Bladder cancer Dr/omar hashim

Anatomy of bladderBladder is lie behind pubic bone,it is the

maximum storage is 500 ml.it has stronge muscular wall. It is

shape and relation according to containing volume. The

empty bladder is pyramidal ,having apex, base

superior, and two inferolateral surface. The superior surface is covered by

Peritoneum, when bladde is fills the superior surface bulges

Up ward so the bladder is become in direct contact to the

Abdomen wall.Lymphatic drange of the bladder is to the

internal and external lymph nodes

Epidemiology and etiology

the incidence of bladder cancer is 9.9/100.000 in men

And 2.3/100.000 in women in USA. New case in US in 2010

Is 70.530 .and death 13,060 .Risk factors ;-Age and gender ;-incidence ↑with age (more

common Age 60—70) .m:f ratio is 4:1Twice more common in white American than in

non cau-Cassians .Lifestyle cigarette smoking

Past medical history ;-pelvic radiation, chemotherapyBladder lithiasis,chronic catheterization, recurrent urinaryInfection exposure to schistosomiasis.Genetic factors ;-these is some gene associated withPoorer prognosis and↑chance of progression include(EGFR),P53,ras oncogene .Industrial chemicals ;- aniline dye,naphthylamineBenzidine.so aniline dye,leather,paint,and rubberWorkers more affected than general population.Drugs :-cyclophosphamide

pathologyPathologic subtypes of ca prostate;-1)Transitional cell carcinoma ;- represent 90% of bladder Cancer inUSA,70% are superficial carcinoma,arise fromNormal urohtellium and associated with smoking and Carcinogen exposure . 2) Squamous cell carcinoma;- caused by chronic irritationFrom urinary calculi,long term indwelling catheter,chronicUrinary infection,infection by schistomiasis or bladderDiverticula( transitional cell→squamous change ).The incidence is ↑in the Egypt 50%

Transitional cell carcinoma of bladder

Squamous cell carcinoma of the ca bladder

3) Adenocarcinoma ;- represent 2% ,include 3groups,1ry

Urachal and metastatic .4) Small cell carcinoma ;-represent 1%, behaves

similarly toSmall cell carcinoma found elsewhere in the body.5) Mixed histology ;- represent 25% of the

case ,usuallyTransitional with adenocarcinoma or squamous *most common site is trigone (inferiorly below ureter-Ovesical juncation,laterial wall,posterior wall,and

bladderneck

diagnosisClinical presentation ;-Hematuria is the most common presenting symptoms

75%. Irritative /obstructive symptoms occur in quarter of patients. plevic pain occur in local advanced disease

invading into adjacent organs. Poor appetite and weigth loss late systemic symptoms.Examination:- for metastatic sites / PR:- to see the local Extension .Cystoscopy:- is cornerstone procedure,biopsy should beTaken from abnormal area,of normal at random to searchFor cis, cystoscopy is followed by bimanual plevic

examination under general anesthesia

Cystoscopy is indicated in following:-a) Any gross or microscopic hematuria.b) Unexplained or chronic lower urinary tract symptomsc) Urine cytology that is suspicious for cancer.d) History of bladder cancer.CT:-to detect the 1ry sites and any enlarged LNs andMetastasis if is present.Urine cytology:-is not used for 1ry diagnosis but for Follow up of ca bladder patients/,screening for environ-Mental carcinogens/.evaluating pts with chronic irritativeBladder symptoms

Doagnosis procedure for bladder cancer;-

Hematuria or irritative bladder cancer

HX/EX /urinary cytologyCBC/CXR.*1

Invasive

Abd-u/s/pelvic CT &bones can

Superficial Muscular is -ve

Tumor,node and metastasis staging (TNM) determine byAmerican Joint Committee on Cancer (AJCC)PRIMARY TUMOR ;-

STAGE DESCRIPTION

T1

tumor invade subepithelial connective tissues

T2 tumor invade muscularis propria

T3 Tumor invade perivesical tissues

T4 Tumor invade any of the following (prostate stroma /seminal vesicle /uterus /vagina /pelvic wall /abdominal wall

Regional LNs include 1ry and 2ry drainage regions all nodesAbove the aortic bifurcation are considered distant metast-Asis ;-

N0 No regional LNs metastasis

N1 single regional LNs metastasis in true pelvic(hypogastric/obturator/external iliac or presacral )

N2 multiple regional LNs metastasis in true plevic

N3 lymph nodes metastasis to the common iliacLNs

Distant metastasis ;-M0;-no distant metastasisM1;- distant metastasis

Stage group of bladder cancer ;-

T1 T2 T3 T4a T4a

N0 1 11 111

111 1V

N1-3 1V 1V 1V 1V 1V

M1 1V 1V 1V 1V 1V

PROGNOSISStage is the most important determinant of the

survival . 5 yrs over all survival (OS) rate after

cystectomyDetermined according to stage

stage

superficialP0a,N0

Organ con-Fined p2,N0

extra vesicle p3-4,N0

nodes +ve

5yra survival

85% T2a 77% T2b 64%

47% 31% …/40%.(1-4) 25%(>4)

Type

description

Prognosis factors ;-

factor Favorable Adverse TURBT complete incomplete

Response to chemo-

complete regression

Residual disease

extent of tumor solitary Diffuse /multiple

disease invasion

organ confined Regional met-

Hydronephrosis absent present

treatmentPrinciple and practice ;- Treatment of ca bladder is multimodal and determined byPatients prognosis factors.1) Superficial bladder cancer is managed primary by trans-Urethral resection ±intravesicular chemotherapy .2) Localized invasive bladder cancer traditionally is treated

by cystectomy .3) If patient has prognostic factors predictive for bladderPreservation, the patient can be treated with chemo-Therapy . 4) mets- disease is primary treated by chemo-With palliative radiation or surgery for symptomatic control

Superficial bladder caner

TURBT

Low risk(low grade papillary)

high risk(high

grade,CIS,papillary)Superfical ca

bladder recurrence

Intravesicular

chemotherapy

Cytoscopic survellance

Every 3monthsx2yrs

then every 6months

x2yrs ,then yearly

Invasive recurrence

Bladder preservation

therapy cystectomy

Progressive high risk disease

Invasive bladder cancer

Unifocal no hydronephrosi

s/noEVD

Partial cystectomy If candidate

Local advanced disease

T3.T4;N+CTH/

preops-RT

cystectomy

CT /bone scan/NOmetastasis

Local advanc

ed disease

CTH

TURBT

CTH+RT

completeRegressio

n of disease

consolidative CTH+RT

yesno

yesno

yes

Definitive surgical intervention

Radical cystectomy ;- involve there move of the bladderProstate and lymph nodes dissection in male. In the

femaleAn anterior exenteration (removal of the bladder,urethra,Anterior vaginal wall and uterus )and pelvic lymph nodes Dissection is performed . Lymph dissection is

include(medialTo the genitofemoral/external iliac up to the bifurcation ofThe common iliac then extended to obturator fossa thenLymph nodes around hypogasteric artery then superorlyTo the aortic bifurcation and presacral LNs included .thenUrinary diversion is with segment of bowel(no continent)Or orthotopic neobladder or abdominal pouch

extent confined extra vesicle

nodes Total(NO ofpt)

Local failure

4% 16% 20% 9% 78810 yrs

distant metas-tasis

9.5% 19%

45% 18%

recurrence-free survival

T2a/b 70%10yrs

T3a/b,52%T4, 35%

15%10 yrs

45%