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Published on : Feb 24, 2014
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Slide 1 - WELCOME
Slide 2 - Bladder Cancer Presented by: Ms. Krantee More.
Slide 3 - INTRODUCTION GENERAL OBJECTIVE: To gain in depth knowledge regarding CANCER OF URINARY BLADDER.
Slide 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
Slide 5 - DEFINATION Bladder cancer is a cancerous tumor in the bladder -- the organ that holds urine
Slide 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)
Slide 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)
Slide 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.
Slide 9 - ANATOMY AND PHYSIOLOGY
Slide 10 - Pathophysiology
Slide 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
Slide 12 - Continue… Lower extremity edema from iliac vessel compression, Physical: occasionally an abdominal or pelvic mass may be palpable.
Slide 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)
Slide 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
Slide 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
Slide 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
Slide 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
Slide 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
Slide 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.
Slide 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.
Slide 21 - Tx & Prognosis of Bladder CA – Muscle-Invasive Dz – Mgmt of Urine Flow Conduit Diversion Urine is drained from the ureters to a loop of small bowel anastomosed to the abdominal skin surface. It is then collected in an external appliance. Currently uncommonly used. Continent Cutaneous Reservoir Created from a detubularized segment of bowel attached to the abdominal wall w/ a continent stoma that can be regularly self-cath’d.  Continence in 65–85% of men at night and 85–90% of men during the day. Orthotopic Neobladder Low-pressure reservoirs anastomosed to the urethra  more natural drainage, as pts can void via the urethra. CI’s = Renal insuff, inability to self-catheterize, or an exophytic tumor or CIS in the urethra.
Slide 22 - Tx & Prognosis of Bladder CA – Muscle-Invasive Dz Sometimes bladder sparing approach is used (~ 5-10% are candidates) Complete endoscopic resection; partial cystectomy; or combination of resection, chemo, and radiation Considered when dz is limited to the bladder dome,  2 cm can be achieved, no CIS in other sites, & bladder capacity adequate after tumor removal.
Slide 23 - Tx & Prognosis of Bladder CA – Metastatic Dz 2 Main Regimens (Gemcitabine + Cisplatin OR MVAC) 6 cycles over 6 mos GC is often better tolerated. Both  5 yr survival rate of ~ 15% (20-33% if good performance status and mets confined to LNs), w/ median survival of ~ 14 mos.
Slide 24 - 2. Radiation therapy: External beam radiation therapy has been shown to be inferior to radical cystectomy.
Slide 25 - 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.
Slide 26 - 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.
Slide 27 - 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.”
Slide 28 - SUMMARY
Slide 29 - CONCLUSION
Slide 30 - References
Slide 31 - Harrison’s Internal Medicine Cecil Textbook of Medicine Cancer: Principles & Practice of Oncology National Cancer Institute website American Cancer Society website
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Slide 36 - THANK YOU