!DOCTYPE html PUBLIC “-//W3C//DTD XHTML 1.1//EN” “http://www.w3.org/TR/xhtml11/DTD/xhtml11.dtd”>
|
I. PRESENTATION
A. Subjective. The most common presenting symptom of bladder cancer is hematuria, which is usually gross, intermittent, and total (present during the entire urine stream). Virtually all patients with bladder cancer have at least microscopic hematuria. Since the hematuria is usually intermittent, further evaluation after the first episode should be pursued even if the repeated subsequent urinalyses are negative. In a prospective study evaluating 1,930 patients with either microscopic or gross hematuria, 230 patients (11.9%) had bladder cancer, including 47 (4.8%) with microscopic and 183 (19.3%) with gross hematuria (J Urol 2000;163:524). Irritative lower urinary tract symptoms including frequency, urgency, and dysuria may indicate the presence of microscopic hematuria, and should prompt additional workup. Obstructive lower urinary tract symptoms such as incomplete emptying and decreased force of the urinary stream may occur in patients with tumor located at the bladder neck or prostatic urethra. Symptoms related to distant metastases are uncommon at presentation.
B. Objective. Most patients have no disease-specific findings in the physical examination. With more advanced disease, a pelvic mass may become palpable.
II. WORKUP AND STAGING
A. Workup. Evaluation of patients with hematuria includes urinalysis, cystoscopy, and imaging of the upper urinary tracts. Hematuria is considered to be clinically significant when there are more than three red blood cells (RBCs) per high power field (HPF). The gold standard for the diagnosis of bladder cancer is cystoscopy with transurethral resection of the bladder tumor (TURBT). Urine cytology, which has a low sensitivity but a very high specificity, should also be performed to increase the detection of upper urinary malignancies. Imaging studies help define the extent of the tumor and the presence of additional synchronous lesions. The most commonly used imaging test is CT urography, although intravenous pyelogram (IVP) may also be used in selected cases.
B. Pathology and staging
1. Pathology. Urothelial or transitional cell carcinomas are the most common histologic subtypes of bladder cancer, representing more than 90% of cases in the Western countries. The most common non-urothelial malignancies are squamous cell carcinomas, adenocarcinoma, and small cell carcinomas. Pathologic features such as identification of the “nested” variant of urothelial carcinoma, as well as the presence of sarcomatoid or plasmacytoid elements predicts for a more aggressive clinical course.
2. Staging. Bladder cancer may be broadly subdivided into three categories including non-muscle–invasive, muscle-invasive, and metastatic tumors. Noninvasive tumors belong to stages 0 to I and are divided into Ta (noninvasive papillary carcinoma), T1 (invasion of the subepithelial connective tissue), and Tis (carcinoma in situ). Stage II is defined as invasion of the muscularis propria, and stage III indicates the invasion of perivesical tissue, either microscopically or macroscopically as a vesical mass or invasion of adjacent organs. Invasion of the pelvic or abdominal wall indicates T4b, which is classified as stage IV. Involvement of regional or iliac lymph nodes and the presence of distant metastases also indicate stage IV. The prognosis and goals of therapy are distinct for each category, ranging from prevention of relapse in non-muscle–invasive tumors to palliation in those with metastatic disease.
III. NON-MUSCLE–INVASIVE BLADDER CANCER. Approximately 75% of the bladder tumors are non-muscle–invasive. The treatment of choice for these tumors is TURBT with bimanual examination under anesthesia. The resection should sample the muscle to evaluate for invasion. Without additional therapy after a complete TURBT, more than half of the patients will have recurrence, with 10% of recurrences progressing to muscle-invasive disease. The most important factor for progression to muscle invasion is the tumor grade. Other risk factors for recurrence and progression include tumors larger than 3 cm, multifocal tumors, stage T1, and sessile lesions. Most patients with metastases have concurrent or prior diagnosis of muscle-invasive tumor, with the development of metastasis in patients without history of previous muscle invasion being rare. The use of immediate intravesical chemotherapy using mitomycin, thiotepa, or epirubicin decreases the risk of recurrence (J Urol 2004;171:2186). The International Bladder Cancer Group recommends immediate intravesical chemotherapy for patients with low risk disease (solitary and primary tumor, low grade Ta). The most commonly used drug in this setting is mitomycin. Patients with intermediate (multiple or recurrent low grade tumors) or high risk (T1, Tis, or grade 3) should be treated with Bacillus Calmette–Guerin (BCG) with six weekly instillations starting after bladder healing from surgery (J Urol
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
