bladder cancer ppt

1. Bladder Cancer
OKOA SUKUNALA

2. …so that's the problem…

3. Bladder cancer: Epidemiology
• Incidence: 20/100000/year (Europe)
• Mortality: 8-9/100000/year
• Fourth most common cancer in men
• Incidence: 31.1 mortality: 12.1
• Thirteenth most common cancer in women
• Incidence: 9.5 mortality: 4.5
• At diagnosis >70%: > 65 y of age

4. Bladder cancer: Epidemiology
• In Tanzania the study done by Mahenda D.E at Muhimbili
and Tumaini hospital in 2012 identified women are more
affected than men, and the male to female ratio was 1:1.7.
• Globally men are more commonly affected than females with
a male/female ratio of 10:3

5. Bladder cancer: Aetiology
• Smoking – 4x increased risk
• Causes 50% of cases
• Occupational – rubber/dye industry
• Napthylamine, benzidine
• Schistosomiasis, chronic infection
• Medications – cyclofosfamide, fenacetin

6. Bladder cancer: Histology
• 90-95% transitional-cell carcinoma
• 3% squamos-cell carcinoma
• 2% adenocarcinoma
• <1% small-cell carcinoma
• 99% primary tumors

7. Situation in our setting
Study at MNH and Tumaini hospital documented four
histological types in all patients of bladder cancer,
• squamous cell carcinoma 47 (70.1%)
• transitional cell carcinoma 16(23.9%)
• Adenocarcinoma 3 and Adenosquamous 1.
• Histological grades; were either well or moderately
differentiated.

8. Bladder cancer: Presentation
• Classically painless frank haematuria, sometimes
intermittent
• Frequent urination, urgency
• symptoms with involvement of neighboring organs /kidneys,
lymphoedema, pelvic pain

9. Bladder cancer: Examination
• History
• Physical examination
• Urine examination / urinalysis, cultivation,
cytology – can be only 60% sensitive
• Ultrasound

10. Bladder cancer: Examination
• Cystoscopy is mandatory
• Biopsy or TURBT
• Bimanual pelvic examination /before and
after TURBT/
• Chest X-ray
• IVU – not routinely, (5% chance upper tract
involvement)

11. Bladder cancer: Stage and Prognosis
• Ta – confined to the epithelium, no invasion
through basement membrane
• Tis – carcinoma in situ – aggressive (grade
3) cells confined to epithelium – 50%
progression risk
• T1 – invades lamina propria
• T2 – invades bladder muscle
• T3 – outside bladder
• T4 – adjacent organs involved

12. Bladder cancer: Stage and Prognosis

13. 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%
any T N+Mo 14%
any T M+ med. 6-9 Mo

14. Bladder cancer: Grade (WHO 1973)
• Grade 1 – well differentiated – good prognosis
• Grade 2 – moderately differentiated
• Grade 3 – poorly differentiated
• Least common
• Most progress to invasive disease

15. Bladder cancer: Grade (WHO/ 1998)
• PNLMP - papilar neoplasia low malignant
potential
• LG - papillary carcinoma of low-grade
malignancy
• HG - papillary carcinoma of high-grade
malignancy

16. Carcinoma in situ (CIS)
• Precursor infiltrating tumors
• Primary or secondary
• Subjectively – frequent urination, urgency,
cystalgia
• Objectively – no pathologies
• Laboratory
• Microhematuria
• Cytology positive

17. CIS diagnosis
• Cystoscopy
• Pink areas
• Random biopsy
• Fluorescent cystoscopy

18. CIS treatment
• Primary CIS: BCG
• Secondary CIS: TURB + BCG
• Recurrent CIS /after therapy/: cystectomy

19. Bladder cancer: Treatment
• Superficial Bladder Cancer
pTa, pT1, Tis
• Invasive bladder cancer
pT2-pT4

20. Superficial Bladder Cancer
pTa, pT1, Tis
• Standard of care=intravesical therapy
transurethral resection bladder tumors
/TURBT/
• Relapse rate: 70%
adjuvant therapy

21. TURBT

22. TURBT

23. TURBT

24. TURBT – bladder perforation

25. Superficial Bladder Cancer
• Histological grading is important
G1 G2 G3
Relapse rate 42% 50% 80%
Progression rate 2% 11% 45%

26. Superficial Bladder Cancer
Adjuvant Therapy
• Reduces relapse rate by 30-80%
• Mitomycin C – in patient with intermediate-risk
Bladder tumor
• BCG – in patient with CIS, high risk Bladder
tumor

27. Invasive bladder cancer
• Standard of care =
Radical cystectomy with pelvic lymphadenectomy
Only about 50% of patients with high-grade invasive
disease are cured

28. Radical cystectomy

29. Radical cystectomy

30. Chemotherapy for bladder cancer
• Bladder cancer is a chemosensitive disease
• Active single agents.
• Cisplatin 30%
• Carboplatin 20%
• Gemcitabine 20-30%
• Ifosfamide 20%

31. Chemotherapy for bladder cancer
Combination chemotherapy.
RR CR
• MVAC 40-75% <20%
• Gemzar / Cisplatin 40-70% 5-15%
• Gemzar / Carboplatin 65% 5%
• Taxol / Carboplatin 20-40%
• CR-Clinical reponse
• RR-reduced relapse rate
• MVAC-Methotrexate, vinblastine, doxorubicin (Adriamycin),
and cisplatin

32. Neoadjuvant chemotherapy
• Meta-analysis of ten randomised trials
(2688 patients)
13% reduction in risk of death
5% absolute benefit at 5 years
Overall Survival(O.S) increased from 45% to
50%
ABC Meta-analysis Collaboration. Lancet 2003;361:1927

33. Combined Radio- and Chemotherapy
CR 5y.OS
• Radiotherapy 57% 47%
• RT and cisplatin 85% 69%
• RT and carboplatin 70% 57%
Birkenhake et al. Strahlenther Onkol 1998;174:121

34. Bladder-sparing protocol
Transurthral resection
Induction Therapy: Radiation + chemotherapy
(cisplatin, paclitacel)
Cystoscopy after 1 month
no tumor tumor
Consolidation: RT + CT cystectomy

35. Combined-modality treatment and organ preservation in
invasive bladder cancer
• Rödel et al. JCO 2002;20:3061
• Complete remission 72%
• Local control after CR 64% (10 y.)
• distant metastasis 35% (10 y.)
• Disease-specific survival 42% (10 y.)
• Preservation of bladder >80%

36. Situation in our setting
In a study done by Mahenda D.E at MNH and Tumaini hospital
 patients presented with clinical stage 4 diseases (46.3%).
 Among all 67 patients 13 (26.5%) had cystectomy and 3 (6.1%)
had TURBT.
 The rest had palliation either in the form of chemoradiotherapy
or home palliative care (16(12.2%) and 27 (55.1%) respectively.
 Anaemia was the leading complication (30.5%).
 49.3% died before any treatment .
 15.2% died of renal failure and 54.5% died of advanced bladder
cancer

37. ….so, the bladder has been
removed….then??
and urine, how to get it out…?

38. Urinary diversion
• Diversion of urinary pathway from its natural path
• Types:
• Temporary
• Permanent

39. A nephrostomy is a
surgical procedure by
which a tube, stent, or
catheter is inserted
through the skin
into the kidney

40. Cutaneous
Ureterostomy…
•One kidney
drainage, with
short-live prognosis
•Complications
(infection, stone,
stenosis)

41. Permanent urinary diversion
• Uretero – sigmoidostomy
• Ileal conduit
• Colon conduit
• Ileocaecaecal segment

42. Cutaneous urinary
diversions
Ileal conduit (ileal loop)
A 12 cm loop of ileum led
out through abdominal wall
Stents used
The space at cystectomy
site drained by a drainage
system
After surgery a skin
barrier and a transparent
disposable urinary
drainage bag
Constantly drains

44. Complications of ileal conduit
• Wound infection
• Wound dehiscence
• Urinary leakage
• Ureteral obstruction
• Small bowel obstruction
• Ileus
• Stomal gangrene
• Narrowing of the stoma
• Pyelonephritis
• Renal calculi

45. Continent Urinary Diversions
• Continent Ileal Urinary Reservoir
Indiana Pouch
• Most common continent urinary diversion
• Periodically catheterized
Koch Pouch
Ureterosigmoidostomy
• Voiding occurs from rectum

46. Uretero-
sigmoideostomy

47. Uretero- sigmoidostomy
• Complications:
• Reflux of urine
• Hyperchloraemic acidosis (ammonium chloride
reabsorption, bicarbonates secretion)
• Renal infection
• Stricture formation

49. Potential complications
• Peritonitis due to disruption of anastomosis
• Stoma ischaemia and necrosis due to
compromised blood supply to stoma
• Stoma retraction and separation of
mucocutaneous border due to tension or
trauma

52. Bladder reconstruction

53. references
• Slideshare.com Tomáš Novotný urinary bladder cancer
• Mahenda E.M profile and early treatment outcome of patients with
carcinoma of the urinary bladder as seen in two hospitals (Muhimbili
National hospital and Tumaini) in Dar es Salaam from March 2012 to
December 2012.