Bladder tumor dr,mohamed fawzi alshahwani 1

facts Bladder cancer is the second most common cancer of the genitourinary tract.Bladder cancer is the second most common cancer of the genitourinary tract. Bladder cancer three times more common in men.Bladder cancer three times more common in men. The average age at diagnosis is 65 years.The average age at diagnosis is 65 years. At the time of diagnosis, approximately 75% of bladder cancers are localized to the bladder; 25% have spread to regional lymph nodes or distant sites.At the time of diagnosis, approximately 75% of bladder cancers are localized to the bladder; 25% have spread to regional lymph nodes or distant sites. 2

Risk Factors & Pathogenesis 1)Cigarette smoking 2 )Occupational exposure. Workers in the chemical, rubber, petroleum, leather, and printing industries 3- Pelvic Irradiation. 4- Cyclophosphamide. 5- physical trauma to the urothelium induced by infection, instrumentation, and calculi. 3

Histopathology Ninety-eight percent are epithelial, with most being transitional cell carcinomas 1- Transitional Cell Carcinoma (TCC): commonly appear as papillary, ; less commonly, sessile or ulcerated.commonly appear as papillary, ; less commonly, sessile or ulcerated. Carcinoma in situ (CIS) is recognizable as flat, anaplastic epithelium.Carcinoma in situ (CIS) is recognizable as flat, anaplastic epithelium. 2- Adenocarcinoma: account for <2%. 2- Adenocarcinoma: account for <2%. 4

Secondary bladder tumors: Cancers of the prostate, cervix, and rectum may involve the bladder by direct extension.Cancers of the prostate, cervix, and rectum may involve the bladder by direct extension. The most common tumors metastatic to the bladder include melanoma, lymphoma, stomach, breast, kidney, lung and liver.The most common tumors metastatic to the bladder include melanoma, lymphoma, stomach, breast, kidney, lung and liver. 5

Clinical Findings A. SYMPTOMS: Hematuria 85–90% of patients with bladder cancer usually painless.Hematuria 85–90% of patients with bladder cancer usually painless. Symptoms of advanced disease include bone pain from bone metastases or flank pain from retroperitoneal metastases or ureteral obstruction Symptoms of advanced disease include bone pain from bone metastases or flank pain from retroperitoneal metastases or ureteral obstruction 6

LABORATORY FINDINGS 1.Routine testing GUE…….. Hematuria most common …. pyuria,.. from concomitant UTIs pyuria,.. from concomitant UTIs Azotemia in patients with ureteral occlusion owing to the primary tumor or lymphadenopathy.Azotemia in patients with ureteral occlusion owing to the primary tumor or lymphadenopathy. Anemia may be a presenting symptom owing to chronic blood loss, or replacement of the bone marrow with metastatic disease.Anemia may be a presenting symptom owing to chronic blood loss, or replacement of the bone marrow with metastatic disease. 7

2. Urinary cytology: 3. Other markers: Commercially available tests include, the BTA test and NMP22. 8

4- Imaging Studies: A- IVU.A- IVU. B- U/S.B- U/S. C- CT. SCAN, MRI.C- CT. SCAN, MRI. D- chest x-ray and radionuclide bone scan.D- chest x-ray and radionuclide bone scan. 5..difinit diagnosis by cystoscopy and biobsy

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TREATMENT Once a tumor is visualized or suspected, the patient is scheduled for examination under anesthesia and TURT and biopsy of the suspicious lesion.Once a tumor is visualized or suspected, the patient is scheduled for examination under anesthesia and TURT and biopsy of the suspicious lesion. The objectives of TURT areThe objectives of TURT are 1 tumor diagnosis, 1 tumor diagnosis, 2 assessment of the degree of bladder wall invasion (staging), 2 assessment of the degree of bladder wall invasion (staging), 3 and complete excision of the lesions. 3 and complete excision of the lesions. 16

TURT 17

TREATMENT SUPERFECIAL BT (Ta, T1 ) Small,low grade,single, TURT then check scope every three months SUPERFECIAL BT (Ta, T1 ) large, multiples,high grade,associated CIS, recurrent TURT,intrasical chimotherapy,and check scope every three months DEEP BT (T2-T4) Radical cystectomy with urinary diversion (radiotherapy for unfit patient) METASTATIC TUMOR Systemic chimotherapy

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Treatment intravasical chimotherapy Immunotherapeutic (Bacillus Calmette- Guérin BCG) or chemotherapeutic agents (mitomycin C, thiotepa, and Gemcitabin) can be instilled into the bladder directly via catheter, thereby avoiding the morbidity of systemic administration in most cases.Immunotherapeutic (Bacillus Calmette- Guérin BCG) or chemotherapeutic agents (mitomycin C, thiotepa, and Gemcitabin) can be instilled into the bladder directly via catheter, thereby avoiding the morbidity of systemic administration in most cases. Most agents are administered weekly for 6 weeks.Most agents are administered weekly for 6 weeks.

B. SURGERY 1. TURT : is the initial form of treatment for all bladder cancers. It allows a reasonably accurate estimate of tumor stage and grade and the need for additional treatment.1. TURT : is the initial form of treatment for all bladder cancers. It allows a reasonably accurate estimate of tumor stage and grade and the need for additional treatment. Patients who presented initially with multiple or higher grade lesions (or both) and those who have recurrences at 3 months require more careful surveillance. In such patients, cystoscopy at 3-month intervals is necessary.Patients who presented initially with multiple or higher grade lesions (or both) and those who have recurrences at 3 months require more careful surveillance. In such patients, cystoscopy at 3-month intervals is necessary. 21

Complications of TURBT: Bleeding, Clot Retention And Bladder Perforation. Bleeding, Clot Retention And Bladder Perforation.

2. Partial cystectomy: Patients with solitary, infiltrating tumors (T1– T3) localized along the posterior lateral wall or dome of the bladder are candidates for partial cystectomy, as are patients with cancers in a diverticulum.Patients with solitary, infiltrating tumors (T1– T3) localized along the posterior lateral wall or dome of the bladder are candidates for partial cystectomy, as are patients with cancers in a diverticulum. 3. Radical cystectomy and Urinary diversion: implies removal of the anterior pelvic organs: in men, the bladder with its surrounding fat and peritoneal attachments, the prostate, and the seminal vesicles;implies removal of the anterior pelvic organs: in men, the bladder with its surrounding fat and peritoneal attachments, the prostate, and the seminal vesicles; 23

in women, the bladder and surrounding fat and peritoneal attachments, cervix, uterus, anterior vaginal vault, urethra, and ovaries.in women, the bladder and surrounding fat and peritoneal attachments, cervix, uterus, anterior vaginal vault, urethra, and ovaries. This remains the “gold standard” of treatment for patients with muscle invasive bladder cancer This remains the “gold standard” of treatment for patients with muscle invasive bladder cancer

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CHEMOTHERAPY 15% of patients who present with bladder cancer have regional or distant metastases.15% of patients who present with bladder cancer have regional or distant metastases. The regimen of methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC) has been the most commonly used.The regimen of methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC) has been the most commonly used. 27