Bladder Cancer Staging

Stage Information for Low-Grade Bladder Cancer

The clinical staging of carcinoma of the bladder is determined by the depth of invasion of the bladder wall by the tumor. This determination requires a cytoscopic examination that includes a biopsy and examination under anesthesia to assess the following:

• Size and mobility of palpable masses.
• Degree of induration of the bladder wall.
• Presence of extravesical extension or invasion of adjacent organs.

Clinical staging, even when computed tomography (CT) and/or magnetic resonance imaging (MRI) scans and other imaging modalities are used, often underestimates the extent of the tumor, particularly in cancers that are less differentiated and more deeply invasive. CT imaging is the standard staging modality. A clinical benefit from obtaining MRI or positron emission tomography scans rather than CT imaging has not been demonstrated.

Stage 0 Bladder Cancer

Patients with stage 0 bladder cancer can be cured by a variety of treatments, even though the tendency for new tumor formation is high. In a series of patients with Ta or T1 tumors who were followed for a minimum of 20 years or until death, the risk of bladder cancer recurrence after initial resection was 80%. Of greater concern than recurrence is the risk of progression to muscle-invasive, locally-advanced, or metastatic bladder cancer. While progression is rare for patients with low-grade tumors, it is common among patients with high-grade cancer. One series of 125 patients with TaG3 cancers followed for 15 to 20 years reported that 39% progressed to more advanced-stage disease while 26% died of urothelial cancer. In comparison, among 23 patients with TaG1 tumors, none died and only 5% progressed.

Risk factors for recurrence and progression are the following:

• High-grade disease.
• Presence of carcinoma in situ.
• Tumor larger than 3cm.
• Multiple tumors.
• History of prior bladder cancer.

Standard treatment options for stage 0 tumors include the following:

• Transurethral resection (TUR) with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy.
• TUR with fulguration. TUR with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by periodic intravesical installations of bacillus Calmette-Guerin (BCG).
• TUR with fulguration followed by and immediate postoperative instillation of intravesical chemotherapy followed by intravesical chemotherapy.
• Segmental cystectomy (rarely indicated).
• Radial cystectomy (in rare, highly selected patients with extensive or refractory superficial high-grade tumors).

Transurethral resection (TUR) with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy TUR and fulguration are the most common and conservative forms of management. Careful surveillance of subsequent bladder tumor progression is important. Because most bladder cancers recur after TUR, one immediate intravesical instillation of chemotherapy after TUR is often administered. Numerous randomized controlled trials have evaluated this practice, and a meta-analysis of seven trials reported that a single intravesical treatment with chemotherapy reduced the odds of recurrence by 39% (odds ratio, [OR] 0.61; P < .0001). However, although a single instillation of chemotherapy lowers the relapse rate in patients with multiple tumors, the majority still relapse. Such treatment is thus not sufficient by itself for these patients. One retrospective series addressed the value of performing a second TUR within 2 to 6 weeks of the first TUR [9]. A second TUR performed on 38 patients with Tis or Ta disease revealed that nine patients (24%) had lamina propria invasion (T1) and three patients (8%) had muscle invasion (T2). Such information may change the definitive management options in these individuals. Patients with extensive multifocal recurrent disease and/or other unfavorable prognosis feature require more aggressive forms of treatment.

Stage I Bladder Cancer

Patients with stage I bladder tumors are unlikely to die from bladder cancer, but the tendency for new tumor formation is high. In a series of patients with Ta or T1 tumors who were followed for a minimum of 20 years or until death, the risk of bladder cancer recurrence after initial resection was 80%. Of greater concern than recurrence is the risk of progression to muscle-invasive, locally-advanced, or metastatic bladder cancer. While progression is rare for patients with low-grade tumors, it is common among patients with high-grade cancer. One series of 125 patients with TaG3 cancers followed for 15 to 20 years reported that 39% progressed to more advanced-stage disease while 26% died of urothelial cancer. In comparison, among 23 patients with TaG1 tumors, none died and only 5% progressed.

Risk factors for recurrence and progression include the following:

• High-grade disease.
• Presence of carcinoma in situ.
• Tumor larger than 3cm.
• Multiple tumors.
• History of prior bladder cancer.

Standard treatment options for Stage I bladder cancer are the same as stage 0.

Source:

https://www.cancer.gov/types/bladder/hp/bladder-treatment-pdq#section/all