Pre management of carcinoma urinary bladder

2. TOPICS COVERED
 Anatomy
 Epidemiology
 Risk factors
 Screening
 Clinical Features
 Pathological Classification
 Natural History
 Diagnosis & Work Up
 Staging

3. Anatomy

5. PARTS

7. .

8. Lymphatic drainage

9. EPIDEMIOLOGY
 9th most common cancer in the world
 M: F, 3: 1
 Whites > blacks
 Incidence increases with age (peaks in the 6th , 7th ,
and 8th decades)
 Median age ≥ 70 yrs

10. INDIAN DATA

11. RISK FACTORS
 Gene abnormalities
 Chemical exposure
 Chronic irritation

12. GENE ABNORMALITIES
 Deletions of part or all of chromosome 9
 Alterations in the gene encoding for fibroblast growth
factor receptor 3 (FGFR3)
 Inactivation of the cohesion subunit stromal antigen 2
 RAS and p21 proteins
 Alterations in the retinoblastoma gene (rb), p53, and
phosphatase and tensin homolog (PTEN).

13. CHEMICAL EXPOSURE
 Aromatic amines, aniline dyes, and nitrites and
nitrates
 Cigarette smoking
 Industrial contact to chemicals, plastics, coal, tar, and
asphalt, and aristolochic acid
 Cyclophosphamide administration over long term

14. Balkan Nephropathy
 Etiology : Aristolochic
acid.
 In the Balkan region,
the exposure seems to
occur via consumption
of bread made from
flour contaminated with
Aristolochia clematitis
seeds.

15. CHRONIC IRRITATION
 Catheters
 Recurrent urinary
tract infections
 Schistosoma
haematobium
 Irradiation

16. FIELD CANCERIZATION AND
CLONALITY
Field Cancerization
Whole urothelium exposed
to carcinogen
Transforms independent
separate groups of cells
Multiple tumors which are
genetically unrelated
Clonality
Single carcinogenic insult to
a single cell
Clones from this cell spread
throughout the Bladder
Topographically distinct
lesions but genetically
related

17. Screening
 Not particularly useful in the detection of bladder
cancer
 The only useful test is urinalysis to detect
microhematuria
 If significant microhematuria detected, then specific
diagnostic studies performed

18. Noninvasive screening
 Cytology : Gold standard
 Sensitivity : 40 % to 60 % & specificity > 90 %
 Other method: FISH, microsatellite analysis of free
DNA, and telomerase reverse transcriptase
determination
 All of these:
 sensitivity 40 % to 75 %
 specificity of 50 % to 90 %

19. Clinical Features
 Painless gross hematuria 75%
 Symptoms of Bladder irritation
 Advanced disease : pelvic pain, ureteral obstruction,
HUN, Rectal obstruction

20. Pathology
 Transitional cell carcinoma >90%
 Squamous Cell Carcinoma 5%
 Adenocarcinoma
 Small Cell Cancer
 Carcinosarcoma
 Melanoma

21. PATHOLOGICAL CLASSIFICATION
 Transitional cell
carcinoma (TCC)*: 90%
of all bladder cancers
 papillary & superficial
(70–75%)
 solid & invasive (20–25%)
 CIS (intraepithelial
carcinoma): 10% of cases:
Appears same as normal
mucosa or as a red velvety
patch

23. GRADING of TCC
 Grade 0- Papilloma
 Grade 1- Well differentiated, Papillary urothelial tumor
of low malignant potential (10% will be invasive)
 Grade 2- Moderately differentiated, high grade
urothelial tumor (50% will be invasive)
 Grade 3- Poorly differentiated, high grade urothelial
tumor (>80% will be invasive)

24. DIAGNOSIS & WORK UP
 History & GPE
 PR
 Complete hemogram, LFTs, KFTs
 Urinalysis (Microscopic hematuria)
 Urine Cytology

25. Cystoscopy+Biopsy
 Indicated in patients with:
 Gross/microscopic
hematuria
 Unexplained or chronic
lower urinary tract
symptoms
 If urine cytology is
suspicious for cancer
 H/O bladder cancer

27. TURBT
 Bimanual examination under anesthesia
If mass palpable : invasive
Mobile mass : T3
Fixed mass : T4
 Sample muscle within the area of tumor to assess
invasion
 Sample biopsies from multiple sites and prostatic
urethra to r/o CIS only if high grade/sessile/in bladder
neck

28. TURBT
Pathology report should include whether:
1. Muscle is present in the sample or not
2. Muscle is invaded or not
3. CIS is present
4. LVI is present

29. Imaging
 To assess extravesical spread and pelvic LN
 MRI is better than CT
 Imaging of the upper pelvis : CT urogram for ruling
out synchronous lesions
 Chest Xray/ CT Thorax to rule out metastasis
 Bone scan if symptomatic or raised ALP
 FDG PET for LN or Distant metastasis

31. MRI

32. PET SCAN

33. Staging (AJCC 2010)

36. Stage 0 (Papillary Carcinoma and Carcinoma in Situ)
Abnormal cells are found in the tissue lining the inside of the bladder

37. Stage I Bladder Cancer
Cancer has spread to the layer of connective tissue next to the inner lining of the bladder.

38. Stage II Bladder Cancer
Cancer has spread to the layers of muscle tissue of the bladder.

39. Stage III Bladder Cancer
Cancer has spread from the bladder to the layer of fat surrounding it. It may also have
spread to the prostate and/or seminal vesicles in men or the uterus and/or vagina in
women.

40. Stage IV Bladder Cancer
Cancer has spread from the bladder to (a) the wall of the abdomen or pelvis, (b) one or
more lymph nodes, and/or (c) other parts of the body, such as the lung, liver, or bone.

41. Bladder cancer: Stage and Prognosis
Stage TNM 5yr 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