外科英文--何衛(wèi)陽(yáng)-腫瘤

1、重慶醫(yī)科大學(xué)臨床學(xué)院教案講稿 重慶醫(yī)科大學(xué)臨床學(xué)院教案及講稿（教 案）課程名稱(chēng)泌尿男生殖系腫瘤年級(jí)2005七年制授課專(zhuān)業(yè)外科學(xué)泌尿外科專(zhuān)業(yè)教 師何衛(wèi)陽(yáng)職稱(chēng)講師授課方式大課 示教學(xué)時(shí)2題目章節(jié)泌尿男生殖系腫瘤 Tumours of The Genitourinary Tract教材名稱(chēng)自編作者何衛(wèi)陽(yáng) 泌尿外科教研室出 版 社版次教學(xué)目的要求1 使學(xué)生通過(guò)本課的學(xué)習(xí)，初步掌握泌尿男腫瘤的病因、發(fā)病機(jī)制和病理變化，對(duì)泌尿男生殖系腫瘤有一個(gè)初步的了解。2 掌握泌尿男生殖系腫瘤的臨床癥狀和表現(xiàn)，以及診斷標(biāo)準(zhǔn)。3 掌握泌尿男生殖系腫瘤的治療方法。教學(xué)難點(diǎn)1針對(duì)外國(guó)留學(xué)生的全英語(yǔ)教學(xué)，對(duì)授課教師的專(zhuān)業(yè)英語(yǔ)和

2、口語(yǔ)水平有較高的要求。2泌尿男生殖系腫瘤的病理及臨床分期極易混淆，學(xué)生不容易掌握。3泌尿男生殖系腫瘤的臨床表現(xiàn)既有典型性，又有多樣性，尤其其診斷和鑒別診斷的理解有一定難度。4泌尿生殖系腫瘤治療方法的選擇不易掌握。教學(xué)重點(diǎn)1膀胱腫瘤的病因、發(fā)病機(jī)制、臨床及病理分期、臨床表現(xiàn)及治療方法，必須闡述清楚。2腎癌的臨床表現(xiàn)、診斷及治療。外語(yǔ)要求全英語(yǔ)教學(xué)（Full English Teaching）教學(xué)方法手段多媒體教學(xué)和傳統(tǒng)板書(shū)、掛圖相結(jié)合參考資料Smiths Urology 第15版Campbells Urology 第7版外科學(xué) 第6版教研室意見(jiàn) 教學(xué)組長(zhǎng)： 教研室主任： 年 月 日 21制表時(shí)間

3、：2009年12月（講 稿）教學(xué)內(nèi)容輔助手段時(shí)間分配Bladder Tumor一、Overview 1、Most common urologic malignancy in men, the fourth most common cancer ； accounting for 6.2% of all cancer cases； in women, the eighth most common cancer； accounting for 2.5% of all cancers； men: women in a 4:1 ratio； 80% of cases occur in patients

4、over 50 years of age 2、80% of bladder cancers are superficial.3、15 - 20% of bladder cancers are invasive.二、EtiologyAs with most cancers, no definitive cause of bladder cancer is known. However, there is strong circumstantial evidence that environmental exposure to carcinogens plays a major role. occ

5、upational exposuresdyetextilerubbercableprintingand plastics industries nonoccupational exposurescigarette smokingdietary nitrosaminesSchistosoma haematobium of the bladdercaffeinesaccharinand cyclamates三、Pathology1、Tumor type Transitional cell carcinoma (TCC) accounts for 90%of these cases squamous

6、 cell carcinoma about 8% adenocarcinoma 2% 2、Patterns of tumor growthBladder cancer manifests in a variety of patterns of tumor growth papillary, sessile, infiltrating, nodular, mixed, and flat intraepithelial growth (carcinoma-in-situ) These tumors usually grow in a papillary fashion and are often

7、multicentric 3、Tumor grade An estimation of how aggressive the tumor will behave Tumor grade refers to the histologic morphology as determined by cellular atypia, nuclear abnormalities, and the number as well as the location of mitotic figures. Grade I well differentiated (10% invasive) Grade II mod

8、erately differentiated (50% invasive) Grade III poorly differentiated (>80% invasive) Tumor Staging The depth of invasion into the bladder wall is the basis of the histologic stage and clinical stage. The tumor stage is the single most important prognostic factor. TNM classification is commonly u

9、sed now.Tis Carcinoma-in-situTa Noninvasive papillary carcinomaT1 Tumor invades submucosa/lamina propriaT2 Tumor invades superficial muscleT3a Tumor invades deep muscleT3b Tumor invades perivesical fatT4 Tumor invades adjacent organs 4、Patterns of Spread Direct extension This is the process of tumor

10、 invasion, in which malignant transitional epithelial cells extend beneath the basal lamina into the connective tissue of the lamina propria and, subsequently, into muscularis propria and perivesical fat. Lymphatic Spread The most common sites of metastases in bladder cancer are the pelvic lymph nod

11、es Lymphatic metastases occur earlier and independent of hematogenous metastases in some patients.Vascular Spread The common sites of vascular metastases are liver, 38%; lung, 36%; bone, 27%; adrenal glands, 21%; and intestine, 13% Any other organ may be involved Despite advances in treatment of sys

12、temic urothelial cancer, few patients with distant metastases survive 5 yearsImplantation Bladder cancer also spreads by implantation in abdominal wounds, denuded urothelium, resected prostatic fossa, or traumatized urethra Implantation occurs most commonly with high-grade tumors 四、Signs and Symptom

13、s The most common presenting symptom of bladder cancer is painless hematuria (gross or microscopic) Most bladder tumors have no other symptoms unless they become invasive or there is an associated condition called carcinoma-in- situ(CIS) urinary frequency Urgency dysuria五、Diagnosis1 History Painless

14、 hematuria is the hallmark of bladder cancer either alone or associated with irritative symptoms.2 、Physical Exam The physical exam is usually unremarkable except in far advanced disease. palpable tumor indicates that at least the muscular wall is involved.3 、Lab tests Urinalysis and culture are man

15、datory to confirm hematuria and to look for evidence of infection. Even if infection is demonstrated and hematuria clears after treatment with antibiotics, further investigation should be undertaken in high risk individuals (age, sex, industrial exposure, smoker). 4、Conventional Microscopic Cytology

16、 Malignant urothelial cells can be observed on microscopic examination of the urinary sediment or bladder washings Microscopic cytology is more sensitive in patients with high-grade tumors or carcinoma-in-situ Even in patients with high-grade tumors, however, urinary cytology may be falsely negative

17、 in 20%. 5 、Flow Cytometry (FCM) In general, flow cytometry has not been found to be more clinically valuable than conventional cytology. 6 、X-rays Excretory urography is indicated in all patients with signs and symptoms suggestive of bladder cancer. Intravenous urography (IVU) is not a sensitive me

18、ans of detecting bladder tumors, particularly small ones. However, 1. IVU is useful in examining the upper urinary tracts for associated urothelial tumors.2. Large tumors may appear as filling defects. 3. Ureteral obstruction caused by a bladder tumor is usually a sign of muscle-invasive cancer.4. u

19、rography can assess other upper tract abnormalities that may affect management decisions. 7.Cystoscopy All patients suspected of having bladder cancer should have careful cystoscopy. Abnormal areas should be biopsied. Random or selected-site mucosal biopsy specimens may also be obtained8 Biopsies Th

20、is approach usually enables complete removal of the tumor and provides valuable diagnostic information about the grade and depth of infiltration of the tumor. Selected-site mucosal biopsies from areas adjacent to the tumor as well as from the opposite bladder wall, bladder dome, trigone, and prostat

21、ic urethra have been recommended at time of resection of the primary tumor.Staging Tests Computed Tomography Scan(CT) In addition to assessing the extent of the primary tumor, CT scanning also provides information about the presence of pelvic and para-aortic lymphadenopathy and visceral metastases.

22、Magnetic Resonance Imaging Scan (MRI ) scanning is not much more helpful than CT scanning.六、Treatment The following is a general guideline to the management of bladder cancerTreatment options must be carefully individualized Major prognostic factors include stage, grade, size, number of lesions, rec

23、urrence, and the presence of CISSuperficial bladder cancer The term superficial bladder cancer refers to Ta, T1, and Tis lesions of any grade The principal technique for the diagnosis and treatment of superficial bladder lesions remains endoscopic management cystoscopy TURbt (transurethral resection

24、 of the bladder tumor) Carcinoma-in-situ (Tis) Radical cystectomy is the therapy of choice until recent studies demonstrate favorable response rates using intravesical BCG or mitomycin C chemotherapy. Ta-T1 TURbt is curative in most cases.Intravesical chemotherapy Agents Bacillus Calmette-Guerin (BC

25、G) 70% Mitomycin C 50% Indications1.       rapid tumor recurrence2.       multicentricity3.       higher grade or invasion of the lamina propria4.      presence of CISFollow-up All patients with superficia

26、l tumors should be closely followed with local cystoscopy and cytologies every 3 months for 2 years If no tumor recurrences are noted after 2 years, the schedule for follow-up cystoscopy may be decreased to twice yearly Muscle invasive bladder cancer The term muscle-invasive bladder cancer refers to

27、 T2, T3 and T4 lesions of any grade the standard treatment for muscle invasive bladder cancer is a radical cystectomyDifferent types of urinary diversion ileal conduit continent urinary diversion orthotopic neobladder Advanced Bladder Cancer When bladder cancer is found to involve either thepelvic l

28、ymph nodes or distant organs, removal of the primary tumor is unlikely to cure the patientTherapeutic strategy chemotherapy and/or radiation therapy 3分鐘3分鐘10分鐘多幅圖片說(shuō)明板書(shū)說(shuō)明7分鐘10分鐘多幅圖片及影像學(xué)圖片加以說(shuō)明多幅膀胱鏡下圖片說(shuō)明7分鐘圖片說(shuō)明板書(shū)及繪簡(jiǎn)圖說(shuō)明教學(xué)內(nèi)容輔助手段時(shí)間分配Renal Cell Carcinoma 1、Definition Renal cell carcinoma is a type of kidne

29、y cancer. The cancerous cells are found in the lining of very small tubes (tubules) in the kidney. It is the most common type of kidney cancer in adults.2、Alternative Names Renal cancer. Kidney cancer. Hypernephroma. Adenocarcinoma of renal cells. Cancer - kidney 3、Pathology Most RCCs are round to o

30、void and circumscribed by a pseudocapsule. Tumor size can vary from a few millimeters to large enough to fill the entire abdomen,most from 5 to 8 cm. Cystic degeneration is found in 10% to 25%,and Calcification is in 10% to 20% of RCCs. Approximately 12% of patients have produced occlusive tumor thr

31、ombi in the renal vein and the inferior vena cava. The tumor metastasizes commonly to the lungs(30%),adjacent renal hilar lymph nodes( 25%).ipsilateral drenal(12%),opposite kidney(2%)and bones.TNM staging classificationstageTNM.Tumor confined by renal capsuleT1(<7.5cm)T2(>7.5cm)N0(nodes negati

32、ve)M0(lack of distant metastases).Tumor extension to perirenal fat or ipsilateral adenal but confined by Gerotas fasciaT3aN0M0a.Renal vein or inferior vena cava involvementT3b(renal vein)T3c(caval below the diaphragm)T4b (caval above the diaphragm)N0M0b.Lymphatic involvementT1-3N1,N2,N3,N4M0c.Combin

33、ation of a and bT3-4N1-4M0a. Sprend to contiguous orrgans except ipsilateral adrenalT4aN3-4M0b.Distant metastasesT1-4N0-4M14、General Considerations Renal cell carcinoma account for approximately 3% of all tumors in adults, and is the most lethal of the urologic cancers. The disease occurs in males t

34、hree times more commonly than in females. In china,there is no exact report about incidence5、Etiology and risk factors The cause of renal adenocarcinoma is unknown. Smoking Genetics Family history of the disease Dialysis treatment von Hippel-Lindau disease, a hereditary disease that affects the capi

35、llaries of the brain6、Signs & Symptoms of RCC Classic triad Flank pain Palpable flank mass Hematuria Scrotal varicocele Secondary to tumor obstruction of gonadal vein PE, ascites, hepatic dysfunction Secondary to tumor occluding IVCSymptoms and Signs Painless gross or microscopic hematuria throu

36、ghout the urinary stream (“total hematuria”) occurs in 60% of patients. The degree of hematuria is not necessarily related to the size or stage of the tumor. Although a triad of hematuria, flank pain, and a palpable flank mass suggests renal cell carcinoma, fewer than 10% of patients will so present

37、. Symptoms due to metastases may be the initial complaint (e.g., bone pain, respiratory distress). Symptoms of Paraneoplastic syndromes hypercalcemia, eryrheoxyroai , hypertension, fever of unknown origin, anemia, and hepatopathy . Symptoms of tumor metastases Pathologic fractures, hemoptysis, menta

38、l status changes7、Laboratory Findings Microscopic urinalysis will reveal hematuria in most patients. Anemia unrelated to blood loss occurs in 10%-15% of patents.8、Imaging Studies Abdominal plain film IV urogram with tomogram Ultrasound CT MRI AngiographyX-ray findings plain abdominal X-rays may reve

39、al a calcified renal mass, but only 20% of renal masses contain demonstrablecalcificationIntravenous urography intravenous urography alone will define only 75% of renal mass lesions. Features suggestive of malignancy include: calcification within the mass. increased tissue density. irregularity of t

40、he margin. invasion of the collecting (system displacement or distortion of renal calyces by mass; Invasion of calices by tumor resulting in filling defect)Ultrasonography Abdominal ultrasonography can define the mass as a benign simple cyst or a solid mass in 90%-95% of cases . Abdominal ultrasound

41、 can also identify a vena caval tumor thrombus and it s cephalad extent in the cava.Isotope scanning Isotope scans of a tenal tumor or cyst will show an area of decreased uptakeCT scan CT scan is chosen when a solid renal mass is noted on ultrasound. CT scan accurately delineates renal cell carcinom

42、a in over 95% of cases. Over 80% of tumors are enhanced by iodinated contrast medium . CT scan is also helpful in local staging and tumor thrombi in the renal vein or inferior vena cava.Magnetic resonance imaging(MRI) It is not more accurate than CT and is much more ecpensive. It is the most accurat

43、e noninvasive means of detecting renal veinor vena caval thrombi. Renal angiography with the widespread availability of CT scanners, the role of renal angiography in the diagnostic evaluation of RCC has markedly diminished. Angiography is commonly used for pre-operative or palliative embolization of

44、 renal carcinomas Reduce persistent hematuria Reduce intraoperative bleeding Reduce surgical hematogenous dissemination of tumorOther Diagnostic or Staging Techniques Isotopic bone scanning, chest X-ray, and CT scan of the chest can be used to examine the most common sites of metastases and are nece

45、ssary before determining treatment. The needle aspiration is required only in indeterminate cases(10%).9、Differential Diagnosis The radiographic and ultrasonographic techniques described above should make the differentiateion. Cyctoscopy is obligatory in hematuric patients with a normal intervenous

46、urogram to rule out disease of the bladder and to determine the sourse of the hematueia10、Complications Occasionally,patients may present with acute flank pain. avaricocele . lower extremity edema. pathologic fractures,. brain metastases. 11、Treatment Stageing is the key to designing the treatment p

47、lan(Table-1). patients with stages,and A are best treated by open radical nephrectomy. laparoscopic radical or partial nephrectomy has been advocated as a method equal to the open approach.Surgical Treatment Radical nephrectomy Resection of kidney, perirenal fat, and ipsilateral adrenal gland Partia

48、l nephrectomy Resection of portion of one kidney Surgical excision of tumors that have invaded the IVC is dangerous and has an operative mortality of 5-10%. Nephrectomy has not been associated with improved survival rates in patients with stage . Radiation therapy and hormonal isof little benefit ex

49、cept as trentment for symptomatic bone,brain and lung metastases.ImmuntherapyClinical trials of combined IL-2and interferon alfa show a 30% response rate with exended survival,and this is currently the best conventional method available.Chemotherapy Chemotherapy may be used in some cases, but cure is unlikely unless all the cancer is removed