1. Transitional Cell Carcinoma of the Urinary Tract
Manish Patel
Urology Registrar
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Transitional Cell Carcinoma of the Urinary Tract

2. Epidemiology Men >women Incidence increasing in men
Mortality decreasing
Age- middle aged and elderly
Race- blacks > whites
All symptomatic before death
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Transitional Cell Carcinoma of the Urinary Tract

3. Etiology Smoking Occupational exposure Analgesic abuse
Cyclophosphamide
?heredity
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Transitional Cell Carcinoma of the Urinary Tract

4. Pathology Carcinoma insitu Superficial invasive Low grade Mod grade
High Grade
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Transitional Cell Carcinoma of the Urinary Tract

5. Natural History 75% superficial at presentation
2/3 well-mod diff.- 0nly 10% become invasive or metastastic
1/3 high grade-50% become invasive
25% invasive- most are high grade
CIS- 16% become invasive
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Transitional Cell Carcinoma of the Urinary Tract

6. Natural History 40% muscle invasive TCC have occult distant mets
Nearly all Pts with mets die within 2 years
Spread
Lymphnodes, Liver, Lung, Bone, Adrenal
Local Complications
Bleeding, Pain, Ureteral Obstruction, Local invasion
surrounding structures/fistula.
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Transitional Cell Carcinoma of the Urinary Tract

7. Diagnosis Microurine, urine cytology IVP, U/S, CT
Cystoscopy and biopsy
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Transitional Cell Carcinoma of the Urinary Tract

8. Staging Biopsy CT abdomen and pelvis CXR Bone scan
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Transitional Cell Carcinoma of the Urinary Tract

9. Management superficial bladder TCC
Transurethral resection or fulgration
70% 5 year survival
10% will ultimately require more aggressive Treatment
Lamina Propria invasion has 46% muscle invasion later
multiple or recurrent TCC will respond to intravesical chemo or BCG
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Transitional Cell Carcinoma of the Urinary Tract

10. Management of Muscle Invasive TCC Bladder
TURBT
Partial Cystectomy
DXRT with cystectomy salvage
35% 5 year survival
50-70% bladder recurence at 5 years
10% severe persistent complications
Only 8-15% are suitable for salvage cystectomy- 40% 5 year survival
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Transitional Cell Carcinoma of the Urinary Tract

11. Management of Muscle Invasive TCC Bladder
Radical Cystectomy
Most effective form of cure
70% 5 year survival
45% 5 year survival outside bladder
Complications-25%
infection, intestinal obstruction, hemorrage, DVT, urine or faecal leak
Mortality-1%
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Transitional Cell Carcinoma of the Urinary Tract

12. Adjuvant chemotherapy
Radical cystectomy
Ileal conduit
Neobladder
Continent urinary diversions
ureterosigmoidostomy
Adjuvant chemotherapy
Sig survival advantage for tumour outside bladder and minor nodal involvement.
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Transitional Cell Carcinoma of the Urinary Tract

13. Metastatic TCC 4 drug regimen MVAC used
improves median survival from 8 months to 12 months.
6% mortality rate from toxicity
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Transitional Cell Carcinoma of the Urinary Tract

14. TCC of renal pelvis and ureter
10% or renal tumours, 5% of TCC
Same risk factors as bladder TCC
30%-75% also have bladder TCC at some stage
Ureteral tumours more common at lower end
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Transitional Cell Carcinoma of the Urinary Tract

15. TCC upper tract-symptoms & signs
Haematuria, pain, metastatic disease, incidental
Diagnosis
IVP
C/E RGP cytology and brushings CT
U/S
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Transitional Cell Carcinoma of the Urinary Tract

16. Most tumours are low stage, low grade Treatment Nephroureterectomy
Staging
Similar to bladder
Most tumours are low stage, low grade
Treatment
Nephroureterectomy
91% 5 years survival-superficial
43% 5 year survival -muscle invasive
0-23% advanced disease
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Transitional Cell Carcinoma of the Urinary Tract

17. Treatment Conservative excision
Only low grade +stage and renal disease
Endoscopic Treatment
Ureteroscope with laser or fulgration
Again only for low grade+stage/ renal disease.
Major medical illness
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Transitional Cell Carcinoma of the Urinary Tract

18. Carcinoma in-situ No symptoms to frequency and dysuria
C/E normal or velvety erythema
High grade, 25% of HG TCC will have it
Often detected on urine cytology
>20% risk of developing invasive TCC or already harbouring it.
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Transitional Cell Carcinoma of the Urinary Tract

19. Carcinoma in-situ Best treatment is intravesical BCG
Can also give other cytotoxic eg. Mitomycin
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Transitional Cell Carcinoma of the Urinary Tract