0521779407-B01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:52
Bladder Tumors 241
Nephrogenic adenoma: metaplastic response to trauma,
resembles primitive collecting tubules, often have irritative
symptoms
Inverted papilloma: benign lesion associated with TC Ca
➣Carcinoma in situ (CIS) – Flat, high-grade, noninvasive lesion;
usually velvety patch of erythematous urothelium; often irrita-
tive symptoms; urine cytology positive in 95%; often recurrent
and progressive; BCG intravesical immunotherapy after TURBT
is standard first-line local therapymanagement
What to Do First
■Perform accurate tissue diagnosis and staging.
General Measures
■Assess general health and comorbidities of patient (i.e., performance
status concerning cardiac, pulmonary, liver, GI, renal function, etc.).specific therapy
Refer to urologist to manage
■CIS: TURBT + bacillus Calmette-Guerin (BCG) intravesical
immunotherapy (BCG or other)+/−interferon; for diffuse recur-
rence, consider radical cystectomy
■Noninvasive: TURBT, 50% recur, 5% progress to muscle invasion
■Invasion into lamina propria: >70% recur after TURBT, >40% may
progress to muscle invasion, TURBT+/−intravesical BCG or
chemotherapy
■Invasion into muscle and local pelvic structures: TURBT for diagno-
sis, then radical cystectomy+pelvic lymphadenectomy
■Invasion into pelvic or abdominal wall, lymph nodes, or metastasis:
chemotherapy (Cisplatinum combination – gemcitabine+cisplatin
best tolerated vs. MVAC), possible adjuvant surgery or XRT
follow-up
■Cystoscopy protocol at lengthening intervals q 3–4 to q 6–12 months
for localized, low-grade and -stage disease, often followed 5–15 years
for recurrence
■1- to 2-yearly intervals for upper tract imaging (U/S, IVP, CT) for local
disease
■Higher-stage cancer, S/P cystectomy: Needs lifelong surveillance for
progression, recurrent UTI, upper tract cancer, urethral recurrence