WELCOME

1. WELCOME

2. Bladder Cancer

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

4. 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

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

6. 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) • M:F = 3:1 • Annual Deaths = 14,100 (7,750 in M & 4,150 in F)

7. 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)

8. Risk Factors for Bladder CA • Infections • Schistosoma haematobium (N Africa)  Inc’d risk for squamous & transitional cell CAR • Chronic UTIs, chronic bladder stones, indwelling Foleys  inc’d risk for squamous cell CAR • Other • Prior h/o bladder CA • Low fluid intake (inc’d exposure to carcinogens via dec’d bladder emptying) • Genetics (eg, Retinoblastoma gene) • Bladder birth defects (eg, persistent urachus)  inc’d risk for adenocarcinoma.

9. ANATOMY AND PHYSIOLOGY

10. Pathophysiology

11. 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 dec’d 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

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

13. Dx of Bladder CA • Pts w/ hematuria, especially if > 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)

14. Continue.. • Retrograde pyelography in patients in whom contrast CT scan can’t 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

15. 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

16. 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, > 40% involvement of bladder surface, diffuse CIS, T1 dz • Generally not needed for solitary papillary lesions

17. 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

18. For muscle invasive disease (T2 & greater) • Neo-adjuvant chemo x 12 wks prior to cystectomy • Inc’d 5-yr dz-free survival • MVAC (Methotrexate, Vinblastine, Doxorubicin, Cisplatin) – 3 cycles q 28 days

19. 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.

20. 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.

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

22. 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.

23. 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.

24. 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.”

25. SUMMARY

26. CONCLUSION

27. Harrison’s Internal Medicine • Cecil Textbook of Medicine • Cancer: Principles & Practice of Oncology • National Cancer Institute website • American Cancer Society website

28. THANK YOU