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% of urothelial ca |
Survival |
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Urothelial carcinoma variants
80% will have some mixed differentiation; most commonly squamous cell
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Micropapillary
- Aggressive - LVI common even in non-muscle invasive (but only 9% have noninvasive disease at presentation)
- Resembles papillary serous carcinoma of ovary
- When matched stage for stage similar outcomes, but overall poor inter-observer diagnosis correlation, poor correlation between presence on TURBT vs subsequent cystectomy.
- Neoadjuvant chemotherapy may or may not be effective (may vary based on % of micropapillary, split opinions on whether or not it works).
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0.7%-2.2% of urothelial ca |
51% 5 year cancer-specific (24% at 10 years) |
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Nested variant
- Rare but aggressive
- Can be confused with benign lesions eg von Brunn nests, cystitis cystica, inverted papilloma
- Radical cystectomy - limited efficacy of neoadjuvant chemo
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70% die of disease within 3 years |
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Clear cell variant
- 70% of urothelial cancer will have some clear cell; however similar prognosis
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Glandular/adenocarcinoma differentiation
- Presence of two glandular spaces in the tumor - can produce mucin
- A/w bladder exstrophy (can arise from urachus)
- Exclude GI primary
- Urachal adenocarcinoma - could do partial or radical cystectomy
- Radical cystectomy; neoadjuvant chemo not recommended
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6% of urothelial ca, but more common in squamous |
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Plasmacytoid
- Diagnosed at advanced stage (often already invading into perivesical fat) because hematuria is delayed due to sessile growth pattern
- Respond poorly to chemotherapy
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1-3% |
Survival < 27 months from diagnosis |
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Prostatic urethral cancer
- Risk factors - CIS of bladder neck, hx intravesical chemotherapy
- Secondary prostatic urethral involvement in patients with urothelial ca is 15% at 5 years, 30% at 15 years, a/w extensive intravesical therapy
- Should TURBT prostatic urethra if + urine cytology but negative bladder biopsy, or recurrent ca after multiple courses of intravesical chemotherapy
- Treat with TURP and BCG
- Prostatic stromal disease (T4) occurs in 7.5-25% of patients with prostatic urethral cancer
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3%
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| Non-urothelial carcinoma |
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Sarcoma
- Leiomyosarcoma > rhabdomyosarcoma (eg botryoides tumors in children) > angio, osteo, carcino
- Not smoking related
- Majority are high grade
- Treat with cystectomy; chemo is lacking but doxorubicin, ifosfamide, and cisplatin are most effective
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< 1% |
52-62% disease free survival |
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Signet ring
- Generally high grade, high stage at presentation (majority have metastases)
- Can be of urachal origin
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< 1% |
Mean survival time < 20 months |
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Small cell (neuroendocrine)
- Should be treated as metastatic even if no radiologic evidence.
- Very chemosensitive - carboplatin/cisplatin + etoposide
- Common to have complete response but > 80% relapse
- Chromogranin A staining
- Chemoradiation primary treatment; adjunctive radical cystectomy shows equal/perhaps better disease free survival, but similar cancer specific survival
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<< 1% of bladder tumors |
16-18% |
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Squamous
- A/w schistosoma haematobium: chronic infection/inflammation → conversion from urothelial to squamous cell, which has higher proliferation rate and thus more likely to form cancer
- Schistosoma infection also increases ability of bacteria to converts nitrates to nitrites→ nitrosamines which are carcinogenic
- Of patients with schistosoma and bladder cancer, 60-90% is SCC
- Historically higher SCC rate in SCI population (irritation from catheter) - 2.5-10% incidence - but more recently 0.38% (likely due to better catheter care)
- Unclear role for chemo - treat with radical cystectomy
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5% |
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