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(same organ but 2 different tumours)

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All the photos are from the urogenital tract
Think of a first name for your patient - choose names that are gender and age specific eg Rose is normally a woman in her 70's, Nigel is a man in his 60's, Harry is a man in his 20/30's
What pathology does the picture show?
Think how they would present to their GP - what are their symptoms not just their signs.
We will discuss treatment and prognosis but there are golden rules for this.....

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Hint - look at scale

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Blue probe in urethra. Tubes on top are vas deferens with adjacent seminal vesicles.

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1. A tube can be blocked by something in its lumen, something in the wall, something outside its wall
2. Treatment/Prognosis is related to the Stage and Grade of the tumour as well as the type of tumour/site
3. Acute damage will retain the shape and size of an organ - chronic damage will cause scarring.
4. Patients can always present with metastatic disease eg back pain due to a met to the back from a prostate cancer
5. Look at the Scale if ones present
6. For inherited conditions then autosomal recessive diseases tend to cause death before adulthood, whereas autosomal dominant conditions can reach adulthood.

FOR MORE INFO on Histopathology and other tumours:
www.jonoxley.com

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Chloe

Age: 5
Organ: Kidney
This is a small kidney as its a childs
Pathology
Wilms tumour (nephroblastoma).
Comprised of very immature cells.
Presentation
GOLDEN RULE 4
Failure to thrive
Abdominal mass
Treatment
Chemotherapy and excision
Prognosis
Excellent but beware secondary tumours in adult life.

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Mildred
Age: 65
Organ: Kidney
Pathology: There is a large tumour in the upper pole of the kidney - it is yellow with haemorrhagic areas.
It is RENAL CELL CARCINOMA - the commonest type is CLEAR CELL CARCINOMA - the histology shows "Clear cells" - as the fat in the cytoplasm has dissolved out during the processing of the tissue.
Presentation:
GOLDEN RULE 4 - you can present with mets - common site is the lung - where you get a classical chest Xray - CANNONBALL METS. Can present with brain mets as well.
Local disease can cause haematuria, loin(flank) pain.
Often NO SYMPTOMS and it is incidental finding when investigated for other symptoms eg gallstones.
Treatment
Treatment is really dependent on STAGE and patient condition. Renal cell carcinoma can grow into the vena cava and up into the heart but will still be resectable. When there are mets there is evidence that removing the main tumour can cause these to shrink but if the volume of mets is greater than primary then this is not done.
Surgery is normally laproscopic unless tumour is massive (>15cm). Partial nephrectomy for tumours up to 5cm is possible.
Chemotherapy with novel agents (Sunitanab etc) has improved prognosis of metastatic RCC.
Prognosis
GOLDEN RULE 2 - depends on stage and grade.
RCC can recur many years after primary excised.

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Norman
Age: 80
Organ
Kidney
Pathology
Hydronephrosis.
The collecting system is dilated - it is scarred so this is a CHRONIC process (c/w Patient 1). The cystic change is not in the kidney parenchyma (c/w Patient 4).
Caused by increased pressure in collecting system - blocking the ureter - GOLDEN RULE 1
In the lumen = stone
In the wall = tumour
Outside the wall = tumour or scar tissue - the ureters pass close to the cervix so cervical tumours or treated tumours can cause problems.
Benign prostate disease can cause back pressure in the bladder and eventually this refluxes up the ureter.
Presentation
Norman had 2 kidneys - so it took a while as his other kidney compensated but eventually he presented with renal failure (itch, fatigue) and haematuria.
But could have got infected as stasis of urine - so sepsis and pain.
Treatment
Renal replacement therapy.
If repeated sepsis then can remove.
Prognosis
Depends on other kidney.
Renal transplant etc.

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George
Age: 65
Organ: Kidney - opended up down middle
Pathology: The upper pole of the kidney appears pale beacuse it has been starved of blood - and has died - infarcted. Note the normal outline of the kidney - so this is an acute infarct (chronic ischaemia would cause it to shrink due to scarring).
Infarcts due to BLOCKAGE of artery - SEE GOLDEN RULE 1 -
lumen = embolism
wall = atheroma
outside = tumour pushing onto vessel
This case is embolic - causes - atrial fibrillation, infective endocarditis BUT NOT DVT as this would go to lungs (unless they have patent foramen ovale in heart)
Presentation:
George presented with signs of embolic disease (splinter haemorrhages in finger nails, stroke) He died unfortunately - this is a PM picture - the shiny thing at top of picture is the IVC opened up.
Treatment: Treatment of renal infarcts is supportive - as you have 2 kidneys normally - but it is normally part of a widespread systemic disease - so it depends on this.
Prognosis: Depends on what else is going on.....

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Slice through the prostate - central hole is urethra. Orange ink is anterior - tumour nodule on posterior aspect.

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Margeret
Age 71
Organ
Bladder with attached uterus(with fibroid)
Pathology
Massive tumour in the dome of the bladder.
Commonest tumour in bladder in UK is UROTHELIAL CARCINOMA (Transitional cell carcinoma). Risk factors include smoking and Azo dyes (also hair dyes).
In Egypt more common to have SQUAMOUS CELL CARCINOMA (SCC) as they have Schistosomiasis - which is a parasite that infects the bladder and causes chronic irritation - squamous metaplasia - squamous dysplasia and then carcinoma.
In the UK SCC tends to be in women as they are more likely to have UTIs.
Presentation
GOLDEN RULE 4 - tends to go to lungs and bones
Local disease - haematuria, pain
Treatment
Metastatic urothelial carcinoma - chemotherapy but very poor prognosis.
Localised low grade tumours can be resected - burnt or scraped off the bladder endoscopically.
For higher grade non-muscle invasive tumours then BCG therapy
or other intravesical chemo agents.
When muscle invasive then surgery or radiotherapy.
Removing the bladder and forming an ileal conduit (ureters are plumbed into length of small bowel which has been disconnected from rest of bowel)
Prognosis
Depends on Stage and Grade - low grade non invasive tumours can be traeted endoscopically for years and never progress.

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Harry
Age 25
Organ Testis
Pathology
Germ cell tumours are the commonest tumours in the testis. The two basic types are TERATOMA and SEMINOMA.
Teratoma - "monster" the top picture shows a tumour with cysts and solid areas - in ovaries teratomas can show hair and teeth - in men the tumours tend to be less mature (what a surprise!) - so there are primative glands and cysts and very immature elements called embryonal carcinoma - and rarely choriocarcinoma (which is like malignant placental tissue - so men can have positive pregannacy tests!)
The bottom tumour is a SEMINOMA and it has a "cut potato" appearance as it is a single cell type.
Presentation
GOLDEN RULE 4 - the drainage of the lymphatics is to the paraaortic nodes - as thats where testes develop (NOT Inguinal nodes). Goes to lungs and brain etc.
Local symptoms of pain and swelling
Treatment
Depends on Stage and tumour type.
If localised then remove testis via the groin - keeping the coverings intact to stop spreading tumour.
If mets then very chemo / radio sensitive.
Prognosis
RULE 2 - but even metastatic disease has excellent prognosis - though not guarenteed to win tour de france 7 times (see Lance Armstrong)

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Core of prostate tissue with tumour

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Fred
Age: 45
Organ Kidney
Pathology Polycystic kidney disease.
Note the cysts are in the tissue (parenchyma) of the kidney. The scale shows these are massive - 30cms - your kidney is roughly the size of your hand - so the bigger your hand the bigger your kidney (see patient 8).
Presentation
As this affects BOTH kidneys they will present with renal failure - though the age of presentation does vary. Renal failure symptoms related to ureamia and anaemia - itch fatigue
Treatment
Supportive therapy - renal transplant - often the polcytic kidney is removed to allow room for transplant kidney - (which are put in iliac fossa)
Prognosis
Depends if a transplant can be found.
They can also have BERRY ANEURYSMS - so can have subarachnoid haemorrhages.
AUTOSOMAL DOMINANT - (the recessive variant is fatal at birth)

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Steve
Age 61
Organ
Prostate
Pathology
Prostatic adenocarcinoma
Presentation
RULE 4 - Classically CaP goes to the bone causing SCLEROTIC METS - most tumours cause LYTIC mets (these show up as holes in bone at Xray) but in CaP the mets are denser than bone.
Localised disease can cause very little symptoms and most symptoms can be from co-existant benign disease - benign disease is around the URETHRA and causes blockage of urethra (leading to lower urinary symptoms - retention, poor flow, frequency etc).
Another presentation is "Daily Mail" syndrome - some papers push PSA (prostate specific antigen) tests - so a celebrity gets CaP and says they wish they had had a PSA test and why dont we offer screening etc etc.
PSA test is not very accurate for prostate cancer - as its raised in infection, benign hyperplasia and after palpation of prostate - it was first used to monitor patients after treatment - its good for this as after treatment it should go to 0 so any raise is recurrence.
Steve - our patient - went to his GP and asked for a PSA test - it was raised at 9ng/ml-  so referred to urologist - nowadays Steve got an MRI scan - which showed a tumour (the radiologists grade this on a scale of 1 to 5 (PIRADS) - 5 has a very high risk of tumour.
The next stage is to biopsy the prostate - this used to be via rectal ultrasound guided biopsy - long needles - but risk of sepsis - as faeces injected into prostate...
Moving to transperineal biopsy - through skin between scrotum and anus.
The middle picture shows a core biopsy - these are about 12mm long and 0.5mm wide. The picture shows prostatic adenocarcinoma - these are graded using a Gleason Score - (expressed as two numbers eg 3+4=7) the total ranges from 6 to 10 - 10 is BAD.
Treatment
Depends of the Grade and Stage and co-morbidities.
Surgery carries morbidity - incontinence and impotence.
Many men die WITH and NOT FROM prostate cancer.

Lower grade and stage disease can be watched - ACTIVE MONITORING - using combinaton of PSA value and MRI with repeat biopsies
RADICAL PROSTATECTOMY - for fit men up to about 73 - localised disease can be removed - use a ROBOT now to do this (NBT performs nearly 300 per year).
RADIOTHERAPY with HORMONES - some patients are not fit for surgery or prefer RT - can be used for locally advanced.
HORMONES - for metastatic disease or unfit - CaP is very sensitive to hormones - as androgen receptors.
Prognosis
RULE 2
Even with metastatic disease tend to be hormone sensitive so on average 2 year survival - which is much better than other organ tumours.
Loaclised tumours that are removed have excellent prognosis and recurrences can be treated with hormones.