RENAL and BLADDER NEOPLASMS

RENAL PARENCHYMA NEOPLASM

ADENOCARCINOMA (RENAL CELL CARCINOMA). Adenocarcinoma of kidney represent about 3% of adult cancer Male-female ratio 2-1 equal in whites and blacks

ETIOLOGY

The cause is unknown. There are various theories: Environmental and occupational factors Cigarette smoking Chromosomal aberration and tumor suppressor genes(chromosome 3 and 8) Aquired cystic disease

PATHOLOGY

The tumor occur in equal frequency in either kidney originates in the cortex ,grow out in the perinephric tissue it is characteristically yellow to orange because of high lipid content

PATHOGENESIS

RCC is a vascular tumor , tend to spread by Direct invasion Vascular invasion is through renal vein About 1\3 of patients have metastasis at presentation The most common site of distant metastasis is lung oppposite kidney Followed by liver, bone.


TUMOR STAGING Stage 1: tumor is confined within kidney parenchyma StageII:tumor involve perinephric fat but is confined within Gerota,s fascia Stage IIIa : tumor involve the main renal vein or inferior vena Cava Stage IIIb :tumor involve regional lymph node

Stage IIIc : tumor involve both local vessels and regional lymph nodeStage IVa : tumor involves adjacent organs (colon,pancreas,….)Stage IVb :distant metastasis


TNM Classification

CLINICAL PICTURE

It has a wide variety of presentation Classic triade : gross haematuria Flank pain Palpable mass Occur in about 10-15% of patients,frequently in advanced disease. Abd pain ,abd mass, (30%) Symptoms of metastasisdisease: Dyspnea,couph,headache,bone pain


Paraneoplastic syndrome Erythrocytosis Hypercacemia Hypertention Nonmetastatic hepatic dysfunction 3-10% of RCC present by paraneoplastic syndrome RCC is the most common cause of paraneoplastic erythrocytosis Hypercalcemia occur in about 20% of patients with RCC Hypertention in 40%

Laboratory FINDINGS CBC anemia (30%) High ESR Haematuria (60%)

imaging
IVP 75% accurate U\S CT scan it is the leader for diagnosis and staging And detect distant metastasis Renal angiography MRI Fine needle aspiration idicated in : 1 metastatic disease , planned for nonsurgical management 2 establishing diagnosis in patients who are not surgical Candidate

Differential diagnosis

Carcinoma of renal pelvis Renal lymphoma Adrenal cancer Benign renal tumor Renal cysts Renal abscess

TREATMENT

LOCALISED DISEASE Stage (I, II , IIIa ) Radical nephrectomy


DISSEMINATED DISEASE 30% of RCC are metastatic The role of radical nephrectomy is limited It is a palliative therapy Radiotherapy (RCC is a radioresistant) Chemotherapy (is also chemotherapy resistant )


Prognosis is according to stage: T1 disease 5 years survival 88-100% T2 T3a 5 years survival 60 % T3a 5 years survival rate 15-20 %

BENIGN TUMOR 

Renal adenoma is the most common benign tumorRenal oncocytoma occur in variant organ( adrenal, salivary gland, thyroid,…) represent about 3% of kidney tumorAngiomyolipoma: is very rare ,

BLADDER CARCINOMA

Male- female ratio 3-1 Common in wights than in blacks Is the second most common cancer of genitourinary tract Average age is 65 years 85% are Localised , 15 % have distant sites

PATHOGENESIS AND ETIOLOGY

Cigarette smoking account for 50 % of men and 30% of women the causative agent are to be alpha and beta naphthylamine wich are secreates in urine of smokers Occupational exposure to certain chemicals(rubber ,petroleum, printing industries) Cyclophosphamide Artificial sweeeners Calculi and infection Genetic predisposition

STAGING

HYSTOPATHOLOGY
PAPILOMA: is uncommon Represent about <2 % of all transiotional cell Tumor , has a very good prognosis Transitional cell carcinoma: Accounts for 90% of all bladder cancer Appears as papillary exophytic lesion May be sessile or ulcerated



NONTRANSITIONAL CELL CARCIMOMA 1: ADENOCARCINOMA : Accounts for <2% of bladder cancer Mucous secreting tumor Arise along the floor of bladder Muscle invasion is usually present 5 years survival <40%


2 SQUAMOUS CELL CARCINOMA Accounts for 5-10% of bladder tumor Often associated with H\O bilharsial infectionVesical caculi , chr ctheterisation In Egypt represent about 60% of bladder cancer


3 UNDIFFERENTIATED CARCINOMA: Is rare , represent < 2% of bladder carcinoma 4 MIXED CARCINOMA Constitute 4-6% of all bladder carcinoma Composed of transitional , squamous, or Undifferentiated carcinoma

Clinical picture

A :SYMPTOMS: Haematuria is the presenting symptom in 85-90% May be gross or micriscopic Intermittent rather than constant Symptoms of vesical irritability Symptoms of advanced disease


B: SIGNS: The majority of patients have no pertinent physical signs. patients with advanced disease may have a Palpable mass, Hepatomegaly and supraclavicular lymph node Indicates advanced disease

LABORATORY FINDINGS The most common is hematuria Azootemia in case of ureteral occlusion Anemia may be a presenting symptom due to chr blood loss and replacement of bone marrow by metastatic cells. Urine cytology .


IMAGING: Used To Evaluate the upper urinary tract Assess the depth of muscle infiltration Presence of regional or distant metastasis IVU: the most common imaging test for evaluation of hematuria CTscan Cystourthroscopy

TREATMENT

TUR or laser vaporization : For patients with single low grade, noninvasive tumor Partial cystectomy For solitary infiltrating tumor (t1-t3) cancer of bladder diverticula Radical cystectomy In locally advanced disease


URETERAL AND RENAL PELVIS
Carcinoma of renal pelvis and ureter are rare Represent about 4% of all utothelial cancer Ratio bladder renal pelvis ureter 51 3 1 Age group > 65 years Patients with single upper tract carcinoma are at risk of Developing bladder carcinoma (30-50%) and contralateralUpper tract (2-4%).

ETIOLOGY AND PATHOLOGY As urinary bladder carcinoma

CLINICAL PICTURE Haematuria 70-90% Flank pain 50% Irritative symptoms Weight loss Flank mass

LABORATORY FINDINGS Hematuria is identified in majority of cases Anemia Elevated liver function

IMAGING IVU RETROGRADE PYELOGRAPHY is more accurate CTscan identify soft tissue abnormality of renal pelvis URETEROPYELOSCOPY allow direct visualization Of upper urinary tract

TREATMENT Based on: grade, stage, position and multiplicity The standard therapy is nephroureterectomy

Tumor of distal ureter : distal ureterectomy and ureter reimplantation