B/4. Superficial bladder cancer B/5. Muscle-invasive bladder cancer Flashcards by M AAB

Transitional cell tumors (urothelial carcinoma) include

bladder cancer (90%)
renal pelvis tumor (8%)
ureter or urethra tumor (2%).

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Epidemiology of bladder cancer

2nd most common urological malignancy in males
Male to female ratio 4:1
Median age of diagnosis 65 years

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2nd most common urological emergency malignancy in males

bladder cancer

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bladder cancer
median age of diagnosis, gender ratio

Male to female ratio 4:1
Median age of diagnosis 65 years

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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

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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

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Schistosoma haematobium parasitic infection associated with which type of carcinoma

squamous cell carcinoma

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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

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Histopathological classification, pathology of bladder cancer

Transitional cell cancer >75%:
*papillary tumor
*carcinoma in situ (CIS)
*solid tumor
Squamous cell carcinoma 3%
Adenocarcinoma 2%

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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%

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bladder Squamous cell
carcinoma

pathology

3%
- chronic irritation of bladder > squamous metaplasia > dysplasia > carcinoma

Common in regions with high prevalence of Schistosoma haematobium
infection

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Adenocarcinoma of bladder

2%
Develop:

urachal remnant in the dome of the bladder ( primarily )
or
periurethral tissues

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mutations in Low-grade, non-invasive bladder tumors

ras mutation
FGF-R3 mutation

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High-grade, invasive bladder tumors mutations

p53
RB mutation

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Grading of bladder cancer ( new approach)

PUNLMP (papillary urinary neoplasm of low malignant potential)
Low-grade
High-grade

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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

1. when disease is confined to the dome of the bladder, 2. > 2 cm clean margin can be achieved, 3. 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