腎臟癌

Renal cell CA

　

60, white M, heavy smoker x 24y, c/o R flank pain & hematuria. Lost 5 lb x 1m (not on diet).

V/S: low fever, mod HTN, pallor; palpable mass in R flank. ↑RBC (polycythemia), ↑ESR.

CBC/PBS: normocytic normochromic anemia.

UA: gross hematuria.  IVP/CT/US: mass in upper pole of R kidney.

MR: no invasion of renal vein or IVC. 

Patho: (yellowish area of necrotic tiss w/ focal areas of hge w/in renal parenchyma) clear cells (containing glycogen) w/ atypia

Invading renal parenchyma.

　

-mc renal tumor.↑in von Hippel-Lindau synd, acquired polycystic Kidney Dz (PKD).)

-freq invade renal vein & IVC.

-Mets (lung, bone) via hematogenous.

-Can cause paraneoplastic synd. (EPO, PTH, ACTH, renin)

　

Tx:

R nephrectomy.

Renal sparing partial nephrectomy (consider)

攝護腺癌

Prostate cancer

　

68, black M, c/o dysuria, progressively↑ed urinary freq, back pain x ms. High animal fat intake.

PE: (digital) nodular, (rock-hard, irregular area of induration in periph lobe of prostate).

Midline furrow b/t prostatic lobes obscured不明. Extension to seminal vesicle detected.

Markedly↑PSA & acid phosphatase.

Transrectal US-prostate : Hypoechoic masses in periph zone w/ extension to seminal vesicles.

Nuc-Bone scan: hot lesions of spine, sacrum, & pelvic bones (axial skeleton).

CT/MR: prostate mass w/ capsular penetration & enlarged seminal vesicles.

Bx : (irregular enlarged, firm, nodular) Core Needle Bx-prostate : single layer of malig cell arranged haphazardly in adenoplastic stroma. 

　

(1∘malig com arising fr periph zone (70%), mc male cancer.) Px & Tx depend heavily on stage.

Exhibit hematogenous spread: Mc to bone (osteoblastic lesion (bone forming), may also to sacral nerve roots (signif pain))

　

Tx:

Prostatectomy w/ radiation; Orchiectomy;

Leuprolide; androgens; flutamide

攝護腺肥大

BPH

　

78, M, c/o having to wake up 6-7x at night (Nocturia) to urinate. Also urgent, weak stream, terminal dribbling, and a need to push in order to initiate micturition排尿.has had 2 episodes of acute urinary retention (required Foley to relieve). Denied wt loss, fatigue, bone pain. VS=N∘. PE: cardiopulm & abd : unremarkable. Rectal exam: enlarged, nodular, nontender prostate gland (rubbery w/o area of ↑consistency; median ridge not palpable;  postvoid catheterizationà150cc residual urine) UA: 8 wbc/HPF; nitrate & leukocyte esterase (+); proteinuria & slight hematuria (due to concomitant infxn).

CBC=N∘Alkaline & acid phosphatase =N∘. PSA=5.5 (N∘=4, >10 suggest cancer); BUN & Cr=N∘. Ca=N∘

US-prostate: enlarged prostate w/o focal mass; transrectal guided Bx may performed in multiple regions. 

IVP: elevated bladder, w/ impression of enlarged prostate on inf surface.

　

(Incidence is proportional to age. >90% man has histological evidence of BPH at 85y.)

(generally originates in periurethral & transition zone) (while prostate Ca usu present in peripheral aspect of prostate)

-it can coexist w/ prostate cancer, but BPH is not a premalig dz.

(Occurs as hyperplasia of stromal & epith tiss) in periurethral zone of aging men. It can cause urinary flow obst ± obst prostatism.

The size of gland on PE dose not generally correlate w/ symp.

Condition will precipitate or worsen symp= cold exposure, Anti-Ach, anesthetic drugs, alc.

(age-dependent changes of estrogen & androgens are believe the cause of BPH. Dz start at 40y.)

　

Tx:

Finasteride;

TURP (transurethral resection of prostate).

Tx asso UTI – Bactrim or ciprofloxacin

　

膀胱癌

Bladder cancer (papillary CA)

　

56, M, heavy smoker, Thai immigrant c/o painless hematuria x days. Once loved to swim in a lake harbor many snails (risk of schistosomiasis). Lung-clear, abd nontender; no palpable mass; genitalia WNL; No LAD. 

CBC: slight normocytic normochromic anemia.

UA: hematuria & abundant epith cells. Remainder routine bld w/u & stool –N∘.

IVP/Cystogram : irregular filling defects above trigone.

Cytology of urine: malig cells.

Bladder Bx : (nodular, cauliflower-like w/ central necrosis) grade I, stage B transitional cell CA (TCC) arising fr uroepith & projecting into bladder.

　

-Man (4x), expose to arylamines, smoke, Schistosoma haematobium, analgesic abuse (esp. phenacetin), cyclophosphamide.

-transitional cell ca: a/w mutation in p53 (tumor suppressor gene) & deletion in Chrom 9q.

Cx : invasion of perivesicular tiss, ureteral invasion w/ urinary obst (àhydronephrosis, APN, RF), Mets (lung, bone, liver)

　

Tx:

Surgery (aggressive fulguration電灼)

R/T ; C/T