PPT by Basheer Oudah -Bladder Cancer

1. Bladder Cancer
• I JAvahishvili Tbilisi StateUniversity
Division of Medicine
Department of Urology
PPT madeby student Basheer Oudah

2. Epidemiology
• 5th male, 9th female cancer
• Incidence ( M:F = 3:1)
• 142/100 000 in Men
• 33/100 000 in Women
• Pathology usually Transitional Cell Carcinoma (95%)
also
• Squamous cell, adenocarcinoma, small cell, lymphoma,
sarcoma, carcinosarcoma

3. Etiology
• Smoking ( accounts for 2/3 of bladder cancer cases)
• Other risk factors
• Age, male sex
• Chronic bladder inflammation, schistosomiasis
• External beam radiation
• Previous exposure to cyclophosphamide.
• At risk occupations (carcinogens, aniline dyes, diesel)
• Hairdressers, machinists, printers, painters
• Rubber, chemical, textile, metal, leather industries

4. Pathology of Bladder Cancer
• 90% Transitional Cell Carcinoma (TCC)
• 5% squamous cell -more common in middle east –
schistosomiasis
-also seen in chronic catheterization
• 0.5%-2% Adenocarcinoma – urachal
• Rare- Small cell Carcinoma

5. Transitional Cell Carcinoma
• Accounts for 90-95% of all bladder tumors.
• Ranges from low grade superficial papillary tumour to high
grade invasive disease
• Histologically – Increased epithelial cell layer
-- Papillary folding of mucosa, Prominent Nuclei
,Clumping of chromatin,Loss of cell polarity.

6. Staging

7. Bladder cancer: Stage and Prognosis
Stage TNM 5-y. Survival
0 Ta/Tis NoMo >85%
I T1 NoMo 65-75%
II T2a-b NoMo 57%
III T3a-4a NoMo 31%
IV T4b NoMo 24%
each T N+Mo 14%
each T M+ med. 6-9 Mo

8. Symptoms
• Hematuria (80%)
• Painless Microscopic
Hematuria
• ‘Cystitis’ and sterile pyuria
• Bladder irritability
• Anemia
• Urinary tract infection
• Pain (advanced disease)
• Ureteric orifice obstruction

9. Investigations
• Cystoscopy
• EUA ( Examination Under Anesthesia)
• Transurethral Resection of the Bladder Tumors ( TURBT)
• Biopsies
• Ultrasound kidneys/abdomen
• CT scan/MRI scan
• Differential diagnosis
• Staging ( In muscle invasive disease, CT abdomen must always
be performed for staging prior to making treatment decisions)
• IVU.
• Bone scan if symptomatic or raised alkaline phosphatase

10. DIAGNOSIS SYSTEMIC EXTENT (M STAGE )
• Pulmonary - chest film
- Linear tomography
- CT/PET
• BONE - Bone scan /Bone survey
- MR
• LIVER - Liver scan
- CT/MR/PET
- Laproscopy

11. IMAGING
IVU
• Filling defect, Irregularity

12. CT SCAN
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.

13. MRI

14. Ultrasound

15. CYSTOSCOPY
• Cystoscopy is the gold standard for diagnosis of bladder cancer
since it allows complete visualization of the urethral and
bladder mucosa. Any lesions visualized during cystoscopy are
biopsied and/or resected . Resection has therapeutic value, and
also allows for staging and provides pathologic information.
Cystoscopy is 73% sensitive and 68.5% specific in diagnosing
bladder cancer.

16. Management
• Non-Muscle Invasive Bladder Cancer
•Muscle-Invasive Bladder Cancer
•T4 Disease
•Metastatic Bladder Cancer

17. Superficial Bladder Cancer
• 70%, Ta, T1, Tis {CIS}
• Presence of Tis in the mucosa adjacent to a Ta or
T1 tumor  increases the risk for muscle invasive
disease
• Recurs at primary site or elsewhere in UT.
• May be lifelong disease
• Diagnose by cystoscopy
• TURBT then adjuvant intravesical therapy for high
risk ( BCG is most commonly used and superior
intravesical agent. Mitomycin C single shot - (17%
decrease in early recurrence rate)
• Further management depending on pathology
and risk stratification ( risk for recurrence or
progression).

18. Muscle invasive disease
• T2-T3 disease (40-60% 5 year survival)
• Options are
• cystectomy (+/- reconstruction) with neoadjuvant chemotherapy or
• radiotherapy +/- chemotherapy
• Radical cystectomy
• Main treatment modality for muscle invasive bladder cancer for patients
who are not candidates for bladder preservation approaches.
• Involves lymph node dissection and removal of bladder and prostate and
seminal vesicles or anterior vaginal wall, uterus, fallopian tubes and
ovaries
• Side effects include loss of native bladder and impotence.
• Bladder preservation strategies
• Elderly, those with significant comorbidities, poor performance status,
those who desire to preserve their bladder.

19. Radical cystectomy

20. Chemoradiation
• Combines radical TURBT followed by
external-beam radiation therapy .
• Repeat Cystoscopy to evaluate the
response
• 60 to 75% will achieve a complete
response to chemoradiation and
preserve their bladders
• 25 to 40 percent of non-responders will
need immediate salvage cystectomy.

21. Muscle Invasive
• Chemotherapy should be added to surgery
( cystectomy).
• Improves survival - 5% survival benefit at 5 years for
neoadjuvant chemotherapy
• Preferred regimen – Cisplatin based combination
therapy

22. Stage T4 Disease
• T4a -prostate, uterus, vagina involved
• T4b - pelvic side wall or abdominal wall
• 10 % 5 year survival for T4a
- give chemotherapy if patient is fit ( good
performance status) and then radiotherapy to pelvis.
- For those with good PS and adequate renal function,
Cisplatin-based chemotherapy. Gemcitabine + Cisplatin is
the preferred regimen .
- For those with poor PS and impaired renal function,
carboplatin based therapy
• Palliative treatment for T4b

23. THE END
Questions ?