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INTRODUCTION

Epidemiology

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Epidemiology
Incidence: Estimated new cases in 2020 in the United States: 81,400 (62,100 in men and 19,300 in women) Stage at presentation
Deaths: Estimated in 2020: 17,980 (13,050 in men and 4,930 in women) Stage I: 70%
Median age: 73 (seventh decade) Stages II/III: 25%
Male:female ratio: 3:1 Stage IV: 5%
www.cancer.org [accessed 2018]

Work-up

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Work-up
Stage I H&P, cystoscopy, transurethral resection of the bladder tumor (TURBT), examination under anesthesia (EUA), and cytology. In patients with high-grade and/or invasive tumors, radiologic assessment should be performed with high-resolution CT or magnetic resonance (MR) of the abdomen and pelvis prior to TURBT. The TURBT specimen should include muscle to accurately assess the depth of tumor invasion. A repeat TURBT is recommended in the case of T1 high-grade disease, even if muscle is present in the specimen, as T1 tumors can be understaged by TURBT, and a repeat TURBT has prognostic value in predicting response to intravesical therapy. TURBT is performed with an EUA. Consider upper tract imaging with either CT urogram, retrograde pyelogram, or MR urogram. This full investigation of the upper tracts is especially important in patients with positive cytology and normal cystoscopy.
Stages II/III

H&P, cystoscopy, TURBT, EUA, and cytology. In patients with high-grade and/or invasive tumors, radiologic assessment should be performed with high-resolution CT or MR of the abdomen and pelvis prior to TURBT. The TURBT specimen should include muscle to accurately assess the depth of tumor invasion. A repeat TURBT is recommended in the case of T1 high-grade disease, even if muscle is present in the specimen, as T1 tumors can be understaged by TURBT, and a repeat TURBT has prognostic value in predicting response to intravesical therapy. EUA is important in clinical staging as it can detect locally advanced bladder cancer by assessing for invasion into adjacent organs, extravesical extension, and abdominal or pelvic sidewall extension. A bladder fixed on EUA suggests that it may be surgically unresectable. Also consider a CT chest.

 A 99mTc bone scan is recommended for patients with elevated blood alkaline phosphatase or bone pain. NaF-PET/CT to assess bone disease is also under investigation in bladder cancer. Consider upper tract imaging with CT urogram, retrograde pyelogram, or MR urogram. This full investigation of the upper tracts is especially important in patients with positive cytology and normal cystoscopy.

Stage IV H&P, cystoscopy, TURBT, EUA, and cytology. High-resolution CT chest, abdomen, and pelvis with IV contrast or CT chest without contrast and MR of the abdomen and pelvis. Upper tract imaging with either CT urogram, retrograde pyelogram, or MR urogram. A 99mTc bone scan is recommended for patients with elevated blood alkaline phosphatase or bone pain. NaF-PET/CT to assess bone disease is also under investigation in bladder cancer. The value of FDG-PET/CT for initial staging is still under investigation, but it appears to be ...

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