Bladder tumor TCC Bladder

1. TUMORS OF THE URINARY
BLADDER

2. BLADDER CANCER
• 2nd Most common cancer tumor of the urinary tract
• 4th Most common cancer in male accounting for 6% of
all cancers
• 8th Most common cancer in female accounting for
2.5% of all cancers
• 2.5 Times more common in male than female
• In USA whites affected 2.5 times more commonly
than blacks
• Average age at presentation is 65 years
• 85% Localized to bladder and 15% metastatic at the
time of presentation

3. AETIOLOGY AND PATHOGENESIS OF
BLADDER CANCER
Cigarette smoking
• 50% of the bladder cancer in male and 30% in females
• Causative agent is α and β Naphthylamine
Occupational exposure to chemicals
• Aniline and acroleyne dyes
• Leather industry
• Printing industry
• Auto mechanics
• Rubber industry
• Petroleum and petrochemicals

4. AETIOLOGY AND PATHOGENESIS OF
BLADDER CANCER (CONTD.)
• The underlying chemicals are aromatic amines
• 4-aminobiphenyle
• 4-nitrobiphenyle
• 2-napthylamine
• 2-amino 1-naphthole
• Artificial sweeteners
• Saccharin
• Cyclamates

5. AETIOLOGY AND PATHOGENESIS OF
BLADDER CANCER (CONTD.)
• Chronic irritation of bladder mucosa
• Vesicle calculi
• Schistomiasis
• Prolonged indwelling catheter
• Analgesic abuse
• Pelvic irradiation
• Cyclophosamide therapy

6. ONCOGENSIS
• Activation of oncogens by initiators that alter the
DNA of normal genome leading to escape from
normal mechanism of growth control. Promoters
are not capable of causing genetic mutation but
help already mutated cell to proliferate.
• Inactivation of tumor suppressor gene
• Inactivation of p-53 gene. This gene directs DNA
damaged cells towards apoptosis before DNA
replication. Tumors associated with p-53 suppression
tends to be high grade or Ca-in-situ.
• Inactivation of retinoblastoma gene (pRb) through
genetic deletion or mutation permits cells to go
through the G1 to S checkpoint more easily thus
stimulating cell proliferation.

7. HISTOLOGY OF BLADDER CANCER
99% of bladder tumors are epithelial malignancies
Of these 90% are TCC
5 – 10 % Sq. cell carcinoma
2% adenocarcinoma

8. TRANSITIONAL CELL CARCINOMA
• Accounts for 90% of bladder tumor
• Usually papillary and exophytic often superficial
• Less commonly it may be sessile / ulcerated and often
invasive
• According to degree of differentiation TCC may be: -
• G1 - well differentiated
• G2 - moderately differentiated
• G3 - poorly differentiated or anaplastic

9. TRANSITIONAL CELL CARCINOMA
• Ca-in-situ
• Velvety red patch of bladder mucosa on cystoscopy
• Its is poorly differentiated TCC confined to urothelium.
No invasion of lamina propria
• Associated with 25% of high grade superficial tumor
• 50% progress to muscle invasion
• p-53 mutation seen in majority of Ca-in-situ

10. CLINICAL FEATURES
• Classical presentation is painless haematuria.
• It may be microscopic in 10% of cases but in majority it is profuse and
associated with clots.
• Dysuria and frequency may be seen in Ca-in-situ.
• Advanced tumor may have variable presentation.

11. UICC STAGING OF BLADDER CANCER

12. UICC STAGING (TNM) CLASSIFICATION
• T Tumor
• Ta Confined to epithelium and no
involvement of lamina propria
• TIS Flat in Situ carcinoma
• T1 Invasion of lamina propria but not
muscle
• T2 Tumor involving bladder muscle
• T3 involvement of perivesical fat
• T3a Microscopic invasion
• T3b Macroscopic invasion
• T4 involvement of paravesical tissue

13. UICC STAGING (TNM) CLASSIFICATION
N Lymph nodes
• N1 Nodes < 2cm
• N2 Nodes 2 – 5cm
• N3 Nodes > 5cm
M Metastasis
• M0 No distant metastasis
• M1 Distant metastasis

14. INVESTIGATIONS
• Blood CP
• Serum Urea / Creatinine
• Urine RE
• Urine Cytology
• Ultrasound Scan KUB
• IVU

15. INVESTIGATIONS
• Chest X-Ray
• CT Scan
• MRI Scan
• Cystoscopy
• Bone Scan

16. TREATMENT
• Stage wise treatment
• Ta TUR-BT followed by serial check
cystoscopies
• T1 G1 G2TUR-BT followed by intravesical
installation of BCG / Mitomycine and
regular check cystoscopies
• T1 G3 TUR-BT and intravesical BCG. If
unresponsive then Radical cystectomy
with urinary diversion

17. TREATMENT
• T2 Preferred management is curative
Radical cystectomy and urinary
diversion. If patient is unfit/unwilling
then Radical radiotherapy and regular
check cystoscopies.
• Alternate protocol is neoadjuvant
radiotherapy with radiosensitizer and
regular check cystoscopies. If
unresponsive then salvage cystectomy

18. TREATMENT
• T3
Paliative Radical cystectomy and
adjuvant chemoradiation
OR
Neoadjuvant chemotherapy followed
by Radical cystectomy
• T4 Chemoradiation

19. TREATMENT OF CA-IN-SITU
• Intravesical BCG if unresponsive then curative Radical
cystectomy

20. THANK YOU