Bladder Cancer

Richard Tuli and Alexander Lin

Background

How prevalent is bladder cancer in the U.S.?

In the U.S., bladder cancer is the 4^th most commonly diagnosed cancer in men behind prostate, lung, and colorectal malignancies and the 9^th most commonly diagnosed cancer in women.

How do race and gender affect the prognosis of bladder cancer?

With bladder cancer, blacks have a poorer prognosis than whites, and women have a poorer prognosis than men.

Approximately how many cases of bladder cancer are diagnosed and how many deaths occur annually in the U.S.?

There are ~70,000 cases of bladder cancer and ~14,000 deaths annually in the U.S.

What are common risk factors for bladder cancer?

Common risk factors for bladder cancer:

Smoking
Chronic bladder irritation (nephrolithiasis, urinary tract infection [UTI], etc.)
Chemical exposures (Cytoxan, amino biphenyl, naphthylamines, etc.)
Prior pelvic irradiation
Schistosoma haematobium infection (squamous cell carcinoma [SCC] only)

What is the median age at Dx of bladder cancer?

The median age at Dx of bladder cancer is 65 yrs.

Is bladder cancer more common in men or women?

In the U.S., bladder cancer is diagnosed 3 times more frequently in men than women. For squamous histology, the incidence between men and women are equal.

What is the most common histologic subtype of bladder cancer in developed and developing countries?

In developed countries, 90% of bladder cancers are transitional cell carcinomas (TCCs). In developing countries, 75% of bladder cancers are SCCs.

What are the different histopathologic types of bladder cancer in order of decreasing frequency?

The most common histology of bladder cancer in the U.S. is TCC/urothelial carcinoma (94%) > SCC (3%) > adenocarcinoma (2%) > small cell tumors (1%).

What % of newly detected bladder tumors are Ta/Tis/T1 lesions?

~70% of all newly diagnosed bladder cancers are exophytic papillary tumors, with 70% of these confined to the mucosa (Ta/Tis) and 30% confined to the submucosa (T1). (Herr HW et al., Cancer: Principles and practice of oncology. 6^th ed. 2001)

What are important prognostic factors in pts with bladder cancer?

Bladder cancer prognostic factors:

Tumor grade
DOI
Stage
Histologic subtype

Approximately what % of bladder cancer pts have metastatic Dz at presentation, and what are the common sites of mets?

~8% of newly diagnosed bladder cancer pts have metastatic Dz at presentation, usually involving the bone, lungs, or liver.

Workup/Staging

What are the common presenting signs and Sx of bladder cancer?

In pts with bladder cancer, the most common presenting Sx is hematuria → urinary frequency and pelvic/flank pain.

What are the initial steps in the workup of a pt suspected to have bladder cancer? What additional workup is needed after a cancer Dx is made?

Pts suspected to have bladder cancer should 1^st obtain urine cytology or undergo cystoscopy. If a lesion is identified, they should proceed to have a transurethral resection of bladder tumor (TURBT) and EUA. If the lesion identified by cystoscopy is solid, of high grade, or suspicious for muscle invasion, then CT abdomen/pelvis should be performed. If a cancer Dx is made, image the upper urinary tract (intravenous pyelogram, retrograde pyelogram, renal US, or MRI urogram) and chest (CXR or CT). Consider bone scan if there is locally advanced Dz. Recommended blood work includes CBC/CMP. (NCCN 2010)

In the initial TURBT sample of a bladder tumor, what should be present in the pathologic specimen?

The Bx specimen should contain muscle from the bladder wall to properly stage the tumor. If there is presence of muscle-invasive Dz, the pathology specimen should also contain perivesicular fat to assess the extent of Dz.

What are the indications for re-resection after initial TURBT?

Repeat resection should be performed after initial TURBT when there is incomplete initial resection, no muscle in tissue sample, a large lesion, any T1 lesion, or insufficient sample to definitively call a T2 lesion.

What is the AJCC 7^th edition (2009) T-stage criteria for bladder cancer?

Ta: noninvasive papillary carcinoma
Tis: CIS (“flat tumor”)
T1: tumor invades subepithelial connective tissue
T2a: tumor invades superficial muscularis propria (inner half)
T2b: tumor invades deep muscularis propria (outer half)
T3a: microscopic invasion of perivesical tissue
T3b: macroscopic invasion of perivesical tissue (extravesical mass)
T4a: tumor invades prostatic stroma, uterus, vagina
T4b: tumor invades pelvic wall, abdominal wall

What is the probability of pelvic nodal involvement based on the T stage of a bladder tumor?

Pelvic node involvement by bladder cancer T stage based on the surgical series by Stein JP et al.:

Overall: 24% LN+
T0-T1: 5%
T2: 18%
T3a: 26%
T3b: 46%
T4: 42%

(JCO 2001)

What is the AJCC 7^th edition (2009) N- and M-stage criteria for bladder cancer?

N0: no regional LN mets
N1: single LN in true pelvis (hypogastric, obturator, external iliac, or presacral)
N2: multiple LNs in true pelvis
N3: mets to common iliac LN
M0: no DM
M1: DM