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BLADDER CANCER Powered By Docstoc

Shahid Waheed, M.D.
   There are approximately 55,000 new
    cases of bladder, ureter and renal pelvis
    cancers in the United States with
    approximately over 13,000 deaths each
   Gender
       Men have more incidence of bladder
        cancer than women and increased
        incidence in 7th decade of life.
   Race
       Cancers are more common in whites than
        blacks – 2:1.
Etiology and Risk Factors
   Cigarette smoking
   Analgesic abuse
       Analgesic compounds, especially Phenacetin, has
        been associated with increased risk of bladder
   Chronic urinary inflammation
   Occupational exposures
       Workers with organic chemicals, rubber, paint,
        and dye industries have increased risks of
        urothelial cancers.
Etiology and Risk Factors
   Balkan nephropathy
       Increase of cancer with renal pelvis and
        ureters in patients in Balkan nephropathy,
        unknown cause that results in progressive
        inflammation of the renal parenchyma
Etiology and Risk Factors

   Genetic factors
       Families with higher risk of transitional cell
        carcinoma, no genetic basis has been
        found as of yet
Signs and Symptoms
   Hematuria
   Urinary voiding symptoms
   Symptoms of advanced disease usually
    involve swelling in lower extremities
    secondary to a lymphatic obstruction
   Pain and frank hematuria
Diagnostic Work-up
   CT scan
   Ultrasound
   Intravenous pyelogram
   Urine cytology from both ureters at
    time of cystoscopy
   Bone scan
   Chest x-ray
   Transitional cell carcinoma constitutes 90-
    95% of bladder, ureter and renal pelvis
   Squamous cell carcinoma up to 7%
   Adenocarcinoma, rare, less than 3%
       Adenocarcinoma in the bladder which arises from
        the dome is felt to be urachal in origin.
   Carcinoma in situ 30% of newly diagnosed
    bladder cancer with multiple sites of bladder
TNM Staging
   TX    Definition – Primary tumor cannot be
   T10   No evidence of primary tumor
   TA    Noninvasive papillary tumor
   Tis   Carcinoma in situ flat tumor
   T1    Tumor in wedge
           Subepithelial connective tissue
   T2    Tumor in wedge muscle
            T2a tumor in wedge, superficial
                muscle, inner half
             T2a tumor in wedge, deep
             muscle, outer half
Prognostic Factor
   Lesions up to T1, especially TA, without
    carcinoma in situ have 95% survival rate
    whereas those with high grade T1 lesion have
    a 10-year survival rate of 50%.
   Muscle invasive carcinoma 5-year survival
    rates are 20-50%. With regional lymph node
    involvement 5-year survival rate is 0-20%.
   Optional for localized disease
   Treatment of superficial lesions: T0,
    T1S, T1 and low grade T2 is endoscopic
    resection and fulguration with
    cystoscopy, repeated every 3 months.
   Low grade papillomas can be followed
    at much less frequent intervals.
   Intravesical therapy is used prophylactically
    to prevent new lesions and delay or prevent
    development of both metastasis and muscle
    invading tumors, and therapeutically to
    eradicate an existing lesion and known
    visualized disease evidenced by a positive
    cytology. The most intravesical treatment is
    weekly BCG given for six weeks with
    complete remission achieved in 47-85% of

   Other options include transureteral
       Survival rates are more than 70% at 5
   The neodymium-Yttrium-Aluminum,
    NDYAG laser is used to achieve good
    local control of superficial bladder
   Partial cystectomy can be used for
    patients whose tumors are not
    amenable to transureteral resection.
   Radical cystectomy generally not used
    for superficial bladder tumors but can
    be used for:
       Large tumors
       High grade tmors
       Multiple tumors
       Extensive local involvement including
        prostatic stromal involvement
   Other surgical approaches available for
    resection of bladder cancer
       Radical cystectomy for Stage II or greater
       Partial cystectomy
       Urethrectomy
       Urinary reconstruction using intestinal
        conduits, ileo, jejunal or colonic or
        orthoptic reconstruction in both male and
        female patients

   Radiation treatment
       Chemotherapy for advanced disease