Genitourinary Neoplasms

Neoplasms of GUT

Kidney Bladder Penis

Benign (Rare) Malignant TCC SCC

Should be

considered

Malignant

(if can clinically

recognized)

Adult Children

Renal Cell

Carcinoma

Nephroblastoma

(Wilm’s Tumour )

Benign Kidney Tumours

Fibroma

Adenoma

Villous Papillary Tumour

Angioma

Angiomyolipoma

Tubular Adenoma (Kidney)

Neoplastic Tubular Epithelium

Adenoma (Kidney)

Well Circumscribed Tumour

Nephroblast oma (Wilm’s Tumour)

Constitute 25-30% of Childhood Cancer

Peak age 2-4 y/o

Arise from Primitive Blastema Cells (that may persists in outer part of kidney)

Genetic – Deletion of Short Arm of Chromosome 11

Hereditary

• All Bilateral Wilms

• 1/3rd

of Unilateral Wilms

Clinical Features

Large Abdominal Mass – unilateral or cross the midline when very large

Hematuria – Indicate Tumour has Burst into Renal Pelvis

Pain in Abdomen

Pyrexia

Pulmonary Metastasis

Wilms’ Tumour

Large, Solitary, Well-circumscribed mass

Tumour

Soft, Homogenous, Tan → Gray, Foci of

Hemorrhage, Cystic Degeneration, Necrosis

Wilm’s Tumour

Nests, Sheets of Primitive Blastema

Abortive Tubules

Spindle Cell Stroma

Abortive Glomeruli

Striated muscles or other mesenchymal differentiation

Spread

Blood (Early) → Lungs (common), Liver, Bone

Investigations

AXR, U/S, CT Scan, Pyelography

Treatment

Immediate Nephrectomy, Postoperative Radiotherapy, Chemotherapy

Prognosis

90% Long Term Survival

Renal Cell Carcinoma (RCC)

Clear Cell Carcinoma, Hypernephroma, Grawitz Tumour

Arise from Tubular Epithelium

Occurs in Parenchyma of Kidney

Epidemiology

Most common type of Re nal Cancer

3% of Adult Malignancy

Male ↑

Rare – Age <35 y/o

2 Forms (Structural Alterations of Short Arm of Chromosome 3 – 3p)

Hereditary Non-Here ditary

von Hippel-Lindau (VHL) syndrome

(RCC Develop in 40% VHL Disease)

VHL gene is mutated in ↑ %

Hereditary Papillary Renal

Carcinoma (HPRC)

Familial Renal Oncocytoma (FRO)

Hereditary Renal Carcinoma (HRC)

Risk Factors

Cigarette smoking (25-30% case directly attributable to smoking)

Chronic Haemodialysis

Prolonged Estrogen Administration

(induce Kidney Tumours in Animals, Questionable in Humans)

Phenacetin (contain Analgesics)

Exposure to Asbestos, Cadmium, Gasoline

Patients who develop Cystic Disease

Clinical Features

Intermittent Hematuria

Clot Colic

Dragging Loin Pain

Palpable Renal Swelling

Rapidly developing Vericocele (Male)

Persistent Pyrexia, LOW, LOA

Polycythemia

Hypercalcemia

If Classical Traid

(Carcinoma has Metastasized)

• Hematuria

• Pain

• Palpable Renal Swelling

Renal Cell Carcinoma

Occupies 1 Pole

Well Circumscribed

Limited by Kidney Capsule

Kidney – Adenocar cinoma

(Clear Cell Type)

Cells in Solid Masses

Occur in Acinar Arrangement

Stroma Scanty

Rich in Blood Vessels

Renal Cell Carcinoma

Large Uniform Cells

Abundant Glycogen

Staging for Diagnosis

Cystoscopy Computed Tomography (CT)

KUB Magnetic Resonance Imaging (MRI)

Excretory Urogram (IVP)

(Distortion of Calyces)

Renal Angiography

Bone Scan

Renal Ultrasound

Spread

Local Distant

Medulla of Kidney Blood → Lungs, Bones, Brain, Liver

Renal Vein → IVC Lymphatics

(Renal Capsule Bursts → Node s at

Kidney Hilum → Paraaortic Nodes)

Perinephric Fat

Principles of Treatment

Surgery (Radical Nephrectomy) – Localized Tumour, Renal Vein/ IVC Involved

Radiation – Controversial

Chemotherapy – Ineffective

Immunotherapy

• Lymphocyte Activated Killer (LAK) cells combine d with IL-2

• Alpha Antiferon

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Bladder Carcinoma (Bladder Neoplasm)

Urothelial Origin (95%)

(eg. from Transitional Epithelium)

Common cancer in Malaysia

Benign counterpart – Rare

Villous Papilloma → Transitional Cell Carcinoma

(TCC)

Villous Papilloma is similar to Papillary TCC except

Thicker Epithelium

↑ Numerous Mitoses

Epithelial cells Larger, more Deeply Stained

Villi Stunted – Closely Packed

Surface Ulcerate, Necrotic

Foci of Invasion/ Extension to Lymphatics

Solid TCC – Raised plaque attaches to surface on broad base

TCC – Pathogenesis

Cigarette smokers (2-4X compared to non-smokers)

↑ Risk if exposed to

• Azo dyes

• Pigments used in Textiles, Printing, Plastic, Rubber, Cable Industries

β-naphtylamine, 4-aminobiphenyl, 4-nitrobiphenyl, 4,4-diaminobiphenyl

L-Tryptophan metabolite

Cyclophospha mide

Schistoma Hematobium Infe ction

TCC – Clinical Features

Features

• Intermittent Painless Hematuria

• Urinary Tract Infection if Uretheral Orifice is involved

Staging

• 0 – Carcinoma in situ

• A – Invades Lamina Propria

• B – Involves Muscle

• C – Invades Perivesicle Region

• D – Regional Metastasis

TCC – Macroscopy

Solid Type Papillary Type

Stage

T1 T2 T3 T4

Involve

Subepithelial

Connective Tissue

Infiltrate

Muscle

Infiltrate Full Muscle

Thickness, Mobile

Fixed to

Adjoining

Organs

TCC – Histology

Transitional Cell Carcinomas (90%)

Squamous Cell Carcinomas (5%)

Adenocarcinomas (2%)

Classifications (WHO)\

Grade Growth Pattern

Low (Grade 1, 2) Papillary (70%)

High (Grade 3) Sessile, Pluque (20%)

Nodular (10%)

Microscopy

Grade 1 Grade 2 Grade 3

Management

Investigation Treatment

Urine Exfoliative Cystology Coagulative Diathermy (for small

papillary lesion) Excretory Pyelography

Cystoscopy (should be done on all

cases of hematuria)

Local DXT

Cystectomy

Biopsy

Carcinoma of Penis

Epidemiology

Age 40-70 y/o

Male Malignancies (10-20%) in Africa, Asia, South America

Uncommon – Europe, US, Australasia

Circumcision Protective – Rare among Jews, Muslims

(↓ likelihood of HPV infection due to circumcision)

Causes

Smoking-related Tumour

HPV Detectable in Cancer Cells (50% patients) – Types 16 > 18

• ↓ common than in CIS (Bowen’s disease)

• HPV on its own cannot cause transformation

• Acts in concert with other carcinogenic influences (eg. Cigarette smoke)

Usually Arises on Glans or Inner Surface of Foreskin

Papillary or Flat – Papillary Lesions stimulate condylomata

Squamous Cell Carcinoma

Clinical

Slow Growing, Locally Invasive

Often there for Years before presentation

Classically Painless, unless Ulcerated/ Infected, Often Bleed

Early Nodal Spread (Inguinal/ Iliac), but Wide Dissemination uncommon

Prognosis (depend on Tumour Stage)

Small Lesion, No Nodal Involvement 66% - 5 year Survival Rate

Nodal Involvement 27% - 5 year Survival Rate

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