GENITOURINARY CANCER

Urology Division, Surgery Department

Medical Faculty,
University of Sumatera Utara
BENIGN TUMORS
Adenoma
Oncocytoma
Angiomyolipoma
Leiomyoma
Lipoma
Hemangioma

1. Renal adenoma
The most common benign renal parenchymal
lesion
Small, well-diff glandular tumors of the
renal cortex
Asymptomatic
Should be treated of an early renal cancer
and the patient should be evaluated and
treated appropriately
2. Renal oncocytoma
3 5% of renal tumor, : = 2 : 1
Gross hematuria & flank pain in < 20%
Radical nephrectomy is the safest method of
treatment unless other factors argue for a
conservative approach
3. Angiomyolipoma (Renal hamartoma)
Composed of fat, muscle & blood vessels
Rare, 4 : 1
Acute flank pain or shock due to spontaneous
renal or retroperitoneal hemorrhage
Asymptomatic tumors < 4 cm followed
closely with serial imaging
Symptomatic tumors or > 4 cm selective
embolization or tumor enucleation by partial
nephrectomy
RENAL PARENCHYMAL TUMORS
The most common type of renal tumor is
renal cell carcinoma
80 85% of all renal cancers
Survival is based on tumor stage
Other types of kidney tumors include
metastatic lesions, sarcomas,
juxtaglomerular tumors and lymphomas
ADENOCARCINOMA OF THE KIDNEY
(RENAL CELL CARCINOMA)
3% of adult cancer
: = 2 : 1, 5
th
6
th
decades of life
racial distribution is equal
more common in urban settings
= hypernephroma = clear cell carcinoma =
alveolar carcinoma
Etiology is unknwon
Risk factor : Cigarret smoking strongest
Obesity
Acquired renal cystic disease
GRADING & STAGING
Fuhrman system (I IV) most often used
General classification system :
- Robson system
- TNM system
CLINICAL PRESENTATION
Symptom & sign
Classic triad : hematuria
flank pain
palpable mass
General symptom : weight loss, fever,
anemia, night sweats
Presenting symptoms associated with the
primary tumor :
- hematuria
- mass - typically appreciated with lower
pole masses in thin patients
- varicocele : typically on left side, will not
decompress when patient is supine
- edema, and lower extremity varices
associated with vena cava obstruction

Presenting symptoms associated with metastases :
- bone pain
- neurological symptom
- ascites
Paraneoplastic syndrome
- erythrocytosis (1 5%)
- hypercalcemia
- hepatic dysfunction
- amyloidosis
- anemia

Initial evaluation
Physical examination
Laboratory studies
- CBC
- serum electrolytes
- LFT
Imaging for staging
IMAGING EVALUATION
Intravenous excretory urography
Renal sonography
CT
MRI
Angiography
Radionuclide imaging

TREATMENT FOR LOCALIZED DISEASE
Radical nephrectomy is gold standard
Partial nephrectomy
Energy ablative techniques

TREATMENT FOR METASTATIC RCC
30% of newly diagnosed cases of RCC are
metastatic
Associated with extremely poor survival
Common sites : lung, bone, liver, brain, ipsilateral
or contralateral kidney
Generally chemotherapy-resistant
Disseminated disease
- surgery
- radiation therapy
- hormonal therapy
- radioimmunotherapy
- biologic response modifier

PROGNOSIS
related to the stage at presentation
5-yr survival rate for T1 88 100%
T2 & T3a 60%
T3b 15 20%
with metastatic 0 20%
NEPHROBLASTOMA (WILMS TUMOR)
The most common solid renal tumor of
childhood; 5% of childhood cancer
3
rd
year of life, no sex predilection
Commonly unicentric, occur in either kidney
with equal frequency
Metastatic is present at diagnosis in 10
15%, with lungs (85-95%) and liver (10-15%)
the most common sites


Clinical findings
present with palpable abdominal mass,
smooth and rarely crossing midline
Abdominal pain, anorexia, nausea &
vomiting, fever, hematuria
Hypertension (25-60%)
DD : hydronephrosis
cystic kidneys

treatment
Surgical
Radiation
- radiosensitive
- its use complicated by potential growth
disturbances, recognized cardiac, pulmonary &
hepatic toxicities
Chemotherapy
- chemosensitive neoplasm
- actinomycin D, vincristine, doxorubucin,
cyclophosphamide, etoposide, cisplatin
SARCOMA OF THE KIDNEY
Rare, 1-3% of all malignant renal neoplasm
5
th
decade, alight male predominance
Flank or abdominal pain, weight loss
Leiomyosarcoma (50%), fibrosarcoma,
liposarcoma,hemangiopericytomas,
osteogenic sarcoma, malignant schwannomas
Radical nephrectomy for localized disease

LYMPHOMA
Primary renal lymphoma are extremely rare
Kidney may be involved by either direct
extension or hematogenous spread
Suspect lymphoma if the mass appears
infiltrating or multifocal, there is diffuse
adenopathy
Biopsy warranted if lymphoma suspected
CARCINOMA OF THE BLADDER
2
nd
most common urologic malignancy after
prostate ca
70% are superficial, 10 20% will progress to
muscle invasive disease
Chance of tumor recurrence is 70 80%
Environmental exposures are strongly
associated
The most common histologic diagnosis is TCC




etiologi
Industrial carcinogens aniline dyes, naphtylamin
Tobacco exposure
Chemotherapeutic agent
Schistosomiasis
Pelvic irradiation
Chronic irritation & infection
Phenacetin
Baldder exstrophy
Coffee not strong
Saccharin in experimental animal
Epidemiology
Age 6
th
8
th
decades
Race twice in American men
Gender : = 3 : 1
Genetics
Demography higher in US compared to
Japan

Symptom
Gross, painless hematuria
- most common (85% cases)
- intermittence is not a reason to exclude an
evaluation
- indicates cancer until proven otherwise
Irritative voiding symptom frequency,
dysuria, urgency (frequently associated with
CIS)
Bladder filling defect on urography
Unanticipated finding on cystoscopy

Diagnosis
History & physical examination
Urine culture
Urine cytology highly specific
Flow cytometry
Tumor markers
Upper tract imaging
Cystoscopy

Pathology
Epithelial dysplasia
Carcinoma in situ
Superficial TCC 70%
Muscle invasive TCC
Squamous cell ca
Adenoca
Sarcoma of the bladder
Small cell carcinoma
treatment
Superficial bladder cancer
1. TURBT - initial & standard therapy
2. Laser photocoagulation less dyscomfort,
minimal bleeding
3. Intravesical therapy
- weekly treatment
- mitomycin C, adriamycin, thiotepa, BCG, interferons
Muscle invasive TCC
1. radical cystectomy
2. partial cystectomy
3. radiation therapy
4. TUR
5. combined
6. adjuvant therapy
7. metastatic disease MTX, vinblastine,
adriamycin
8. palliative therapy