Bladder cancer


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  • *1 = HX = History . / EX = Examination .
  • Bladder cancer

    1. 1. Bladder cancer Dr/omar hashim
    2. 2. Anatomy of bladderBladder is lie behind pubic bone,it is the maximum storageis 500 has stronge muscular wall. It is shape and relation according to containing volume. The emptybladder is pyramidal ,having apex, base superior, and two inferolateral surface. The superior surface is covered byPeritoneum, when bladde is fills the superior surface bulgesUp ward so the bladder is become in direct contact to the
    3. 3. Epidemiology and etiology the incidence of bladder cancer is 9.9/100.000 in menAnd 2.3/100.000 in women in USA. New case in US in 2010Is 70.530 .and death 13,060 .Risk factors ;- Age and gender ;-incidence ↑with age (more commonAge 60—70) .m:f ratio is 4:1 Twice more common in white American than in non cau-Cassians .
    4. 4. Past medical history ;-pelvic radiation, chemotherapyBladder lithiasis,chronic catheterization, recurrent urinarInfection exposure to schistosomiasis.Genetic factors ;-these is some gene associated withPoorer prognosis and↑chance of progression include(EGFR),P53,ras oncogene .Industrial chemicals ;- aniline dye, aniline dye,leather,paint,and rubberWorkers more affected than general population.Drugs :-cyclophosphamide
    5. 5. pathologyPathologic subtypes of ca prostate;-1)Transitional cell carcinoma ;- represent 90% of bladderCancer inUSA,70% are superficial carcinoma,arise fromNormal urohtellium and associated with smoking andCarcinogen exposure .2) Squamous cell carcinoma;- caused by chronic irritationFrom urinary calculi,long term indwelling catheter,chronic
    6. 6. Transitional cell carcinoma of bladder
    7. 7. Squamous cell carcinoma of the ca bladder
    8. 8. 3) Adenocarcinoma ;- represent 2% ,include 3groups,1ryUrachal and metastatic .4) Small cell carcinoma ;-represent 1%, behaves similarly toSmall cell carcinoma found elsewhere in the body.5) Mixed histology ;- represent 25% of the case ,usuallyTransitional with adenocarcinoma or squamous*most common site is trigone (inferiorly below ureter-Ovesical juncation,laterial wall,posterior wall,and
    9. 9. diagnosisClinical presentation ;-Hematuria is the most common presenting symptoms 75%. Irritative /obstructive symptoms occur in quarter ofpatients. plevic pain occur in local advanced disease invadinginto adjacent organs. Poor appetite and weigth loss latesystemic symptoms.Examination:- for metastatic sites / PR:- to see the localExtension .
    10. 10. Cystoscopy is indicated in following:-a) Any gross or microscopic hematuria.b) Unexplained or chronic lower urinary tract symptomc) Urine cytology that is suspicious for cancer.d) History of bladder cancer.CT:-to detect the 1ry sites and any enlarged LNs andMetastasis if is present.Urine cytology:-is not used for 1ry diagnosis but forFollow up of ca bladder patients/,screening for environMental carcinogens/.evaluating pts with chronic irritativBladder symptoms
    11. 11. 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
    12. 12. Tumor,node and metastasis staging (TNM) determine bAmerican 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
    13. 13. Regional LNs include 1ry and 2ry drainage regions all nAbove the aortic bifurcation are considered distant metaAsis ;- 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
    14. 14. Stage group of bladder cancer ;- T1 T2 T3 T4a T4a N0 1 11 111 111 1VN1-3 1V 1V 1V 1V 1V M1 1V 1V 1V 1V 1V
    15. 15. PROGNOSISStage is the most important determinant of the survival . 5 yrs over all survival (OS) rate after cystectomyDetermined according to stage Type descriptio n stage Organ extra nodes superficial con- vesicle +ve P0a,N0 Fined p3-4,N0 p2,N05yra 85% T2a 77% 47% 31% T2b 64%survival …/40%.(1 -4)
    16. 16. Prognosis factors ;- factor Favorable Adverse TURBT complete incompleteResponse to complete regression Residualchemo- disease extent of tumor solitary Diffuse /multiple disease invasion organ confined Regional met- Hydronephrosis absent present
    17. 17. treatmentPrinciple and practice ;-Treatment of ca bladder is multimodal and determined byPatients 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 bladderPreservation, the patient can be treated with chemo-
    18. 18. Superficial bladder caner TURBT high risk Low risk Superfical ca (high(low grade papillary) bladder grade,CIS,papillary) recurrence Cytoscopic IntravesicularInvasive recurrence survellance chemotherapy Every 3monthsx2yrs then every 6months x2yrs ,then yearly Bladder Progressive high preservation risk disease therapy cystectomy
    19. 19. Invasive bladder cancer CT /bone scan/NO metastasis yes Unifocal no hydronephrosis/noEVD nPartial 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
    20. 20. Definitive surgical interventionRadical cystectomy ;- involve there move of the bladderProstate and lymph nodes dissection in male. In the femaleAn anterior exenteration (removal of the bladder,urethra,Anterior vaginal wall and uterus )and pelvic lymph nodesDissection is performed . Lymph dissection is include(medialTo the genitofemoral/external iliac up to the bifurcation ofThe common iliac then extended to obturator fossa thenLymph nodes around hypogasteric artery then superorly
    21. 21. 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