Clinical presentation, diagnosis, and staging of bladder cancer
- Yair Lotan, MD
Yair Lotan, MD
- Department of Urology
- UT Southwestern Medical Center at Dallas
- Toni K Choueiri, MD
Toni K Choueiri, MD
- Director, The Lank Center for Genitourinary Oncology
- Dana-Farber Cancer Institute and Brigham and Women's Hospital
- Associate Professor of Medicine
- Harvard Medical School
Bladder cancer is the most common malignancy involving the urinary system. Urothelial (transitional cell) carcinoma is the predominant histologic type in the United States and Europe, where it accounts for 90 percent of all bladder cancers. In other areas of the world, non-urothelial carcinomas are more frequent. Much less commonly, urothelial cancers can arise in the renal pelvis, ureter, or urethra. (See "Epidemiology and risk factors of urothelial (transitional cell) carcinoma of the bladder", section on 'Epidemiology'.)
The spectrum of bladder cancer includes non-muscle-invasive (superficial), muscle-invasive, and metastatic disease, each with its own clinical behavior, biology, prognosis, and treatment.
The clinical presentation, diagnosis, and staging of bladder cancer will be presented here.
The management of patients with bladder cancer, including specific recommendations based upon the stage of disease, is discussed separately:
●Overview of bladder cancer treatment (see "Overview of the initial approach and management of urothelial bladder cancer")
- Wallace DM, Raghavan D, Kelly KA, et al. Neo-adjuvant (pre-emptive) cisplatin therapy in invasive transitional cell carcinoma of the bladder. Br J Urol 1991; 67:608.
- Mitra AP, Skinner EC, Schuckman AK, et al. Effect of gender on outcomes following radical cystectomy for urothelial carcinoma of the bladder: a critical analysis of 1,994 patients. Urol Oncol 2014; 32:52.e1.
- MARSHALL VF. Current clinical problems regarding bladder tumors. Cancer 1956; 9:543.
- Khadra MH, Pickard RS, Charlton M, et al. A prospective analysis of 1,930 patients with hematuria to evaluate current diagnostic practice. J Urol 2000; 163:524.
- Grossman HB, Messing E, Soloway M, et al. Detection of bladder cancer using a point-of-care proteomic assay. JAMA 2005; 293:810.
- Mariani AJ, Mariani MC, Macchioni C, et al. The significance of adult hematuria: 1,000 hematuria evaluations including a risk-benefit and cost-effectiveness analysis. J Urol 1989; 141:350.
- Grossfeld GD, Litwin MS, Wolf JS, et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy--part I: definition, detection, prevalence, and etiology. Urology 2001; 57:599.
- Messing EM, Young TB, Hunt VB, et al. Home screening for hematuria: results of a multiclinic study. J Urol 1992; 148:289.
- Mohr DN, Offord KP, Owen RA, Melton LJ 3rd. Asymptomatic microhematuria and urologic disease. A population-based study. JAMA 1986; 256:224.
- Satoh E, Miyao N, Tachiki H, Fujisawa Y. Prediction of muscle invasion of bladder cancer by cystoscopy. Eur Urol 2002; 41:178.
- Krieg RC, Messmann H, Rauch J, et al. Metabolic characterization of tumor cell-specific protoporphyrin IX accumulation after exposure to 5-aminolevulinic acid in human colonic cells. Photochem Photobiol 2002; 76:518.
- Lotan Y, Roehrborn CG. Sensitivity and specificity of commonly available bladder tumor markers versus cytology: results of a comprehensive literature review and meta-analyses. Urology 2003; 61:109.
- Grégoire M, Fradet Y, Meyer F, et al. Diagnostic accuracy of urinary cytology, and deoxyribonucleic acid flow cytometry and cytology on bladder washings during followup for bladder tumors. J Urol 1997; 157:1660.
- Chou R, Gore JL, Buckley D, et al. Urinary Biomarkers for Diagnosis of Bladder Cancer: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:922.
- Xylinas E, Kluth LA, Rieken M, et al. Urine markers for detection and surveillance of bladder cancer. Urol Oncol 2014; 32:222.
- Schlomer BJ, Ho R, Sagalowsky A, et al. Prospective validation of the clinical usefulness of reflex fluorescence in situ hybridization assay in patients with atypical cytology for the detection of urothelial carcinoma of the bladder. J Urol 2010; 183:62.
- Lotan Y, Bensalah K, Ruddell T, et al. Prospective evaluation of the clinical usefulness of reflex fluorescence in situ hybridization assay in patients with atypical cytology for the detection of urothelial carcinoma of the bladder. J Urol 2008; 179:2164.
- Kamat AM, Dickstein RJ, Messetti F, et al. Use of fluorescence in situ hybridization to predict response to bacillus Calmette-Guérin therapy for bladder cancer: results of a prospective trial. J Urol 2012; 187:862.
- Seideman C, Canter D, Kim P, et al. Multicenter evaluation of the role of UroVysion FISH assay in surveillance of patients with bladder cancer: does FISH positivity anticipate recurrence? World J Urol 2015; 33:1309.
- Chang SS, Bochner BH, Chou R, et al. Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline. J Urol 2017; 198:552.
- Badalament RA, Ryan PR, Bahn DK. Imaging for transitional cell carcinomas. In: Comprehensive Textbook of Genitourinary Oncology, Vogelzang NJ, Scardino PT, Shipley WU, Coffey DS (Eds), Williams and Wilkins, Baltimore 2000. p.357.
- Herr HW. Routine CT scan in cystectomy patients: does it change management? Urology 1996; 47:324.
- JEWETT HJ, STRONG GH. Infiltrating carcinoma of the bladder; relation of depth of penetration of the bladder wall to incidence of local extension and metastases. J Urol 1946; 55:366.
- Donat MD, Herr HW. Transitional cell carcinoma of the renal pelvis and ureter: diagnosis, staging, management, and prognosis. In: Urologic Oncology, Osterling JE, Richie JP (Eds), WB Saunders Harcourt Brace & Co, Philadelphia 1997. p.215.
- Mitra AP, Skinner EC, Miranda G, Daneshmand S. A precystectomy decision model to predict pathological upstaging and oncological outcomes in clinical stage T2 bladder cancer. BJU Int 2013; 111:240.
- Tekes A, Kamel I, Imam K, et al. Dynamic MRI of bladder cancer: evaluation of staging accuracy. AJR Am J Roentgenol 2005; 184:121.
- Kim B, Semelka RC, Ascher SM, et al. Bladder tumor staging: comparison of contrast-enhanced CT, T1- and T2-weighted MR imaging, dynamic gadolinium-enhanced imaging, and late gadolinium-enhanced imaging. Radiology 1994; 193:239.
- Tachibana M, Baba S, Deguchi N, et al. Efficacy of gadolinium-diethylenetriaminepentaacetic acid-enhanced magnetic resonance imaging for differentiation between superficial and muscle-invasive tumor of the bladder: a comparative study with computerized tomography and transurethral ultrasonography. J Urol 1991; 145:1169.
- Tanimoto A, Yuasa Y, Imai Y, et al. Bladder tumor staging: comparison of conventional and gadolinium-enhanced dynamic MR imaging and CT. Radiology 1992; 185:741.
- Datta SN, Allen GM, Evans R, et al. Urinary tract ultrasonography in the evaluation of haematuria--a report of over 1,000 cases. Ann R Coll Surg Engl 2002; 84:203.
- Jana S, Blaufox MD. Nuclear medicine studies of the prostate, testes, and bladder. Semin Nucl Med 2006; 36:51.
- Drieskens O, Oyen R, Van Poppel H, et al. FDG-PET for preoperative staging of bladder cancer. Eur J Nucl Med Mol Imaging 2005; 32:1412.
- Apolo AB, Riches J, Schöder H, et al. Clinical value of fluorine-18 2-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography in bladder cancer. J Clin Oncol 2010; 28:3973.
- Shariat SF, Palapattu GS, Karakiewicz PI, et al. Discrepancy between clinical and pathologic stage: impact on prognosis after radical cystectomy. Eur Urol 2007; 51:137.
- Shariat SF, Karakiewicz PI, Palapattu GS, et al. Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the Bladder Cancer Research Consortium. J Urol 2006; 176:2414.
- Stein JP, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol 2001; 19:666.
- Bochner BH, Hansel DE, Efstathiou JA, et al. Urinary Bladder. In: AJCC Cancer Staging Manual, 8th, Amin MB (Ed), Springer, New York 2017. p.757.
- Herr HW, Donat SM. Prostatic tumor relapse in patients with superficial bladder tumors: 15-year outcome. J Urol 1999; 161:1854.
- Culp SH, Dickstein RJ, Grossman HB, et al. Refining patient selection for neoadjuvant chemotherapy before radical cystectomy. J Urol 2014; 191:40.
- CLINICAL PRESENTATION
- Voiding symptoms
- Constitutional symptoms
- PHYSICAL EXAMINATION
- INITIAL EVALUATION
- - Procedure
- - Fluorescence cystoscopy
- Urine cytology
- Urine-based markers
- Urinary tract imaging
- - CT scan
- - Intravenous pyelogram
- - MRI
- - Ultrasound
- Imaging for metastatic disease
- - Lung lesions
- - Bone scan
- - PET
- HISTOLOGIC GRADE
- Clinical staging
- Pathologic staging
- - Tumor (T) stage
- - Nodal (N) disease
- - Metastatic (M) disease
- INFORMATION FOR PATIENTS