BLADDER CANCER

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BLADDER CANCER

• Shahid Waheed, M.D.

2
Incidence

• There are approximately 55,000 new cases of
  bladder, ureter and renal pelvis cancers in the
  United States with approximately over 13,000
  deaths each year.

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Epidemiology

• Gender
• Men have more incidence of bladder cancer than
  women and increased incidence in 7th decade of
  life.
• Race
• Cancers are more common in whites than blacks
  21.

4
Etiology and Risk Factors

• Cigarette smoking
• Analgesic abuse
• Analgesic compounds, especially Phenacetin, has
  been associated with increased risk of bladder
  cancer
• Chronic urinary inflammation
• Occupational exposures
• Workers with organic chemicals, rubber, paint,
  and dye industries have increased risks of
  urothelial cancers.

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Etiology and Risk Factors

• Balkan nephropathy
• Increase of cancer with renal pelvis and ureters
  in patients in Balkan nephropathy, unknown cause
  that results in progressive inflammation of the
  renal parenchyma

6
Etiology and Risk Factors

• Genetic factors
• Families with higher risk of transitional cell
  carcinoma, no genetic basis has been found as of
  yet

7
Signs and Symptoms

• Hematuria
• Urinary voiding symptoms
• Symptoms of advanced disease usually involve
  swelling in lower extremities secondary to a
  lymphatic obstruction
• Pain and frank hematuria

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Diagnostic Work-up

• CT scan
• Ultrasound
• Intravenous pyelogram
• Urine cytology from both ureters at time of
  cystoscopy
• Bone scan
• Chest x-ray

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Pathology

• Transitional cell carcinoma constitutes 90-95 of
  bladder, ureter and renal pelvis cancers.
• Squamous cell carcinoma up to 7
• Adenocarcinoma, rare, less than 3
• Adenocarcinoma in the bladder which arises from
  the dome is felt to be urachal in origin.
• Carcinoma in situ 30 of newly diagnosed bladder
  cancer with multiple sites of bladder involvement

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TNM Staging

• TX Definition Primary tumor cannot be
• assessed
• T10 No evidence of primary tumor
• TA Noninvasive papillary tumor
• Tis Carcinoma in situ flat tumor
• T1 Tumor in wedge
• Subepithelial connective
  tissue
• T2 Tumor in wedge muscle
• T2a tumor in wedge, superficial
• muscle, inner half
• T2a tumor in wedge, deep
• muscle, outer half

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Prognostic Factor

• Lesions up to T1, especially TA, without
  carcinoma in situ have 95 survival rate whereas
  those with high grade T1 lesion have a 10-year
  survival rate of 50.
• Muscle invasive carcinoma 5-year survival rates
  are 20-50. With regional lymph node involvement
  5-year survival rate is 0-20.

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Treatment

• Optional for localized disease
• Treatment of superficial lesions T0, T1S, T1
  and low grade T2 is endoscopic resection and
  fulguration with cystoscopy, repeated every 3
  months.
• Low grade papillomas can be followed at much less
  frequent intervals.

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Treatment

• Intravesical therapy is used prophylactically to
  prevent new lesions and delay or prevent
  development of both metastasis and muscle
  invading tumors, and therapeutically to eradicate
  an existing lesion and known visualized disease
  evidenced by a positive cytology. The most
  intravesical treatment is weekly BCG given for
  six weeks with complete remission achieved in
  47-85 of cases.

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Treatment

• Other options include transureteral resection
• Survival rates are more than 70 at 5 years

15
Treatment

• The neodymium-Yttrium-Aluminum, NDYAG laser is
  used to achieve good local control of superficial
  bladder tumors.
• Partial cystectomy can be used for patients whose
  tumors are not amenable to transureteral
  resection.

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Treatment

• Radical cystectomy generally not used for
  superficial bladder tumors but can be used for
• Large tumors
• High grade tmors
• Multiple tumors
• Extensive local involvement including prostatic
  stromal involvement

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Treatment

• Other surgical approaches available for resection
  of bladder cancer
• Radical cystectomy for Stage II or greater
• Partial cystectomy
• Urethrectomy
• Urinary reconstruction using intestinal conduits,
  ileo, jejunal or colonic or orthoptic
  reconstruction in both male and female patients

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Treatment

• Radiation treatment
• Chemotherapy for advanced disease