外科英文何卫阳肿瘤.docx

外科英文何卫阳肿瘤.docx

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外科英文何卫阳肿瘤

重庆医科大学临床学院教案及讲稿

（教案）

课程名称

泌尿男生殖系肿瘤

年级

2005七年制

授课专业

外科学泌尿外科专业

教师

何卫阳

职称

讲师

授课方式

√大课示教

学时

2

题目章节

泌尿男生殖系肿瘤TumoursofTheGenitourinaryTract

教材名称

自编

作者

何卫阳泌尿外科教研室

出版社

版次

教

学

目

的

要

求

1使学生通过本课的学习，初步掌握泌尿男肿瘤的病因、发病机制和病理变化，对泌尿男生殖系肿瘤有一个初步的了解。

2掌握泌尿男生殖系肿瘤的临床症状和表现，以及诊断标准。

3掌握泌尿男生殖系肿瘤的治疗方法。

教

学

难

点

1针对外国留学生的全英语教学，对授课教师的专业英语和口语水平有较高的要求。

2泌尿男生殖系肿瘤的病理及临床分期极易混淆，学生不容易掌握。

3泌尿男生殖系肿瘤的临床表现既有典型性，又有多样性，尤其其诊断和鉴别诊断的理解有一定难度。

4泌尿生殖系肿瘤治疗方法的选择不易掌握。

教

学

重

点

1膀胱肿瘤的病因、发病机制、临床及病理分期、临床表现及治疗方法，必须阐述清楚。

2肾癌的临床表现、诊断及治疗。

外语要求

全英语教学（FullEnglishTeaching）

教学方法手段

多媒体教学和传统板书、挂图相结合

参考资料

Smith’sUrology第15版

Campbell’sUrology第7版

外科学第6版

教研室意见

教学组长：

教研室主任：

年月日

（讲稿）

教学内容

辅助手段

时间分配

BladderTumor

一、Overview

1、Mostcommonurologicmalignancy

inmen,thefourthmostcommoncancer；

accountingfor6.2%ofallcancercases；

inwomen,theeighthmostcommoncancer；

accountingfor2.5%ofallcancers；

men:

womenina4:

1ratio；

80%ofcasesoccurinpatientsover50yearsofage

2、80%ofbladdercancersaresuperficial.

3、15-20%ofbladdercancersareinvasive.

二、Etiology

Aswithmostcancers,nodefinitivecauseofbladdercancerisknown.However,thereisstrongcircumstantialevidencethatenvironmentalexposuretocarcinogensplaysamajorrole.

•occupationalexposures

dye

textile

rubber

cable

printing

andplasticsindustries

•nonoccupationalexposures

cigarettesmoking

dietarynitrosamines

Schistosomahaematobiumofthebladder

caffeine

saccharin

andcyclamates

三、Pathology

1、Tumortype

Transitionalcellcarcinoma（TCC）accountsfor90%

ofthesecases

squamouscellcarcinomaabout8%

adenocarcinoma2%

2、Patternsoftumorgrowth

Bladdercancermanifestsinavarietyofpatternsoftumorgrowthpapillary,sessile,infiltrating,nodular,mixed,andflatintraepithelialgrowth（carcinoma-in-situ）Thesetumorsusuallygrowinapapillaryfashionandareoftenmulticentric

3、Tumorgrade

Anestimationofhowaggressivethetumorwillbehave

Tumorgradereferstothehistologicmorphologyasdeterminedbycellularatypia,nuclearabnormalities,andthenumberaswellasthelocationofmitoticfigures.

•GradeIwelldifferentiated（~10%invasive）

•GradeIImoderatelydifferentiated（~50%invasive）

•GradeIIIpoorlydifferentiated（>80%invasive）

TumorStaging

Thedepthofinvasionintothebladderwallisthebasisofthehistologicstageandclinicalstage.Thetumorstageisthesinglemostimportantprognosticfactor.TNMclassificationiscommonlyusednow.

TisCarcinoma-in-situ

TaNoninvasivepapillarycarcinoma

T1Tumorinvadessubmucosa/laminapropria

T2Tumorinvadessuperficialmuscle

T3aTumorinvadesdeepmuscle

T3bTumorinvadesperivesicalfat

T4Tumorinvadesadjacentorgans

4、PatternsofSpread

Directextension

Thisistheprocessoftumorinvasion,inwhichmalignanttransitionalepithelialcellsextendbeneaththebasallaminaintotheconnectivetissueofthelaminapropriaand,subsequently,intomuscularispropriaandperivesicalfat.

LymphaticSpread

Themostcommonsitesofmetastasesinbladdercancerarethepelviclymphnodes

Lymphaticmetastasesoccurearlierandindependentofhematogenousmetastasesinsomepatients.

VascularSpread

Thecommonsitesofvascularmetastasesare

liver,38%;lung,36%;bone,27%;adrenalglands,21%;andintestine,13%

Anyotherorganmaybeinvolved

Despiteadvancesintreatmentofsystemicurothelialcancer,fewpatientswithdistantmetastasessurvive5years

Implantation

Bladdercanceralsospreadsbyimplantationinabdominalwounds,denudedurothelium,resectedprostaticfossa,ortraumatizedurethra

Implantationoccursmostcommonlywithhigh-gradetumors

四、SignsandSymptoms

Themostcommonpresentingsymptomofbladdercancerispainlesshematuria（grossormicroscopic）

Mostbladdertumorshavenoothersymptomsunlesstheybecomeinvasiveorthereisanassociatedconditioncalledcarcinoma-in-situ（CIS）

•urinaryfrequency

•Urgency

•dysuria

五、Diagnosis

1History

Painlesshematuriaisthehallmarkofbladdercancer

eitheraloneorassociatedwithirritativesymptoms.

2、PhysicalExam

Thephysicalexamisusuallyunremarkableexceptin

faradvanceddisease.

palpabletumorindicatesthatatleastthemuscular

wallisinvolved.

3、Labtests

Urinalysisandculturearemandatorytoconfirmhematuriaandtolookforevidenceofinfection.Evenifinfectionisdemonstratedandhematuriaclearsaftertreatmentwithantibiotics,furtherinvestigationshouldbeundertakeninhighriskindividuals（age,sex,industrialexposure,smoker）.

4、ConventionalMicroscopicCytologyMalignanturothelialcellscanbeobservedonmicroscopicexaminationoftheurinarysedimentorbladderwashings

Microscopiccytologyismoresensitiveinpatientswithhigh-gradetumorsorcarcinoma-in-situ

Eveninpatientswithhigh-gradetumors,however,urinarycytologymaybefalselynegativein20%.

5、FlowCytometry（FCM）

Ingeneral,flowcytometryhasnotbeenfoundtobemoreclinicallyvaluablethanconventionalcytology.

6、X-rays

Excretoryurographyisindicatedinallpatientswithsignsandsymptomssuggestiveofbladdercancer.Intravenousurography（IVU）isnotasensitivemeansofdetectingbladdertumors,particularlysmallones.

However,

1.IVUisusefulinexaminingtheupperurinarytractsforassociatedurothelialtumors.

2.Largetumorsmayappearasfillingdefects.

3.Ureteralobstructioncausedbyabladdertumorisusuallyasignofmuscle-invasivecancer.

4.urographycanassessotheruppertractabnormalitiesthatmayaffectmanagementdecisions.

7.Cystoscopy

Allpatientssuspectedofhavingbladdercancershouldhavecarefulcystoscopy.Abnormalareasshouldbebiopsied.Randomorselected-sitemucosalbiopsyspecimensmayalsobeobtained

8Biopsies

Thisapproachusuallyenablescompleteremovalofthetumorandprovidesvaluablediagnosticinformationaboutthegradeanddepthofinfiltrationofthetumor.

Selected-sitemucosalbiopsiesfromareasadjacenttothetumoraswellasfromtheoppositebladderwall,bladderdome,trigone,andprostaticurethrahavebeenrecommendedattimeofresectionoftheprimarytumor.

StagingTests

ComputedTomographyScan（CT）Inadditiontoassessingtheextentoftheprimarytumor,CTscanningalsoprovidesinformationaboutthepresenceofpelvicandpara-aorticlymphadenopathyandvisceralmetastases.

MagneticResonanceImagingScan（MRI）scanningisnotmuchmorehelpfulthanCTscanning.

六、Treatment

Thefollowingisageneralguidelinetothemanagement

ofbladdercancer

Treatmentoptionsmustbecarefullyindividualized

Majorprognosticfactorsincludestage,grade,size,

numberoflesions,recurrence,andthepresenceofCIS

Superficialbladdercancer

ThetermsuperficialbladdercancerreferstoTa,T1,andTislesionsofanygrade

Theprincipaltechniqueforthediagnosisandtreatmentofsuperficialbladderlesionsremainsendoscopicmanagement

•cystoscopy

•TURbt（transurethralresectionofthebladder

tumor）

•Carcinoma-in-situ（Tis）

RadicalcystectomyisthetherapyofchoiceuntilrecentstudiesdemonstratefavorableresponseratesusingintravesicalBCGormitomycinCchemotherapy.

•Ta-T1

TURbtiscurativeinmostcases.

Intravesicalchemotherapy

•Agents

BacillusCalmette-Guerin（BCG）70%

MitomycinC50%

•Indications

1.     rapidtumorrecurrence

2.     multicentricity

3.     highergradeorinvasionofthelaminapropria

4.    presenceofCIS

Follow-up

Allpatientswithsuperficialtumorsshouldbecloselyfollowedwithlocalcystoscopyandcytologiesevery3monthsfor2years

Ifnotumorrecurrencesarenotedafter2years,thescheduleforfollow-upcystoscopymaybedecreasedtotwiceyearly

Muscleinvasivebladdercancer

Thetermmuscle-invasivebladdercancerrefersto

T2,T3andT4lesionsofanygrade

thestandardtreatmentformuscleinvasivebladder

cancerisaradicalcystectomy

Differenttypesofurinarydiversion

•ilealconduit

•continenturinarydiversion

•orthotopicneobladder

AdvancedBladderCancer

Whenbladdercancerisfoundtoinvolveeitherthe

pelviclymphnodesordistantorgans,removalofthe

primarytumorisunlikelytocurethepatient

Therapeuticstrategy

•chemotherapyand/or

•radiationtherapy

3分钟

3分钟

10分钟

多幅图片说明

板书说明

7分钟

10分钟

多幅图片及影像学图片加以说明

多幅膀胱镜下图片说明

7分钟

图片说明

板书及绘简图说明

教学内容

辅助手段

时间分配

RenalCellCarcinoma

1、Definition

•Renalcellcarcinomaisatypeofkidneycancer.

•Thecancerouscellsarefoundintheliningofverysmalltubes（tubules）inthekidney.

•Itisthemostcommontypeofkidneycancerinadults.

2、AlternativeNames

•Renalcancer.

•Kidneycancer.

•Hypernephroma.

•Adenocarcinomaofrenalcells.

•Cancer-kidney

3、Pathology

•MostRCCsareroundtoovoidandcircumscribedbyapseudocapsule.Tumorsizecanvaryfromafewmillimeterstolargeenoughtofilltheentireabdomen,mostfrom5to8cm.

•Cysticdegenerationisfoundin10%to25%,andCalcificationisin10%to20%ofRCCs.

•Approximately12%ofpatientshaveproducedocclusivetumorthrombiintherenalveinandtheinferiorvenacava.

•Thetumormetastasizescommonlytothelungs（30%）,adjacentrenalhilarlymphnodes（25%）.ipsilateraldrenal（12%）,oppositekidney（2%）andbones.

TNMstagingclassification

stage

T

N

M

Ⅰ.Tumorconfinedbyrenalcapsule

T1（<7.5cm）

T2（>7.5cm）

N0（nodesnegative）

M0（lackofdistantmetastases）

Ⅱ.TumorextensiontoperirenalfatoripsilateraladenalbutconfinedbyGerotasfascia

T3a

N0

M0

Ⅲa.Renalveinorinferiorvenacavainvolvement

T3b（renalvein）

T3c（cavalbelowthe