RENAL PARENCHYMA NEOPLASM ADENOCARCINOMA (RENAL CELL CARCINOMA). Adenocarcinoma of kidney represent about 3% of adult cancer Adenocarcinoma of kidney represent about 3% of adult cancer Male-female ratio 2-1 Male-female ratio 2-1 equal in whites and blacks equal in whites and blacks

ETIOLOGY The cause is unknown. The cause is unknown. There are various theories: Environmental and occupational factors Environmental and occupational factors Cigarette smoking Cigarette smoking Chromosomal aberration and tumor suppressor genes(chromosome 3 and 8) Chromosomal aberration and tumor suppressor genes(chromosome 3 and 8) Aquired cystic disease Aquired cystic disease

PATHOLOGY The tumor occur in equal frequency in either kidney The tumor occur in equal frequency in either kidney originates in the cortex,grow out in the perinephric tissue originates in the cortex,grow out in the perinephric tissue it is characteristically yellow to orange because of high lipid content it is characteristically yellow to orange because of high lipid content

PATHOGENESIS RCC is a vascular tumor, tend to spread by RCC is a vascular tumor, tend to spread by Direct invasion Direct invasion Vascular invasion is through renal vein Vascular invasion is through renal vein About 1\3 of patients have metastasis at presentation About 1\3 of patients have metastasis at presentation The most common site of distant metastasis is lung oppposite kidney Followed by liver, bone. The most common site of distant metastasis is lung oppposite kidney Followed by liver, bone.

TUMOR STAGING Stage 1: tumor is confined within kidney parenchyma Stage 1: tumor is confined within kidney parenchyma StageII:tumor involve perinephric fat but is confined within Gerota,s fascia StageII:tumor involve perinephric fat but is confined within Gerota,s fascia Stage IIIa : tumor involve the main renal vein or inferior vena Cava Stage IIIa : tumor involve the main renal vein or inferior vena Cava Stage IIIb :tumor involve regional lymph node Stage IIIb :tumor involve regional lymph node

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

TNM Classification TNM Classification

CLINICAL PICTURE It has a wide variety of presentation It has a wide variety of presentation Classic triade : Classic triade : gross haematuria Flank pain Palpable mass Occur in about 10-15% of patients,frequently in advanced disease. Occur in about 10-15% of patients,frequently in advanced disease. Abd pain,abd mass, Abd pain,abd mass, (30%) Symptoms of metastasisdisease: (30%) Symptoms of metastasisdisease: Dyspnea,couph,headache,bone pain

Paraneoplastic syndrome Erythrocytosis Erythrocytosis Hypercacemia Hypercacemia Hypertention Hypertention Nonmetastatic hepatic dysfunction Nonmetastatic hepatic dysfunction 3-10% of RCC present by paraneoplastic syndrome 3-10% of RCC present by paraneoplastic syndrome RCC is the most common cause of paraneoplastic erythrocytosis RCC is the most common cause of paraneoplastic erythrocytosis Hypercalcemia occur in about 20% of patients with RCC Hypercalcemia occur in about 20% of patients with RCC Hypertention in 40% Hypertention in 40%

Laboratory FINDINGS CBC anemia (30%) CBC anemia (30%) High ESR High ESR Haematuria (60%) Haematuria (60%)

imaging IVP 75% accurate IVP 75% accurate U\S U\S CT scan it is the leader for diagnosis and staging And detect distant metastasis CT scan it is the leader for diagnosis and staging And detect distant metastasis Renal angiography Renal angiography MRI MRI Fine needle aspiration idicated in : Fine needle aspiration idicated in : 1 metastatic disease, planned for nonsurgical management 1 metastatic disease, planned for nonsurgical management 2 establishing diagnosis in patients who are not surgical Candidate 2 establishing diagnosis in patients who are not surgical Candidate

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

TREATMENT LOCALISED DISEASE Stage (I, II, IIIa ) Radical nephrectomy

DISSEMINATED DISEASE 30% of RCC are metastatic 30% of RCC are metastatic The role of radical nephrectomy is limited The role of radical nephrectomy is limited It is a palliative therapy It is a palliative therapy Radiotherapy (RCC is a radioresistant) Radiotherapy (RCC is a radioresistant) Chemotherapy (is also chemotherapy resistant ) Chemotherapy (is also chemotherapy resistant )

Prognosis is according to stage: T1 disease 5 years survival % T1 disease 5 years survival % T2 T3a 5 years survival 60 % T2 T3a 5 years survival 60 % T3a 5 years survival rate % T3a 5 years survival rate %

BENIGN TUMOR Renal adenoma is the most common benign tumor Renal adenoma is the most common benign tumor Renal oncocytoma occur in variant organ Renal oncocytoma occur in variant organ ( adrenal, salivary gland, thyroid, … ) represent about 3% of kidney tumor Angiomyolipoma: is very rare, Angiomyolipoma: is very rare,

BLADDER CARCINOMA Male- female ratio 3-1 Male- female ratio 3-1 Common in wights than in blacks Common in wights than in blacks Is the second most common cancer of genitourinary tract Is the second most common cancer of genitourinary tract Average age is 65 years Average age is 65 years 85% are Localised, 15 % have distant sites 85% are Localised, 15 % have distant sites

PATHOGENESIS AND ETIOLOGY Cigarette smoking account for 50 % of men and 30% of women the causative agent are to be alpha and beta naphthylamine wich are secreates in urine of smokers Cigarette smoking account for 50 % of men and 30% of women the causative agent are to be alpha and beta naphthylamine wich are secreates in urine of smokers Occupational exposure to certain chemicals(rubber,petroleum, printing industries) Occupational exposure to certain chemicals(rubber,petroleum, printing industries) Cyclophosphamide Cyclophosphamide Artificial sweeeners Artificial sweeeners Calculi and infection Calculi and infection Genetic predisposition Genetic predisposition

STAGING

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

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

2 SQUAMOUS CELL CARCINOMA Accounts for 5-10% of bladder tumor Accounts for 5-10% of bladder tumor Often associated with H\O bilharsial infectionVesical caculi, chr ctheterisation Often associated with H\O bilharsial infectionVesical caculi, chr ctheterisation In Egypt represent about 60% of bladder cancer In Egypt represent about 60% of bladder cancer

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

Clinical picture A :SYMPTOMS: Haematuria is the presenting symptom in 85-90% Haematuria is the presenting symptom in 85-90% May be gross or micriscopic Intermittent rather than constant Symptoms of vesical irritability Symptoms of vesical irritability Symptoms of advanced disease Symptoms of advanced disease

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

LABORATORY FINDINGS The most common is hematuria The most common is hematuria Azootemia in case of ureteral occlusion Azootemia in case of ureteral occlusion Anemia may be a presenting symptom due to chr blood loss and replacement of bone marrow by metastatic cells. Anemia may be a presenting symptom due to chr blood loss and replacement of bone marrow by metastatic cells. Urine cytology. Urine cytology.

IMAGING: Used To Evaluate the upper urinary tract Evaluate the upper urinary tract Assess the depth of muscle infiltration Assess the depth of muscle infiltration Presence of regional or distant metastasis Presence of regional or distant metastasis IVU: the most common imaging test for evaluation of hematuria IVU: the most common imaging test for evaluation of hematuria CTscan CTscan Cystourthroscopy Cystourthroscopy

TREATMENT TUR or laser vaporization : For patients with single low grade, noninvasive tumor For patients with single low grade, noninvasive tumor Partial cystectomy For solitary infiltrating tumor (t1-t3) cancer of bladder diverticula For solitary infiltrating tumor (t1-t3) cancer of bladder diverticula Radical cystectomy In locally advanced disease In locally advanced disease

URETERAL AND RENAL PELVIS URETERAL AND RENAL PELVIS Carcinoma of renal pelvis and ureter are rare Carcinoma of renal pelvis and ureter are rare Represent about 4% of all utothelial cancer Represent about 4% of all utothelial cancer Ratio bladder renal pelvis ureter Ratio bladder renal pelvis ureter Age group > 65 years Age group > 65 years Patients with single upper tract carcinoma are at risk of Developing bladder carcinoma Patients with single upper tract carcinoma are at risk of Developing bladder carcinoma (30-50%) and contralateralUpper tract (2-4%).

ETIOLOGY AND PATHOLOGY As urinary bladder carcinoma As urinary bladder carcinoma

CLINICAL PICTURE Haematuria 70-90% Haematuria 70-90% Flank pain 50% Flank pain 50% Irritative symptoms Irritative symptoms Weight loss Weight loss Flank mass Flank mass

LABORATORY FINDINGS Hematuria is identified in majority of cases Hematuria is identified in majority of cases Anemia Anemia Elevated liver function Elevated liver function

IMAGING IVU IVU RETROGRADE PYELOGRAPHY is more accurate RETROGRADE PYELOGRAPHY is more accurate CTscan identify soft tissue abnormality of renal pelvis CTscan identify soft tissue abnormality of renal pelvis URETEROPYELOSCOPY allow direct visualization URETEROPYELOSCOPY allow direct visualization Of upper urinary tract Of upper urinary tract

TREATMENT Based on: grade, stage, position and multiplicity Based on: grade, stage, position and multiplicity The standard therapy is nephroureterectomy The standard therapy is nephroureterectomy

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