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PATIENT STORY

A 68-year-old man, who is a retired painter and in good health, comes to the office at the insistence of his wife. He reports that his urinary stream has become slow, and he has occasional dysuria. He has no major medical problems, although he continues to smoke one pack of cigarettes per day. His urinalysis in the office shows microscopic hematuria. An irregular mass is seen in the bladder on CT scan (Figure 74-1). Cystoscopy shows a bladder tumor (Figure 74-2). Complete endoscopic resection is performed and confirms transitional cell carcinoma.

FIGURE 74-1

CT with contrast reveals a bladder cancer in a 68-year-old man with hematuria. (Reproduced with permission from Michael Freckleton, MD.)

FIGURE 74-2

Cystoscopic view of the transitional cell carcinoma in the man in Figure 74-1. (Reproduced with permission from Carlos Enrique Bermejo, MD.)

INTRODUCTION

Bladder cancer is a malignant neoplasm of the bladder, almost exclusively urothelial (transitional cell) carcinoma.

EPIDEMIOLOGY

  • In 2013, there were approximately 438,068 men and 149,358 women alive in the United States who had a history of cancer of the urinary bladder.1

  • An estimated 76,960 new cases (58,950 men and 18,010 women) were diagnosed and approximately 16,390 deaths occurred from bladder cancer in 2016.1 Mean age at diagnosis is 73 years.

  • The age-adjusted incidence rate (based on 2009 to 2013 data) was 20.1 per 100,000 men and women per year with a male-to-female ratio of approximately 4:1. For both men and women, bladder cancer is most prevalent in white non-Hispanics, followed by blacks, Hispanics, Asian/Pacific Islanders, and American Indian/Alaska Natives.1

ETIOLOGY AND PATHOPHYSIOLOGY

  • More than 95% are transitional cell cancers, and the remainder are nonurothelial neoplasms, including primarily squamous cell, adenocarcinoma, and small cell carcinoma2,3 (Figures 74-1, 74-2, 74-3, 74-4). Rare forms include nonepithelial neoplasms (approximately 1%), including benign tumors, such as hemangiomas or lipomas, and malignant tumors, such as angiosarcomas.3

  • Transitional cells line almost all of the urinary tract, including the renal pelvis, the ureters and the bladder, and the proximal two thirds of the urethra. Ninety percent of transitional cell tumors develop in the bladder, 8% in the renal pelvis, and 2% in the ureters or urethra.2

  • At presentation, 75% of tumors are non–muscle invasive, 20% are muscle invasive, and 5% are metastatic.2

  • The most common transitional cell tumor is a low-grade papillary lesion on a central stalk that is friable, tends to bleed, and has a high risk of recurrence but rarely progresses to become muscle invasive. Carcinoma in situ, however, is a high-grade ...

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