外科学课件泌尿男性生殖系肿瘤.ppt

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1、Genitourinary Tumors RENAL CELL CARCINOMA(RCC)Occupational exposures,chromosomal aberrations（染色体突变）（染色体突变）,and tumors suppressor genes have been implicated.Etiology Exposure to asbestos（石棉）（石棉）,solvents（溶剂）（溶剂）,and cadmium（镉）（镉）has also been associated with an increased incidence of RCC Cigarette sm

2、oking is the risk factor consistently linked to RCCEtiology Grossly,the tumor is characteristically yellow to orange because of the abundance of lipids,particularly in the clear cell type.RCC do not have true capsules but may have a pseudocapsule（假包（假包膜）膜）of compressed renal parenchyma,fibrous tissu

3、e,and inflammatory cells.Pathology RCC originates from the proximal renal tubular epithelium.Histologically，clear cells are rounded（圆形）（圆形）or polygonal（多边形）（多边形）with abundant cytoplasm,which contains cholesterol（胆固醇）（胆固醇）,triglycerides（甘油三酯）（甘油三酯）,glycogen（糖）（糖）,and lipids（脂类）（脂类）.Pathology Many pat

4、ients remain asymptomatic and non-palpable until they are advanced.Triad（三联症）（三联症）:The classically described triad of gross hematuria,flank pain,and a palpable mass occurs in only 710%of patients and is frequently a manifestation of advanced disease.Clinical Presentation Patients may also present wi

5、th dyspnea（呼吸困（呼吸困难）难）,cough,and bone pain which are typically symptoms secondary to metastases.With the routine use of CT scanning for evaluation of nonspecific findings,asymptomatic renal tumors are increasingly detected incidentally.Clinical Presentation Paraneoplastic syndromes（副瘤综合症）（副瘤综合症）：RCC

6、 is associated with a wide spectrum of paraneoplastic syndromes including erythrocytosis（红细胞增多）（红细胞增多）,hypercalcemia（高钙血症）（高钙血症）,hypertension,and nonmetastatic hepatic dysfunction.Overall,these manifestations can occur in 1040%of patients with RCC.Clinical PresentationA.Symptoms and signsB.Ultrasoun

7、ography US examination is a noninvasive,relatively in-expensive technique able to further delineate a renal mass seen on IVU.It is approximately 98%accurate in distinguishing simple cysts from solid lesions.DiagnosisDiagnosisC.CT Scanning CT scanning is more sensitive than US or IVU for detection of

8、 renal masses.A typical finding of RCC on CT is a mass that becomes enhanced with the use of intravenous contrast media.In addition to defining the primary lesion,CT scanning is also the method of choice in staging the patient by visualizing the renal hilum（肾门）（肾门）,perinephric space,renal vein and v

9、ena cava（腔（腔静脉）静脉）,adrenals,regional lymphatics（局部淋巴（局部淋巴结）结）,and adjacent organs.DiagnosisDiagnosisDX-ray findings IVU is rarely used for the diagnosis or evalu-ation of RCC.E.Renal angiography With the widespread availability of CT scanners,the role of renal angiography in the diagnostic evaluatio

10、n of RCC has markedly diminished and is now very limited.DiagnosisF.Magnetic resonance imaging（MRI）MRI is equivalent to CT for staging of RCC.Its primary advantage is in the evaluation of patients with suspected vascular extension.The great majority of renal masses are simple cysts（囊肿）（囊肿）.Once the

11、diagnosis of a cyst is confirmed by US,no additional evaluation is required if the patient is asymptomatic.Differential Diagnosis With the liberal（大量）（大量）use of B type ultrasound、computed tomography(CT)scans and magnetic resonance imaging(MRI),benign renal masses are being detected more frequently.B

12、enign renal tumors include adenoma（腺瘤）（腺瘤）,oncocytoma（嗜酸性细胞瘤）（嗜酸性细胞瘤）,angiomyolipoma（血管平滑（血管平滑肌脂肪瘤）肌脂肪瘤）,leiomyoma（平滑肌瘤）（平滑肌瘤）,lipoma（脂肪瘤）（脂肪瘤）,hemangioma（血管瘤）（血管瘤）.Differential Diagnosis Angiomyolipomas(with large fat components)can easily be identified by the low-attenuation areas classically prod

13、uced by substantial fat content.Differential Diagnosis Radical nephrectomy（根治性肾切除术）（根治性肾切除术）is the primary treatment for localized RCC.Its goal is to achieve the removal of tumor and to take a wide margin of normal tissue.Treatment Radical nephrectomy entails en bloc removal of the kidney and its en

14、veloping fascia(Gerotas)including the ipsilateral adrenal（同侧的肾上腺）（同侧的肾上腺）,proximal one-half of the ureter,and lymph nodes up to the area of transection of the renal vessels.Removal of the adrenal is unnecessary if the tumor is not in the upper pole.Treatment Preoperative renal artery embolization（肾动

15、脉栓（肾动脉栓塞）塞）patients with very large tumors in which the renal artery may be difficult to reach early in the procedure.Treatment Partial nephrectomy（肾部分切除术）（肾部分切除术）and wedge resection（楔形切除术）（楔形切除术）with an adequate margin of normal parenchyma is increasingly being used as primary surgical therapy for

16、patients with tumors 5%of tissue in resection for benign disease has cancer,normal DRETNM Staging System for Prostate Cancer.T1c Detected from elevated PSA alone,normal DRE and TRUST2a Tumor palpable by DRE or visible by TRUS on one side only,confined to prostateT2b Tumor palpable by DRE or visible

17、by TRUS on both sides,confined to prostatePathologyPathologyTNM Staging System for Prostate Cancer.T3a Extracapsular extension on one or both sidesT3b Seminal vesicle involvementT4 Tumor directly extends into bladder neck,sphincter,rectum,levator muscles,or into pelvic sidewallClinical PresentationS

18、ymptoms Most patients with early-stage CaP are asym-ptomatic.The presence of symptoms often suggests locally advanced or metastatic disease.Clinical Presentation Symptoms Obstructive or irritative voiding complaints can result from local growth of the tumor into the urethra or bladder neck or from i

19、ts direct extension into the trigone of the bladder.Clinical PresentationSymptoms Metastatic disease to the bones may cause bone pain.Symptoms Metastatic disease to the vertebral column（脊柱）（脊柱）with impingement（冲击）（冲击）on the spinal cord（脊（脊髓）髓）may be associated with symptoms of cord compression（脊髓压迫）

20、脊髓压迫）,including paresthesias（感觉异常）（感觉异常）and weakness of the lower extremities（下肢）（下肢）and urinary or fecal（大便）（大便）incontinence.Clinical PresentationA physical examination,including a DRE,is needed.Clinical PresentationDiagnosisA.Symptoms and signsB.Tumor markers:Prostate-Specific Antigen(PSA)PSA is

21、a serine protease produced by benign and malignant prostate tissues.Normal PSA values are those 4 ng/mL.DiagnosisC.Imaging.TRUSTRUS is useful in performing prostatic biopsies and in providing some useful local staging information if cancer is detected.Almost all prostate needle biopsies are performe

22、d under TRUS guidance.Diagnosis.MRI CT.Bone scanDiagnosisTreatment1.Watchful waiting and active surveillance-T1a DRE,PSA 2.Radical prostatectomy-T1b、T2 ，recently use a laparoscopic approach to radical pros-tatectomy 3.Endocrine therapy-T3,T4 Sources of Androgens：The major source of androgens in male

23、s is the Leydigs cells located in the testes.Adrenal androgens are produced in the zona fasciculata and zona reticularis of the adrenal cortex.Treatment Methods of Endocrine Treatment：1.Surgical Castration（阉割）（阉割）：Castration is considered the“gold standard”of endocrine treatment of advanced prostate cancer.2.Medical Castration：Estrogens，Luteinizing HormoneReleasing Hormone agonists（LHRH-A）,bicalutamide，flutamideTreatmentEndocrine Dependence and IndependenceTreatment