Bladder Tumors 2016 PDF

Male Reproductive and Genitourinary Tumors Copyright © 2016 by Mosby, an imprint of Elsevier Inc. Male Reproductive and Genitourinary Tumors  Kidney cancer  Bladder cancer  Ureter cancer  Urethra cancer Copyright © 2016 by Mosby, an imprint...

Male Reproductive and Genitourinary Tumors Copyright © 2016 by Mosby, an imprint of Elsevier Inc. Male Reproductive and Genitourinary Tumors  Kidney cancer  Bladder cancer  Ureter cancer  Urethra cancer Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 2 Bladder carcinoma Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 4 Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 5 Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 6 Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 7  Bladder: Epidemiology Incidence:  68,810 new cases/annum  14,100 deaths = US - annually.  Peak age: 7th decade  Men: 4th most prevalent malignant disease.  Men: women = 4:1 Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 8  Bladder: prognostic indicators Tumor extent Depth of muscle invasion Tumor morphology: o Papillary tumors:  Low grade & superficial - favorable prognosis. o Infiltrating tumours:  Higher grade, sessile/immobile and nodular  Invade muscle, vascular, and lymphatic spaces  Worse prognosis. Degree of histologic differentiation: o Well-differentiated tumors = less aggressive & better prognosis o Poorly differentiated tumors - more invasive. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 9  Bladder: Etiology  Unknown  Occupational exposure to certain carcinogens  Aniline dyes and processing of rubber  Smoking: 6 x common in smokers than non-smokers  Birth defects Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 10  Bladder: Clinical Presentation  Symptoms 75% to 80% - gross painless hematuria. Blood or blood clots in the urine 25% of patients - vesical irritability Carcinoma in situ = frequency, dysuria, and hematuria Pain or burning sensation during urination Feeling the need to urinate many times throughout the night Feeling the need to urinate, but not being able to pass urine Lower back pain on 1 side of the body Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 11  Bladder: Detection and Diagnosis Complete history & physical examination Rectal & pelvic examination Chest x-ray examination Urinalysis Complete blood cell count & liver function tests Cystoscopic evaluation Bimanual examination - under anesthesia. Biopsy Abdominal CT scan + contrast before cystoscopy Retrograde pyelogram, ureteroscopy, brush biopsy, and cytology can then be done, if necessary. CT or MRI - evaluate bladder-wall thickening and detect extra-vesical extension and lymph node metastases. Bone scans - T3 and T4 disease & bone pain. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 12  Bladder: Detection and Diagnosis  Types  Transitional cell carcinoma (urothelial carcinoma)  Most common type  Origin: urothelial cells that line the inside of the bladder.  Superficial  Papillary  Flat Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 13  Bladder: Detection and Diagnosis  98% - epithelial in origin.  92% of epithelial tumors = transitional cell carcinomas,  6% to 7% = squamous cell carcinomas  1% to 2% = adenocarcinomas.  Morphologically: four categories:  Papillary  Papillary infiltrating  Solid infiltrating  Non-papillary, non-infiltrating, or carcinoma in situ. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 14  Bladder: Patterns of Spread  Direct extension  Muscle  Lymphatics  Metastasis  3% of patients  Sites Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 15  Bladder: routes of spread  Direct extension into or through the bladder wall.  75% - 85% = superficial (Tis, Ta/T1)  15% - 25% = muscle invasion at time of diagnosis. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 16  Bladder: Disease Classification  TNM  Ta  Tis  T1  T2a  T2b  T3a  T3b  T4a  T4b Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 17 Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 18  Bladder: Treatment  Surgery  Transurethral surgery Fulguration  Cystectomy  Radical cystectomy A urostomy is a way  Reconstruction of collecting urine through a bag Urostomy outside the body. It is also called an ileal  Ileal conduit conduit.  Continent A continent urinary diversion – after cystectomy, a new diversion internal pouch made from a section of the bowel is made Neobladder surgical to store urine; a new opening procedure to construct a new (stoma) is made on the bladder abdomen 19 Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 20 Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 21  Bladder: Treatment  Chemotherapy  Intravesical vs. systemic  Investigational methods  Intravesical immunotherapy Bacille Calmette- Guérin (BCG) Interferon  Photodynamic therapy Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 22 Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 23 Photodynamic therapy (PDT): Photodynamic therapy is a two-stage treatment that combines light energy with a medicine called a photosensitizer. The photosensitizer kills cancerous and precancerous cells when activated by light, usually from a laser. The photosensitizer is nontoxic until it is activated by light. A photosensitizer (PS) converts light into cytotoxic radical oxygen species to cause cell death Was approved for bladder cancer in 1993. It failed clinically due to morbidity affecting the muscle layers, resulting in reduced bladder volume and incontinence. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 24  Bladder: Treatment  Radiation therapy  Indications  Beam arrangement  Borders Anteroposterior/posteroanterior (AP/PA)  Superior  Inferior  Lateral Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 25  Bladder: Treatment  Treatment will depend:  The stage  The histology  The size and multiplicity of tumours  The age  The general medical condition of the patient. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 26  Bladder: Treatment  Carcinoma in situ = radical cystectomy = curative.  Conservative initial management std rx:  Lesions < 5 cm, well delineated, no involvement of bladder neck, prostatic urethra, or ureters = electrofulguration then intravesical chemotherapy or bacillus Calmette-Guérin (bCG).  Ta and T1 lesions = transurethral resection and fulguration.  Diffuse grade 3, T1 disease, or involvement of the prostatic urethra/ducts = cystectomy.  T1, grade 2/3 lesions = Intravesical immunotherapy chemotherapy administered after a transurethral resection  Most physicians withhold intravesical treatment for patients with T1, grade 1 tumors. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 27  Bladder: Treatment  Definitive treatment with transurethral resection is not applicable to most patients with muscle-invasive disease.  Failure to completely eradicate high-grade disease, progression to muscle invasion, or involvement of the prostatic urethra or prostatic periurethral ducts usually signals the need for radical cystectomy. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 28  Bladder: Treatment Partial Cystectomy. Indications:  Relatively small, solitary, well-defined lesions with muscle invasion or superficial disease  Lesions not suitable for transurethral resection  Lesion location: bladder dome, right or left bladder wall, and well removed from the ureteral orifices and trigone area  Recurrence rates +/- 50% to 70% Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 29  Bladder: Treatment Radical Cystectomy With or Without Preoperative Radiation Indications:  Superficial disease (Tis, Ta, T1) conservative management = unsuccessful.  Recurrences after each successive transurethral resection and/or intravesical chemotherapy treatment increase in frequency  Grade or progress to muscle invasion.  If local tumor persists 3 months after resection  Recurrent tumors → ↓ bladder capacity by repeated transurethral resections and intravesical chemotherapy rx  Stage T2, T3 & resectable T4a disease = radical cystectomy = commonly  Stage T3 and T4a disease = preoperative radiation - if resectability questionable. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 30  Bladder: Treatment Full-Dose External Beam Radiation With Surgery Reserved for Salvage:  Radical radiation indications:  Adequate bladder capacity without substantial voiding symptoms or incontinence.  Approximately 40% of patients will have a bladder free of tumor after radiation alone - doses = 65 to 70 Gy.  Post radiation - cystoscopy every 3 months for 2 years and every 6 months thereafter.  Endoscopic resection- persistent or recurrent lesions, esp low-grade tumors, down staged with radiation therapy Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 31  Bladder: Treatment Bladder Sparing With Chemotherapy Plus Irradiation.  Radiotherapy alone → high rate of local recurrence & high incidence of distant mets → concurrent chemotherapy - sensitize the local tumor & mets  Tri-modality approach = maximal transurethral resection, chemotherapy + radiation:  T2 to T3 muscle-invasive tumors  Contra-indications: poor renal function & irritable bladder  Doses = 40 to 45 Gy - larger pelvic field + lymph nodes; Boost - involved area of the bladder = total of 65 Gy.  Cystoscopy with biopsy and cytology:  Post 40 to 45 Gy  If residual tumor documented = cystectomy performed. 32  Bladder: Treatment Radiation Therapy: Initial Target Volume.  Total bladder & TV, prostate and prostatic urethra, and pelvic lymph nodes.  4-fields = AP/PA, laterals) pelvic technique Borders:  Inf: 1 cm inferiorly to the caudal border of the obturator foramen  Sup: below the sacral promontory or below the S1-L5 disc interspace on the AP projection.  Include the perivesical, obturator, external iliac, and internal iliac lymph nodes  Field width: extend 1.5 cm laterally to bony margin of the pelvis at its widest point.  F/S: 12 × 12 cm - include the empty bladder. 33  Bladder Lat fields borders:  Ant border = 1 cm ant to most ant portion of the bladder mucosa seen on an air contrast cystogram/CT scan/1 cm ant to ant tip of the symphysis, whichever is more anterior.  Posterior border = 2 cm post the most post portion of the bladder/ 2 cm post to the tumor mass if it present on a pelvic CT scan.  Lateral fields = shaped with MLCs inferiorly to shield the tissues outside the symphysis anteriorly and to block the entire anal canal and as much of the posterior rectal wall as possible (Figure 37-17).  CT scan planning NB.  Energy: 10 to 20 MV) 34  Bladder Boost Target Volume.  Simulation - supine position.  Foley catheter inserted - sterile technique  150 - 250 ml of iodinated contrast material (20% concentration) – outline posterior portion of the bladder.  100 - 150 ml of air - visualization of the anterior wall of the bladder on lateral (cross-table) radiographs,  CT scan planning 35  Bladder Doses:  The larger pelvic field (bladder and pelvic lymph nodes): 45 to 50 Gy at 180 cGy/day, 5 to 5½ weeks  With chemotherapy - nodal dose = 45 Gy.  Boost volume = 65 Gy, or 70 Gy, if radiation alone is being used. 36  Bladder Radiation reaction: Acute reactions  Frequency and urgency, from radiation cystitis  During and after the course, are common but not usually serious unless bacterial infection is gross.  Painful spasm may require an antispasmodic drug.  Fluid intake must be strongly encouraged.  The patient should be warned that he or she might pass fragments in the urine (blood clot and tumour) and a little fresh blood.  Bowel reactions –  usually mild diarrhea and tenesmus.  If they are severe, treatment may have to be suspended or dosage reduced. 37  Bladder Radiation reaction: Late reactions  Fibrosis of the bladder.  Telangiectasia on the bladder lining  Late bowel reactions similar to those after the irradiation of cancer of the cervix  Less common (80 years) or  Poor general condition with either significant local symptoms (e.g. hematuria) or symptomatic metastases, e.g. bone and skin. Technique  //-opposed anterior and posterior pair of fields  A cystogram = for bladder localization preferably or virtual simulation if available.  TV = the bladder with a 2 cm margin/bladder and pelvic nodes if involved. Dose and energy  30 Gy in 10 daily fractions over 2 weeks (9–16 MV)  or 21 Gy in 3 fractions over 1 week (9–16 MV). 39  Bladder Chemotherapy  SELF STUDY Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 40