1、Key points in todays classv Renal Cell Carcinnomav Stage and Grade of Bladder Cancer v Diagnosis and treatment for Bladder CancerRenal Parenchymal Neoplasmsq Benign Tumors Renal Adenoma(肾腺瘤) Renal Hamartoma (肾错构瘤)q Malignant Tumors Renal carcinoma(肾癌) Nephroblastoma(Wilms Tumor) (肾母细胞瘤)Renal carcino
2、ma (renal cell carcinoma, RCC)Incidence Renal carcinoma is the Second most common genitourinary neoplasm in China. Each year, renal carcinoma afflicts 30,600 people in the United States, and at least 12,000 deaths occur. There is a two-fold to three-fold male predominance No obvious racial predilect
3、ion has been noted The peak incident is in the sixth and seventh decades of life, but the disease is seen occasionally even in adolescentsPhotomicrograph of RCC RCCs originate from the proximal renal tubular epithelium. 透明细胞 颗粒细胞 肉瘤样细胞Clear cells Granular cells Sarcomatoid cells RCCS originate in th
4、e cortex and tend to grow out into perinephric tissue. Grossly, the tumor is characteristically yellow to orange because of the abundance of lipids, Particularly in the clear cell type.RCCs generally do not have a true histologic capsule but almost always have a pseudocapsule composed of compressed
5、parenchyma（肾实质） and fibrous tissue.假性包膜假性包膜(pseudocapsule)Tumor metastasis Direct invasion By Blood By lymph By urine duct Thirty percent of patients with renal cell carcinoma have metastatic disease at diagnosis, and in 40% who undergo nephrectomy, disease ultimately recurs (25% distant metastases,
6、 10% regional nodes, 5% local recurrence) The most common site of distant metastases is the lung. However, liver, bone, ipsilateral adjacent lymph nodes, adrenal gland, and the opposite kidney are frequent sites of disease spread.Tumor statingStage : Tumor is confined within the kidney parenchymaSta
7、ge : Tumor involves the perinephric fat but is confined with Gerotas fasciaStage A: Tumor involves the main vein or inferior vena cavaStage B: Tumor involves regional lymph nodesStage C: Tumor involves both local vessels and regional lymph nodesStage A: Tumor involves adjacent organs other than the
8、adrenal Stage B: Distant metastasesSymptoms and signs Hematuria(60%) Flank pain(45%) Flank mass(40%)Paraneoplastic Syndromes Fever(发热) Erythrocytosis(红细胞增多症) Hypercalcemia(高钙血症) Hypertension(高血压)Laboratory FindingsThese findings are nonspecific, and normal finding can not rule out a diagnosis of RCC
9、 Anemia（贫血） : occurs in about 30% of RCC patients Gross or microscopic hematuria（血尿） : can be seen in up to 60 of RCC patients An elevated ESR（血沉）: is commonly seen with reported incident as high as 75%Ultrasonography(US) US has come to play an important role in diagnosis of lesions by virtue of its
10、 safety, accuracy, and relatively low cost Renal US can determine whether a mass is solid（实质性） or cystic（囊性）, the presence of enlarged retroperitoneal nodesRadiologic diagnosis Plain film of the abdomen: may show renal enlargement, distortion, or axis shift IVU:distortion or obstruction of the urina
11、ry collecting system may be seen肾癌IVU图像 肾盏、肾盂因受肿瘤挤压不规则变形、狭窄、拉长或充盈缺损。手托球征CT Scanning CT allows differentiation of cystic from solid masses, determination of the local extent of the tumor, visualization of the renal vein and inferior vena cava, and examination of possible sites of metastatic disease,
12、such as adrenals, liver and lymph nodes.Magnetic Resonance Imaging (MRI) MRI is equivalent to CT for staging of RCC. Its primary advantages is in the evaluation of patients with suspected vascular extension.图： CT、MRI 检查平扫 增强CT、MRI 检查图检查图MRIRenal Angiography With the widespread availability of CT sca
13、nners, the role of renal angiography in the diagnostic evaluation of RCC has markedly diminished.Treatment Treatment is based on stage, size, location in the kidney, number of lesions, and bilaterality. Operation: partial nephrectomy; radical nephrectomyImmunotherapy Chemotherapy Region radical neph
14、rectomyLaparoscopic radical nephrectomyWilms tumor(nephroblastoma) Wilmss tumor is a malignant renal tumor that occurs predominantly in children and rarely in adolescents and adults. The annual incidence is approximately eight cases per million children, with a peak at 3 years of age.肉眼观肉眼观：肿瘤增长极快、柔
15、软；切面均匀肿瘤增长极快、柔软；切面均匀呈黄色，但可有囊性变和块状出血，肿瘤呈黄色，但可有囊性变和块状出血，肿瘤与正常组织无明显界限。与正常组织无明显界限。Signs and symptoms A palpable mass(80%) Abdominal pain(30%) Constitutional symptoms of malaise or fever(50%) Gross or microscopic hematuriaTreatment Treatment with a combination of surgery, chemotherapy, and radiation ther
16、apy yield a survival greater than 90%. Carcinoma of the Renal Pelvis and Ureter Tumors of the upper urinary tract account for about 5% of urothelial neoplasms. A male-to-female preponderance of 2:1 is noted, with an average age at diagnosis of 65.Tumor classification Transitional cell carcinoma（移行细胞
17、癌）: accounts for 85% of renal pelvic tumors and 93% of ureteral tumors. Squamous cell carcinoma（鳞癌）: is seen in association with chronic inflammation or irritation and accounts for 14% of renal pelvic tumors and 5% of ureteral carcinomas. Adenocarcinoma（腺癌）: accounts for fewer than 1% of renal pelvi
18、c tumors.Diagnosis Hematuria is the presenting sign in 80% of patients. Pain with or without obstruction may be seen in 40% patients. A palpable mass is rare. Gross or microscopic hematuria: can be seen in up to 90 of patients Urinary cytology: Cells for microscopic examination are collected from vo
19、ided urine.Laboratory FindingsSpecial examination 尿路造影片 肾盂内充盈缺损、变形。 Intravenous urography (IVU) displays a radiolucent filling defect that can be confimed by retrograde pyelography （逆行肾盂造影）.CT or MRI CT or MRI is essential for staging and evaluating regional lymph nodes.Ureteroscopy Ureteroscopy has
20、 allowed direct visualization and biopsy of suspected lesions.Treatment Nephroureterctomy(kidney, ureter and cuff of bladder)Carcinoma of the BladderIncidence Bladder cancer is the most common genitourinary neoplasm in China, the second common in United States. The peak incidence is in persons from
21、50 to 70 years old, with a male-to-female predominance of 3:1.Etiology Industrial toxins Cigarette smoking Other risk factors: cyslophosphamide, alkylating agents such as thiotepa, radiotherapy of the pelvis, ectTumor classification Transitional cell carcinoma（移行上皮细胞癌）: accounts for more than 90% of
22、 all cases of bladder cancer Squamous cell carcinoma（鳞癌）: accounts for 7% to 8% of cases of bladder cancer Adenocarcinoma（腺癌）: accounts for 1% to 2% of cases Other types: small-cell carcinoma, sarcoma, melanoma, and carcinoid tumorsTis：原位癌Ta： 乳头状无浸润T1： 限于固有层以内T2a： 浸润浅肌层T2b： 浸润深肌层T3： 浸润膀胱周围脂肪组织T4： 浸润
23、前列腺或膀胱邻近组织* 浅表性膀胱肿瘤浸润深度是肿瘤临床（T）和病理（P）分期依据，可分为：Grade mild anaplasiaGrade moderate anaplasiaGrade marked anaplasiaSigns and symptoms Approximately 80% of patients present with gross, painless hematuria. Approximately 20% of patients with bladder cancer present solely with microscopic hematuia Dysuria
24、and irritative symptoms are present in 20% of patients. Secondary urinary infection may be present in about 30% patients.Cystocopy Urinary cystology Cells for microscopic examination are collected from voided urine or bladder washing.Flow cytometry Flow cytometry is the computerized analysis of DNA
25、content in exfoliated cells. The main advantage over routine cytologic study is the ability of flow cytometry to detect low-grade tumors accurately. Radiologic examinationsThe IVU demonstrates a filling defect in the bladder only 60% of the time. Pelvic Ultrasonography(US) US may help determine the
26、extent of local invasion. The advent of newer transurethral and transrectal probes may provide better detail and clarity.CT、MRI CT、MRI may detect nodal metastases greater than 2 cm in size and provide gross assessment of extent of local disease.Treatment -by stage of disease vTransurethral resection
27、（经尿道膀胱肿瘤切除术， TURBT ）: for low-grade, noninvasive tumor(Tis, Ta, T1)vPartial or radical cystectomy（膀胱部分或根治性膀胱切除术）: more invasive, but still localized, tumors (T2, T3)vSystemic chemotherapy, follow by irradiation or surgery (T4)TURBTIntravesical Chemotherapy Chemotherapeutic agents: Mitomycin C, Thiot
28、epa, Doxorubicin Immuno agents: BCG, IFN, IL-2Follow-up TURBT and Partial cystectomy is follow by cystoscopic and Urinary cystology surveillance every 6 months for 2 years, every 12 months for 5 years. Prostate Cancer Prostate cancer is the second most common malignancy in male adults as well as the
29、 second most common cause of cancer-deaths in the United States. The cause of prostate cancer is unknown, but all prostate cancer cell exhibit some degree of androgen dependence.Tumor histology More than 95% of prostatic neoplams are adenocarcinomas arising from prostatic acinar cells at the periphe
30、ry of the gland. BPH develops from inner periurethral tissues.Dignosis Sign: Obstruction Digital rectal examination Prostate-specific antigen(PSA) Transrectal ultrasonography(TRUS)TRUSProstate biopsy Bone scanningPelvic CT/MRI They can assess gross local extension and nodal metastases larger than 2
31、cm. The sensitivity is ranging from 27% to 75%, specificity is between 66% to 100%Treatment Surgical: Radical prostatectomy Radiotherapeutic: External-beam radiation therapy; Interstitial irradiation Hormonal approaches:Bilateral orchiectomy; Luteinizing homone-releasing hormone(LHRH) analogs; Antiandroens甄，男，48岁，机关干部。间断性无痛性肉眼血尿8月。患者近8月来反复出现无痛性肉眼血尿，多为终末血尿，无明显尿频、尿急、尿痛及夜尿增多表现，无明显双侧腰痛、腹痛、发热等不适，精神食欲可，无明显消瘦，大便正常，夜间睡眠好。尿道膀胱镜提示膀胱三角区有一个2cm大小乳头状新生物。既往无特殊病史。有20多年抽烟习惯，约每天20支；无嗜酒嗜好。 谢谢大家
