外科英文何卫阳肿瘤.docx

1、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 Tumours of The Genitourinary Tract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

2、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（Full English Teaching）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Smiths Urology 第15版Campbells Urology 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

3、手段时间分配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 over 50 years of age

4、 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. occupational exposuresd

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

6、 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 multicentric 3、Tumor

7、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 moderately differentiated

8、(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 used now.Tis Carcinoma-in-sit

9、uTa 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 invasion, in which malignan

10、t 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 nodes Lymphatic metastases occu

11、r 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 systemic urothelial cancer, few

12、 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 Symptoms The most common presenting

13、 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 hematuria is the hallmark o

14、f 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 mandatory to confirm hematuria

15、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 Malignant urothelial cells

16、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 in 20%. 5 、Flow Cytometry (

17、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 means of detecting bladder tum

18、ors, 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. urography can assess other upper

19、 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 This approach usually enables com

20、plete 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 prostatic urethra have been recommende

21、d 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. Magnetic Resonance Imaging Scan

22、 (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, recurrence, and the presence of CI

23、SSuperficial 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 of the bladder tumor)Carcinoma

24、-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 chemotherapyAgents Bacillus Calmette-Guerin (BCG) 70% Mitomycin C 50%Indications

25、1. rapid tumor recurrence2. multicentricity3. higher grade or invasion of the lamina propria4. presence of CISFollow-up All patients with superficial 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

26、 schedule for follow-up cystoscopy may be decreased to twice yearly Muscle invasive bladder cancer The term muscle-invasive bladder cancer refers to T2, T3 and T4 lesions of any grade the standard treatment for muscle invasive bladder cancer is a radical cystectomyDifferent types of urinary diversio

27、n ileal conduit continent urinary diversion orthotopic neobladder Advanced Bladder Cancer When bladder cancer is found to involve either thepelvic lymph nodes or distant organs, removal of the primary tumor is unlikely to cure the patientTherapeutic strategy chemotherapy and/or radiation therapy 3分钟

28、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Renal Cell Carcinoma 1、Definition Renal cell carcinoma is a type of kidney 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

29、.2、Alternative NamesRenal cancer.Kidney cancer. Hypernephroma.Adenocarcinoma of renal cells.Cancer - kidney 3、PathologyMost RCCs are round to ovoid 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 d

30、egeneration is found in 10% to 25%,and Calcification is in 10% to 20% of RCCs.Approximately 12% of patients have produced occlusive tumor thrombi 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(1

31、2%),opposite kidney(2%)and bones.TNM staging classificationstageTNM.Tumor confined by renal capsuleT1(7.5cm)N0(nodes negative)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