Transcript RCC

In the name of God
Genitourinary Tumors
ALI ARIAFAR, MD
Fellowship of Uro-oncology
Shiraz University of Medical Sciences
Kidney tumors
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Primary or Secondary (metastatic)
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Malignant:
RCC represents 80-85% of primary renal neoplasms
Transitional cell carcinoma 8%
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Benign tumors:
simple renal cyst
Oncocytomas
Angiomyolipoma
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Inflammatory
Radiologic Evaluation of Renal Mass
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Sonography
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CT Scan
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MRI
Oncocytoma
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Mostly benign
Eosinophilic cytoplasm with fine granule.
3-5% of renal tumors
CT :central scar
Angiography :spoke wheel appearance.
No definitive diagnostic test.
Treatment: radical nephrectomy
Angiomyolipoma
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Renal hamartoma
F>M
Incidence in tuberose sclerosis: 45-80%
Diagnosis : CT( HF -20 to -60)
Treatment:
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asymtomatic <4cm : annual F/U
>4cm or symptomatic :angioembolization or partial
nephrectomy
Renal Cell Carcinoma (RCC)
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Rcc is the most lethal of the urologic
cancers.
2-3% of all adult malignancies is RCC
MR of RCC is 40% in contrast with the 20%
MR of bladder and prostatic cancers
Rcc is primarily a disease of the elderly pt.
with presentation in the 6th and 7th decades
M/F ratio is 3/2
Risk Factors
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The majority of cases of RCC are believed to be
sporadic; only 2% to 3% are familial
The only generally accepted environmental risk factor
for RCC is tobacco exposure. (1.5 to 2.5 times)
 Tobacco use accounts for 20% to 30% of cases of
RCC in men and 10% to 20% in women
Obesity
HTN
Acquired cystic kidney disease due to dialysis
Western diet (high in fat and protein and low in fruits
and vegetables), increased intake of dairy products,
and increased consumption of coffee or tea
Familial RCC
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Von Hippel-Lindau (VHL)
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Major manifestation: retinal Angioma, CNS
hemangioblastoma,
pheoQ,
epididymal
cystandenoma, endolymphatic tumor of ear and RCC.
Genetic element: loss of chromosome 3.
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The most common cause of MR in VHL is RCC.
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Tuberous sclerosis
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Epilepsy, Sebaceous adenoma, mental retardation
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Hereditary papillary RCC (HP RCC)
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Hereditary leiomyomatosis and RCC
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Autosomal dominant mode.
Proto-oncogene on chromosome 7.
Uterine leiomhyoma + RCC
Birt- Hogg-Dube syndrome
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lung problem + RCC
Genetic: chromosome 17.
Pathology
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Clear cell carcinoma: VHL, 70-80% of all RCC
Papillary RCC (10%-15%) : ARCD
Chromophobe RCC(3%-5%)
Collecting duct RCC. (<1%)
Renal modularly RCC(rare)
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almost exclusively with sickle cell trait and young African-American
Clear cell and papillary RCC arise from proximal
tubules.
Chromophobe and collecting duct RCC arise from
distal part of nephron.
Clinical Presentation
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More than 50% of RCC are now detected
incidentally
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The classic triad of flank pain, gross hematuria,
and palpable abdominal mass is now rarely found
Paraneoplastic syndromes
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Anemia- anemia of chronic disease 30%
Hepatic dysfunction in the absence of metastasis
3-20%(stauffer syndrome)
Hypercalcemia 20%
Cachexia and Fever 20%
Erythrocytosis: 3-10% produce erythropoietin
Elevated ESR
Neuromyopathy
Diagnosis
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Imaging
IVP or Sonograghy
 CT Scan
 MRI
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Biopsy
Staging and Prognosis
Cohen HT, McGovern FJ. NEJM. 2005;353:2477.
Prognosis
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Prognosis depends
upon stage
Other poor
prognostic
indications include
poor performance
status, anemia,
hypercalcemia, and
elevated LDH
Five-year relative survival rates by tumor
stage at diagnosis based on cases diagnosed
during 1992–1999, followed through 2000.
Drucker BJ. Cancer Treat Rev. 2005;31:536.
Treatment
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Radical nephrectomy remains the main stay
for treatment RCC.
Partial nephrectomy is standard treatment
for small (<4cm), unilateral, confined tumor,
and for pts with bilateral or solitary kidney.
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RCC is radio- and chem. Resistant.
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Advanced RCC Treatment
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Primary treatments are systemic therapy with
molecularly targeted therapy or immunotherapy
Surgery is palliative therapy
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Solitary metastatic site
Solitary recurrence following nephrectomy
Symptoms related to bulkiness of disease including
pain, nausea, or GI obstruction
Advanced RCC
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Immunotherapy
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IL-2
INF
Targeted Therapy
Sorafenib
 sunitinib
 temsirolimus
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Bladder Tumors
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In men, BT is the fourth most common cancer
after prostate, lung, and colorectal cancer
In women it is the ninth most common cancer
whites> blacks; But blacks have a worse
prognosis
M/F=3:1 . But Women have a worse prognosis
Median age at diagnosis is 68 y, incidence
increases with age
Risk Factor
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Cigarette Smoking
Occupation
Infection
Inflammation
Pelvic Irradiation
Chemotherapy
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Nutritional Factors
Fluid Intake
Analgesic Abuse
Coffee and Tea
Risk Factor
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Hereditary
First-degree relatives of patients with bladder cancer
have a twofold increased risk of developing
urothelial cancer
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Tumor suppressor gene
P53 gene is the most common altered gene in human cancers.
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Oncogenes (p21 ras, c-myc, and c-jun)
Pathology of Bladder Cancer
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Transitional Cell Carcinoma 90% (TCC)
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squamous cell carcinoma 5-7%
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more common in middle east
schistosomiasis
also seen in chronic catheterization
Adenocarcinoma 2-3%
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Urachal tumor
Symptoms
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The most common presenting symptom of BT is
painless hematuria which occurs in 85% of pts.
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The 2nd most common presenting symptom is
frequncy, urgency and dysuria.
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Blank pain, ureteral
metastasis symptoms.
obstruction,
edema,
Physical Exam
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Superficial bladder cancer is rarely found during a
physical examination.
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Occasionally, an abdominal or pelvic mass may be
palpable.
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Examine for lymphadenopathy
Diagnosis
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U/A
Cytology
Cystoscopy and biopsy
Urinary Cytology
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Voided or urine washing
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40-60% sensitivity
(as high as 90% in G3 Lesions)
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Dependent on grade of tumor
Incidence of + urine cytology according to grade
Grade
# patients
Negative (%) Positive (%)
I
68
62(91)
6(9)
II
60
41(68)
19(32)
III
20
6(30)
14(70)
Heney et al. J Urol, 130: 1083, 1983
Imaging
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Sonography
CT Scan
IVP
Staging of Bladder Cancer
Stage at diagnosis
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More than 70% of all newly diagnosed bladder
cancers are superficial
50-70% are Ta
20-30% are T1
10% are CIS
5% of patients present with metastas
25% of affected patients have muscle-invasive
disease at diagnosis.
Surgical treatment
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TURB(gold standard in superfacial BC)
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Partial cystectomy
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Radical cystectomy(gold standard in muscle
invasive)
Medical treatment
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Non–muscle-invasive disease (Ta, T1, CIS)
Intravesical immunotherapy ( BCG)
Intravesical chemotherapy
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Muscle-invasive disease (T2 and greater)
Adjuvant and neoadjuvant chemotherapy
Cancer of prostate (Ca.P)
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Ca.P has been the most common visceral
malignant neoplasma in USA.
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The estimated life time risk of disease is 17.6% for
whites and 20.6% for blacks.
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The black men have the highest incidence of Ca.P
and the lowest rate occur in Asia.
Risk Factors
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Age
Prostate cancer is rarely diagnosed in men
younger than 50 years old, accounting for only
2% of all cases .
 The median age at diagnosis is 68 years, with
63% diagnosed after age 65
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Risk Factors
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Androgens.
Family Hx.
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Relative risk increase according to the number of affected family
members, their degree of relatedness and the age at which they
were affected.
Accumulating evidence suggests that Ca.P may have an
infectious etiology. (prostatitis or STD)
Symptoms and signs
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Most patient are asymptomatic
LUTS: frequency, urgency, hesitancy, ↓ed caliber
of urine stream, obstructive uropathy
Metastatic symptoms: Bone pain, Dyspnea,
Cough, etc.
D.x
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DRE
PSA: cut off= 4ng/ml
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Free PSA: free PSA: free/total<18%, PSA density> 15%,
PSA velocity>75%
TRUS-bx
Digital Rectal Exam
• Start annual
exams when 50
years old
Based on: Mayo Clinic Health Letter, April
PSA Levels by Age
Based on: Time, April 1, 1996
PSA Test
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Detects an enzyme (prostate specific antigen) made by the
prostate
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PSA increases with age in healthy men
PSA increases dramatically with prostate cancer but can also
increase with inflammation or an enlarged prostate
Needle Biopsy for Prostate Cancer
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Biopsy gun inserted through anus
Needles shot into prostate from rectum
6 to 18 samples taken
Attempting to detect cancer in stage A
Analysis of cancer spread and cell type
Based on: Mayo Clinic Health Letter, April,
Treatment
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Watchful Waiting
Active Surveillance
Radical prostatectomy
Radiotherapy
Hormone therapy
Chemotherapy
TESTICULAR TUMOUR
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1% to 2% of cancers among men in the United
States
The most common malignancy among men aged
20 to 40 years
99% of all Testicular Tumors are malignant.
The incidence of bilateral GCT is approximately
2%
95% of which are germ cell tumors (GCTs).
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GCTs are broadly classified as
seminoma (52% to 56%)
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Classic Typical Seminoma
Spermatocytic Seminoma
Seminoma is the most common type of GCT.
On average, seminomas occur at an older average age
than NSGCTs, with most cases diagnosed in the fourth
or fifth decade of life
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NSGCT (44% to 48%)
Embryonal Carcinoma.
 Choriocarcinoma
 Yolk Sac Tumor.
 Teratoma
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Risk Factors
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Cryptorchidism
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Males with cryptorchidism are four to six times
more likely to be diagnosed with testicular
cancer, but the relative risk (RR) falls to 2.0 to
3.0 if orchidopexy is performed before puberty
Testis Atrophy ( infection,trauma)
Risk Factors
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family history of testicular cancer
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An individual’s RR for testicular cancer is 8.0 to 12.0
with an affected brother compared with 2.0 to 4.0 in
those with an affected father
personal history of testicular cancer
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Men with a history of testicular cancer are at a 12-fold
increased risk of developing GCT in the contralateral
testis
Signs and Symptoms
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The most common presentation of testicular cancer is a
painless testicular mass
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Dull Ache or Heaviness in Lower Abdomen
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10% - Acute Scrotal Pain
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10% - Present with Metatstasis
- Neck Mass / Cough / Anorexia / Vomiting / Back
Ache/ Lower limb swelling
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5% - Gynecomastia
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Rarely - Infertility
Diagnostic Testing and Initial
Management
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ScrotalUltrasonography
Serum Tumor Markers
(LDH, AFP, and hCG)
Chest X Ray
CT Scan
All patients with a solid, Firm
Intratesticular Mass that cannot be
Transilluminated should be regarded
as Malignant unless otherwise proved
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AFP
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EC and yolk sac tumors secrete AFP.
Choriocarcinomas and seminomas do not produce AFP.
Patients with pure seminoma in the primary tumor with an elevated
serum AFP value are considered to have NSGCT.
The half-life of AFP is 5 to 7 days.
 HCG
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Approximately 15% of seminomas secrete hCG.
hCG is also secreted by choriocarcinoma and EC
The half-life of hCG is 24 to 36 hours
TREATMENT
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Radical Inguinal Orchiectomy
A transscrotal orchiectomy or biopsy is
contraindicated
TREATMENT
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Seminomas:
Radio-Sensitive.
Treat
with
surveillance ,Radiotherapy or chemotherapy
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Non-Seminomas are Radio-Resistant and best
treated by surveillance ,Surgery(RPLND) or
chemotherapy
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Advanced Disease or Metastasis - Responds well to
Chemotherapy
Limits of Lymph Nodes Dissection For Right &
Left Sided Testicular Tumours
PROGNOSIS
Seminoma
Stage I99%
Nonseminoma
95% to 99%
Stage II
70% to 92%
90%
Stage III
80% to 85%
70% to 80%