Bladder Neoplasms- Benign and NMIBC

Question 1

Arterial supply to the bladder

Answer 1

Sup. and inf. vesical arteries- branches of ant. division of int. iliac

Question 2

Venous drainage of the bladder

Answer 2

Sup. and inf. vesical veins- drain into int. iliac

Question 3

Lymphatic drainage of bladder- Level I nodes

Answer 3

internal iliac, external iliac and obturator

Question 4

Lymphatic drainage of bladder- Level II nodes

Answer 4

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)

Question 5

Lymphatic drainage of bladder- Level III nodes

Answer 5

paracaval, paraaortic, interaorotocaval

Question 6

Urothelial Histology- cell types

Answer 6

Basal cells, intermediate cells, and umbrella cells

Question 7

From what cell type does urothelial carcinoma arise?

Answer 7

basal cells

Question 8

Follicular cystitis

Answer 8

Benign, asymptomatic. Yellowish papules, common after BCG or chronic UTI, no w/u or tx needed

Question 9

Eosinophilic cystitis

Answer 9

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.

Question 10

Granulomatous cystitis

Answer 10

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.

Question 11

Bilharzial/schistosomal cystitis

Answer 11

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)

Question 12

Bladder Malakoplakia

Answer 12

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)

Question 13

Bladder amyloidosis

Answer 13

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.

Question 14

Cystitis cystica et glandularis/ Intestinal metaplasia

Answer 14

Erythematous polypoid masses, Dx with TUR, unsure if premalignant (probably not), cysto annually or QOyear

Question 15

Non-keratinizing squamous metaplasia

Answer 15

Not pre-malignant, whitish area extending from urethra to trigone in females

Question 16

Keratinizing squamous metaplasia

Answer 16

Aka leukoplakia. Likely premalignant –>SCC. Tx with TUR, cysto annually or QOyear

Question 17

Nephrogenic adenoma/metaplasia

Answer 17

Looks like UC cystoscopcally but like renal parenchyma microscopically. Tx with TUR

Question 18

Inflammatory Myofibroblastic Tumor (IMT) and Postoperative Spindle Cell Nodule (PSCN)

Answer 18

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

Question 19

Bladder leiomyoma

Answer 19

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

Question 20

Bladder paraganglioma

Answer 20

Pheochromocytoma of bladder. May present as hypertensive crisis with urination or at TUR.

Question 21

Bladder hemangioma

Answer 21

Presents as hematuria, usu.

Question 22

Bladder cancer environmental risk factors

Answer 22

Tobacco, arylamines (dyes), polyaromatic hydrocarbons, arsenic, low-fluid intake, meat consumption, schistosomiasis, chronic UTI, BK virus

Question 23

Molecular biology of bladder cancer

Answer 23

Allelic loss on chromosome 9, loss of RB1 and P53, abnomalities of Ki67

Question 24

Bladder cancer Ta

Answer 24

non-invasive;

Low grade: 15-70% recur at 1yr,

Question 25

Bladder cancer T1

Answer 25

invades lamina propria; 80% recur, 50% progress

Question 26

Bladder cancer Tis

Answer 26

carcinoma in situ

Question 27

Bladder cancer T2

Answer 27

T2a: Invades detrusor muscle superficially
T2b: Invades detrusor muscle deeply

Question 28

Bladder cancer T3

Answer 28

T3a: Invades peri-vesical fat microscopically
T3b: Invades peri-vesical fat macroscopically

Question 29

Bladder cancer T4

Answer 29

dT4a: Invades prostate or vagina/uterus
T4b: Invades pelvic side wall or abdominal wall

Question 30

Bladder cancer N1

Answer 30

1 positive pelvic node

Question 31

Bladder cancer N2

Answer 31

2 or more positive pelvic nodes

Question 32

Bladder cancer N3

Answer 32

positive common iliac nodes

Question 33

Hexaminolevulinate (HAL) Cystoscopy

Answer 33

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%

Question 34

Restaging TURBT

Answer 34

Indications- incomplete resection, tumors >5cm, HG Ta, or T1. About 50% have residual tumor and about half of these will be upstaged.

Question 35

Immediate post-operative intravesical chemotherapy

Answer 35

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.

Question 36

Adjuvant intravesical therapy- BCG vs. mitomycin

Answer 36

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.

Question 37

Salvage intravesical chemo after BCG failure

Answer 37

Offer for pts that recur after BCG. Gemcitabine most effective. Still 60-80% recur, 10-20% progress.

Question 38

Risk factors for upper tract recurrence after bladder cancer

Answer 38

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.

Question 39

Partial cystectomy for NMIBC

Answer 39

Consider for cancer in a diverticulum, or cancer at dome (in this case do with en bloc resection of urachus)

Question 40

Radical cystectomy for NMIBC

Answer 40

Consider for pts with small capacity or neurogenic bladder, BCG refractory/high risk cancer, or very large cancers