Transitional cell carcinoma of urinary bladeder
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Transcript of Transitional cell carcinoma of urinary bladeder
TRANSITIONAL CELL TRANSITIONAL CELL CARCINOMA OF URINARY CARCINOMA OF URINARY
BLADEDERBLADEDER
Presented byPresented by
DR. Md.Rezaul KarimDR. Md.Rezaul KarimFCPS (Surgery)FCPS (Surgery)
MS Urology Thesis Part StudentMS Urology Thesis Part Student
Urology Department, BSMMU, Dhaka.Urology Department, BSMMU, Dhaka.
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).
Etiology & Risk factorsEtiology & Risk factors
Risk factors are Risk factors are
Cigarette smokingCigarette smoking Lather industriesLather industries
Textile industriesTextile industries Analgesics (phenacetin)Analgesics (phenacetin)
Rubber fire industryRubber fire industry CyclophosphamideCyclophosphamide
Hair dresser, PainterHair dresser, Painter Chronic irritationChronic irritation
Metal works Metal works RadiotherapyRadiotherapy
Tryptophan metabolitesTryptophan metabolites Coffee & tea drinkingCoffee & tea drinking
Artificial sweetenersArtificial sweeteners Schistosoma Schistosoma haematobiumhaematobium
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.
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
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
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.
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%
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.
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.
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 Superficial TCC (Ta/T1/CIS) of the bladder, Badrinath R. Koney and Richard D. Williams, BJU, 2004)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, Prognosis of seminal vesicle involvement by TCC of the bladder, Siamak Daneshmand, Jhon P. Stein et al, J of Urol, Vol 172, 81-Siamak Daneshmand, Jhon P. Stein et al, J of Urol, Vol 172, 81-84, Jul’04)84, Jul’04)
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
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
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
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)
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.
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
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
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
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,
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 Superficial TCC (Ta/T1/CIS) of the bladder, Badrinath R. Koney and Richard D. Williams, BJU, 2004, Vol 94: R. Koney and Richard D. Williams, BJU, 2004, Vol 94: 18-21.)18-21.)
DiagnosisDiagnosis
ImagingImaging UltrasoundUltrasound IVUIVU CT scanCT scan MRIMRI CXRCXR Radionuclide bone scanRadionuclide bone scan UrethrocystoscopyUrethrocystoscopy BiopsyBiopsy
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
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 (Effect of routine repeat TUR for superficial bladder cancer: a
long term observational study, Marc- oliver Grimm, C. Steinhoff long term observational study, Marc- oliver Grimm, C. Steinhoff et al, J of Urol.)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-
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 (BCG therapy in stage Ta/T1 bladder cancer: prognostic factors for
time to recurrence and progression,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)
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
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
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 Superficial TCC (Ta/T1/CIS) of the bladder, Badrinath R. Koney and
Richard D. Williams, BJU, 2004)Richard D. Williams, BJU, 2004)
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.
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
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 1stst yr yr
6 mo for 26 mo for 2ndnd yr yr Annually for thereafter.Annually for thereafter. High risk group needs frequent follow up- 1High risk group needs frequent follow up- 1stst 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
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
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 (Does extended lymphadenectomy increase the morbidity of radical
cystectomy? C. Brossner, A. Pycha et al,cystectomy? C. Brossner, A. Pycha et al,
BJU, 2004:Vol 93: 64-66)BJU, 2004:Vol 93: 64-66)
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
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.
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 (T2a TCC of the bladder: long-term experience with intravesical
immunoprophylaxis with BCG, B. G. Volkmer, J.E. Gschwend et al, J of immunoprophylaxis with BCG, B. G. Volkmer, J.E. Gschwend et al, J of Urol, Vol 169, 931-935, March’2003)Urol, Vol 169, 931-935, March’2003)
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
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
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.
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%
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.
ReferencesReferences
Emil A. Tanagho, Jack W. McAninch;Emil A. Tanagho, Jack W. McAninch; Smith’s General Smith’s General Urology; 16Urology; 16thth 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; 8thth 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; 1stst edn; edn; MAS publication,2002.MAS publication,2002.