Methodological Instructions for Students icon

Methodological Instructions for Students

Скачати 28.58 Kb.
НазваMethodological Instructions for Students
Розмір28.58 Kb.

Methodological Instructions for Students

Theme: Tumors of the kidneys and ureter.

Aim: Teach students how to diagnose tumors of the kidney and ureter. Principles of treatment and pathology of this disease.

Professional Motivation:

Tumors of the kidneys are noted in majors 2-3% out of all tumors. Men suffers 2 times more than woman. Cancer is noted 80-90 %. Out of all kinds of tumors in the kidney's tumors of urinary tract are noted up to 1%.

Basic Level:

1. Anatomy and physiology of the kidneys and ureter.

2. Collect anamnesis, carry out physical examination.

3. Etiology and pathogenesis of the tumors kidneys and ureter.

4. X-ray, functional, instrumental, laboratory, endoscopial, morphological methods of investigation used to diagnose tumors of the kidneys.

5. Principles of treatment of tumors of the kidneys and ureter.

Student's Independent Study Program

I. Objectives for Students' Independent Studies

You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:

  1. Etiology and pathogenesis of the tumors kidneys and ureter.

In the kidney tumour genesis it is led to the role of hormone violations, influencing an ionizing radiation and chemical matters and lacks of development. Some authors abide by the viral theory of origin of new formations of kidney. In origin of kidney tumour the smoking assists. A prognosis and tactic of medical treatment at tumours is built on the basis of results of morphological and histological researches of remote neu formation. About 90 % malignant tumours of kidney make a cancer. The kidney cancer makes 5-6 % of all urology diseases and 2-3 % of neu formations. It arises up mainly in age 40-70 years, at men – in the 2,5-3 times more frequent. It develops from epithelium of different departments of nefron and collective tubes: ball capsule epithelium, kidney tubulla (descending part of loop of nefron, distal part of tubulla loop of nefron). Actually lightcellular, alveolar, grainycellular (darkcellular), polymorphic.

  1. Classification of the kidney's tumors.

They classify the tumours by system of TNM:
Т – a primary tumour;
Тх – it’s impossible to set a presence and tumour diffusion degree. This category can be used for histological or citological confirmed metastases in the region lymphatic knots or remote organs;
Т0 – there are the signs of primary tumour. This category is applied in that cases and Тх;
Т1 – a tumor is 7 cm, thin bounds of kidney. They set from the datas of roentgenologic and radionuclid research;
T2 – a tumor by size over 7 cm within bounds of kidney; palpated, mobile. The clinic-roentgenologic data testifies to the tumour presence;
T3 – a tumor by size over 7 cm outside kidney fascia; palpated, mobile;
Т4 – the tumour spreads outside fat renalis and others organs;
N – regional lymphatic nodes;
Nx – it is impossible to set the presence of metastases in the region of the lymphatic nodes.
There isn’t any deformation of lymphatic nodes region, after which it is possible to mark the presence of metastases;
N2 – there are metastases in the remote lymphatic nodes by size over 2 cm, but less than 5 cm;
Мз – there are metastases in the lymphatic nodes by size over 5 cm;
М – there are remotemetastases;
Мх – the defining of remote metastases is impossible
Мо – there are the signs of remote metastases;

In case of clinical supervision of sick with tumours of the kidney (and of peripheral organs of the urogenital system) and by the suspicion on the malignant new formation they can divide them in such groups:
I – with the diseases; II – with the malignant tumours, which is the subject of a special medical treatment; III – practically healthy patients in which a radical medical treatment is conducted; relapses of tumour and its metastases does not exist; By the IV-with neglected forms of malignant neu formations, which need a palliative or a symptomatic medical treatment.

  1. Pathological anatomy of the kidney's tumors.

They distinguish ferrous, papillari and solid-cellular forms of kidney cancer after the morphological structure. As the great number of various morphological forms of kidney cancer exists that’s why it is very difficult to clear up the nature of neu formation – a primary tumor or a metastasis.

The kidney sarcoma seldom exists, in 3,3 % cases. The source of its origin can be connecting tissue, kidney capsule, remains of muscles and kidney, wall of kidney vessels. The tumour’s consistency is soft (liposarcoma) or dense (fibrosarcoma); it is grey, grey-rouse or yellow on section.

  1. Tract of metastases of the kidney's tumors.

By the basic symptoms of the metastasis in bones there is a pain and a slight swelling above the defected place. The metastases in liver can be single and plural. Thus the function of organ can’t be violated. They mark a high temperature of body, weakness, hydrosis. Antyhotting facilities in this cases are uneffective. Kidney cancer metastases in lung are accompanied by the rise of body temperature, by cough with sputum, sometimes with the blood admixtures, by pain in side or after breastbone. A plural new formations appear. Sometimes the metastasis in lung has a type of solitarry (single) knot, that is not clinically shown for a long time. In such case it is possible to delete a metastatic tumour. The clinical displays of metastases in the central nervous system rely on localization of pathological cell.

  1. Symptoms and clinical findings of kidney's tumours.

The clinical picture of tumours of kidney is extraordinary various. In some cases tumours are not accompanied by the subjective feeling for a long time. A diagnosis is setting in case of inspection of patients concerning other disease, most frequently in the tie with appearance of metastases in lights, bones and others like that. However in majority of sicks in case of tumor appearance the general state of body gets worse as a result of intoxication by products of exchange in the tumular fabric. A sick mark a general weakness, rapid fatigue, decline or loss of appetite, he is becoming thin, it is a rising of body temperature (sometimes about 38-39С),chill, anemization.

In most cases of kidney tumour total haematuria (60-88 %) is shown. It appears suddenly or on the pain background in area of kidney. Sometimes after haematuria there is the typical attack of kidney colic which stops when the clots of blood in the ureter are passed out thorough urine. Haematuria exists at one-two urinations or a few hours proceed or days, and then it is suddenly halted. The next bleeding can appear in a few days, months and even years.

Haematuria due to kidney tumours often has a profuse nature, it can causes the tamponede urinary bladder and the sharp delay of urine. Then there is a pain after the value symptom of kidney tumour. It exists in 50 % sick, it can be dull and sharp, permanent and changed. A third symptom of kidney tumour is palpation of neu formation. It exists in 50-75% sick. The kidney tumour symptoms often haven’t urological nature, continue for few months, and sometimes years. It is inludes unknown rising of body temperature (20-30% sick), general weakness (20-40%), weight loss(20-30%), loss of appetite, nausea, vomiting (10-15 %), neuropatia, miozitis (4-6 %) and etc. About 30 % sicks enter to a permanent establishment with the undiagnosed tumour.

  1. Diagnose of the kidney's tumors.

Excretory urography helps to estimate a functional and anatomic state of kidney. Function of kidney, staggered by tumor, is satisfactory for a long time. The absence of selection by kidney of renthgenocontrastive matter (“mute” kidney) testifies the prevalence of tumular process or about infiltration by tumor of vessels of kidney leg. On excretoryl urogram expansion of contours of kidney is exposed on account of tumular knot, defect of the filling or pushing back a bowl and bowls, amputated or arched of bowls, deformation of cap-bowl system, displacement of overhead department of uterus to the middle line.

Nefrothomography gives a possibility to expose the surplus satiation by the rentgenocontrastive matter of tumor area. The tumor differs from the kidney cyst, in area of which contrasting expressed considerably less. Retrograde pielography is executed only after the strict testimonies, in the case of necessity to differentiate a kidney tumor with the papillary tumor of bowl and uterus. On retrograde pyelography deformation of bowls, amputation of bowls, compression and displacement of them, increase of corner between them are frequently exposed. These changes vary and can combine. Besides the excretory urography and retrograde pyelography conduct at haematuria and for the first days after it, so far as the blood clots in bowls or bowls can simulate a defect of the filling, conditioned by tumor. In such case kidney angiogram, kavography, scanning and scintigraphy of kidney, echography have a great value. Kidney angiography is done with aim of exposure of early forms of kidney tumors, by this method is conducted the differential diagnostics between tumor and kidney cyst, set the location of tumor in relation to the arterial vessels. A wide range of vascularisation malignant tumors is marked on angiogram: from expressed pathological to avascularisatia. Tumor vessels are sharply deformed, chaotically located, often arcuated or, opposite, straightened, have sinuosity or ampule expansion. Area of pathological vascularisation can be expressly marked off from surrounding parenchime or have signs of infiltration with diffusion of process for the fibre capsule of kidney.

  1. Differential diagnosis of the kidney's tumors.

Frequently it has to differentiate a kidney tumor with the solitary and cyst, polycistos, by the kidney carbuncle, by tuberculosis, by hydronefrose, by the urostones illness, paranefrut.

Kidney tumor that have solitary cyst have a row of general clinic-roentgenologic signs. At that rate important diagnostic value have data of x-ray photography computer thomography, kidney angiography, echography, punction cystography, hefrotomography.

For the polycystosis kidney character their chronic insufficiency, bilateral changes on pielograma as a promoted fork of bowls, clench and lengthening kidney bowls, and also presence on arteriograma much rounded areas and lengthened thin arteries.

  1. Nefroblastoma (Wilms` Tumor ).

Nephroblastoma, or Wilms` tumor, is a malignant mixed renal tumor that occurs predominantly in children but can in adolescents and adults. The median age of incidence is 2 years 11 months. Wilms` tumor is associated with congenital anomalies in 15% of patients. Wilms` tumor is believed to be at least in part congenital, as it is the only common tumor of mixed embryonic origin.

  1. Treatment of the kidney's tumors.

The low sensitity of kidney cancer to the radial therapy,so is apply the combined medical treatment. Conduct distance gamut-therapy after the intensive method from two meeting fields size 8х10 and 10х15 sm (depending on the tumor size). Hearth dose (POD)-5 Gr, total (SOD) – 20 Gr. Nefrectomia execute through 24-48 hours after the radial therapy.

If the tumor germinated in the kidney leg and the infiltration of leg and surrounding fabrics or metastases in the region lymphatic knots exist, appoint a postoperation radial therapy. SOD promote about 60 Gr. How independent method of medical treatment radial therapy possible only in the not operatioonisation cases. After the irradiation the tumour diminishes and becomes operation

  1. Symptoms tumors of the ureter.

The most common symptom is hematuria, wich occurs in 59-99% of patients and is usually intermittent and sometimes quite profuse. Flanc pain is observed in 20-50% of patients. Chronic obstruction from the enlarged ureteral tumor causes dull flanc pain, while passage of clots down the ureter causes acute and severe pain. Symptoms of bladder irritation ( frequency, urgency, dysuria) are reported in 10-52% of patients. The tumor is silent in 12-26 % of patients and is discovered on excretory urograms or endoscopic examination in patients with a history of bladder cancer.

  1. Diagnosis of tumors of the ureter.

The excretory urogram usually shows abnormal findings in all patients with carcinoma of the ureter. The 2 most common urographic findings are an intraluminal filling defect and hydronephrosis, with or without hydroureter. In over one-third of patients, the kidney on the affected side is nonfunctioning and fails to visualize. Angiography is of little value because of the avascular nature of most urotherial tumors.

Ultrasonography and CT Scanning: Not enough patients have been evaluated with either ultrasonography or CT scanning to allow adequate assessment of these procedures in helping to establish a diagnosis.

Instrumental examination: If the patient is actively bleeding, cystoscopy shoud be perfomed immediately in order to locate the source of the blood. At cystoscopy, the ureteral tumor is seen protruding trom the ureteral orifice in 6-18 % of patients. In these patients, biopsy confirms the diagnosis.

  1. Treatment of tumor of the ureter.

In the absence of demonstrable metastases, nephroureterectomy with resection of the periureteral bladder wall and adjacent vesical mucosa remains standard therapy. However, in patients with noninvasive low-grade tumors of the lower ureter, distal ureterectomy with reimplantation may be considered. Partial ureterectomy for lesions located elsewhere in the ureter (middle- or upper-third) carries with it a high risk of tumor developing later below the line of resection; therefore, local resection should be avoided.
  1. ^

    Tests and Assignments for Self-assessment

1. Which tumor of the kidney mostly we can feel by fingers?

A. Tumor of Williams.

B. Tumor of Graves.

C. Adenocarcinoma of the kidney.

D. Hypemephroma.

Answer: A

2. What is the main character of tumor of Williams?

A. Non-malignant.

B. Embrional adenocarcinoma of the kidney.

C. Metastasis of the kidney's tumor.

D. Angiosarcoma of the kidney.

E. Dermoid of the kidney.

Answer: В

3. Symptom «dead flower» characterize for:

A. Tumor of down pole.

B. Tumor of.

C. Tumor of the ureter.

D. Tumor of upper pole.

E. Tumor of pelvis cavity.

Answer: D

^ Real life situation to be solved:

1. Patient K., at the age of 54, complains of left side back pain in the region of the kidney,urine with blood since a week. Examination. of left side it is noted thick round structure 10*14 cm with out pain when it is touched.

A. What is the diagnosis?

B. What methods should be used to put a correct diagnosis?

Answer: Tumor of the left kidney. Patient should be done ultrasound screening.

Excretory urography.

2. Patient M., at the age of 62, in the examination of ultrasound screening in left kidney upper pole echogen 8*6 cm is noted. Through X-ray blood vessels are bulged. From his life history haematuria is noted 2 times in last year.

A. What is a diagnosis?

В. Extra examinations which should be done to the patient?

C. What is the tactics of treatment?

Answer: Tumor of left kidney. We should do excretory urography. Nephroectomy of left kidney.

Visual Aids and Material Tools:

1. Slides.

2. X-ray photographs. Excretory urography – tumors of parenchyma of kidneys. Retrograde ureteropyelography- tumor of the kidney, computer tomography.

3. Ultrasound screening.

Students' Practical Activities:

Students-must know:

1. Classification the kidney's tumors.

2. Pathanatomy of the kidney's tumors.

3. Pass of metastases of the kidney's tumors.

4. Symptoms and clinical findings of the kidney's tumors.

5. Diagnosis of the kidney's tumors.

6. Tactics of therapist and urologist at the case of haematuria.

7. Differential diagnosis of tumors of the kidney with hydronephrosis, polycystits, carbuncles.

8. Tumor of Williams.

9. Treatment of tumors of the kidney.

10. Symptoms of tumors of the ureter.

11. Diagnose tumors of the ureter.

12. Treatment tumors of the ureter.

Students should be able to:

1. Note main symptoms and symptoms of tumors of the urinary tract.

2. Motivate clinical diagnosis.

3. Know tactics of treatment of tumors of the kidneys and ureter.

4. Note and to point out analysis of blood and urine, ultrasound screening of kidneys, X-ray (excretory urography, retrograde pyelogram), computer tomography.


Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Додайте кнопку на своєму сайті:

База даних захищена авторським правом © 2000-2013
При копіюванні матеріалу обов'язкове зазначення активного посилання відкритою для індексації.
звернутися до адміністрації