Dr Tekle B.

Gen. Surgeon

Benign Tumors

Papilloma
- intact basement membrane
- one end of malignant spectrum - follow

Inverted papilloma
- rare, usu. Dxed accidentaly
- resemble sebaceous cyst: smooth, pale, rounded

Hemangioma

- any size
- appear like collection of veins
- profuse bleeding, responds well to coagulation
Others:- nephrogenic adenoma, vesical leukoplacia,
pseudosarc. spindle cell nodule
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Malignant Tumors
BLADDER CANCER

Epidemiology

M:F=2.5-5:1, any age ( with age)

4th Tu in M, 6.2%; 8th Tu in F, 2.5%
White:Black = 2:1(invasive black > whites)

Etiology & Risk factors

No obvious exposure to known carcinogens

Epidem. & experimental evidences:3

Etiology
* Occupational exposures:- aniline dyes, aromatic
amines, pesticides, etc.
- in 20% of bladder Cas
- long latency (30-50yrs)
* Cigarette smoking:- degree & duration
- four fold
* Analgesic abuse: - phenacetin
* Pelvic irradiation:- four fold, highly invasive
*Chronic cystitis & schistosomiasis:
- catheters, infections, calculi, bilharzia SCC
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Etiology
* Genetics:
- activation of protoncogens (overexpression)
- inactivation of tumor suppressor genes eg. p53,pRb
interfers cell growth regulation tumor growth
* Viruses: HPV-16 &18
* Cyclophosphamide Rx:-9 fold, high-grade, invasive

Pathology
TCC:- >90%, CIS invasive disease
Invasive TCC (20%): 80% G3 poor prognosis
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Superficial TCC (80%): G -G

Pathology

Staging & Grading

Grading:- low-grade (G1&G2 ) = 55-60% cases

- high-grade (G3 ) = 45%
- both can happen in the some pat.
Staging:- superficial V invasive!
Union International Centre le Cancer
Ta: Papillary Tu, no invasion of lamina propria
Tis: Flat carcinoma in situ (high-grade)
T1: Invasion of lamina propria
T 2:
superficial muscle (m. propria)

T3a: Invasion of deep muscle

T3b: Invasion of fat - i) microscopically
ii) macroscopically
T4a: Invasion of prostate, Uterus, Vagina
T4b:
pelvic wall, abd. wall; N+, M+

origin & Pattern of Spread

Multicentric origin
Direct extention:
- through perivesical fat to bowel, Uterus
Metastatic spread:
- 5% of low-grade & 20% of high-grade superficial
disease ; and also have muscle invasion

Spread

1. Lymphatic spread
- occur earlier independent of vascular spread
- pelvic LNs: paravesical (16%), obturator(74%),
external iliac(65%), parasacral(25%)
2. Vascular spread
- late event; liver(38%), lung(36%), bone(27%),
adrenal gland(21%), intestine(13%)
- bone, common esp. in bilhrzial SCC
Implantation:- traumatized site or wound eg. urethra,
abd. wound, prostatic fossa; (also intraop.)
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- high-grade Tu

C/presentation

Painless hematuria (80-85%)

Sx complex of bladder irritability, frequency,
urgency, dysuria (malignant/infectious cystitis)
Advanced dis:- pelvic mass, loin pain, LAP, lower
limb edema, wt. loss, abd. or bone pain

Other malignant tumors of bladder

Squamous cell Ca 1-8%(75% devping country)
- chr. irritation (metaplasia), relat. younger pat.
- advanced dis. & relat. resistant to radiation,
poor prognosis
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 Adenocarcinoma 2%
- poor response to radiation & chemotherapy
Small cell carcinoma
Carcinosarcoma
Metastatic carcinoma
Neurofibroma
Pheochromocytoma
Primary lymphoma
Sarcomas:- eg. rhabdo-, liomyosarcoma
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Clinical Prognostic Indicators

(tumor recurrence & progression)
Grade & stage (depth of penetration)
Multifocality
Size > 5cm
Lymphatic invasion
Urothelial dysplasia or CIS near or other site
Papillary or solid Tu architecture
Frequency of prior Tu recurrence
* No imp. lab. parameter
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Investigations

U/A blood & protein; culture

Urine microscopic cytology sensit. 90% in
high-grade (+CIS)
RFT
Chest X-ray
U/S
Flexible cystoscopy
Excretory urography
CT
MRI- staging
Bone scans; laparoscopic staging

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Management

= 70-80% superficial
= 5% metastatic
= 25% muscle invasion
= 25-30% limited to regional LNs

A. Superficial Bladder Tumor

- any grade
Endoscopic Mx
Laser therapy
Photodynamic therapy
Cystectomy - failed above Rx
- high-grade T1

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Management

Radiation therapy - not usu. used

- refuse or unfit for surgery
Intravesical chemotherapy - recurrence, prevent
progression, eradicate residual Tu
- mitomycin-C, doxorubicin, epirubicin,
thiotepa; valrubicine (recent for BCG resist.)
Intravesical immunotherapy:
- BCG: weekly for 6wks; 70% 5yr dis. free
- IF & IL-2
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B. Mx of Invasive & Metastatic Ca

* generally have poor prognosis ( T2,T3,T4 )
- most are anaplastic(G3)
- many have already spread to regional LNs
Radical cystectomy:
- muscle invasion & if no metastasis
lymphadenectomy +
M = bladder, prostate
F = Uterus, fallop. tube, ovaries, bladder,
urethra, & segment of ant. vaginal wall
- mort. 1-2% & morb. 25%
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- follow up: P/E, CXR, CT

Mx of Invasive
Urinary diversion

Ileal conduit (incontinent)

- use ileal segment to make stoma to abd. wall
Indiana pouch (continent)
- uses Rt colon & terminal ileum
- ileocecal valve continent
- intermittent catheterization
Orthotopic neobladder (reservoir)
- uses segments of intestine
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- void by valsalva

Mx of Invasive
Adjuncts to standard surgical therapy
(>stage T3)

Preop. radiation therapy

- treat local micrometastasis
- downstage unresectable Tu
- improve local control after cystectomy
ischemia, fibrosis, enteritis
obliterate plane of surgery & failure of
anastomosis
responders 70% 5yr survival, (nonresponders17%)

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Adjunct therapy
Neoadjuvant chemotherapy
- given before definitive local Rx
- test chemosensitivity & downstage

Adjuvant chemotherapy
- reduce local recurrence & distant metastatic
relapse objective response 70%, complete
response 15-20%, 2yr survival 15-20%

Alternative to standard therapy

Ix:- patient preference
- organ-preservation
TUR complex surgery, systemic
chemotherapy, radiation therapy

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Partial cystectomy
- for Ca of urachus & diverticula
- not for TCC

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Prognosis
5yr survival for TCC of bladder
Stage Surgery(%)
Ext. beam radiation(%)
T1
85-95
35
T2
75
40
T3
44
26
T4
16
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Risk of progression of TCC
Grade
Risk (%)
G1
10-15
G2
14-37
G3
33-64
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Prognosis
5yr survival M > F
- white > black (?invasive, late Dx, aggressive)
- mortality rate in elderly
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The END

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