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Bladder Cancer

Bernard S. Tjandra
Bedah Urologi

Epidemiology
350.000 new cases worldwide per annum
>70.000 new cases in the USA alone
Man : woman = 3 : 1
White : Black =
2:1
The 5th most common cancer in Europe

Aetiology
1894 Rehn
Aniline dye
(beta naphthylamine)
Smoking 2.2 - 4 x risk (passive smokers !)
Schistosomiasis (squamous
(squamous cancer)
cancer)
Bladder stone
Permanent Foley Catheter

Protective factors
Vitamine A, B6, C and E
Soy
Garlic
Selenium
Green tea

Grades
G1 well differentiated
G2 intermediate
G3 undifferentiated
undifferentiated

Pathology
Macro / micro scopic

single or multiple

papillary, solid

mostly urothelial (transitional cell)

may undergo metaplasia squamous cell carcinoma


infection, urachus adenocarcinoma

Stages
Tis carcinoma insitu
Ta non invasive
T1 invasion of the lamina propia
T2 invasion of the superficial muscle
T3a invasion of the deep muscle
T3b invasion of the perivesical fat
T4a infiltration of prostate, uterus or vagina
T4b fixation to the pelvic and/or abdominal wall

In situ
Spread of bladder cancer
direct
lymphatic
superficial
T1
deep
T2 T3
systemic

bone

lungs

liver

cor

brain

skin

Symptoms
Painless gross haematuria
Frequency
Pain on voiding
Anaemia
Urinary infection

Radiating pain to the perineum and sacrum

Investigations
Urinalysis, cytology, culture
Urea, creatinine, haematology
IVU (2.3 % develop upper tract tumours)
Cystoscopy
Photodynamic diagnosis (PDD)
Computed tomography
USG of the bladder
Chest X-ray
Markers ?

Markers
Cyfra 21-1
Cytokeratin 20
Microsatelite
LewisX
NMP 22
ImmunoCyt

I.V.U

Cystoscopy

Fluorescenc
e
cystoscopy

USG

non-muscle
invasive (TaT1)
muscle-invasive
(>T2)

Manageme
nt /
Treatment

Follow-up :
2nd
cystoscopy
after 3 mo.

Follow-up

Prognostic factors for recurrence


Multiplicity
Recurrence at 3 month
Size of the tumor
Tumor grade
T category
Presence of CIS

Treatment
Goals of intravesical chemotherapy
Prevent tumor recurrence
Prevent tumor progression
Prolong the disease-free interval
Eradicate the disease

Commonly used cytotoxic agents


Antibiotics
Mitomycine-C *
Epirubicine
Alkylating agents
Thiotepa
Epodyl
Others
BCG vaccine
RIVM
Connaught
Tice

Ureterosigm
oidostomy
Ileoureterocutaneosto
ma
Ta T1 (non-muscle)
5 year survival rate 70 % (TURB 1967, Barnes)
Recurrence rate of superficial cancer within 3 years
Ta 52 % (multifocal)
T1 69 %
Tumor progression
Ta 19 % (multifocal)
T1 34 %
Complete response Mitomycine-C 40 %
T2 / T3 / T4 (muscle-invasive)
50 % have metastases at the time of diagnosis
TURB 1977 Barnes
5 year survival rate T2
31 %
External radiotheraphy (60 Gy) Wijnmalen
5 year survival rate
T2
28 42 %
T3
20 33 %
T4
1 13 %
Radical cystectomy + diversion 1983 Jacobi
5 year survival rate T2
44 86 %
Combination chemotheraphy 1984 Harker
(cisplatin, methotrexate, vinblastin)
Complete response 30 - 50 %
Objective response 57 - 70 %
(gemcitabine, cisplatin)
Urinary diversion
Ureterosigmoidostomy
Coffey
Incontinent
Incontinent reservoir
Ureteroileostomy Bricker
Continent reservoir / pouch
Koch pouch
Mainz pouch
Studer
cave hyperchloraemic acidosis

(Bricker
diversion)

Studer
Neoblad
der