Bladder Neoplasms- Benign and NMIBC Flashcards
Arterial supply to the bladder
Sup. and inf. vesical arteries- branches of ant. division of int. iliac
Venous drainage of the bladder
Sup. and inf. vesical veins- drain into int. iliac
Lymphatic drainage of bladder- Level I nodes
internal iliac, external iliac and obturator
Lymphatic drainage of bladder- Level II nodes
common iliac, presacral (note: Bladder tumors may spread directly to level II nodes (skipping the level I nodes) in about 7% of cases but do not skip to level III nodes without first affecting level I or II nodes)
Lymphatic drainage of bladder- Level III nodes
paracaval, paraaortic, interaorotocaval
Urothelial Histology- cell types
Basal cells, intermediate cells, and umbrella cells
From what cell type does urothelial carcinoma arise?
basal cells
Follicular cystitis
Benign, asymptomatic. Yellowish papules, common after BCG or chronic UTI, no w/u or tx needed
Eosinophilic cystitis
Benign. P/w irritative sx. Due to allergic reaction. Red patches on urothelium.
Treat with anticholinergics, beta 3 agonists, antihistamines, or steroids. Usually resolved with meds but may require TUR or even cystectomy.
Granulomatous cystitis
Mycobacterial bladder infection. Most commonly from BCG (1 in 200 risk) but may be 2/2 TB. Cystoscopically appears red and inflamed with decreased capacity. Treat with isoniazid and pyroxidine x 3mos.
Bilharzial/schistosomal cystitis
Due to infection by Hematobium mansoni. Parasites start in liver then move to pelvic veins and release ova for 5-25yrs that produce inflammation in surrounding tissues. Causes bladder hyperplasia, calcification, ulcers, scarring/fibrosis, and keratinizing squamous metaplasia. 1-5% chance of developing malignancy (SCC most common, then adenocarcinoma)
Bladder Malakoplakia
P/w LUTS, usu. in immunosuppressed pts, brown plaques. Microscopically shows von Hanseman cells with Michaelis Gutman bodies. Due to defective digestion of bacteria (cGMP mediated). Tx with TUR, quinolone, and possibly vit C and bethanochol (activate vit C)
Bladder amyloidosis
Nodular or plaque-like lesion, looks like tumor. Caused by protein deposition. Birefringence with polarized light and positive congo red staining microscopically. Tx with TUR and refer to amyloidosis expert. Protein deposits can be dissolved with intravesical DMSO.
Cystitis cystica et glandularis/ Intestinal metaplasia
Erythematous polypoid masses, Dx with TUR, unsure if premalignant (probably not), cysto annually or QOyear
Non-keratinizing squamous metaplasia
Not pre-malignant, whitish area extending from urethra to trigone in females
Keratinizing squamous metaplasia
Aka leukoplakia. Likely premalignant –>SCC. Tx with TUR, cysto annually or QOyear
Nephrogenic adenoma/metaplasia
Looks like UC cystoscopcally but like renal parenchyma microscopically. Tx with TUR
Inflammatory Myofibroblastic Tumor (IMT) and Postoperative Spindle Cell Nodule (PSCN)
P/w irritative sx, often in pt with recent bladder surgery. Looks like UC, microscopically has spindle cells and myofribroblasts. TUR to tx, recurs in 10% of cases
Bladder leiomyoma
Appear as suburothelial humps, benign smooth muscle tumor; dx with TUR, often require partial cystectomy since they arise outside the bladder and can be very large
Bladder paraganglioma
Pheochromocytoma of bladder. May present as hypertensive crisis with urination or at TUR.
Bladder hemangioma
Presents as hematuria, usu.
Bladder cancer environmental risk factors
Tobacco, arylamines (dyes), polyaromatic hydrocarbons, arsenic, low-fluid intake, meat consumption, schistosomiasis, chronic UTI, BK virus
Molecular biology of bladder cancer
Allelic loss on chromosome 9, loss of RB1 and P53, abnomalities of Ki67
Bladder cancer Ta
non-invasive;
Low grade: 15-70% recur at 1yr,
Bladder cancer T1
invades lamina propria; 80% recur, 50% progress
Bladder cancer Tis
carcinoma in situ
Bladder cancer T2
T2a: Invades detrusor muscle superficially
T2b: Invades detrusor muscle deeply
Bladder cancer T3
T3a: Invades peri-vesical fat microscopically
T3b: Invades peri-vesical fat macroscopically
Bladder cancer T4
dT4a: Invades prostate or vagina/uterus
T4b: Invades pelvic side wall or abdominal wall
Bladder cancer N1
1 positive pelvic node
Bladder cancer N2
2 or more positive pelvic nodes
Bladder cancer N3
positive common iliac nodes
Hexaminolevulinate (HAL) Cystoscopy
Intravesical instillation of HAL for 1-3hrs, blue light causes tumors to fluoresce pink, that stays in the bladder for 1-3 hours prior to cystoscopy. When done at the time of TURBT, leads reduction in bladder tumor recurrences of 25%
Restaging TURBT
Indications- incomplete resection, tumors >5cm, HG Ta, or T1. About 50% have residual tumor and about half of these will be upstaged.
Immediate post-operative intravesical chemotherapy
Given within 6hrs of TURBT, recommended for all NIMBC, reduces recurrence by 35%. Use mitomycin C, or anthracyclines (“-rubicin” drugs). Do not give if perforation occurs.
Adjuvant intravesical therapy- BCG vs. mitomycin
Both BCG and mitomicin C have been shown to be effective. BCG is better for intermediate and high risk pts. BCG efficacy is decreased with warfarin, statins, or immunosuppression.
Salvage intravesical chemo after BCG failure
Offer for pts that recur after BCG. Gemcitabine most effective. Still 60-80% recur, 10-20% progress.
Risk factors for upper tract recurrence after bladder cancer
High grade, location near the ureteral orifices, tumor multiplicity, frequent recurrences, presence of bladder CIS, and intravesical therapy failures. Do annual upper tract imaging in these pts.
Partial cystectomy for NMIBC
Consider for cancer in a diverticulum, or cancer at dome (in this case do with en bloc resection of urachus)
Radical cystectomy for NMIBC
Consider for pts with small capacity or neurogenic bladder, BCG refractory/high risk cancer, or very large cancers
