Hematuria is the initial sign in 80-90%; however, cystitis is a more common cause of hematuria (22% of all hematuria) than is bladder cancer (15%). Pts are initially staged and treated by endoscopy. Superficial tumors are removed at endoscopy; muscle invasion requires more extensive surgery.
Treatment: Bladder Cancer Management is based on extent of disease: superficial, invasive, or metastatic. Frequency of presentation is 75% superficial, 20% invasive, and 5% metastatic. Superficial lesions are resected at endoscopy. Although complete resection is possible in 80%, 30-80% of cases recur; grade and stage progression occur in 30%. Intravesical instillation of bacille Calmette-Guérin (BCG) reduces the risk of recurrence by 40-45%. Recurrence is monitored every 3 months. The standard management of muscle-invasive disease is radical cystectomy. 5-year survival is 70% for those without invasion of perivesicular fat or lymph nodes, 50% for those with invasion of fat but not lymph nodes, 35% for those with one node involved, and 10% for those with six or more involved nodes. Pts who cannot withstand radical surgery may have 30-35% 5-year survival with 5000- to 7000-cGy external beam radiation therapy. Bladder sparing may be possible in up to 45% of pts with two cycles of chemotherapy with CMV (methotrexate, 30 mg/m2 days 1 and 8, vinblastine, 4 mg/m2 days 1 and 8, cisplatin, 100 mg/m2 day 2, q21d) followed by 4000-cGy radiation therapy given concurrently with cisplatin. Metastatic disease is treated with combination chemotherapy. Useful regimens include CMV (see above), M-VAC (methotrexate, 30 mg/m2 days 1, 15, 22; vinblastine, 3 mg/m2 days 2, 15, 22; doxorubicin, 30 mg/m2 day 2; cisplatin, 70 mg/m2 day 2; q28d) or cisplatin (70 mg/m2 day 2) plus gemcitabine (1000 mg/m2 days 1, 8, 15 of a 28-day cycle) or carboplatin plus paclitaxel. About 70% of pts respond to treatment, and 20% have a complete response; 10-15% have long-term disease-free survival. |
Section 6. Hematology and Oncology