Transcript The Role of Surgery for Refractory Prostate Carcinoma

Urological Divisions
1、Pediatric urology， 2、Urologic Oncology
3、Renal Transplantation 4、Male Infertility
5、Urinary Tract Stones 6、Endourology
7、Female Urology
8 、Urinary Incontinence
9、Genitourinary Trauma 10、Erectile Dysfunction
11、Genitourinary Reconstruction）
12、Voiding Disorders
TUMORS OF
GENITOURINARY TRACT
Yiran Huang
Department of Urology,
Renji Hospital, SSMU,
Renal cell carcinoma
Renal cell carcinoma (RCC) is the most
common type of kidney cancer. These
tumors occur twice as often in men as in
women and usually occur in adults between
the ages of 50 and 70. Between 25 and 30%
of patients have metastases at the time of
diagnosis.
Environmental risk factors include
smoking , Phencetin-containing
painkillers abused or over-used, some
heavy metals exposure ( lead and
cadmium).
Other risk factors include long-term
dialysis, overweight, a high fat diet.
There are also hereditary risk factors.
There are some genes mutations in
rare syndromes like tuberous sclerosis
and von Hippel Lindau Disease that
are associated with an increased risk
of developing kidney tumors.
Von Hipple-Lindau (VHL) disease is an
autosomal dominant disorder in which
affected individuals are at risk for retinal
angiomas, central nervous system
hemangioblastomas, renal cysts and
carcinomas, pancreatic cysts and tumor,
pheochromocytomas,endolymphatic sac
tumors, and/or epididymal cystadenomas.
Types of renal cell carcinoma:
Clear cell RCC (60 to 75 percent), papillary
RCC (15 percent), chromophobe RCC (5
percent), collecting duct carcinoma (less
than I percent), and unclassified carcinoma
(up to 5 percent).
Clinical Presentation
1. Renal cell carcinoma can become quite
large without causing any symptoms.
Many tumors are found incidentally.
2. Hematuria is the most common symptom.
Other signs and symptoms include low back
pain, a mass in the abdomen,
3. General symptoms. fatigue, weight loss,
fever, anemia, swelling of the legs and
night sweats
4. Paraneoplastic syndromes.
Hypercalcemia , Stauffer's syndrome
protein-wasting enteropathy, erythrocytosis,
neuromyopathy, and gonadotropin
production. Amyloidosis is present in
approximately 2 percent of patients.
There are multiple imaging studies,
including intravenous pyelogram (IVP),
ultra-sonography, computerized
tomographic (CT) scans, magnetic
resonance imaging (MRI) which can
produce images of the kidney.
Arteriography and angiography can
demostrate blood vessels and image
the kidney. A chest x-ray is used to
evaluate the lungs metastases. A bone
scan can identify cancer in bone.
•Staging of Renal Cell Carcinoma
Stage Ⅰ cancer is confined to the kidney,
Stage Ⅱ means the cancer has broken
through the kidney capsule and has spread
into adjacent tissue,
Stage Ⅲ indicates that it may have spread
further into lymph nodes or blood vessels,
Stage Ⅳ indicates that it is more widespread, particularly in other organs
Treatment
Radical nephrectomy is the gold standard
treatment for localized RCC. Components
of a radical nephrectomy include early
vascular ligation and en bloc removal of the
kidney, Gerota's fascia, ipsilateral adrenal,
upper ureter, and, for some, lymph nodes
from the crus of the diaphragm to the
aortic bifurcation.
Laparoscopic radical nephrectomy
Nephron sparing surgery
Absolute indications: include a solitary
kidney, bilateral tumors, poor bilateral
or contralateral renal function.
Relative indications: smaller tumors (4
cm or smaller) with a normal
contralateral kidney.
Approaches include segmental polar
nephrectomy, wedge resection, or tumor
enucleation
Imunotherapy: Interferon alpha provides
a 15 percent partial response rate and I
percent CR. lnterleukin-2. The only
drug approved by the FDA specifically
for metastatic carcinoma. A partial
response rate of 14 percent with 5 percent
CR. Continuous infusion or subcutaneous
injections are less toxic.
Chemotherapy
Radiation therapy
NEPHROBLASTOMA
( Wilms’ Tumor )
Wilms’ tumor, is exclusively a disease
of children under age 4 years. It is a
highly malignant mixed tumor
consisting of tissues of connective
tissue origin and epithelial structures.
It is usually discovered as a
palpable mass by the mother or by
an examining physician.
Treatment of the primary tumor is
radical nephrectomy. Adjunctive
therapy with irradiation and
chemotherapy is important in
improving survival.
TUMOR OF THE RENAL
PELVIS
The transitional epithelium of the renal
pelvis may arise to malignant tumors that
are similar to lesion that occur in the
bladder. Hematuria is the most commonly
the presenting complain. Intravenous
urography and retrograde urography can
show the filling defect.
Treatment
Nephroureterectomy
The classic therapy for upper tract TCC
is nephroureterectomy with excision of
a bladder cuff.
Laparoscopic nephrourectomy
BLADDER CANCER
Bladder cancer is the most common
urologic malignancy The most common
histologic diagnosis is transitional cell
carcinoma (TCC). Sixty to 75 percent of
these lesions are noninvasive, superficial
tumors, but 10 to 20 percent of these tumors
will progress to muscle-invasive disease,
especially patients with high-grade disease
and transitional cell carcinoma in situ.
Several factors are associated with the development
of bladder cancer.
1.Occupational exposure to chemicals is thought to
cause the disease.
2.Smoking is also related to developing bladder
cancer. The risk of developing the disease in
smoking is four times that in non-smoking.
3.Chronic cystitis and bladder stone can cause
squamous cell carcinoma.
Pathology
Types of bladder tumor:
transitional cell carcinoma, squamous cell
carcinoma, adenocarcinoma, and others.
More than 95% primary bladder carcinomas
are transitional cell carcinoma.
Squamous cell carcinoma and adenocarcinoma
account for approximately 2-3% respectively.
Adenocarcinoma may arise from an urachal
remnant at the dome of the bladder or from
submucosal gland in the vicinity of the bladder
neck.
Grade
The grade is based on the degree of
cellular differentiation
gradeⅠbeing well differentiation, and
gradeⅡ being moderate
differentiation
grade Ⅲ being poorly differentiation.
Stage
The stage of Bladder carcinoma
includes tumor in situ (Tis), papillary
tumor confined to mucosa (Ta),
invades submucosa only (T1), invades
superficial muscle (T2), invades deep
muscle (T3), spreads beyond the
bladder, including into the prostate or
other organs (T4).
Transitional cell carcinoma has
three features: multiple lesions in
bladder, multiple organs (pelvis, ureter,
and post urethral can develop
transitional cell carcinoma at same
time.), recurrence (more than 50%
patient will recur after the operations).
Location of Bladder Tumor
Most are located on lateral and
posterior wall of bladder, then on
the top and the triangle.
Transitional cell carcinoma of the
bladder develops more frequently in
men than in women, and its frequency
increases with age. The Prognosis is
poor for aging patient and female.
Carcinoma of bladder is quite rare in
children.
Clinical presentations
Hematuria. Either gross or microscopic
hematuria is present in 85 percent of cases.
The amount of hematuria is not necessarily
proportional to the severity of the lesion,
and intermittence is not a reason to exclude
an evaluation. Hematuria in older patients
may result in the diagnosis of a urologic
malignancy in 10 percent of patients, with
the majority of these lesions being TCC.
Microscopic or gross hematuria indicates
cancer until proven otherwise and must be
evaluated.
Irritative voiding symptoms. Increased
frequency of urination, dysuria, and
urgency may be present in up to 20
percent of patients with bladder cancer,
particularly CIS.
Diagnosis
1.The diagnosis is established by cystoscopy
and biopsy of the tumor.
2.Urinary cytological test may be used to
find the cancer cell.
3.Intravenous urography is essential for the
bladder carcinoma.
4.Ultrasound, CT scan, and MRI detect the
tumor in bladder, especially for the tumor
stage.
Treatment
Superficial bladder tumors (Ta and T1)
are often amenable to transurethral
resection or transurethral coagulation
of laser.
Invasive bladder tumors (T2 and T3)
may require partial cystotectomy, or
radical cystotectomy.
Systemic chemotherapy with multiple
drug regimens incorporating cisplatin
has shown promise for the advanced
disease.
Intravesical chemotherapy may be
effective in controlling superficial
disease but is ineffective for treatment
of invasive lesion.
•
The most effective agent is bacillus
Calmette-Guerin (BCG) intravesical
immunotherapy, which decreases tumor
recurrence by 40 to 70 percent. In the
case of transitional cell carcinoma in situ
(CIS), it may reduce tumor progression.
After treatment of the superficial tumor,
periodic cystoscopy and urinary cytological
examination is necessary for at least 5
years. New tumors may also be well
controlled by transurethral means, but if
they tend to recur they apt to become
progressively invasive and of higher grade.
Cystectomy must then be considered.
PROSTATE CARCINOMA
Prostate carcinoma is the most common
malignance in the West countries, and the
second death after lung cancer. Although the
incidence of prostate carcinoma is low in
China and eastern countries, remarkable
increase has been found recently.
It occurs predominantly in old men.
It has the capacity to grow and
invade locally and to metastasize by
blood and lymph. There is a strong
predilection for metastases to bone,
and these metastases have the
unique characteristic of being
osteoblastic.
Prostate cancer has few dramatic
primary signs or symptoms. It can be
associated with urinary obstructive
symptoms or hematuria, although these
findings are usually due to other causes.
Bone pain can unfortunately be an
initial symptom, but it represents very
advanced disease.
Diagnosis
1. digital rectal examination,
2. prostate specific antigen,
3. transrectal ultrasound exam,
4. biopsy,
5. bone scan, and so on.
Androgen blockade is the best method
for the treatment of advanced prostate
carcinoma.
Radical prostatectomy and Radiation
can be used for early stage patient.
TESTICULAR TUMORS
Testis tumors most commonly occur in
men between 18 and 35 years of age.
Tumors arising from the Leydig’s cell
and Sertoli’s cells are rarely seen.
Most of the testis tumors arise from
the germinal epithelium, and all of
these tumors should be considered
malignant except for teratomas that
occur before puberty.
The histologic types of germinal
tumors of the testis are seminoma, and
non-seminoma (embryonal carcinoma,
teratoma, and choriocarcinoma). The
diagnosis is usually suspected because
of discomfort and enlargement of the
testis. а-FP and β-HCG are the
tumor markers, and the later is a poor
prognosis marker.
Radical orchetectomy is the initial
treatment. Seminoma is quite
radiosensitive, and metastatic disease
may be definitively treated with
radiotherapy. Non-seminoma is
usually managed by a combination of
retroperitoneal lymph node dissection
and multiple drupe chemotherapy.
CARCINOMA OF THE PENIS
Squamous cell carcinoma of the
penis is encountered most often in
older men who have not been
circumcised. It has a tendency to
invade the erectile tissue of the penile
shaft and to metastasize to inguinal
lymph nodes. Penectomy is usually
required.
Questions of the lessons
1. What paraneoplastic syndromes are
associated with renal cell carcinoma?
2. What are the indications for intravisical
therapy for bladder carcinoma?
3. What are the indications for radical
cystotectomy?
4. The diagnosis of prostate carcinoma.