Urothelial Carcinoma: Cancer of the bladder, Ureter, Renal pelvis
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- Urothelial Carcinoma: Cancer of the bladder, Ureter, Renal
pelvis
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- Epidemiology 1-bladder cancer three time more common in men
than in women. But women 30% higher chance of dying of bladder
cancer / 2-bladder cancer is rare
- Imaging Sonography IVP, ) CT.SCAN (w&wo contrast) 40-85%
accuracy range, MRI (50-90%) A.R lymph node >1cm metastasis
Chest x-ray.bone scan (alkaline phosphates' is high).
Cystoscopy.
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- Staging (1) Ta papillary,epithelium confined Tis flat carcinoma
in situ T1 Lamina propria invasion. T2a superficial propria
invasion T2b deep muscularis propria invasion. T3a microscopic
extention into perivesical fat. T3b macroscopic E.P F
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- Staging (2) T4a cancer invading pelvic viscera. T4b extention
to pelvic sidewall abdoman wall / No no histologic pelvic node
metastasis N1 single positive node < 2 cm below common iliacs N2
single positive node 2-5cm N3 positive node >5cm
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- Stage(3) M0 nodal status unknown M1 distant metastases
documented Mx distant metastases status uncertain
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- Grading Grading system is now accepted ( 1up 3 ) Grade1
:minimal architectural abnormalities ;and nuclear
atypical.papilllomas (recurrence- Not risk of progression, LOW
grade. High grade
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- Treatment Tis complete TUR followed inra vesicle BCG. Ta
(single low to moderate grate not recurrent) complete TUR. Ta
(large multiple,high grate,or recurrent ). complete TUR +intra
vesicles chemio -or immuno- T1 complete TUR +chimo -or
immuno-(intra - ves. T2-T4 radical cystectomy or neoadjuvant
chemio-+radical cystectomy.Radical cys -+ adju - chemio. neoadj
-chemio-+chemio & Radio
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- Treatment(continue ) Any T,,N+ M+. Systemic chemotherapy
followed by selective Surgery or Irradiation
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- Chemotherapy 15%of patient have regional or distant metastases
and 30-40 % with invasive diseases Cisplatin ( single
agent).30%responses Methotrexate,doxorubicin -vinblastine
cyclophosphamide gemcitabine -5fu (MVAC)combination therapy the
most commonly used for advanced bladder cancer
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- Radiotherapy External beam irradiation (5000-7000 cGy-) in 5- 8
week. 5yearys survival rate for stage T2-T3 is 18- 40% and
Recurrence is 33-68%
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- ureteral& renal pelvic cancer. Renal pelvis and ureteral
cancer are rare.4% The ratio of bladder/real pelvis-ureter.51-3-1.
M /F ratio is 2/4.2. Mean age 65 years. With upper tract carcinoma
bladder CA-(30-50%) &conversely 10yr )
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- Etiology As with bladder -CA smoking,industrial dyes or
solvents. Excessive analgesic (acetaminophen aspirin. caffeine
phenacetin (Balkan nephropathy ).
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- Pathology. 90-97% is TCCs. Grading is similar of bladder CA.
Papillomas (15-20%).and 50%have multiple papillomas. Most upper
tract CA is localized and most common metastases site regional
lymph node. Bone and lung. SCC :10% ACC is rare.mesodermal tumor is
rare.metastases from stomach,prostate,kidney,breast and
lymphoma
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- Staging. Ta,Tis confined to mucosa. 0 (Batata sys-) T1 invasion
to lamina propria. A T2 invasion to muscularis. B T3 extension
through muscularis. C in to fat or renal parenchyma T4. spread to
adjacent organ. D N+ lymph node metastases. D M+ metastases D
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- Clinical Findings Gross hematuria (70-90%). Flank pain (8-50%).
Voiding symptom (5-10%) Anorexia,weight loss, lethargy
(metastases). Flank mass,tenderness. Supraclavicular node,inguinal
node. Hepathomegaly
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- Laboratory& Imaging Hematuria, liver function test
abnormality, Pyuria,bacteriuria.urincytology positive (30-
40%)low-grade and (60%) in high grade. IVP,retrograde
pyelography.(goblet sign ) CT,urography (choice for evaluating the
upper tract. Sonography CT SCAN MRI Ureteropyeloscopy
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- treatment THE standard therapy is nephroureterectomy and
excision of bladder cuff,(open or laparoscopic ). Distal
ureterectomy &reimplantation, Endoscopic excision (recurrences
15-80%) and,maybe avoided by treatingwith BCG orChmiothrapy.(local)
Radiotherapy. Systemic chemotherapy (cisplatin)
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