Ca bladder symptomatology diagnosis

1. Ca Bladder :
Diagnosis
DR. DEEPESH KALRA
INSTITUTE OF UROLOGY
MMC, CHENNAI

2.  Hematuria
 Irritative LUTS - 30% , especially those with CIS
 Upper urinary tract obstruction - rare on initial presentation, a sign of
advanced disease
 Pain in suprapubic region, buttock, perineum may suggest invasion of
paravesical tissue
 Weight loss
 Bony pain

3. Hematuria
 Gross or microscopic?
 Timing ?
 Associated with pain?
 Clots?
 Hematuria, particularly in the adult, should be regarded as a symptom of
malignancy until proved otherwise and demands immediate urologic
examination

4.  Gross, painless hematuria - 85%
 Microscopic hematuria occurs in virtually all patients
 Intermittent and can be related to Valsalva
 Any episode of gross hematuria should be evaluated even if subsequent
urinalysis is negative.
 Gross - 12% will have a bladder tumor
 Microscopic - 4.1% risk of bladder cancer

5. Common Risk Factors for Urinary Tract Malignancy in
Patients with Microscopic Hematuria
 Male gender
 > 35 years
 Smoker
 Exposure to chemicals or dyes (benzenes or aromatic amines)
 Analgesic abuse
 History of gross hematuria
 History of irritative voiding symptoms
 History of pelvic irradiation
 History of chronic urinary tract infection
 Chemotherapy such as alkylating agents
 History of chronic indwelling foreign body

6.  A full hematuria evaluation for bladder cancer includes
Cystoscopy
Urine cytology
Upper-tract imaging

8. Symptomatic MH
 Cystoscopy is recommended in such patients, regardless of age
 Cytologic examination is considered an option in the setting of irritative
voiding symptoms
 Cystoscopy should not be omitted even if the cytologic findings are
negative

9.  The main diagnostic tests for bladder cancer are cystoscopy and biopsy
 White light cystoscopy (WLC) is the gold standard
 excellent sensitivity and specificity for papillary tumors but is relatively
poor for CIS
 Cystoscopy with porphyrin dye (commonly referred to as blue light
cystoscopy) may be more sensitive in the detection of CIS

10.  Porphyrin-induced fluorescence cystoscopy uses photoactive
porphyrins, such as 5-aminolevulinic acid (ALA) or hexyl-
aminolevulinate (HAL) , that accumulate preferentially in
neoplastic tissue and emit red fluorescence under blue-
wavelength light

11.  Blue light cystoscopy detected 58% of CIS compared with 15%
for WLC.
 The sensitivity of blue light was 87% and was 83% for white
light.
 Blue light cystoscopy has a false-positive rate of 39%
 The true impact of blue light cystoscopy on the detection of
bladder cancer is unclear

12.  Narrow-band imaging (NBI) is an endoscopic optical image
enhancement technique
 enhances the contrast between mucosal surfaces and
microvascular structures without the use of dyes.
 NBI illuminates the mucosal surface with light of a narrow
bandwidth in the blue (415 nm) and green (540 nm) light
spectrum, which are strongly absorbed by hemoglobin.
 Consequently, the vascular structures appear dark brown or
green against a pink or white mucosal background.

13.  For WLC and NBI cystoscopy, overall sensitivities were 87%
and 100% and the overall specificities were 85% and 82%,
respectively.
 A recent study suggests that NBI more accurately detects
tumor recurrence after BCG therapy than do urine cytology or
WLC
 and NBI can obviate the need for random bladder biopsies in
post-BCG bladders

14. Random biopsies
 High-risk individuals, such as those given post-intravesical
therapy
 Positive cytology and an endoscopically negative bladder.

15. Cytology
 Detection of cancer in high-risk patient
 Follow-up of patients with history of urinary tract neoplasia
 Patients with low-grade noninvasive tumors can be followed up cytologically
 Patients with negative cytologic findings have a very low risk of recurrence
 High-grade cytologic abnormalities predict an aggressive tumor course

16.  A positive cytology should always be confirmed histologically before
definitive therapy.
 False positive - stones, chemotherapy, radiation, viruses, BPH, prostatitis,
and pseudopapillary clusters.
 False-negative diagnosis may be of more clinical consequence.
 Cytologic diagnosis of papillomas and well-differentiated papillary
transitional cell carcinoma (TCC) can be difficult or impossible because the
cells are nearly normal appearing.

17.  Morning
 First void
 50 ml
 Refrigerated in 1 hour

19.  Cytologic diagnosis of papillomas and well-differentiated
papillary transitional cell carcinoma (TCC) can be difficult or
impossible because the cells are nearly normal appearing.

20.  PUNLMP and low grade urothelial neoplasia
Cytologic Criteria:
Cytoplasmic homogeneity
High nuclear to cytoplasmic ratio
Irregular borders.
Architectural criteria:
Papillary fragments with fibrovascular cores
Irregular cell clusters

21.  High grade urothelial carcinoma:
High nuclear to cytoplasmic ratio,
Marked nuclear hyperchromasia
Coarsely granular chromatin
irregular nuclear outline
large nucleoli (some cases).

22.  Squamous cell carcinoma
Cytoplasmic keratinization
Pearls,
Bridges
Angulated hyperchromatic nuclei.
 Adenocarcinoma
Glandular differentiation is common in otherwise typical urothelial carcinoma,
therefore the definitive diagnosis of pure adenocarcinoma is left to biopsy.

23.  Clear cell carcinoma:
abundant clear cytoplasm
large irregular nuclei,
vesicular chromatin
large nucleoli.
 Lymphoma
Rare but can potentially be diagnosed with urine cytology.

24. • Diagnostic categories for The Paris System for Reporting Urinary
Cytology
1 Nondiagnostic/unsatisfactory
2 Negative for high-grade urothelial carcinoma (NHGUC)
3 Atypical urothelial cells (AUC)
4 Suspicious for high-grade urothelial carcinoma (SHGUC)
5 High-grade urothelial carcinoma (HGUC)
6 Low-grade urothelial neoplasm (LGUN)
7 Other: primary and secondary malignancies and
miscellaneous lesions

25. Category Risk of malignancy % Management
Nondiagnostic/unsatisfactory < 5-10 Repeat
Negative for High grade 0-10 Clinical follow up
Atypical 8-35 Clinical follow up
Suspicious for high grade 50-90 Aggessive followup,Cystoscopy +
biopsy
Low grade 10 Cystoscopy + biopsy, staging
High grade >90 Cystoscopy + biopsy, staging
Other malignancy >90 Cystoscopy + biopsy, staging

26. Markers

28. Marker Median Sensitivity Median Specifcicity
BTA stat 70 75
BTA trak 69 65
NMP 22 73 80
FDP 61 79
ImmunoCyt 83 80
LEWIS X 83 85
FISH 84 95
Microsatellite 91 94
Cyfra 21 94 86
Cytoketin 20 91 84

29.  NMP-22 is a nuclear matrix protein that is used to form the cell nuclei.
 20-times higher concentration in the urine of bladder cancer patients
in noncancer controls
 With use of a cutoff level of 10 units/mL, the overall sensitivity and
specificity for detecting urothelial cancer were 49% and 87%, respectively.

30.  The Lewis blood group antigen X -
The sensitivity and specificity for the detection of bladder cancer are 75% and 85%,
respectively.
There is no commercially available test to date.
 FISH -
identifies fluorescently labeled DNA probes that bind to intranuclear chromosomes.
Commercially available probes evaluate aneuploidy for chromosomes 3, 7, and 17 and
homozygos loss of 9p 21 .
The median sensitivity and specificity of FISH analysis are 79% and 70%, respectively

31.  Multiple markers are available to identify short DNA repeats present
throughout the chromosomes that are lost in some tumor cells.
 Microsatellite analysis amplifies these repeats
 If the microsatellite analysis was persistently positive, there was an 83% 2-
year recurrence rate, but
 if the analysis was persistently negative, only 22% of patients had recurrent
tumors

32.  Together, because current evidence indicates that none of the available
urinary biomarkers, including cytology, appear to be sufficiently
sensitive or sufficiently validated to replace cystoscopy or imaging,
 these studies are not recommended in the initial evaluation of patients
with asymptomatic MH
 However, cytologic examination may be considered in patients with a
negative initial workup in whom urothelial carcinoma is still suspected,
as well as in patients with symptomatic MH.

33.  Patients with a negative complete evaluation can be released
from care if subsequent urinalyses confirm resolution of MH.
 Re-evaluation should be considered in patients with
persistent/recurrent MH and those with an incomplete initial
evaluation.

34. Imaging
 USG
Useful screening tool
To r/o other causes of hematuria
Helps to identify the growth(size/sessile or
polyp,number )
Helps to detect upper tract changes

37. CT
 Staging of the tumor
 Extent of primary tumor
 Rule out invasive bladder cancer
 Assess pelvic LN status ( > 1 cm )
 Visceral metastasis
 Evaluation of upper urinary tract

38.  Asymmetric mural thickening should be viewed with suspicion.
 The masses are of soft tissue attenuation and may be encrusted with small
calcifications.
 Although unable to distinguish between T1, T2 and T3a (microscopic extravesical
spread),
 CT is able to distinguish T3b tumors (stranding/nodules in perivesical fat) and T4
tumors (direct extension into adjacent structures/loss of normal fat plane)

39. MRI
 MRI is superior to other modalities in locally staging the tumor
 In some instances able to distinguish T1 from T2 tumors on T2 weighted images.
 T1: isointense compared to muscle
 T2
 slightly hyperintense compared to muscle
 useful in determining the low signal muscle layer and its discontinuity when muscle
wall invasion

40. T1
 Urine low signal
 Tumor and detrusor –
indeterminate
 Fat – high signal intensity
 luminal extension and perivesical
fat infiltration

41. T2
 Urine – high intense
 Tumor –indeterminate to high
intensity
 Detrusor – low signal
 Differentiate between non
muscle invasive and
invasive tumor

42. DWI
 Tumor is more cellular,
less ADC (apparent
diffusion coefficiant)
 Used to differentiate
between scar tissue
and recurrence .
 Chemotherapy
response

43. PET
 Unfortunately, FDG is excreted into the urine and thus accumulates in the
bladder, making it unsuitable for diagnosis of urinary tract tumors.
 It does have a role to play in the assessment of nodal or distant
metastases

44. THANK YOU