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Urology > B/4. Superficial bladder cancer B/5. Muscle-invasive bladder cancer > Flashcards

B/4. Superficial bladder cancer B/5. Muscle-invasive bladder cancer Flashcards

1
Q

Transitional cell tumors (urothelial carcinoma) include

A
  • bladder cancer (90%)
  • renal pelvis tumor (8%)
  • ureter or urethra tumor (2%).
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2
Q

Epidemiology of bladder cancer

A
  • 2nd most common urological malignancy in males
  • Male to female ratio 4:1
  • Median age of diagnosis 65 years
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3
Q

2nd most common urological emergency malignancy in males

A

bladder cancer

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4
Q

bladder cancer
median age of diagnosis, gender ratio

A

Male to female ratio 4:1
Median age of diagnosis 65 years

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5
Q

Risk factors of bladder cancer

A
  • Smoking ( increased risk by 2-3x)
  • Aromatic amines (aniline dyes)
  • Radiation exposure
  • Phenacetin exposure
  • Chronic cyclophosphamide exposure
  • Chronic cystitis
  • Schistosoma haematobium parasitic infection (endemic in some middle-east countries); associated with squamous cell carcinoma
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6
Q

which infection is a risk factor for developing bladder cancer

A
  • Schistosoma haematobium parasitic infection
    (endemic in some middle-east countries); associated with squamous cell carcinoma
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7
Q

Schistosoma haematobium parasitic infection associated with which type of carcinoma

A

squamous cell carcinoma

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8
Q

Clinical findings of bladder cancer

A
  • Painless hematuria (macroscopic > microscopic)
  • Irritative symptoms (urgency, frequency, dysuria)
  • Recurrent UTI
  • *Symptoms of metastatic disease are rarely the first presenting sign
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9
Q

Histopathological classification, pathology of bladder cancer

A
  • Transitional cell cancer >75%:
    *papillary tumor
    *carcinoma in situ (CIS)
    *solid tumor
  • Squamous cell carcinoma 3%
  • Adenocarcinoma 2%
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10
Q

Transitional cell cancer of bladder types

A
  • Papillary tumor: tend to bleed, usually low-grade, high recurrence
    rates
  • Carcinoma in-situ (CIS) : usually high-grade???
  • Solid tumor: invasive, poor prognosis

> 75%

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11
Q

bladder Squamous cell
carcinoma

pathology

A

3%
- chronic irritation of bladder > squamous metaplasia > dysplasia > carcinoma

  • Common in regions with high prevalence of Schistosoma haematobium
    infection
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12
Q

Adenocarcinoma of bladder

A

2%
Develop:

  • urachal remnant in the dome of the bladder ( primarily )
    or
  • periurethral tissues
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13
Q

mutations in Low-grade, non-invasive bladder tumors

A
  • ras mutation
  • FGF-R3 mutation
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14
Q

High-grade, invasive bladder tumors mutations

A
  • p53
  • RB mutation
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15
Q

Grading of bladder cancer ( new approach)

A
  • PUNLMP (papillary urinary neoplasm of low malignant potential)
  • Low-grade
  • High-grade
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16
Q

Grading of bladder cancer ( old approach)

A
  • Grade 1 : well-differentiated
  • Grade 2: moderately differenciated
  • grade 3 poorly differenciated
17
Q

Diagnostics of bladder cancer

A
  • Once hematuria is documented: urinary cytology and cystoscopy are indicated
  • endoscopic evaluation (rigid/flexible endoscope) includes an examination under local anesthesia to determine whether a palpable mass is present.
  • All visible tumors should be resected, and a sample of the muscle underlying the tumor should be obtained to assess the depth of invasion.
  • Normal-appearing areas are biopsied randomly to ensure no CIS is present
  • CT or MRI are indicated if histopathologic analysis of resected sample is positive for muscle-invasive growth.
  • US may also be used during evaluation, including doppler assessment for tumor vascularization. Consider as initial evaluation (before cystoscopy) if obstructive symptoms are present. *Bladder masses are seen only when the bladder is full.
18
Q

what is indicated once hematuria is documented in bladder cancer

A

Once hematuria is documented,
urinary cytology and bladder cystoscopy are indicated

19
Q

US is Considered as initial evaluation (before cystoscopy) if

A

obstructive symptoms are present.

masses only visualized if bladder if full!!!

20
Q

when is CT or MRI indicated in bladder cancer

A

CT or MRI are indicated if histopathologic analysis of resected sample is positive for muscle-invasive growth.
Required to assess the level of invasion, and evaluate for local/distant spread

21
Q

Visual inspection of bladder cancer includes

A

mapping the location, size, and number of lesions; as well as description of
the growth pattern (solid vs. papillary).

22
Q

Visualization of the upper urinary tract is indicated in all cases (even if bladder cystoscopy is negative) WHY??

A

since urothelial tumors may be multifocal with one or more lesions anywhere from the renal pelvis to the proximal urethra

23
Q

since urothelial tumors may be multifocal with one or more lesions anywhere from the renal pelvis to the proximal urethra
What should be done in all cases?

A

Visualization of the upper urinary tract is indicated in all cases (even if bladder cystoscopy is negative)

24
Q

staging of bladder cancer - TX, T0

A

TX Primary tumor cannot be assessed
T0 No evidence of primary tumor

25
Q

staging of bladder cancer Tis, Ta

A

Tis -Urothelial carcinoma in-situ: “Flat tumor
Ta -Noninvasive papillary carcinoma

26
Q

STAGING bladder cancer T1-T3

A

T1 Tumor invades lamina propria (subepithelial connective tissue)
T2 Tumor invades muscularis propria
T3 Tumor invades peri-vesical soft tissue (microscopically or macroscopically)

27
Q

staging of bladder cancer - T4

A

T4 Extravesical tumor directly invades any of the following:
prostatic stroma,
seminal vesicles,
uterus, vagina,
pelvic wall, abdominal wall

28
Q

which LN are involved in bladder cancer

A
  • True pelvic nodes : (Peri-vesical, obturator, internal and external iliac, sacral),
  • common iliac nodes
29
Q

where does bladder cancer metastasize

A

LN
bone
lung
liver
peritoneum

30
Q

treatment of bladder cancer depends on

A

Management depends on whether the tumor invades muscle and whether it has spread to the regional lymph nodes and beyond.
The probability of spread increases with increasing T stage

31
Q

Non-muscle
invasive disease
(Ta, T1, Tis) treatment

A

Complete endoscopic resection +/- intravesical therapy

  • Endoscopic resection:
    *TURBT = transurethral resection of bladder tumor
    *Reoccurrence rate up to 50%
  • Intravesical therapy
    *Adjuvant for endoscopic resection
    *Alternatively, may be used to eliminate disease that cannot be controlled by endoscopic resection alone (diffuse CIS, recurrent disease, > 40% involvement of the bladder surface by tumor)
    *Mitomycin-C and/or Epirubicin are used as adjuvant. Side effects include dysuria and urinary frequency
    *BCG (Bacillus Calmette-Guerin) is used for CIS, 6 weekly instillations. Rarely, may
    cause systemic illness associated with granulomatous infection.
32
Q

what may be used to eliminate disease that cannot be controlled by endoscopic resection alone

A

Intravesical therapy may be used to eliminate disease that cannot be controlled by
endoscopic resection alone
* diffuse CIS,
* recurrent disease,
* > 40% involvement of the bladder surface by tumor)

33
Q

Following the endoscopic resection of bladder cancer, patients are monitored for?
how long
what is used

A

reoccurrence at 3-month interval for the first 2 years (cystoscopy + US).
Reoccurrence may occur anywhere along the urothelial tract.

34
Q

Muscle-invasive bladder cancer
disease treatment

A
  • Radical cystectomy +/- adjuvant chemotherapy +/- neoadjuvant chemotherapy
  • Partial cystectomy may be considered when disease is confined to the dome of the bladder, > 2 cm clean margin can be achieved, and no evidence of CIS.
  • Urine deviation: Ileal conduit (Bricker operation), Orthotopic bladder
35
Q

Radical cystectomy male

A

removal of
* Bladder
* prostate
* seminal vesicles
* pelvic LN

36
Q

Radical cystectomy females

A

removal of
* bladder
* urethra
* uterus, fallopian tubes, ovaries
* upper vagina
* pelvic LN

37
Q

when is Partial cystectomy considered in muscle invasive bladder cancer

A
  1. when disease is confined to the dome of the bladder,
  2. > 2 cm clean margin can be achieved,
  3. and no evidence of CIS
38
Q

Urine deviation in muslce invasive bladder cancer

A
  • Ileal conduit (Bricker operation) : use ileum to create connection with stoma on the skin, cutaneous resevoir, no continent
  • Orthotopic bladder: ‘neo-bladder’, provides continent; efficacy is questionable
39
Q

Metastatic bladder cancer
disease treatment

A

Chemotherapy +/- radiotherapy
Palliative approach
- GC protocol = Gemcitabine, Cisplatin
- MVAC protocol = Methotrexate, Vinblastine, Adriamycin (= Doxorubicin), Cisplatin

Urology (30 decks)

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