Bladder Carcinomas
description
Transcript of Bladder Carcinomas
Bladder Carcinomas
Bladder Carcinomas• Incidence• Risk factors• Staging• Histopathology
– Papilloma– Transitional Cell Carcinoma– Nontransitional Cell Carcinoma
• Adenocarcinoma• Squamous cell carcinoma• Undifferentiated carcinomas• Mixed carcinoma
– Rare epithelial and nonepithelial cancers• Clinical Findings• Treatment
Incidence
• The second most common cancer of the genitourinary tract
• Accounts for 7% of new cancer cases in men • Accounts for 2% of new cancer cases in women• Average age at diagnosis is 65 years– 75% of bladder cancers localized to the bladder– 25% have spread to regional lymph nodes or distant
sites
B L A D D E R C A R C I N O M A
Risk Factors
• Cigarette smoking
• Occupational exposure
• Management with cyclophosphamide(Cytoxan)
• Physical trauma to the urothelium
B L A D D E R C A R C I N O M A
Risk Factors• Cigarette smoking
– 50% of cases in men – 31% of cases in women – Confers a twofold increased risk of bladder cancer than nonsmokers;
dose-related– Causative agents: alpha- and beta-naphthylamine secreted into
the urine of smokers
• Occupational exposure
• Management with cyclophosphamide(Cytoxan)
• Physical trauma to the urothelium
B L A D D E R C A R C I N O M A
Risk Factors• Cigarette smoking
• Occupational exposure – 15–35% of cases in men – 1–6% of cases in women – Increased risk: workers in the chemical, dye, rubber, petroleum, leather, and
printing industries – Specific occupational carcinogens include benzidine, betanaphthylamine, and
4-aminobiphenyl– Latency period may be prolonged
• Management with cyclophosphamide(Cytoxan)
• Physical trauma to the urothelium – Infection, instrumentation, calculi
B L A D D E R C A R C I N O M A
Risk Factors
• Cigarette smoking
• Occupational exposure
• Management with cyclophosphamide(Cytoxan)
• Physical trauma to the urothelium – Infection, instrumentation, calculi
B L A D D E R C A R C I N O M A
Staging
Nodal (N) stage • Nx – cannot be assessed• N0 – no nodal metastases• N1 – single node <2 cm involved• N2 – single node involved 2–5cm
in size or multiple nodes none >5 cm
• N3 – one or more nodes >5cm in size involved
Metastases (M) stage• Mx – cannot be defined• M0 – no distant metastases• M1 – distant metastases present
B L A D D E R C A R C I N O M A
Histopathology• Papilloma• Transitional Cell Carcinoma• Nontransitional Cell Carcinoma
– Adenocarcinoma– Squamous cell carcinoma– Undifferentiated carcinomas– Mixed carcinoma
• Rare epithelial and nonepithelial cancers– Villous adenomas, carcinoid tumors, carcinosarcomas, melanomas– Pheochromocytomas, lymphomas, choriocarcinomas, and various
mesenchymal tumors
B L A D D E R C A R C I N O M A
Papilloma
• Papillary tumor with a fine fibrovascular stalk supporting an epithelial layer of transitional cells with normal thickness and cytology
• Rare benign condition
• Usually occurs in younger patients
B L A D D E R C A R C I N O M A
Transitional Cell Carcinoma• 90% of all bladder cancers• Most commonly appear as papillary,
exophytic lesions – Superficial
• Less commonly, may be sessile or ulcerated– Often invasive
• Carcinoma in situ (CIS) – flat, anaplastic epithelium– Urothelium lacks the normal cellular
polarity, and cells contain large, irregular hyperchromatic nuclei with prominent nucleoli
B L A D D E R C A R C I N O M A
Nontransitional Cell Carcinoma: Adenocarcinoma
• <2% of all bladder cancers• 2 types:
– Primary adenocarcinomas of the bladder• Preceded by cystitis and metaplasia• Often arise along the floor of the bladder
– Adenocarcinomas arising from the urachus • Occur at the dome
– Both tumor types are often localized at the time of diagnosis, but muscle invasion is usually present
• Histology: mucus-secreting and may have glandular, colloid, or signet-ring patterns
• Five-year survival: <40%, despite aggressive surgical management
B L A D D E R C A R C I N O M A
Nontransitional Cell Carcinoma: Squamous cell carcinoma
• 5% -10% of all bladder cancers in the US• History of:– Chronic infection– Vesical calculi– Chronic catheter use– Bilharzial infection owing to Schistosoma haematobium
(60%)
B L A D D E R C A R C I N O M A
Nontransitional Cell Carcinoma: Undifferentiated carcinomas
• Rare (<2%)• No mature epithelial elements• Very undifferentiated tumors with neuroendocrine
features and small cell carcinomas tend to be aggressive and present with metastases
B L A D D E R C A R C I N O M A
Nontransitional Cell Carcinoma: Mixed carcinomas
• 4–6% of all bladder cancers • Composed of a combination of transitional,
glandular, squamous, or undifferentiated patterns• Most common type comprises transitional and
squamous cell elements • Most are large and infiltrating at the time of
diagnosis
B L A D D E R C A R C I N O M A
Rare Epithelial and Nonepithelial Cancers
• Rare epithelial cancers: villous adenomas, carcinoid tumors, carcinosarcomas, melanomas
• Rare nonepithelial cancers: pheochromocytomas, lymphomas, choriocarcinomas, and various mesenchymal tumors
• Cancers of the prostate, cervix, and rectum may involve the bladder by direct extension
• Most common tumors metastatic to the bladder include (in order of incidence)– Melanoma, lymphoma, stomach, breast, kidney, lung and
liver
B L A D D E R C A R C I N O M A
Signs and symptoms
• Hematuria (85–90%) – Gross or microscopic, intermittent rather than constant
• Vesical irritability– Frequency, urgency, and dysuria
• Irritative voiding symptoms– More common in patients with diffuse CIS
• Symptoms of advanced disease:– Bone pain from bone metastases or – Flank pain from retroperitoneal metastases or ureteral
obstruction
B L A D D E R C A R C I N O M A
Laboratory Findings• Urinalysis
– Hematuria; may be accompanied by pyuria– Azotemia in patients with ureteral occlusion (primary bladder tumor or
lymphadenopathy)• CBC
– Anemia (chronic blood loss, or replacement of the bone marrow with metastatic disease)
• Urinary cytology– Voided urine: exfoliated cells from both normal and neoplastic
urothelium – Barbotage: larger quantities of cells can be obtained by gently irrigating
the bladder with isotonic saline solution through a catheter or cystoscope
B L A D D E R C A R C I N O M A
Laboratory FindingsB L A D D E R C A R C I N O M A
Imaging• Uses:
– To evaluate the upper urinary tract– To assess the depth of muscle wall infiltration in infiltrating bladder tumors– To detect the presence of regional or distant metastases
• Intravenous urography – One of the most common imaging tests for the evaluation of hematuria
• Computed tomography (CT) urography– More accurate for evaluation of the entire abdominal cavity, renal
parenchyma, and ureters in patients with hematuria– Largely replaces intravenous pyelography– Bladder tumors: pedunculated, radiolucent filling defects projecting into
the lumen; nonpapillary, infiltrating tumors may result in fixation or flattening of the bladder wall
B L A D D E R C A R C I N O M A
Imaging• CT and magnetic resonance imaging (MRI)
– Characterize the extent of bladder wall invasion– Detect enlarged pelvic lymph nodes– Overall staging accuracy ranging from 40% to 85% for CT and
from 50% to 90% for MRI (– Rely on size criteria for the detection of lymphadenopathy:
• LN >1 cm = metastases
• Chest X-Ray– Metastasis to the lungs
• Radionuclide bone scan– Metastasis to the bones– Can be avoided if the serum alkaline phosphatase is normal
B L A D D E R C A R C I N O M A
Image of the urinary bladder obtained on an intravenous urogram. The filling defect represents a papillary bladder cancer.
MRI scan of invasive bladder carcinoma: A: T1-weighted image; B: T2-weighted image. Bladder wall invasion is best assessed on T2-weighted images because of heightened contrast between tumor (asterisks) and detrusor muscle along with ability to detect
interruption of the thin high-intensity line representing normal bladder wall. The heterogeneous appearance of the prostate (arrow) on the T2-weighted image owes to
benign prostatic hypertrophy, confirmed at cystectomy.
Cystouretheroscopy and Tumor Resection
• The diagnosis and initial staging of bladder cancer is made by cystoscopy and transurethral resection (TUR).
B L A D D E R C A R C I N O M A
Cystouretheroscopy and Tumor Resection
• Once a tumor is visualized or suspected, the patient is scheduled for examination under anesthesia and transurethral resection (TUR) or biopsy of the suspicious lesion.
• The objectives are tumor diagnosis, assessment of the degree of bladder wall invasion (staging), and complete excision of the low-stage lesions amenable to such treatment.
B L A D D E R C A R C I N O M A
transurethral resection (TUR)
Treatment Principles• Initial low-grade small tumors low risk of
progression – TUR alone followed by surveillance or intravesical
chemotherapy• T1, high-grade, multiple, large, recurrent
tumors or those associated with CIS on bladder biopsies higher risk of progression and recurrence– Intravesical chemotherapy or immunotherapy
after complete and careful TUR
B L A D D E R C A R C I N O M A
Treatment Principles
• T2, T3, more invasive, but still localized, tumors– More aggressive local treatment, including partial
or radical cystectomy– Combination of radiation and systemic
chemotherapy• Unresectable local tumors (T4B) are candidates
for – Systemic chemotherapy, followed by surgery (or
possibly irradiation)
B L A D D E R C A R C I N O M A
Treatment: Intravesical Chemotherapy• Immunotherapeutic or chemotherapeutic agents instilled into the bladder
directly via catheter• Avoids the morbidity of systemic administration • Most common agents in the US are mitomycin C, thiotepa, and Bacillus
Calmette-Guérin (BCG)• Unable to reach cancer cells:
– that have grown deeply into the bladder wall– in the kidneys, ureters, and urethra, or in other organs
• Used only for noninvasive (stage 0) or minimally invasive (stage I) bladder cancers.
B L A D D E R C A R C I N O M A
Treatment: Surgery
• Transurethral resection– Initial form of treatment for all bladder cancers– Allows a reasonably accurate estimate of tumor stage and
grade and the need for additional treatment– Patients with single, low-grade, noninvasive tumors may
be treated with TUR alone
B L A D D E R C A R C I N O M A
Treatment: Surgery
• Partial Cystectomy– Removal of a part of the bladder– For patients with solitary, infiltrating tumors (T1–
T3) localized along the posterior lateral wall or dome of the bladder
– For patients with cancers in a diverticulum
B L A D D E R C A R C I N O M A
Treatment: Surgery• Radical Cystectomy– Removal of the entire bladder, nearby
lymph nodes (lymphadenectomy), part of the urethra, and nearby organs that may contain cancer cells.
– In men: prostate, seminal vesicles, and part of the vas deferens
– In women: cervix, uterus, ovaries, fallopian tubes, and part of the vagina
– The “gold standard” of treatment for patients with muscle invasive bladder cancer
B L A D D E R C A R C I N O M A
http://www.webmd.com/cancer/bladder-cancer/cystectomy-for-bladder-cancerhttp://www.healthline.com/images/staywell/36680.jpg
Treatment: Radiotherapy
• External beam irradiation (5000–7000 cGy), delivered in fractions over a 5- to 8-week period, is an alternative to radical cystectomy in well-selected patients with deeply infiltrating bladder cancers
B L A D D E R C A R C I N O M A
Treatment: Chemotherapy
• Early results with single chemotherapeutic agents and, more recently, combinations of drugs have shown that a significant number of patients with metastatic bladder cancer respond partially or completely– Regional or distant metastases: 15%– With invasive disease: 30–40% develop distant
metastases despite radical cystectomy or definitive radiotherapy
B L A D D E R C A R C I N O M A