Workup/Staging

Question 1

What is the most common presenting Sx of bladder cancer?

Answer 1

The most common presenting Sx is painless hematuria.

Question 2

What are the initial steps in the workup of suspected bladder cancer? What additional workup is needed after a cancer Dx is established?

Answer 2

1. Perform cystoscopy and urine cytology.
2. If a lesion is identified that is solid or suspicious for muscle invasion, then obtain a CT/MRI of the abdomen and pelvis, ideally prior to Bx so induced inflammatory changes do not result in overstaging.
3. Perform an EUA and TURBT.
4. If a cancer Dx is made, image the upper urinary tract (CT or MRI urography, intravenous pyelogram, renal US, retrograde pyelogram, or ureteroscopy).
5. For muscle-invasive Dz, obtain chest imaging (CXR or CT) and consider a bone scan if the pt is symptomatic or has an elevated alk phos level.
6. Recommended blood work includes CBC/CMP.

Question 3

For adequate clinical staging, what should be present in the initial transurethral resection of bladder tumor (TURBT) pathologic specimen?

Answer 3

The Bx specimen should contain muscle from the bladder wall to properly stage the tumor.

Question 4

What are the indications for re-resection after initial TURBT?

Answer 4

Repeat resection should be performed when there is:

1. Incomplete resection of gross tumor
2. High-grade Dz and no muscle in specimen
3. Any T1 lesion

Question 5

What are the AJCC 8th edition (2017) T-stage criteria for bladder cancer?

Answer 5

Ta: noninvasive papillary carcinoma

Tis: CIS (“flat tumor”)

T1: tumor invades lamina propria (subepithelial connective tissue)

T2a: tumor invades superficial muscularis propria (inner half)

T2b: tumor invades deep muscularis propria (outer half)

T3a: microscopic invasion of perivesical tissue

T3b: macroscopic invasion of perivesical tissue

T4a: tumor invades directly into prostatic stroma, seminal vesicles, uterus, vagina

T4b: tumor invades pelvic wall, abdominal wall

Question 6

Can a TURBT be used to define the pT stage?

Answer 6

No. pT stage is defined by an evaluation of a cystectomy specimen. TURBT findings are included in the clinical T-stage (cT) staging.

Question 7

What is the probability of pathologic pelvic nodal involvement based on the pT stage of a bladder tumor?

Answer 7

Pelvic node involvement by pT stage (Stein JP et al., JCO 2001):

Overall: 24% LN+

pT0–T1: 5%

pT2: 18%

pT3a: 26%

pT3b: 46%

pT4: 42%

Question 8

Can the cT stage reliably predict occult pathologic pelvic node involvement?

Answer 8

No. cT stage does not reliably predict occult pathologic node involvement b/c there is significant discordance b/t cT stage and pT stage. (Goldsmith B et al., IJROBP 2014)

Question 9

What are the AJCC 8th edition (2017) N- and M-stage criteria for bladder cancer?

Answer 9

N0: no regional LN involvement

N1: single +LN in true pelvis (perivesical, obturator, internal and external iliac, or sacral)

N2: multiple regional LNs in true pelvis

N3: mets to common iliac LN

M0: no DMs

M1: DMs

M1a: DMs limited to LNs beyond the common iliacs

M1b: non-LN DMs

Question 10

Define the AJCC 8th edition (2017) bladder cancer stage grouping based on TNM status.

Answer 10

Stage 0a: Ta, N0, M0

Stage 0is: Tis, N0, M0

Stage I: T1, N0, M0

Stage II: T2a/T2b, N0, M0

Stage IIIA: T3a/T3b/T4a, N0, M0 or T1–T4a, N1, M0

Stage IIIB: T1–T4a, N2/N3, M0

Stage IVA: T4b, Any N, M0 or Any T, Any N, M1a

Stage IVB: Any T, Any N, M1b

Question 11

Estimate the 5-yr OS by stage.

Answer 11

5-yr OS rates for bladder cancer based on SEER data:

Stage 0: 98%

Stage I: 88%

Stage II: 63%

Stage III: 46%

Stage IV: 15%