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Blader cancer
 

Blader cancer

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    Blader cancer Blader cancer Presentation Transcript

    • BLADDERBLADDER CANCERCANCER
    • BACKGROUNDBACKGROUND  The incidence of bladder carcinoma is rising in WesternThe incidence of bladder carcinoma is rising in Western countries.countries.  In 1996, approximately 53,000 patients were diagnosedIn 1996, approximately 53,000 patients were diagnosed with bladder cancer in the USA, 9,000 in France, 2,000with bladder cancer in the USA, 9,000 in France, 2,000 in Sweden 8,000 in Spain and 1,120 in Belgium.in Sweden 8,000 in Spain and 1,120 in Belgium.  Approximately 75-85% of patients present with diseaseApproximately 75-85% of patients present with disease confined to the mucosa (stage Ta-Tis) or submucosaconfined to the mucosa (stage Ta-Tis) or submucosa (stage T1). The other 15-25% have muscle invasion or(stage T1). The other 15-25% have muscle invasion or nodal disease (stages T2-T4, N+) at presentation.nodal disease (stages T2-T4, N+) at presentation.
    • EpidemiologyEpidemiology  Carcinoma of the bladder isCarcinoma of the bladder is three times more commonthree times more common among men then women.among men then women.  Neoplasm of bladder canNeoplasm of bladder can occur at any age of patientsoccur at any age of patients but it is most common inbut it is most common in elderly persons (55 years andelderly persons (55 years and older) and incidence of bladderolder) and incidence of bladder cancer increases directly withcancer increases directly with age.age.  The median age at the time ofThe median age at the time of diagnosis is, depending on thediagnosis is, depending on the country, 60-70 years.country, 60-70 years.
    • EpidemiologyEpidemiology  The rise in incidence of bladderThe rise in incidence of bladder cancers is observed in the last 20cancers is observed in the last 20 years.years.  Bladder cancer is diagnosed 1,5 toBladder cancer is diagnosed 1,5 to 2 times more common among2 times more common among whites then among blacks,whites then among blacks, depending on gender.depending on gender.  The bladder cancer was the causeThe bladder cancer was the cause of death of 11 200 patient and thisof death of 11 200 patient and this accounts for 2,6% all cancersaccounts for 2,6% all cancers death in man and 1,4% in women.death in man and 1,4% in women.
    • BLADDER CANCERBLADDER CANCER  During last 50 years incidence rate ofDuring last 50 years incidence rate of bladder cancer has increased ofbladder cancer has increased of approximately 50% but mortality hasapproximately 50% but mortality has decreased of approximately 33%.decreased of approximately 33%.  It is hard to state, to which factorsIt is hard to state, to which factors changing in the biology of cancer,changing in the biology of cancer, earlier diagnosis, better treatment orearlier diagnosis, better treatment or alteration in risk factors thisalteration in risk factors this phenomenon can be attributed.phenomenon can be attributed.
    • Histological grading of World Health Organisation andHistological grading of World Health Organisation and International Pathology Concensus Committee 1988International Pathology Concensus Committee 1988  PTNM pathological classificationPTNM pathological classification  The pT, pN, and pM categories correspond to the T, N,The pT, pN, and pM categories correspond to the T, N, and M categories.and M categories.  GG -- Histopathological gradingHistopathological grading  GXGX -- Grade of differentiation cannot be assessedGrade of differentiation cannot be assessed  G1G1 -- Well differentiatedWell differentiated  G2G2 -- Moderately differentiatedModerately differentiated  G3G3-4 --4 - Poorly differentiated/undifferentiatedPoorly differentiated/undifferentiated
    • 2002 TNM classification of urinary bladder cancer2002 TNM classification of urinary bladder cancer  T - Primary tumourT - Primary tumour  TTXX Primary tumour cannot be assessedPrimary tumour cannot be assessed  T0T0 No evidence of primary tumourNo evidence of primary tumour  Ta Non-invasive papillary carcinomaTa Non-invasive papillary carcinoma  Tis CarcinomaTis Carcinoma in situin situ: 'flat tumour‘: 'flat tumour‘  T1Tumour invades subepithelialT1Tumour invades subepithelial connective tissueconnective tissue  T2Tumour invades muscleT2Tumour invades muscle  T2aTumour invades superficial muscleT2aTumour invades superficial muscle (inner half)(inner half)  T2bTumour invades deep muscle (outerT2bTumour invades deep muscle (outer half)half)  T3Tumour invades perivesical tissue:T3Tumour invades perivesical tissue:  T3aMicroscopically T3bMacroscopicallyT3aMicroscopically T3bMacroscopically (extravesical mass)(extravesical mass)  T4Tumour invades any of the following:T4Tumour invades any of the following: prostate, uterus, vagina, pelvic wall,prostate, uterus, vagina, pelvic wall, abdominal wallabdominal wall  T4aTumour invades prostate, uterus orT4aTumour invades prostate, uterus or vaginavagina  T4bTumour invades pelvic wall orT4bTumour invades pelvic wall or abdominal wallabdominal wall
    • 2002 TNM classification of urinary bladder cancer2002 TNM classification of urinary bladder cancer  N - Lymph nodesN - Lymph nodes  NXNX Regional lymph nodes cannot be assessedRegional lymph nodes cannot be assessed  N0N0 No regional lymph node metastasisNo regional lymph node metastasis  N1N1 Metastasis in a single lymph node 2cm or less in greatestMetastasis in a single lymph node 2cm or less in greatest dimensiondimension  N2N2 Metastasis in a single lymph node more than 2 cm but not moreMetastasis in a single lymph node more than 2 cm but not more than 5 cm in greatest dimension, or multiple lymph nodes, nonethan 5 cm in greatest dimension, or multiple lymph nodes, none more than 5 cm in greatest dimensionmore than 5 cm in greatest dimension  N3 Metastasis in a lymph node more than 5 cm in greatestN3 Metastasis in a lymph node more than 5 cm in greatest dimensiondimension  M - Distant metastasisM - Distant metastasis  MXMX Distant metastasis cannot be assessedDistant metastasis cannot be assessed  M0M0 No distant metastasisNo distant metastasis  M1M1 Distant metastasisDistant metastasis
    • CLASSIFICATIONCLASSIFICATION  More than 90% of bladderMore than 90% of bladder cancers are transitionalcancers are transitional cell carcinoma (TCC); thecell carcinoma (TCC); the remainder are squamousremainder are squamous cell or adenocarcinoma.cell or adenocarcinoma.  Bladder tumours areBladder tumours are considered superficial (Tis-considered superficial (Tis- Ta-T1) or infiltrative (T2-T3-Ta-T1) or infiltrative (T2-T3- T4) based on cystoscopy,T4) based on cystoscopy, transurethral resectiontransurethral resection (TUR), imaging studies and(TUR), imaging studies and histopathological findings.histopathological findings.
    • RISK FACTORSRISK FACTORS  Aromatic amines were the first to be recognized. AtAromatic amines were the first to be recognized. At risk groupsrisk groups include workers in the following industries: printing, ironinclude workers in the following industries: printing, iron foundry, aluminium smelting, industrial painting, gas and tarfoundry, aluminium smelting, industrial painting, gas and tar manufacturing.manufacturing.  Another prominent risk factor is cigarette smoking. SmokingAnother prominent risk factor is cigarette smoking. Smoking leads to higher mortality from bladder cancer during long-termleads to higher mortality from bladder cancer during long-term follow-up, even though in a multivariate analysis, the prognosticfollow-up, even though in a multivariate analysis, the prognostic effect of smoking was weaker than that of other factors, such aseffect of smoking was weaker than that of other factors, such as stage, grade, size and multifocality of the tumour . Patients withstage, grade, size and multifocality of the tumour . Patients with initial grade III tumours were significantly more likely to be heavyinitial grade III tumours were significantly more likely to be heavy smokers than those with less aggressive disease .smokers than those with less aggressive disease .
    • SymtomatologySymtomatology  Haematuria is the mostHaematuria is the most common finding in bladdercommon finding in bladder cancer. The degree ofcancer. The degree of haematuria does not correlatehaematuria does not correlate with the extent of the disease. Itwith the extent of the disease. It may be grossly visible to themay be grossly visible to the patient or simply found onpatient or simply found on routine urinalysis.routine urinalysis.  Bladder cancer may alsoBladder cancer may also present symptoms of voidingpresent symptoms of voiding irritability. Patients may complainirritability. Patients may complain of urgency, dysuria andof urgency, dysuria and increased urinary frequency.increased urinary frequency.  Urinary tract infection isUrinary tract infection is observed in 30% of patients.observed in 30% of patients.
    • SymtomatologySymtomatology  Pain appears in advancedPain appears in advanced stages of the tumour. When it isstages of the tumour. When it is located in the suprapubic regionlocated in the suprapubic region it signals that the tumourit signals that the tumour infiltrates the perivesicalinfiltrates the perivesical tissues.tissues.  Flanc pain, often accompaniedFlanc pain, often accompanied by fever, is due to the ureteralby fever, is due to the ureteral obstructions.obstructions.
    • DIAGNOSISDIAGNOSIS Physical examinationPhysical examination  Physical examination, includingPhysical examination, including digital rectal examinationdigital rectal examination andand bimanual pelvic palpation, isbimanual pelvic palpation, is recommended when haematuriarecommended when haematuria is found.is found.  However, 85% of patients withHowever, 85% of patients with bladder cancer initially presentbladder cancer initially present with superficial disease.with superficial disease.  Therefore, physical examinationTherefore, physical examination plays a limited role in theplays a limited role in the diagnosis, except to exclude co-diagnosis, except to exclude co- existing pathologyexisting pathology..
    • DIAGNOSISDIAGNOSIS (Laboratory Findings)(Laboratory Findings)  The most commonly assessedThe most commonly assessed laboratory parameters are:laboratory parameters are:  Haemoglobin and erythrocyteHaemoglobin and erythrocyte sedimentation rate: prognosissedimentation rate: prognosis  Creatinine: overall kidneyCreatinine: overall kidney functionfunction  Alkaline phosphatase: liverAlkaline phosphatase: liver metastasis, bone metastasis.metastasis, bone metastasis.  Serum calcium is frequentlySerum calcium is frequently included in the preoperativeincluded in the preoperative assessment because of itsassessment because of its association with paraneoplasticassociation with paraneoplastic manifestation, which may havemanifestation, which may have clinical implicationsclinical implications..  TheThe erytrocit-erytrocit-,, protein-protein- andand leukocyturialeukocyturia are exposed in urine.are exposed in urine.
    • DIAGNOSIS ImagingDIAGNOSIS Imaging  Urography with cystography areUrography with cystography are performed in all patientsperformed in all patients suspected of bludder tumours.suspected of bludder tumours.  Filling defects in the central partFilling defects in the central part of the cystogram can indicate theof the cystogram can indicate the papillary growth of the tumour.papillary growth of the tumour.  Marginal filling defects are typicalMarginal filling defects are typical of flat tumours, which are alwaysof flat tumours, which are always invasive.invasive.
    • DIAGNOSIS ImagingDIAGNOSIS Imaging  Intravenous pyelography IVPIntravenous pyelography IVP  Large tumours may be seen as fillingLarge tumours may be seen as filling defects in the bladder or may restrictdefects in the bladder or may restrict symmetrical bladder wall expansionsymmetrical bladder wall expansion during filling in invasive tumours.during filling in invasive tumours.  Intravenous pyelography (IVP) is alsoIntravenous pyelography (IVP) is also used to detect filling defects in theused to detect filling defects in the calices, renal pelvis and ureters, andcalices, renal pelvis and ureters, and hydronephrosis, which may indicatehydronephrosis, which may indicate the presence of a ureteral cancer or athe presence of a ureteral cancer or a muscle-invasive bladder cancer at themuscle-invasive bladder cancer at the ureteral orifice.ureteral orifice.  The necessity to perform routine IVP atThe necessity to perform routine IVP at initial diagnosis is now questionedinitial diagnosis is now questioned because of the low incidence ofbecause of the low incidence of important findings obtained with thisimportant findings obtained with this methodsmethods..
    • DIAGNOSIS ImagingDIAGNOSIS Imaging
    • DIAGNOSIS ImagingDIAGNOSIS Imaging (metastasis)(metastasis)  In order to specify staging of the bladder tumour, besides clinicalIn order to specify staging of the bladder tumour, besides clinical examination, USG and bimanual investigation of patients, followingexamination, USG and bimanual investigation of patients, following additional procedures are performed:additional procedures are performed:  1. transurethral diagnostic (primary) resection1. transurethral diagnostic (primary) resection  2. transurethral ultrasonography2. transurethral ultrasonography  3. computed tomography of pelvis minor, retroperitoneum and liver3. computed tomography of pelvis minor, retroperitoneum and liver  4. magnetic resonance of pelvis minor and bones - sites suspected4. magnetic resonance of pelvis minor and bones - sites suspected of the metastases,of the metastases,  5. chest radiograph.5. chest radiograph.
    • DIAGNOSIS ImagingDIAGNOSIS Imaging  UltrasonographyUltrasonography  Transabdominal sonography makes itTransabdominal sonography makes it possible to identify exclusivelypossible to identify exclusively exophytic tumours whose diameterexophytic tumours whose diameter exceeds 10 mm.exceeds 10 mm.  USG is more discriminationg method.USG is more discriminationg method. It helps to determine the depth of theIt helps to determine the depth of the tumour invasion into the bladder wall.tumour invasion into the bladder wall.  Transabdominal ultrasound permitsTransabdominal ultrasound permits characterization of renal masses,characterization of renal masses, detection of hydronephrosis anddetection of hydronephrosis and visualization of intraluminal fillingvisualization of intraluminal filling defects in the bladderdefects in the bladder..
    • DIAGNOSIS ImagingDIAGNOSIS Imaging  Computed tomography is of little use in the diagnosis ofComputed tomography is of little use in the diagnosis of bladder cancers.bladder cancers.  Computed tomography (CT) scanning may be part of theComputed tomography (CT) scanning may be part of the evaluation of invasive bladder tumours and the evaluationevaluation of invasive bladder tumours and the evaluation of pelvic and abdominal lymph node metastasis.of pelvic and abdominal lymph node metastasis.
    • DIAGNOSIS CystoscopyDIAGNOSIS Cystoscopy  TheThe diagnosis of bladderdiagnosis of bladder cancer ultimately depends oncancer ultimately depends on cystoscopiccystoscopic eexamination of thexamination of the bladder and pathologicalbladder and pathological evaluation of the resected lesion.evaluation of the resected lesion.  Cystoscopy shows the size ofCystoscopy shows the size of the tumour, its appearance andthe tumour, its appearance and surroundingsurrounding..
    • DIAGNOSISDIAGNOSIS BiopsyBiopsy  Biopsy is also applied the histology of the tumour as wellBiopsy is also applied the histology of the tumour as well as its grade can be determined.as its grade can be determined.  The biopsy of non-affected parts of the bladder shouldThe biopsy of non-affected parts of the bladder should be obtained in search of carcinoma in situ.be obtained in search of carcinoma in situ.
    • DIAGNOSISDIAGNOSIS BiopsyBiopsy and TURand TUR  Biopsy specimens of the tumour andBiopsy specimens of the tumour and suspected area should be taken tosuspected area should be taken to map the extent of the disease.map the extent of the disease.  Both cold cup biopsies to preserveBoth cold cup biopsies to preserve the histological architecture and TURthe histological architecture and TUR biopsies to determine the extent ofbiopsies to determine the extent of the disease should be performed.the disease should be performed. Random biopsies of normal mucosaRandom biopsies of normal mucosa are indicated in the presence ofare indicated in the presence of positive cytology, even in the absencepositive cytology, even in the absence of a tumour, or in any non-papillaryof a tumour, or in any non-papillary tumour.tumour.  Prostatic urethra biopsies by TUR areProstatic urethra biopsies by TUR are indicated if there is suspicion of Tis ofindicated if there is suspicion of Tis of the bladder in view of the highthe bladder in view of the high frequency of involvement of thefrequency of involvement of the prostatic urethraprostatic urethra..
    • DIAGNOSISDIAGNOSIS Cytological examinationCytological examination  Cytological examination isCytological examination is particularly useful for patients whoparticularly useful for patients who underwent treatment due to bladderunderwent treatment due to bladder cancer. It may also be used as acancer. It may also be used as a screening procedure for people whoscreening procedure for people who are especially vulnerable to bladderare especially vulnerable to bladder cancers because of theircancers because of their professions.professions.  The sensitivity of the methodThe sensitivity of the method increases with the tumour grade. Inincreases with the tumour grade. In grade 3 tumours it varies from 60 tograde 3 tumours it varies from 60 to 87%. The drawback of cytological87%. The drawback of cytological examination is its low specificity.examination is its low specificity.
    • Surgical treatmentSurgical treatment  Three methods ofThree methods of surgical treatment aresurgical treatment are commonly used incommonly used in bladder cancer.bladder cancer.  These are: transurethralThese are: transurethral resection, partialresection, partial cystectomy and radicalcystectomy and radical cystoprostatectomy.cystoprostatectomy.  The choice of theThe choice of the appropriate procedure isappropriate procedure is determined by thedetermined by the following factors: tumourfollowing factors: tumour stage, grade andstage, grade and multifocal growth.multifocal growth.
    • Transurethral resectionTransurethral resection  Transurethral resection as primary therapy should beTransurethral resection as primary therapy should be reserved for patients who have small, solitary, low gradereserved for patients who have small, solitary, low grade superficial carcinomas and bladder papillomas. Thesuperficial carcinomas and bladder papillomas. The procedure makes it possible to remove deep layers ofprocedure makes it possible to remove deep layers of the bladder muscle, which renders the treatment morethe bladder muscle, which renders the treatment more radical.radical.
    • Partial resection of the bladderPartial resection of the bladder  Partial resection of the bladder isPartial resection of the bladder is performed rarely.performed rarely.  The treatment is reserved forThe treatment is reserved for patients with solitary muscle-patients with solitary muscle- infililtrative tumours localised oninfililtrative tumours localised on top of the bladder, far from thetop of the bladder, far from the trigone or vesicle neck. A tumour-trigone or vesicle neck. A tumour- free margin of 1,5 to 2,0 cm mustfree margin of 1,5 to 2,0 cm must be obtained. The results forbe obtained. The results for patients selected carefully for thepatients selected carefully for the procedure were not inferior toprocedure were not inferior to those of cystectomy.those of cystectomy.  In order to improve theIn order to improve the therapeutic results partialtherapeutic results partial resection was combined withresection was combined with chemotherapy.chemotherapy.
    • Radical cystectomyRadical cystectomy  indications for the operation.indications for the operation. These are:These are:  1 invasive bladder cancer1 invasive bladder cancer irrespective of the tumour grade,irrespective of the tumour grade,  2 recurrences of the tumour after2 recurrences of the tumour after transurethral resection,transurethral resection, particularly when the gradeparticularly when the grade increases,increases,  3 high grade tumours coexisting3 high grade tumours coexisting with carcinoma in situ,with carcinoma in situ,  4 multifocally growing superficial4 multifocally growing superficial bladder cancers resistant tobladder cancers resistant to intravesical chemo- orintravesical chemo- or immunotherapy administeredimmunotherapy administered after transurethral resection,after transurethral resection,  5 recurrences of carcinoma in5 recurrences of carcinoma in situ following chemo- orsitu following chemo- or immunotherapy.immunotherapy.
    • Radical cystectomyRadical cystectomy  At present radical cystectomy appears to be the most effectiveAt present radical cystectomy appears to be the most effective therapeutic option for patients with invasive bladder cancer.therapeutic option for patients with invasive bladder cancer.  Five-year survival is assessed by different authors as 30-54% ofFive-year survival is assessed by different authors as 30-54% of cases. However, the operation is dangerous, technically difficult, forcases. However, the operation is dangerous, technically difficult, for which the risk of perioperative morbidity is high.which the risk of perioperative morbidity is high.
    • RadiotherapyRadiotherapy  Poorly differentiated or multiple T1-T2Poorly differentiated or multiple T1-T2 tumours may be treated by localtumours may be treated by local radiotherapy to the bladder andradiotherapy to the bladder and perivesical tissues with five- year survivalperivesical tissues with five- year survival rates of 40-60%. Lymphatic involvementrates of 40-60%. Lymphatic involvement occurs in about 60% of patients with T3occurs in about 60% of patients with T3 tumours and radiation is usually given totumours and radiation is usually given to the whole pelvis. Five-years survival ratesthe whole pelvis. Five-years survival rates after radiotherapy, however are less thanafter radiotherapy, however are less than 35%.35%.  Brachytherapy should only be applied inBrachytherapy should only be applied in selected patients with solitary tumours ofselected patients with solitary tumours of less than 5 cm in diameter.less than 5 cm in diameter.  External -beam radiotherapy is often firstExternal -beam radiotherapy is often first line therapy in Great Britain and Europe,line therapy in Great Britain and Europe, with salvage cystectomy reserved forwith salvage cystectomy reserved for treatment failures.treatment failures.
    • Complication of radiation therapyComplication of radiation therapy  Radiotherapy is generally wellRadiotherapy is generally well tolerated, most patientstolerated, most patients experience dysuria, urgency,experience dysuria, urgency, urinary frequency, andurinary frequency, and diarrhea as acute self limitingdiarrhea as acute self limiting symptoms.symptoms.  Late complication includedLate complication included hematuria, bladder and rectalhematuria, bladder and rectal ulceration, rectal stricture, andulceration, rectal stricture, and small bowel obstruction.small bowel obstruction.  Severe complication requiringSevere complication requiring surgery occurred in 12%.surgery occurred in 12%.
    • Intravesical chemotherapyIntravesical chemotherapy Table : Advantages and disadvantages of therapeutic compounds used in treatment of bladder cancer Name Molecular weigh t Advantages Disadvantages Therapeutic use Thiotepa Small Inexpensive Systemic absorption leading to myelosuppression and renal failure +/- Epodyl Small Inexpensive Systemic side-effects; myelosuppression +/- Adriamycyn Large Minimal absorption Chemical cystitis; expensive + + Epirubicin Large Minimal absorption Chemical cystitis; expensive + + Mitomycin C Large Minimal absorption Chemical cystitis, bladder ulceration; expensive + + Mitoxantron C Large Minimal absorption Chemical cystitis, expensive + + BCG Large Relatively inexpensive Local toxicity, BCG-itis (absorption) + + + Cytokines Interferon Relatively small Effective Systemic toxicity; extremely expensive +
    • Intravesical Bacille Calmette-Guerin (BCG)Intravesical Bacille Calmette-Guerin (BCG) therapytherapy  In 1976 Morales et al. presented the first results ofIn 1976 Morales et al. presented the first results of intravesical BCG instillation in the treatment of superficialintravesical BCG instillation in the treatment of superficial bladder tumours.bladder tumours.  BCG is commonly given in three clinical settings:BCG is commonly given in three clinical settings: (1)prophylaxis in tumour-free patients, (2) treatment of(1)prophylaxis in tumour-free patients, (2) treatment of residual tumour in patients with papillary TCC andresidual tumour in patients with papillary TCC and (3)treatment of patients with carcinoma in situ.(3)treatment of patients with carcinoma in situ.
    • RECOMMENDATIONSRECOMMENDATIONS  Mandatory evalutionsMandatory evalutions::  Physical examination (including digital rectal and pelvic examination)Physical examination (including digital rectal and pelvic examination)  Renal and bladder ultrasonography and/or IVPRenal and bladder ultrasonography and/or IVP  Cystoscopy with description of the tumour: size, site, appearance (a diagram oCystoscopy with description of the tumour: size, site, appearance (a diagram o  UrinalysisUrinalysis  Urinary cytologyUrinary cytology  TUR with:TUR with:  biopsy of the underlying tissuebiopsy of the underlying tissue  random biopsies in the presence of positive cytology, large or non-papillary tumourrandom biopsies in the presence of positive cytology, large or non-papillary tumour  biopsy of the prostatic urethra in cases of Tis or suspicion of itbiopsy of the prostatic urethra in cases of Tis or suspicion of it  When the bladder tumour is muscle infiltrative and radical treatment is indWhen the bladder tumour is muscle infiltrative and radical treatment is ind  Chest X-rayChest X-ray  IVP and/or abdominal/pelvic CT scanIVP and/or abdominal/pelvic CT scan  Liver ultrasonographyLiver ultrasonography  Bone scan if symptoms are present or alkaline phosphatase level is elevatedBone scan if symptoms are present or alkaline phosphatase level is elevated
    • THANK YOU FORTHANK YOU FOR ATTENTIONATTENTION