Transitional cell carcinoma of urinary bladeder

Transitional cell carcinoma of urinary bladeder PPT presentation

2. TRANSITIONAL CELL TRANSITIONAL CELL
CARCINOMA OF URINARY CARCINOMA OF URINARY
BLADEDERBLADEDER
Presented byPresented by
DR. Md.Rezaul KarimDR. Md.Rezaul Karim
FCPS (Surgery)FCPS (Surgery)
MS Urology Thesis Part StudentMS Urology Thesis Part Student
Urology Department, BSMMU, Dhaka.Urology Department, BSMMU, Dhaka.

3. Incidence : sex & raceIncidence : sex & race
Second most Second most common GU cancercommon GU cancer
53,200 new case diagnosed annually in USA, 53,200 new case diagnosed annually in USA,
(33%) in 2000.(33%) in 2000.
M:FM:F ratio is ratio is 2-3:12-3:1
Black : whiteBlack : white ratio ratio 4:14:1
Average age at diagnosis (65-69 yrs)Average age at diagnosis (65-69 yrs)
Mean age-Mean age- Male 69yr, Female 74 yr, Male 69yr, Female 74 yr,
Adolescent & youngAdolescent & young >30-40 yr (more indolent). >30-40 yr (more indolent).

4. Etiology & Risk factorsEtiology & Risk factors
Schistosoma
haematobium
Artificial sweeteners
Coffee & tea drinkingTryptophan metabolites
RadiotherapyMetal works
Chronic irritationHair dresser, Painter
CyclophosphamideRubber fire industry
Analgesics (phenacetin)Textile industries
Lather industriesCigarette smoking
Risk factors are

5. Risk factorsRisk factors
Others:Others: Black foot diseaseBlack foot disease
Arsenic ingestionArsenic ingestion
Chinese herb nephropathyChinese herb nephropathy
Heridity:Heridity:
slightly elevated in relatives ( in smokers)slightly elevated in relatives ( in smokers)
Genetic:Genetic:
Oncogenes- p21 ras mutation – high hist. gradeOncogenes- p21 ras mutation – high hist. grade
Tumor suppressor gene- p53 high hist. grade, del 17pTumor suppressor gene- p53 high hist. grade, del 17p
pRb-aggressive TCCpRb-aggressive TCC
Loss of ch. 9 – both low & high gradeLoss of ch. 9 – both low & high grade
ch. 11 – cHa-ras in 40% bladder cancer.ch. 11 – cHa-ras in 40% bladder cancer.

6. Clinical carcinogensClinical carcinogens
Exogenous carcinogensExogenous carcinogens
αα & & ββ naphthylamine naphthylamine
BenzidineBenzidine
4-aminobiphenyl4-aminobiphenyl
CyclophosphamideCyclophosphamide
Phenacetin, artificial sweetenersPhenacetin, artificial sweeteners
Endogenous Endogenous carcinogenscarcinogens
Nitrosamine, tryptophane metabolitesNitrosamine, tryptophane metabolites

7. PathologyPathology
Bladder papillomaBladder papilloma
stage 0, benign condition, rare malig. transforamtionstage 0, benign condition, rare malig. transforamtion
but some associates with TCCbut some associates with TCC
3% progress to frank carcinoma, recurrence -47%3% progress to frank carcinoma, recurrence -47%
Carcinoma in situCarcinoma in situ
velvety patch of erythematous mucosavelvety patch of erythematous mucosa
consists of poorly differentiated TCC confined to consists of poorly differentiated TCC confined to
urotheliumurothelium
focal or diffuse, concomitantfocal or diffuse, concomitant

8. Carcinoma in situ cont..Carcinoma in situ cont..
High rate of recurrence >80%High rate of recurrence >80%
may be asymptomatic or present with urinary frequency, may be asymptomatic or present with urinary frequency,
urgency, dysuriaurgency, dysuria
urine cytopathology positive – 80- 90%.urine cytopathology positive – 80- 90%.
Rapidly shades in urine.Rapidly shades in urine.
Cystoscopic appearance – cystitis.Cystoscopic appearance – cystitis.
Bears a very bad prognosis. Bears a very bad prognosis.

9. Pathology cont..Pathology cont..
TCCTCC
 - >90% - >90%
 papillary (70%), sessile (invasive), infiltrating, papillary (70%), sessile (invasive), infiltrating,
nodular(20%), mixed (20%), flat intraepithelial (CIS). nodular(20%), mixed (20%), flat intraepithelial (CIS).
Papillary tumor are superficial.Papillary tumor are superficial.
Relative tumor frequency in urinary bladderRelative tumor frequency in urinary bladder
 Posterior & lateral wall- 70%Posterior & lateral wall- 70%
 Trigone & bladder neck- 20%Trigone & bladder neck- 20%
 Vault of bladder – 10%Vault of bladder – 10%
 Diverticulum - <1%Diverticulum - <1%

10. Staging of TCCStaging of TCC
Jewett- Marshall staging systemJewett- Marshall staging system
Stage 0-Stage 0- CIS or superficial papillary tumor confined to the CIS or superficial papillary tumor confined to the
mucosa with no invasionmucosa with no invasion
Stage A-Stage A- Papillary tumor invading the lamina propria Papillary tumor invading the lamina propria
Stage B1-Stage B1- Tumor with superficial muscle invasion Tumor with superficial muscle invasion
Stage B2-Stage B2- Tumor with deep muscle invasion Tumor with deep muscle invasion
Stage C-Stage C- Invasion of the perivesical fat Invasion of the perivesical fat
Stage D1-Stage D1- Involvement of adjacent viscera and/ or pelvic Involvement of adjacent viscera and/ or pelvic
nodesnodes
Stage D2 -Stage D2 - Involvement of nodes above the aortic Involvement of nodes above the aortic
bifurcation or distant spread.bifurcation or distant spread.

13. Staging cont..Staging cont..
TNM ClassificationTNM Classification
T =T = primary tumor primary tumor
Tx-Tx- primary tumor can’t be assesed primary tumor can’t be assesed
Tis-Tis- Carcinoma in situ Carcinoma in situ
Ta-Ta- Noninvasive papillary carcinoma Noninvasive papillary carcinoma
T1-T1- Tumor invades submucosa/ lamina propria Tumor invades submucosa/ lamina propria
T2a-T2a- Tumor invades superficial muscle Tumor invades superficial muscle
T2b-T2b- Tumor invades deep muscle Tumor invades deep muscle
T3a-T3a- Tumor invades perivesical fat (microscopic) Tumor invades perivesical fat (microscopic)
T3b-T3b- Tumor invades perivesical fat (macroscopic) Tumor invades perivesical fat (macroscopic)
T4a-T4a- Tumor invades adjacent organ Tumor invades adjacent organ
T4b- T4b- Tumor invades pelvic wall, abdominal wall.Tumor invades pelvic wall, abdominal wall.

14. Staging cont..Staging cont..
T1aT1a superficial lamina propria above superficial lamina propria above
muscularis mucosaemuscularis mucosae
T1bT1b deep lamina propria beyond deep lamina propria beyond
muscularis mucosaemuscularis mucosae
((Superficial TCC (Ta/T1/CIS) of the bladder, Badrinath R. Koney and Richard D. Williams, BJU, 2004)Superficial TCC (Ta/T1/CIS) of the bladder, Badrinath R. Koney and Richard D. Williams, BJU, 2004)
Seminal vesicle involvement should be included as Seminal vesicle involvement should be included as
pT4b.pT4b.
((Prognosis of seminal vesicle involvement by TCC of the bladder, Siamak Daneshmand, Jhon P. Stein et Prognosis of seminal vesicle involvement by TCC of the bladder, Siamak Daneshmand, Jhon P. Stein et
al, J of Urol, Vol 172, 81-84, Jul’04) al, J of Urol, Vol 172, 81-84, Jul’04)

15. TNM Classification cont..TNM Classification cont..
N=N= Regional lymph nodes (below aortic bifurcation) Regional lymph nodes (below aortic bifurcation)
NX-NX- Regional lymph nodes can’t be assessed Regional lymph nodes can’t be assessed
N0-N0- No regional lymph nodes metastasis No regional lymph nodes metastasis
N1-N1- Metastasis in single node < 2 cm Metastasis in single node < 2 cm
N2-N2- Metastasis in single node > 2 cm but <5 cm or multiple Metastasis in single node > 2 cm but <5 cm or multiple
nodes < 5 cmnodes < 5 cm
N3-N3- Metastasis in nodes >5 cm. Metastasis in nodes >5 cm.
M= M= Distant metastasisDistant metastasis
MX-MX- Presence of distant metastasis can’t be assessed Presence of distant metastasis can’t be assessed
M0-M0- No distant metastasis No distant metastasis
M1-M1- Distant metastasis Distant metastasis

16. Staging cont..Staging cont..
Clinical stagingClinical staging
Imaging with US, CT, MRIImaging with US, CT, MRI
CXR, bone scanCXR, bone scan
Bimannual palpation after Bimannual palpation after
TURBTTURBT
No thikening- No thikening- superf. tumorsuperf. tumor
Tumor was palpable- Tumor was palpable-
invasive tumorinvasive tumor
Pathological stagingPathological staging
‘‘p’ stagingp’ staging
hist. examination of the hist. examination of the
tissue from the base oftissue from the base of
resected arearesected area
‘‘P’ stagingP’ staging
hist. examination of hist. examination of
specimen after radical specimen after radical
cystectomy cystectomy

18. Staging cont..Staging cont..
Bimannual palpation after TURBT Bimannual palpation after TURBT

No palpable mass No palpable mass T1T1

No mass but thickening No mass but thickening T2 T2

Hard mass Hard mass T3T3

Hard fixed mass Hard fixed mass T4T4

19. Grading of TCCGrading of TCC
Grade 0-Grade 0- papilloma papilloma
Grade 1- Grade 1- well differentiated, Papillary urothelial well differentiated, Papillary urothelial
tumor of low malignant potential (10% will be tumor of low malignant potential (10% will be
invasive)invasive)
Grade 2-Grade 2- moderately differentiated, low grade moderately differentiated, low grade
urothelial tumor (50% will be invasive)urothelial tumor (50% will be invasive)
Grade 3- Grade 3- poorly differentiated, high grade poorly differentiated, high grade
urothelial tumor (>80% will be invasive)urothelial tumor (>80% will be invasive)

22. Spread of tumorSpread of tumor
Origin:Origin: multicentic, field change diseasemulticentic, field change disease
Direct extensionDirect extension
Lymphatic spread-Lymphatic spread- pelvic LN, perivesical 16%, pelvic LN, perivesical 16%,
obturator 74%, exrternal iliac 65%, presacral 25%, obturator 74%, exrternal iliac 65%, presacral 25%,
common iliac 20%common iliac 20%
Vascular spread-Vascular spread- liver, lungs, bone, adrenal, liver, lungs, bone, adrenal,
intestine.intestine.
Implantation-Implantation- abdominal wound, denuded urothelium, abdominal wound, denuded urothelium,
resected prostatic fossa, traumatized urethra- most resected prostatic fossa, traumatized urethra- most
commonly with high grade tumor.commonly with high grade tumor.

23. Natural historyNatural history
55-60%-55-60%- newly diagnosed bl. Cancer are well differentiated or moderately newly diagnosed bl. Cancer are well differentiated or moderately
differentiated, majority develop recurrence after TURBT, differentiated, majority develop recurrence after TURBT, 16-25%16-25% with high with high
gradegrade
40-45%-40-45%- newly diagnosed bl. Cancer are high grade, more than half muscle newly diagnosed bl. Cancer are high grade, more than half muscle
invasive or more extensive at the time of diagnosis, more chance of invasive or more extensive at the time of diagnosis, more chance of
recurrence & metastasisrecurrence & metastasis
Low grade tumor have recurrence with high gradeLow grade tumor have recurrence with high grade
High & low grade simultaneously not uncommonHigh & low grade simultaneously not uncommon
85-95%85-95% muscle invasive tumor already have invasion at the time of muscle invasive tumor already have invasion at the time of
diagnosis, diagnosis,
about about 50%50% muscle invasive tumor already have occult metastsis muscle invasive tumor already have occult metastsis

24. DiagnosisDiagnosis
History:History:
 Painless hematuria (85%-90%), gross/ Painless hematuria (85%-90%), gross/
microscopic; intermittent rather constant.microscopic; intermittent rather constant.
 Irritative voiding symptomsIrritative voiding symptoms
 Flank pain from ureteral obstructionFlank pain from ureteral obstruction
 Lower leg odema & pelvic painLower leg odema & pelvic pain
 Bone pain, loss of weight, abdomminal painBone pain, loss of weight, abdomminal pain

25. DiagnosisDiagnosis
Physical examination:Physical examination:
 Superficial bl. Carcinoma- no signSuperficial bl. Carcinoma- no sign
 Palpable mass- at least muscle involvedPalpable mass- at least muscle involved
 Bimanual palpation at the time of cystoscopy-Bimanual palpation at the time of cystoscopy-
movable tumor- stage movable tumor- stage ≥ T3a≥ T3a
fixed contiguous structure- stage IVfixed contiguous structure- stage IV
 Hepatomegaly, supraclavicular lymphadenopa.Hepatomegaly, supraclavicular lymphadenopa.
 Lymphodema- from pelvic lymphadenopathy.Lymphodema- from pelvic lymphadenopathy.
 AnaemiaAnaemia

26. DiagnosisDiagnosis
Investigations:Investigations:
 Urine analysis and C/SUrine analysis and C/S
 Urine for cytolgyUrine for cytolgy
 Blood for TC,DC,Hb%,ESRBlood for TC,DC,Hb%,ESR
 Blood urea & serum creatinineBlood urea & serum creatinine
 Flow cytometry & image analysisFlow cytometry & image analysis
 Tumor markers- Tumor markers- BTA, BTA stat, BTA TRAK, NMP 22BTA, BTA stat, BTA TRAK, NMP 22
Cytokeatin 20, lewis x Ag, telomerase activity, HA, HA-ase, Cytokeatin 20, lewis x Ag, telomerase activity, HA, HA-ase,

27. Investigations cont..Investigations cont..
UroVysin test-UroVysin test- ‘FISH’ analysis ‘FISH’ analysis
Sensitivity 81%, Specificity 96%Sensitivity 81%, Specificity 96%
HA-HA- more sensitive for low grade (92%, 93%) more sensitive for low grade (92%, 93%)
Hyaluroniase-Hyaluroniase- for high grade (100%, 89%) for high grade (100%, 89%)
Survivin-Survivin- anti apoptosis protein (100%, 95%) anti apoptosis protein (100%, 95%)
detect new or recurrent casesdetect new or recurrent cases
Endothelial growth factor, p53, Her-2-neu-Endothelial growth factor, p53, Her-2-neu-
more applicable to invasive diseasemore applicable to invasive disease
((Superficial TCC (Ta/T1/CIS) of the bladder, Badrinath R. Koney and Richard D. Superficial TCC (Ta/T1/CIS) of the bladder, Badrinath R. Koney and Richard D.
Williams, BJU, 2004, Vol 94: 18-21.)Williams, BJU, 2004, Vol 94: 18-21.)

28. DiagnosisDiagnosis
ImagingImaging
 UltrasoundUltrasound
 IVUIVU
 CT scanCT scan
 MRIMRI
 CXRCXR
 Radionuclide bone scanRadionuclide bone scan
 UrethrocystoscopyUrethrocystoscopy
 BiopsyBiopsy

35. Management of superficial Bladder Management of superficial Bladder
carcinomacarcinoma
Treatment options:Treatment options:
 TisTis Complete TUR followed by BCG Complete TUR followed by BCG
 TaTa( single, low to moderate grade) Complete TUR( single, low to moderate grade) Complete TUR
 TaTa( large, multiple, high grade, recurrent)-Complete ( large, multiple, high grade, recurrent)-Complete
TUR followed by intravesical Chx or immunotherapyTUR followed by intravesical Chx or immunotherapy
 T1T1 Complete TUR followed by intravesical Chx or Complete TUR followed by intravesical Chx or
immunotherapy but controversy- high grade-III, immunotherapy but controversy- high grade-III,
radical cystectomy if recurrence after a trial needs radical cystectomy if recurrence after a trial needs
aggressive treatmentaggressive treatment

36. Mx of superf. TCC cont..Mx of superf. TCC cont..
Transurethral resection (TUR)Transurethral resection (TUR)
Role of ReTURBRole of ReTURB
(Effect of routine repeat TUR for superficial bladder cancer: a long term observational study, Marc- (Effect of routine repeat TUR for superficial bladder cancer: a long term observational study, Marc-
oliver Grimm, C. Steinhoff et al, J of Urol.)oliver Grimm, C. Steinhoff et al, J of Urol.)
 Complications- perforation, clot retention, ureteric Complications- perforation, clot retention, ureteric
orifice strictureorifice stricture
Laser therapy-Laser therapy- Nd:YAG, Holmium, Potassium Nd:YAG, Holmium, Potassium
titanyl phosphate (PTP)titanyl phosphate (PTP)
Photodynamic therapy-Photodynamic therapy-

37. Mx of superf. TCC cont..Mx of superf. TCC cont..
Intravesical chemotherapy-Intravesical chemotherapy-
Mitomycin-C-Mitomycin-C- just after TUR, wkly just after TUR, wkly
40 mg in 60 ml water40 mg in 60 ml water
Complications:Complications: chemical cystitis, dec. bladder capacity chemical cystitis, dec. bladder capacity
palmer desquamation.palmer desquamation.
Bacille Calmette Guerin:Bacille Calmette Guerin:
M/A-M/A- activity through activation of CD8 cell activity through activation of CD8 cell
40 mg in 60 ml water for 6 wks, 3 wkly at 3 & 6 m40 mg in 60 ml water for 6 wks, 3 wkly at 3 & 6 m
every 6 mo thereafter for 3 yrs.every 6 mo thereafter for 3 yrs.
(BCG therapy in stage Ta/T1 bladder cancer: prognostic factors for time to recurrence and progression,(BCG therapy in stage Ta/T1 bladder cancer: prognostic factors for time to recurrence and progression,
P. Andius, S. Holmang, BJU,2004, Vol. 93: 980-984)P. Andius, S. Holmang, BJU,2004, Vol. 93: 980-984)

38. BCG cont..BCG cont..
Indications:Indications:
Cis, Residual tumor, Tumor prophylaxisCis, Residual tumor, Tumor prophylaxis
Contraindications:Contraindications:
immunosuppression, immunocompromised pt. immunosuppression, immunocompromised pt.
relative: poor overall performance, advance age, H/O TBrelative: poor overall performance, advance age, H/O TB
Side effects:Side effects:
hematuria, granulomatous prostatitis, hematuria, granulomatous prostatitis,
fever- Isoniazid 300 mg for 3 mofever- Isoniazid 300 mg for 3 mo
systemic BCGosis- INH+Rifam, Etham for 6 mosystemic BCGosis- INH+Rifam, Etham for 6 mo
BCG sepsis- standard life support, tripple therapyBCG sepsis- standard life support, tripple therapy

39. Mx of superf. TCC cont..Mx of superf. TCC cont..
ThiotepaThiotepa
alkylating agent, 30 mg in 30 ml, wkly for 6 wksalkylating agent, 30 mg in 30 ml, wkly for 6 wks
Doxorubicin, epirubicinDoxorubicin, epirubicin
Valrubicin-Valrubicin- BCG refractory Cis who can’t tolerate BCG refractory Cis who can’t tolerate
cystectomycystectomy
Ethoglucid-Ethoglucid- alkylating agent, podophylline alkylating agent, podophylline
derivative.derivative.
Combination-Combination- mitomycin(20mg) day 1 mitomycin(20mg) day 1
doxorubicin(40mg) day 2 for 5wkdoxorubicin(40mg) day 2 for 5wk
chemotherapy & BCG chemotherapy & BCG

40. Mx of superf. TCC cont..Mx of superf. TCC cont..
Newer intravesical chemotherapyNewer intravesical chemotherapy
Gemcitabine-Gemcitabine- twice wkly for 6 wks with a 1-wk twice wkly for 6 wks with a 1-wk
break after first 3 wks.break after first 3 wks.
salvage intravesical agent for BCG failure.salvage intravesical agent for BCG failure.
Mycobacterial cell wall extract-Mycobacterial cell wall extract- Myco. Phlei. Myco. Phlei.
induction regimen for 6 wks followed by monthly induction regimen for 6 wks followed by monthly
maintenance dose maintenance dose

((Superficial TCC (Ta/T1/CIS) of the bladder, Badrinath R. Koney and Richard D. Williams, BJU, 2004)Superficial TCC (Ta/T1/CIS) of the bladder, Badrinath R. Koney and Richard D. Williams, BJU, 2004)

41. Mx of superf. TCC cont..Mx of superf. TCC cont..
Other forms of immunotherapy:Other forms of immunotherapy:
Interferon(Interferon(αα-2b)- combined with BCG(low dose)-2b)- combined with BCG(low dose)
Keyhole-Limpet HaemocyaninKeyhole-Limpet Haemocyanin
Bropirimine- inducer of IF & NK cellBropirimine- inducer of IF & NK cell
IL12, IL2, TNFIL12, IL2, TNF
Gene therapy:Gene therapy:
Cystectomy-Cystectomy- persistent/ recurrentpersistent/ recurrent,,high risk superf. who high risk superf. who
failed to iv Chx., T1 high grade, multifocal.failed to iv Chx., T1 high grade, multifocal.

42. Mx of superf. TCC cont..Mx of superf. TCC cont..
Alternatives:Alternatives:
External beam radiation therapy-External beam radiation therapy-
refuse cystectomy, unsuitable for major surgeryrefuse cystectomy, unsuitable for major surgery
Chemoprevention:Chemoprevention:
High water intakeHigh water intake
Vitamins-Vitamins- megadoses(vit A,B6,C,E,Zinc) megadoses(vit A,B6,C,E,Zinc)
Difluoromethylornithine-Difluoromethylornithine- enzyme inhibition enzyme inhibition
Soy products-Soy products- phytochemicals phytochemicals
Cyclooxigenase inhibitors-Cyclooxigenase inhibitors- COX2 COX2

43. Follow upFollow up
Tumor categorized as low, medium & high risk and Tumor categorized as low, medium & high risk and
follow up according to riskfollow up according to risk
3 mo for 13 mo for 1
stst
yr yr
6 mo for 26 mo for 2
ndnd
yr yr
Annually for thereafter.Annually for thereafter.
High risk group needs frequent follow up- 1High risk group needs frequent follow up- 1
stst
at at
6wk6wk
Urine cytologyUrine cytology
Tumor marker in urine-Tumor marker in urine- NMP 22, Ha-HAase NMP 22, Ha-HAase
sesitivity- 50-90%, specificity- 60-90%sesitivity- 50-90%, specificity- 60-90%
IVUIVU

44. Management of invasive and Management of invasive and
metastatic bladder cancermetastatic bladder cancer
Treatment options:Treatment options:
T2-T3T2-T3 Radical cystectomy(RC) Radical cystectomy(RC)
Neoadjuvant Chx followed by RCNeoadjuvant Chx followed by RC
Neoadjuvant Chx followed by irradiationNeoadjuvant Chx followed by irradiation
RC followed by adjuvant ChxRC followed by adjuvant Chx

Any stage T,N+,M+Any stage T,N+,M+ Systemic Chx followed by Systemic Chx followed by
selective surgery or irradiationselective surgery or irradiation

45. Rx of invasive bladder cancer cont..Rx of invasive bladder cancer cont..
Radical cystectomyRadical cystectomy
Indications:Indications: Muscle invasive bladder cancer in Muscle invasive bladder cancer in
absence of metastasisabsence of metastasis
Surgical technique:Surgical technique:
Cystectomy, bil. Pelvic lymphadenectomyCystectomy, bil. Pelvic lymphadenectomy
Male- prostate bladder en blockMale- prostate bladder en block
Female- uterus, tubes, ovaries, ant wall of vaginaFemale- uterus, tubes, ovaries, ant wall of vagina
Nerve sparing modification in maleNerve sparing modification in male
Preservation of urethra in male/ female Preservation of urethra in male/ female
Role of pelvic lymphadenectomyRole of pelvic lymphadenectomy
(Does extended lymphadenectomy increase the morbidity of radical cystectomy? C. Brossner, A. Pycha et al,(Does extended lymphadenectomy increase the morbidity of radical cystectomy? C. Brossner, A. Pycha et al,
BJU, 2004:Vol 93: 64-66)BJU, 2004:Vol 93: 64-66)

47. Radical cystectomy cont..Radical cystectomy cont..
Complications: Complications:
MortalityMortality 1-2% 1-2%

Morbidity-Morbidity- cardiac arrest, postoperative pul cardiac arrest, postoperative pul
embolism, rectal injury, bowel obstr.embolism, rectal injury, bowel obstr.
ureteral-enteric anastomotic stricture, meta.ureteral-enteric anastomotic stricture, meta.
disorder, vitamin def., chronic UTI, renal disorder, vitamin def., chronic UTI, renal
calculous disease, depressioncalculous disease, depression

48. Radical cystectomy cont..Radical cystectomy cont..
Follow up:Follow up:
tumor recurrence,tumor recurrence,
complication related to interposition of bowelcomplication related to interposition of bowel
Annual screening withAnnual screening with
Physical examination, serum electrolytesPhysical examination, serum electrolytes
Chest X-ray (PT1)Chest X-ray (PT1)
semiannual- (PT2), quarterly- (PT3) with annual semiannual- (PT2), quarterly- (PT3) with annual
CT scan. CT scan.
Upper tract imaging-Upper tract imaging- to exclude ureteral stenosis, upper to exclude ureteral stenosis, upper
tract tumor.tract tumor.

49. Treatment cont..Treatment cont..
Adjunct to standard surgical therapyAdjunct to standard surgical therapy
Preoperative radiation therapyPreoperative radiation therapy
Neoadjuvant Chx Neoadjuvant Chx
Perioperative ChxPerioperative Chx
Adjuvant ChxAdjuvant Chx
Alternatives to standard therapy:Alternatives to standard therapy:
Radiation therapy- external beam radiationRadiation therapy- external beam radiation
hyperfractionation schedulehyperfractionation schedule
T2a- T2a- TUR & BCG immunoprophylaxis who were TUR & BCG immunoprophylaxis who were
unfit for or refused more aggressive surgeryunfit for or refused more aggressive surgery
(T2a TCC of the bladder: long-term experience with intravesical immunoprophylaxis with BCG, B. G. Volkmer, J.E. (T2a TCC of the bladder: long-term experience with intravesical immunoprophylaxis with BCG, B. G. Volkmer, J.E.
Gschwend et al, J of Urol, Vol 169, 931-935, March’2003)Gschwend et al, J of Urol, Vol 169, 931-935, March’2003)

50. Treatment cont..Treatment cont..
 Transurethral resection & partial cystectomyTransurethral resection & partial cystectomy
 TUR , partial cystectomy with ChxTUR , partial cystectomy with Chx
Bladder preservation protocol:Bladder preservation protocol:
TUR, neoadjuvant Chx (MCV), subsequent RTxTUR, neoadjuvant Chx (MCV), subsequent RTx
Contraindication- presence of HDN, Cis, a tumor that Contraindication- presence of HDN, Cis, a tumor that
can’t resect transurethrally.can’t resect transurethrally.
Interstitial radiation therapyInterstitial radiation therapy
preoperative external beam radiation, TUR or partial preoperative external beam radiation, TUR or partial
cystectomy, susequent Iridium192 wire (low stage T1-T2)cystectomy, susequent Iridium192 wire (low stage T1-T2)
Intraarterial ChxIntraarterial Chx ( combined with RC, radiation ) ( combined with RC, radiation )
Hyperthermia and ChxHyperthermia and Chx

51. Treatment of metastatic bladder Treatment of metastatic bladder
cancercancer
Systemic chemotherapySystemic chemotherapy
unresectable, diffusely metastaticunresectable, diffusely metastatic
MVACMVAC
Newer agent- GemcitabineNewer agent- Gemcitabine
Taxoids- Docetaxel, paclitaxelTaxoids- Docetaxel, paclitaxel
Local salvage and palliative therapyLocal salvage and palliative therapy
Selection of patient for urinary diversion following Selection of patient for urinary diversion following
radical cystectomyradical cystectomy
noncontinent divrsion, continent diversionnoncontinent divrsion, continent diversion
orthotopic neobladderorthotopic neobladder
CounsellingCounselling

52. Prognostic indicatorsPrognostic indicators
Clinical & pathological parameters in superf. TCCClinical & pathological parameters in superf. TCC
Laboratory parametersLaboratory parameters ( (P53 nuclear accumulationP53 nuclear accumulation))
A,B,H and other blood group antigenA,B,H and other blood group antigen
Lewisx Ag expressedLewisx Ag expressed
ABH – not presentABH – not present
Growth factor and their receptorsGrowth factor and their receptors
TGFTGFββ-1-1
Amplification of c-erb-B2 oncogeneAmplification of c-erb-B2 oncogene
Chromosomal and genetic abnormalitiesChromosomal and genetic abnormalities
deletion Ch-9, deletion Ch 17p-P53, Ch13q- Rb gene.deletion Ch-9, deletion Ch 17p-P53, Ch13q- Rb gene.

53. PrognosisPrognosis
Tumor stageTumor stage
CisCis
PTaPTa
PT1PT1
PT2PT2
PT3PT3
PT4PT4
5 year survival5 year survival
90%-100%90%-100%
90%-95%90%-95%
40%-75%40%-75%
55%-60%55%-60%
30%-40%30%-40%
5%-10%5%-10%

54. What’s newWhat’s new
Staging-Staging- T1a & T1b, T4b (sem. vesicle) T1a & T1b, T4b (sem. vesicle)
Tumor markers-Tumor markers- UroVysin, HA,H-ase, SurvivinUroVysin, HA,H-ase, Survivin
Role of Role of ReTURBReTURB
New intravesical cheomtherapy-New intravesical cheomtherapy- GemcitabineGemcitabine
Role of Role of lymphadenectomylymphadenectomy in RC in RC
Bladder preservationBladder preservation protocol in T2a protocol in T2a with BCG with BCG
Prognostic significancePrognostic significance in seminal vesical in seminal vesical
involvement.involvement.

55. ReferencesReferences
Emil A. Tanagho, Jack W. McAninch;Emil A. Tanagho, Jack W. McAninch; Smith’s General Smith’s General
Urology; 16Urology; 16
thth
edn.; McGraw Hill 2004. edn.; McGraw Hill 2004.
Fagbemi S, Stadler W.Fagbemi S, Stadler W. New Chemotherapy regimens for New Chemotherapy regimens for
advanced bladder cancer. Semin Uro Oncol 1998;16:23.advanced bladder cancer. Semin Uro Oncol 1998;16:23.
Gillenwater JY, Grayhack JT;Gillenwater JY, Grayhack JT; Adult and Pediatric Urology; Adult and Pediatric Urology;
Mosby 1996.Mosby 1996.
Russel, Williams and Bulstrode;Russel, Williams and Bulstrode; Baily & Love’s short practice Baily & Love’s short practice
of surgery; 24th edn; Arnold, 2000.of surgery; 24th edn; Arnold, 2000.
Walsh, Retik, Vaughan & Wein;Walsh, Retik, Vaughan & Wein; Campbell’s urology; 8 Campbell’s urology; 8
thth
edn.; edn.;
W.B. Saunders Company, 2002.W.B. Saunders Company, 2002.
Salam MA;Salam MA; Principles & Practice of Uromlogy; 1 Principles & Practice of Uromlogy; 1
stst
edn; edn;
MAS publication,2002.MAS publication,2002.