kidney • This is rare and often associated with chronic inflammation and leucoplakia resulting from stone. • The tumours are radiosensitive but metastasise early • Prognosis is poor
- 33.
- 34. • Rare before50 years old. • Male > Female • 95% of primary bladder tumor originate in transitional epithelium (TCC) • Secondary tumors : Sigmoid & rectum, prostate, uterus or ovaries • Histological Types : Urothelial, Squamous and Adenocarcinoma INTRODUCTION
- 35. • Cigarette Smoking(40%) • Long term use Analgesic • Occupational risk factors - Textile, Dye, Tyre rubber, Petrol etc. • SCC: Schistosoma Haematobium (in Endemic areas), usage of catheter, bladder stone. RISK FACTORS
- 36. • Hematuria. Painless,end micturition • Bladder Outlet Obstruction (Male) • Cystitis (Female) • Constant pain in Pelvis • Referred pain to suprapubic region, groins, perineum, anus & into thigh • Loss of Weight, Loss of Appetite CLINICAL FEATURES
- 37. • Usually negative •Maybe a palpable suprapubic mass • Rectal Examination: - May reveal large tumors (Invaded pelvic side walls) • Bimanual Examination: - Necessary for staging evaluation. PHYSICAL EXAMINATION
- 38. • URINE • BLOOD •IMAGING INVESTIGATIONS
- 39. URINE TESTS UrineFEME - Hematuria, WBC Urine Cytology - Malignant cell. Urine CnS - To rule out Infection INVESTIGATIONS
- 40. BLOOD TEST • FullBlood Count • Renal Profile • Liver Function Test • Random Blood Sugar • Coagulation Profile • Prostate Specific Antigen (PSA) • GXM and GSH
- 41. IMAGING Ultrasound/IVU – Most commondefect: Filling defect – Irregularity of bladder wall (Invasive tumor) Contrast CT/MRI – For staging – Demonstrate lymph node & muscular invasion Cystourethroscopy – Mainstay of Diagnosis
- 42. Ultrasound of Bladder •Irregular, echogenic mass
- 44.
- 45. Cystoscopy of BladderCancer See the cauliflower appearance of the tumor?
- 46. • Carcinoma InSitu Superficial Tumor • Ta. Confined to urothelium • T1. Lamina propia involvement Invasive Tumor • T2a. Sup. Muscle involvement • T2b. Deep muscle involvement • T3a. Invades perivesicle tissue microscopically • T4. Extravesicle mass (macro) Fixed Tumor • T4a. Prostate, uterus, vagina • T4b. Fixed to pelvic wall. STAGING (UICC SYSTEM)
- 47. STAGING • Stage 0.pTa & TIS • Stage 1. T1N0M0 • Stage 2. T2N0M0 • Stage 3. T3 (a/b) • Stage 4. Any metastasis
- 48. Superficial Tumor(Ta, T1) Invasive Tumor ( T2, T3) Fixed & Metastatic Tumor (T4) - Poor prognosis MANAGEMENT
- 49. 1. Superficial Tumor(pTa, pT1) • Trans Urethral Resection Bladder Tumor (TURBT) and send tissue for HPE • pT1 - Repeat Cystoscopy & resection of tumor base after 6 weeks - Followed by Intravesical BCG Regular follow up for cystoscopic exam : Every 3monthly for 3 years -> 6 monthly for 2 years
- 50. Trans Urethral ResectionBladder Tumor (TURBT)
- 51.
- 52. Cystoscopy • Endoscopy ofthe urinary bladder
- 53. Intravesical Chemo/Immunotherapy • Usedafter TURBT for Stage 0 or Stage 1 Ca. • It’s used only for early stage Ca – affect mainly the cell lining inside bladder, no effects on cells elsewhere. • BCG : Is put directly into bladder through a catheter- attract immune system cells to the bladder –attack the cancer cells.
- 54. 2. Invasive Tumor(pT2, pT3) • Partial Cystectomy. Limited to small adenocarcinoma • Radical Cystectomy. - Followed by chemotherapy/radiotherapy - Localised pT2-3 that has no spread and CIS refractory to BCG, Pt >70 years old • Neoadjuvant Chemotherapy. To shrink tumor before surgery • Chemotherapy & Radiotherapy. Unfit, Older or decline cystectomy
- 55. • Orthotopic BladderReplacement. If urethra can be retained, reconstruct new bladder from intestine • Ileal Conduit.
- 56. 3. Metastatic Tumor(pT4) • Poor prognosis. Incurable • Palliative. No surgery • Treat with chemotherapy
- 57. PROGNOSIS • Mucosal Tumor-50-60% 5 years survival • Deep muscle invasion: 20-30% 5 years survival rate • Overall 1/3 patient survive for 5 years
- 58.
- 59. Epidemiology • Age >65 years old • 10-15% of younger men with positive family history but unclear etiology • Rates of clinically evident disease are low in Japan & China • In Malaysia :6th among top 10 cancers for men
- 60. Risk Factors • Age>65 years old • Family history :first degree relatives • Hormonal : high testosterone • Exposure to cadmium
- 61. Pathology • Almost alladenocarcinoma • Origin : peripheral zones of prostatic glands • Gleason scoring – degree of glandular differentiation & relationship to stroma
- 63. Mode of presentation i.Found on autopsy or at cystoprostatectomy ii. Accidental findings during TURP (T1a & T1b) or by PSA (T1c) iii. Early, palpable, localised prostate cancer (T2) iv. Advanced local prostate cancer (T3 & T4) v. Metastatic disease
- 64. Spread Local • Seminal vesicle •Bladder : neck & trigone • Lower end of ureter • rectum Hematogenous • Bone Lymphatics • External iliac • Internal iliac • Mediastinal • supraclavicular
- 65. Clinical Features -History • Asymptomatic – screening by per rectal examination and PSA - Suspiciously raised serum PSA - Found on histological examination after TURP • Only advanced disease gives rise to symptoms, but even advance disease may be asymptomatic
- 66. • Symptoms ofadvanced disease - Bladder outlet obstruction - Pelvic pain & hematuria - Bone pain - Renal failure
- 67. Clinical Features –Physical Examination • Sign of anaemia • Nodular, irregular, stony hard, fixed prostate on per rectal examination
- 68. TNM Staging TUMOUR • T1– clinically inapparent tumour neither palpable nor visible by imaging • T2a – tumour confined within prostate & 1 lobe T2b – tumour involved both lobes • T3 – tumour extends through prostate capsule T3a – uni or bilateral extension T3b – seminal vesicle extension • T4 – tumour is fixed or invades adjacent structure other than seminal vesicles
- 70. NODAL • N1 –lymph node metastasis METASTASIS • M1 – distant metastasis * If prostate Ca is palpable it is incurable
- 71. Investigations Diagnostic • Prostate SpecificAntigen (PSA) - Cancer detection rate 2-4% - Lack sensitivity & specificity - 30% men with PSA, cancer confirmed by biopsy - 20% men with prostate Ca have normal PSA - Good at following course of advanced disease
- 72. • Also raisedin : Acute Urinary Retention, TURP, prostatitis, large BPH, catheterization Level Possibility <4ng/ml Normal 4-10ng/ml Benign prostate hyperplasia, prostatitis >10ng/ml Suggestive malignancy >35ng/ml Diagnostic for advanced cancer >100ng/ml Distant bone metastasis
- 73. • Trans-rectal ultrasound(TRUS) - Image the prostate irrespective findings on palpation - Guide transrectal needle biopsy - Diagnosis of locally extensive disease (T2) • Prostate biopsy (transrectal) - Take multiple biopsy - If patient has bladder outlet obstruction, then can do transurethral resection of prostate (TURP)
- 74. Transrectal US showing normalseminal vesicles Transrectal US showing local extension of T3 prostate cancer
- 75. Obtaining a specimen ofprostatic tissue by means of a biopsy needle
- 76. Investigation Routine • Full bloodcount - Anaemia (leucoerytroblastic anaemia, renal failure or hematuria) - Thrombocytopenia (DIC) • Liver function test - Abnormal if liver metastasis present (ALP in both bone & liver metastasis)
- 77. • Chest X-ray -Lung metastasis • Pelvic & lumbar X-ray - Sclerotic / osteolytic metastasis in lumbar vertebrae & pelvic bones • MRI/CT scan - Local staging, node & metastasis
- 78. Osseous metastasis of thepelvic bones in carcinoma of the prostate
- 79. • Bone scan -After establish diagnosis, as part of diagnosis - If PSA >10nmol/ml or biopsy showed high grade cancer - If PSA <10nmol/ml with clinical indication
- 80. Bone scan showing multiplehot spots suggestive of metastatic disease in a man with prostate cancer
- 81. Management Treatment Modalities • Surgery– radical prostectomy - Removal of whole prostate until distal sphincter & seminal vesicle - Complications : impotence, stress incontinence
- 82. • Radiotherapy - ExternalBeam : T1, T2, locally advanced T3 - Brachytherapy : T1 disease (Iodine 125, Palladium 103) - General radiotherapy : for metastasis
- 83. • Androgen ablation -Orchidectomy : bilateral, subscapular - Medical : LHRH agonist like goserelin : anti androgen like flutamide, bicalutamide or cyproterone - Anti androgen drugs can cause hormone resistance & hepatotoxic
- 84. Treatment Summary • Atany stage, transurethral resection for bladder outlet obstruction Stage T1 & T2 - Active monitoring or radical local treatment i.e. prostectomy or radiotherapy Stage T3 - Radiotherapy, often with neoadjuvant or adjuvant hormonal therapy
- 85. Stage T4 - Antiandrogen therapies (bilateral orchidectomy) plus - Radiotherapy ; painful bone metastases or spinal cord compression or - Drug treatment with LHRH agonist anti androgen drugs
- 86.
- 87. Epidemiology • Uncommon malignancy •Elderly man, 50-70 years old • Mostly squamous cell carcinoma, other rare carcinomas are melanoma, haemangiosarcoma or fibrosarcoma
- 88. Aetiology & RiskFactors • Phimosis - Circumcision at birth confer’s immunity & at later ages has no immunity • Pre cancerous lesion : - Genital warts : HPV, condyloma acuminate - Leucoplakia, Paget’s Disease of the penis - Bowen’s Disease (carcinoma in situ)
- 89. • Poor hygiene& smoking • Chronic inflammatory condition of the penis (balanophostitis)
- 90. Pathology • Typically squamouscell carcinoma arising from skin of the glans/prepuce • May be flat & infiltrating - arises from leukoplakia • Papillary projections – exists from papilloma, more common
- 91. Penile squamous cell carcinomaappearing as a reddish, raised, and firm nodule in the inner portion of the foreskin
- 92. Spread • Direct spread •Lymphatic spread • Blood spread
- 93. Clinical Features • Manypresent late (due to embarrassment/ misdiagnosis) • Growth is often large with foul bloody discharge (2nd infection) • Typically little/no pain • 50% have inguinal lymph node enlargement, often reflects infection • The prepuce is non-retractile & must be split to view the lesion
- 94. A squamous cellcancer of the penis with an ulcerating groin node
- 95. • The wholeglans may be replaced by fungating mass (untreated) • Later, the inguinal nodes can erode the skin of the groin
- 96. Physical Examination • Site: glans penis or inner surface of foreskin • Inspection - Painless ulcer, irregular margin, rolled edges & indurated or gray, crusted popular lesion - Bleeding & yellowish discharge can be seen
- 97. • Palpation - Firmto hard - Retract foreskin ( some are found under the foreskin ) - Check for phimosis - Feel for inguinal lymph nodes
- 98. Staging • Jackson’s staging Stage1 Tumour confined to the glans/ prepuce Stage 2 Tumour invade shaft or corpora but no nodes involvement Stage 3 Tumour confined to the penis & operable nodes involvement Stage 4 Tumour involves adjacent structures & inoperable nodes metastasis
- 99. TNM staging Tumour Tis: carcinoma in situ Ta : noninvasisve verrucous tumour T1 : Tumour invading subepitelial connective tissue T2 : Tumour invading corpora T3 : tumour invading urethra or prostate T4 : tumour invading other adjacent structures
- 100. Node N1 :1 superficial inguinal lymph node N2 : multiple bilateral inguinal lymph nodes N3 : deep inguinal & pelvic lymph nodes, bilateral or unilateral Metastasis M1 : distant metastasis
- 101. A late presenting squamouscell cancer of the penis
- 102. Investigations (special) • Punchor excisional biopsy of the lesion • Fine needle aspiration for palpable lymph nodes • CT/MRI to evaluate metastasis
- 103. Management • Divided intotreatment of primary tumour & inguinal lymph nodes • Primary treatment : 2 methods i. Radiotherapy - Indicated for small & well differentiated growth limited to penis glans - Disadvantage : scarring caused painful erection
- 104. ii. Surgery - Indicated: anaplastic growth, big growth, infiltrate shaft of penis & radiotherapy failed - Methods of surgery A. partial amputation of penis : distal growth limited to glans penis & prepuce B. total amputation of penis : lesions affecting the shaft of penis & anaplastic lesions
- 105. • Secondary tumour– associated with inguinal lymph nodes - No nodes enlarged : follow up carefully - LN enlarged which are not fixed : wait for 3 weeks after treating primary growth - LN enlarged are massive & inoperable : deep radiotherapy is given & may be treated with chemotherapy - Sentinel node biopsy
- 106. REFERENCES • William NS,Bulstrode CJK, O’connell PR, Cholelithiasis. Bailey & Love’s Short Practice of Surgery. 26th edition, CRC press
- 107.
Editor's Notes
- #41 FBC – Anemia , Urosepsis LFT – Hypoalbunimenia RBS – Hypoglycemia Coagulation Profile – TRO Coagulation ds PSA – TRO Prostat Ca
- #50 How is the procedure performed? The procedure requires general or spinal anaesthesia, with patient placed in the gynaecological examination position. Initially, the genital area is cleansed and the urethra lubricated. A special camera is inserted through the urethra searching for abnormal areas of the bladder to be removed with the use of an instrument attached to the camera. This instrument uses heat to remove abnormal tissue. Then the site is cauterized to prevent bleeding. If there is suspicion for malignancy, the surgeon obtains tissue sample for biopsy. At the end of the procedure, a catheter is placed for continuous bladder irrigation with normal saline. The average length of hospital stay is about 3 days, depending on the size of bladder tumor. The catheter is usually removed on the first postoperative day.
- #54 It is used only for these early-stage cancers because medicines given this way mainly affect the cells lining the inside of the bladder, with little to no effect on cells elsewhere. This means that any cancer cells outside of the bladder lining, including those that have grown deeply into the bladder wall, are not treated. Drugs put into the bladder also can’t reach cancer cells in the kidneys, ureters, and urethra, or those that have spread to other organs.