indepth detail about bladder carcinoma...

1. BLADDER

2. BLADDER CARCINOMA
PRESENTED by---Dr.Jyotindra
Singh

4. Introduction
Most common site of cancer in the urinary tract.
2.7 times more common among men
White >black
Men-Fourth commonest cause of cancer.
Women- Eight most common cause
Incidence: 20/100000/year
Mortality: 8-9/100000/year
Disease of elderly- 67-70 yrs
Young patients- better prognosis

5. Estimated new cancer cases.
10 leading sites by gender
38 300
14 900

6. SEMINAR PLAN
INTRODUCTION
SURGICAL ANATOMY
RISK FACTORS
PRE NEOPLASTIC / CIS
BLADDER MALIGNANCY
INVESTIGATIONS/WORK UP
CANCER STAGING/MANAGEMENT
VARIOUS SURGERIES/ SURGICAL VIDEOS
RECENT UPDATES
VARIOUS STUDIES/TRIALS

7. Urinary Tract – Urinary Bladder
It is positioned immediately superior and
posterior to the pubic symphysis.
In females, the urinary bladder is in contact with
the uterus posterosuperiorly and with the vagina
posteroinferiorly.
In males, it is in contact with the rectum
posterosuperiorly and is immediately superior to
the prostate gland.
Retroperitoneal organ.
When empty - Pyramidal shape.
When filled - Oval shape.
1

8. Bladder

9. TRIGONE
the Trigone is formed by imaginary lines connecting
the two posterior ureteral openings and the anterior
urethral opening.
The trigone remains immovable as the urinary bladder
fills and evacuates.
It functions as a funnel to direct urine into the urethra
as the bladder wall contracts to evacuate the stored
urine.
The four tunics that form the wall of the bladder are
the mucosa, submucosa, muscularis, and adventitia.
2

10. Bladder- structure of
3 layers
– Outer layer
Loose connective tissue
– Middle layer
Smooth muscle and
elastic fibres
– Inner layer
Lined with transitional
epithelium

12. Structure of Urinary bladder
Serous – formed by peritoneum
Muscular- DETRUSOR & TRIGONE
Detrusor- External longitudinal layer
- Middle circular layer
- Internal longitudinal layer
Trigone – Detrusor + Ureters
Mucosa & Submucosa
Urothelium- Multilayered transitional cell
epithelium 3-7 layers thick

14. Urothelium
Superficial layer- large flat umbrella cells
Umbrella cells- binucleated/multinucleated
Oval nuclei- perpendicular to basement
membrane
Cellular polarity exists
Basement membrane separate the epithelium
from lamina propria

15. 15

16. BLOOD SUPPLY
Majorly- Superior & Inferior vesical arteries.
Lower part of the bladder- by Obturator,inferior
gluteal ,uterine & vaginal arteries.
Veins -Vesicoprostatic plexus-Internal iliac
veins
Lymphatic drainage- External iliac nodes

17. Normal Micturition
Motor cortex/frontal lobe centers
for micturition
Voluntary control
Pontine mesencephalic nucleus
Sacral spinal cord segments S2, S3, S4
Pelvic nerve
Pudendal nerve
Bladder

18. RISK FACTORS

19. Risk Factor : Family History
Bladder cancer is typically
not inherited as a genetic mutation.
Reported in association with
retinoblastoma
&
Osteosarcoma ( Chr 13 )
Increase incidence of HLA-B5
& CW4

20. Genetic
Abnormalities in chromosome 1,5,7,9,11,17,18&21
have been reported in bladder cancers.
A) ONCOGENES
Tumor suppressor gene
P53
RB gene
B) Amplification
EGF
ERBB2
ERBB1

21. Chemical Exposure
 Aniline dyes
 2-naphthlamine
 4 amino-biphenyl
benzidine
 common in
manufacturing:


petroleum
textiles
paint
 dyes
Aromatic amines are
slow acetylators

22. Risk Factor : Smoking
Smoking is the greatest risk
factor- four fold higher.
Use of black tobacco
Unfiltered cigarettes
Both current smoking and a prior
history of smoking raise the risk
Cessation- 30-60% reduction
 Carcinogens in tobacco become concentrated in the
urine and eventually damage the bladder lining

23. Miscellaneos
Artificial sweeteners
Endogenous tryptophan metabolites
Analgesic abuse- 5-15 kg for 10 yrs-phenacetin
Coffee & tea drinkin
Cyclophosphamide – 9 fold risk
Immunosupressed patients
Balkan Nephropathy
Diet rich in Vitamin A & C ,carotene- protective

24. Risk Factor : Urinary Disorders
Chronic inflammation of the bladder
increases the risk of bladder cancer
Irritative effect leads to cell damage

over time
Common history includes:
repeated urinary tract infection, eg. Cystitis
recurrent kidney, ureter or bladder calculi
chronic urinary retention requiring catheter
(spinal cord injury or neurogenic bladder)

25. Risk Factor : Irradiation
Bladder cells are known to
be reactive to ionizing
radiation
 Therapeutic exposure, eg.
radiation for cervical,
prostate, or rectal cancer
 May occur as a result of
environmental exposure,
eg. nuclear power plant
workers

26. Risk Factor : Arsenic Exposure
Arsenic is a naturally
occurring element found in
soil and rocks
High levels of arsenic can be
found in well water, as well
as drinking water near farms
and mines
 Long-term exposure to arsenic raises the
risk of bladder cancer

27. Preneoplastic Abnormalities
Atypical Hyperplasia
Von Brunn nests
Cystitis Cystica
Cystitis Grandularis
Inverted Papilloma
Nephrogenic Adenoma
Squamous Metaplasia
Vesical leukoplakia

29. Carcinoma In Situ
Proliferation confined to epithelium of mucosa.
Considerable potential for invasiveness
Within 4 yrs- 80% of pts. develop invasive ca
Asymptomatic/ Frequency/Urgency/Dysuria
Urine cytopathology – Positive in 80-90% cases
Cystoscopy- Velvety patch of erythematous
mucosa
Main site- Verumontanum area
Non urothelial mucosa involvement- seminal
vesicles,ejaculatory duct, urethral meatus

30. CIS

32. MANAGEMENT- Surgical
1. Asymtomatic FOCAL primary disease –
i. removal of carcinogen exposure
ii. Intravesical therapy
2. Primary DIFFUSE symptomatic disease
without associated bladder tumour
i. BCG immunotherapy
ii. Early Cystectomy
iii. BCG immunotherapy followed by cystectomy

33. Management
CIS + concurrent stage Ta or T1 TCC
i.
TURBT & BCG immunotherapy
ii.
Early Cystectomy

34. Non Surgical Approach
2. INTRAVESICAL CHEMOTHERAPY
i. Thiotepa
ii. Doxorubicin
iii. Mitomycin C
3. BCG IMMUNOTHERAPY
- 6 Week course ( 120 mg of connaught BCG )
- 3 wkly instillation at- 3 months
- 6 months
- Every 6 months for 3 yrs
- 75% patients complete response

37. CLINICAL FEATURES
Hematuria
Approximately 80% of patients present with gross,
painless hematuria. Approximately 20% of patients
with bladder cancer present solely with microscopic
hematuria.
Dysuria and irritative
Dysuria and irritative symptoms are present in up to
30% of patients—especially those with carcinoma in
situ.
Upper urinary tract
obstruction
Upper urinary tract obstruction is rare on initial presentation
and is a sign of advanced disease in 50% of cases.

38. Advanced Malignancy
Pain in suprapubic region,buttock,perineum
may suggest invasion of paravesical tissue
Weight loss
Bony pain

39. Pathology of Bladder Cancer
90% Transitional Cell Carcinoma (TCC)
5% squamous cell -more common in middle
east – schistosomiasis
-also seen in chronic catheterization
0.5%-2% Adenocarcinoma – urachal
Rare- Small cell Carcinoma

40. Transitional Cell Carcinoma
Accounts for 90-95% of all bladder tumors.
Ranges from low grade superficial papillary
tumour to high grade invasive disease
Histologically – Increased epithelial cell layer
-- Papillary folding of mucosa
-- Prominent Nuclei
-- Clumping of chromatin
-- Loss of cell polarity

41. Transitional Cell Carcinoma

42. Cancer- Division
Superficial Bladder tumour
- not invaded the muscularis
Invasive tumour
- those that have invaded musclaris
propria,perivesical fibroadipose tissue or
adjacent structures.
Common in trigone,bladder base ,lateral walls
70% papillary,10% nodular,20% mixed

44. Transitional cell carcinoma
A: Irregular filling defect represents tumor.
B: Enhanced computed tomographic scan of the same patient as in A. Note rim of calcification involving tumor
(arrows).

45. Transitional cell carcinoma
Unenhanced computed tomogram shows a sessile tumor along the right posterolateral bladder wall. A Foley
catheter balloon filled with air is in the center of the bladder.

46. Transitional cell carcinoma
A and B: Coronal and axial T1-weighted magnetic resonance images demonstrate invasion of the tumor through
the perivesical fat to the pelvic sidewall.

47. TUMOR GRADING
DEGREE OF ANAPLASIA
PAPILLOMA=GRADE-0
WELL DIFFERENTIATED TUMORS
Confined to mucosa=grade 1
Papillary urothelial tumors of low malignant potential (PUTLMP)
MOD. DIFFERENTIATED TUMORS=GRADE 2
Low grade urothelial carcinoma
POORLY DIFFERENTIATED TUMORS=grade 3
High grade urothelial carcinoma

49. Bladder cancer:
Entities
75-85%
superficial bladder cancer
pTa, pTis, pT1
10-15%
muscle-invasive
pT2, pT3, pT4
5%
metastatic bladder cancer
N+, M+

52. Squamous cell carcinoma
5-10 % of bladder tumours
Two types- Bilharzial/ Non-bilharzial
Bilharzial Bladder Cancer
- chronic infection with S. haematobium
- exophytic ,nodular fungating lesion
- well differentiated
- incidence of lymph node,metastasis-low
Non Bilharzial SCC
- chr. irritation- calculus/ indwelling catheters
- keratinized cells- Squamous pearls

53. SCC

54. ADENOCARCINOMA
PRIMARY VESICAL ADENOCARCINOMA
URACHAL CARCINOMA
METASTATIC ADENOCARCINOMA – from
rectum,stomach,endometrium,breast,prostrate
ovary.

56. AJCC Stage
Description
Jewett Stage
AJCC STAGING
Clinical Stage
Primary tumor
Tx
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Ta
Noninvasive papillary carcinoma
0
TIS
Carcinoma in situ
0
T1
Tumor invades subepithelial connective tissue
A
T2a
Tumor invades superficial muscle
B1
T2b
Tumor invades deep muscle
B2
T3a
Tumor invades perivesical tissue—microscopic only
C
T3b
Tumor invades perivesical tissue—macroscopic
C
T4a
Tumor invades prostate, uterus, vagina
C
T4b
Tumor invades pelvic wall, abdominal wall
C
N1
Single regional lymph node, <2 cm in diameter
D1
N2
One or more lymph nodes, none >5 cm in diameter
D1
N3
One or more lymph nodes, >5 cm in diameter
D1
Distant metastasis
D2
Lymph nodes
Metastases
M1

58. Stage 0 Bladder Cancer
Stage 0a: The cancer is
only found on the
surface of the inside
lining of the
bladder, also called
noninvasive papillary
urothelial carcinoma
Stage 0is: The cancer
is found only on the
inner lining of the
bladder, also called flat
or carcinoma in situ

59. Stage I Bladder Cancer
The cancer
has grown
through the
inner lining of
the bladder
to the
connective
tissue layer
but has not
spread to the
thick muscle
wall of the
bladder

60. Stage II Bladder Cancer
The cancer
has spread
into the thick
muscle wall of
the bladder
(called
invasive or
muscleinvasive
cancer) but
not to the fatty
tissue
surrounding
the bladder

61. Stage III Bladder Cancer
The cancer has
spread to the fatty
layer of tissue
surrounding the
bladder and may
have spread to the
prostate (men) or
the uterus and
vagina (women)

62. Stage IV Bladder Cancer
The cancer has
spread to the pelvic or
abdominal wall but
not to lymph nodes or
other parts of the
body, or
The cancer has
spread to one or more
regional lymph nodes
but not to other parts
of the body, or
The cancer has
spread to other parts

63. Bladder cancer:
Stage and Prognosis
Stage
TNM
5-y. Survival
0
Ta/Tis
NoMo
>85%
I
II
T1
T2a-b
NoMo
NoMo
65-75%
57%
III
T3a-4a
NoMo
31%
IV
T4b
NoMo
24%
each T
each T
N+Mo
M+
14%
med. 6-9 Mo

64. SPREAD
Direct spread- Local invasion
i.Enblock spread- 60%
ii. Tentacular invasion- 25%
iii. Lateral spread- 10%
Metastatic spread
Lymphatic spreadpelvic,paravesical,obturator,external iliac nodes
Vascular spread- Liver,lung,bone,adrenal
Implantation- abdominal wounds,denuded
urothelium,resected prostatic fossa,traumatized
urethra

65. Adjacent organs involved are
prostate(40%),uterus,vagina,ureters,rectum & intestine

66. Diagnosis of Urinary Bladder Cancer
Signs and Symptoms
Urine Cytological Studies
Flow cytometry
Diagnostic TUMOUR MARKERS
Ultrasonography
Diagnostic Imaging
–
–
–
–
IVP
Ultrasound
CT
MRI
Cystoscopy and Biopsy
Bimanual Examination
Transurethral resection of bladder tumour

67. Modalities for Staging
LOCAL EXTENT ( T STAGE )
Excretory Urography
Transurethral Ultrasonography
Transurethral Resection
Select Mucosal Biopsy
Cytology
Prostate fossa biopsy
Examination Under Anaesthesia
CT
MR

68. Modalities for Staging
REGIONAL EXTENT ( N STAGE )
CT
MR
LYMPHANGIOGRAPHY
LAPROSCOPY
PET SCANNING

69. SYSTEMIC EXTENT (M STAGE )
Pulmonary - chest film
- Linear tomography
- CT/PET
BONE
- Bone scan /Bone survey
- MR
LIVER
- Liver scan
- CT/MR/PET
- Laproscopy

72. Flow Cytometry
Measures DNA content of cells (S-phase cells)
It quantitates the aneuploid cell population.
If > 15% cells are aneuploid-suggests cancer
Diploid tumours- favourable prognosis
Triploid /Tetraploid tumours- unfavourable
If > 10 % S Phase cells – lymphnode
metastasis

74. IMAGING
CHEST X-RAY
CT is better than chest X-ray
ULTRASONOGRAPHY
IVU
Upper urinary tract
Filling defect
Irregularity

75. Ultrasonography of Bladder Ca

76. IVU of Bladder Tumor

78. CT SCAN
Staging of the tumour
Extent of primary tumour
Rule out invasive bladder cancer
Assess pelvic LN status ( > 1 cm )
Visceral metastasis
Evaluation of upper urinary tract

79. CT scan of bladder Ca

80. IMAGING
MRI
Staging ,better than CT
PET scan
Metastatic workup
LAPROSCOPIC STAGING
Port site recurrence
BONE SCAN –not much role

84. CYSTOURETHROSCOPY
MOST IMP.
BIOPSY

87. Bladder Ca under cystoscopy

90. Complications and Sequela of Cystoscope
Profuse bleeding.
Damaged urethra.
Perforated bladder.
Urinary tract infection.
Injured penis.
scar tissue.

91. BIMANUAL EXAMINATION
Under GA with full relaxation
Performed prior to tumour resection and then
again after endoscopic resection
Superficial tumour- Disappearance of mass
Invasive tumour -Fixed/Indurated or mass
persists after resection

93. Bladder cancer:
Management
Carcinoma In Situ
75-85% superficial bladder cancer
pTa, pTis, pT1
10-15% muscle-invasive bladder cancer
pT2, pT3, pT4
5%
metastatic bladder cancer
N+, M+

96. ENDOSCOPIC SURGERIES
VIDEO ASSISTED TURBT
Under GA/Regional
Remove all visible tumors
Bimanual examination must before and after
Ideal Method – 2 specimen to be collected
First superficial portion of the tumour
Deep portion along with underlying bladder muscle
The base of resection site is fulgrated

97. ENDOSCOPIC SURGERIES

98. ENDOSCOPIC SURGERIES

99. TUR of Bladder Tumor (TURBT)

100. After TUR

101. ENDOSCOPIC SURGERIES

102. ENDOSCOPIC SURGERIES
COMPLICATIONS
Irritation and minor bleeding
Uncontrolled haematuria
Perforation
REPEAT TURBT
Incomplete removal
T1 tumor
Second opinion
ROLE OF ADDITIONAL BIOPSIES
All suspicious lesions
Not required for low risk groups

103. BCG Therapy
Wait for 2 weeks after tumour resection
Early administration- risk of severe complication
Commonest side effect- Bladder irritability
Due to immune stimulation & inflammatory
reaction.
No direct toxic effect on malignant cells
Stimulates a generalized immune response –
result in tumour destruction

104. IMMUNOTHERAPY
BCG VACCINE
6wk induction course (weekly)
6wk gap
3wk instillation at 3rd and 6th month
Then every 6months for 3 years
Don’t give more than 6wks in single sitting
Avoid quinolones

106. IMMUNOTHERAPY
BCG VACCINE
Contraindications
Immunocompromised
Immediately after TURBT
Allergic
Gross haematuria
Traumatic catheterization
Total incontinence

107. ELIMINATION OF
RECURRENCE
after prophylaxis
EXISTING DISEASE
BCG
ERADICATION OF
CIS
20
60
72
Mitomycin-C
30
50
40
Doxorubicin
40
30
25
Thiotepa
45
35
15

108. Fever<38.5 Fever > 38.5
Allergic
reaction
12- 24 HRS
NO Rx
Isoniazid 300
mg daily for 3
months
Acute severe
SEPSIS
iIlness
Isoniazid 300
mg daily for 3
months
Isoniazid 300
mg
Isoniazid 300 mg
Rifampicin 600 mg
Rifampicin 600
mg
Hold BCG
until
symptoms
have
resolved
May resume
BCG when
asymtomatic
Further BCG is
indicated only
if benefit
excess risk
Ethambutol
1200 mg daily
for 3 months no
further BCG
Ethambutol 1200 mg
Cycloserine 500 mg
Twice daily
To consider
prednisolone 40 mg
iv acutely

113. IMMUNOTHERAPY
INTERFERONS
Expensive
Less effective
With BCG
Decreases side effect
Decreases dose of BCG
OTHERS
Key hole limpet hemocyanin (KLH)- Copper
containing antigenic protein.

114. LASER THERAPY
ARGON LASER- 1 mm penetration
Nd:YAG laser – 4-5 mm penetration
Used to treat the tumour bed following TUR
Newer KTP LASER- Safer ( 4-5 mm )
Indication- Small,superficial,recurrent lesion
Tumour larger 2.5 cm not available.
Drawback- tumour tissue not available

115. PERIOPERATIVE INTRAVESICAL
CT
MMC(MITOMYCIN-C)
Administer within <6hr
Retain solution for 1hr
Reduces recurrences about 50%
Single dose
Through 3 way catheter
No role after 24 hr
With held CT if extensive resection
BCG contraindicated (sepsis + death)

116. ADJUVANT CT
MMC
DOXORUBICIN
THIOTEPA
GEMCITABINE
TAXANES
PACILITAXEL
COMBINATION THERAPY

117. Photodynamic Therapy
Combines non toxic photo sensitivity dyes +
Visible light to destroy cancer cells.
Indication- CIS, Ta, T 1 tumour
Photofrin-II – 2 mg/kg body weight is given
After 48 hrs –bladder illuminated with red light
(630 mm)
Cascade of photo chemical reaction- generate
cytotoxic molecular oxygen.

118. Indications for Cystectomy
Persistent carcinoma in situ
Recurrence with invasion of the lamina propria
Persistent involvement of the prostate by TCC
Invasion of the muscularis propria
Rarely contracture and incontinence resulting
from intravesical therapy

121. Invasive Bladder Cancer
Diagnosis of muscle invasion (T2 – T3 ) established
Metastatic disease should be excluded
Aggressive therapy- Bladder preservation
- Bladder reconstruction
Radical cystectomy- gold standard
TUR- small tumors with superficial muscle invasion

122. Segmental cystectomy
Tumour > 2 cm from bladder neck
No evidence of CIS
Tumors in vesical diverticulum
Tumours arising from urachus.
Complications- implantation of tumour cells in
surgical wound
- Recurrence – upto 70 %

124. RADICAL
CYSTOPROSTATECTOMY
Radical cystoprostatectomy in male
and anterior exenteration In female
coupled with en bloc pelvic
lymphadenectomy ,remain the
standard surgical treatment in the
absence of metastatic disease.

125. Radical Cystectomy
INDICATIONS
Primary adenocarcinomas
Squamous cell carcinoma with or without
schistosomasis
Sarcoma of the bladder
Carcinoma in situ
Superficial papillary carcinoma
Invasive carcinoma

126. RADICAL
CYSTOPROSTATECTOMY
STRUCTURES REMOVED MALE
Bladder
Peritoneal attachments
Prostate
Seminal vesicle
B/L pelvic lymphadenectomy
IN WOMEN
Cervix ,uterus, ant.vaginal vault, urethra should
be included

127. RADICAL
CYSTOPROSTATECTOMY
Analysis of the urethral margin at the time of
cystectomy before urinary tract reconstruction is
standard practice
MALE URETHRA
Prostatic urethra involvement –do simultaneous or
delayed urethrectomy .
Pt considered for orthotopic reconstruction should be
cautioned about its use till histological report.
FEMALE URETHRA
Better do enbloc urethrectomy

137. Urinary diversion: Ileal
Conduit
Urine empties through
stoma
No reservoir therefore
incontinent
Nursing: teach
– Appliance application
– Skin care

138. Urinary Diversion:
Ureterostomy
Ureterostomy
– Divert urine directly to
skin opening
– Must wear bag or
pouch after surgery
– Nursing:
Skin care
Bag placement

140. Urinary diversion: Ileal
reservoir
Kock’s pouch
Reservoir created
from ascending
colon and terminal
ileus
No appliance
needed
Nursing:
– teach selfcatheterizations
– Skin care

141. LYMPHADENCTOMY
Pelvic lymphadenectomy provides insight into
the local extent of disease.
Extended lymph node dissection should include
the distal para-aortic and paracaval lymph
nodes as well as the presacral nodes
Lymph nodes positive disease
Concept of ratio based lymph node staging
or lymph node density have have great
prognostic value

142. RADIOTHERAPY
EXTERNAL BEAM RADIO THERAPY
No randomized trail to compare with surgery
5000-7000cGy 5to 7 weeks
Local recurrence common
Only pt who are surgically not fit
Hyperfractionation is a future hope
PRE OP RT
Local control in T3
Survival advantage not demonstrated

143. CHEMOTHERAPY
NEOADJUVANT
Down staging
Inoperable
Rx of micrometastasis
Improved survival.
PERIOPERATIVE
No survival benefit
ADJUVANT
Some studies showed increased survival.

144. Chemotherapy for bladder cancer
Bladder cancer is a chemosensitive disease
Active single agents.
RR
–Cisplatin
–Carboplatin
–Gemcitabine
–Ifosfamide
30%
20%
20-30%
20%

145. Chemotherapy for bladder cancer
Combination chemotherapy.
RR
– MVAC
10-25%
– Gemzar / Cisplatin
40-50%
– Gemzar / Carboplatin
– Taxol / Carboplatin
65%
40-60%

146. Combined Radio- and Chemotherapy
CR
5y.OS
Radiotherapy
57%
47%
RT and cisplatin
85%
69%
RT and carboplatin
70%
57%

147. CHEMOTHERAPY
COMMON REGIMENS
CISCA
CMV
MVAC/MVEC (commonly used)

148. ALTERNATIVE Rx
RT
TUR+PARTIAL CYSTECTOMY
TUR+PARTIAL CYSTECTOMY+CT
BLADDER PRESERVATION PROTOCOL
INTERSTITIAL RT
INTRA ARTERIAL RT
HYPERTHERMIA AND CT

150. Bladder-sparing protocol
Transurthral resection
Induction Therapy: Radiation + chemotherapy
(cisplatin, paclitacel)
Cystoscopy after 1 month
no tumor
Consolidation: RT + CT
tumor
cystectomy

151. Metastatic bladder cancer
50 % patients with high grade cancer die of
disseminated disease within 2 yrs of
presentation.
Palliative Radiation therapy – 3000 to
35OOcGY given in ten fractions
Intravesical alum (1 %) formalin (1-10%)
instillation:to control haemorrhage from
advanced bladder tumor or radiation cystitis.

152. CHEMOTHERAPY
FOUR – DRUG COMBINATION M-VAC
Methotrexate 30 mg/sq.m – 1,15 & 22
Vinblastine 3 mg/sq.m- 2,15 & 22
Adriamycin 30 mg/sq.m on day 2
Cisplatin 70 mg/sq.m on day 2
Repeat cycle every 28 days ,totally 6 cycles

153. RECENT UPDATES/CHANGING
APPROACH

154. MINIMALLY INVASIVE OPEN
ROBOTIC CYSTECTOMY

155. Role of MR Virtual
Cystoscopy in the Detection
of Urinary Bladder
Neoplasms

156. Steps for Creating Virtual Cystoscopy
Patient preparation and Image acquisition
Image processing
Segmentation.
Fly through (creating virtual reality)
Image analysis
Image display

157. Combined virtual and axial MR images for detection
of bladder lesions.
Sensitivity
Specificity
lesions less than 1 cm
90.3%
100%
lesions 1 cm or more
100 %
100 %
Overall lesions
96.9%
100 %

159. Female patient, 45 years old , presenting by
hematuria and frequency.

160. Male patient, 65 years
hematuria and dysuria.
old,
presenting
by

161. Male patient, 74 years old,
hematuria and frequency.
presenting
by

162. The Advantages of Virtual Cystoscopy
versus Conventional Cystoscopy
Non-invasive technique.
No anesthesia .
Accurate localization of a lesion .
Accurate measurement of tumor size.
Data of large number images in one image.
More than view .
Access to the anterior bladder wall or the lumen
of a diverticulum .
Detect lower ureteric extension.
MR images assess extravesical extension.

163. Potential Diagnostic Markers
S phase (Ki67)
P53
P21 – downstream of p53 – if + favorable
outcome
Rb

164. Androgen Receptor Expression in Bladder Cancer
NON-TUMOR
NON-TUMOR
TUMOR
A
A
B
pTa
pT1
pTa
NT
C
C
D
pT2
E
NT
pT3
F

165. Some ―new‖ ones
NMP22 dipstick (BladderChek™)
FISH (Urovysion™)
Immunocyt™

166. NMP22 Antigen
Malignant urothelial cells contain up to 80 times
higher concentration of NMP22 antigen than
normal urothelial cells and release it upon cell
death.
Based on previous studies, an NMP22 test result
> 10 U/ml in the urine is associated with a high
probability of bladder cancer

167. Created to identify urine
with NMP22 antigen  10 U
/ mL
– Requires 4 drops of freshly
voided urine
– results available in 30
minutes
– Positive result if NMP22
antigen level  10 U / mL

168. Molecular Progression of Bladder
Cancer
9q-
Precursor
lesion
14q-
Papillary
hyperplasia
Papillary
cancer
17p- (p53)
9p-(p16)
11pInvasive
Cancer
13q-(Rb)
Dysplasia
CIS

169. Molecular Detection

171. Microsatellite Analysis
32-P Isotopic
technique
Fluorescent
technique

172. Intracavitary Hyperthermic
Perfusion-Chemotherapy
(ICHP)

173. Methods of Intracavitary
Hyperthermic Perfusion ChTx
Intraperitoneal
(IPHC)
Intrapleural (IPlHC)
• Peritoneal Carcinomatosis
• Malignant Ascites
• Pseudomyxoma peritonei
• i.p. disseminated
Mesothelioma
• Neoadjuvant, Salvage &
Consolidation Therapy
• Adjuvant (?)
• Malignant Pleural Effusion
• Pleural Carcinosis
• Malignant
Pleuramesothelioma
Intravesicular
(IVHC)
edh ICHS
Shenzhen 2004
• Recurrent Urothelial
Carcinoma

174. Peri-/postoperative I.P.
Chemotherapy
Preoperative (before surgery)
Perioperative
Intraoperative (during surgery)
Postoperative (early)
edh ICHS
Shenzhen 2004

175. Percutaneous Intraperitoneal
Hyperthermic Chemoperfusion
-
edh ICHS
Shenzhen 2004

176. IVHC with Microwaves
Radiativ (intravesicular microwave antennae,

177. Bladder Cancer – IVHC

178. Bladder Cancer – PR/SD
edh ICHS
Shenzhen 2004

179. Summary & Conclusion
Long-term, percutaneous or intravesicular
hyperthermic perfusion-chemotherapy is one of
the most powerful new treatments in oncology
It is feaseable and has minimal side effects
compared to standard chemotherapy
It can be repeated oftenly (> 30 Tx)

180. PREVENTION
Vitamins-A,B6,C,E.
Polyamine synthetic inhibitors
Deitary factors
Acidification of urine
Avoid high fat /cholestrol diet
Green tea consumption decreases chances
Take more fluids
Cox -2 inhibitor (celecoxib) decreases

182. SUMMARY
Bladder CA is not rare
Incidence is increasing in both sexes
Chemical carcinogens have big role
Late presentation in developing world
Lack of awareness in early diagnosis
Urine cytology and cystoscopy are good
screening
Grade is most important for prognosis
Stage before and after endoscopic surgeries
Bimanual examination has big role

183. SUMMARY
Endoscopic surgeries and immunotherapy are main
stay in non- muscle invasive tumors
Surgery is main stay of Rx in muscle invasive tumors
RT is equally challenging
Neoadjuvant Rx has proven role in increasing survival
Newer modalities of treatment are under
investigational

184. REFERENCES
Short text book of BAILEY & LOVE
McGregor Synopsis of surgical anatomy
Cambells Urology
Genitourinary cancer surgery by Crawford
CANCER PRINCIPLES- De Vita
Chemotherapy of urogenital tumours-Murphy
Bladder Cancer:Principles of combination
therapy
Urologics clinics of North America
RECENT ADVANCES- WOLTERS KLUWER
RECENT ADVANCES- RSG

185. HELLO– ANY QUESTIONS

186. Thank you
Have A Great Day…