Bladder Cancer

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WELCOME
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Bladder Cancer

• Presented by Ms. Krantee More.

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INTRODUCTION

• GENERAL OBJECTIVE
• To gain in depth knowledge regarding CANCER OF
  URINARY BLADDER.

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SPECIFIC OBJECTIVES

• SPECIFIC OBJECTIVES
• After completing the seminar students will be
  able to
• Enumerate the etiological factors of urinary
  bladder cancer (ca. bladder),
• Illustrate clinical manifestations.
• Describe the management of Ca bladder
• To enlist the complications occurring due to same
  disease

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DEFINATION

• Bladder cancer is a cancerous tumor in the
  bladder -- the organ that holds urine

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Epidemiology of Bladder CA

• 4th most common CA in men, 9th in women,
• Annual New Cases 68,810 (51,230 in M 17,580
  in F)
• MF 31
• Annual Deaths 14,100 (7,750 in M 4,150 in F)

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Risk Factors for Bladder CA

• Age, Gender, Race
• Cigarette smoking (2-4x higher relative risk)
• Exposures to environmental carcinogens
• Occupational - Polycyclic aromatic
  hydrocarbons,benzene, exhaust from combustion
  gases, aryl amines
• dry cleaners manufacturers of preservatives,
  dye, rubber, leather pesticide applicators
  painters truck drivers hairdressers printers
  machinists
• Pelvic radiation therapy
• Arsenic (eg. in drinking H2O)

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Risk Factors for Bladder CA

• Infections
• Schistosoma haematobium (N Africa) ? Incd risk
  for squamous transitional cell CAR
• Chronic UTIs, chronic bladder stones, indwelling
  Foleys ? incd risk for squamous cell CAR
• Other
• Prior h/o bladder CA
• Low fluid intake (incd exposure to carcinogens
  via decd bladder emptying)
• Genetics (eg, Retinoblastoma gene)
• Bladder birth defects (eg, persistent urachus) ?
  incd risk for adenocarcinoma.

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ANATOMY AND PHYSIOLOGY
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Pathophysiology
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Clinical Manifestations of Bladder CA

• Hematuria (80-90) Generally painless and gross
  hematuria
• However, 20 can have only microscopic hematuria
• Other urinary Sxs
• Frequency, urgency, nocturia d/t irritative Sxs
  or decd bladder capacity
• Pain (less common often reflects tumor
  location)
• Lower abdominal pain Bladder mass
• Rectal discomfort perineal pain Invasion of
  prostate or pelvis.
• Flank pain - Obstruction of ureters

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Continue

• Lower extremity edema from iliac vessel
  compression,
• Physical occasionally an abdominal or pelvic
  mass may be palpable.

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Dx of Bladder CA

• Pts w/ hematuria, especially if gt 40 yrs
• Urinary Cytology- microscopy, culture to rule out
  infection,
• USG- abdomen pelvis,
• CT abdomen pelvis with preinfusion post
  infusion phases,
• Cystoscopy, regardless of cytology results
  (mainstay of dx)

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Continue..

• Retrograde pyelography in patients in whom
  contrast CT scan cant be performed because of
  azotemia or due to severe allergy to IV contrast,
• Transurethral resection of all visible tumors to
  determine histology depth of invasion
• Biopsies of erythematous ( possibly normal)
  areas to assess for CIS

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STAGES

• Stage 0 -- Non-invasive tumors that are only in
  the bladder lining
• Stage I -- Tumor goes through the bladder
  lining, but does not reach the muscle layer of
  the bladder
• Stage II -- Tumor goes into the muscle layer of
  the bladder
• Stage III -- Tumor goes past the muscle layer
  into tissue surrounding the bladder
• Stage IV -- Tumor has spread to neighboring
  lymph nodes or to distant sites (metastatic
  disease)
• Stage V--Prostate 2)Rectum 3)Ureters 4)Uterus
  5)Vagina 6)Bones 7)Liver 8)Lungs

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Treatment Medical(Ta, T1, CIS) non muscle
invasive

• Intravesical immunotherapy
• Indications
• Adjuvant tx w/ resection to prevent recurrence
• Eliminate disease that cannot be controlled by
  endoscopic resection alone (less common)
• Recurrent disease, gt 40 involvement of bladder
  surface, diffuse CIS, T1 dz
• Generally not needed for solitary papillary
  lesions

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Continue..

• Agents
• Std agent -- BCG
• Generally 6 weekly txs then monthly maintenance x
  1-3 yrs
• Toxicities Bladder irritability / spasm,
  hematuria, dysuria, rarely systemic TB
• Other agents Mitomycin-C, Interferon,
  Gemcitabine

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For muscle invasive disease (T2 greater)

• Neo-adjuvant chemo x 12 wks prior to cystectomy
• Incd 5-yr dz-free survival
• MVAC (Methotrexate, Vinblastine, Doxorubicin,
  Cisplatin) 3 cycles q 28 days

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Surgical Rx For Ta, T1, CIS (non muscle invasive)

• 1. Endoscopic treatment
• TURBT- To dignose, to stage, to treat visible
  tumors.
• Electrocautry or LASER fulguration of bladder is
  sufficient for low grade, small volume tumors.
• 2. Radical cystectomy
• Patients withunresectable, prostatic urethra
  involvement BCG failure are indications for
  this procedure.

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Muscle invasive disease T2 greater

• 1. Radical cystoprostectomy (men)
• Remove the bladder, prostate pelvic lymph
  nodes.
• After removal of bladder, urinary diversion must
  be created.
• Types
• Continent,
• Incontinent.

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Tx Prognosis of Bladder CA Muscle-Invasive Dz
Mgmt of Urine Flow

• Conduit Diversion
• Urine is drained from the ureters to a loop of
  small bowel anastomosed to the abdominal skin
  surface. It is then collected in an external
  appliance. Currently uncommonly used.
• Continent Cutaneous Reservoir
• Created from a detubularized segment of bowel
  attached to the abdominal wall w/ a continent
  stoma that can be regularly self-cathd.
• ? Continence in 6585 of men at night and 8590
  of men during the day.
• Orthotopic Neobladder
• Low-pressure reservoirs anastomosed to the
  urethra ? more natural drainage, as pts can void
  via the urethra.
• CIs Renal insuff, inability to
  self-catheterize, or an exophytic tumor or CIS in
  the urethra.

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Tx Prognosis of Bladder CA Muscle-Invasive Dz

• Sometimes bladder sparing approach is used (
  5-10 are candidates)
• Complete endoscopic resection partial
  cystectomy or combination of resection, chemo,
  and radiation
• Considered when dz is limited to the bladder
  dome, ? 2 cm can be achieved, no CIS in other
  sites, bladder capacity adequate after tumor
  removal.

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Tx Prognosis of Bladder CA Metastatic Dz

• 2 Main Regimens (Gemcitabine Cisplatin OR
  MVAC)
• 6 cycles over 6 mos
• GC is often better tolerated.
• Both ? 5 yr survival rate of 15 (20-33 if
  good performance status and mets confined to
  LNs), w/ median survival of 14 mos.

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• 2. Radiation therapy
• External beam radiation therapy has been shown
  to be inferior to radical cystectomy.

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Complications

• Body image disturbances,
• Skin irritation,
• Recurrence,
• Infertility in women as uterus is removed,
• Infertility in men if prostate is removed,
• Menopause if ovaries are removed,
• Sexual disturbances if vagina has been made
  shorter,
• Metastasis to distant organs.

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Nursing Diagnosis

• Dysurea related to disease condition,
• Disturbed sleep pattern due to urgency
  frequency of micturition,
• Acute pain related to disease condition,
• Altered nutrition secondary to pain due to
  disease condition,
• Anxiety related to surgery,
• Disturbed body image related to surgery.

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Research evidence

• A research carried out by Yursh Xia 4th military
  medical university states that, Adjuvant
  Radiotherapy in addition to cystectomy also
  increases survival rates.
• A research by Dept of Urology Health Science,
  Centre West Virginia Morgan Town says that
  Garlic can be used an immunotherapy besides BCG.

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• SUMMARY

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• CONCLUSION

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References
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• Harrisons Internal Medicine
• Cecil Textbook of Medicine
• Cancer Principles Practice of Oncology
• National Cancer Institute website
• American Cancer Society website

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• THANK YOU