Bladder cancer is a common urologic cancer that has the highest recurrence rate of any malignancy. In North America, South America, Europe, and Asia, the most common type is transitional cell carcinoma. Other types include squamous cell carcinoma (see the image below) and adenocarcinomas.
Signs and symptoms
Clinical manifestations of bladder cancer are as follows:
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Painless gross hematuria - Approximately 80-90% of patients; classic presentation
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Irritative bladder symptoms (eg, dysuria, urgency, frequency of urination) - 20-30% of patients
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Pelvic or bony pain, lower-extremity edema, or flank pain - In patients with advanced disease
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Palpable mass on physical examination - Rare in superficial bladder cancer
See Clinical Presentation for more detail.
Diagnosis
Urine studies include the following:
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Urinalysis with microscopy
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Urine culture to rule out infection, if suspected
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Voided urinary cytology
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Urinary tumor marker testing
Urinary cytology
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Standard noninvasive diagnostic method
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Low sensitivity for low-grade and early stage cancers
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Fluorescence in situ hybridization (FISH) may improve the accuracy of cytology
Cystoscopy
Upper urinary tract imaging
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Necessary for the hematuria workup
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American Urologic Association Best Practice Policy recommends computed tomography (CT) scanning of the abdomen and pelvis with contrast, with preinfusion and postinfusion phases
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Imaging is ideally performed with CT urography, using multidetector CT
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Ultrasonography is commonly used, but it may miss urothelial tumors of the upper tract and small stones
The diagnostic strategy for patients with negative cystoscopy is as follows:
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Negative urine cytology and FISH - Routine follow-up
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Negative urine cytology, positive FISH - Increased frequency of surveillance
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Positive urine cytology, positive or negative FISH - Cancer until proven otherwise
No blood tests are specific for bladder cancer, but a general evaluation is necessary prior to initiating therapy with intravesical bacillus Calmette-Guérin (BCG) vaccine. Laboratory tests include the following:
Management
The treatment of non–muscle-invasive bladder cancer (Ta, T1, carcinoma in situ [CIS]) begins with transurethral resection of bladder tumor (TURBT). Subsequent treatment is as follows:
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Small-volume, low-grade Ta bladder cancer - An immediate single, postoperative dose of intravesical chemotherapy
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High-risk Ta, T1, and CIS urothelial carcinoma - Intravesical BCG vaccine
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Persistent or recurrent high-risk disease - Repeat resection prior to additional intravesical therapy (eg, interferon alfa or gamma); consider cystectomy for high-risk disease
The treatment of muscle-invasive bladder cancer is as follows:
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Radical cystoprostatectomy in men
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Anterior pelvic exenteration in women
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Bilateral pelvic lymphadenectomy (PLND), standard or extended
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Creation of a urinary diversion
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Neoadjuvant chemotherapy - May improve cancer-specific survival
Alternatively, a bladder-sparing approach of TURBT followed by concurrent radiation therapy and systemic chemotherapy (trimodality therapy) may be used.
Chemotherapeutic regimens for metastatic bladder cancer include the following:
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Methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC)
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Gemcitabine and cisplatin (GC)