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Bladder cancer
 Dr/omar hashim
Anatomy of bladder
Bladder is lie behind pubic bone,it is the maximum
  storage
is 500 ml.it has stronge muscular wall. It is shape and
 relation according to containing volume. The empty
bladder is pyramidal ,having apex, base superior, and
  two inferolateral surface. The superior surface is
  covered by
Peritoneum, when bladde is fills the superior surface
  bulges
Up ward so the bladder is become in direct contact to
  the
Epidemiology and etiology
 the incidence of bladder cancer is 9.9/100.000 in
  men
And 2.3/100.000 in women in USA. New case in US in
  2010
Is 70.530 .and death 13,060 .
Risk factors ;-
 Age and gender ;-incidence ↑with age (more common
Age 60—70) .m:f ratio is 4:1
 Twice more common in white American than in non
  cau-
Cassians .
Past medical history ;-pelvic radiation, chemotherapy
Bladder lithiasis,chronic catheterization, recurrent urinar
Infection exposure to schistosomiasis.
Genetic factors ;-these is some gene associated with
Poorer prognosis and↑chance of progression include
(EGFR),P53,ras oncogene .
Industrial chemicals ;- aniline dye,naphthylamine
Benzidine.so aniline dye,leather,paint,and rubber
Workers more affected than general population.
Drugs :-cyclophosphamide
pathology
Pathologic subtypes of ca prostate;-
1)Transitional cell carcinoma ;- represent 90% of
  bladder
Cancer inUSA,70% are superficial carcinoma,arise
  from
Normal urohtellium and associated with smoking and
Carcinogen exposure .
2) Squamous cell carcinoma;- caused by chronic
  irritation
From urinary calculi,long term indwelling
  catheter,chronic
Transitional cell carcinoma of bladder
Squamous cell carcinoma of the ca bladder
3) Adenocarcinoma ;- represent 2% ,include
  3groups,1ry
Urachal and metastatic .
4) Small cell carcinoma ;-represent 1%, behaves
  similarly to
Small cell carcinoma found elsewhere in the body.
5) Mixed histology ;- represent 25% of the case
  ,usually
Transitional with adenocarcinoma or squamous
*most common site is trigone (inferiorly below ureter-
Ovesical juncation,laterial wall,posterior wall,and
diagnosis
Clinical presentation ;-
Hematuria is the most common presenting symptoms
  75%. Irritative /obstructive symptoms occur in quarter
  of
patients. plevic pain occur in local advanced disease
  invading
into adjacent organs. Poor appetite and weigth loss
  late
systemic symptoms.
Examination:- for metastatic sites / PR:- to see the
  local
Extension .
Cystoscopy is indicated in following:-
a) Any gross or microscopic hematuria.
b) Unexplained or chronic lower urinary tract symptom
c) Urine cytology that is suspicious for cancer.
d) History of bladder cancer.
CT:-to detect the 1ry sites and any enlarged LNs and
Metastasis if is present.
Urine cytology:-is not used for 1ry diagnosis but for
Follow up of ca bladder patients/,screening for environ
Mental carcinogens/.evaluating pts with chronic irritativ
Bladder symptoms
Doagnosis procedure for bladder cancer;-

                   Hematuria or irritative
                     bladder cancer



          HX/EX /urinary
                                Cystoscopy/pyelography
       cytologyCBC/CXR.*1



            Invasive
                                    Superficial
                                   Muscular is -ve



            Abd-u/s/pelvic CT &bones
                       can
Tumor,node and metastasis staging (TNM) determine b
American Joint Committee on Cancer (AJCC)
PRIMARY TUMOR ;-


 STAGE             DESCRIPTION

   T1    tumor invade subepithelial connective tissues

  T2     tumor invade muscularis propria

  T3     Tumor invade perivesical tissues

  T4     Tumor invade any of the following (prostate
         stroma /seminal vesicle /uterus /vagina /pelvic
         wall /abdominal wall
Regional LNs include 1ry and 2ry drainage regions all n
Above the aortic bifurcation are considered distant meta
Asis ;-
    N0          No regional LNs metastasis

     N1        single regional LNs metastasis in true pelvic
              (hypogastric/obturator/external iliac or presacral
              )

     N2        multiple regional LNs metastasis in true plevic

     N3        lymph nodes metastasis to the common
              iliacLNs
    Distant metastasis ;-
    M0;-no distant metastasis
    M1;- distant metastasis
Stage group of bladder cancer ;-

            T1        T2           T3    T4a   T4a

  N0        1         11           111   111   1V

N1-3        1V        1V           1V     1V   1V

  M1         1V       1V           1V    1V    1V
PROGNOSIS
Stage is the most important determinant of the survival
 . 5 yrs over all survival (OS) rate after cystectomy
Determined according to stage

  Type                descriptio
                      n
   stage                Organ        extra     nodes
            superficial con-        vesicle   +ve
            P0a,N0      Fined       p3-4,N0
                        p2,N0
5yra          85%         T2a 77%    47%       31%
                         T2b 64%
survival                                      …/40%.(1
                                              -4)
Prognosis factors ;-

    factor               Favorable         Adverse
    TURBT                 complete          incomplete
Response to            complete regression Residual
chemo-                                     disease
 extent of tumor        solitary           Diffuse
                                           /multiple
 disease invasion      organ confined      Regional met-
  Hydronephrosis          absent            present
treatment
Principle and practice ;-
Treatment of ca bladder is multimodal and determined
  by
Patients prognosis factors.
1) Superficial bladder cancer is managed primary by
    trans-
Urethral resection ±intravesicular chemotherapy .
2) Localized invasive bladder cancer traditionally is
    treated by cystectomy .
3) If patient has prognostic factors predictive for
    bladder
Preservation, the patient can be treated with chemo-
Superficial bladder caner



                               TURBT


                                                          high risk
      Low risk               Superfical ca                  (high
(low grade papillary)           bladder              grade,CIS,papillary)
                              recurrence



                            Cytoscopic                     Intravesicular
Invasive recurrence         survellance                    chemotherapy
                        Every 3monthsx2yrs
                        then every 6months
                         x2yrs ,then yearly
     Bladder
                                                     Progressive high
   preservation
                                                       risk disease
     therapy               cystectomy
Invasive bladder cancer


                                CT /bone scan/NO
                                    metastasis

           yes                     Unifocal no
                              hydronephrosis/noEVD            n
Partial cystectomy                                            o
                                                           Local advanced disease
   If candidate
                                                                  T3.T4;N+
                                                                   ye
                            TURBT                                  s
                                            no              CTH/preops-RT

                           CTH+RT
                                                                  cystectomy
                            complete
                           Regression
                     yes   of disease             Local
 consolidative                                   advance
                                                    d                     CTH
   CTH+RT
                                                 disease
Definitive surgical intervention
Radical cystectomy ;- involve there move of the bladder
Prostate and lymph nodes dissection in male. In the
  female
An anterior exenteration (removal of the bladder,urethra,
Anterior vaginal wall and uterus )and pelvic lymph
  nodes
Dissection is performed . Lymph dissection is
  include(medial
To the genitofemoral/external iliac up to the bifurcation
  of
The common iliac then extended to obturator fossa then
Lymph nodes around hypogasteric artery then superorly
extent         confined    extra        nodes    Total(NO
                            vesicle                ofpt)
Local failure       4%         16%          20%       9% 788
                                                   10 yrs
 distant           9.5%        19%           45%       18%
metas-
tasis
 recurrence-    T2a/b 70%   T3a/b,52%    15%          45%
free survival   10yrs       T4, 35%     10 yrs

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Bladder cancer

  • 2. Anatomy of bladder Bladder is lie behind pubic bone,it is the maximum storage is 500 ml.it has stronge muscular wall. It is shape and relation according to containing volume. The empty bladder is pyramidal ,having apex, base superior, and two inferolateral surface. The superior surface is covered by Peritoneum, when bladde is fills the superior surface bulges Up ward so the bladder is become in direct contact to the
  • 3.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 9. Epidemiology and etiology the incidence of bladder cancer is 9.9/100.000 in men And 2.3/100.000 in women in USA. New case in US in 2010 Is 70.530 .and death 13,060 . Risk factors ;-  Age and gender ;-incidence ↑with age (more common Age 60—70) .m:f ratio is 4:1  Twice more common in white American than in non cau- Cassians .
  • 10. Past medical history ;-pelvic radiation, chemotherapy Bladder lithiasis,chronic catheterization, recurrent urinar Infection exposure to schistosomiasis. Genetic factors ;-these is some gene associated with Poorer prognosis and↑chance of progression include (EGFR),P53,ras oncogene . Industrial chemicals ;- aniline dye,naphthylamine Benzidine.so aniline dye,leather,paint,and rubber Workers more affected than general population. Drugs :-cyclophosphamide
  • 11. pathology Pathologic subtypes of ca prostate;- 1)Transitional cell carcinoma ;- represent 90% of bladder Cancer inUSA,70% are superficial carcinoma,arise from Normal urohtellium and associated with smoking and Carcinogen exposure . 2) Squamous cell carcinoma;- caused by chronic irritation From urinary calculi,long term indwelling catheter,chronic
  • 13. Squamous cell carcinoma of the ca bladder
  • 14. 3) Adenocarcinoma ;- represent 2% ,include 3groups,1ry Urachal and metastatic . 4) Small cell carcinoma ;-represent 1%, behaves similarly to Small cell carcinoma found elsewhere in the body. 5) Mixed histology ;- represent 25% of the case ,usually Transitional with adenocarcinoma or squamous *most common site is trigone (inferiorly below ureter- Ovesical juncation,laterial wall,posterior wall,and
  • 15. diagnosis Clinical presentation ;- Hematuria is the most common presenting symptoms 75%. Irritative /obstructive symptoms occur in quarter of patients. plevic pain occur in local advanced disease invading into adjacent organs. Poor appetite and weigth loss late systemic symptoms. Examination:- for metastatic sites / PR:- to see the local Extension .
  • 16. Cystoscopy is indicated in following:- a) Any gross or microscopic hematuria. b) Unexplained or chronic lower urinary tract symptom c) Urine cytology that is suspicious for cancer. d) History of bladder cancer. CT:-to detect the 1ry sites and any enlarged LNs and Metastasis if is present. Urine cytology:-is not used for 1ry diagnosis but for Follow up of ca bladder patients/,screening for environ Mental carcinogens/.evaluating pts with chronic irritativ Bladder symptoms
  • 17. Doagnosis procedure for bladder cancer;- Hematuria or irritative bladder cancer HX/EX /urinary Cystoscopy/pyelography cytologyCBC/CXR.*1 Invasive Superficial Muscular is -ve Abd-u/s/pelvic CT &bones can
  • 18. Tumor,node and metastasis staging (TNM) determine b American Joint Committee on Cancer (AJCC) PRIMARY TUMOR ;- STAGE DESCRIPTION T1 tumor invade subepithelial connective tissues T2 tumor invade muscularis propria T3 Tumor invade perivesical tissues T4 Tumor invade any of the following (prostate stroma /seminal vesicle /uterus /vagina /pelvic wall /abdominal wall
  • 19.
  • 20. Regional LNs include 1ry and 2ry drainage regions all n Above the aortic bifurcation are considered distant meta Asis ;- N0 No regional LNs metastasis N1 single regional LNs metastasis in true pelvic (hypogastric/obturator/external iliac or presacral ) N2 multiple regional LNs metastasis in true plevic N3 lymph nodes metastasis to the common iliacLNs Distant metastasis ;- M0;-no distant metastasis M1;- distant metastasis
  • 21. Stage group of bladder cancer ;- T1 T2 T3 T4a T4a N0 1 11 111 111 1V N1-3 1V 1V 1V 1V 1V M1 1V 1V 1V 1V 1V
  • 22. PROGNOSIS Stage is the most important determinant of the survival . 5 yrs over all survival (OS) rate after cystectomy Determined according to stage Type descriptio n stage Organ extra nodes superficial con- vesicle +ve P0a,N0 Fined p3-4,N0 p2,N0 5yra 85% T2a 77% 47% 31% T2b 64% survival …/40%.(1 -4)
  • 23. Prognosis factors ;- factor Favorable Adverse TURBT complete incomplete Response to complete regression Residual chemo- disease extent of tumor solitary Diffuse /multiple disease invasion organ confined Regional met- Hydronephrosis absent present
  • 24. treatment Principle and practice ;- Treatment of ca bladder is multimodal and determined by Patients prognosis factors. 1) Superficial bladder cancer is managed primary by trans- Urethral resection ±intravesicular chemotherapy . 2) Localized invasive bladder cancer traditionally is treated by cystectomy . 3) If patient has prognostic factors predictive for bladder Preservation, the patient can be treated with chemo-
  • 25. Superficial bladder caner TURBT high risk Low risk Superfical ca (high (low grade papillary) bladder grade,CIS,papillary) recurrence Cytoscopic Intravesicular Invasive recurrence survellance chemotherapy Every 3monthsx2yrs then every 6months x2yrs ,then yearly Bladder Progressive high preservation risk disease therapy cystectomy
  • 26.
  • 27.
  • 28. Invasive bladder cancer CT /bone scan/NO metastasis yes Unifocal no hydronephrosis/noEVD n Partial cystectomy o Local advanced disease If candidate T3.T4;N+ ye TURBT s no CTH/preops-RT CTH+RT cystectomy complete Regression yes of disease Local consolidative advance d CTH CTH+RT disease
  • 29. Definitive surgical intervention Radical cystectomy ;- involve there move of the bladder Prostate and lymph nodes dissection in male. In the female An anterior exenteration (removal of the bladder,urethra, Anterior vaginal wall and uterus )and pelvic lymph nodes Dissection is performed . Lymph dissection is include(medial To the genitofemoral/external iliac up to the bifurcation of The common iliac then extended to obturator fossa then Lymph nodes around hypogasteric artery then superorly
  • 30. extent confined extra nodes Total(NO vesicle ofpt) Local failure 4% 16% 20% 9% 788 10 yrs distant 9.5% 19% 45% 18% metas- tasis recurrence- T2a/b 70% T3a/b,52% 15% 45% free survival 10yrs T4, 35% 10 yrs

Editor's Notes

  1. *1 = HX = History . / EX = Examination .