37- Hematuria & RCC (1)

7/23/2019 37- Hematuria & RCC (1)

http://slidepdf.com/reader/full/37-hematuria-rcc-1 1/53

Hematuria and TransitionalHematuria and Transitional

Cell CarcinomaCell CarcinomaRami Al-Azab,MDRami Al-Azab,MD

Onco- urologistOnco- urologist

7/23/2019 37- Hematuria & RCC (1)


7/23/2019 37- Hematuria & RCC (1)


DefinitionsDefinitions

Hematuria is presence of blood in urine ,Hematuria is presence of blood in urine ,

this is a misnomer.this is a misnomer.

This is detected b either dipstic! and"orThis is detected b either dipstic! and"ormicroscop.microscop.

The urinalsis also loo!s at differentThe urinalsis also loo!s at different

factors that ma point out certain crucialfactors that ma point out certain crucial

pointspoints

7/23/2019 37- Hematuria & RCC (1)


### Medical causes### Medical causes

$resence of casts.$resence of casts. %i&ed specific gra'it,%i&ed specific gra'it,

(lucosuria.(lucosuria. significant proteinuria.significant proteinuria. red cell casts.red cell casts.

renal insufficiency.renal insufficiency.

Predominance of dysmorphic RBC’s in the urine.Predominance of dysmorphic RBC’s in the urine.

$resence or absence of smptoms is )ea! rele'ant$resence or absence of smptoms is )ea! rele'antinformationinformation

7/23/2019 37- Hematuria & RCC (1)


Classifing hematuriaClassifing hematuria

According to the act of 'oid* According to the act of 'oid*

-+nitial.-+nitial.

-Terminal.-Terminal.-Total.-Total.

mptomatic 's. Asmptomatic.mptomatic 's. Asmptomatic.

Mode of disco'er* (ross 's. microscopicMode of disco'er* (ross 's. microscopic

7/23/2019 37- Hematuria & RCC (1)


The recommended definition of microscopicThe recommended definition of microscopic

hematuria is “ hematuria is “ three or more red blood cellsthree or more red blood cells

per high-power field on microscopic

per high-power field on microscopic

evaluation of urinary sediment from two ofevaluation of uri

nary sediment from two ofthree properly collected urinalysisthree

properly collected urinalysis

specimens”

specimens” ..

the chances of identifying significantthe chances of identifying significantpathology increase with the degree ofpathology increase with the degree of

hematuria.hematuria.

7/23/2019 37- Hematuria & RCC (1)


ignificance of hematuriaignificance of hematuria

Hematuria is a sign of malignancy untilHematuria is a sign of malignancy until

proven otherwise. proven otherwise.Microscopic hematuria is more dangerousMicroscopic hematuria is more dangerous

because time can elapse before diagnosis. andbecause time can elapse before diagnosis. and

maignanc is more li!el to present asmaignanc is more li!el to present as

microscopic hematuria .microscopic hematuria .

e'erit of the condition can be proportionate toe'erit of the condition can be proportionate tothe se'erit of hematuria.the se'erit of hematuria.

7/23/2019 37- Hematuria & RCC (1)


+nitial uestions+nitial uestions

Is the hematuria gross or microscopic?Is the hematuria gross or microscopic? At what time during urination does theAt what time during urination does the

hematuria occur (beginning or end ofhematuria occur (beginning or end of

stream or during entire stream)?stream or during entire stream)? Is the hematuria associated with pain?Is the hematuria associated with pain? Is the patient passing clots?Is the patient passing clots?

If the patient is passing clots, do the clotsIf the patient is passing clots, do the clotshave a specific shape?have a specific shape?

7/23/2019 37- Hematuria & RCC (1)


Total hematuria is most commonTotal hematuria is most commonand indicates that the bleeding isand indicates that the bleeding ismost likely coming from the bladdermost likely coming from the bladderor upper urinary tracts.or upper urinary tracts.

the most common cause of grossthe most common cause of grosshematuria in a patient older thanhematuria in a patient older thanage 50 years is bladder cancer.age 50 years is bladder cancer.

7/23/2019 37- Hematuria & RCC (1)


Initial hematuria usually arises fromInitial hematuria usually arises from

the urethra;the urethra; it occurs least commonl andit occurs least commonl and

is usuall secondar to inflammation.is usuall secondar to inflammation.

Terminal hematuria occurs at theTerminal hematuria occurs at the

end of micturition and is usuallyend of micturition and is usually

secondary to inflammation in the areasecondary to inflammation in the area

of the bladder neck or prostaticof the bladder neck or prostaticurethra.urethra.

7/23/2019 37- Hematuria & RCC (1)


is usually not painful unless it isis usually not painful unless it isassociated with inflammation orassociated with inflammation orobstruction.obstruction.

pain in association with hematuriapain in association with hematuria

usually results from upper urinary tract inusually results from upper urinary tract in

the LUT the associated symptoms arethe LUT the associated symptoms are

usually irritative.usually irritative.

7/23/2019 37- Hematuria & RCC (1)


Presence of ClotsPresence of Clots

The presence of clots usuall indicates aThe presence of clots usuall indicates a

more significant degree of hematuria, and,more significant degree of hematuria, and,

accordingl, the probabilit of identifingaccordingl, the probabilit of identifing

significant urologic patholog increases.significant urologic patholog increases.

7/23/2019 37- Hematuria & RCC (1)


/hat0s ne&t#/hat0s ne&t#

+n a patient )ho presents )ith gross+n a patient )ho presents )ith gross

hematuria, cstoscop should behematuria, cstoscop should be

performed as soon as possible, becauseperformed as soon as possible, because

freuentl the source of bleeding can befreuentl the source of bleeding can be

readil identified.readil identified.

Cstoscop )ill determine )hether theCstoscop )ill determine )hether the

hematuria is coming from the urethra,hematuria is coming from the urethra,bladder, or upper urinar tract .bladder, or upper urinar tract .

7/23/2019 37- Hematuria & RCC (1)


/or! up/or! up

Cstoscop, Cstoscop and Cstoscop.Cstoscop, Cstoscop and Cstoscop.

1A for confirmation, 1rine C2.1A for confirmation, 1rine C2.

1rine Ctolog.1rine Ctolog.1pper tract imaging 3CT, +41, 1", Angio51pper tract imaging 3CT, +41, 1", Angio5

Retrograde pelograph.Retrograde pelograph.

7/23/2019 37- Hematuria & RCC (1)


7/23/2019 37- Hematuria & RCC (1)


$ossible outcome$ossible outcome

All o'er abo'e the age of 67, TCC is the All o'er abo'e the age of 67, TCC is the

most common cause of gross hematuria.most common cause of gross hematuria.

8$H is the most common cause in aging8$H is the most common cause in aging

men.men.

1T+ is the most common cause in1T+ is the most common cause in

females.females.

7/23/2019 37- Hematuria & RCC (1)


Risk Factors for Significant DiseaseRisk Factors for Significant Disease

in Patients with icroscopic !ematuriain Patients with icroscopic !ematuria

mo!ing histormo!ing histor Occupational e&posure to chemicals or desOccupational e&posure to chemicals or des 3benzenes or aromatic amines53benzenes or aromatic amines5 Histor of gross hematuriaHistor of gross hematuria Age 9:7 ears Age 9:7 ears Histor of urologic disorder or diseaseHistor of urologic disorder or disease Histor of irritati'e 'oiding smptomsHistor of irritati'e 'oiding smptoms Histor of urinar tract infectionHistor of urinar tract infection Analgesic abuse Analgesic abuse

Histor of pel'ic irradiationHistor of pel'ic irradiation

Summary of the "#" $est Practice Policy RecommendationsSummary of the "#" $est Practice Policy Recommendations

7/23/2019 37- Hematuria & RCC (1)


1rolthelial not 8ladder cancer 1rolthelial not 8ladder cancer

Transitional epithelium lines the urinarTransitional epithelium lines the urinar

tract from the minor calces to the end oftract from the minor calces to the end of

the prostatic urethra.the prostatic urethra.

+t is the most commonl diagnosed+t is the most commonl diagnosed

malignanc in patients )ith hematuria.malignanc in patients )ith hematuria.

7/23/2019 37- Hematuria & RCC (1)


$ladder cancer is more than %.& times$ladder cancer is more than %.& times

more common in men than in womenmore common in men than in women..

bladder cancer has rarely been foundbladder cancer has rarely been found

incidentally at autopsyincidentally at autopsy

7/23/2019 37- Hematuria & RCC (1)


Ris! %actorsRis! %actors

7/23/2019 37- Hematuria & RCC (1)


7/23/2019 37- Hematuria & RCC (1)


Ris! factorsRis! factors

Dyes, paints and other industrial exposure.Dyes, paints and other industrial exposure.

Aniline and benzene based dyes, Most bladderAniline and benzene based dyes, Most bladder

carcinogens are aromatic amines.carcinogens are aromatic amines.

Chronic irritation (chronic cystitis), more withChronic irritation (chronic cystitis), more with

squamous and adeno.squamous and adeno. el!ic irradiationel!ic irradiation

7/23/2019 37- Hematuria & RCC (1)


;;. Ris! factors. Ris! factors

p53 p53 "he p#$ gene is the most %requently"he p#$ gene is the most %requently

altered gene in human cancers .altered gene in human cancers .

&uman 'ncogene, or inacti!ation o%&uman 'ncogene, or inacti!ation o%

suppressor gene.suppressor gene.

Di%%erent genes are lined to di%%erent "CCDi%%erent genes are lined to di%%erent "CC

grades .grades .

atients treated with cyclophosphamide ha!e up to aatients treated with cyclophosphamide ha!e up to a

nine%old increased ris o% de!eloping bladder cancernine%old increased ris o% de!eloping bladder cancer

7/23/2019 37- Hematuria & RCC (1)


$resentation$resentation

Hematuria <6= .Hematuria <6= .

+rritati'e >1T.+rritati'e >1T.

Distant metsDistant mets

7/23/2019 37- Hematuria & RCC (1)


/or! up/or! up

That of the presentation.That of the presentation.

+mportance of ctolog 3flo) ctometr5.+mportance of ctolog 3flo) ctometr5.

/or! up of Hematuria should be directed/or! up of Hematuria should be directedto rule out 1rological malignanc not TCC.to rule out 1rological malignanc not TCC.

Again cstoscop ? retrograde Again cstoscop ? retrograde

pelographpelograph

7/23/2019 37- Hematuria & RCC (1)


(rading and taging(rading and taging

trong correlation bet)een tumor gradetrong correlation bet)een tumor grade

and stage.and stage.

(rade from @- , onl grade is(rade from @- , onl grade is

considered high grade and is b itself aconsidered high grade and is b itself a

poor prognostic factor.poor prognostic factor.

7/23/2019 37- Hematuria & RCC (1)


The concept of field change effect.The concept of field change effect.

$attern of spread.$attern of spread.

7/23/2019 37- Hematuria & RCC (1)


Batural HistorBatural Histor

(rade and stage related.(rade and stage related.

Different modalities of spreading.Different modalities of spreading.

+ndependent prognostic factors.+ndependent prognostic factors.

7/23/2019 37- Hematuria & RCC (1)


7/23/2019 37- Hematuria & RCC (1)


Treatment optionsTreatment options

Dri'en b tage , (rade and mode ofDri'en b tage , (rade and mode of

recurrence.recurrence.

All prognostic factors are considered All prognostic factors are considered

independent.independent.

7/23/2019 37- Hematuria & RCC (1)


+ntra'esical Chemotherap+ntra'esical Chemotherap

+ndications*+ndications*

>arge tumour size ,rapid and freuent>arge tumour size ,rapid and freuentrecurrences, multicentricit, presence ofrecurrences, multicentricit, presence of

Cis,Cis, Common Agents* 8C(,Metamcin C,Common Agents* 8C(,Metamcin C,

Adriamcin,thiotepa,;. Adriamcin,thiotepa,;.

8C( is the most commonl used8C( is the most commonl used,cheapest and has best results regarding,cheapest and has best results regardingrecurrence rate.recurrence rate.

7/23/2019 37- Hematuria & RCC (1)


+nra'esical Chemotherap+nra'esical Chemotherap

Does not affect progression.Does not affect progression.

%ailure of +4 chemotherap denotes bad%ailure of +4 chemotherap denotes badprognosis.prognosis.

Contraindicated in* immunosupression ,Contraindicated in* immunosupression ,Hematuria or acti'e 1T+, Acti'e T8Hematuria or acti'e 1T+, Acti'e T8

7/23/2019 37- Hematuria & RCC (1)


T1R8T.T1R8T.

T1R8T +ntra'esical chemotherap.T1R8T +ntra'esical chemotherap.

$artial cstectom 3Onl in selected$artial cstectom 3Onl in selectedpatients5.patients5.

Radical cstectom ? neo or adu'antRadical cstectom ? neo or adu'ant

Chemotherap.Chemotherap.

Chemo-Radio combinationChemo-Radio combination

7/23/2019 37- Hematuria & RCC (1)


Radical CstectomRadical Cstectom

+n males * Resection of the bladder,+n males * Resection of the bladder,

prostate, seminal 'esicle, and the urethraprostate, seminal 'esicle, and the urethra

3in selected cases53in selected cases5

+n females * Resection of the 8ladder,+n females * Resection of the 8ladder,

Anterior 'agina, uterus and cer'i&, Anterior 'agina, uterus and cer'i&,

fallopian tube, o'aries and the urethra.fallopian tube, o'aries and the urethra.

+n both this is follo)ed b e&tended pel'ic+n both this is follo)ed b e&tended pel'ic

lmph node disection.lmph node disection.

7/23/2019 37- Hematuria & RCC (1)


7/23/2019 37- Hematuria & RCC (1)


/hate'er )e do TCC has high recurrence/hate'er )e do TCC has high recurrence

rate * 67= , 3 <7= of recurrences arerate * 67= , 3 <7= of recurrences are

distant and E7= are local5distant and E7= are local5

Our onl chance in )inning this )ar is bOur onl chance in )inning this )ar is b

diagnosing the disease in an earl stage .diagnosing the disease in an earl stage .

7/23/2019 37- Hematuria & RCC (1)


Remember Remember

+t all starts )ith+t all starts )ithHematuriaHematuria

37- Hematuria & RCC (1)

Documents

Transcript of 37- Hematuria & RCC (1)