Bladder Cancer Treatment

My 86 year old mother has a high probability of TCC (bladder cancer).  We have not told her yet as we want to know all the facts before, so we can explain things to her carefully and not panic her.  She has never had a pap smear or breast screen as she is so afraid of cancer. Do we put her through the final tests to find out for sure?  Is this a fast growing cancer in a person of her age?  How invasive is the treatment?

[DrNavneetMD]

;Hello Dear,
The investigations of the bladder cancer are-
Any patient with gross or microscopic hematuria should be urologically evaluated. Microscopic hematuria from bladder cancer may be intermittent; therefore, a repeat negative result on urinalysis does not exclude the diagnosis. Infection may cause hematuria and is usually associated with irritative voiding symptoms (eg, dysuria, frequency, urgency). Irritative voiding symptoms may also be caused by CIS or muscle-invasive bladder cancer. Further evaluate irritative voiding symptoms caused by a urinary tract infection that do not resolve with treatment.  

• Urinalysis with microscopy
• Urine culture to rule out infection, if suspected
• Voided urinary cytology (This may be helpful if results are positive, but a negative cytology result cannot be considered definitive. Urinary cytology for routine screening is controversial.)
• Newer molecular and genetic markers may help in the early detection and prediction of TCC.  
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Imaging Studies
• Upper-tract imaging is necessary for the hematuria workup and should be able to visualize both the kidneys and the urothelium.
• The American Urologic Association Best Practice Policy recommends CT scanning of the abdomen and pelvis with preinfusion and postinfusion phases. This is ideally performed with a CT urography or followed by radiography of the kidneys, ureters, and bladder (KUB) to obtain images similar to those produced with intravenous pyelography (IVP).
• Two commonly used alternative studies are IVP and renal ultrasonography.  
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o The IVP is the traditional standard for upper-tract urothelium imaging; however, it is poor for evaluating the renal parenchyma.
o Ultrasonography is also commonly used; however, urothelial tumors of the upper tract and small stones are easily missed.
• Conduct retrograde pyelography in patients in whom contrast CT scanning cannot be performed because of azotemia or a severe allergy to intravenous contrast.
Procedures
• Cystoscopy  
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• Obtain biopsy samples of suspicious lesions during cystoscopy. Attempt to include the bladder muscle in the biopsy specimen. This allows the pathologist to determine whether the tumor is muscle invasive.
• Transitional cell tumors are typically papillary or sessile, and CIS may appear as an erythematous, velvety lesion. Unless the lesion is in a bladder diverticulum (pseudodiverticulum), attempt to resect the primary tumor completely.
• A bladder diverticulum lacks a surrounding muscle layer, and a deep biopsy of a lesion within a diverticulum risks perforating the bladder and extravesical extravasation of cancer cells.
• Because no muscle layer surrounds the bladder diverticulum, the next step in the progression of a superficial tumor is extravesical spread, requiring more aggressive surgical therapy (eg, partial cystectomy, open diverticulectomy) rather than a simple resection followed by surveillance.
• Further investigate efflux of blood from either ureteral orifice with retrograde pyelography, ureteroscopy, or both.
• Urine cytology  
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• Perform urine cytology at the same time as cystoscopy, although its routine use for screening is controversial.
• Urine cytology is associated with a significant false-negative rate, especially for low-grade carcinoma (10-50% accuracy rate).
• The false-positive rate is 1-12%, but it has a 95% accuracy rate for diagnosing high-grade carcinoma and CIS.
• The sensitivity of urine cytology can be increased by obtaining a bladder barbotage cytology (70%) as opposed to a voided cytology (30%).
• With a normal finding on cystoscopic examination, further evaluate a positive cytology result on urine study with an upper-tract study and random biopsies of the bladder. Obtain biopsy samples of the prostatic urethra in men.
• Other urine markers for bladder cancer  
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o The use of additional urine markers such as UroVysion (FISH), BTA, and NMP-22 in the initial diagnosis of bladder cancer is controversial. All of these assays may yield false-positive and false-negative results.
o These other tests should not replace urine cytology and cystoscopy, with or without biopsy, for the diagnosis of bladder cancer. However, they may be useful adjuncts to urine cytology and cystoscopy.
Histologic Findings
More than 90% of bladder cancer cases are TCC, approximately 5% are SCC, and less than 2% are adenocarcinoma. Both the stage and tumor grade correlate independently with prognosis.
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• Clinically stage a patient who has muscle-invasive disease with CT scanning of the abdomen and pelvis, chest radiography, and serum chemistries.
• If the patient is asymptomatic with normal calcium and alkaline phosphatase levels, a bone scan is unnecessary.
• As many as 50% of patients with muscle-invasive bladder cancer may have occult metastases that become clinically apparent within 5 years of initial diagnosis.
• Most patients with overt metastatic disease die within 2 years despite chemotherapy.
• Approximately 25-30% of patients with only limited regional lymph node metastasis discovered during cystectomy and pelvic lymph node dissection may survive beyond 5 years.
The treatment of non–muscle-invasive (Ta, T1, CIS) and muscle-invasive bladder cancer should be differentiated. Treatments within each category include both surgical and medical approaches
Refer . http://www.emedicine.com/med/TOPIC2344.HTM
Best