Tuesday, February 19, 2019
Uro-oncology, a summary, Feb 2019, Dr Lei
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 wereused 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 mortality (e.g. very low mortality in Japanese) may be related to genetics, diet & lifestyle.
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 in young men – 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), LDH.
Management: Radical orchidectomy as biopsy – inguinal route mandatory to control vascular pedicle to prevent tumour embolisation. When diagnosis confirmed, to stage tumour with CT TAP
CHEMOTHERAPYIS 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 18 February 2019
ADJUNCT PROFESSOR
UNIVERSITI MALAYSIA SARAWK
Dr Clarence Lei Chang Moh, FRCS Urol,
Consultant Urologist,
clarencelei@gmail.com; whatsapp 0128199880
Saturday, February 2, 2019
ROBERT KUOK, truly remarkable man, at 94 years!
BOOK REVIEW by Dr Clarence Lei Chang Moh on the book:
ROBERT KUOK, A MEMOIR WITH ANDREW TANZER, published in 2018, 24 chapters with 376 pages
The book title first caught by attention when Dato Dr Rohan Malek, Head of Urology Services of Ministry of Health of Malaysia included 2 slides regarding this. He was giving a lecture on the criteria for selection of new urology specialist trainees. The 3 important criteria for employing new staff to the Robert Kuok empire are:
Integrity; talent/ability; capacity for hard work. The second slide is a reminder that material wealth is not a guarantee for happiness!
I then asked my second son to search for a PDF version of the book so that I can read it on my laptop which I carry with me every way. However, he came out with diferrent version. It is a 24-page article published in the Australian Economic History Review Volume 53 No. 3 in November 2013. The article was written by Lee Kam Hin et al of University of Malaya. It quotes Robert Kuok as the richest man in South East Asia, Forbes Asia in its March 2018 Issue (Page 24 to 28) also quoted Robert Kuok as a legendary tycoon.
I must confess that I read most of the book from my toilet seat in the morning. This is possible because the book is written in small chapters. There is no real story line that “compels” one to read the entire book. In the end, I completed reading the last few chapters in one night.
I would not have read the book if my daughter has not bought (the “last” copy) while she was transiting at Heathrow Airport on the way back to Kuching; the book was priced at £25. Most parts of the book are about Robert Kuok’s personal dealings of his family business, in the sugar and oil business, complete with names, probably real. Although he is less than complimentary on some of the business associates, he is usually full of praise for the government officials in Malaysia and Singapore.
One usually looks for any underlying message in such a book, especially in somebody who is still healthy and alive at the age of 94 at the time of publishing the book in 2018. The self-declared principles are: Honesty, Humility, Hardwork, avoid Greed. He also emphasises on a simple lifestyle to keep healthy. Basically, he admitted to being a responsible capitalistbut expects failures. He confronts problems but admitted to being a fatalist in a later chapter, However, his beloved brother died as a hard core communist in the Malaysian jungles.
He is true to his roots: with his humble beginnings in his birth place of Johor Bahru, Malaysia. He is proud of his parents’ home country in China. His mother continues to be the “hidden captain” of his life. He has 2 wives and he established foundation for all the three important women in his life.
I am impressed that the hidden captain has steered him away from “businesses like hospitals ... How can you insist on charging a sick patient who needs care but cannot afford it?......... (quote from Page 337). How I wish his charities can help the poor patients in Sarawak.
31stJanuary 2019
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