We will first discuss the treatment for Localised bladder cancer. In this technique, a hollow tube called a cystoscope which is fitted with a camera is inserted into the urethra and is slowly advanced into the bladder. It helps to confirm the presence of a bladder tumor and see its location, number, and extent. Also, it helps in transurethral resection of bladder tumor which is both diagnostic and therapeutic.
As you can see in this figure, only cancer containing superficial layers are removed, without damaging the deeper layers. After TURBT, the histopathology reports tells us whether the tumor is non-muscle invasive or muscle invasive, i.e., whether it has infiltrated the muscle or not. We will first discuss the treatment for non-muscle invasive bladder tumors. This is carcinoma in situ which is a flat tumor, limited to the epithelium. Intravesical chemotherapy should be given in all cases of This disease. As you can see in the figure, in this procedure the chemotherapy drug is directly instilled into the bladder, with the help of a catheter. And Ta is the papillary tumor which is limited to the epithelium.
For Ta disease also, intravesical chemotherapy may be given. But in some cases, intravesical chemotherapy may not be required, when we can keep the patient under observation. When the tumor infiltrates into the lamina propria, it is called as T1. For T1 disease, the treatment depends on whether the tumor is low grade or high grade. Intravesical chemotherapy is the treatment of choice for low-grade tumors. Whereas, for high-grade tumors, the preferred modality of treatment is cystectomy or surgical resection of the bladder. When it infiltrates into the inner muscle layer, it is called as T2a. And T2b, when it infiltrates the outer muscle layer.
For a T2 disease with nodes negative, the preferred modality of treatment is chemotherapy followed by cystectomy. Usually, the cystectomy is radical cystectomy in which the whole bladder is removed. But in highly selected cases we can do partial cystectomy also. But for non-cystectomy candidates in which we are not planning for surgery, a combination of chemotherapy and radiation therapy may be used. But the final decision whether to do surgery or not, or to do total or partial cystectomy will be taken by the oncologist, on an individual patient basis, depending upon the exact stage of the disease, number, and location of bladder tumors, and co-morbidities and performance status of the patient. With this we come to the end of the treatment of localised bladder tumors, now let’s come to the treatment of locally advanced bladder tumors. Till T2, the tumor is limited to the bladder wall.
But when the tumor infiltrates through the bladder wall to involve the perivesical tissue, it is called T3. And in T4 disease, the tumor infiltrates through the bladder wall to involve the adjacent structures. It may extend downwards to infiltrate prostate gland in males, as you can see in this figure. Whereas in females, it may extend posteriorly to involve the uterus or vagina. For T3 disease, and selected patients of T4 disease, as discussed above, with nodes negative, the preferred modality of treatment is cystectomy, with chemotherapy, which may be given before or after surgery. But for non-cystectomy candidates, in which we are not planning surgery, a combination of chemotherapy and radiotherapy may be used. The tumor may also extend anterolaterally, to involve or abdominal wall.
This figure shows the pelvic and iliac group of lymph nodes, which are the regional nodes for a bladder. Depending upon the number and location of the nodes involved, it can be N1, N2 or N3. In selected patients of T4 disease, with abdominal or pelvic wall extension, and any patient with the node-positive disease, the preferred modality of treatment is chemotherapy, with or without radiation therapy. And further therapy maybe decided to depend upon the response to initial treatment.
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