Bladder cancer treatment

Bladder cancer spectrum can be divided into three categories that differ in prognosis, management, and therapeutic goals.

bladder cancer treatment recommendations are related to non-muscle invasive disease Ta, T1, and Tis, and muscle invasive disease T2 or greater.

The first category consists of non-muscle invasive disease for which treatment is directed at reducing recurrences and preventing progression to a more advanced disease. 

Approximately 75% of newly detected cases are non-muscle invasive disease-Exophytic papillary tumors confined largely to the mucosal (Ta; 70 to 75% or less often, to the lamina propria (T1; 20 to 25%) or flat high-grade lesions (CIS: 5 to 10%).

Non-muscle invasive disease tend to be friable, have a high propensity for bleeding, and natural history is characterized by a tendency to recur in the bladder: these are currencies can either be at the same stage as the initial tumor or at a more advanced stage.

Papillary tumors confined to the mucosa or submucosa are generally managed endoscopically  with complete resection.

An estimated 31 to 78% of patients with a tumor confined to the mucosa or submucosa will experience a recurrence or a new occurrence of a urothelial carcinoma within five years.

Muscle-invasive disease is the second group with a goal of therapy to determine whether the bladder should be removed or if it can be preserved without compromising survival, and to determine if the primary lesion can be managed independently or if patients are at high risk for distance spread requiring systemic management. 

The third group consists of metastatic lesions and an attempt to prolong quantity and quality of life. 

Muscle invasive bladder cancer (MIBC) includes stage II and III bladder cancer, including disease that invades the muscularis propria and can extend to the depths of the bladder and into the extra vesicular tissue.

Muscle invasive disease (T2) is defined by malignant expansion into the detrussor muscle, and perivesical tissue involvement defines T3 disease.

Some patients with MIBC have regional lymph node involvement. 

In general, MIBC is a curable condition with the use of multimodal therapy.

MIBC treatment is either surgical removal of the tumor and bladder, or irradiation of the bladder.

Extravesicle invasion into surrounding organs (prostate stroma, seminal vesicles, uterus, vagina, pelvic wall, abdominal wall) delineates T4 disease.

An estimation of risk of recurrence of metastases may require intensive systemic therapy to aid in management.

The depth of invasion is the most important determinant of prognosis and treatment of localized bladder cancer.

Standard therapy for adequately fit patients includes neoadjuvant chemotherapy followed by radical cystectomy and an extended lymph node dissection. 

Trimodality therapy including maximal transurethral resection of bladder tumor followed by combined chemotherapy and radiation may be appropriate.

TURBT is bimanual examination under anesthesia to resect the visible tumor and to sample underlying muscle to assess invasion.

MRI or CT of the abdomen and pelvis is recommended before TURBT, for a better anatomical characterization of a bladder lesion and possible delineation of its suspected depth of invasion.

Work up prior to TURBT includes urine cytology, evaluation of the upper urinary tract with imaging.

The goals of TURBT are used to correctly identify bladder cancer clinical stage, grade of disease, as well completely respecting all visible tumor.

White light cystocopy is the current standard in evaluation and staging of bladder cancer.

White light cystoscopy has a high sensitivity for detecting papillary lesions and has limited ability to discern non-papillary and flat lesions for inflammatory lesions, reducing its accuracy of tumor staging.


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