1. Bladder cancer
Dr/omar hashim

2. Anatomy of bladder
Bladder is lie behind pubic bone,it is the maximum
storage
is 500 ml.it has stronge muscular wall. It is shape and
relation according to containing volume. The empty
bladder is pyramidal ,having apex, base superior, and
two inferolateral surface. The superior surface is
covered by
Peritoneum, when bladde is fills the superior surface
bulges
Up ward so the bladder is become in direct contact to
the

9. Epidemiology and etiology
the incidence of bladder cancer is 9.9/100.000 in
men
And 2.3/100.000 in women in USA. New case in US in
2010
Is 70.530 .and death 13,060 .
Risk factors ;-
 Age and gender ;-incidence ↑with age (more common
Age 60—70) .m:f ratio is 4:1
 Twice more common in white American than in non
cau-
Cassians .

10. Past medical history ;-pelvic radiation, chemotherapy
Bladder lithiasis,chronic catheterization, recurrent urinar
Infection exposure to schistosomiasis.
Genetic factors ;-these is some gene associated with
Poorer prognosis and↑chance of progression include
(EGFR),P53,ras oncogene .
Industrial chemicals ;- aniline dye,naphthylamine
Benzidine.so aniline dye,leather,paint,and rubber
Workers more affected than general population.
Drugs :-cyclophosphamide

11. pathology
Pathologic subtypes of ca prostate;-
1)Transitional cell carcinoma ;- represent 90% of
bladder
Cancer inUSA,70% are superficial carcinoma,arise
from
Normal urohtellium and associated with smoking and
Carcinogen exposure .
2) Squamous cell carcinoma;- caused by chronic
irritation
From urinary calculi,long term indwelling
catheter,chronic

12. Transitional cell carcinoma of bladder

13. Squamous cell carcinoma of the ca bladder

14. 3) Adenocarcinoma ;- represent 2% ,include
3groups,1ry
Urachal and metastatic .
4) Small cell carcinoma ;-represent 1%, behaves
similarly to
Small cell carcinoma found elsewhere in the body.
5) Mixed histology ;- represent 25% of the case
,usually
Transitional with adenocarcinoma or squamous
*most common site is trigone (inferiorly below ureter-
Ovesical juncation,laterial wall,posterior wall,and

15. diagnosis
Clinical presentation ;-
Hematuria is the most common presenting symptoms
75%. Irritative /obstructive symptoms occur in quarter
of
patients. plevic pain occur in local advanced disease
invading
into adjacent organs. Poor appetite and weigth loss
late
systemic symptoms.
Examination:- for metastatic sites / PR:- to see the
local
Extension .

16. Cystoscopy is indicated in following:-
a) Any gross or microscopic hematuria.
b) Unexplained or chronic lower urinary tract symptom
c) Urine cytology that is suspicious for cancer.
d) History of bladder cancer.
CT:-to detect the 1ry sites and any enlarged LNs and
Metastasis if is present.
Urine cytology:-is not used for 1ry diagnosis but for
Follow up of ca bladder patients/,screening for environ
Mental carcinogens/.evaluating pts with chronic irritativ
Bladder symptoms

17. Doagnosis procedure for bladder cancer;-
Hematuria or irritative
bladder cancer
HX/EX /urinary
Cystoscopy/pyelography
cytologyCBC/CXR.*1
Invasive
Superficial
Muscular is -ve
Abd-u/s/pelvic CT &bones
can

18. Tumor,node and metastasis staging (TNM) determine b
American Joint Committee on Cancer (AJCC)
PRIMARY TUMOR ;-
STAGE DESCRIPTION
T1 tumor invade subepithelial connective tissues
T2 tumor invade muscularis propria
T3 Tumor invade perivesical tissues
T4 Tumor invade any of the following (prostate
stroma /seminal vesicle /uterus /vagina /pelvic
wall /abdominal wall

20. Regional LNs include 1ry and 2ry drainage regions all n
Above the aortic bifurcation are considered distant meta
Asis ;-
N0 No regional LNs metastasis
N1 single regional LNs metastasis in true pelvic
(hypogastric/obturator/external iliac or presacral
)
N2 multiple regional LNs metastasis in true plevic
N3 lymph nodes metastasis to the common
iliacLNs
Distant metastasis ;-
M0;-no distant metastasis
M1;- distant metastasis

21. Stage group of bladder cancer ;-
T1 T2 T3 T4a T4a
N0 1 11 111 111 1V
N1-3 1V 1V 1V 1V 1V
M1 1V 1V 1V 1V 1V

22. PROGNOSIS
Stage is the most important determinant of the survival
. 5 yrs over all survival (OS) rate after cystectomy
Determined according to stage
Type descriptio
n
stage Organ extra nodes
superficial con- vesicle +ve
P0a,N0 Fined p3-4,N0
p2,N0
5yra 85% T2a 77% 47% 31%
T2b 64%
survival …/40%.(1
-4)

23. Prognosis factors ;-
factor Favorable Adverse
TURBT complete incomplete
Response to complete regression Residual
chemo- disease
extent of tumor solitary Diffuse
/multiple
disease invasion organ confined Regional met-
Hydronephrosis absent present

24. treatment
Principle and practice ;-
Treatment of ca bladder is multimodal and determined
by
Patients prognosis factors.
1) Superficial bladder cancer is managed primary by
trans-
Urethral resection ±intravesicular chemotherapy .
2) Localized invasive bladder cancer traditionally is
treated by cystectomy .
3) If patient has prognostic factors predictive for
bladder
Preservation, the patient can be treated with chemo-

25. Superficial bladder caner
TURBT
high risk
Low risk Superfical ca (high
(low grade papillary) bladder grade,CIS,papillary)
recurrence
Cytoscopic Intravesicular
Invasive recurrence survellance chemotherapy
Every 3monthsx2yrs
then every 6months
x2yrs ,then yearly
Bladder
Progressive high
preservation
risk disease
therapy cystectomy

28. Invasive bladder cancer
CT /bone scan/NO
metastasis
yes Unifocal no
hydronephrosis/noEVD n
Partial cystectomy o
Local advanced disease
If candidate
T3.T4;N+
ye
TURBT s
no CTH/preops-RT
CTH+RT
cystectomy
complete
Regression
yes of disease Local
consolidative advance
d CTH
CTH+RT
disease

29. Definitive surgical intervention
Radical cystectomy ;- involve there move of the bladder
Prostate and lymph nodes dissection in male. In the
female
An anterior exenteration (removal of the bladder,urethra,
Anterior vaginal wall and uterus )and pelvic lymph
nodes
Dissection is performed . Lymph dissection is
include(medial
To the genitofemoral/external iliac up to the bifurcation
of
The common iliac then extended to obturator fossa then
Lymph nodes around hypogasteric artery then superorly

30. extent confined extra nodes Total(NO
vesicle ofpt)
Local failure 4% 16% 20% 9% 788
10 yrs
distant 9.5% 19% 45% 18%
metas-
tasis
recurrence- T2a/b 70% T3a/b,52% 15% 45%
free survival 10yrs T4, 35% 10 yrs