Male genital tract tumors Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital.
adenocarcinoma Prostate Cancer most common male cancer in western countries more detected in Thailand etiology : multifactors - race, gene, diet, environment - male hormone
Natural history peripheral zone, slow progress cancer direct invasion to bladder and distal ureter lymphatic metastasis pelvic lymphnodes vascular metastasis bone metastasis vertebra, pelvic bone, rib
Histological features Well, moderate, poor differentiation Gleason score (2-10)
Diagnosis Symptoms : no symptoms, LUTS DRE : nodule, induration, hard gland PSA : normal 0-4 ng/ml Trus Bx : if abnormal PSA or abnormal DRE TUR-P : incidental detection KUB, Bone scan
Stagings Whitmore Jewett TNM Localized A, B T1, T2 No Mo Locally advanced C T3, T4 No Mo Advanced D1, D2 Any TN+ M+
Treatments depend on : staging : age : life expectation : side effects observation in low grade, low stage in men > 80 years old
Localized disease : radical prostatectomy or radiation Locally advanced disease : Combined therapy of hormonal and surgery or radiation Advanced disease : hormonal therapy : chemotherapy : palliative treatment
Hormonal therapies bilateral orchiectomy estrogen LHRH agonist antiandrogen other drugs inhibiting androgen
Prognosis localized disease: 10 yrs survival > 80-90% locally advanced disease: 5 yrs median survival advanced disease: 2 yrs median survival
Testicular cancer Germ cell tumor Non germ cell tumor : Leydig, sertoli Secondary testicular tumor : lymphoma
Seminoma Germ cell tumor Non Seminoma : embryonic carcinoma : teratocarcinoma : yolk sac tumor : choriocarcinoma Mixed tumor
Natural history young adult 10-35 yrs, left > right risk factor : undercend testis metastasis to retroperitoneal lymphnode cisterna chyli supraclavicular lymph node vascular metastasis : lung
Diagnosis Scrotal mass, abdominal mass Ultrasound testis : evaluate testis IVP, CT scan : evaluate lymph node CXR Tumor marker : AFP, b HCG
AFP : alpha -feto protein : found in nonseminoma : not found in seminoma b HCG : choriocarcinoma : 50% of embryonal carcinoma : 5-10% of pure seminoma
Staging A (I) : tumor in testis only B (II) : metastasis to retroperitoneal lymphnode C (III) : distant metastasis
Treatments radical orchiectomy retroperitoneal lymph node dissection retroperitoneal lymph node radiation chemotherapy
Prognosis : depend on staging stage I, early stage II : 5 years survival 80-90%
Tumor of the penis benign : condyloma acuminata (warts) malignant : squamous cell carcinoma
Carcinoma of the penis common in 50-70 years old phimosis squamous cell carcinoma metastasis to regional lymphnode (inguinal and pelvic lymph nodes)
Diagnosis : tissue biopsy
Staging : Jackson : TNM
Treatments Primary tumor : excision, amputation Regional lymphnode : lymph node discetion
Prognosis : staging : no metastasis : good : metastasis : poor : histological grading
1 urothelial cancer Occurs in all urothelial lining Bladder, pelvis, lower third of ureter Peak incidence 40-70 years Cell types transitional cell carcinoma, squamous cell carcinoma, adenocarcinoma
Urothelial cancer Aetiology cigarette drugs phenacetin-containing analgesia, cyclophoshamide genetics Bilharzia Balkan s nephropathy chronic inflamation stones, radiation exstrophy of the bladder
Diagnosis by history Hematuria (70-95%) Pain (8-40%) Urothelial cancer Bladder irritation (5-10%) Mass (10-20%)
Investigation (for diagnosis) Urothelial cancer Cytology (35% false +, 30% false negative) IVP CT scan Cystoscopy Retrograde pyelography Ureteroscopy
Urothelial cancer Investigation (for staging) CXR LFT Bone scan CT scan
Urothelial cancer Staging Ureteral tumors Bladder tumors
Staging system for ureteral tumors TMN Tis Ta T1 T2 T3 Carcinoma in situ Confined epithelial tumor (papillary) Invasion of lamina propria Invasion of muscularis propria Description Invasion of peripelvic-periureteral tissue or renal parenchyma
Staging system for ureteral tumors TMN T4 N1 N2 N3 M1 Invasion of contiguous organs One node < 2cm. in diameter One node 2-5 cm. in diameter Nodes > 5cm. In diameter Distant metastases Description
The TNM classification of bladder tumors Tis Tis pu Tis pd Ta T1 T2 Carcinoma in sity Carcinoma in situ in prostatic urethra Carcinoma in situ in prostatic ducts Noninvasive papilary carcinoma Tumor invades subepithelial connective tissue Tumor invades muscle T2a Tumor invades superficial muscle (inner half) T2b Tumor invades deep muscle (outer half)
The TNM classification of bladder tumors T3 T4 Tumor invades perivesical tissue T3a Microscopically T3b Macroscopically (extravesical mass) Tumor invades any of the following: proste, uterus, vagina, pelvic wall, Abdominal wall T4a T4b Tumor invades prostate, uterus or vagina Tumor invades pelvic wall or abdominal wall
Treatment Upper tract Urothelial cancer Standard Nephro ureterectomy Conservative approaches in (Functionally or anatomically abnormalities)
Treatment Urothelial cancer Bladder Superficial TUR-BT + intravesical chemotherapy Invasive Radical cystectomy Radiation Advanced Adjuvant Neo adjuvant Palliative treatment
The technique of transurethral resection of bladder tumors Specimen 1 Specimen 2
Renal cell carcinoma 3% of adult malignancy 40-60 years Male : Female 2:1
Renal cell carcinoma Risk factor Smoking ESRD Polycystic Von-Hippel-Lindau Cytogenetics
Signs and symptoms Renal cell carcinoma Pain, Hematuria, Flank mass Weitht loss, Fever Varisocele Hypertension Paraneoplastic syndrome
Renal cell carcinoma Investigation U/S IVP CT scan MRI Angiography
Bosniak classification I (Benign) Simple cyst II (Probably benign) Septated ; minimally calcified ; nonenhancing highdensity ; or obviously infected cyst III (Suspicious) Multiloculated hemorrhagic ; IV (Probably malignant) coarse or pleomorphic calcifications ; or nonenhacing solid components Marginal irregularity and enhancing solid component - renal cell carcinoma
Definition of TNM staging system Primary tumor TX T0 T1 T2 Primary tumor cannot be assessed No evidence of primary tumor Description Tumor 7 cm in greatest dimension limited to the kidney Tumor >7cm in greatest dimension limited to the kidney Tumor extends into major veins or invades the ipsilateral adrenal gland or perinephric tissues, but confined to Gerota s fascia
Definition of TNM staging system Primary tumor TX T0 T1 T2 Primary tumor cannot be assessed No evidence of primary tumor Description Tumor 7 cm in greatest dimension limited to the kidney Tumor >7cm in greatest dimension limited to the kidney Tumor extends into major veins or invades the ipsilateral adrenal gland or perinephric tissues, but confined to Gerota s fascia
Definition of TNM staging system Primary tumor TX T0 T1 T2 T3 Primary tumor cannot be assessed No evidence of primary tumor Description Tumor < 7 cm in greatest dimension limited to the kidney Tumor >7cm in greatest dimension limited to the kidney Tumor extends into major veins or invades the ipsilateral adrenal gland or perinephric tissues, but confined to Gerota s fascia
Definition of TNM staging system Primary tumor T3a T3b T3c T4 Description Tumor invades the ipsilateral adrenal gland or perinephric tissues, but confined to Gerota s fascia Tumor grossly extends into the renal vein(s) involvement or vena cava below the diaphragm Tumor grossly extends into the renal vein(s) involvement or vena cava above the diaphragm Tumor invades beyound Gerota s fascia
Definition of TNM staging system Description Primary tumor N1 Single ipsilateral node ivolved N2 Multiple regional, contralateral, or bilateral nodes involved N3 Fixed regional nodes N4 Juxtaregional nodes involved M1 Distant metastases
Treatment Renal cell carcinoma Radical nephrectomy Nephron - sparing surgery Chemotherapy Immunotherapy
Indications for partial nephrectomy for renal cell carcinoma Cancer in solitary kidney Bilateral renal cell carcinoma Poorly functioning contralateral kidney Small peripheral lesion Incidentally detected tumor Malignancy uncertain preoperatively Renal cell carcinoma in von Hippel-Lindau disease Normal contralateral kidney?