Slide 1

Urothelial Carcinoma: Cancer of the bladder, Ureter, Renal pelvis

Slide 2

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.

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

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

Slide 19

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

Slide 20

Stage(3) M0 nodal status unknown M1 distant metastases documented Mx distant metastases status uncertain

Slide 21

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

Slide 22

Slide 23

Slide 24

Slide 25

Slide 26

Slide 27

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

Slide 28

Treatment(continue ) Any T,,N+ M+. Systemic chemotherapy followed by selective Surgery or Irradiation

Slide 29

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

Slide 30

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%

Slide 31

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 )

Slide 32

Etiology As with bladder -CA smoking,industrial dyes or solvents. Excessive analgesic (acetaminophen aspirin. caffeine phenacetin (Balkan nephropathy ).

Slide 33

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

Slide 34

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

Slide 35

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

Slide 36

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

Slide 37

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)

Slide 38

Slide 39

Slide 40

Slide 41

Slide 42