Transitional Cell Carcinoma of the Urinary Tract Manish Patel Urology Registrar Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Epidemiology Men >women Incidence increasing in men Mortality decreasing Age- middle aged and elderly Race- blacks > whites All symptomatic before death Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Etiology Smoking Occupational exposure Analgesic abuse Cyclophosphamide ?heredity Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Pathology Carcinoma insitu Superficial invasive Low grade Mod grade High Grade Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Natural History 75% superficial at presentation 2/3 well-mod diff.- 0nly 10% become invasive or metastastic 1/3 high grade-50% become invasive 25% invasive- most are high grade CIS- 16% become invasive Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Natural History 40% muscle invasive TCC have occult distant mets Nearly all Pts with mets die within 2 years Spread Lymphnodes, Liver, Lung, Bone, Adrenal Local Complications Bleeding, Pain, Ureteral Obstruction, Local invasion surrounding structures/fistula. Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Diagnosis Microurine, urine cytology IVP, U/S, CT Cystoscopy and biopsy Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Staging Biopsy CT abdomen and pelvis CXR Bone scan Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Management superficial bladder TCC Transurethral resection or fulgration 70% 5 year survival 10% will ultimately require more aggressive Treatment Lamina Propria invasion has 46% muscle invasion later multiple or recurrent TCC will respond to intravesical chemo or BCG Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Management of Muscle Invasive TCC Bladder TURBT Partial Cystectomy DXRT with cystectomy salvage 35% 5 year survival 50-70% bladder recurence at 5 years 10% severe persistent complications Only 8-15% are suitable for salvage cystectomy- 40% 5 year survival Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Management of Muscle Invasive TCC Bladder Radical Cystectomy Most effective form of cure 70% 5 year survival 45% 5 year survival outside bladder Complications-25% infection, intestinal obstruction, hemorrage, DVT, urine or faecal leak Mortality-1% Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Adjuvant chemotherapy Radical cystectomy Ileal conduit Neobladder Continent urinary diversions ureterosigmoidostomy Adjuvant chemotherapy Sig survival advantage for tumour outside bladder and minor nodal involvement. Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Metastatic TCC 4 drug regimen MVAC used improves median survival from 8 months to 12 months. 6% mortality rate from toxicity Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

TCC of renal pelvis and ureter 10% or renal tumours, 5% of TCC Same risk factors as bladder TCC 30%-75% also have bladder TCC at some stage Ureteral tumours more common at lower end Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

TCC upper tract-symptoms & signs Haematuria, pain, metastatic disease, incidental Diagnosis IVP C/E RGP cytology and brushings CT U/S Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Most tumours are low stage, low grade Treatment Nephroureterectomy Staging Similar to bladder Most tumours are low stage, low grade Treatment Nephroureterectomy 91% 5 years survival-superficial 43% 5 year survival -muscle invasive 0-23% advanced disease Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Treatment Conservative excision Only low grade +stage and renal disease Endoscopic Treatment Ureteroscope with laser or fulgration Again only for low grade+stage/ renal disease. Major medical illness Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Carcinoma in-situ No symptoms to frequency and dysuria C/E normal or velvety erythema High grade, 25% of HG TCC will have it Often detected on urine cytology >20% risk of developing invasive TCC or already harbouring it. Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract

Carcinoma in-situ Best treatment is intravesical BCG Can also give other cytotoxic eg. Mitomycin Water Works By The Waves Transitional Cell Carcinoma of the Urinary Tract