?? ?? (Bladder Tumor)

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?? ?? (Bladder Tumor)

• ????? ????
• ? ? ?

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??

• ?? ?? ??? ? ? ?? ???.
• ?? 10? ? ? ?? 7.76?, ?? 1.19?
• 85 localized bladder cancers
• 15 regional LN or
• distant metastasis
• M F 2.7 1
• white gt black

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Pathogenesis(1)

• Multistep phenomenon of neoplastic change of
  urothelium
• - Initiator or its metabolites
• normal cell DNA ? malignant cell
• ?? genetic transformation? ??
• (DNA ? RNA) ? abnormal protein
• - Promoters not carcinogenic
• proliferate already transformed cell

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Pathogenesis(2)

• Bladder cancer initiator or promoters
• 1) cigarette smoking
• - 50(male), 31 (female)
• - a ß-naphthylamine in urine of smoker
• 2) occupational exposure
• - dye, rubber, petroleum, leather, printing
• - benzidine, ß-naphthylamine,
• 4-aminobiphenyl
• 3) cytoxan 4gt artificial sweetners
• 5) Schistosomiasis, instrumentation, calculi

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Pathogenesis(3)

• Activation of oncogenes
• c-Ha-ras,
• c-myc, c-ERB-2, Rb-1
• Tumor suppressor gene
• p53

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Staging
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Staging

• Jewett-Strong-
• Finding Marshall
  TNM ??
• No tumor in the specimen 0 T0
• Carcinoma in situ 0
  Tis
• Noninvasive papillary tumor 0
  Ta
• Submucosal invasion A
  T1
• Superficial muscle invasion B1
  T2
• Deep muscle invasion B2
  T3a
• Invasion of perivesical fat C
  T3b
• Invasion of contiguous organ D1
  T4
• Regional lymph node metastases D2
  (N1-3)
• Juxtaregional lymph node metastases D2
  -
• Distant metastases D2
  M1

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Histopathology

• Papilloma (Ta)
• - Papillary tumor with fine fibrovascular
• stalk
• - 2 of all TCC
• Transitional cell Ca.(TCC)
• - 90
• - papillary, exophytic lesion superficial
• sessile invasive

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WHO grading (by Mostofi)

• Grade ? ????,?? ??? ??, ?? ??,??? ??, ??? ?? ???
  ??
• Grade ? ?????, ?? ???, ? ???,??? ?? ???? ???
  ???. grade I ??? ?? ? ??? ?? ??? ?? ??
• Grade ? ????, ??? ???(atypia),????, ??? ????,???
  ??

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CIS(Carcinoma in Situ)

• flat, nonpapillary anaplastic epithelium
• exophytic lesion? ??? remote site? ?? ? ?? ????
  ???? ??? ?? focal or diffuse?? ??? ? ??.
• ???? ?? invasive disease? progression?
• CIS? ?? ?? exophytic lesion? recur?? invade? ?
  ??.

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Non-transitional cell Ca.

• Adenocarcinoma
• - 2 ??
• - primary adenoca. bladder floor
• urachal adenoca. dome
• - 5 YSR 40 ??

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Non-transitional cell Ca.

• Squamous cell carcinoma
• - 5 - 10
• - chronic infection, bladder stone,
• chronic catheter use? ??
• - Schistosoma haematobium?? ??
• (Egypt 60)
• cf) Most common metastatic tumor to bladder
• melanoma, lymphoma, stomach Ca.,
• breast Ca., kidney Ca.

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Clinical findings

• Sxs
• hematuria 85-90
• irritative voiding Sx CIS
• bone pain bone metastasis
• flank pain retroperitoneal metastasis or
• ureteral obstruction
• Signs
• bimanual exam. under general anesthesia

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Lab. findings

• routine testing
• hematuria with or without pyuria
• azotemia, ureteral obstruction
• anemia
• urinary cytology flow cytometry
• flow cytometry ? cytology? ???
• intravesical chemotherapy? response
• monitoring? ??

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Imaging

• ?? bladder cancer? ???
• cystoscopy? biopsy? ????
• - evaluation of upper urinary tract
• - detection of muscle wall infiltration
• presence of regional or distant
• metastasis

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IVP

• most common imaging test for hematuria
• findings
• - filling defect projecting into the lumen
• - fixation or flattening of bladder wall
• in nonpapillary, infiltrating tumor
• - hydronephrosis in ureteral obstruction

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US

• mass echogenic foci projecting into bladder
• bladder wall invasion
• normal wall? intensely echogenic ??,less
  echogenic tumor? interruption??.

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CT MRI

• bladder wall invasion? enlarged pelvic LN detect
• overall staging accuracy
• CT 40 - 85
• MRI 50 - 90

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Cystoscopy TUR

• bladder tumor? ??
• 1gt superficial, low-grade tumor
• - single or multiple papillary
• - lt 3cm
• 2gt higher grade tumor
• - larger, sessile
• 3gt CIS
• - flat area of erythema mucosal
• irregularity
• - initial bladder tumor ? 15 ??

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Treatment

• Superficial bladder tumor(Ta, T1)
• - TUR /or intravesical chemotherapy
• or immunotherapy
• - initial, low-grade, small tumor
• TURB alone with surveillance

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Agents of intravesical CTx

• Thiotepa
• Mitomycin-C
• Adriamycin(Doxorubicin)
• Epodyl
• BCG ??? 60-80

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High Risk Group

• TURB with intravesical CTx
• stage T1
• multiple ( gt4?)
• large ( gt5cm)
• high grade
• CIS or severe dysplasia

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Localized bladder tumor (T2, T3)

• TURB or laser vaporization
• Radical Cystectomy with/without pelvic
• lymphadnectomy
• -? bladder with fat, peritoneal attachment,
• prostate, SV
• -? bladder with fat, peritoneal attachment,
• cervix, uterus, ant. vaginal wall, ovary
• partial cystectomy

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Metastatic disease

• Systemic CTx. cisplatin based
• M-VAC, CMV, CISCA
• External beam irradiation
• deeply infiltrating cancer?? cystectomy ???
  5,000-7,000 rad? 5-8 ?? ?? ??
• bowel, bladder rectal Cx 15
• Chemoradiotherapy

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??? ???? ??

• ? ? ? ? ?
  5? ???
• ??? (65) Ta ????? 90
• T1 BCG (????) 71
• ??? (21) T2 ????? 53
• T3 ??????
  39
• T4 20
• ??? (14) N(), M() MVAC 10??

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????

• ? 2? 3??? ??? Urine cytology,cystoscopy
• ?? 2?? 6??
• ?? ??