外科学教学课件：泌尿男性生殖系肿瘤（全英文）

GenitourinaryTumors

RENALCELLCARCINOMA(RCC)Occupationalexposures,chromosomalaberrations（染色体突变）,andtumorssuppressorgeneshavebeenimplicated.

Etiology

Exposuretoasbestos（石棉）,solvents（溶剂）,andcadmium（镉）hasalsobeenassociatedwithanincreasedincidenceofRCCCigarettesmokingistheriskfactorconsistentlylinkedtoRCCEtiology

Grossly,thetumorischaracteristicallyyellowtoorangebecauseoftheabundanceoflipids,particularlyintheclearcelltype.RCCdonothavetruecapsulesbutmayhaveapseudocapsule（假包膜）ofcompressedrenalparenchyma,fibroustissue,andinflammatorycells.Pathology

RCCoriginatesfromtheproximalrenaltubularepithelium.Histologically，clearcellsarerounded（圆形）orpolygonal（多边形）withabundantcytoplasm,whichcontainscholesterol（胆固醇）,triglycerides（甘油三酯）,glycogen（糖）,andlipids（脂类）.Pathology

Manypatientsremainasymptomaticandnon-palpableuntiltheyareadvanced.Triad（三联症）:Theclassicallydescribedtriadofgrosshematuria,flankpain,andapalpablemassoccursinonly7–10%

ofpatientsandisfrequentlyamanifestationofadvanceddisease.ClinicalPresentation

Patientsmayalsopresentwithdyspnea（呼吸困难）,cough,andbonepainwhicharetypicallysymptomssecondarytometastases.WiththeroutineuseofCTscanningforevaluationofnonspecificfindings,asymptomaticrenaltumorsareincreasinglydetectedincidentally.ClinicalPresentation

Paraneoplasticsyndromes（副瘤综合症）：RCCisassociatedwithawidespectrumofparaneoplasticsyndromesincludingerythrocytosis（红细胞增多）,hypercalcemia（高钙血症）,hypertension,andnonmetastatichepaticdysfunction.Overall,thesemanifestationscanoccurin10–40%ofpatientswithRCC.ClinicalPresentationA.SymptomsandsignsB.UltrasounographyUSexaminationisanoninvasive,relativelyin-expensivetechniqueabletofurtherdelineatearenalmassseenonIVU.Itisapproximately98%accurateindistinguishingsimplecystsfromsolidlesions.DiagnosisDiagnosisC.CTScanningCTscanningismoresensitivethanUSorIVUfordetectionofrenalmasses.AtypicalfindingofRCConCTisamassthatbecomesenhancedwiththeuseofintravenouscontrastmedia.

Inadditiontodefiningtheprimarylesion,CTscanningisalsothemethodofchoiceinstagingthepatientbyvisualizingtherenalhilum（肾门）,perinephricspace,renalveinandvenacava（腔静脉）,adrenals,regionallymphatics（局部淋巴结）,andadjacentorgans.DiagnosisDiagnosisD．X-rayfindingsIVUisrarelyusedforthediagnosisorevalu-ationofRCC.E.RenalangiographyWiththewidespreadavailabilityofCTscanners,theroleofrenalangiographyinthediagnosticevaluationofRCChasmarkedlydiminishedandisnowverylimited.DiagnosisF.Magneticresonanceimaging（MRI）

MRIisequivalenttoCTforstagingofRCC.Itsprimaryadvantageisintheevaluationofpatientswithsuspectedvascularextension.

Thegreatmajorityofrenalmassesaresimplecysts（囊肿）.OncethediagnosisofacystisconfirmedbyUS,noadditionalevaluationisrequiredifthepatientisasymptomatic.DifferentialDiagnosis

Withtheliberal（大量）useofBtypeultrasound、computedtomography(CT)scansandmagneticresonanceimaging(MRI),benignrenalmassesarebeingdetectedmorefrequently.Benignrenaltumorsincludeadenoma（腺瘤）,oncocytoma（嗜酸性细胞瘤）,angiomyolipoma（血管平滑肌脂肪瘤）,leiomyoma（平滑肌瘤）,lipoma（脂肪瘤）,hemangioma（血管瘤）.DifferentialDiagnosis

Angiomyolipomas(withlargefatcomponents)caneasilybeidentified

bythelow-attenuationareasclassicallyproducedbysubstantialfatcontent.DifferentialDiagnosis

Radicalnephrectomy（根治性肾切除术）istheprimarytreatmentforlocalizedRCC.Itsgoalistoachievetheremovaloftumorandtotakeawidemarginofnormaltissue.Treatment

Radicalnephrectomyentailsenblocremovalofthekidneyanditsenvelopingfascia(Gerota’s)includingtheipsilateraladrenal（同侧的肾上腺）,proximalone-halfoftheureter,andlymphnodesuptotheareaoftransectionoftherenalvessels.Removaloftheadrenalisunnecessaryifthetumorisnotintheupperpole.

Treatment

Preoperativerenalarteryembolization（肾动脉栓塞）patientswithverylargetumorsinwhichtherenalarterymaybedifficulttoreachearlyintheprocedure.Treatment

Partialnephrectomy（肾部分切除术）andwedgeresection（楔形切除术）withanadequatemarginofnormalparenchymaisincreasinglybeingusedasprimarysurgicaltherapyforpatientswithtumors<4cminsize,eveninthepresenceofanormalcontralateralkidney.TreatmentTreatmentRadiotherapyandchemotherapyBiotherapy:Interferon-alpha(IFN-α) Interleukin-2(IL-2)

Nephroblastoma（肾母细胞瘤）,alsoknownasWilmstumor,isthemostcommonsolidrenaltumorofchildhood.NEPHROBLASTOMA

(WILMSTUMOR)

Grossly,Wilmstumorsaregenerallylarge,multi-lobulated（分叶状）,andgray（灰色）ortan（黄褐色）incolorwithfocalareasofhemorrhageandnecrosis.Afibrouspseudocapsule（纤维性假包膜）isoccasionallyseen.PathologyTumordisseminationcanoccurbydirectextensionthroughtherenalcapsule,hematogenously（血原性）viatherenalveinandvenacava（腔静脉）,orvialymphaticspread.Pathology

ThediagnosisofWilmstumorismostcommonlymadeafterthediscoveryofanasymptomaticmassbyafamilymemberoraphysicianduringaroutinephysicalexamination.ClinicalPresentation

Commonsymptomsatpresentationincludeabdominalpain（腹痛）anddistention(腹胀),anorexia（食欲减退）,nauseaandvomiting（恶心呕吐）,fever,andhematuria.Themostcommonsignisanabdominalmass.

ClinicalPresentation

SymptomsandsignsAbdominalUSCTscanningandMRIareper-formedinitiallytoevaluatethemass.CToftheabdomenisperformedwithsuspectedWilmstumorandcanbeusefulinprovidinginfor-mationregardingtumorextension,thestatusofthecontralateralkidney,andthepresenceofregionaladenopathy（腺病）.Diagnosis

Thedifferentialdiagnosisofaflankmassinachildincludeshydronephrosis（肾积水）,cystickidneys（囊性肾病）,intrarenalneuroblastoma（肾神经母细胞瘤）.Diagnosis

SignificantimprovementsinsurvivalratesforchildrenwithWilmstumorhavebeenachievedbyanimprovedunderstandingofthediseaseandamultimodalityapproachtotherapy,thatincorporatessurgery（radicalnephrectomy）,radiationtherapy,andchemotherapy.TreatmentTUMOROFTHE

RENALPELVIS

Transitionalcell:renalcalices（肾盏），renalpelvis（肾盂），ureter，bladder，posteriorurethra.Pathology

Transitionalcellcarcinoma(移行细胞癌)accountsformorethan90%ofuppertracturothelialtumors.Histopathologic（组织病理学）featuresaresimilartothoseoftransitionalcellcarcinomaofthebladder.SquamousCellCarcinoma（鳞状细胞癌）andAdenocarcinoma（腺癌）arerare.Pathology

Transitionalcellcarcinomaoftherenalpelvismayspreadbydirectinvasionintotherenalparenchymaorsurroundingstructures,byepithelialextension(eitherdirectextensionorseeding),bylymphaticinvasion,orbyvascularinvasion.ClinicalPresentation

Themostcommonpresentingsymptomisgrossormicroscopichematuria.Flankpainisusuallydull（钝的）becauseofgradualobstructionanddistention（扩张）ofthecollectingsystem.Acutecolicoccursfrompassageofbloodclotsthatacutelyobstructthecollectingsystem.DiagnosisSignsandSymptomsExamineexfoliatedcells（脱落细胞）intheurinarysediment（尿沉渣）.

Intravenousurography（IVU）：Themostcommonabnormalitiesidentifiedincludeanintraluminalfillingdefect（充盈缺损）,unilateralnonvisualization（不显影）ofthecollectingsystem,andhydronephrosis.ItmustbeDifferen-tiatedfromnonopaque（透光的）calculi,bloodclots.Diagnosis

Ultrasonography,CT,andMRIfrequentlyidentifysofttissueabnormalitiesoftherenalpelvis.Theuseofrigidandflexibleureteropyelo-scopes（输尿管肾盂镜）hasalloweddirectvisualizationofupperurinarytractabnormalities.DiagnosisTreatment

Thestandardtherapyisnephroureterectomy（肾输尿管全切术）withexcisionofabladdercuff（膀胱袖状部分切除术）owingtothepossibilityofmultifocaldiseasewithintheipsilateralcollectingsystem.TUMOROFBLADDER

Bladdercanceristhemostcommoncanceroftheurinarytract.Etiology

Occupationalexposure：Workersinthechemical,dye（染料）,rubber（橡胶）,petroleum（石油）,leather（皮革）,andprintingindustries（印刷）areatincreasedrisk.

Specificoccupationalcarcinogensincludebenzidine（联苯胺）,beta-naphthylamine（β-萘胺）,and4-aminobiphenyl（4-氨基联苯胺）,andthelatencyperiod（潜伏期）betweenexposureandtumordevelopmentmaybeprolonged.Etiology

Cigarettesmokingaccountsfor50%ofcasesinmenand31%inwomen.Ingeneral,smokershaveapproximatelyatwo

foldincreasedriskofbladdercancerthannonsmokers,andtheassociationappearstobedoserelated.Etiology

Patientswhohavereceivedcyclophosphamide（环磷酰胺）forthemanagementofvariousmalignantdiseasesarealsoatincreasedrisk.Ingestionofartificialsweeteners（人造甜味剂）hasbeenproposedtobeariskfactor.EtiologyEtiology

Physicaltraumatotheurotheliuminducedbyinfection,instrumentation,andcalculiincreasestheriskofmalignancy.Geneticevents：theactivationofoncogenesandinactivationorlossoftumorsuppressorgenes.Pathology

Ninety-fivepercentofallbladdertumorsareepithelialtumors,withmostbeingtransitionalcelltumors.MostofallbladdercancersareTCCs.Papillomas（乳头状瘤）areararebenignconditionusuallyoccurringinyoungerpatients.Adenocarcinomas（腺癌）accountfor2-3%ofallbladdercancers.Pathology

MulticentricOrigin（多中心起源）:Traditionally,transitionalcellcarcinomahasbeenconsideredafieldchangedisease,withtumorsarisingatdifferenttimesandsitesintheurothelium.Thissuggestsapolyclonal（多克隆）etiologyofbladdercancer.PatternsofSpreadDirectExtensionLymphaticSpread:Themostcommonsitesofmetastasesinbladdercancerarethepelviclymphnodes.VascularSpreadPathologyPathologyTumorGrading①Well-differentiated(grade1)transitionalcellcarcinomaPathologyTumorGrading②Moderatelydifferentiated(grade2)tumorsPathologyTumorGrading③Poorlydifferentiated(grade3)tumors

Pathology

Stagingpapillaryepithelium–confinedtumorsareclassifiedasstageTa.FlatinsitucarcinomasareclassifiedasTis.Tumorsthathaveinvadedthelaminapropria（固有层）areclassifiedasstageT1.

StagingMuscle-invasivetumors,dependingonwhetherthereissuperficialordeepmuscleinvasion,areclassifiedasstageT2aorT2b,respectively.PathologyStagingTumorsthathaveinvadedtheperivesicalfatareclassifiedasstageT3a(microscopicinvasion)orT3b(macroscopicinvasion).PathologyPathology

StagingTumorsinvadingthepelvicviscera（脏器）,suchastheprostaticstroma,rectum（直肠）,uterus（子宫）,orvagina（阴道）,areclassifiedasstageT4a,whereasthoseextendingtothepelvicside

wallsorabdominalwallarestageT4b.ClinicalPresentationA.Syptoms

Hematuriaisthepresentingsymptomin85–90%ofpatientswithbladdercancer.Itmaybegrossormicroscopic,intermittent（间歇性）ratherthanconstant.

Inasmallerpercentageofpatients,itisaccompaniedbysymptomsofvesicalirritability（膀胱刺激症）:frequency,urgency,anddysuria.Symptomsofadvanceddiseaseincludebonepainfrombonemetastasesorflankpainfromretroperitonealmetastasesorureteralobstruction.ClinicalPresentationB.SignsPatientswithlarge-volumeorinvasivetumorsmaybefoundtohavebladderwallthickeningorapalpablemass.Hepatomegaly（肝肿大）andsupraclavicular（锁骨上）lymphadenopathy（淋巴结肿大）aresignsofmetastaticdisease.ClinicalPresentationDiagnosisA.SyptomsandsignsB.Laboratoryfindings①Routinetesting—Themostcommonlaboratoryabnormalityishematuria.Itmaybeaccompaniedbypyuria（脓尿）,whichonoccasionmayresultfromconcomitant（相伴的）urinarytractinfection.Diagnosis

Azotemia(氮质血症)maybenotedinpatientswithureteralocclusionowingtotheprimarybladdertumororlymphadenopathy.Anemia（贫血）maybeapresentingsymptomowingtochronicbloodloss,orreplacementofthebonemarrowwithmetastaticdisease.②.Urinarycytology（尿细胞学）—Exfoliatedcellsfromneoplasticurothelium（尿路上皮肿瘤）canbeidentifiedinvoidedurine.DiagnosisDiagnosisC.ImagingImagingisusedtoevaluatetheupperurinarytractand,wheninfiltratingbladdertumorsaredetected,toassessthedepthofmusclewallinfiltrationandthepresenceofregionalordistantmetastases.

Transabdominalortransrectalsonographyhasbeenofminimalvalue.Intravenousurographyremainsoneofthemostcommonimagingtestsfortheevaluationofhematuria.Diagnosis

However,intravenouspyelographyisincreasinglybeingreplacedbycomputedtomography(CT)urography,whichismoreaccurate,forevaluationoftheentireabdominalcavity,renalparenchyma,anduretersinpatientswithhematuria.Diagnosis

TheresolutionofthepelvicandabdominalanatomywithtraditionalMRIhasnotbeenreportedtobeasgoodasthatwithCTscanning.DiagnosisD.CystoscopyAllpatientssuspectedofhavingbladdercancershouldhavecarefulcystoscopy.Diagnosis

Superficial,low-gradetumorsusuallyappearassingleormultiplepapillarylesions.Highergradelesionsarelargerandsessile（固着）.CISmayappearasflatareasoferythema（红斑）andmucosalirregularity（粘膜不规则）.Abnormalareasshouldbebiopsied.DiagnosisTreatment

Tis，high-grade：intravesicalBCG（bacillecalmette-guerin）

Immunotherapeuticorchemotherapeuticagentscanbeinstilledintothebladderdirectlyviacatheter,therebyavoidingthemorbidityofsystemicadmini-strationinmostcases.Intravesicaltherapycanhaveaprophylacticortherapeuticobjective,eithertoreducerecurrenceinpatients.

Ta、T1：Intravesicalchemotherapy（mitomycinC,adriamycin阿霉素,hydroxylcamptothecine羟基喜树碱）orimmunotherapy（BCG、INF）aftercompleteandcarefulTUR.TreatmentPatientswithmoreinvasive,butstilllocalized,tumors(T2,T3)arecandidatesformoreaggressivelocaltreatment,includingpartialorradicalcystectomy,oracombinationofradiationandsystemicchemotherapy.Treatment

Patients（T4）arecandidatesforsystemicchemotherapyorradiotherapy.Follow-up：cystoscopyTreatmentCARCINOMAOFTHEPROSTATE

ProstatecanceristhemostcommoncancerinAmericanmen.Althoughprostatecanceristhesecondleadingcauseofcancerdeathformen,mortalityrateshavebeendecliningsincethemid-1990s.

However,becauseofreductionsindeathduetocardiovasculardiseaseandtheagingofAmericanmen,prostatecancerwillcontinuetobeamajorhealthcareconcernunlessmoreeffectiveformsofpreventionandtreatmentareidentified.

Severalriskfactorsforprostatecancerhavebeenidentified.IncreasingageEtiology

Diet:Epidemiologicstudieshaveshownthattheincidenceofclinicallysignificantprostatecancerismuchlowerinpartsoftheworldwherepeopleeatapredominantlylowfat,plant-baseddiet.EtiologyTotalfatintake,animalfatintake,andredmeatintakeareassociatedwithanincreasedriskofprostatecancer.Etiology

whereasintakeoffishisassociatedwithadecreasedrisk.Additionally,lycopene(番茄红素),selenium(硒),omega-3fattyacids(fish),andvitaminEintakehavebeenshowntobeprotective,whereasvitaminDandcalciumincreaserisk.

Over95%ofthecancersoftheprostateareadenocarcinomas.Oftheother5%,90%aretransitionalcellcarcinomas,andtheremainingcancersareneuroendocrine(神经内分泌的)carcinomasorsarcomas（肉瘤）.PathologyPathology

Approximately,60–70%ofcasesofCaPoriginateintheperipheralzone.ThecytologiccharacteristicsofCaPincludehyperchromatic（深染）,enlargednucleiwithprominentnucleoli（核仁显著）.Cytoplasmisoftenabundant.Pathology

Grading&StagingTheGleasongradingsystemisthemostcommonlyemployedgradingsystemintheUnitedStates.Inassigningagradetoagiventumor,pathologistsassignaprimarygradetothepatternofcancerthatismostcommonlyobservedandasecondarygradetothesecondmostcommonlyobservedpatterninthespecimen.Gradesrangefrom1to5.Pathology

TheGleasonscoreorGleasonsumisobtainedbyaddingtheprimaryandsecondarygradestogether.AsGleasongradesrangefrom1to5,Gleasonscoresorsumsthusrangefrom2to10.Well-differentiatedtumorshaveaGleasonsumof2–4,moderatelydifferentiatedtumorshaveaGleasonsumof5–7,andpoorlydifferentiatedtumorshaveaGleasonsumof8–10.PathologyTNMStagingSystemforProstateCancer.TxCannotbeassessedT0NoevidenceofprimarytumorTisCarcinomainsitu(PIN)T1a﹤5%oftissueinresectionforbenign diseasehascancer,normalDRET1b>5%oftissueinresectionforbenign diseasehascancer,normalDRETNMStagingSystemforProstateCancer.T1cDetectedfromelevatedPSAalone,normal DREandTRUST2aTumorpalpablebyDREorvisiblebyTRUS ononesideonly,confinedtoprostateT2bTumorpalpablebyDREorvisiblebyTRUS onbothsides,confinedtoprostatePathologyPathologyTNMStagingSystemforProstateCancer.T3aExtracapsularextensionononeorboth sidesT3bSeminalvesicleinvolvementT4Tumordirectlyextendsintobladderneck, sphincter,rectum,levatormuscles,orinto pelvicsidewallClinicalPresentationSymptomsMostpatientswithearly-stageCaPareasym-ptomatic.Thepresenceofsymptomsoftensuggestsl