BLADDER CARCINOMAS

تسلسل 5 المرحلة الرابعة جراحة د.محمد فوزي العدد8 20\2\2018

Bladder tumor dr,mohamed fawzi alshahwani

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facts

Bladder cancer is the second most common cancer of the genitourinary tract. Bladder cancer three times more common in men . The average age at diagnosis is 65 years. At the time of diagnosis , approximately 75% of bladder cancers are localized to the bladder; 25% have spread to regional lymph nodes or distant sites.

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Risk Factors & Pathogenesis

Cigarette smoking 2 )Occupational exposure . Workers in the chemical, rubber, petroleum, leather, and printing industries 3- Pelvic Irradiation. 4- Cyclophosphamide. 5- physical trauma to the urothelium induced by infection, instrumentation, and calculi .

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Histopathology

Ninety-eight percent are epithelial , with most being transitional cell carcinomas 1- Transitional Cell Carcinoma (TCC): commonly appear as papillary, ; less commonly, sessile or ulcerated. Carcinoma in situ (CIS) is recognizable as flat, anaplastic epithelium. 2- Adenocarcinoma: account for <2% .


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Secondary bladder tumors:

Cancers of the prostate, cervix, and rectum may involve the bladder by direct extension. The most common tumors metastatic to the bladder include melanoma, lymphoma, stomach, breast, kidney, lung and liver .

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Clinical Findings

A. SYMPTOMS:Hematuria 85–90% of patients with bladder cancer usually painless. Symptoms of advanced disease include bone pain from bone metastases or flank pain from retroperitoneal metastases or ureteral obstruction *

LABORATORY FINDINGS

Routine testingGUE…….. Hematuria most common …. pyuria,.. from concomitant UTIs Azotemia in patients with ureteral occlusion owing to the primary tumor or lymphadenopathy. Anemia may be a presenting symptom owing to chronic blood loss, or replacement of the bone marrow with metastatic disease. *

2. Urinary cytology: 3. Other markers: Commercially available tests include, the BTA test and NMP22.
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4- Imaging Studies: A- IVU. B- U/S. C- CT. SCAN , MRI. D- chest x-ray and radionuclide bone scan. 5..difinit diagnosis by cystoscopy and biobsy

IVU

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MRI
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TREATMENT

Once a tumor is visualized or suspected, the patient is scheduled for examination under anesthesia and TURT and biopsy of the suspicious lesion. The objectives of TURT are 1 tumor diagnosis, 2 assessment of the degree of bladder wall invasion (staging), 3 and complete excision of the lesions.
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TURT

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TREATMENT

SUPERFECIAL BT (Ta , T1 ) Small,low grade ,single,


TURT then check scope every three months SUPERFECIAL BT (Ta , T1 ) large, multiples ,high grade ,associated CIS, recurrent TURT,intrasical chimotherapy ,and check scope every three months
DEEP BT (T2-T4) Radical cystectomy with urinary diversion (radiotherapy for unfit patient) METASTATIC TUMOR Systemic chimotherapy

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Treatment intravasical chimotherapy

B. SURGERY
1. TURT : is the initial form of treatment for all bladder cancers. It allows a reasonably accurate estimate of tumor stage and grade and the need for additional treatment. Patients who presented initially with multiple or higher grade lesions (or both) and those who have recurrences at 3 months require more careful surveillance. In such patients, cystoscopy at 3-month intervals is necessary.

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Complications of TURBT: Bleeding , Clot Retention And Bladder Perforation.

2. Partial cystectomy: Patients with solitary, infiltrating tumors (T1–T3) localized along the posterior lateral wall or dome of the bladder are candidates for partial cystectomy, as are patients with cancers in a diverticulum.3. Radical cystectomy and Urinary diversion: implies removal of the anterior pelvic organs: in men, the bladder with its surrounding fat and peritoneal attachments, the prostate, and the seminal vesicles; *

in women, the bladder and surrounding fat and peritoneal attachments, cervix, uterus, anterior vaginal vault, urethra, and ovaries. This remains the “gold standard” of treatment for patients with muscle invasive bladder cancer

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CHEMOTHERAPY

15% of patients who present with bladder cancer have regional or distant metastases. The regimen of methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC) has been the most commonly used.

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