8 bladder tumor
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1. Bladder tumors can be epithelial like papillomas or carcinomas, or mesenchymal like leiomyomas or sarcomas. 2. In Egypt, bladder cancer is most common in males, with a male to female ratio of 3:1 and peak incidence between ages 30-50 due to bilharziasis. 3. Bilharzial bladder carcinoma presents at a younger age, with higher male predominance and more squamous cell carcinoma histology compared to non-bilharzial bladder cancer.
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8 bladder tumor
- 1. Bladder Tumor Mohamed Adel Atta
- 2. Classification • Epithelial: papilloma, carcinoma.. • Mesenchymal: leiomyoma, sarcoma.
- 3. Epidemiology • Commonest cancer in males in Egypt. • Male:female ratio 3 • Age of peak incidence 50-70, in Egypt 30- 50
- 4. Bilharzial bladder carcinoma • Bilharziasis results in younger age, • Higher male:female ratio, • More squamous cell carcinoma, • Presents in advanced stage because bilh. cystitis masks symptoms of the tumor
- 5. Pathogenesis • Bilharziasis • Smoking • Aniline dyes • Balkan residency • Bladder extrophy (adenocarcinoma), all have strong etiologic relationship to bladder carcinoma.
- 6. Spread Bladder carcinoma spreads equally by all routes local, lymphatic and vascular. Bladder carcinoma spreads mainly locally in bilharzial bladder because of intense fibrosis that limits lymph and vascular spread.
- 7. Staging T0: Intraepithelial, Tis: High grade intraepithelial neoplasia (CIS). T1: Lamnia propria invasion T2: invasion of muscle layer: T2a: superficial muscle layer T2b: deep muscle layer. T3: invasion of perivesical fat T3a: microscopic invasion T3b: macroscopic invasion. T4: invasion of pelvic wall or nearby organs.
- 8. Staging • Superficial bladder tumor (non muscle invasive bladder carcinoma NMIBC ): Ta, T1, CIS • Invasive Bladder carcinoma (MIBC): T2-4
- 9. Natural History • Superficial bladder tumor: Ta&T1 and CIS, usually recur in other site of the bladder(70%), but rarely invades bladder wall (10%), solitary or multiple with mobile fronds long stalk and narrow base. CIS carcinoma in situ: high grade intraepithelial carcinoma, appear as velvety hyperemic areas. • Invasive deep tumor:T2-4 cauliflower, nodular or ulcerative with necrotic surface.
- 10. Gross Types • Papillary: sea-weed appearance • Cauliflower mass with stunt fronds, some necrotic. • Nodular • Ulcerative.
- 12. GROSS TYPES
- 15. Clinical Presentations • Hematuria: Total painless hematuria (papillary tumors), may be terminal, intermittent or continuous bright red or with amorphous clots. • Necroturia: pathognomonic symptom especially in bilharzial bl. Ca. • Malignant cystitis: isolated CIS may present by severe cystitis resisting Rx • Microhematuria • Complications: clot retention, anuria, hydro or pyonephrosis.
- 16. Diagnosis • Ultrasonography: echogenic intravesical mass • Plain&IVU: bladder filling defect • Pelvic and abdominal CT: confirm and stage bladder carcinoma
- 20. Diagnosis • Urine cytology • Cystoscopy and biopsy: tumor and tumor bed for proper staging, bimanual examination under anathesia to asses the degree of pelvic spread of the tumor • Metastatic workup X-ray chest and bone scan.
- 21. Urine cytology Cytology is the detection of cells in fluid, cells should be viable to take up the stain Malignant cells have ameboid movement due to loss of intercellular attachments (nexi) and according can be seen in urine frequently especially in CIS and grade 2 carcinoma
- 22. Voided urine cytology high grade uroth ca: nuclear hyperchromatism and irregular nucl memb.
- 23. Voided urine cytology high grade uroth ca: nuclear hyperchromatism and irregular nucl memb.
- 24. Bladder wash cytology clump malignant cells nuclear hyperchromatisia, vacuolated cytoplasm
- 25. Bladder wash cytology low grade car, thick nuclear memb, hypochromatasia, homogenous cytoplasm
- 26. Voided urine cytology low grade carcinoma
- 27. Transurethral Biopsy: The definitive Diagnosis • 1- Tumor Tissue • 2- Tumor bed biopsy to properly stage muscle infiltration • 3- Bimanual examination under anasthesia to asses clinically infiltration of nearby organs and pelvic wall.
- 28. Histopathology • 1- Transitional cell carcinoma: the commonest type • 2- Squamous cell carcinoma: develops on top of squamous metaplasia due to bilharziasis • 3- Verrucous Ca: subtype of sq. c. ca., hyperkerratotic low grade squamous ca., locally malignant with no vascular spread. • 4- Adenocarcinoma: bladder dome on top of allantoic remnant, or bladder base on top cloacal remnants.
- 29. The papilloma is composed of a delicate fibrovascular core covered by normal urothelium
- 30. Low Grade urothelial carcinoma The low-grade papillary urothelial carcinoma group includes all former grade 1 (WHO 1973) cases and some former grade 2 cases (if a variation of architectural and cytological features exist at high magnification).
- 31. High grade Urothelial carcinoma High grade urothelial carcinoma showing atypical urothelial cells that vary in size and shape. The nuclei are enlarged, with coarsely granular chromatin, hyperchromasia, abnormal nuclear contours and prominent nucleoli
- 32. High grade Urothelial carcinoma High grade urothelial carcinoma showing atypical urothelial cells that vary in size and shape. The nuclei are enlarged, with coarsely granular chromatin, hyperchromasia, abnormal nuclear contours and prominent nucleoli
- 33. CIS High grade urothelial carcinoma limitted to the urothelium. No invasion of the underlying basement.. Lamnia propria underneath shows angiogenesis
- 37. Bilharzial egg S Hemmatobiu
- 38. Treatment Superficial Bladder Tumor • 1- Transurethral resection (TURT): • 2- In multiple, big,T1, and recurrent tumors: Intravesical chemotherapy (thiotepa, mitomycin, adriamycin) or better immunotherapy (BCG Vaccine) is advised to reduce tumor recurrence and avoid tumor progression 6 weekly instillations followed by maintenance 3 weekly inst. every 6 months.
- 39. Treatment Superficial Bladder Tumor • 3- Followup Protocol: including US, urine cytology, cystoscopy and biopsy • 4- Radical cystectomy in high grade tumors resisting treatment and rapidly recurrent.
- 40. Treatment Of Invasive Tumors • Radical cystectomy is the gold standard excision of bladder, lower ureters, as well as prostate, seminal vesicles in males and uterus upper vagina and ovaries in females together with pelvic lymph nodes. • Radical radiotherapy: less efficient • Bladder saving protocol using initial chemotherapy followed by radiotherapy in responding tumors or salvage cystectomy in non-responding tumors.
- 41. Post-Cystectomy Urinary Reconstruction 1- Orthotopic bladder substitutes 2- Ectopic bladder substitutes: A- Cutaneous: a- Wet stoma: ileal conduit b- Continent stoma: cont.reservoir B- Anal: a- Ureterosigmoidostomy & its variants b- Rectal bladder with left terminal colostomy
- 42. Post-Cystectomy Urinary Reconstruction Any part of GI tract can be used: ileum, colon or stomach. Detubularization and refashioning in the form of a sphere results in bigger (3 times the volume of the tubular intestine) and less intraluminal pressure (la Place law).
- 44. Orthotopic Neobladder • Detubularized intestinal segment fashioned in the form of sphere is anastomosed to the urethra and both ureters are anastomosed to the pouch with an antireflux mechanism. • Is the first option unless tumor invades the proximal urethra.
- 47. Ileal Conduit • Both ureters are anastomosed to 15 cm ileal segment , one end is closed and the other end is anastomosed to the skin. • Urine bag is applied to the stoma
- 48. Ileal Conduit
- 49. Ileal conduit
- 50. Continent Reservoir • Detubularized intestinal segment is fashioned in the form of sphere, both ureters are anastomosed to the pouch with antireflux mechanism. • The pouch is anastomosed to the umblicus with continent mechanism to prevent urine leakage • Patient uses plastic catheter to evacuate the pouch every 6-8 hours
- 51. Kock Reservoir
- 52. Indiana & Florida pouches
- 53. Ureterosigmoidostomy • First known continent diversion, both ureters are anastomosed to the sigmoid colon with proper antireflux technique • Sequelae: electrolyte imbalance hyperchloremic hypokalemic acidosis, ascending infection, colonic carcinogenesis. • New variants are introduced to avoid such sequelae with better outcome.
- 56. UERETEROSIGMOIDOSTOM Y 1- Drawbacks: electrolyte imbalance hypokalemic hyperchloremic acidosis, repeated UTI, colonic cancer, inconvenient evacuation 2- Less with the new modifications 3- Not accepted in all centers