B/4. Superficial bladder cancer B/5. Muscle-invasive bladder cancer Flashcards
Transitional cell tumors (urothelial carcinoma) include
- bladder cancer (90%)
- renal pelvis tumor (8%)
- ureter or urethra tumor (2%).
Epidemiology of bladder cancer
- 2nd most common urological malignancy in males
- Male to female ratio 4:1
- Median age of diagnosis 65 years
2nd most common urological emergency malignancy in males
bladder cancer
bladder cancer
median age of diagnosis, gender ratio
Male to female ratio 4:1
Median age of diagnosis 65 years
Risk factors of bladder cancer
- Smoking ( increased risk by 2-3x)
- Aromatic amines (aniline dyes)
- Radiation exposure
- Phenacetin exposure
- Chronic cyclophosphamide exposure
- Chronic cystitis
- Schistosoma haematobium parasitic infection (endemic in some middle-east countries); associated with squamous cell carcinoma
which infection is a risk factor for developing bladder cancer
- Schistosoma haematobium parasitic infection
(endemic in some middle-east countries); associated with squamous cell carcinoma
Schistosoma haematobium parasitic infection associated with which type of carcinoma
squamous cell carcinoma
Clinical findings of bladder cancer
- Painless hematuria (macroscopic > microscopic)
- Irritative symptoms (urgency, frequency, dysuria)
- Recurrent UTI
- *Symptoms of metastatic disease are rarely the first presenting sign
Histopathological classification, pathology of bladder cancer
- Transitional cell cancer >75%:
*papillary tumor
*carcinoma in situ (CIS)
*solid tumor - Squamous cell carcinoma 3%
- Adenocarcinoma 2%
Transitional cell cancer of bladder types
- Papillary tumor: tend to bleed, usually low-grade, high recurrence
rates - Carcinoma in-situ (CIS) : usually high-grade???
- Solid tumor: invasive, poor prognosis
> 75%
bladder Squamous cell
carcinoma
pathology
3%
- chronic irritation of bladder > squamous metaplasia > dysplasia > carcinoma
- Common in regions with high prevalence of Schistosoma haematobium
infection
Adenocarcinoma of bladder
2%
Develop:
- urachal remnant in the dome of the bladder ( primarily )
or - periurethral tissues
mutations in Low-grade, non-invasive bladder tumors
- ras mutation
- FGF-R3 mutation
High-grade, invasive bladder tumors mutations
- p53
- RB mutation
Grading of bladder cancer ( new approach)
- PUNLMP (papillary urinary neoplasm of low malignant potential)
- Low-grade
- High-grade
Grading of bladder cancer ( old approach)
- Grade 1 : well-differentiated
- Grade 2: moderately differenciated
- grade 3 poorly differenciated
Diagnostics of bladder cancer
- Once hematuria is documented: urinary cytology and cystoscopy are indicated
- endoscopic evaluation (rigid/flexible endoscope) includes an examination under local anesthesia to determine whether a palpable mass is present.
- All visible tumors should be resected, and a sample of the muscle underlying the tumor should be obtained to assess the depth of invasion.
- Normal-appearing areas are biopsied randomly to ensure no CIS is present
- CT or MRI are indicated if histopathologic analysis of resected sample is positive for muscle-invasive growth.
- US may also be used during evaluation, including doppler assessment for tumor vascularization. Consider as initial evaluation (before cystoscopy) if obstructive symptoms are present. *Bladder masses are seen only when the bladder is full.
what is indicated once hematuria is documented in bladder cancer
Once hematuria is documented,
urinary cytology and bladder cystoscopy are indicated
US is Considered as initial evaluation (before cystoscopy) if
obstructive symptoms are present.
masses only visualized if bladder if full!!!
when is CT or MRI indicated in bladder cancer
CT or MRI are indicated if histopathologic analysis of resected sample is positive for muscle-invasive growth.
Required to assess the level of invasion, and evaluate for local/distant spread
Visual inspection of bladder cancer includes
mapping the location, size, and number of lesions; as well as description of
the growth pattern (solid vs. papillary).
Visualization of the upper urinary tract is indicated in all cases (even if bladder cystoscopy is negative) WHY??
since urothelial tumors may be multifocal with one or more lesions anywhere from the renal pelvis to the proximal urethra
since urothelial tumors may be multifocal with one or more lesions anywhere from the renal pelvis to the proximal urethra
What should be done in all cases?
Visualization of the upper urinary tract is indicated in all cases (even if bladder cystoscopy is negative)
staging of bladder cancer - TX, T0
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
staging of bladder cancer Tis, Ta
Tis -Urothelial carcinoma in-situ: “Flat tumor
Ta -Noninvasive papillary carcinoma
STAGING bladder cancer T1-T3
T1 Tumor invades lamina propria (subepithelial connective tissue)
T2 Tumor invades muscularis propria
T3 Tumor invades peri-vesical soft tissue (microscopically or macroscopically)
staging of bladder cancer - T4
T4 Extravesical tumor directly invades any of the following:
prostatic stroma,
seminal vesicles,
uterus, vagina,
pelvic wall, abdominal wall
which LN are involved in bladder cancer
- True pelvic nodes : (Peri-vesical, obturator, internal and external iliac, sacral),
- common iliac nodes
where does bladder cancer metastasize
LN
bone
lung
liver
peritoneum
treatment of bladder cancer depends on
Management depends on whether the tumor invades muscle and whether it has spread to the regional lymph nodes and beyond.
The probability of spread increases with increasing T stage
Non-muscle
invasive disease
(Ta, T1, Tis) treatment
Complete endoscopic resection +/- intravesical therapy
- Endoscopic resection:
*TURBT = transurethral resection of bladder tumor
*Reoccurrence rate up to 50% - Intravesical therapy
*Adjuvant for endoscopic resection
*Alternatively, may be used to eliminate disease that cannot be controlled by endoscopic resection alone (diffuse CIS, recurrent disease, > 40% involvement of the bladder surface by tumor)
*Mitomycin-C and/or Epirubicin are used as adjuvant. Side effects include dysuria and urinary frequency
*BCG (Bacillus Calmette-Guerin) is used for CIS, 6 weekly instillations. Rarely, may
cause systemic illness associated with granulomatous infection.
what may be used to eliminate disease that cannot be controlled by endoscopic resection alone
Intravesical therapy may be used to eliminate disease that cannot be controlled by
endoscopic resection alone
* diffuse CIS,
* recurrent disease,
* > 40% involvement of the bladder surface by tumor)
Following the endoscopic resection of bladder cancer, patients are monitored for?
how long
what is used
reoccurrence at 3-month interval for the first 2 years (cystoscopy + US).
Reoccurrence may occur anywhere along the urothelial tract.
Muscle-invasive bladder cancer
disease treatment
- Radical cystectomy +/- adjuvant chemotherapy +/- neoadjuvant chemotherapy
- Partial cystectomy may be considered when disease is confined to the dome of the bladder, > 2 cm clean margin can be achieved, and no evidence of CIS.
- Urine deviation: Ileal conduit (Bricker operation), Orthotopic bladder
Radical cystectomy male
removal of
* Bladder
* prostate
* seminal vesicles
* pelvic LN
Radical cystectomy females
removal of
* bladder
* urethra
* uterus, fallopian tubes, ovaries
* upper vagina
* pelvic LN
when is Partial cystectomy considered in muscle invasive bladder cancer
- when disease is confined to the dome of the bladder,
- > 2 cm clean margin can be achieved,
- and no evidence of CIS
Urine deviation in muslce invasive bladder cancer
- Ileal conduit (Bricker operation) : use ileum to create connection with stoma on the skin, cutaneous resevoir, no continent
- Orthotopic bladder: ‘neo-bladder’, provides continent; efficacy is questionable
Metastatic bladder cancer
disease treatment
Chemotherapy +/- radiotherapy
Palliative approach
- GC protocol = Gemcitabine, Cisplatin
- MVAC protocol = Methotrexate, Vinblastine, Adriamycin (= Doxorubicin), Cisplatin
