BLADDER CANCER

OUTLINE
 Introduction
 Etiology

 Risk factors

 Diagnosis

 Classification

 Management

 Take home message

ANATOMY
INTRODUCTION
  It is any of several types of cancer arising from
the tissues of the urinary bladder
  2015, 3.4 million were affected , resulted in 188,000
deaths
 430,000 new cases a year

  Age between 65 - 85 years.

   3x more common in M

 4th most common cancer in men after prostate, lung,

colon.
 9th most common among women

 2x more common in Caucasian compared to Black

ETIOLOGY AND RISK FACTORS
  Smoking: 4-fold increase in incidence
specific carcinogen not identified
 Family history

 Prior radiation therapy

 Genotoxic chemotherapy: cyclophosphamide ↑ risk of

bladder Ca by 9-fold
 Frequent bladder infections

 Exposure to certain chemicals

 mutations at HRAS, KRAS2, RB1, and FGFR3 may be

associated in some cases
“COBRA SCARS”
 Cyclophosphamide - Smoking
 Occupational exposure to chemicals - Chronic UTIs
 - Blackfoot disease - Analgesic abuse
 - RADs to pelvis - Renal Tx recipients
 - Aristolochia fangchi - Schistosomiasis H
SIGNS AND SYMPTOMS

 Hematuria: most common symptom in bladder cancer,

and is painless
 80-90% of people with bladder cancer initially presented
with visible blood
 Dysuria

  Frequent urination,

 Feeling the need to urinate without being able to do so

DIAGNOSIS

  cystoscopy
 IV urography

 Urine cytology:

 CT Scan
PATHOLOGICAL CLASSIFICATION

 Transitional cell carcinoma: 95% of bladder ca

 adenocarcinoma, Squamous cell ca sarcoma, small cell
carcinoma: account 5%
 80% of bladder tumours are confined to the bladder
mucosa, the so called superficial tumours.
 20% invade the muscle layer.

 superficial tumours are fairly benign, and invasive

tumours are highly malignant.
TRANSITIONAL CELL CARCINOMA
  Most bladder cancers begin in the transitional cells.
 It can be low-grade or high-grade

 Low-grade TCC often recurs after treatment, but

rarely spreads .
 High-grade TCC often recurs after treatment and
often spreads
 Almost all deaths from bladder cancer are due to
high-grade disease.
TCC
 CIS
 high grade

 pleomorphic, dark staining, large atypical nuclei

 may be asymptomatic or may present with severe

irritative storage symptoms
 +ve cytology in 80-90% of CIS patients

 40-80% progress to muscle invasive cancer

 75% present with superficial disease
 55-60% present with low grade Ta tumours

 20% recur with high grade disease

 5% progress onto ≥T2 disease

 most young patients (<30yrs) present with TaG1

 almost 50% have occult distant mets clinical mets seen

within 1yr in most
 2% has upper tract disease at initial presentation
 Papillary TCC low grade:15% progression to invasive
disease.
 Papillary TCC high grade: commonly invasive, life
threatening.
 Nested form TCC: higher risk than standard TCC,
chemo sensitive.
 Micropapillary TCC: higher risk than standard TCC, not
chemo sensitive.
SCC
 bilharzial :Schistosomiasis haematobium
 usually younger patients

 less male predominance (only 2:1)

 associated with chronic infection/inflammation

 cancers are exophytic, nodular, fungating lesions

 usually low grade

 low incidence of LN or distant mets

 similar prognosis, stage for stage, with TCC

 usually poor prognosis b/c of advanced disease at

presentation
 urine cytology useless

 bone is the most common site of mets

ADENOCARCINOMA

 account for <2% of primary bladder cancers

 majority represent mets from GI tract, breast, lung r/o colon
primary
 usually arise in trigone or in dome (urachal)

 Develop in response to chronic inflammation and irritation

 most are poorly differentiated and invasive

 more often associated with cystitis glandularis than CIS

 generally poor prognosis due to advanced stage at

presentation
 Not chemosensitive or radiosensitive

 Treatment surgical : radical cystectomy

Carcinosarcoma

Aggressive, not chemosensitive or radiosensitive,

20% 5 yr survival

Small
cell, neuroendocrine: Chemosensitive, Rx neo
adjuvant chemo and cystectomy if responds, rare cure

Leiomyosarcoma: Surgical treatment, cystectomy. 65% five

year survival

Pheochromocytoma

Younger, 20 – 40 years. Adrenergic blockade and

care with TURBT
Metastatic tumor: rare, from breast mets or direct infiltration
colorectal
STAGING PROCEDURE
STAGES
 Stage 0a: Ta, N0, M0
 Stage 0is: Tis, N0, M0

 Stage I: T1, N0, M0

 Stage II: T2a or T2b, N0, M0

 Stage III: T3a, T3b, or T4a, N0, M0

 Stage IV; any of the following:

T4b, N0, M0
any T, N1 to N3, M0
any T, any N, M1
TREATMENT : SUPERFICAL TCC
 Superficial tumors can be "shaved off" using
resectoscope.
 The procedure is called ‘’TURBT’’

 It also serves primarily for pathological staging.

 In case of muscle invasive cancer, the procedure is

insufficient for final treatment
 Immunotherapy by intravesicle delivery of  BCG is also
used to treat and prevent the recurrence of superficial
tumors
 Intravesicle instillation of chemotherapy (mytomicin
C,..) also reduce recurrence but not progression.
MUSCLE INVASIVE DISEASE

 Untreated, superficial tumors may gradually begin to

infiltrate the muscular wall
 Tumors that infiltrate the bladder wall require more radical
surgery:
  cystectomy

 and the urinary stream is diverted into an isolated bowel

loop (called an ileal conduit or urostomy
 neobladder from a segment of intestinal tissue, but depends
on age of patient, renal function, and the site of the disease.
 A combination of radiationand chemotherapy in conjunction
with transurethral (endoscopic) bladder tumor resection can
be used.
MICROMETASTATIC DISEASE

 it is generally not treatable by surgery alone,

and neoadjuvant chemotherapy is needed.
 they first receive systemic cisplatin-based combination
chemotherapy in 3 or 4 cycles.
 Survival benefits are between 5–8%, in a typical follow
up time of 5 years
COMPLICATION

 stomal stenosis and prolapse

 ureteric anastomotic strictures

 para stomal hernias, late bowel obstruction

COMMON SITES OF DISTANT BLADDER
METASTASIS “LL BAG”

 Liver (40%)
 Lung (35%)

 Bone (27%)

 Adrenals (20%)

 GI tract (15%)
SURVIVAL RATE ON BLADDER CANCER?
 higher 5 yr survival among M (esp when compared to
black F)
 F have 30% higher chance of mortality when compared
to M
 blacks almost 2x more likely to die from bladder cancer

 Hispanics have the best survival rates, even for invasive

and advanced disease
 overall mortality from bladder cancer is decreasing
despite increasing incidence
 better survival rates among younger patients
5-YEAR SURVIVAL IN THE U.S.

Stage %

0 98

I 88

II 63

III 46

IV 15
TAKE HOME MESSAGE
 Exposure to industrial chemicals and smoking are major
risk factors
 Haematuria is the key symptom

 In superficial bladder cancer, intravesical chemotherapy

can prevent recurrences but not progression to invasive
bladder cancer
 50% of patients with muscle invasive tumours will die
within 5 years
 Quality of life has been improved but not survival

 Systemic chemotherapy for invasive bladder cancer has

not proved to be beneficial in large series of patients
REFERENCES
 Campbell-walsh urology 11th edition
 Uptodate

 Schwartz principles of surgery 10th edition