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Muscle invasive bladder cancer

About 25 % of bladder cancer presents initially as muscle invasive

Majority of muscle invasive patients present de novo – about 20 % of muscle invasive bladder cancers are patients who have progressed from NMIBC

25 – 50 % will have micrometastatic disease (nodal or distant) at the time of cystectomy.

 

85 % will die within 2 years if left untreated.

Death after local treatment is usually due to distant or systemic disease – with majority of deaths occurring within 2 years.

Both nodal and haematogenous spread – pelvic nodal disease most common, but a third of metastatic cases (liver, lung, bone, adrenal) will not have obvious nodal disease first.

 

Staging

Clinical staging – bimanual EUA pre and post TURBT

Pathological staging – on TURBT or cystectomy

Radiological staging:

  • CT chest / abdo / pelvis is routine for metastatic and nodal staging
    • Widely available
    • Nodal sensitivity is limited (high false negatives)
    • Local T staging is limited – can’t differentiate muscle layers and may be compromised by artefact post-op
    • Allows assessment of upper tracts and hydronephrosis
  • MRI
    • Probably better local staging with more accurate differentiation between T1 and T2 and T3
    • Useful for T4 disease and questions of organ invasion and resectability
    • Equivalent for nodal assessment (i.e., still understages nodes)
    • VIRADs score can be given based on multiparametric appearances
    • Need experienced radiologist and centre
    • MRI abdomen can be used as alternative for follow up surveillance if CT contraindicated
  • Bone scan
    • Not routine – consider if raised ALP or other concerns on CT needing clarification
  • FDG PET
    • Local staging limited by radiourine
    • Not as accessible or available as usual CT
    • Emerging evidence FDG PET may be more sensitive than CT for nodal and metastatic disease – often useful for equivocal nodes

 

Management options for muscle invasive bladder cancer

  1. Radical cystectomy and PLND
    1. +/- neoadjuvant chemotherapy
  2. Trimodal therapy
    1. Maximal TURBT, chemotherapy and radiotherapy
  3. Partial cystectomy
  4. Radiation therapy alone (+ TURBT)
  5. Best endoscopic management

 

Recommend multidisciplinary approach and inform patients of all options.