BLADDER CANCER

General

  • 55000 new cases/year
  • 7700 deaths/year
  • 50-70 years old (median age 64-68 years)
  • male:female ratio is 3:1
  • Etiology includes: smoking, chemicals (cytoxan, phenacetin, naphthalene), chronic irritation, Schistosoma haematobium (SCCA)
  • Genetics: p53

Anatomy

  • Layers of the bladder wall: mucosa, muscles, and adventia.
  • Lymphatic drainage: perivesicular, hypogastric/internal iliacs, external iliacs, pre-sacral, sacral. Common iliacs and para-aortics are distant mets.
  • Tumor location: 40% lateral, 11% posterior, 3% anterior.

Pathology

  • Transitional cell (90%)
  • Papillary – 80%
  • Solid – 20%, more likely high grade and deeply invasive than papillary.
  • Others: SCCA (8%), adenocarcinoma (2%), small cell, sarcoma, lymphoma, and melanoma.
  • There is increased recurrence with loss of ABO H antigen
  • Tumor growth:
  • CIS is patchy, velvety, flat red areas.
  • Papillary is exophytic with stalk.
  • Invasive mass.

Presentation

  • Painless hematuria 80% – micro or gross and often throughout micturation; "total gross painless hematuria."
  • Vesicular pain 25%.
  • Asymptomatic 20%
  • CIS typically with frequency, urgency, and dysuria.

Workup

  • Imaging
    • CT C/A/P
    • Cystoscopy
  • Pathology
    • Urine Cytology
    • Cold cut biopsy of all suspicious areas followed by TURBT of all visible tumor
    • biopsy the base of TURBT area
  • Exam
    • Bimanual examination under anesthesia before and after cystoscopy/TURBT.
  • Chemestry
    • CBC
    • CHEM20
    • UA

Staging

Clinical Staging

Primary tumor assessment include bimanual examination under anesthesia before and after TURBT.

Clinical Staging Exam Findings Pathological Equivalent
T3a bladder wall thickening microscopic invasion of the perivesical tissue
T3b a mobile mass extravesical mass
T4b fixed mass Tumor invades pelvic wall, abdominal wall

Clinical staging also uses information obtained from the TURBT.

  • This resection should include a sample of the muscularis propria.
  • Once the specimen has been resected, the base of the resected area should be separately biopsied.
  • many advocate selected biopsies of the bladder mucosa and prostatic urethra.

Note

  • Clinical staging underestimates true extent of disease seen after cystectomy.
  • Depth of invasion by TURBT is correct only 50-60% of the time.
  • If induration of the bladder after TURBT then T3 disease.

Pathologic Staging

  • Total cystectomy and LN dissection are required for this staging

AJCC 6th Edition

T Stage Description
Ta Noninvasive papillary
Tis CIS, flat tumor
T1 Subepithelial invasion
T2 Tumor Invades Muscle
T2a < 1/2
T2b > 1/2
T3 Into perivesicular tissue
T3a Microscopic
T3b Macroscopic/mass
T4 Tumor invades other structures
T4a prostate, uterus, vagina
T4b Abd or pelvic wall
N Stage Description
N1 Single node < 2 cm
N2 Single node >2cm - 5cm, or
Multiple nodes all < 5cm
N3 Node(s) >5cm
  • Note: Common iliac nodes are M1
Stage T N
I T1 N0
II T2 N0
| III T3 N0
IV T4 or N+ or M1

Prognostic Factors

  • Depth of invasion/stage
  • Grade
  • CIS present
  • LVSI
  • Solid worse than papillary
  • Multifocal disease
  • Presence of hydronephrosis
  • Residual disease after treatment
  • Path + lymph nodes

Surgery

Radical cystectomy for a man

  • removal of bladder
  • prostate + SV
  • perivesicular fat
  • low ureters, proximal urethra,
  • and pelvic nodes.

Radical cystectomy for a female

  • bladder
  • pelvic nodes
  • TAH-BSO
  • and anterior exenteration.

Diversions

  • either ilial conduit
  • or neobladders formed (Indiana or Koch).

Notes

  • 15% of surgery patients have cystectomy aborted due to intraoperative findings of extensive disease.
Stage 5 year survival
T2 50-80%
T3a 35-70%
T3b 11-40%

Bladder Preservation

Selection Criteria

Tumor

  • TURBT maximal
  • No Hydronephrosis
  • No prostate stromal invasion
  • No +LN
  • Muscle Invasive tumor

Patient

  • Good bladder function
  • KPS > 70
  • CrCl > 60 ml/min
  • > 18 years old

Treatment

treatment.jpg

Timing

  • 3 weeks between initial TURBT and Chemoradiation
  • 3 weeks from CRT to Cystoscopic response evaluation

Follow-up

  • cystoscopy q 3 months x 2 years then Q 6 months.

Chemotherapy

  • Concurrent chemoradiation with cisplatin
  • Adjuvant 2 to 3 drug combinations
    • cisplatin
    • taxanes
    • gemcitabine

Radiation

Initial Field

RT0
  • Treat with bladder empty. (some air contrast during simulation to see the bladder)
  • Give rectal contrast for lateral films
  • 40 Gy in 1.8 Gy

Boost Field

RT2
  • Treat with bladder full
  • Oppossed laterals or 3D CRT to cover initial tumor volume (based on cystoscopy review)
  • Boost to 60-64.8 Gy

Results of Bladder Preservation

Complete Response Rate

RT 35-55%
CT 11-37%
TURBT + CT 45-61%
TURBP + RT + CT 64-87%

Bladder Preservation

5-OS 5-DSS 5-DSS with bladder % Undergoing Cystectomy
All patients 55% 64% 44% 37%
TURBT Visibly Complete 59% 69% 51% 29%
TURBT not Complete 49% 58% 35% 50%

Overall Survival

5-OS
Stage I 80-90%
Stage IIA 50%
Stage IIB 20%
Stage III 10-15%
Stage IVA 10%
Stage IVB 0%
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