jslum.

com | Medicine
Genitourinary Neoplasms

Neoplasms of GUT Renal Cell Carcinoma (RCC)

Kidney Bladder Penis Clear Cell Carcinoma, Hypernephroma, Grawitz Tumour
Benign (Rare) Malignant TCC SCC Arise from Tubular Epithelium
Should be Adult Children Occurs in Parenchyma of Kidney
considered Renal Cell Nephroblastoma Epidemiology
Malignant Carcinoma (Wilm’s Tumour ) Most common type of Re nal Cancer
(if can clinically 3% of Adult Malignancy
recognized) Male ↑
Rare – Age <35 y/o
Benign Kidney Tumours
Fibroma
Adenoma 2 Forms (Structural Alterations of Short Arm of Chromosome 3 – 3p)
Villous Papillary Tumour Hereditary Non-Here ditary
Angioma von Hippel-Lindau (VHL) syndrome VHL gene is mutated in ↑ %
Angiomyolipoma (RCC Develop in 40% VHL Disease)
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
Tubular Adenoma (Kidney) (induce Kidney Tumours in Animals, Questionable in Humans)
Neoplastic Tubular Epithelium Phenacetin (contain Analgesics)
Adenoma (Kidney)
Well Circumscribed Tumour Exposure to Asbestos, Cadmium, Gasoline
Patients who develop Cystic Disease
Nephroblast oma (Wilm’s Tumour) Clinical Features
Constitute 25-30% of Childhood Cancer Intermittent Hematuria If Classical Traid
Peak age 2-4 y/o Clot Colic (Carcinoma has Metastasized)
Arise from Primitive Blastema Cells (that may persists in outer part of kidney) Dragging Loin Pain • Hematuria
Genetic – Deletion of Short Arm of Chromos ome 11 Palpable Renal Swelling • Pain
Hereditary Rapidly developing Vericocele (Male) • Palpable Renal Swelling
• All Bilateral Wilms Persistent Pyrexia, LOW, LOA
• 1/3rd of Unilateral Wilms Polycythemia
Clinical Features Hypercalcemia
Large Abdominal Mass – unilateral or cross the midline when very large Renal Cell Carcinoma
Hematuria – Indicate Tumour has Burst into Renal Pelvis Occupies 1 Pole
Pain in Abdomen Well Circumscribed
Pyrexia Limited by Kidney Capsule
Pulmonary Metastasis

Wilms’ Tumour
Large, Solitary, Well-circumscribed mass
Tumour
Soft, Homogenous, Tan → Gray, Foci of
Hemorrhage, Cystic Degeneration, Necrosis

Kidney – Adenocar cinoma Renal Cell Carcinoma

(Clear Cell Type) Large Uniform Cells
Cells in Solid Masses Abundant Glycogen
Occur in Acinar Arrangement
Stroma Scanty
Rich in Blood Vessels
Staging for Diagnosis
Cystoscopy Computed Tomography (CT)
KUB Magnetic Resonance Imaging (MRI)
Excretory Urogram (IVP) Renal Angiography
Wilm’s Tumour (Distortion of Calyces) Bone Scan
Nests, Sheets of Primitive Blastema Renal Ultrasound
Abortive Tubules Spread
Spindle Cell Stroma Local Distant
Abortive Glomeruli Medulla of Kidney Blood → Lungs, Bones, Brain, Liver
Striated muscles or other mesenchymal differentiation Renal Vein → IVC Lymphatics
Spread Perinephric Fat (Renal Capsule Bursts → Node s at
Blood (Early) → Lungs (common), Liver, Bone Kidney Hilum → Paraaortic Nodes)
Investigations
Principles of Treatment
AXR, U/S, CT Scan, Pyelography
Surgery (Radical Nephrectomy) – Localized Tumour, Renal Vein/ IVC Involved
Treatment
Radiation – Controversial
Immediate Nephrectomy, Postoperative Radiotherapy, Chemotherapy Chemotherapy – Ineffective
Prognosis Immunotherapy
90% Long Term Survival
• Lymphocyte Activated Killer (LAK) cells combine d with IL-2
• Alpha Antiferon
 jslum.com | Medicine

Bladder Carcinoma (Bladder Neoplasm) Carcinoma of Penis

Urothelial Origin (95%) Epidemiology
(eg. from Transitional Epithelium) Age 40-70 y/o
Common cancer in Malaysia Male Malignancies (10-20%) in Africa, Asia, South America
Benign counterpart – Rare Uncommon – Europe, US, Australasia
Villous Papilloma → Transitional Cell Carcinoma Circumcision Protective – Rare among Jews, Muslims
(TCC) (↓ likelihood of HPV infection due to circu mcision )
Causes
Villous Papilloma is similar to Papillary TCC except
Smoking-related Tumour
Thicker Epithelium
HPV Detectable in Cancer Cells (50% patients) – Types 16 > 18
↑ Numerous Mitoses
• ↓ common than in CIS (Bowen’s disease)
Epithelial cells Larger, more Deeply Stained
• HPV on its own cannot cause transformation
Villi Stunted – Closely Packed
Surface Ulcerate, Necrotic • Acts in concert with other carcinogenic influences (eg. Cigarette smoke)
Foci of Invasion/ Extension to Lymphatics Usually Arises on Glans or Inner Surface of Foreskin
Papillary or Flat – Papillary Lesions stimulate condylomata
Solid TCC – Raised plaque attaches to surface on broad base
Squamous Cell Carcinoma
TCC – Pathogenesis
Cigarette smokers (2-4X compared to non-s mokers)
↑ 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
Clinical
• D – Regional Metastasis Slow Growing, Locally Invasive
TCC – Macroscopy Often there for Years before presentation
Solid Type Papillary Type Classically Painless, unless Ulcerated/ Infected, Often Bleed
Early Nodal Spread (Inguinal/ Iliac), but Wide Dissemination uncommon
Prognosis (depend on Tu mour Stage)
Small Lesion, No Nodal Involvement 66% - 5 year Survival Rate
Nodal Involvement 27% - 5 year Survival Rate

Stage
T1 T2 T3 T4
Involve Infiltrate Infiltrate Full Muscle Fixed to
Subepithelial Muscle Thickness, Mobile Adjoining
Connective Tissue 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
Excretory Pyelography papillary lesion)
Cystoscopy (should be done on all Local DXT
cases of hematuria) Cystectomy
Biopsy