Genitourinary Cancer PART – 20 – Bladder

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for explaining important points related to bladder cancer.

1. Surgery i.e. radical cystectomy is standard of care for muscle invasive stage. 2. This surgery requires a urine diversion procedure. There are several techniques, with different pros and cons. However broadly they provide similar quality of life. 3. Organ preservation, as in several other cancer types, is now feasible i.e. no surgery, only chemoradiation. However this requires very strict evaluation to ensure suitable patient characteristics. It also requires close follow up of preserved bladder. 4. Chemotherapy is used pre or post operation, more commonly preoperative. It improves survival. Most commonly gemcitabine cisplatin. 5. For metastatic or stage 4 disease, after failure of palliative chemotherapy, immunotherapy with check point inhibitors is a new option. These drugs are generally much better tolerated compared with chemotherapy. About 10% of patients have prolonged disease control. Considering overall results however, chemotherapy is still preferred as first treatment. Also, these medicines are very expensive at this time.
   I understand that apart from bladder, ureters also can have transitional cell carcinoma. Are these treated in a similar manner?
   Ans: Almost similar. What you are referring to are more specifically called as Upper Urinary Tract Tumors. Or Upper Tract Urothelial Cancers.
   Of course there are few other histologies other than urothelial carcinoma (previously known as Transitional Cell Carcinoma), but they are very rare. Most common of these are squamous cell carcinoma, adenocarcinoma, small cell carcinoma.
   Upper urinary tract tumors include that of Ureter and Renal pelvis. Both of these areas have same epithelium as in urinary bladder, since there is common embryologic origin.
   Risk factors are same as bladder cancer. and same as in bladder cancer, multiple tumors are possible due to field cancerization. This is important in planning of treatment.
   Que: How do these tumors present and how are they diagnosed?
   Ans:. These tumors also present most commonly with hematuria. Additionally there may be obstruction and/or pain due to small diameter of these areas. They are detected on imaging studies generally such as USG, CT or MRI. However diagnosis requires ureteroscopy for biopsy, especially for smaller lesions. Urine cytology may be helpful in some cases for diagnosis, without biopsy, with appropriate radiologic imaging.
   Que: How are they treated?
   Ans: Treatment principles are broadly like bladder cancer. Surgery however combines principles of kidney surgery too i.e. kidney sparing. Surgery is the mainstay of treatment.
   For small tumors, low grade disease, occasionally endoscopic resection is possible. More importantly, such kidney sparing approach is offered to patients with singly kidney or poor kidney reserve such as with chronic renal failure.
   Most of the patients however are treated by removal of ipsilateral kidney and whole ureter (nephroureterectomy) with bladder cuff. Due to field cancerization as mentioned above, whole ureter is removed rather than only the affected segment. For the same reason, one dose of intravesical chemotherapy instillation immediately postoperative reduces risk of recurrence in bladder.
   For higher T stages, perioperative chemotherapy is used same as in bladder cancer. preoperative is preferred as postoperative renal function may not allow use of cisplatin in several patients.
   For metastatic cancers, principles of treatment are same as for bladder cancer, including same agents used.
   Occasional patients with bladder or upper tract cancers may have other histologies as mentioned above. They need same surgical principles in general, but no kidney sparing surgery. But chemotherapy agents used are different, more suitable to the histology, rather than the organ. For example, small cell carcinoma is treated by cisplatin etoposide rather than cisplatin gemcitabine. This is true for small cell carcinoma of essentially any other organ site too, such as for prostate, esophagus, breast etc.
   May 16th 2019. Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com