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Surgery M4 part 2 > urological neoplasms > Flashcards

urological neoplasms Flashcards

1
Q

What are the benign renal neoplasms?

A

ADENOMA

  • pea-like cortical adenoma
  • has malignant potential

ANGIOMA

  • may cause profuse hematuria in young adults
  • difficult to find bleeding source without renal angiography

ANGIOMYOLIPOMA
- v high malignant potential

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2
Q

What are the malignant renal neoplasms?

A
  • Wilm’s tumor (nephroblastoma)
  • Renal adenocarcinoma
  • Transitional cell carcinoma
  • squamous cell carcinoma
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3
Q

a rapidly growing tumor in one pole of the kidney that is smooth, soft, fleshy, pinkish white in color & has hemorrhagic areas discovered in the first 5 years of life is?

A

WILM’S TUMOR (nephroblastoma)
- large palpable abdominal mass

Micro
- malignant primitive glomeruli & primitive tubules with epithelial & connective tissue cells exist side by side

  • spreads through blood into lungs
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4
Q

What are the clinical features of Wilm’s tumor?

A

ABDOMINAL MASS - FEVER - HEMATURIA

mass

  • smooth, mobile, firm or hard, lobular, located in loin, moves with RESPIRATION
  • bimanually palpable
  • ballotable
  • dullness in renal angle with resonant band in front

fever -> tumor necrosis

hematuria -> grave sign signifying rupture of tumor into renal pelvis

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5
Q

How is Wilm’s tumor diagnosed & treated?

A

Diagnosis

  • ultrasound
  • CT
  • IVU
  • renal angiography
  • x-ray -> egg shell peripheral calcification

Treatment

  • Unilateral tumor -> neoadjuvant chemotherapy followed by nephrectomy
  • Bilateral tumors -> partial nephrectomy if POLAR
    - > bilateral nephrectomy with renal transplantation
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6
Q

large tumors irregular in shape with central hemorrhage & necrosis located in upper pole commonly affecting women causing total hematuria is?

A

Adenocarcinoma (hypernephroma, renal cell carcinoma)
- yellowish or dull white, semi transparent cut surface

spread

  • direct -> to surrounding structures
  • hematogenous -> grows in renal vein -> reach the lungs -> cannonball secondary deposits
  • lymphatics (LATE) -> para-aortic nodes & beyond
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7
Q

What are the clinical features of adenocarcinoma?

A

Hematuria

  • painless
  • profuse
  • total hematuria

Pain

  • clot colic
  • dragging discomfort in loin or patient may detect a mass

Secondary rapidly developing varicocele
- left side

Pyrexia after nephrectomy -> metastases

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8
Q

What are the investigations used to diagnose adenocarcinoma?

A

US -> most important
CT or MRI -> confirmation
Angiography -> massive hematuria

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9
Q

How is adenocarcinoma treated?

A

NEPHRECTOMY
- ligate renal vessels to decrease risk of hemorrhage

  • removal of large neoplasm is curative
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10
Q

What are the clinical features of papillary transitional cell tumors of the renal pelvis?

A
  • multifocal & metastasize
  • multiple ureteric tumors predispose the whole urothelium to metaplasia
  • hematuria is most common
  • hydronephrosis
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11
Q

How is transitional cell tumors of renal pelvis treated?

A

nephroureterectomy + life-long follow up using cystoscope

ureter must be disconnected with a cuff of bladder wall

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12
Q

What is the cause of transitional cell carcinoma of the bladder?

A
  • cigarette smoking
  • genetic -> activation of RAS & c-erbB-1 & 2 - inactivation of p53, p21, p16 & RB
  • occupational exposure to urothelial carcinogens

most commonly in lateral wall then trigone

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13
Q

What is the classification of transitional cell carcinoma of the bladder?

A

NON-MUSCLE INVASIVE

MUSCLE INVASIVE

CARCINOMA IN SITU (least complex - cystectomy)

  • primary CIS -> CIS alone
  • Concomitant CIS -> occurs in association with a new tumor
  • Secondary CIS -> in patient who had a previous tumor
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14
Q

Which tumor of the bladder is always associated with muscle invasion?

A

squamous cell carcinoma of the bladder

- most commonly where bilharzia is endemic

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15
Q

Which tumor of the bladder arises at the site of urachal remnant + ectopia vesica?

A

Adenocarcinoma of the bladder

- treated by partial cystectomy

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16
Q

What are the clinical features of transitional cell carcinoma of the bladder?

A

Hematuria

  • painless
  • gross
  • increases at the end of the stream
  • may give clots & cause clot colic

LUTS

  • frequency
  • dysuria

Pain

  • infiltration of muscle
  • constant pain in the pelvis -> extravesical spread
  • suprapubic pain -> nerve involvement
17
Q

What investigations are used to diagnose transitional cell carcinoma of the bladder?

A

URINE -> cytology for malignant cells is highly specific
CYSTOURETHROSCOPY -> guide for biopsy in patients with hematuria

all patients with painless hematuria
1- US scanning
2- CT (local staging) or MRI (local & lymphatic staging)
3- IVU -> irregular filling defect -> hydroureter or hydronephrosis

18
Q

How should non muscle invasive transitional cell carcinoma of the bladder be treated?

A

NON MUSCLE INVASIVE
endoscopic surgery
- resected in layers using resectoscope & base is sent for histological examination
- small pinch biopsies are taken near to & distant from primary lesion when CIS is suspected
- exclude muscle invasion
- INTRAVESICAL MITOMYCIN before catheter removal to decrease risk of recurrence

  • follow up is mandatory
  • if recurrence is detected -> intravesical & systemic chemotherapy could be used
19
Q

How should muscle invasive transitional cell carcinoma of the bladder be treated?

A

SURGICAL

  • radical cystectomy + pelvic lymphadenectomy + urine diversion -> main line
  • partial cystectomy -> in adenocarcinoma

CHEMOTHERAPY

  • intravesical mitomycin
  • systemic CT

RADIOTHERAPY

  • could be used as primary curative line to preserve function of the bladder
  • 2 types -> interstitial RT & deep external bean RT
20
Q

What are the indications for urinary diversion?

A

TEMPORARY -> to relieve distal obstruction

  • urinary catheter -> urine retention
  • supra-pubic catheter -> prolonged catheterization
  • nephrostomy tube -> if internal stent is not feasible

PERMANENT -> if bladder is removed or lost normal neurological control

                  - > incurable fistula 
                  - > irremovable obstruction
21
Q

What are the types of permanent urinary diversion?

A

EXTERNAL
ileal conduit
- ureters are implanted into a short, isolated segment of ileum
- conduit diverts urine downwards to cutaneous stoma for collection in a ileostomy bag

INTERNAL
colon & rectum
- anal sphincter must be competent
- could cause -> recurrent UTI
-> in the long term cancer can develop at long standing ureterocolic junctions
-> working overload on the kidney
bladder reconstruction
- ileum, ileum & caecum or sigmoid colon could be used
- results are good after radical cystectomy in younger patients
- only indicated when urethra can be preserved

22
Q

What are the complications of internal diversion?

A
  • stricture
  • reflux of urine
  • risk of malignancy
  • resorption of solutes
  • malabsorption

PATIENT MUST EMPTY RECTUM OR RESERVOIR 3 HOURLY BY DAY TO AVOID COMPLICATIONS

23
Q

What is the most common malignant tumor in men over the age of 55 is?

A

CARCINOMA OF THE PROSTATE (adenocarcinoma)

- most commonly affects the peripheral zone

24
Q

How does the carcinoma of the prostate spread?

A

LOCAL -> seminal vesicles, the bladder neck & trigone, & the distal sphincter

BLOOD -> to bone (esp pelvic bones & lower lumbar vertebrae) -> osteosclerotic lesions

LYMPHATIC -> Virchow’s node

25
Q

How is prostatic cancer staged?

A 
T1 
incidentally discovered 
T1a -> involving <5%
T1b -> involving > 5%
T1c -> raised PSA

T2
local palpable nodule
T2a -> involving 1 lobe
T2b -> involving both lobes

T3
invasion of the capsule
T3a -> uni or bilateral extension
T3b -> seminal vesicle extension

T4
extra-prostatic invasion
- fixed or invading adjacent structures OTHER than seminal vesicles

26
Q

What are the clinical features of prostate cancer?

A
  • asymptomatic -> most common
  • advanced disease gives rise to symptoms
  • > bladder neck obstruction
  • > pelvic pain & hematuria
  • > bone pain, malaise, arthritis, anemia, or pancytopenia
  • > renal failure

Rectal Examination

  • detect nodules within the prostate
  • advanced disease
  • irregular induration -> stony hard
  • non tender enlargement with obliteration of the median sulcus
27
Q

What laboratory investigations should be done in suspected prostate cancer?

A

Prostate-specific antigen

  • PSA > 10 is suggestive of cancer
  • PSA > 35 is almost diagnostic of advanced cancer

CBC
- anemia -> extensive bone marrow invasion OR secondary to renal failure

Liver Function Tests
- alkaline phosphatase may be raised in hepatic involvement or secondaries in bone

28
Q

What radiological investigations should be done in suspected prostate cancer?

A

XRAY

  • metastases in lung fields or ribs
  • sclerotic & osteolytic metastasis in lumbar vertebrae & pelvic bone -> characteristic

MRI -> most accurate method for staging local disease
TRUS -> to guide biopsy

BONE SCAN
- if PSA is >10 nmol/mL or if biopsy shows high-grade cancer

29
Q

How is early prostatic cancer treated?

A

T1a, T1b, T1c, & T2
- managed by active surveillance
or
- radical prostatectomy -> localized disease T1 & T2 in men with life expectancy of >10 years
- radiotherapy -> external beam (T1 & 2)
-> brachytherapy (T1)

30
Q

How is advanced prostatic cancer treated?

A

androgen ablation
- bilateral orchidectomy -> used for T3 & T4
- medical castration -> Stilbestrol
-> LHRH agonists (monthly or 3 monthly depot injection)
-> cyproterone acetate
radiotherapy -> bone metastasis

T3 in good general condition -> radical prostatectomy

31
Q

What are the risk factors for testicular tumors?

A
  • undescended testis
  • history of contralateral testicular tumor
  • Klinefelter’s syndrome
32
Q

What is the most common testicular tumor?

A

SEMINOMA

spreads through lymphatics

  • para-aortic LNs
  • inguinal LNs in case of scrotal wall infiltration
33
Q

What are the types of non-seminomatous germ cell tumors (NSGCT)?

A

Embryonal Carcinoma -> highly malignant -> invades cord structures

Yolk Sac Tumour -> secrete alpha fetoprotein (AFP)

Choriocarcinoma -> secretes human chorionic gonadotrophin (HCG) -> highly metastatic

Teratoma -> component derived from ectoderm, endoderm, & mesoderm

34
Q

What are the types of interstitial cell tumours?

A

LEYDIG CELL TUMOR -> masculinizes

SERTOLI CELL TUMOR -> feminises

35
Q

What are the stages of testicular tumors?

A

Stage I -> confined to testis
Stage II -> lymph nodes below diaphragm are affected
Stage III -> lymph nodes above diaphragm affected
Stage IV -> non-lymphatic metastatic disease (lungs)

36
Q

What are the clinical features of testicular tumors?

A
  • painless testicular lump
  • sensation of heaviness
  • pain
  • manifestations of metastasis
  • intratesticular solid mass
  • lax secondary hydrocele
  • epididymis becomes more difficult to feel when its flattened or incorporated in the growth
37
Q

What investigations should be done for any testicular mass?

A

SCROTAL US

metastatic workup -> in confirmed cases -> staging (MRI)

Tumor markers
- LDH in seminoma
- AFP in NSGCT
used to reassess after orchidectomy to indicate if all tumor tissue has been removed

38
Q

What is the treatment for testicular tumors?

A

SCROTAL EXPLORATION & ORCHIDECTOMY -> inguinal incision
+
adjuvant treatment (post-orchidectomy radiotherapy or chemotherapy)

Stage I

  • Seminomas -> adjuvant radiotherapy to para-aortic nodes
  • NSGCT -> chemotherapy

Stage II-IV

  • combination chemotherapy -> seminoma II-IV & NSGCT
  • retroperitoneal lymph node dissection in some cases of NSGCT

Surgery M4 part 2 (36 decks)

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