一、 History:
1. Family history of cancer.
2. Local symptoms; Hematuria, dysuria, frequency.
3. Other symptoms: Flank pain, bone pain, sciatica, peripheral edema, weight loss.
4. Carefully record nature and date and pathology finding relative to all previous treatments.
二、 Past and social history:
1. Occupation related Carcinogen exposure, time, durations.
2. Smoking habit: Amount and duration.
3. Faimily factors: Parents occuption, or special prefer food intake.
4. Analgesico or herb drugs medication (Dose and duration) 三、 Physical examination:
Palpation of neck, abdomen, groins, urethra and pelvic examination (rectal in males;
rectal and pelvic examination in females.) 四、 Special laboratory studies:
Urine cytology, initially and immediately post treatment and at appropriate intervals during follow up.
五、 Tumor spreading:
1. Regional Lymph Nodes. The regional lymph nodes are the nodes of the true pelvis, which essentially are the pelvic nodes below the bifurcation of the common iliac arteries.
The significance of regional lymph node metastasis in stasins bladder cancer lies in the number and size and not in whether metastasis is unilateral or contralateral.
Regional nodes include:
Hypogastric Obturator
Iliac (internal, external, NOS) Perivesical
Pelvic, NOS
Sacral (lateral, sacral promontory [Gerota's]) Presacral
The common iliac nodes are considered sites of distant metastasis and should be coded as Ml.
2. Metastatic Sites. Distant spread to lymph nodes, lung, bone, and liver is most common.
六、 Clinical Staging:
Primary tumor assessment includes bimanual examination under anesthesia before and after endoscopic surgery (biopsy or transurethral resection) and histologic verification of the presence or absence of tumor when indicated. Bimanual examination following endoscopic surgery is an indicator of clinical stage. The
finding of bladder wall thickening, a mobile mass, or a fixed mass suggests the presence ofT3a, T3b, and T4b disease, respectively. Add "m" for multiple tumors.
Add "is" to anv T to indicate associated carcinoma in situ.
Appropriate imaging techniques for lymph node evaluation should be used. When indicated, evaluation for distant metastases includes imaging of the chest, biochemical studies, and isotopic studies to detect common metastatic sites.
Computed tomography or other modalities may subsequently be used to supply information concerning minimal requirements for staging. The primary tumor may be superficial or invasive and can be partially or totally resected with sufficient tissue from the tumor base for evaluation of full depth of tumor invasion. Visually adjacent cystoscopically normal mucosa should be considered for biopsy; urinary cytology and pyelography are important.
七、 Pathologic Staging:
Microscopic examination and confirmation of extent is required. Total cystectomy and lymph node dissection generally are required for this staging. Laterality does not affect the N classification.
DEFINITION OF TNM 1. Primary Tumor (T)
TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ: "flat tumor"
Tl Tumor invades subepithelial connective tissue T2 Tumor invades muscle
T2a Tumor invades superficial muscle (inner half) T2b Tumor invades deep muscle (outer half) T3 Tumor invades perivesical tissue
T3a microscopically
T3b macroscopically (extravesical mass)
T4 Tumor invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall
T4a Tumor invades prostate, uterus, vagina T4b Tumor invades pelvic wall, abdominal wall 2. Regional Lymph Nodes (N)
Regional lymph nodes are those within the true pelvis; all others are distant lymph nodes. NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single lymph node, 2 cm or less in greatest dimension N2 Metastasis in a single lymph node, more than 2 cm but not more than 5 cm
in greatest dimension; or multiple lymph nodes, none more than 5 cm in greatest dimension
N3 Metastasis in a lymph node more than 5 cm in greatest dimension Distant Metastasis (M)
MX Distant metastasis cannot be assessed M0 No distant metastasis
3. STAGE GROUPING
Stage 0a Ta N0 M0 Stage 0is Tis N0 M0 Stage I Tl N0 M0 Stage II T2a N0 M0
T2b N0 M0 Stage III T3a N0 M0
T3b N0 M0 T4a N0 M0 Stage IV T4b N0 M0
AnyT N1 M0 Any T N2 M0 Any T N3 M0 Any T Any N M1 八、 HISTOPATHOLOGIC TYPE
The histologic types are:
Transitional cell carcinoma (urothelial) In situ
Papillary Flat
With squamous metaplasia With glandular metaplasia
With squamous and glandular metaplasia Squamous cell carcinoma
Adenocarcinoma Undifferentiated carcinoma
The predominant cancer is transitional cell carcinoma.
九、 HISTOPATHOLOGIC GRADE (G) GX Grade cannot be assessed G1 Well differentiated G2 Moderately differentiated
G3-4 Poorly differentiated or undifferentiated 十、 X-ray and scans:
1. I.V.P.
2. Staging procedures.
CT Scan of abdomen &
pelvis Liver & bone scan.
十一、 Every patients subjected to bimanual examination
Endoscopic procedure under general anesthesia. TURBt for resectable lesion with deep cut (to musule) biopsies. Complete bladder diagram include representation of the size and extent of the tumors, and operator's impression of clinical stage.
十二、 Treatment.
1. Benign papilloma/low stage, low grade carcinoma:
TUR. and/or fulguration. Follow up cystoscopy 6 months intervals for two years, thereafter one year intervals.
In-travesical therapy for multiple, or recurrent low stage &; low grade tumor
following TUR.
2. In situ carcinoma:
Focal: TUR
Diffuse: Intravesicle BCG or chemotherapy (MMC or Doxorubicin). Follow up cystoscopy and cytology at 2-3 months interval. Cystourethrectomy for patients failing conservative treatment.
3. Low stage, high grade carcinoma.
TUR. with Intravesical BCG therapy and close follow up.
Consider repeat TUR staging following BCG immunotherapy in selected case.
Radical cystectomy preceded or recurrent or advanced cases.
4. High stage carcinoma:
a. Segmental resection or radical cystectomy with ilial conduit or continent ilial bladder.
b. Adjuvant MEC chemotherapy for high risk patients.
十三、 Follow up:
1. For patients with superfical TCC of bladder who have had T.U.R.B.
Cystoscopy and cytology every 3 months for first 2 years thereafter every 6 months.
2. In patients who have had cystectomy:
Arranged IVP before dischange or within one month after surgery.
Follow up visits are scheduled every 3 months for 3 years and at 6 months interval thereafter. Urine cytology at each vist.
Examination include neek, abdomen, pelvis, perineum and stoma (periodic check of residual urine)
Careful palpation of urethra with cytologic studies ofurthral washing every 6 months.
I.V.P. every year for 3 years and every 2 years thereafter
I.V.P. every year for 3 years and every 2 years thereafter
BUN, creatinine, electrolyte and chest x-ray every 6 months.
Abdominal CT scan.
十四、 Pre-operative preparation for radical cystectomy:
1. Chest physiotherapy instruction.
2. Preoperative electrolyte & fluid supplements.
3. Mark the Suitable site for stoma.
4. Urine culture & sensitivity test.
5. Complete date (CBC, coagulation profile/chest, EKG.) 6. Bowel Preparation:
Low residual diet for 2 days.
Citrate of magnesia 240ml (or caster oil 30ml) 2 days preop.
Clear fluids for 48hr preop.
Enema until clear night before surgery.
Neormycin 1.0 gm p.o. at 12N, 2:00 pm, 6:00 pm 10:00 pm on day prior to surgery.
十五、 Post-operative care:
1. Antibiotics pre-op. and immediately post-op.
No antibiotics without specific indication.
3. Early ambulation.
4. Periodic electrolyte CBC, BUN.
5. Heal conduit are intubated with 26 F catheter at least until small bowel peristalsis return.
6. In patients with ureteral stent placed is generally removed at day 10 and the remaining stent one day later.
7. In patients having cutaneous ureterostomies, the ureteral catheter should be kept securely in place until such time as either primary skin to mucosa healing, or slough with secondly organization of tract has occurred.
腎盂及輸尿管癌 (Carcinoma of the renal pelvis and/or ureter)
一、History:
1. Family history of cancer.
2. Local symptoms: Gross hematuria, flank pain, mass.
3. Systemic symptoms: weight loss, weakness, fever back pain.
4. G-I symptoms: Anorexia nausea, vomiting.
二、 Past history:
1. Past history of bladder tumor.
2. Renal calculus, disease, prior hematuria or prior surgery.
3. If the patient has already been treated elsewhere then include the details of prior surgery, radiation or chemotherapy.
三、 Social history:
History of exposure to known carcinogens; smoking habits, analgesics and herb drug.
四、 Laboratory Studies:
Urine cytology. Renal function test, ERPF 五、 Diagnostic X-ray:
1. I.V.P.
2. Retrograde pyelograms.
3. CT Scan of abdomen when indicated for staging work up.
六、 Possible spreading:
1. Regional Lymph Nodes. The regional lymph nodes are:
For Renal Pelvis:
Renal hilar Paracaval Aortic
Retroperitoneal For Ureter:
Renal hilar
Iliac (common, internal [hypogastric], external) Paracaval
Peri-ureteral Pelvic, .KgS
Any amount of regional lymph node metastasis is a poor prognostic finding and outcome is minimally influenced by the number, size, or location of the regional nodes which are involved.
2. Metastatic Sites. Distant spread to lung, bone, or liver is most common.
七、 Staging:
Clinical Stagins. Primary turmor assessment includes radiographic imaging, usually by intravenous and/or retrograde pyelography. Computerized tomography
is desirable and tissue biopsy through the ureterocope may be performed if feasible.
Urine cytology may help determine tumor grade if tissue is not available. Staging of tumors of the renal pelvis and ureter is not influenced by the presence of any concomitant bladder tumors which may be identified.
八、 Pathologic Staging.
Pathologic staging depends upon histologic determination of the extent of invasion by the primary tumor. Treatment frequently requires resection of the entire kidney, ureter, and a cuff of bladder surrounding the ureteral orifice.
Appropriate regional nodes may be sampled. A more conservative surgical resection may be performed, especially with distal ureteral tumors or in the presence of compromised renal function.
Endoscopic resection through a ureteroscope or a percutaneous approach may be used in some circumstances. Submitted tissue may be insufficient for accurate histologic examination and pathologic staging. Laser or electrocautery coagulation or vaporization of the tumor may be performed, especially if the visible appearance is consistent with a low grade and low stage tumor. Under these circumstances, there may be no material available for histologic review.