URO-ONCOLOGY
HEMATURIA :Painless gross haematuria can
be a symptom of kidney or bladder cancer.
Therefore, it is usually investigated with an Ultrasound scan and CTU (CT
urogram) to see the upper tract and a cystoscopy to see the bladder. Painful gross haematuria is commoner and may
be caused by stones or infection. Other
sources of gross haematuria include BPH, benign prostatic hyperplasia (usually
> 55 years of age), glomerulonephritis (usually young) and vascular
malformations. Radiocontrast is contra-indicated if there is renal failure or a strong history
of allergy.
The main tumours of the
urinary system are:
1) Kidney: adenocarcinoma,
Wilm’s tumour (the later in children).
2) Bladder: transitional
cell tumour, the commonest tumour of the urinary system.
3) Prostate: adenocarcinoma.
4) Testis: seminoma,
nonseminomatous
5)
Penis: squamous cell
carcinoma.
KIDNEY:
Adenocarcinoma (or RCC, renal
cell carcinoma, usu CCC, clear cell carcinoma)
Presentation: Gross painless
haematuria; renal mass.
Investigations: CT shows a solid mass
Ultrasound to
distinguish solid tumour from cyst, see IVC and renal vein invasion by tumour
thrombus (feature of RCC).
CXR
CT Abdomen
Thorax, esp to see para-aortic lymph nodes.
Management: Surgical removal is currently the
only hope of cure. This is possible in
locally confined disease; embolus present in the renal vein/IVC can be removed
with the cardiac surgeon. Chemotherapy
and radiotherapy are not effective. Immunotherapy (e.g. interleukin-2) and
kinase inhibitors (eg sorafenib, sunitinib) is useful for metastatic disease.
PARTIAL
NEPHRECTOMY is gaining popularity, especially if need to preserve nephrons to
avoid dialysis.
In Wilm’s tumour, chemotherapy has important role and hence,
important to manage with paediatric oncologist.
BLADDER:
Clinically commoner then cancer prostate
in Malaysia. Usually TCC (transitional
cell carcinoma). Almost ALL tumours in the bladder are TCCs.
Presentation: Gross painless haematuria;
suprapubic mass rarely (i.e. unusual to have clinical signs).
Aetiology: Smoking
increases risk 4 x
An
‘industrial disease’ where aromatic amines were used e.g. in rubber/dye
industries.
Investigations: (1)
Ultrasound
(2) CTU
(2)
CT TAP, thorax, abdomen and pelvis,
Management: Depends on stage and grade:
(a)
NMIBT, non muscle invasive bladder tumour –
transurethral resection (TURBT, transurethral resection bladder tumour). May
reduce recurrence with immediate intravesical Mitomycin C /BCG; weekly x6 and
maintainence
(b)
Bladder Muscle Invasive – radical surgery to remove
bladder and urinary diversion.
Radiotherapy if not fit for surgery.
5-year survival: 50%. Grade 3 TCC especially if associated with CIS
(carcinoma in situ) may be treated with radical surgery. Urinary diversion may
be with ileal conduit, orthotopic neobladder or continent cutaneous stoma (eg
with appendix)
(c)
Advanced (locally fixed, node positive or
metastatic) – palliative chemotherapy.
Note: T.C.C. may be found
occasionally in other parts of the urothelium e.g. ureter and renal pelvis.
cessation of
smoking important
PROSTATE:
Radical differences in incidence (e.g.
very low mortality in Japanese) may be related to genetics and diet.
Presentation: If early,
detected by blood test, PSA (prostatic specific antigen). If advanced, urinary retention, bone pain
from secondaries.
Investigation: Biopsies: transrectal ultrasound
guided, occa transperineal
X-ray (pelvis)
osteosclerotic lesions (Ca prostate is the commonest cause of such lesions).
CT TAP
MRI
Bone Scan.
Management: (a) Localised disease: radical prostatectomy (or radiotherapy)
if life expectancy > 10 years as
disease may be slow growing. Robot assisted laparoscopic radical prostatectomy
(RALRP) is the preferred treatment for localized disease. In low grade low
volume disease with slow PSA doubling time, active surveillance may be an
option.
(b)
Advanced disease (local invasion, node +ve,
metastatic) palliation by androgen deprivation.
This may be surgical (orchidectomy) or medical (injection LHRH analogue
3 monthly). Localised bone pain can be treated with radiotherapy.
TESTIS:
Presentation: Testicular mass – any SUCH MASS
SHOULD BE CONSIDERED MALIGNANT UNLESS PROVEN OTHERWISE.
Aetiology: A maldescended testis has a
higher incidence (5%), patients with such a history should do TSE (testicular self
examination) monthly; usu. a cancer of young men.
Investigation: Ultrasound – to determine that the
swelling is actually testicular (and not, e.g. a hydrocele).
Tumour markers – alpha-fetoprotein, beta-HCG (raised in teratoma).
Management: Radical orchidectomy as biopsy –
inguinal route mandatory to control vascular pedicle to prevent tumour
embolisation. When diagnosis confirmed,
to stage tumour with CXR, CT TAP
CHEMOTHERAPY
IS THE MAINSTAY OF TREATMENT AND OFTEN CURATIVE.
PENIS:
Presentation: Penile ulcer and
growth, often in an advanced state although the penis is an easily visible and
often used organ.
Aetiology: Circumcision in infancy gives complete immunity.
Investigation: Biopsy (including inguinal lymph
nodes if these are enlarged).
Management: Surgery,
chemo and radiotherapy.
Seminar on 17 August 2017
UNIVERSITI MALAYSIA SARAWK
No comments:
Post a Comment