Guide Lines for Management of Bladder Cancer'

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Guide Lines for Management of Bladder Cancer.

• Mohamed S. Zaghloul
• Hussein Khaled
• Moneir Aboul Ella

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Essential Work up

• History taking clinical assessment.
• Laboratory.
• CBC
• LFTS S.albumin, S.bilirubin, prothrombin time,
  SGOT, SGPT alkaline phosphatase.
• S. Creatinine.
• Urinalysis.
• Radiologic
• Chest x-ray
• CT abdomen and pelvis (or IVU ,especially in
  superficial multifocal tumors abdominopelvic
  US)
• Bone scan in muscle invasive tumor.

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• Cystoscopy EUA Together with biopsy are
  mandatory.
• Describe the cystoscopic features of the
  tumor including site, number, distance from
  bladder neck , gross type and associated mucosal
  lesions. The condition of the urethra and
  ureteric orifices must be reported upon. Biopsies
  from the tumor as well as from muscle tissue at
  its base must be taken. When carcinoma in situ is
  suspected (positive cytology in absence of gross
  tumors) random biopsies (at least 4) are taken
  from bladder mucosa.

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Staging according to TNM classification (UICC
1997 AJCC 1997)

• Regional Lymph Nodes (N)
• NX Regional lymph nodes cannot be assessed
• NO No regional lymph nodes metastasis
• N1 Metastasis in a single lymph node, 2 cm
  or less in greatest dimension
• N2 Metastasis in a single lymph node gt2 cm
  but lt5 cm in greatest dimension
• or multiple lymph nodes, none gt5 cm in
  greatest dimension
• Distant Metastasis (M)
• MX Distant metastasis cannot be assessed
• MO No distant metastasis
• M1 Distant metastasis

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Treatment

• Non-muscle invasive (Superficial) tumors 
• a) Ta (G1 or G2 ) 
• Transurethral
  Resection (TUR).
• b) Ta G3 (high risk of recurrence)
• TUR 6 weekly
  intravesical instillation of BCG
• started 3-4 weeks
  after TUR.
• c) Tis (precursor for invasiveness)
• TUR intravesical
  instillation of BCG once
• weekly for 6 weeks.
• T1 ( G1 or G2, solitary , not associated with
  Tis )
• Same as Ta (G1 or G2).
• T1 (G3, multifocal, associated with Tis,
  vascular invasion or
• recurrent
  after BCG)
• TUR intravesical instillation
  of BCG, OR radical
• cystectomy and bilateral pelvic
  lymphadenectomy.
• All superficial tumors must undergo monthly FU
  urine
• cytology cystoscopy TUR every 3
  months

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Treatment

• Recurrent superficial cases
• TUR and intravesical BCG (6 weekly
  applications), Radical cystectomy may be
  performed after the 3rd recurrence

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Pathological exam of cystoscopic biopsy should
include

• Tumor growth pattern
• Grade
• Evidence of muscle invasion
• Multifocality
• Presence of associated carcinoma in situ or cell
  nests of Brunn.

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Treatment

• Muscle invasive tumors (T2, T3 and T4a)
• Radical cystectomy (cystoprostatovesiculectomy
  with bilateral pelvic nodal dissection up to the
  bifurcation of the common iliac LN) together with
  urinary diversion
• (continent diversions in suitable patients).

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The pathological examination of the cystectomy
specimen

• should include
• Tumor type transitional, squamous or adeno. Ca.
• Tumor size and multifocality.
• Tumor P-stage (TNM, 1997).
• Associated conditions Ca. in situ, bilharzial
  affection.
• Number of examined nodes (not less than 10) and
  number of infiltrated nodes.

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Treatment

• Postoperative radiotherapy (PORT) 5000 cGy/5-5.5
  wks using megavoltage machines and 3-fields or
  box technique including the entire pelvis PORT to
  start 3-6 weeks after cystectomy .
• Indications
• a) All stages P2b (P2b-P4a)
• b) In less advanced stages (P2a) whenever
  having either
• G3 or positive LN infilteration.
• NB PORT is also indicated in presence of
  positive safety margin or gross residual disease

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Treatment

• Adjuvant chemotherapy ,in the form of
• 4 courses of Gem-cis ,
• is indicated in
• a) P3 and P4 stages
• b) positive LN
• c) Grade III

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• Preoperative radiotherapy
• 4000-5000 cGy/4-5 weeks
• is indicated in
• - previously explored (after previous
• cystostomies)
• - T4 explorable.

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• T4b, recurrent or metastatic patients
• treated by palliative
• radiotherapy and/or chemotherapy.
• Gemcitabine 1000 mg/m2 D1 D8
• Platinol 70 mg/m2 D2
• This is given with proper hydration and other
  supportive measures and to be repeated every 21
  day.

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Medically unfit for radical cystectomy or
complete refusal of surgery

• Trimodal therapy can be performed in
• Organ confined non-metastatic disease (T2a
  or T2b) with no Carcinoma in situ (Cis).
• No hydronephrosis
• Procedure
• 1. Maximal TUR
• 2. Three cycles of chemotherapy
  (Gemcitabine platinum).
• 3. Cystoscopic evaluation biopsy from
  any residual lesions.
• A. If Complete remission (CR) another 3
  cycles of chemotherapy
• then radical radiotherapy.
• B. Less than CR , radical cystectomy
  (if still medically
• unfit radiochemotherapy)
  postoperative 3 courses
• of chemotherapy.

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Medically unfit for radical cystectomy or
complete refusal of surgery

• (Radical concurrent radiochemotherapy using
  weekly Gemcitabine (250 mg/m2) or cisplatinum
  (30mg/m2) may replace sequential
  chemoradiotherapy as organ preserving radical
  treatment).

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• Follow-up
• Every 2 months in the first year, every 3
  months in the 2nd every 6 months thereafter.
• CXR and CT abdomen pelvis are performed
  every year.
• Bone scan to be performed whenever necessary.

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Follow up

• - At every follow up visit the physician
• should be able to evaluate
• Tumor response No evidence of disease, site
  size of recurrence local, bone, chest, liver,
  etc.
• Immediate late treatment morbidity including
  surgery, radiotherapy, chemotherapy or the
  combination.