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renal neoplasim

الكلية كلية الطب     القسم  الجراحة     المرحلة 4
أستاذ المادة محمد رضا جودي عبود جلو       12/23/2011 5:39:39 AM
dr. Mohammed ridha Judi Renal neoplasms

Two type:
1.urothelial (renal pelvis and ureter).
2. renal parenchymal tumor.

Urothelial tumor:
benign :
fibro epithelial polyp ,liomyomas and angiomas.

Malignant:
Carcinoma of the renal pelvis and ureter is rare , often present as a widespread urothelial abnprmality: patient with single upper tract carcinoma are at risk of developing bladder carcinomas (30-50%).
Etiology:
Smoking and exposure to certain industrial dyes or solvents.
Long history of excessive analgesic intake, those with Balkan nephropathy, and those exposed to special contrast agent.

Pathology;
The mucosal surface of the renal pelvis composed of transitional epithelium., thus the most renal pelvic tumor are transitional cell carcinoma (90-97%)., most of the tumor are localized at the time of diagnosis, the most common metastatic sites include regional lymph nodes , bone and lung.
Sequamous cell carcinoma (10%) rare, patient with a history or chronic inflammation from infection or stone.
Adenocarcinoma are very rare , like SCC ,tend to be advanced at the time of diagnosis.

Mesoderm tumors are quite rare.

Staging based on accurate assessment of the degree of tumors infiltration and paralls the staging system developed for bladder cancer. Tumors stage and grade correlate with survival

Clinical finding:
Gross haematuria in (70-90%), irritative voiding symptoms, constitutional symptoms of anorexia, weight loss, and lethargy are uncommon and are usually associated with metastasis disease., flank mass, flank tenderness, supraclavicular or inguinal adenopathy or hepatomegaly.

Diagnosis:
1.lab. finding:
GUE; hematuria, pyuria, bacteruria.
Elevated liver enzymes in case of liver metastasis.
Urine cytology by examining exfoliated cells in the urinary sediment.

2.imaging;
IVU: usually abnormal
CT scan with contrast: test of choice.
U/S important for diagnosis.
MRI. Important for staging.
3. uretropyeloscopy . for urine sampling and urine cytology.

Treatment;
Treatment should be based on grade and stage, position , and multiplicity.
The standard treatment for both tumor type has been nephrectomy with excision of bladder cuff.
Sometime partial nephrectomy.

Recurrence may be avoided by treating with instillation of immunotherapeutic or chemotherapeutic .radiotherapy.
Plays a limited role in upper urinary tract cancer.
In case of metastatc one ,transitional call carcinoma, chemotherapeutic regimens.



Renal parenchymal neoplasms:

1.benign tumors;
renal adenomas, renal oncocytoma, angiomyolipoma (renal hamertoma),leiomyomas, hemangiomas ,lipoma ,juxtaglomerular cell tumor.
Usually rare difficult to diagnose, may diagnosed after nephrectomy.

2.malignant tumor:
Adenocarcinoma of the kidney (renal cell carcinoma ,hypernephroma):
It accounts for roughly 2.8% of all adult cancers and approximately 85% of all primary malignant renal tumors. RCC occurs in the 5th or 6th decade, male –female ratio of 2:1 ,may based on race, black higher incidence, Asians the lowest incidence.
Etiology:
The cause is unknown. Occupational, exposures , chromosomal aberrations ,cigarette smoking ,exposure to asbestos, solvents, cadmium ,associated with high incidence of RCC.

Pathology:
It originate from the proximal renal tubular epithelium, it originate in the cortex and tend to grow out into perinephric tissue, grossly yellow to orange, histologically it is a mixed adenocarcinoma containing clear cells, granular cells, and occasionally sarcomatoid-appearing cells.
It is vascular tumor. that tend to spread either by direct invasion through the renal capsule into perinephric fat, the most common site for distant metastasis is the lung.

Staging and grading:
For staging using TNM:
Tx: primary tumor cant assessed
T0; no evidence of primary tumor.
T1;tumor 7 cm or less limited to the kidney.
T2: more than 7 cm limited to the kidney.
T3: extend to into major veins or invades adrenal gland or perinephric tissue but not exted beyond gerotas fascia
T4:invade beyonds gerotas fascia.

N: regional lymph node cant be assessed.
N0: no regional LN metastasis.
N1:etastasis to single regional LN , 2cm or less.
N2:more than single LN.

Mx:distant metastasi cant assessed.
M0: no distant metastasis.
M1:distant metastasis.

Grading:
using system with 4 grades based on nuclear size and irregularity and nucleolar prominence.

Clinical finding:
Gross hematuria ,flank pain, palpable mass occur only in 7-10%, may present with dyspnea, cough , and bone pain(due to metastasis), sometime Asymptomatic detected incidentally in 50% .
Paraneoplastic syndrome: it includes erythrocytosis ,hypercalcimia ,hypertension, non metastatic hepatic dysfunction( elevated alkaline phosphatase and bilirubin ,hypoalbuminemia, prolong prothrombin time and hypergammaglobulinemia). These manifestation occur in 10-40% of patient with RCC.


Diagnosi:
1.anemia, hematuria elevated ESR,paraneoplasti csyndrom lab. Abnormalities.
2.imaging: CT scan with contrast is the best for diagnosis., other include U/S is very important non invasive for diagnosis, MRI is equivocal for CT scan in staging. Also is important but IVU is rarely used .
3. renal angiography: rarely use
4.radionuclide imaging most accurate for bone metastasis.
5.FNA: it has limited rule in the evaluation for RCC.
6. cystoscopy to exclude other cause .
7.urine cytology(with renal pelvis washing).

Treatment:
1.localised disease;
Surgical removal of early stage lesion remain the only potentially curative therapy available for RCC. By radical nephrectomy( open surgical or laparoscopic).
Radiation therapy has been advocated as neoadjuvant(preoperative) or adjuvant method to radical nephrectomy.
Partial nephrectomy in solitary kidney.
Observation as treatment for small mass less than 3 cm in old age.
Other theraputic approach for small mass as cryoablation.

2.disseminated disease: include : surgery by radical nephrectomy ,radiation therapy in the palliation of patients with metastasis, RCC is relatively radio resistant., effective for brain , bone ,lung.
Biologic response modifiers as partially purified human leukocyte interferon, human lymphoblast interferon., interleukin-2.
Other newer biologic agent as antiangiogenic agent.

The patient need follow up according to the stage of the disease, good prognosis for early stages.


Nephroblastoma (wilms tumor):
Is the most common solid renal tumor of childhood,, 5% of childhood cancers. The peak age of presentation is during the third year of life, it occur in familial and non familial forms.
Etiology non definite cause but there is identification for of agene associated with wilms tumor development.
In pathology of the tumor ,their correlated pathologic specimen with clinical outcome and divided various histological features into favorable and unfavorable prognostic group.
Tumor dissemination can occur by direct extension through the renal capsule , hematogenously via the renal vein and venacava. or via lymphatic spread..

Tumor staging:
It based on surgical and pathological finding:
Stage 1: tumor limited to kidney a and completely excised before or during operation no residual , not rapture .
Stage 2 :tumor extend beyond the kidney but completely removed not spillage during operation.
Stage 3: residual non hematogenous tumor confined to abdomen with any of these: regional lymph node, diffuse peritoneal contamination by tumor ,spillage, implant found on peritoneal cavity , tumor extend beyond the surgical margin, not completely resected tumor because local infiltration into vital structure,.
Stage 4:hematogenous metastasis to lung, liver . bone, and brain.
Stage5: bilateral renal involvement at diagnosis.


Clinical finding:
Asymptomatic mass discovered by the family or doctor .pain and distention, anorexia, nausea and vomiting.
The common sign is abdominal mass. Hypertension, and hematuria and coagulopathy .

Diagnosis:
1. lab.: hematuria ,anemia, abnormal liver function in liver metastasis.

Imaging;
Abdominal US and CT scan are performed initially., but CTscan remain imperfect for diagnosis of liver metastasis.
MRI important for diagnosis of inferior vena cava invasion.
Chest X-ray: important for lung metastasis.
CT scan chest.

Needle biopsy is indicated routinely in tumors deemed too large for safe primary surgical resection and for which preoperative chemotherapy or radiation therapy is planned.

Differential diagnosis:
Hydronephrosis ,cystic kidney, internal neuroblastoma, mesoplastic tumor.



Treatment:
The goal from therapy is to provide the highest cure rate with lowest treatment related morbidity.

a. surgical measures;
b. radical nephrectomy for unilateral involvement, whose tumor are deemed surgically resectable.
c. In bilateral tumor the patient require individualized approach: preoperative chemotherapy followed by renal sparing surgery.

d. chemotherapy;

this tumor Is chemotherapy sensitive , used as adjuvant chemotherapy(post operative),or used before surgery in advanced or bilateral..


radiotherapy:
the tumor is radiosensitive. the use of radiotherapy in children is complicated by its potential for growth disturbance and recognized cardiac, pulmonary,, and hepatic toxicities. Post operative radiation is recommended for the patients ,especially for unfavorable histopathology.


Prognosis;
Good prognosis for favorable histopathology.



Benign renal tumor:
Angiomyolipoma (hamartoma):
It may present in patients with tuberous sclerosis (typically bilateral an asymptomatic), but in patients without tuberous sclerosis, usually unilateral and larger.
It may rupture to retro peritoneum causing hemorrhage , it may present with pain. It has three histological component : mature fat cell, smooth muscle and blood vessels..

Diagnosis:
US ,CT scan usually diagnostic, MRI.

Treatment ;
In small tumor follow up is advisable , but if large with symptoms renal sparing surgery, or embolization.


Renal adenoma :
Is the most common benign renal tumor,, small , glandular tumor in the renal cortex.
Asymptomatic discover incidentally.
Difficult to differentiate it from adenicarcinoma .even it is difficult to differentiated from adenocarcinoma at histopathology

المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .