Bladder


 * **Epidemiolgy:** || ** Cancer of the Bladder1 **
 * Estimated to have an annual incidence in the United States of 68,810 cases, accounting for 5% of all newly diagnosed cancers
 * Approximately 14,100 people per year will die of this disease, accounting for 2.5% of all cancer-related mortality in the U.S., accounting for 3% of all cancer deaths in men
 * Incidence varies among countries, with the highest incidence rates in Western countries
 * At diagnosis, 75% of patients have localized disease, 20% have regional disease, and 5% present with distant metastases
 * 2/3 of all bladder cancer diagnoses occur among persons 65 years of age or older
 * Male/female ratio is 3:1
 * In the U.S., the risk for white men is approximately twice that for African-American or Hispanic men
 * Over the past 40 years, the incidence of bladder cancer has risen while mortality has fallen ||
 * **Etiology:** || ** Risk Factors for Bladder Cancer1 **
 * Cigarette smoking is the most significant known cause
 * Risk increases as the number of pack-years increases
 * 50% of all diagnoses can be linked to a smoking history
 * Female smokers are at higher risk than male smokers
 * Younger age of smoking initiation increases the risk
 * Exposure to industrial chemicals
 * Contact with chemicals used in the production of dyes, rubber, plastics, and synthetic materials increases the risk
 * Schistosoma haematobium
 * Chronic urinary tract infections
 * Upper tract urothelial cancer
 * 20% to 50% chance of developing bladder cancer regardless of treatment modality
 * Poor diet
 * Evidence is not conclusive
 * Accidental consumption of crop fertilizer
 * Radiation exposure
 * Chronic Phenacetin usage
 * Administration of cyclophosphamide
 * Genetic predisposition ||
 * **Signs & Symptoms:** || ** Signs and Symptoms of Bladder Cancer ** 1
 * Gross or microscopic hematuria
 * Bladder irritation (urinary frequency, urgency, dysuria)
 * Pelvic pain
 * Ureteral obstruction
 * Hydronephrosis
 * Rectal obstruction ||
 * **Diagnostic Procedures:** || Diagnostic Procedures for Bladder Cancer2
 * Patients with bladder cancer should have a complete clinical history, physical examination (including careful rectal/bimanual examination), chest roentgenogram, urinalysis, complete blood cell count, liver function tests, complete cystoscopic evaluation, and bimanual examination under anesthesia both before and after endoscopic surgery (biopsy or TUR).
 * An intravenous program should be obtained before cytoscopy so that the upper tracts can be evaluated by retrograde pyelogram, cytology, brush biopsy, or ureteroscopy at the time of cystoscopy, if indicated. The number, size, and configuration of all tumors should be recorded and diagrammed.
 * Cystograms provide minimal information.
 * Computed tomography (CT) is widely used to help detect bladder wall thickening, extravesical extension, and lymph node metastases and is useful in follow-up. After TUR of a bladder tumor, CT findings that suggest extravesical extension may be caused by hemorrhage and edema; therefore, the results must be interpreted with caution.
 * Magnetic resonance imaging (MRI) in coronal or sagittal projections is sometimes useful in defining tumor extent.
 * PET scanning, in patients with deep muscle invasion may be useful in the detection of lymph node or distant metastasis. ||
 * **Histology:** || In the U.S. around 92% of all bladder cancers are transitional cell carcinomas, 6-7% are squamous cell carcinoma with 1-2% being adenocarcinoma. Occasionally small cell carcinoma may occur.2 ||
 * **Lymph node drainage:** || Lymphatic drainage includes the internal and external iliac nodes as well as the presacral lymph nodes.3

||
 * **Metastatic spread:** || * Spreads via: 3
 * Direct extensions into or through the bladder wall
 * Submucosally under intact, normal-appearing mucosa
 * Involvement of the distal ureters, prostatic urethra and periurethral prostatic ducts is frequently found 3
 * About 15-25% of patients have muscle invasion at time of detection 3 ||
 * **Grading:** || According the the American Joint Committee on Cancer Staging System for Carcinoma fo rhte Urinary Bladder, Histolologic Grading (G): 3

GX-Grading cannot be assessed G1-Well differentiated G2-Moderately differentiated G3-4--Poorly differentiated or undifferentiated || || Surgery Radiation Therapy AP/PA Margins: Lateral Margins: Dose:
 * **Staging:** || The AJCC system for staging combines histologic findings from transurethral resection specimens and clinical findings from bimanual examination 3
 * **Radiation side effects:** || The most common acute side effects of radiation include nausea, vomiting, abdominal cramps, cystitis (10% patients), and diarrhea. If the cystitis is severe enough, urinary tract infections can occur. Bladder contracture occurs in 1% of patients. Morbidity is associated with complications of the bladder (8-10%), rectum (3-4%), and small bowel (1-2%) from radical irradiation. Late radiation complications attribute to the 1% mortality rate.2 ||
 * **Prognosis:** || Prognostic factors for bladder cancer include:2
 * Depth of tumor invasion and grade
 * Lymphatic and blood vessel invasion is a significant indicator even without the presence of positive lymph nodes or confined to lamina propria
 * Poor prognostic indicators include: carcinoma in situ, solid tumor morphology, large tumor size, large number of tumors, muscle invasion, positive lymph nodes, and obstructive uropathy ||
 * **Treatments:** || Treatments:2
 * Transurethral resection; fulguration
 * Segmental resection (partial cystectomy)
 * Radical cystectomy
 * Lymphadenectomy
 * patient supine
 * 10-18 MV photons
 * AP/PA
 * three-field
 * arc rotation
 * four-field box technique (preferred)
 * IMRT
 * Superior: mid-SI joint or L-5 - SI joint
 * Inferior: 2 cm below inferior extent of tumor or 1.5 cm below obturator foramen
 * Lateral: 2 cm lateral to bony pelvis
 * 2 cm anterior to air bubble of bladder (front of symphysis pubis)
 * 64.8-68.4 Gy total tumor dose with irradiation alone
 * The portals are reduced after 45.0 to 54.4 cGy
 * Pre-op: 30-44 Gy in 2-4.5 weeks

AP/PA and Lateral Fields for carcinoma of the bladder
 * [[image:bladder1.jpg]]

Reduced Fields (Boost Fields) for carcinoma of the bladder
 * [[image:bladder2.jpg]]

AP treatment port film
 * [[image:bladder3.jpg]]

Lateral treatment port film
 * [[image:bladder4.jpg]]

4 field "box" plan for carcinoma of the bladder
 * [[image:bladder5.jpg]]

IMRT plan for carcinoma of the bladder
 * [[image:bladder6.jpg]]

Chemotherapy Intravesicle chemotherapy Systemic chemotherapy:
 * Thiotepa
 * Mitomycin C
 * Doxorubicin
 * Bacille Calmette-Guérin
 * Methotrexate
 * Cisplatin
 * Vinblastine ||
 * **TD 5/5:** || TD 5/5 is a statistical guideline to consider which states that there has been a five percent probability of complication in five years. These values are based on a 200cGy 5 fraction a week treatment schedule.4

Spinal Cord: (1/3) 5cm-5000 cGy, (2/3) 10cm- 5000 cGy, (3/3) 20cm- 4700 cGy

Bladder: (1/3)N/A, (2/3)8000 cGy, (3/3)6500 cGy Colon: (1/3)5500 cGy, (2/3)N/A, (3/3)4500 cGy Rectum: (1/3)N/A, (2/3)N/A, (3/3)6000 cGy Small Intestine: (1/3)5000 cGy, (2/3)N/A, (3/3)4000 cGy Skin: (1/3)7000 cGy. (2/3)6000 cGy. (3/3)7000 cGy ||
 * **References:** || # Hoppe RT, Phillips TL, Mack III M. Leibel and Phillips Textbook of Radiation Oncology. 3rd ed. Philadelphia Pa: Elsevier Saunders; 2010.
 * 1) Chao KSC, Perez CA, Brady LW. Bladder. Radiation Oncology Management Decisions. 2nd ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2002:437-438.
 * 2) Kuban DA, Trad ML. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, Missouri; Mosby Inc: 845-848.
 * 3) Radiation Oncology/Toxicity/Emami. Wikibooks. Available at: [] . Accessed: June 12, 2012. ||

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