This document provides tips for using a PowerPoint presentation (PPT) as an active learning tool. Some key points: - Blank slides are included between content slides to allow time for student discussion of what they already know about each topic. - The presenter should first show a blank slide, ask students for their input, then show the next slide with content. - This process of blank slide + discussion, then content slide, is repeated for each topic and can be done through multiple revisions for deeper learning. - It can be used for self-study by displaying a blank slide, thinking about what you know, then reading the next content slide.

1. Tips on using my ppt.
1. You can freely download, edit, modify and put your
name etc.
2. Don’t be concerned about number of slides. Half the
slides are blanks except for the title.
3. First show the blank slides (eg. Aetiology ) > Ask
students what they already know about ethology of
today's topic. > Then show next slide which enumerates
aetiologies.
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
three revisions.
6. Good for self study also. Good for self study also.
Display blank slide> Think what you already know about
this > Read next slide.

2. Learning Objectives
1.

3. Learning Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.
•

5. Introduction & History.
• Bladder cancer is a common urologic
cancer that has the highest recurrence rate
of any malignancy.
• The most common type is urothelial
carcinoma (UC).
• Other types squamous cell and
adenocarcinomas.

6. Relevant Anatomy
•

7. Relevant Anatomy
• Arises in urothelium- transitional
epithelium.
• It lines urinary ducts
• Multilayered-
– renal calyxes (2 cell layers),
– ureters (3 to 5 cell layers),
– urethra (4 to 5 cell layers)
– and urinary bladder (up to 6 cell layers).

8. Relevant Anatomy
• The bladder is lined by epithelial cells that
are somewhere in between the thick layers
of squamous cells and the single layer of
tall cells of glandular epithelia. Logically,
these cells are called transitional cells
because they represent a transition
between these two disparate epithelial
cell types.

9. Aetiology

10. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

11. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

12. Aetiology of Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

13. Risk Factors
•

14. Risk Factors
• Up to 80% of bladder cancer cases are associated
with environmental exposure.
• Upto 50% bladder cancer is due to smoking.
• Tobacco smoking nitrosamine, 2-naphthylamine,
and 4-aminobiphenyl are possible carcinogenic
agents found in cigarette smoke..
• Workers exposed to aromatic amines , polycyclic
aromatic hydrocarbons and heavy metals.

15. Risk Factors
who work with organic chemicals and dyes:
• Beauticians
• Dry cleaners
• Painters
• Paper production workers
• Rope-and-twine industry workers
• Dental workers
• Physicians
• Barbers

16. Risk Factors
• People living in urban areas are also more likely to
develop bladder cancer.
• Arsenic exposure
• Radiation treatment of the pelvis
• Chemotherapy with cyclophosphamide

17. Risk Factors for SCC
• Long-term indwelling catheters - A 16- to 20-fold
increase in the risk of developing SCC
• Schistosoma haematobium infection
• Bladder diverticula
• BCG treatment for CIS has been reported to lead
to development of SCC.
• Bladder exstrophy
• Urachal remnants

18. Risk Factors
• No convincing evidence exists for a hereditary
factor
• Coffee consumption does not increase the risk of
developing bladder cancer.
• Artificial sweeteners (eg, saccharin, cyclamate)
and bladder cancer;

19. Pathophysiology

20. Pathophysiology
• Urothelial carcinoma (UC) initiates by
carcinogens excreted in urine.
• SCC – Chronic irritation.

21. Pathophysiology
• Bladder cancer is often described as a
polyclonal field change defect with frequent
recurrences due to a heightened potential
for malignant transformation.
• Urothelial carcinoma (UC) arises from stem
cells that are adjacent to the basement
membrane of the epithelial surface.

22. Pathophysiology
Important early molecular events-
– somatic mutations in-
• Fibroblast growth receptor3 (FGFR-3)
noninvasive
• Tumor protein p53 (TP53) and
invasive pathways
– Loss of heterozygosity (LOH) on
chromosome 9.

23. Pathology
•

24. Pathology
• The most common type is urothelial carcinoma
(UC).
• Other types squamous cell and adenocarcinomas.
• Growth patterns:
– Papillary (70%)
– Sessile
– Mixed
– Nodular

25. Classification

26. Classification
• Non–muscle-invasive bladder cancer
• Muscle-invasive bladder cancer
• The current WHO/International Society of
Urological Pathology (ISUP) system
classifies bladder cancers as low grade or
high grade.

27. Staging

28. TNM Classification
• T

29. TNM Classification
• TX -
• T0 -
• Tis -
• T1 -
• T2 -
• T3 -
• T4 -

30. TNM Classification
• CIS - Carcinoma in situ, high-grade dysplasia, confined to
the epithelium
• Ta - Papillary tumor confined to the epithelium
• T1 - Tumor invasion into the lamina propria
• T2 - Tumor invasion into the muscularis propria: T2a,
superficial muscularis propria; T2b, deep muscularis
propria
• T3 - Tumor involvement of the perivesical fat: T3a,
microscopic invasion; T3b, macroscopic invasion
• T4 - Tumor involvement of adjacent organs: T4a, invasion
of prostatic stroma, seminal vesicles, uterus, or
vagina; T4b, invasion of pelvic or abdominal wall

31. TNM Classification
• N- Regional lymph nodes

32. TNM Classification
N- Regional lymph nodes
• NX -
• N0 -
• N1 -
• N2
• N3

33. TNM Classification
N- Regional lymph nodes
• N0: No regional lymph node metastasis
• N1: Metastasis in a single lymph node in
true pelvis
• N2: Metastasis in multiple regional lymph
nodes in true pelvis
• N3: Metastasis in common iliac lymph
node(s).

34. TNM Classification
M- Metastasis-
• MX -
• M0 -
• M1 -

35. TNM Classification
M- Metastasis-
• M0: No distant metastsis
• M1a: Non regional lymph nodes
• M1b: Other distant metastasis.

36. Clinical Features
•

37. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

38. Demography

39. Demography
• Incidence & Prevalence
• Geographical distribution.
• Race
• Age
• Sex
• Socioeconomic status
• Temporal behaviour

40. Demography
• Incidence & Prevalence-

41. • Incidence & Prevalence-
– Bladder cancer is the fourth most common
cancer in men in the United States
Demogrphy

42. • Geographical distribution.
Demography

43. Demography
• Geographical distribution.
– In industrialized countries, 90% of bladder
cancers are TCC.
– In developing countries—particularly in the
Middle East and Africa—the majority of
bladder cancers are SCCs, and most of these
cancers are secondary to Schistosoma
haematobium infection.

44. Demography
• Race.

45. Demography
Race.
• The incidence of bladder cancer is twice as
high in white men as in black men in the
United States.

46. Demogrphy
• Age

47. Demography
• Age
– The incidence of bladder cancer increases with
age, with the median age at diagnosis being 73
years; bladder cancer is rarely diagnosed before
age 40 years.

48. Demography
• Sex

49. Demography
• Sex
– 3 times more common in men than in women.

50. Symptoms

51. Symptoms
7 warning signals of cancer
1. Change in bowel or bladder habits.
2. A sore that does not heal.
3. Unusual bleeding or discharge.
4. Thickening or lump in the breast or
elsewhere.
5. Indigestion or difficulty in swallowing.
6. Obvious change in a wart or mole.
7. Nagging cough or hoarseness.

52. Symptoms
7 warning signals of cancer
1. Change in bowel or bladder habits.
2. A sore that does not heal.
3. Unusual bleeding or discharge.
4. Thickening or lump in the breast or
elsewhere.
5. Indigestion or difficulty in swallowing.
6. Obvious change in a wart or mole.
7. Nagging cough or hoarseness.

53. Symptoms
• Painless gross hematuria bladder cancer
unless prooved otherwise.
• Irritative bladder symptoms (eg, dysuria,
urgency, frequency of urination)
• Pelvic or bony pain, lower-extremity
edema, or flank pain - In patients with
advanced disease
• Palpable mass on physical examination -
Rare in superficial bladder cancer

54. Signs

55. Signs
• General Examination
• Systemic Examination
• Local Examination

56. Signs
• Local Examination

57. Signs
• Local Examination-
– Non ̶ muscle-invasive bladder cancer is
typically not found during a physical
examination.
– In rare cases, a mass is palpable during
abdominal, pelvic, rectal, or bimanual
examination.
– Attention to the anterior vaginal wall in women
and the prostate in men may reveal findings that
suggest local extension of bladder cancer.

58. Prognosis

59. Prognosis
• Morbidity
• Mortality rate
• 5 year survival in Malignancy

60. Prognosis
• The recurrence rate for superficial TCC of
the bladder is high.
• Non–muscle-invasive bladder cancer has a
good prognosis, with 5-year survival rates
of 82-100%.
• Prognosis for patients with metastatic
urothelial cancer is poor,

61. Investigations

62. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology
– Germ line Testing and Molecular Analysis
• Diagnostic Laparotomy.

63. Investigations in Malignancy
•

64. Investigations in Malignancy
• For diagnosis
• For staging
• For Screening
• For Monitoring

65. Diagnostic Studies

66. Diagnostic Studies
Laboratory Studies
• Urinalysis with microscopy
• Urine culture to rule out infection, if suspected
• Voided urinary cytology with Fluorescence in situ
hybridization (FISH).
• Bladder washings can be obtained by placing a
catheter into the bladder and vigorously irrigating
with saline (ie, barbotage).
• Urinary tumor marker testing

67. Diagnostic Studies
Urinary tumor marker testing
• Over 30 urinary biomarkers have been
reported for use in bladder cancer diagnosis,
but only a few are commercially available.
• None have been accepted for diagnosis or
follow-up in routine urologic practice or in
guidelines.

68. Diagnostic Studies
Cystoscopy
• The primary modality for the diagnosis of
bladder carcinoma
• Permits biopsy and resection of papillary
tumors

69. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

70. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT – CECT abdomen, CT urography
• Angiography
• MRI
• Endoscopy- Cystoscopy
• Nuclear scan

71. Differential Diagnosis

72. Differential Diagnosis
• Urinary Tract Infection (UTI) and Cystitis
• Hemorrhagic Cystitis: Noninfectious
• Nephrolithiasis
• Renal Cell Carcinoma
• Renal Transitional Cell Carcinoma
• Ureteral Trauma

73. Management

74. Management
• Non–muscle-invasive bladder cancer
carcinoma in situ [CIS]
– -transurethral resection of bladder tumor
(TURBT) with postoperative dose of
intravesical chemotherapy and periodic
cystoscopy.
• Muscle-invasive -
– Radical cystoprostatectomy in men
– Radical cystectomy with anterior pelvic
exenteration in women
• Bilateral pelvic lymphadenectomy (PLND),
standard or extended

75. Management
• Creation of a urinary diversion (eg, ileal
conduit, Indiana pouch, orthotopic bladder
substitution).
• Neoadjuvant chemotherapy - May improve
cancer-specific survival
• Trimodality therapy-
1. TURBT
2. followed by concurrent radiation therapy
3. systemic chemotherapy.

76. Chemotherapeutic regimens

77. Chemotherapeutic regimens
• Methotrexate, vinblastine, doxorubicin
(Adriamycin), and cisplatin (MVAC)
• Gemcitabine and cisplatin (GC)

78. Targeted Therapy
• Atezolizumab
• Nivolumab
• Avelumab
• Pembrolizumab
• Erdafitinib,

79. Prevention

80. Prevention
• Screening
• Risk Reduction
– Cigarette smoking
– occupational exposure to carcinogens, with a
recommendation that workers be informed of
the risk and protective measures taken.
• Aromatic hydrocarbons - common in metal
processing
• Aromatic amines - used in dyes
• N-nitrosamines - found in rubber and tobacco
• Formaldehyde

81. Guidelines
• American Urological Association/Society of
Urological Oncology (AUA/SUO)
• European Association of Urology (EAU)
• European Society for Medical Oncology
(ESMO)
• National Comprehensive Cancer Network
(NCCN)

82. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

84. Get my ppt collection
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