Bladder tumorBladder tumordr,mohamed fawzi alshahwanidr,mohamed fawzi alshahwani

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facts• Bladder cancer is the Bladder cancer is the second second most common most common

cancer of the genitourinary tract. cancer of the genitourinary tract. • Bladder cancer three times Bladder cancer three times more common more common

in men .in men .• The average age at diagnosis is The average age at diagnosis is 65 years65 years..• At the time of diagnosis , approximately At the time of diagnosis , approximately

75%75% of bladder cancers are of bladder cancers are localized localized to the to the bladder; 25% have spread to regional lymph bladder; 25% have spread to regional lymph nodes or distant sites.nodes or distant sites.

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Risk Factors & Pathogenesis1)1) Cigarette smokingCigarette smoking2 )Occupational exposure2 )Occupational exposure . Workers in the . Workers in the

chemicalchemical, rubber, , rubber, petroleumpetroleum, leather, and , leather, and printing industriesprinting industries

3- 3- Pelvic Irradiation.Pelvic Irradiation.4- 4- Cyclophosphamide.Cyclophosphamide. 5- 5- physical traumaphysical trauma to the urothelium induced to the urothelium induced

by infection, instrumentation, and calculi .by infection, instrumentation, and calculi .

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HistopathologyHistopathology• Ninety-eight percent are epithelial ,

with most being transitional cell carcinomas

1- 1- Transitional Cell Carcinoma (TCC):Transitional Cell Carcinoma (TCC):• commonly appear as commonly appear as papillary, papillary, ; less commonly, ; less commonly,

sessile sessile or ulcerated. or ulcerated. • Carcinoma in situ (Carcinoma in situ (CIS)CIS) is recognizable as is recognizable as flat, flat,

anaplastic epithelium.anaplastic epithelium. 2- 2- AdenocarcinomaAdenocarcinoma:: account for <2% . account for <2% .

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Secondary bladder tumorsSecondary bladder tumors::

• Cancers of the Cancers of the prostateprostate, , cervixcervix, and , and rectumrectum may involve the bladder by direct extension. may involve the bladder by direct extension.

• The most common tumors metastatic to the The most common tumors metastatic to the bladder include bladder include melanomamelanoma, , lymphomalymphoma, , stomach, breaststomach, breast, , kidneykidney, , lung lung and and liverliver . .

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Clinical FindingsClinical FindingsA. SYMPTOMS:• HematuriaHematuria 85–90% of patients with bladder 85–90% of patients with bladder

cancer usually painless.cancer usually painless.• Symptoms of advanced disease include Symptoms of advanced disease include

bone painbone pain from bone metastases or from bone metastases or flank flank painpain from retroperitoneal metastases or from retroperitoneal metastases or ureteral obstructionureteral obstruction

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LABORATORY FINDINGSLABORATORY FINDINGS1.1. Routine testingRoutine testing

GUEGUE…….. …….. HematuriaHematuria most common …. most common …. pyuria,..pyuria,.. from concomitant UTIs from concomitant UTIs • AzotemiaAzotemia in patients with ureteral occlusion in patients with ureteral occlusion

owing to the primary tumor or owing to the primary tumor or lymphadenopathy. lymphadenopathy.

• AnemiaAnemia may be a presenting symptom owing to may be a presenting symptom owing to chronic blood loss, or replacement of the bone chronic blood loss, or replacement of the bone marrow with metastatic disease.marrow with metastatic disease.

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2. Urinary cytology:2. Urinary cytology:

3. Other markers3. Other markers:: Commercially Commercially available tests include, the BTA test available tests include, the BTA test and NMP22.and NMP22.

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4- Imaging Studies:4- Imaging Studies:• A- IVU.A- IVU.• B- U/S.B- U/S.• C- CT. SCAN , MRI.C- CT. SCAN , MRI.• D- chest x-ray and radionuclide bone D- chest x-ray and radionuclide bone

scan.scan.5..difinit diagnosis by 5..difinit diagnosis by cystoscopy cystoscopy and and

biobsybiobsy

IVU

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MRI

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TREATMENT• Once a tumor is visualized or suspected, the Once a tumor is visualized or suspected, the

patient is scheduled for examination under patient is scheduled for examination under anesthesia and TURT and biopsy of the suspicious anesthesia and TURT and biopsy of the suspicious lesion. lesion.

• The objectives of TURT areThe objectives of TURT are 1 tumor diagnosis,1 tumor diagnosis, 2 assessment of the degree of bladder wall 2 assessment of the degree of bladder wall

invasion (staging), invasion (staging), 3 and complete excision of the lesions.3 and complete excision of the lesions.

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TURT

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TREATMENT

SUPERFECIAL BT (Ta , T1 ) Small,low grade ,single,

TURT then check scope every three months

SUPERFECIAL BT (Ta , T1 )

large, multiples ,high grade ,associated CIS, recurrent

TURT,intrasical chimotherapy ,and check scope every three months

DEEP BT (T2-T4)Radical cystectomy with urinary diversion(radiotherapy for unfit patient)METASTATIC TUMORSystemic chimotherapy

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Treatment intravasical chimotherapy

•Immunotherapeutic (Bacillus Calmette-Immunotherapeutic (Bacillus Calmette-Guérin BCG) or chemotherapeutic agents Guérin BCG) or chemotherapeutic agents (mitomycin C, thiotepa , and Gemcitabin) (mitomycin C, thiotepa , and Gemcitabin)

can be instilled into the bladder directly via can be instilled into the bladder directly via catheter, thereby avoiding the morbidity of catheter, thereby avoiding the morbidity of

systemic administration in most casessystemic administration in most cases..

•Most agents are administered Most agents are administered weekly for 6weekly for 6 weeksweeks ..

B. SURGERYB. SURGERY• 1. TURT1. TURT : is the initial form of treatment for : is the initial form of treatment for

all bladder cancers. It allows a reasonably all bladder cancers. It allows a reasonably accurate estimate of tumor stage and grade accurate estimate of tumor stage and grade and the need for additional treatment.and the need for additional treatment.

• Patients who presented initially with multiple Patients who presented initially with multiple or higher grade lesions (or both) and those or higher grade lesions (or both) and those who have recurrences at 3 months require who have recurrences at 3 months require more careful surveillance. In such patients, more careful surveillance. In such patients, cystoscopy at 3-month intervalscystoscopy at 3-month intervals is necessary. is necessary.

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Complications of TURBTComplications of TURBT::

• Bleeding , Clot Retention And Bleeding , Clot Retention And Bladder PerforationBladder Perforation..

2. 2. Partial cystectomy:Partial cystectomy: • Patients with solitary, infiltrating tumors (T1–Patients with solitary, infiltrating tumors (T1–

T3) localized along the posterior lateral wall or T3) localized along the posterior lateral wall or dome of the bladder are candidates for partial dome of the bladder are candidates for partial cystectomy, as are patients with cancers in a cystectomy, as are patients with cancers in a diverticulum.diverticulum.

3. 3. Radical cystectomy and Urinary diversion:Radical cystectomy and Urinary diversion: • implies removal of the anterior pelvic organs: implies removal of the anterior pelvic organs: in in

menmen, the bladder with its surrounding fat and , the bladder with its surrounding fat and peritoneal attachments, the prostate, and the peritoneal attachments, the prostate, and the seminal vesicles; seminal vesicles;

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• in womenin women, the bladder and surrounding , the bladder and surrounding fat and peritoneal attachments, cervix, fat and peritoneal attachments, cervix, uterus, anterior vaginal vault, urethra, and uterus, anterior vaginal vault, urethra, and ovaries.ovaries.

• This remains the “gold standard” of This remains the “gold standard” of treatment for patients with muscle treatment for patients with muscle invasive bladder cancerinvasive bladder cancer

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CHEMOTHERAPY

• 15%15% of patients who of patients who presentpresent with with bladder cancer have bladder cancer have regional or distant regional or distant metastases.metastases.

• The regimen of The regimen of methotrexatemethotrexate, , vinblastinevinblastine, , doxorubicin (Adriamycin),doxorubicin (Adriamycin), and and cisplatincisplatin ( (MMVVAACC) has been the most ) has been the most commonly used.commonly used.

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