Bladder cancer is the fourth most common cancer in men and tenth most common in women. The recurrence rate for superficial bladder cancer is high, with 80% having at least one recurrence. Staging is based on tumor grade, invasion depth, and presence of carcinoma in situ. Treatment depends on stage, with transurethral resection of bladder tumors as first-line treatment for visible tumors and close surveillance after due to high recurrence rates.

1. BY Ahmed Tawfeek

2.  Bladder cancer is the fourth most common cancer in men,
after prostate, lung, and colorectal cancer, And is the 10th
most common cancer in women.
 From 1985-2000, the number of patients diagnosed
annually with bladder cancer increased by 33%.
 The recurrence rate for superficial transitional cell cancer
of the bladder is high, and as many as 80% of patients have
at least one recurrence.
 In developed countries, 90% of bladder cancers are TCC. In
developing countries, 75% of bladder cancers are SCCs, and
most of these cancers are secondary to S haematobium
infection

3.  The clinical course of bladder cancer carries a broad spectrum of
aggressiveness and risk. Low-grade, superficial bladder cancers
have minimal risk of progression to death; however, high-grade
muscle-invasive cancers are often lethal.

4.  Almost all bladder cancers are epithelial in origin. The
urothelium consists of a 3- to 7-cell mucosal layer within
the muscular bladder. Of these urothelial tumors, more
than 90% are transitional cell carcinomas. However, up to
5% of bladder cancers are squamous cell in origin, and 2%
are adenocarcinomas
 The World Health Organization classifies bladder cancers
as low grade (grade 1 and 2) or high grade (grade 3).
Tumors are also classified by growth patterns: papillary
(70%), sessile or mixed (20%), and nodular (10%).
Carcinoma in situ (CIS) is a flat, noninvasive, high-grade
urothelial carcinoma. The most significant prognostic
factors for bladder cancer are grade, depth of invasion, and
the presence of CIS

5. The following is the TNM staging system for bladder cancer:
 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
 T3 - Tumor involvement of the perivesical fat
 T4 - Tumor involvement of adjacent organs such as
prostate, rectum, or pelvic sidewall
 N+ - Lymph node metastasis
 M+ - Metastasis

6.  Laboratory Studies :
 Any patient with gross or microscopic hematuria should be
urologically evaluated
 Urinalysis with microscopy
 Voided urinary cytology
 Newer molecular and genetic markers may help in the early
detection and prediction of TCC.
 Newer, voided urine assays (ie, bladder tumor antigen
[BTA-Stat, BTA-TRAK], nuclear matrix protein [NMP-22],
fibrin/fibrinogen degradation products [FDP]) are being
used for the detection and surveillance of TCC

7.  The American Urologic Association Best Practice Policy
recommends CT scanning of the abdomen and pelvis with
preinfusion and postinfusion phases. This is ideally performed
with a CT urography or followed by radiography of the kidneys,
ureters, and bladder (KUB) to obtain images similar to those
produced with intravenous pyelography (IVP).
 Two commonly used alternative studies are IVP and renal
ultrasonography.
 The IVP is the traditional standard for upper-tract urothelium
imaging; however, it is poor for evaluating the renal parenchyma.
 Ultrasonography is also commonly used; however, urothelial
tumors of the upper tract and small stones are easily missed

8.  To obtain biopsy samples of suspicious lesions
during cystoscopy. And attempt to include the
bladder muscle in the biopsy specimen. This
allows the pathologist to determine whether
the tumor is muscle invasive or not.
 Transitional cell tumors are typically papillary or
sessile, and CIS may appear as an erythematous,
velvety lesion.

9. invasive
Ta
T
CIS
 More than 70% of all newly diagnosed bladder cancers
are superficial, approximately 50-70% are Ta, 20-30%
are T1, and 10% are CIS. Approximately 5% of patients
present with metastatic disease

10.  Superficial bladder cancer has a good
prognosis, with 5-year survival rates of 82-100%.
 The 5-year survival rate decreases with increasing
stage, as follows:
 Ta, T1, CIS – 82-100%
 T2 – 63-83%
 T3a – 67-71%
 T3b – 17-57%
 T4 – 0-22%

11.  The risk of progression, defined as an increased tumor
grade or stage, depends primarily on the tumor grade.
 The risk of progression increases with tumor grade, as
follows:
 Grade I – 10-15%
 Grade II – 14-37%
 Grade III – 33-64%
 CIS alone, or in association with Ta or T1 papillary
tumor, carries a poorer prognosis and a recurrence rate
of 63-92%.

12.  Endoscopic treatment
 Transurethral resection of bladder tumor (TURBT) is the
first-line treatment to diagnose, to stage, and to treat
visible tumors.
 Patients with bulky, high-grade, or multifocal tumors
should undergo a second procedure to ensure complete
resection and accurate staging. Approximately 50% of stage
T1 tumors are upgraded to muscle-invasive disease.
 Electrocautery or laser fulguration of the bladder tumor is
sufficient for low-grade, small-volume, papillary tumors.
 No further metastatic workup is needed for obviously
superficial tumors.
 Because bladder cancer is a polyclonal field change
defect, continued surveillance is mandatory.

13.  The high rate of disease recurrence and progression in
superficial bladder cancer underscores the need for
careful follow-up studies.
 Surveillance for patients with superficial transitional
cell bladder cancer includes cystoscopy and bladder
wash cytologies every 3 months for 2 years, then every
6 months for 2 years, and then at least yearly.