外科学：泌尿生殖系统肿瘤

1、Urological and Genital Tumors,1. kidney Tumors,(1) Renal Cell Carcinoma Pathology arises from cells of the proximal convoluted tubule round tumors with a pseudocapsule and areas of hemorrhage and necrosis.,肾上极巨大肿瘤,a huge kidney tumor on its upper pole,肾癌并出血 Bleeding renal cell carcinoma,肾癌侵入肾静脉,Rena

2、l vein invasion,They often invade the collecting system. Local extension does occasionally occur through Gerotas fascia. Tumor thrombus into the renal vein is frequent and may extend into the vena cava. Metastatic spread is to lung, liver, bone, brain, and subcutaneous tissues.,Presentation 40-60 ye

3、ars old ; male:female = 2:1 1. Three symptoms pain (41%) hematuria (36%) flank mass (24%) 2. hypertension (20%), hypercalcemia (6%), and erythrocytosis (3%) 3. hepatic dysfunction(20%), weight loss (36%),Diagnosis,B-US ultrasonic IVUintravenous urography (pyelography) , RP (retrograde pyelograms )Ca

4、lyceal distortion with stretching and separation the calyses CT computed tomography MRI Magnetic Resonance Imaging Selective Renal Arteriography.,Calyceal distortion,Treatment Surgery-is the only effective treatment for primary renal cell carcinoma. radical nephrectomy-excision of the kidney and adr

5、enal including Gerotas fascia, with a limited regional lymphadenectomy,Radiation Therapy. Hormonal Therapy. Immunotherapy.-,肾癌的靶向治疗targeted therapy for renal cell carcinoma,肾癌的靶向治疗targeted therapy for renal cell carcinoma,(2) Wilms Tumor (Nephroblastoma）,A solitary mass fleshy with tan cut surface a

6、nd variable areas of hemorrhage and necrosis. Venous invasion occurs in up to 20% of cases.,肾母细胞瘤，切面所见,cut surface of tumor,An enlarging, smooth abdominal mass confined to one side of the abdomen with hypertension (60%), or microscopic hematuria (25%) in children,Diagnosis,B-US IVU,RP CT MRI,Treatme

7、nt Modern multimodal therapies including surgery, radiation, and chemotherapy are effective. 80-90% of children with Wilms tumor can be expected to survive.,(3) Renal pelvic tumor,Pathology Transitional cell carcinomas (90%). Squamous carcinomas (10%) Adenocarcinomas (very rare) The most common meta

8、static sites include regional lymph nodes, bone, and lung.,Presentation Gross hematuria is noted in 70-90% of patients. Flank pain, present in 8-50%.,Diagnosis Urinary exfoliated cells Imaging : intravenous urography (IVU) (intraluminal filling defect ) Ultrasonography computed tomography (CT) magne

9、tic resonance imaging (MRI) Ureteropyeloscopy,filling defect,Treatment The standard therapy for the tumor has been nephroureterectomy The entire distal ureter with a small cuff of bladder also needs to be removed,2. Bladder Cancer,80% of cases occur in patients over 50 years of age. Men are affected

10、 more commonly than women in a 2-3:1 ratio. Whites are more commonly affected than blacks by a 4:1 ratio.,Etiology 1.occupational exposures to carcinogenic aromatic amines in dye, textile, rubber, cable, printing, and plastics industries:(a)-naphthylamine, (b) 4-aminobiphenyl (xenylamine),(c) 4-nitr

11、o-biphenyl, and (d) 4,4 diaminobiphenyl (benzidine). 2. cigarette smoking, dietary nitrosamines, Schistosoma haematobium of the bladder,Pathology Transitional cell carcinoma(TCC) (90%) Squamous cell carcinoma (8%) Adenocarcinoma (2%),Staging Tis Carcinoma-in-situ. Ta Noninvasive papillary carcinoma.

12、 T1 Tumor invades submucosa/lamina propria . T2 Tumor invades superficial muscle. T3a Tumor invades deep muscle. T3b Tumor invades perivesical fat. T4 Tumor invades adjacent organs.,mucosa submucous layer superficial muscle. deep muscle. perivesical fat. adjacent organs.,Tumor Grade Grade 1 = Well-d

13、ifferentiated (-10% will be invasive) Grade 2 = Moderately differentiated (-50% will be invasive) Grade 3 = Poorly differentiated (80% will be invasive),Presentation,Hematuria is the hallmark of bladder cancer. irritative symptoms (frequency, urgency, and dysuria) flank pain (ureteral obstruction),

14、pelvic pain (spread outside bladder ),and leg edema (lymphatic involvement),Diagnosis 1.Bimanual exam (Vagino-recto-abdominal exam) 2. B-US 3.X-Rays: IVU, retrograde pyelography (RP) 4.Cystoscopy and Biopsies 5.Cytology (Urinary exfoliated cells) 6.CT scan (lymph node, staging ) 7.Magnetic Resonance

15、 Imaging (MRI),Cystoscopy figure,B-US,X-Rays : intraluminal filling defect,Treatment,Superficial Bladder Cancer Carcinoma-in-situ intravesical BCG or mitomycin C chemotherapy. Failure to respond to intravesical therapy requires that radical cystectomy be considered. Stage Ta-T1 1.Transurethral resec

16、tion (TUR). 2.lntravesical Chemotherapy. 3. Follow-Up,Muscle-Invasive Bladder Cancer,Surgery. Radical cystoprostatectomy and pelvic lymphadenectomy for Stages T2 and T3a in young healthy patients. Segmental cystectomy has been successful for highly localized T2 lesions, with 5-year survival rates of

17、 50-70%. Radiation Chemotherapy,ileum 回肠,3. Cancer of the penis,associated with chronic inflammatory disease, venereal disease, and phimosis. circumcision appears to be protective against the development of cancer of the penis.,Pathology,It occurs most frequently on the glans, coronal sulcus and pre

18、puce. Greater than 95% of cases are squamous cell carcinoma (SCC) Hematogenous spread is rare; rather, an orderly spread via the lymphatics is the rule.,Phimosis, cancer,ulcerated carcinoma,Diagnosis a full thickness biopsy inguinal nodes antibiotics (2-6 weeks),Treatment,wide surgical excision leav

19、ing adequate tumor-free margins 1.Lesions confined to the prepuce can be managed with circumcision 2.Tumors confined to the glans or distal shaft will require partial amputation and reconstruction. 3.Involvement of the proximal shaft or base of the penis necessitates total penectomy.,Bilateral ingui

20、nal lymphadenectomy patients with positive nodes Pelvic lymphadenectomy healthy young individuals with positive inguinal nodes. The therapeutic benefit of pelvic node dissection has not been proven.,4. Testicular Cancer,Testicular cancers are rare overall, yet they are the most common solid tumor of

21、 young adult men. Primarily because of effective chemotherapy, they have become the most curable of all cancers,Pathology,Germ cell cancers account for 90-95% of all primary testicular neoplasms 10% of patients have a prior history of an undescended testis, 50% of which were intra-abdominal.,Testicu

22、lar Cancer,60% of germ cell tumors are of a single cell type while 40% will be mixed. Single cell types: Seminomas (35%) Embryonal Carcinoma (20%) Teratomas (5%) Choriocarcinomas (1%) Yolk Sac Tumor (1%) Mixed cell types: Teratocarcinomas, a combination of teratoma and embryonal carcinoma (20%) The

23、others (20%),Tumor Markers,-fetoprotein (AFP) human chorionic gonadotropin (HCG) 90% of patients with nonseminomatous testis tumors will have elevations of one or both markers 5-10% of pure seminomas will demonstrate elevations of HCG only,Diagnosis a painless lump, nodule, swelling, or hardness in

24、the testis of a young adult, HCG, AFP,Treatment,radical orchiectomy A retroperitoneal lymph node dissection (RPLND) -has Both staging and therapeutic value for patients with nonseminomatous tumors and spread to regional lymphatics. Radiation. Chemotherapy.,5. Prostate cancer,the second most common c

25、ause of cancer deaths in males in the United States No clear etiologic factors have been identified,Pathology,acinar adenocarcinomas(95%) ductal carcinomas carcinosarcomas,Adenocarcinomas of the prostate arise primarily in the peripheral zone(70%), however 20% arise in the transition zone and about

26、5% in the central zone. Spread: Direct local extension Lymphatic spread Vascular spread bone metastasis (lumbar spine, proximal femur, pelvis, thoracic spine, ribs, sternum, and skull) lung, liver, and adrenal.,Staging systems,Stage A is microscopic disease found incidentally in 10-20% of simple prostatectomy specimens (TUR or open). Acid phosphatase and digital rectal exam are negative. Tumor is confined to the prostate. Stage B is gross disease confined to the prostate and palpable on digita