Quid Refert, Dummodo non Desinas, Tardius Ire

Subspec GU Tumors

Urology Dr. Reyes

RENAL CELL CARCINOMA  Sites of metastases (noted on autopsies)

 Lungs 55%
 Prevalence  Liver 33%
 30,000 new cases detected each year (USA)  Bone 32% (axial skeleton)
 3% of all adult malignancies  Ipsilateral Adrenal 19% (if mass on upper pole)
 85%, primary renal tumors (5-10% metastatic)  Contra-kidney 11%
 Originates from epithelial cells of the PCT Prevalence  Brain 5.7%
 Common in 6th decade of life  Heart 5%
 Male > Female (2-3x)
 Etiology : UNKNOWN  RENAL MASS (Differential diagnosis)
 Hereditary / Sporadic (more common)  Benign renal cyst
 Abscess
 ↑ INCIDENCE  Hematoma
 Von Hippel-Lindau dse., horseshoe kidneys, APKD, acquired renal  Infarct
cystic dse  Vascular malformation
 Benign mesenchymal tumor
 Possible agents  Renal pseudotumor
 Tobacco users- 5X risk (second-hand smokers – incidence is the  Metastatic carcinoma
same)  Angiomyolipoma
 coffee  Oncocytoma benign solid renal masses
 Chemicals  Transitional cell carcinoma
 Lead, cadmium  Renal cell carcinoma – if a SOLID mass; dictum would be consider
 Radiation it a malignancy until proved otherwise
 Viruses
 Hereditary: (usually bilateral) both kidneys affected  DIAGNOSTICS
 Sporadic: one-sided unilateral  Hx & PE, CBC, Urinalysis (RBC in urine)
 PHYSICAL EXAMINATION  Ultrasonography – most basic & cheapest
 IVP – most common BEFORE
 CT scan
 Most renal masses >50% - incidental
 MRI – if Px is allergic to contrast material, substitute if
pregnant
 Renal arteriography – vascularity of tumor; usually a tumor is
hypervascular
 If mass is really big – embolization
 Percutaneous aspiration (cyst / solid )

 TREATMENT
Bimanual examination  RADICAL NEPHRECTOMY
 press posterior hand upward – sometime there is transmission of  ** Gold standard
impulse to your anterior palpating hand  Connotes a malignancy, in contrast to SIMPLE
 if able to grasp kidney in the ant. hand and able to mobilize → nephrectomy wherein you dissect different
BALLOTABLE; it means kidneys are not fixed to involve adjacent layers/structure enveloping the kidney and
structures (GOOD prognosis) remove the kidney
 If RADICAL, it connote cancer surgery, you DON’T
 SIGNS AND SYMPTOMS dissect different layers, you remove the entire
 TRIAD – occurs in 7-10% (advanced stage already) kidney with the enveloping structures (perirenal
1. Hematuria (gross / microscopic) – sudden change in the color fascia, pararenal fascia, Gerota’s fascia)
of urine  Partial Nephrectomy (nephron- sparing)
 Complete type of hematuria wherein from the start up to  If mass is in the upper/lower pole
the termination of urine – entire stream is tea-colored  For hereditary (bilateral) – you don’t remove all of
 If bright red urine – etiology would be from the origin of the kidney
the urinary tract (uretha/bladder neck)
 If microscopic, check for Ultrasound and KUB  Metastatic disease:
2. Pain (abdominal / flank) – flank pain may be a bleb/blood clot  Radical nephrectomy NOT curable anymore
that’s obstructing the ureter  Hormonal <15% response rate (progesterone)
3. Palpable abdominal mass – normal kidneys are non-palpable  Chemotherapeutic agents
 Metastatic disease (LUNGS most common site)  RT – NOT sensitive
 Dyspnea, cough, bone pain  Immunotherapy – investigational (30-40%)
 Paraneoplastic syndromes (erythrocytosis, ◦ IFN-A, IL-2
hypercalcemia,HPN,hepatic dysfunction) ◦ VEGF, PDGF inhibitors
 Stauffer’s Syndrome (not secondary to metastasis)  CYTOREDUCTIVE – diminish tumor bulk/burden;
remove kidney and tumor and give adjunctive
mgmt.

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 WILMS TUMOR  Metastasize through either direct extension (renal capsule),
hematogenous (renal v., IVC), regional lymphatic spread
 Common in CHILDREN, misnomer to nephroblastoma  Metastatic at diagnosis – 10-15%
 Named after Max Wilms, characterized the tumor in 1899  Lungs 85-95%
 Rance, 1914 = 1st to described Wilms tumor  Liver 10-15%
 5% of all solid chilhood malignancies (hepatoblastoma, neuroblastoma)  Lymphatic 25%
 Represents >80% of all GU cancers in <15 years old
 >90% noted before age 7 years  Staging is based on NWTS – I, II, III
 3 – 4 years = Peak incidence  Histopathology (anaplasia) / tumor stage – Prognostic determinants
 M=F
 Arises from abnormal proliferation of metanephric blastema without  TREATMENT is according to tumor stage
differentiation into normal glomeruli & tubules  Radical nephrectomy – if large enough or unilateral (NOT if
 Majority are NONHEREDITARY (one-sided) bilateral)
 Herediatary if  Sandwhich therapy (if mass is really big) →pre-op
 Bilateral tumors – 4-5% radio/chemotherapy (shrinks size of tumor)
 Hx. of familial tumors  Bilateral partial nephrectomy – if bilateral involvement
 Familial Type - Tumors associated w/ Aniridia or GU anomalies (10%)  Chemotherapy
 11p13(short arm,11th chromosome) – where suppressor gene is located  Radiotherapy

 CLINICAL PRESENTATION:  FAVORABLE SUBTYPES

 90% - palpable abdominal / flank mass (NWTS – III)
 33% - abdominal pain  I - 97%
 30-50% - hematuria ( gross / microscopic )  II - 92%
 25-60% - hypertensive  III – 84%
 10% - coagulopathy  IV - 83%
 UNFAVORABLE SUBTYPES
 WAGR syndrome: Wilms tumor, Aniridia, Genitourinary anomalies,  I – III - 68%
mental Retardartion  IV - 55%

 Differential Diagnosis BENIGN TUMORS of the KIDNEY

 RENAL MASSES
 Wilms tumor  (rare b/c most of the kidney masses are malignant) (5-10%)
 Multicystic dysplastic kidney  Simple cyst – discovered accidentally on UTZ
 Hydronephrosis (…ongoing obstruction)  Cortical adenoma – more solid masses
 Polycystic kidney  Renal oncocytoma – small solid masses
 Congenital mesoblastic nephroma  Angiomyolipoma (renal hamartoma)
 Others – occur rarely
 NONRENAL CAUSES  Fibromas
 Mesenteric/choledochal cysts  Lipomas
 Intestinal duplication cyst  Myomas
 Splenomegaly  Lymphangiomas
 Neuroblastoma  hemangiomas
 Rhabdomyosarcoma
 Lymphoma SIMPLE CYST
 Hepatoblastoma → differentiate it with Wilm’s wherein it
DOESN’T cross the midline, wherein blastoma CROSSES the  Most common benign renal lesion
midline  When present w/ recurrent UTI and workup reveals simple cyst
 Single / multiple, unilateral / bilateral
 IMAGING STUDIES:  Sizes range from few mms. to several cms.
 UTZ (doppler) – see if there’s obstruction to blood flow  Usually found incidentally
 IVP  Simple cyst – homogenously black (benign nature)
 CT scan (abdomen / chest) – b/c common site of metastasis is lungs  Usually asymptomatic →requires no treatment
 Chest x-ray - during follow-up  Large cysts may cause pain / obstruction → need treatment (Excision or
 MRI / MR angiography – vascularity laparoscopic marsupialization) → you can do outpatient percutaneous
aspiration of cyst fluid and sent for cytologic exam
 UNFAVORABLE SUBTYPES  Benign cyst fluid → Xanthochromic/yellow color
(10% of Wilms tumor)  If bloody → could be malignant
(>60% of tumor deaths)  Diagnostics: UTZ, IVP, CT , angiography
 Anaplastic tumor
 Rhabdoid- most lethal BOSNIAK CLASSIFICATION (CT criteria)
 Clear cell sarcoma
 FAVORABLE SUBTYPES - majority
 Type I: seen on CT / UTZ; no Tx. needed
 Better prognosis (5yr survival)
 Type II: may have few internal septations,thin peripheral calcifications,or
 No focal areas of anaplasia
an attenuation value >20 Hus on CT. These minimally complex cysts are
 Multilocular cyst
usually sequelae from prior hge. or infection and are almost always
 Congenital mesoblastic nephroma
benign.
 Rhabdomyosarcoma tumor (not rhabdoid type)
 Type III: may have internal debris, thick walls or septations, or irregular
calcifications. Because 40-50% of these cysts are malignant, they are
managed surgically (excise) by either Radical or Partial nephrectomy
 Type IV: these lesions are complex cystic masses with enhancing nodular
elements and are considered RCC until proven otherwise.

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 RENAL CORTICAL ADENOMA  HISTOLOGIC TYPES
 >90% - Transitional cell carcinoma
 Are small lesions (< 3 cm)  7% - Squamous cell carcinoma
 Asymptomatic solid tumors  Chronic UTI
 Benign tumors histologically  Parasitic inf. – Schistosoma (ova in
 May represent premalignant early stage of renal carcinoma growth muscle layer)
 Can’t be distinguished from small RCCA  Untreated stones → chronic irritation
 Dx. is based solely on pathologic examination → squamous metaplasia
 1 – 2%- adenocarcinoma
 From remnants of hypogastric
URETERAL TUMORS
ligament (patent urachus - that
connect the umbilicus to the dome of
 PRESENTATION: the bladder )
 Hematuria
 Flank pain – because of obstruction (blood clot in lumen)  Mode of spreads
 Slow-growing tumors  Local extension
 Majority are malignant, (calyceal down to the bladder) urothelial in origin  Lymphatics
- lined by Transitional cell - * TRANSITIONAL CELL CA (M/C histologic type)  Hematogenous
 Squamous cell Ca & benign lesions – Rare 
 Risk factors: environmental carcinogens, analgesic abuse, cigarette  CLINICAL SITES OF METASTASIS (↓order)
smoking, papillary necrosis,Balkan nephropathy,  Pelvic lymph nodes
 Lungs
 DIAGNOSTICS  Bones
 IVP (contrast study) – reveals a  Liver
filling defect of the ureter /
obstruction (radioluscent)  11 months – median interval between dx & clinical
recognition of metastasis
 UTZ CANT differentiate
ureteral tumor from  PRESENTATION:
 CT scan luscent stone  Painless hematuria
 Urine cytology  Timing of hematuria
 Brushing the lesion (if no  Start of urination: initial (simula
frank mass) mapula, sa dulo dilaw)
 Ureteroscopy & biopsies – single  NOT RCC
most accurate diagnostic  Think of obstruction to distal
 NEPHROURETERECTOMY – Gold standard urethra (ant. urethral meatus)
 Urothelial CA – more formidable surgery than radical  Terminal – simula dilaw sa dulo namula
nephrectomy b/c you’re going to remove the kidney,  Think of bladder neck tumor
ureter, up to the ureteral orifice (any part of the  Post. urethral tumor (prostatic
urothelium not removed is site for future recurrence) area)
 Others  Trigonal area
 RT - marginal benefit  Total (initial to terminal) – entire
 Chemotx – may be beneficial. Used for stream is tea-colored
invasive disease  Tumor at the Dome of the bladder
 Ureteral
BLADDER CARCINOMA  Renal
 Why brown? Because when RBC
 2nd most common GU tumor mixes w/ urine → it lyses and
 4th most common cancer in men (M/C GU tumor in men is Prostate CA) releases hematin
 8th most common cancer in women  Irritative symptoms
 Accounts for 2% of all malignant diseases  Frequency
 Highest incidence in industrialized countries  Urgency
 3 : 1 (male : female)  Dysuria
 65 years – average age during dx.  Flank pain – due to ureteral obstruction
 Pelvic mass
 RISK FACTORS  Symptoms due to metastasis
 Age (peak incidence in 7th decade)  If lungs- dyspnea, cough
 Exposure to aniline dyes & aromatic amines  If liver – changes in enzymes
 Cigarette smoking (4x increased risk)
 Phenacetin abuse  Hx & P.E. (Bimanual examination: sa lalaki, one of your
 Treatment with cyclophosphamide (chemotherapeutic agent hand inside rectum, the other on top of hypogastric area.
excreted mostly in GU tract; waste products are exposed to the In females: examining finger inside vaginal canal, the
urothelium) other in hypogastric. When doing bimanual exam, usually
under SPINAL anesthesia so that organs are relaxed)
 If movable – good prognosis
 DIAGNOSIS
 CYSTOSCOPY
 Staging – CT Scan

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  TREATMENT (determined by tumor staging)
 TUR-BT: Kung maliit lang – transurethral resection of bladder  TRANSRECTAL UTZ (TRUS)
tumor (scrape off small bladder mass, give intravesical  Uses a rectal probe that outlines the prostate sonographically.
chemotherapy)  Hypoechoicarea (s) are biopsied using springed biopsy needle.
 Radical cystectomy w/ urinary diversion (if bladder tumor is  Systematic / sextant biopsies done if there’s no suspicious
scattered) nodule
 Urinary diversion: Get segment of ileum and tunnel the  Longer probe
two ureters to the segment of the ureter and the other  Ask the patient to lie down or bend forward
head comes out as your urinary stoma (magkakaroon ng  RADIONUCLIDE BONE SCAN
urethra – collecting urine coming out from ileal  Useful in detecting bone metastases
segments) → Ileal conduit to prevent alkalosis or renal  Obtained in patients with significant elevation of PSA
acidosis because of longer holding time (>20ng/dl), high-grade, large-volume tumors, or presence of
 Partial cystectomy (for deeper involvement from lamina bone pain
propria/mucosa) – resect and repair  Xray- >1cm ang kelangan para madetect yung bone mets
 Combined treatment (not amenable to curative)  patients w/ significant elevation of PSA (>20ng/dl)
 Neoadjuvant / adjuvant chemotherapy
 RT  GLEASON’S SUM / SCORE
 Based on pattern of cells
PROSTRATE CARCINOMA  2 regions of the prostate are viewed, each
graded 1 – 5 (well differentiated to poorly
 Most common GU tumor in men differentiated)
 2nd most common malignancy in men,1 male—due to testosterone  Gleason’s sum: (2 – 10)
 Etiology: Unknown  2,3,4 – well differentiated
 Histologic types:  5,6,7 - moderately differentiated
 Adenocarcinoma – most common (>90%)  8,9,10 – poorly differentiated
 TCCA
 Sarcoma  TREATMENTS:
o 30% men >50 years- have histologic evidence of Pca  Radical prostatectomy
o Disease of the ELDERLY !!!  Curative management
o Autopsy clinical  Open Surgery
 Laparoscopy –
 RISK FACTORS:  Robotics –
 Elderly males ;90 years old mas higher  Radiation therapy
 African – Americans,black  External beam
 Familial predilections  Placement of radioactive seeds within the
 One First-degree relative – 2-fold increased prostate (gold, iodine, iridium, palladium)
 Two First-degree relatives – 9-fold increased(father & brother) ,  Brachytherapy-implant a seed in entire
two fold increase pag sibling..mas higher pag sa tatay prostate
 if you don’t want to do surgery
 70% - arises from the PERIPHERAL ZONE,biggest zone  do it with ct scan guided or ultarsound guided,
 20% - TRANSITION ZONE,bph most common site  curative management
 10% - CENTRAL ZONE  Endocrine therapy
 DRE: palpable HARD nodule!  LH/RH analogs total androgen
Consider malignancy until proven otherwise!!!  Castration blockade
 For advanced cases
 In the early stages, no symptoms related to malignancy. May  Surgical Castration
have symptoms similar to those of BPH.
 Cut-off circulating testosterone by
 Nocturia
 Urgency 95%- do bilateral orchiectomy
 Weak urinary stream  The remaining 5% is from adrenal
 In advanced disease, particularly bone metastases, SKELETAL gland, give anti-hormona/anti
PAIN may be a presenting symptom. androgen to counter act the 5%
 PROSTATE CARCINOMA hormones or injectable treatment
 DIGITAL RECTAL EXAM (DRE)--best
 PROSTATE-SPECIFIC ANTIGEN (PSA)
 TRANSRECTAL ULTRASOUND (TRUS) + biopsy
Bone-most common site for metastasis
Skeletal pain-manifestation of adv stage
Nocturia,other urinary prob initial sx
DIAGNOSIS
 DIGITAL RECTAL EXAM
 Lateral Sims position
 Bend forward
 PROSTATE-SPECIFIC ANTIGEN (PSA)
 A serine protease
 Produced both by normal & malignant prostate epithelial cells
 A tumor marker monitoring Pca treated patients
 Prostate specific NOT prostate cancer specific
 Normal value-- 0-4 ng/ml
 Abnormally high pag may tumor,inflammation
 Prosatitis,instrumentation,sexual activity may cause
elevation,so do TRUZ

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 PENILE CARCINOMA

 Squamous cell Ca – most common form

 Persistent sore / ulcer of the glans & / or the foreskin
 Erythroplasia of Queyrat / Bowen’s Disease
 Carcinoma in situ of the penis
 Premalignant lesion

 Develops in Uncircumcised men who are UNHYGIENIC!

 Other risk factor(s)
 Men with HPV & genital herpetic infections– higher
incidence of penile carcinoma

 PREMALIGNANT LESIONS
 Cutaneous horns
 Leukoplakia
 Erythroplasia of Queyrat
 Condylomaacuminatum
 Balanitis xerotica obliterans (BXO)
 Buschke – Lowenstein tumor

 Excisional biopsy – initial diagnosis,initial step or for documentation

then check for nodal involvement
 CT scan of the abdomen / pelvis – assess the status of the pelvic &
abdominal lymph nodes

 TREATMENT
 Partial penectomy – 2-cm cancer-free margin, pag sa distal
 Total penectomy – for extensive lesion,
 Creation of a perineal urethrostomy-
 Circumcision – small lesion involving the foreskin,curative
management
 Inguinal node status – important prognostic factor, poor
prognosis if +

URETHRAL CARCINOMA

 Rare, < 1% of all GU cancers

 6th – 7th decade of life
 Only GU cancer more common in women (4:1)

 Etiology: Unknown
 Secondary to old age ,wala na kasing hormones
 Women: chronic irritative voiding symptoms / UTI
 Men: 25-75%- w/ hx. of stricture disease, Gonococcal strictures
bulbomembranous are(most common site of Ca); 50% have hx.
of venereal disease

END
Black – from power point
Blue – trans from lecturer

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