Cytologic Detection of Urothelial Lesions: 2 (Essentials in Cytopathology)
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Information from reference Tumor invades any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall. Regional lymph nodes are those within the true pelvis; all others are distant lymph nodes. Metastasis in single lymph node, more than 2 cm but not more than 5 cm in greatest dimension; or multiple lymph nodes, none more than 5 cm in greatest dimension.
Any T. Bimanual examination following endoscopic surgery is an indicator of clinical stage. The finding of bladder wall thickening, a mobile mass, or a fixed mass suggest the presence of T3a, T3b, and T4b disease, respectively. Appropriate imaging techniques for lymph node evaluation should be used.
When indicated, evaluation for distant metastases includes imaging of the chest, biochemical studies, and isotopic studies to detect common metastatic sites. Reprinted with permission from Urinary bladder. Painless hematuria is the most common presenting symptom. The incidence of bladder cancer in a patient with gross hematuria is 20 percent 14 , 15 and with microscopic hematuria is 2 percent.
Obstructive symptoms may be present if the tumor is located near the urethra or bladder neck.
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In advanced disease, patients may present with flank pain caused by ureteral obstruction, or with abdominal, pelvic, or bone pain from distant metastases Table 4 1 , Early bladder cancer is not detectable by physical examination; however, a mass may be palpable in advanced disease. A palpable kidney or pelvic mass may be present in metastatic disease.
Dysuria, frequency, urge incontinence, urgency. Decreased force of stream, feeling of incomplete voiding, intermittent stream, straining. Abdominal, bone, flank, or pelvic pain; anorexia, cachexia, or pallor; lower extremity edema; renal failure; respiratory symptoms e. Information from references 1 and The clinical investigation should begin with a careful history, including any history of cigarette smoking or occupational exposures. Patients with urinary symptoms should have a urinalysis with urine microscopy and a urine culture to rule out infection. Urine cytology is a noninvasive test for the diagnosis of bladder cancer.
It is used to identify high-grade tumors and monitor patients for persistent or recurrent disease following treatment. Urine cytology has a high specificity 95 to percent , but a low sensitivity 66 to 79 percent for the detection of bladder cancer. Cystoscopy, an office procedure usually performed under local anesthesia, remains the mainstay of diagnosis and surveillance. Patients presenting with symptoms of bladder cancer should be evaluated with cystoscopy to determine if a lesion is present.
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Cystoscopy provides information about the tumor location, appearance, and size. Detection of flat neoplastic lesions, such as carcinoma in situ, can be enhanced by using fluorescence cystoscopy. This induces macroscopic fluorescence of tumor tissue in the bladder. The procedure carries a 5 percent risk of urinary infection. Bladder wash cytology detects carcinoma in situ in almost all cases, even when the urothelium appears grossly normal, and obviates the need for random bladder biopsies. Upon detection of a lesion, a bimanual examination under anesthesia and transurethral resection of the tumor is performed.
The muscle surrounding the tumor should be sampled to assess the depth of muscle invasion. Additional workup for all patients with bladder cancer includes evaluation of the upper urinary tract with intravenous urography IVU , renal ultrasonography, computed tomography CT urography, or magnetic resonance urography.
For patients unable to undergo contrast injection e. These tests are useful for disease staging and excluding other causes of hematuria. Pelvic imaging should be performed before transurethral resection to improve staging accuracy because postoperative inflammation mimics the appearance of tumor infiltration. Complete blood count, blood chemistry tests including alkaline phosphatase tests , liver function tests, chest radiography, and CT or magnetic resonance imaging of the abdomen and pelvis should be included in the metastatic workup for invasive bladder cancer. In recent years, there has been an intense debate about the role of urine-based tumor markers in the diagnosis and surveillance of bladder cancer.
Food and Drug Administration, such as NMP tests and FISH analysis for chromosomal changes in cells in urine, have demonstrated a superior sensitivity to urine cytology for low-grade tumors and an equivalent sensitivity for high-grade tumors and carcinoma in situ.
There are no current recommendations for bladder cancer screening. Preventive Services Task Force recommends against routine screening for bladder cancer in adults D recommendation. Urine-based tests, such as urine dipstick to assess for hematuria, urine cytology, and tumor markers e. However, because of the low prevalence of bladder cancer, the positive predictive value of these tests is low.
Close follow-up is essential with bladder cancer Table 7 25 , Methotrexate, vinblastine, doxorubicin Adriamycin , and cisplatin Platinol ineffective; consider fluorouracil-based therapy. Some experts suggest a single dose of intravesical chemotherapy not immunotherapy within 24 hours of resection to prevent recurrence. Repeat transurethral resection if lymphovascular invasion, incomplete resection, or no muscle in the specimen , consider intravesical BCG preferred or mitomycin.
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Repeat transurethral resection followed by intravesical BCG preferred or mitomycin. Repeat transurethral resection, followed by intravesical BCG or mitomycin, or cystectomy. Radical cystectomy followed by chemotherapy in high-risk patients e. Radical cystectomy followed by adjuvant chemotherapy, consider neoadjuvant chemotherapy. Two trials have shown survival benefit with neoadjuvant chemotherapy three cycles of methotrexate, vinblastine, doxorubicin [Adriamycin], and cisplatin [Platinol] in T2 or T3 disease.
Chemotherapy alone or in combination with radiation therapy, except in high-risk patients e. Radiation therapy not routinely used in the United States for locally advanced bladder cancer. Algorithm for the management of bladder cancer.
Cystoscopy and urine cytology every three months for two years, then every six months for two years, then annually. Liver function test, creatinine clearance test, electrolyte panel, chest radiography every six to 12 months. Imaging of upper urinary tract, abdomen, and pelvis for recurrence every three to six months for two years, and then as clinically indicated. If bladder-sparing surgery, urine cytology with or without biopsy every three months for one year, then increase interval.
If cystectomy and cutaneous diversion, urethral wash cytology every six to 12 months. Information from references 25 and Three stages of bladder cancer non-muscle-invasive papillary carcinoma [stage Ta], carcinoma in situ [stage Tis], and tumor invading the lamina propria [stage T1] were previously referred to as superficial bladder cancer, but now are described as non-muscle-invasive bladder cancer.
Approximately 70 to 75 percent of bladder cancers present as non-muscle-invasive tumors. These tumors are initially treated by transurethral resection followed by close observation or intravesical chemotherapy or immunotherapy. Depth and grade of tumor invasion, completeness of resection, and estimated probability of recurrence are key factors that guide the use of intravesical therapy.
Low-grade Ta cancers are treated with resection alone. Intravesical BCG therapy is preferred over mitomycin for those at high risk of disease progression. Radical cystectomy should be considered for high-risk, non-muscle-invasive bladder cancers, such as recurrent high-grade T1 disease or tumors with micropapillary histology.
Transurethral resection followed by intravesical BCG once per week for six weeks is recommended for carcinoma in situ. Radical cystectomy with pelvic lymphadenectomy is the standard treatment for muscle-invasive bladder cancer stage T2 and above. Segmental cystectomy may be considered for solitary lesions without carcinoma in situ located in suitable locations.
source link In patients with extensive comorbid disease, bladder preservation strategies transurethral resection with or without chemotherapy are sometimes used instead of cystectomy to limit treatment-associated morbidity. Neoadjuvant and adjuvant chemotherapy has been explored in patients with muscle-invasive disease and is best reserved for high-risk patients e. Combination gemcitabine Gemzar and cisplatin Platinol is the standard treatment for most patients because of its lower toxicity.
Patients with metastatic disease are treated with chemotherapy. The specific chemotherapy regimen depends on existence of medical comorbidities, such as cardiac and renal dysfunction. A commonly used combination is cisplatin and gemcitabine or a multidrug cisplatin-based regimen, such as MVAC. Carboplatin-based regimens are used in patients with insufficient renal reserve.
If muscle invasion has occurred, radical cystectomy with pelvic lymphadenectomy remains the treatment of choice. Lifestyle modifications, including smoking cessation, are an integral part of treatment. Upon diagnosis, patients require continuous surveillance Table 7 25 , 26 because most recurrences can be successfully treated if detected early. Already a member or subscriber? Log in. Reprints are not available from the authors.
American Cancer Society. Atlanta, Ga. Its pragmatic, well-organized approach, nearly full-color illustrations, and at-a-glance boxes and tables make the information you need easy to access. Practical and affordable, this resource is ideal for study and review as well as everyday clinical practice! About this book: The Essentials in Cytopathology book series fulfills the need for an easy-to-use and authoritative synopsis of site specific topics in cytopathology.
These guide books fit into the lab coat pocket and are ideal for portability and quick reference. Each volume is heavily illustrated with a full color art program, while the text follows a user-friendly outline format. Yener S. About this book: The Essentials in Cytopathology series publishes generously illustrated and user-friendly guides with over full color images that illustrate principles and practice in Cytopathology for pathologists and clinicians. Rosenthal, MD and Stephen S. Raab, MD is the second volume in the series. This volume will present a simple approach to dealing with cellular samples from the urinary tract.
About this book: Expansively illustrated, this volume in the "Foundations in Diagnostic Pathology" series encompasses aspiration cytopathology of all major body sites. Experts in the field provide you with a clear, concise, and practical diagnostic approach to the challenges you face every day.
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Color photomicrographs provide a visual image of individual lesions, to make learning quick and easy. The consistent, convenient format provides quick, at-a-glance reference, making it an excellent resource not only for the pathologists-in-training but for those in practice as well. About this book: Clinical and radiologic examinations cannot reliably distinguish benign or inflammatory pancreatic disease from carcinoma.
The increased use of pancreatic fine needle aspiration FNA along with advances in imaging techniques and the introduction of endoscopic ultrasound guidance have led to significantly better detection and recognition of pancreatic masses.