Bladder Tumor 21الجامعه.ppt for healthcare

Goooood

1. 1
Bladder Tumors
Prepared by
Dr. Mohammed Al-subari
MD. UROLOGIST

2. 2
Bladder Anatomy / Histology
*The bladder wall:
-Inner layer (urothelium) is transitional epithelium. .
-Second layer is lamina propria.
-Third layer is the Submucosa.
-Then superficial and deep muscle layers (Detrusor).

-.And outer coat( serosa or Adventitia)

3. 3

4. 4
Bladder cancer EpidemiologyBladder cancer Epidemiology
-4th most common cancer in Men.
-The median age at diagnosis is 68 years, and the
incidence increasing with age.
- Affect men more than women 3:1
(exposure to smoking and environmental toxins
)
-Bladder cancer is more common in whites than in
blacks; however, blacks have a worse prognosis than
whites .

5. 5
Risk factors
-Smoking: implicated in 40-50% of cases.
-Age: rare in less than 30 years old and more common
over 60 year old.
-Bladder cancer is also associated with industrial
exposure to aromatic amines in dyes, paints,
solvents,, rubber. Therefore, higher-risk occupations
associated with bladder cancer include painting, driving
trucks, and working with metal.

6. 6
-Medications: Cyclophosphamide, analgesics (Phenacetin).
-Bladder augmentation, long term catheter.
-Patients with prior exposure to radiation treatment of the
pelvis have an increased risk of bladder cancer
-inflammation and infection risk for squamous cell ca.
(schistosoma, .

7. 7
Pathophysiology
-Almost all bladder cancers are epithelial
(Urothelial) in origin.
-More than 90% are transitional cell
carcinomas (TCC). However, up to 5% of
bladder cancers are squamous cell in origin, and
2% are adenocarcinomas.
-Non-urothelial primary bladder tumors are rare
and may include small cell carcinoma,
carcinosarcoma, primary lymphoma, and
sarcoma.

8. 8
-SCC is associated with persistent inflammation from long-
term indwelling Foley and bladder stones .
In underdeveloped countries , it is associated with bladder
infection by Schistosoma haematobium
-Adenocarcinomas account for less than 2% of primary
bladder tumors. These tumors are observed most commonly
in extrophic bladders or urachus remnants and respond
poorly to radiation and chemotherapy. Radical cystectomy is
the treatment of choice.

9. 9
-The most significant prognostic factors for
bladder cancer are:
grade, depth of invasion, and the presence
of CIS

10. Clinical Presentation
10
-Intermittent painless gross hematuria
-Asymptomatic microscopic hematuria .
-Incidental at cystoscopy or bladder imaging, positive
urine cytology
LUTS.

11. Clinical findings
11
--Anaemia, Wt loss
-Palpable bladder/mass (abdominal, rectal or vaginal
examination)
-Invasion of the vagina or pelvic organs
-Vesico vaginal or colo vesical fistula

12. INVESTIGATIONS:
12
Any patient with gross or microscopic hematuria
should be urologically evaluated. Microscopic
hematuria from bladder cancer may be intermittent;
therefore, a negative result on urinalysis does not
exclude the diagnosis. Infection may cause hematuria
and is usually associated with irritative voiding symptoms
(eg, dysuria, frequency, urgency). Irritative voiding
symptoms may also be caused by CIS or muscle-invasive
bladder cancer. Further evaluate irritative voiding
symptoms caused by a urinary tract infection that do not
resolve with treatment.

13. 13
-Urinalysis,urine culture,CBC,KFT.

(
to rule out infection, if suspected)
-urine for cytology
-Abdominal- pelvic US
-Cystoscopy
-I.V.U
-C.T.U

14. 24-6-2009 14
CT urogram. CT of the abdomen with contrast reformatted in the coronal projection shows a
filling defect in the left lateral wall of the urinary bladder (red arrow) representing a papillary
urothelial tumor of the bladder

15. Procedures:
15
1.Cystoscopy:
(Most effective procedure for detecting bladder
tumors)
-Obtain biopsy samples of suspicious lesions during cystoscopy.
Attempt to include the bladder muscle in the biopsy specimen.
This allows the pathologist to determine whether the tumor is
muscle invasive.

16. 16
2.Urine cytology:
-Urine cytology is associated with a significant false-negative rate,
especially for low-grade carcinoma (10-50% accuracy rate)
-The false-positive rate is 1-12%, but it has a 95% accuracy rate for
diagnosing high-grade carcinoma and CIS
 

 

17. Staging & Grading
17
The following is the TNM staging system for bladder cancer:
CIS - Carcinoma in situ, high-grade dysplasia, confined to the epithelium
Ta - Papillary tumor confined to the epithelium
T1 - Tumor invasion into the lamina propria
T2 - Tumor invasion into the muscularis propria
T3 - Tumor involvement of the perivesical fat
T4 - Tumor involvement of adjacent organs such as prostate, rectum, or pelvic sidewall

N+ - Lymph node metastasis
M+ - Metastasis

18. 18

19. 19
-Ta and
 T1 tumors and CIS were once considered
superficial bladder tumors. T2, T3, and T4
tumors
 were traditionally described as invasive
bladder cancer
-TCC is histologically graded as low grade
(formerly graded 1-2) or high grade (formerly graded
3). CIS is characterized by full mucosal thickness
and high-grade dysplasia of the bladder epithelium
and is associated with a poorer prognosis

20. Treatment
20
Medical treatment:
Non muscle-invasive disease
 (Ta, T1, CIS)
:
1 .Intravesical immunotherapy (Bacillus Chalmette-Guerin [BCG]
immunotherapy):
-BCG is recommended for CIS, T1 tumors, and high-risk Ta tumors (large,
high-grade, recurrent, or multifocal tumors). This therapy is less effective in
reducing the 5-year recurrence rate for low-grade and low-stage TCC
-Typically, BCG is administered weekly for 6 weeks. Another 6-week
course
 may be administered if a repeat cystoscopy reveals tumor
persistence or recurrence. Recent evidence indicates that maintenance
therapy with a weekly treatment for 3 weeks every 6 months for 1-3 years
may provide more lasting results.
-The use of BCG is contraindicated in patients with gross hematuria

21. 21
2 .Intravesical chemotherapy
-Valrubicin has recently been approved as intravesical
chemotherapy for CIS that is refractory to BCG. In patients whose
conditions do not respond to BCG, the overall response rate to
valrubicin is approximately 20%, and some patients can delay time
to cystectomy. Valrubicin is presently not commercially available.
Other forms of adjuvant intravesical chemotherapy for bladder
(thiotepa , mitomycin-C, doxorubicin.)

22. 22
Surgical treatment:
Ta, T1, and CIS:
1 .Endoscopic treatment:
-Transurethral resection of bladder tumor
(TURBT)
is the first-line
treatment to diagnose, to stage, and to treat visible tumors
Patients with bulky, high-grade, or multifocal tumors should undergo a
second procedure to ensure complete resection and accurate staging.

23. 23
Radical cystectomy:
Although typically reserved for muscle-invasive disease, radical surgery is
more appropriately used to treat some cases of
 non–muscle-
invasive
 bladder cancer
.

24. 24
Muscle-invasive disease (T2 and greater):
-Radical cystoprostatectomy (men)
Remove the bladder, prostate, and pelvic lymph nodes.
-Anterior pelvic exentration (women)
emoval of the bladder, urethra, uterus, ovaries, anterior vaginal wall ,
and pelvic lymph nodes.
-Pelvic lymphadenectomy

25. After performing a cystectomy, a
urinary diversion must be created from
an intestinal segment.
24-6-2009 25

26. 24-6-2009 26
In an ileal conduit, a small segment of ileum is taken out of continuity with the
gastrointestinal tract but is maintained on its mesentery. Ureters are
anastomosed to one end of this ileal segment, and the other end is brought out
as a stoma to the abdominal wall

27. 27
Radiation therapy:
--External beam radiation has been shown to be inferior to radical
cystectomy for the treatment of bladder cancer. The overall 5-year
survival rate after treatment with external beam radiation is 20-40%
compared to a 90% 5-year survival after cystectomy for organ-
confined disease
 .
-Although inferior to radical cystectomy, external beam radiation
therapy is used in various countries for T2-T3 TCC of the bladder.

28. Follow -Up
28
- Follow up is very important in bladder Ca due to high rate of
disease recurrence and progression in superficial bladder
cancer .
- Surveillance for patients with superficial transitional cell
bladder cancer includes cystoscopy and bladder wash
cytologies every 3 months for 2 years, then every 6 months
for 2 years, and then at least yearly.

29. 29
Prognosis
Superficial bladder cancer has a good prognosis, with 5-year survival rates
of 82-100%
The 5-year survival rate decreases with increasing stage, as follows:
Ta, T1, CIS – 82-100%
T2 – 63-83%
T3a – 67-71%
T3b – 17-57%
T4 – 0-22%

30. Thank you
24-6-2009 30