Bladder Carcinoma: Epidemiology, Risk Factors, Diagnosis, and Treatment - Prof. Juarez, Apuntes de Medicina

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Bladder Carcinoma

BERNARDO AGUIL AR DAVIDOV, MD

UROLOGIST

EPIDEMIOLOGY

Ninth most common cancer in the world.

◦ (^) With 437,000 new cases and 186,000 deaths diagnosed in 2016

Most common malignancy involving the urinary system.

Since the 1970s, the five-year survival rate in the US has improved to approx 80%.

Many patients do not die of their disease but do experience multiple recurrences.

RISK FACTORS

Chemical carcinogenesis: Most are aromatic amines (2-naphthylamine, benzidine)

Cigarette smoking is the most important factor.

◦ (^) males hazard ratio 3.89; females 4. ◦ (^) Smoking cessation decreases but does not eliminate the increased risk ◦ (^) Exposure to secondhand cigarette smoke in females appears to be a risk factor. Not seen in males.

Cyclophosphamide

◦ (^) Ninefold increase in risk of developing bladder cancer, with a latency period that is generally less than 10 years

Genetics

◦ (^) Mutations of the p53 tumor suppressor gene ( TP53 , on chromosome 17p) and retinoblastoma gene ( RB , on chromosome 13q).

CLINICAL PRESENTATION

Painless hematuria.

Irritative voiding symptoms

Symptoms are often intermittent (delays diagnosis)

Incidental bladder cancer is rare at autopsy

Pain

◦ (^) Advanced or metastatic tumors.

Asymptomatic Microscopic hematuria

Low-risk patients (all of the following)

◦ (^) Females age <50 years or males age <40 years; ◦ (^) Never-smokers or those with <10 pack-years of smoking; ◦ (^) 3 to 10 red blood cells [RBC] per high-power field [HPF] on a single urine analysis(UA).

These patients should be engaged in a shared discussion to have either a repeat urinalysis within

six months or immediate cystoscopy and renal ultrasound (US).

Asymptomatic Microscopic hematuria

Intermediate-risk patients (any of the following):

◦ (^) Females age 50 to 59 years or males age 40 to 59 years; ◦ (^) 10 to 30 pack-years of smoking; ◦ (^) 11 to 25 RBC/HPF on a single UA; ◦ (^) low-risk patients with no prior evaluation and 3 to 10 RBC/HPF on repeat UA;

These patients are referred to a urologist for cystoscopy and a renal US.

Urinary tract imaging

Computed tomography

◦ (^) With and without contrast, is the preferred study. ◦ (^) Should include delayed images to identify defects in the collecting system ◦ (^) May miss tumors <1 cm in size

Magnetic resonance imaging

MRI is as reliable as CT for staging.

MRI is useful for patients with contrast dye

allergy, but…

◦ (^) Difficult in claustrophobic patients ◦ (^) Cannot be used in patients with pacemakers or other metallic foreign bodies.

Cystoscopy

Gold standard for the initial diagnosis and staging of bladder cancer.

Any visible tumor or suspicious lesion seen at the initial (diagnostic) cystoscopy should be:

◦ (^) either biopsied or resected transurethrally… ◦ (^) to determine the histology and depth of invasion into the submucosa and muscle layers of the bladder.

Cystoscopy

Low-grade, noninvasive tumors are papillary with a narrow stalk.

High-grade, invasive tumors frequently can appear sessile, solid, or nodular.

Carcinoma in situ (CIS) is a high-grade, noninvasive tumor, which can appear as a flat velvety

lesion and can arise in patches.

◦ (^) CIS sometimes involves large parts of the urothelial lining.

Urine cytology

Cytology is commonly used as an adjunct to cystoscopy to detect CIS and upper-tract

malignancies.

The underlying concept is that cells in the urinary tract that are proliferating rapidly will be

exfoliated.

However, urine cytology has a relatively poor sensitivity, particularly for low-grade tumors.