1. TUMORS OF URINARY TRACT

2. RENAL PARENCHYMAL NEOPLASMS

3. BENIGN RENAL TUMOURS Angiomyolipoma (Renal Hamartoma)
❏rare benign tumour
❏round, oval, expansible
❏characterized by 3 major histologic components: blood vessels, smooth
muscle and fat cells
❏many asymptomatic, may spontaneously rupture, especially in
pregnant females
❏found in approximately 45-80% of patients with tuberous sclerosis which
is characterized by
• epilepsy
• mental retardation
• sebaceous adenoma
• hamartomas of brain and kidney
❏diagnose by CT ––> fat (negative density on CT) observed in kidneys is pathognomonic for angiomyolipoma
❏treatment: <4cm, >4cm

4. Renal Adenoma ❏commonly found incidentally at autopsy or after nephrectomy for an unrelated disease ❏10-20% of the population ❏asymptomatic ❏need tissue diagnosis to definitively differentiate from renal cell carcinoma Renal Oncocytoma ❏ occur in variant organ (adrenal, salivary gland, thyroid,…) represent about 3% of kidney tumor ❏has a characteristic findings on imagingstudies but need histopathology for diagnosis

5. MALIGNANT RENAL TUMORS
ADENOCARCINOMA
(Renal Cell Carcinoma, Grawitz’s Tumour)
❏also known as hypernephroma
❏eighth most common malignancy (accounts for 3% of all newly diagnosed cancers)
❏85% of primary malignant tumours in kidney
❏male:female = 3:1
❏called the “internist’s tumour” because of paraneoplastic symptomatology

6. ETIOLOGY ❏ The cause is unknown.
❏ There are various theories of risk factors:
• environmental and occupational factors:
• smoking (results in 2x increased relative risk), cadmium exposure, employment in leather industry
• familial incidence seen with von Hippel Lindau syndrome which is characterized by:
• RCC (present in 2/3)
• headache, ataxia, and blindness due to cystic lesions
of cerebellum and retinal vessel aneurysms
• aquired cystic disease

7. PATHOLOGY The tumor occur in equal frequency in either kidney
originates in the cortex, grow out in the perinephric tissue
originates from proximal convoluted tubule epithelial cell
it is characteristically yellow to orange because of high lipid content

8. PATHOGENESIS ❏methods of spread
• direct
• venous
• lymphatic
RCC is a vascular tumor, tend to spread by
direct invasion
Vascular invasion is through renal vein
About 1\3 of patients have metastasis at presentation
The most common site of distant metastasis is lung, opposite kidney, followed by liver, bone.

10. TNM Classification

11. TUMOR STAGING Stage I: tumor is confined within kidney parenchyma
StageII:tumor involve perinephric fat but is confined within Gerota’s fascia, or adrenals
Stage IIIa : tumor involve the main renal vein or inferior vena cava, byeond Gerotas
Stage IIIb :tumor involve regional lymph node

12. Stage IIIc : tumor involve both local vessels and regional lymph node
Stage IVa : tumor involves adjacent organs (colon,pancreas,….)
Stage IVb :distant metastasis

14. CLINICAL PICTURE It has a wide variety of presentation
❏symptoms and signs
• increasingly diagnosed incidentally with U/S and CT
• poor prognostic indicators include
• weight loss
• weakness
• anemia
• bone pain
• classic triad (too late triad!) found in 10-15%
• gross hematuria 50%
• flank pain < 50%
• palpable mass < 30%
• 30% have metastases when first seen: dyspnea, cough, headache, bone pain
• Abd pain, abd mass,

15. Para-neoplastic syndrome
3-10% of RCC present by paraneoplastic syndrome
hematopoietic disturbances: anemia, polycythemia; raised ESR: RCC is the most common cause of paraneoplastic erythrocytosis
endocrinopathies: hypercalcemia 20% (production of PTH), production of other hormones including erythropoietin, renin, prolactin, gonadotropins, TSH, insulin, and cortisol.
PUO
hemodynamic alterations: systolic hypertension 40% (due to AV shunting, production of renin), and peripheral edema (due to caval obstruction)
Non-metastatic hepatic dysfunction: “Staufer’s syndrome”: abnormal liver function tests, decreased WBC count, fever, areas of hepatic necrosis; reversible following removal of primary tumour

16. Laboratory FINDINGS • routine labs for paraneoplastic syndromes
• CBC anemia (30%)
• High ESR
• urinalysis (60-75% have hematuria)

17. Imaging U\S: Doppler IVP 75% accurate
CT scan: it is the leader for diagnosis and staging and detect distant metastasis
MRI
Renal angiography: no longer routinely done
Fine needle aspiration indicated in :
metastatic disease, planned for nonsurgical management
establishing diagnosis in patients who are not surgical candidate

21. Differential diagnosis
Carcinoma of renal pelvis
Renal lymphoma
Adrenal cancer
Benign renal tumor
Renal cysts
Renal abscess

22. TREATMENT LOCALISED DISEASE • surgical (mainstay):
Stage (I, II , IIIa )→
• surgical (mainstay):
• partial Nx:
• small, polar, or bilateral tumors
• radical nephrectomy:
• en bloc removal of kidney, tumour, ipsilateral adrenal gland and intact Gerota’s capsule and periaortic lymphadenectomy

24. Immunotherapy→15% response rate
DISSEMINATED DISEASE
30% of RCC are metastatic
Surgical:
the role of radical nephrectomy is limited. It is a palliative therapy
• surgical removal of solitary metastasis may be considered
Immunotherapy→15% response rate
cytokine interleukin-2
α- INF
Tyrosin kinase inhibitors---monoclonal Abs
Radiotherapy (RCC is a radioresistant):
• radiation for palliation
• for painful bony lesions
Chemotherapy (is also chemoresistant )

25. Prognosis
• stage at diagnosis is the single most important predictor of survival:
• 5 year survival of T1 is %
• 5 year survival of T2-T3 is approximately 60%
• 5 year survival of patients presenting with metastasis is 0-20%

26. CARCINOMA OF THE RENAL PELVIS AND URETER
❏incidence
• rare, accounts for 4% of all urothelial cancers
• frequently multifocal
• papillary transitional cell cancer 85%
• male:female = 3:1
❏relative incidence
• bladder:pelvis:ureter = 100:10:1
❏predisposing factors
• chemical exposure (industrial dyes and solvents)
• smoking
• analgesic abuse (acetaminophen, aspirin, and phenacetin)
• Balkan nephropathy
Age group > 65 years
Patients with single upper tract carcinoma are at risk of developing bladder carcinoma (30-50%) and contralateral upper tract (2-4%).

28. • gross painless hematuria (70-90% of patients)
❏symptoms and signs
• gross painless hematuria (70-90% of patients)
• microscopic hematuria found incidentally
• flank pain 50%
• tenderness over kidney
• flank mass caused by either tumour or associated hydronephrosis (10-20% of patients)
• irritative symptoms
• weight loss

29. LABORATORY FINDINGS Hematuria is identified in majority of cases
Anemia
Elevated liver function
Urine cytology

30. IMAGING
• diagnosis is made by noting a radiolucent filling defect on IVP
• differential diagnosis of filling defect
• transitional cell carcinoma (differentiate via cytology and CT scan)
• uric acid stone (differentiate via cytology and CT scan)
• blood clot
• pyelitis cystica
• papillary necrosis
• fungus ball
• gas bubble from gas producing organisms
RETROGRADE PYELOGRAPHY is more accurate
CT scan identify soft tissue abnormality of renal pelvis
URETEROPYELOSCOPY allow direct visualization of upper urinary tract and tissue sampling

34. TREATMENT
Based on: grade, stage, position and multiplicity
The standard therapy is radical ureteronephrectomy with cuff of bladder

36. Tumor of distal ureter :
distal ureterectomy and ureter reimplantation

37. BLADDER CARCINOMA ❏incidence • male:female = 3:1
• usually > 55 years
• average age is 65 years
• may be characterized by frequent recurrences
• common in whites than in blacks
• is the second most common cancer of genitourinary tract
• 85% are localized, 15% have distant sites

38. ❏classification • transitional cell carcinoma (TCC) 92% • squamous cell carcinoma (SCC) 7% • adenocarcinoma 1% • others < 1%

39. PATHOGENESIS AND ETIOLOGY
Cigarette smoking account for 50 % of men and 30% of women, the causative agent are to be alpha and beta naphthylamine which are secreted in urine of smokers
Occupational exposure to certain chemicals as •naphthylamines, benzidine, tryptophan metabolites (rubber ,petroleum, printing industries)
Cyclophosphamide
phenacetin metabolites
Schistosoma hematobium (associated with SCC)
Artificial sweeteners
Calculi and infection: chronic irritation (cystitis)
Genetic predisposition

40. STAGING

41. HYSTOPATHOLOGY PAPILOMA: is uncommon Transitional cell carcinoma:
Represent about <2 % of all transiotional cell
Tumor , has a very good prognosis
Transitional cell carcinoma:
Accounts for 90% of all bladder cancer
Appears as papillary exophytic lesion
May be sessile or ulcerated

42. ❏stages of transitional cell carcinoma at diagnosis
• superficial papillary (75%)
• 15% of these will progress to invasive TCC
• the majority of these patients will have recurrence
• invasive (25%)
• 85% have no prior history of superficial TCC
• 50% have occult metastases at diagnosis
• carcinoma in situ
• may progress to invasive TCC

43. 1: ADENOCARCINOMA : NONTRANSITIONAL CELL CARCIMOMA
Accounts for <2% of bladder cancer
Mucous secreting tumor
Arise along the floor of bladder
Muscle invasion is usually present
5 years survival <40%

44. 2 SQUAMOUS CELL CARCINOMA
Accounts for 5-10% of bladder tumor
Often associated with H\O bilharzial infection, vesical calculi , chronic catheterisation
In Egypt represent about 60% of bladder cancer

45. 3 UNDIFFERENTIATED CARCINOMA:
Is rare , represent < 2% of bladder carcinoma
4 MIXED CARCINOMA:
Constitute 4-6% of all bladder carcinoma
Composed of transitional , squamous, or undifferentiated carcinoma

46. Clinical picture A :SYMPTOMS:
• hematuria is the presenting symptom in 85-90%
May be gross or microscopic
Intermittent rather than constant
• pain 50%
• clot retention 17%
• no symptoms 20%
• occult hematuria
• irritative urinary symptoms - consider carcinoma in situ
• symptoms of advanced disease

47. B: SIGNS:
The majority of patients have no pertinent physical signs.
patients with advanced disease may have a
palpable mass.
Hepatomegaly and supraclavicular lymph node indicate advanced disease

48. LABORATORY FINDINGS UA: the most common is hematuria
Azotemia in case of ureteral occlusion
Anemia may be a presenting symptom due to chronic blood loss and replacement of bone marrow by metastatic cells.
Urine cytology .

49. IMAGING: Used To ultrasound
Evaluate the upper urinary tract
Assess the depth of muscle infiltration
Presence of regional or distant metastasis
ultrasound
IVU: the most common imaging test for evaluation of hematuria
CT scan
Cystourethroscopy with bladder washings (gold standard)
new advances with specific bladder tumour markers
(NMP-22, BTA, Immunocyt, FDP)
for invasive disease
CT, chest x-ray, liver tests

53. TREATMENT TUR or laser vaporization : Partial cystectomy
For patients with single low grade, noninvasive tumor
Partial cystectomy
For solitary infiltrating tumor (T1-T3) in bladder dome, cancer of bladder diverticula
Radical cystectomy with urinary diversion and/or irradiation
In locally advanced disease (T2a, T2b, T3)
Irradiation +/– systemic chemotherapy
Metastatic disease (T4a, T4b, N+, M+)

56. Thank You
The End