urological neoplasms Flashcards
(38 cards)
What are the benign renal neoplasms?
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
What are the malignant renal neoplasms?
- Wilm’s tumor (nephroblastoma)
- Renal adenocarcinoma
- Transitional cell carcinoma
- squamous cell carcinoma
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?
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
What are the clinical features of Wilm’s tumor?
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
How is Wilm’s tumor diagnosed & treated?
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
large tumors irregular in shape with central hemorrhage & necrosis located in upper pole commonly affecting women causing total hematuria is?
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
What are the clinical features of adenocarcinoma?
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
What are the investigations used to diagnose adenocarcinoma?
US -> most important
CT or MRI -> confirmation
Angiography -> massive hematuria
How is adenocarcinoma treated?
NEPHRECTOMY
- ligate renal vessels to decrease risk of hemorrhage
- removal of large neoplasm is curative
What are the clinical features of papillary transitional cell tumors of the renal pelvis?
- multifocal & metastasize
- multiple ureteric tumors predispose the whole urothelium to metaplasia
- hematuria is most common
- hydronephrosis
How is transitional cell tumors of renal pelvis treated?
nephroureterectomy + life-long follow up using cystoscope
ureter must be disconnected with a cuff of bladder wall
What is the cause of transitional cell carcinoma of the bladder?
- 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
What is the classification of transitional cell carcinoma of the bladder?
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
Which tumor of the bladder is always associated with muscle invasion?
squamous cell carcinoma of the bladder
- most commonly where bilharzia is endemic
Which tumor of the bladder arises at the site of urachal remnant + ectopia vesica?
Adenocarcinoma of the bladder
- treated by partial cystectomy
What are the clinical features of transitional cell carcinoma of the bladder?
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
What investigations are used to diagnose transitional cell carcinoma of the bladder?
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
How should non muscle invasive transitional cell carcinoma of the bladder be treated?
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
How should muscle invasive transitional cell carcinoma of the bladder be treated?
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
What are the indications for urinary diversion?
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
What are the types of permanent urinary diversion?
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
What are the complications of internal diversion?
- stricture
- reflux of urine
- risk of malignancy
- resorption of solutes
- malabsorption
PATIENT MUST EMPTY RECTUM OR RESERVOIR 3 HOURLY BY DAY TO AVOID COMPLICATIONS
What is the most common malignant tumor in men over the age of 55 is?
CARCINOMA OF THE PROSTATE (adenocarcinoma)
- most commonly affects the peripheral zone
How does the carcinoma of the prostate spread?
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
