Lecture 8 PART 2: Bladder Cancer

Question 1

Who gets bladder cancer?

Answer 1

1) male: female 4:1
2) 70’s and 80’s
3) disease prevalence is 10x incidence (new cases)
4) low death rate so a lot of patients on surveillance

Question 2

What is the main risk factor for bladder cancer?

Answer 2

1) cigarette smoking!!!
- smoke has urothelial carcinogens especially biphenyl amines
- dose response relationship to bladder cancer esp if >40 pack years
- responsible for 50% male cases 30% female cases
- 15 to 20 years latency
- quitting lowers risk but never down to non-smoker

Question 3

What are other risk factors for bladder cancer?

Answer 3

1) Environmental/occupational exposure
- 20% cases
- exposure to chemicals, dyes, aluminum, dye, paint, petroleum, rubber, printing
- pesticide NOT risk factor

2) pelvic radiation
3) cyclophosphamide
4) chronic cystitis-indwelling catheters
5) SCHISTO exposure-common malignancy in middle east and Africa-squamous cell cancer
6) GENES!-lynch syndrome, relative risk 2x with family history

Question 4

What are the types of bladder tumors?

Answer 4

1) urothelial carcinoma-MOST COMMON-95%
2) squamous cell carcinoma-5%
3) adenocarcinoma-1%
4) small cell carcinoma, lymphoma, mets-rare

Question 5

What is non-muscle invasive bladder cancer?

Answer 5

1) T1 stage-invades lamina propria
2) Ta stage-non invasive
3) CIS stage-invades carcinoma in situ

Question 6

What is muscle invasive bladder cancer?

Answer 6

T2 stage

Question 7

How does bladder cancer spread?

Answer 7

1) lymphatic spread to PELVIC lymph nodes
2) more advanced disease can spread to RETROPERITONEAL lymph nodes
3) advanced disease can have visceral mets to lung, bone
- standard workup is chest x-ray NO BONE SCAN

Question 8

What are the symptoms of bladder cancer?

Answer 8

1) intermittent, gross (visible), painless hematuria-90%
2) dysuria (painful urination), urgency
3) suprapubic, flank, perineal, bone pain
4) late constitutional symptoms-weight loss, fever, fatigue

Question 9

What do you see on physical exam of bladder cancer?

Answer 9

1) normal in all but advanced disease cases
2) palpable bladder/pelvic mass in late stage
3) rarely palpable lymphadenopathy

Question 10

You have a patient come in with these symptoms. What do you do next?

1) intermittent, gross (visible), painless hematuria-90%
2) dysuria (painful urination), urgency
3) suprapubic, flank, perineal, bone pain
4) late constitutional symptoms-weight loss, fever, fatigue

Answer 10

LAB STUDIES AND CYTOLOGY

1) urinalysis-gross exam and dipstick
2) urine culture to rule out infection
3) LACK of hematuria does NOT rule out bladder cancer if history for gross hematuria
4) urine cytology-modest sensitivity (true positives) but EXCELLENT specificity (true negatives)

Question 11

You have a patient with these symptoms. What kind of IMAGING do you do next?

1) intermittent, gross (visible), painless hematuria-90%
2) dysuria (painful urination), urgency
3) suprapubic, flank, perineal, bone pain
4) late constitutional symptoms-weight loss, fever, fatigue

Answer 11

1) CT abdomen and pelvis +/- contrast (CT urogram) is the single BEST study

Others

1) IV (intravenous) pyelogram
2) Ultrasound-initial kidney imaging
3) retrograde pyelogram-invasive image upper tracts if cannot use contrast due to allergy or azotemia
4) MRI-non-invasive alternative in azotemic or dye allergic patient

Question 12

What is the gold standard to diagnose bladder cancer?

Answer 12

Cytoscopy with biopsy or resection of entire lesion

Question 13

How do you treat bladder cancer tumors?

Answer 13

1) Transurethral resection of bladder tumor (TURBT)-diagnostic and therapeutic for superficial disease, can confirm diagnosis and ablate lesion
2) Bladder Tumor Resection and Fulguration (destroy tissue)

Question 14

For patients with lamina propria invasion but NO muscular propria in the specimen

Answer 14

repeat resection should be performed prior to intravesical therapy….repeat resect sometimes for TI tumors with muscular propria in the specimen to increase accuracy of staging

Question 15

What are the risk factors for bladder tumor recurrence and progression?

Answer 15

1) Tumor Grade (high vs low)
2) Stage (T1 v Ta)
3) Multiplicity
4) Prior recurrence
5) Size (>3 cm)

Question 16

If you have a patient with:

1) multiple or rapid recurrences
2) T1 disease
3) multi-focal disease
4) high grade disease
5) carcinoma in situ or severe dysplasia
6) post-resection immediate prophylaxis (to prevent re-seeding effect)
7) NOT for T2 or greater disease

Answer 16

Indications to perform Intravesical Therapy (1 dose post-op)

Question 17

Prognosis of Bladder Cancer

Answer 17

1) 70% bladder tumors will recur after TUR (transurethral resection) alone within 3 years
2) highest local recurrence rate of any solid malignancy
3) 15-20% superficial tumors progress to muscle-invasion
4) 1/2 of patients who present with or evolve into muscle invasion will die of their disease in 5 years even with radical surgery
5) only 5% with mets survive >5 years

Question 18

How do you treat Muscle Invasive Bladder Cancer?

Answer 18

1) Radical Cystectomy (remove part of bladder)-PREFERRED

Question 19

What is the role of chemotherapy in bladder cancer?

Answer 19

1) Neoadjuvant- BEFORE planned surgery for high risk patients provides 6% absolute survival benefit
2) ADJUVANT- AFTER surgery, patients selected based on final pathology results, similar survival benefits but some patients may be unable
- 60% response rate but only 5% long term survival