Bladder cancer

Anatomy
Superior surface of bladder covered with peritoneum
Nodes: internal iliac/pelvic nodes

Epidemiology
67,000 cases per year in US

Risk factors
Smoking
Males
+ family history
Prior pelvic RT
Aromatic amine (arylamine exposure) -- dye workers, printers
Chronic inflammation associated with squamous cell ca
 -Schistosomiasis
 -Long term indwelling catheter
 -Urinary tract stones
 -Bladder diverticulum

Pathology
90% transitional cell, 5% squamous
1% adeno -- this has a strong association with persistent urachal remnant

Clinical
Most common symptom is gross painless hematuria
85% present with superficial (Ta/T1 disease)

Prognostic factors
Stage
Extent of TURBT
Multifocal tumor
Response to CRT

Therapy
Ta/Tis/T1: TURBT + intravesicular chemo or BCG
T2 and up: cystectomy vs. trimodality bladder preserving therapy
Cystectomy remains standard

Bladder preservation protocol
1) Maximum achievable TURBT
2) 40Gy to whole bladder/pelvic nodes with concurrent cisplatin
3) Repeat cystoscopy at 6 weeks after CRT
4) Complete responders complete CRT with whole pelvis RT to 45Gy + bladder boost to 55Gy and primary tumor boost to 65Gy
5) If residual disease is present (even Tis) cystectomy is performed
5) Consider adjuvant chemo (induction chemo does not change outcomes)

Contraindications for bladder preservation
1) Multifocal tumor
2) Concurrent upper urinary tract cancer
3) Adenopathy
4) Hydronephrosis
5) Renal failure
6) Non-functional bladder

RTOG bladder preservation outcomes
5-year OS - 54%; 10-year OS - 36%
5-year DSS - 63%; 10-year DSS - 59%
Pelvic failure 8% at 5 years
No cystectomy required secondary to RT-induced morbidity
Functional bladder preserved in ~60% of patients