8 bladder tumor

Bladder TumorMohamed Adel Atta

Classification

• Epithelial: papilloma, carcinoma..

• Mesenchymal: leiomyoma, sarcoma.

Epidemiology

• Commonest cancer in males in Egypt.• Male:female ratio 3• Age of peak incidence 50-70, in Egypt 30-

50

Bilharzial bladder carcinoma

• Bilharziasis results in younger age,

• Higher male:female ratio,

• More squamous cell carcinoma,

• Presents in advanced stage because bilh. cystitis masks symptoms of the tumor

Pathogenesis

• Bilharziasis

• Smoking

• Aniline dyes

• Balkan residency

• Bladder extrophy (adenocarcinoma), all have strong etiologic relationship to bladder carcinoma.

Spread

Bladder carcinoma spreads equally by all routes local, lymphatic and vascular.

Bladder carcinoma spreads mainly locally in bilharzial bladder because of intense fibrosis that limits lymph and vascular spread.

StagingT0: Intraepithelial, Tis: High grade intraepithelial neoplasia (CIS).T1: Lamnia propria invasionT2: invasion of muscle layer:

T2a: superficial muscle layerT2b: deep muscle layer.

T3: invasion of perivesical fat

T3a: microscopic invasionT3b: macroscopic invasion.

T4: invasion of pelvic wall or nearby organs.

Staging• Superficial bladder tumor (non muscle

invasive bladder carcinoma NMIBC ): Ta, T1, CIS

• Invasive Bladder carcinoma (MIBC): T2-4

Natural History• Superficial bladder tumor: Ta&T1 and CIS,

usually recur in other site of the bladder(70%), but rarely invades bladder wall (10%), solitary or multiple with mobile fronds long stalk and narrow base. CIS carcinoma in situ: high grade intraepithelial carcinoma, appear as velvety hyperemic areas.

• Invasive deep tumor:T2-4 cauliflower, nodular or ulcerative with necrotic surface.

Gross Types

• Papillary: sea-weed appearance

• Cauliflower mass with stunt fronds, some necrotic.

• Nodular

• Ulcerative.

Invasive Cauliflower Multiple Tumors

GROSS TYPES

Superficial Bladder Tumor

Clinical Presentations• Hematuria: Total painless hematuria (papillary

tumors), may be terminal, intermittent or continuous bright red or with amorphous clots.

• Necroturia: pathognomonic symptom especially in bilharzial bl. Ca.

• Malignant cystitis: isolated CIS may present by severe cystitis resisting Rx

• Microhematuria• Complications: clot retention, anuria, hydro or

pyonephrosis.

Diagnosis

• Ultrasonography: echogenic intravesical mass

• Plain&IVU: bladder filling defect

• Pelvic and abdominal CT: confirm and stage bladder carcinoma

CT bladder tumors

Diagnosis

• Urine cytology

• Cystoscopy and biopsy: tumor and tumor bed for proper staging, bimanual examination under anathesia to asses the degree of pelvic spread of the tumor

• Metastatic workup X-ray chest and bone scan.

Urine cytologyCytology is the detection of cells in fluid,

cells should be viable to take up the stain

Malignant cells have ameboid movement due to loss of intercellular attachments (nexi) and according can be seen in urine frequently especially in CIS and grade 2 carcinoma

Voided urine cytology high grade uroth ca: nuclear hyperchromatism and irregular nucl memb.

Voided urine cytology high grade uroth ca: nuclear hyperchromatism and irregular nucl memb.

Bladder wash cytology clump malignant cells nuclear hyperchromatisia, vacuolated cytoplasm

Bladder wash cytology low grade car, thick nuclear memb, hypochromatasia, homogenous cytoplasm

Voided urine cytology low grade carcinoma

Transurethral Biopsy: The definitive Diagnosis

• 1- Tumor Tissue

• 2- Tumor bed biopsy to properly stage muscle infiltration

• 3- Bimanual examination under anasthesia to asses clinically infiltration of nearby organs and pelvic wall.

Histopathology• 1- Transitional cell carcinoma: the commonest

type• 2- Squamous cell carcinoma: develops on top of

squamous metaplasia due to bilharziasis• 3- Verrucous Ca: subtype of sq. c. ca.,

hyperkerratotic low grade squamous ca., locally malignant with no vascular spread.

• 4- Adenocarcinoma: bladder dome on top of allantoic remnant, or bladder base on top cloacal remnants.

The papilloma is composed of a delicate fibrovascular core covered by normal urothelium

Low Grade urothelial carcinoma

The low-grade papillary urothelial carcinoma group includes all former grade 1 (WHO 1973) cases and some former grade 2 cases (if a variation of architectural and cytological features exist at high magnification).

High grade Urothelial carcinoma

High grade urothelial carcinoma showing atypical urothelial cells that vary in size and shape. The nuclei are enlarged, with coarsely granular chromatin, hyperchromasia, abnormal nuclear contours and prominent nucleoli

High grade Urothelial carcinoma

High grade urothelial carcinoma showing atypical urothelial cells that vary in size and shape. The nuclei are enlarged, with coarsely granular chromatin, hyperchromasia, abnormal nuclear contours and prominent nucleoli

CIS

High grade urothelial carcinoma limitted to the urothelium. No invasion of the underlying basement.. Lamnia propria underneath shows angiogenesis

Lymphovascular invasion

Muscularis propria invasion

Squmous cell carcinoma

Bilharzial egg S Hemmatobiu

TreatmentSuperficial Bladder Tumor

• 1- Transurethral resection (TURT):• 2- In multiple, big,T1, and recurrent

tumors: Intravesical chemotherapy (thiotepa, mitomycin, adriamycin) or better immunotherapy (BCG Vaccine) is advised to reduce tumor recurrence and avoid tumor progression 6 weekly instillations followed by maintenance 3 weekly inst. every 6 months.

Treatment Superficial Bladder Tumor

• 3- Followup Protocol: including US, urine cytology, cystoscopy and biopsy

• 4- Radical cystectomy in high grade tumors resisting treatment and rapidly recurrent.

Treatment Of Invasive Tumors

• Radical cystectomy is the gold standard excision of bladder, lower ureters, as well as prostate, seminal vesicles in males and uterus upper vagina and ovaries in females together with pelvic lymph nodes.

• Radical radiotherapy: less efficient• Bladder saving protocol using initial

chemotherapy followed by radiotherapy in responding tumors or salvage cystectomy in non-responding tumors.

Post-Cystectomy Urinary Reconstruction

1- Orthotopic bladder substitutes

2- Ectopic bladder substitutes:

A- Cutaneous:

a- Wet stoma: ileal conduit

b- Continent stoma: cont.reservoir

B- Anal:

a- Ureterosigmoidostomy & its variants

b- Rectal bladder with left terminal colostomy

Post-Cystectomy Urinary Reconstruction

Any part of GI tract can be used: ileum, colon or stomach.

Detubularization and refashioning in the form of a sphere results in bigger (3 times the volume of the tubular intestine) and less intraluminal pressure (la Place law).

Effect of detubularization

Orthotopic Neobladder

• Detubularized intestinal segment fashioned in the form of sphere is anastomosed to the urethra and both ureters are anastomosed to the pouch with an antireflux mechanism.

• Is the first option unless tumor invades the proximal urethra.

Serous-lined W-shape neobladder

Sigmoid neobladder

Ileal Conduit

• Both ureters are anastomosed to 15 cm ileal segment , one end is closed and the other end is anastomosed to the skin.

• Urine bag is applied to the stoma

Ileal Conduit

Ileal conduit

Continent Reservoir

• Detubularized intestinal segment is fashioned in the form of sphere, both ureters are anastomosed to the pouch with antireflux mechanism.

• The pouch is anastomosed to the umblicus with continent mechanism to prevent urine leakage

• Patient uses plastic catheter to evacuate the pouch every 6-8 hours

Kock Reservoir

Indiana & Florida pouches

Ureterosigmoidostomy

• First known continent diversion, both ureters are anastomosed to the sigmoid colon with proper antireflux technique

• Sequelae: electrolyte imbalance hyperchloremic hypokalemic acidosis, ascending infection, colonic carcinogenesis.

• New variants are introduced to avoid such sequelae with better outcome.

Ureterosigmoidostomy

Ureterosigmoidostomy

UERETEROSIGMOIDOSTOMY

1- Drawbacks: electrolyte imbalance hypokalemic hyperchloremic acidosis, repeated UTI, colonic cancer, inconvenient evacuation

2- Less with the new modifications

3- Not accepted in all centers

Detubularized Isolated Ureterosigmoidostomy (DIUS)

Detubularized Isolated Ureterosigmoidostomy (DIUS)