1. Urogenital Neoplasms Liping Xie
Department of Urology, First Affiliated Hospital, School of Medicine, Zhejiang University

2. Renal Cell Carcinoma (RCC)

3. Renal Cell Carcinoma (RCC)
RCC accounts for 2% to 3% of all adult malignant , 85% of all primary malignant renal tumors, is the most lethal of the urologic cancers
Renal cell carcinoma (RCC) affects 38,000 individuals in the U.S. yearly, and 11,900 patients die of this disease
RCC occurs most commonly in 5th~6th decade, male-female ratio 1.6:1

4. Etiology Renal Cell Carcinoma (RCC)
Majority of RCC occurs sporadically
Tobacco smoking contributes to 24-30% of RCC cases
- Tobacco results in a 2-fold increased risk
Occupational exposure to cadmium, asbestos, petroleum
Obesity
Chronic phenacetin or aspirin use
Acquired polycystic kidney disease due to dialysis results in 30% increase risk

5. Etiology Renal Cell Carcinoma (RCC)
2-4% of RCC associated with inherited disorder
* Von Hippel-Lindau disease
- familial cancer syndrome of retinal angiomas, CNS hemangioblastomas, pheochromocytomas and clear cell RCC.
* Hereditary papillary renal cancer
- Multiple, bilateral papillary renal tumors , C-met oncogene on ch 7
* Birt-Hogg-Duke syndrome
- Fibrofolliculomas, lung cysts, and RCC, Mutation in BHD gene ch 17p

6. Pathology Types: Renal Cell Carcinoma (RCC)
RCC originates from the proximal renal tubular epithelium.
Types:
Clear cell type
Granular cell type
Mixed cell type
RCC is most often a mixed adenocarcinoma.

7. Clinical Findings Renal Cell Carcinoma (RCC) Symptoms & Signs
Renal tumors are increasingly detected incidentally by CT or ultrasound
A. Classical triad——gross hematuria, flank pain, palpable mass (only in 10~15% advanced cases)
Symptoms secondary to metastatic disease: dysnea & cough, seizure & headache, bone pain

8. Clinical Findings Renal Cell Carcinoma (RCC)
B. Paraneoplastic Syndromes
Erythrocytosis, hypercalcemia, hypertension
C. Lab Findings
anemia, hematuria (60%), ESR↑

9. Clinical Findings Renal Cell Carcinoma (RCC)
B. Paraneoplastic Syndromes
Erythrocytosis, hypercalcemia, hypertension
C. Lab Findings
anemia, hematuria (60%), ESR↑

10. Clinical Findings Renal Cell Carcinoma (RCC) D. Imaging
Ultrasonography
Intravenous Urography (IVU):
CT scanning: more sensitive, mass+renal hilum, perinephric space and vena cava, adrenals, regional LN and adjacent organs
Renal Angiography
MRI: to evaluate collecting system and IVC involvement

11. Diagnosis Renal Cell Carcinoma (RCC)
No screening for the general population
No bio-marker available
Radiographic evaluation

12. Renal Cell Carcinoma (RCC)
IVU of right RCC
CT Scan of Left RCC

13. RCC invading renal vein
Renal Cell Carcinoma (RCC)
Righ Cystic RCC
RCC invading renal vein

14. CT scan with 3D reconstruction
Renal Cell Carcinoma (RCC)
CT scan with 3D reconstruction
Neovascularity in Renal Angiography associated with RCC

15. Renal Cell Carcinoma (RCC)
A, Magnetic resonance scan of kidneys without administration of gadolinium suggests anterior right renal mass. B, After intravenous administration of gadolinium-labeled diethylenetriaminepentaacetic acid, MRI shows enhancement of this mass indicative of malignancy.

16. Tissue Diagnosis Renal Cell Carcinoma (RCC)
Tissue diagnosis obtained from nephrectomy or biopsy
Papillary (chromophilic) renal cell carcinoma extending into the collecting system with histological findings

17. Tumor Staging (Robson System)
Renal Cell Carcinoma (RCC)
Tumor Staging (Robson System)

18. Tumor Staging (International TNM Staging System)
Renal Cell Carcinoma (RCC)
Tumor Staging (International TNM Staging System)

19. Renal Cell Carcinoma (RCC)
Tumor Staging

20. Differential Diagnosis
Renal Cell Carcinoma (RCC)
Differential Diagnosis
Benign renal tumors
-Angiomyolipoma
Renal Pelvis Cancer

21. Treatment Renal Cell Carcinoma (RCC) A. Localized disease:
Surgical removal---only potentially curative therapy
Radical Nephrectomy (en bloc removal of the kidney and Gerota’s fascia including ipsilateral adrenal, proximal ureter, regional lymphadenectomy

22. Hand-Assisted Laparoscopic Radical Nephrectomy
Renal Cell Carcinoma (RCC)
Hand-Assisted Laparoscopic Radical Nephrectomy
Laparoscopic Radical Nephrectomy

23. Treatment Renal Cell Carcinoma (RCC) A. Localized disease:
Partial Nephrectomy(nephron-sparing surgery, NSS )
--polar tumor
--tumor size<4cm
--bilateral RCC
--solitary kidney
Laparoscopic NSS

24. Laparoscopic Cryoablation
Renal Cell Carcinoma (RCC)
Treatment
A. Localized disease:
Percutaneous/Laparoscopic Radiofrequency Ablation or Cryoablation
Laparoscopic Cryoablation

25. Treatment Renal Cell Carcinoma (RCC) B. Disseminated disease:
nephrectomy--- reducing tumor burden
radiation--- radioresistant tumor, metastases 2/3 effective
chemotherapy--- <10% effective
immunotherapy--- IL-2/interferon-alpha, 30% response rate
molecular therapy---eg. sorafenib

26. Prognosis Stage 5-year survival rate I 88~100% II 60% III 15~20%

27. Bladder Cancer

28. The peak incidence is in persons from 50-70 years
Bladder Cancer
The second most common cancer of the genitourinary system (most common in China)
The male-female is 2.7:1
The peak incidence is in persons from years

29. Etiology Bladder Cancer Industrial toxins Cigarette smoking
Genetic events
Other risk factors
cyclophosphamide, alkylating agents,
radiotherapy of pelvis.

30. Pathology Bladder Cancer Histopathlogy Grading
1.transitional cell carcinoma 90%
2.squamous cell carcinoma %
3.adenocarcinoma %
4.other types
Grading
Grade mild anaplasia
Grade moderate anaplasia
Grage marked anaplasia

31. Clinical Findings Bladder Cancer A. Symptoms:
Painless Hematuria 85~90%
Irritative voiding symptoms
B. Signs:
The majority of patients have no pertinent physical signs.

32. Clinical Findings Bladder Cancer C. Lab tests: Urine test——hematuria
Urinary cytology——depend on grade and volume of the tumor
Other markers: BTA, NMP22, telomerase

33. Clinical Findings Bladder Cancer D. Imaging: Ultrasonography—screen
IVU—evaluation of upper urinary tract
CT/MRI—assessment of the depth of infiltration and pelvic LN enlargement
E. Cystoscopy

34. Diagnosis Bladder Cancer
Ultrasonography can be used as screening method to detect bladder tumors and upper urinary tract obstruction.
both CT and MRI are used to characterize the extent of bladder wall invasion and detect enlarged pelvic lymph node.

35. Diagnosis Bladder Cancer Cystoscopy
the diagnosis of bladder cancer depends on cystoscopy.
cystoscopy can provide good information on the extent of the tumour.
suspicous areas can be biopsied.

36. Ultrasonography of Bladder Ca (Arrow Head)
Bladder Cancer
Ultrasonography of Bladder Ca (Arrow Head)
IVU of Bladder Tumor

37. Bladder Cancer
CT scan of bladder Ca

38. Cystoscopy of bladder Ca
Bladder Cancer
Cystoscopy of bladder Ca

39. Bladder Cancer
TNM Tumor Staging

40. Bladder Cancer
TNM Tumor Staging

41. Treatment Bladder Cancer Superficial bladder cancer (Ta,T1,Tis)
transurethral resection
intravesical chemotherapy or immnotherapy(BCG)
cystoscopic surveillance

42. Treatment Bladder Cancer Invasive bladder cancer (T2-T4)
partial cyctectomy
solitary, inflitrating tumors localized along the posterior lateral wall or dome of the bladder.
radical cystectomy
1.muscle-invasive bladder cancer T2-T4a, N0-NX, M high-risk superficial tumours (T1G3, BCG-resistant Tis) 3.extensive papillary disease
Urinary diversion after radical cystectomy

43. Bladder Cancer
partial cyctectomy

44. Bladder Cancer
Radical Cystectomy

45. Treatment Bladder Cancer Radiotherapy
Modern 3D-radiotherapy is a reasonable treatment option in patients who wish to preserve their bladder
Chemothery
chemothery for metastatic disease.
adjuvant chemotherapy
Neoadjuvant chemotherapy

46. Prostate Cancer

47. Prostate Cancer
The most common cancer diagnosed and is the second leading cause of cancer death in American men
the incidence of prostate cancer is continuously increasing each year in china
The incidence increases with advancing age

48. Risk factor Prostate Cancer Age Genetic influences
Race－African Americans are at a higher risk than whites
Positive family history
High dietary fat intake
Hormonal factors
androgen dependence
Others

49. Pathology Prostate Cancer
Over 95% of the cancers of the prostate are adenocarcinomas.
Prostatic intraepithelial neoplasia (PIN)
high grade (HGPIN)
low grade (LGPIN)

50. Mostly arise from the peripheral zone of the gland
Prostate Cancer
Mostly arise from the peripheral zone of the gland

51. Grading Prostate Cancer
the Gleason system is widely used for its best clinical correlation

52. Staging Prostate Cancer
Stage I small foci of carcinoma in resection for benign disease
Stage II disease confined to prostate
Stage III extracapsular extension
Stage IV regional lymph node metastases or distant metastases

53. Prostate Cancer
The TNM staging system

54. Clinical Findings Prostate Cancer A. Symptoms
Early stage: asymptomatic
Locally advanced/metastatic disease—obstructive or irritative voiding complaints, bone pain, paresthesias and weakness of lower extremities

55. Clinical Findings Prostate Cancer B. Signs:
Digital rectal examination—induration

56. Clinical Findings Prostate Cancer C. Tumor markers
Prostate Specific Antigen (PSA)
< 4 ng/ml normal
4 ~ 10 ng/ml Grey Zone
> 10 ng/ml highly suspect of PCa

57. Clinical Findings Prostate Cancer D. Imaging
Ultrasonography－hypoechoic lesion
Transrectal ultrasonography (TRUS)
CT, MRI
Bone scan

58. Clinical Findings Prostate Cancer E. Prostate biopsy
The golden standard

59. Prostate Cancer
MRI of prostate cancer

60. Prostate Cancer
Bone scan

61. Treatment Prostate Cancer A. Localized disease
Watchful waiting, older patients with samll, well-differentiated cancer
Radical prostatectomy, patients with a life expectency > 10 years
Radiation

62. Radical Prostatectomy
Prostate Cancer
Radical Prostatectomy

63. Prostate Cancer

64. Treatment Prostate Cancer B. Locally advanced/metastatic diseases
Endocrine therapy—androgen blockade : orchiectomy
antiandrogen agent
LHRH agonist
Radiation
Chemotherapy

65. Further Reading Renal Pelvis Cancer / Tumor of Ureter Penile Cancer
Testicular Cancer

66. Further Reading

67. Thank you for your attention !