Pathology & Selection of Treatment
Ninety-eight percent of primary bladder cancers are epithelial malignancies, with the majority being transitional cell carcinomas (90%). These latter cancers most often appear as papillary growths, but higher-grade lesions are often sessile and ulcerated. Grading is based on histologic architecture: size, pleomorphism, mitotic rate, and hyperchromatism. The frequency of recurrence and progression is strongly correlated with grade. Whereas progression may be noted in few grade I cancers (19–37%), it is common with poorly differentiated lesions (33–67%). Carcinoma in situ is recognizable as a flat, nonpapillary, anaplastic epithelium and may occur focally or diffusely, but it is most often found in association with papillary bladder cancers. Its presence identifies a patient at increased risk of recurrence and progression.
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Adenocarcinomas and squamous cell cancers account for approximately 2% and 7% (respectively) of all bladder cancers detected in the USA. The latter is often associated with schistosomiasis, vesical calculi, or chronic catheter use.
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Bladder cancer staging is based on the extent of bladder wall penetration and the presence of either regional or distant metastases. The TNM classification of the American Joint Cancer Committee for bladder cancer is shown in Table 23–11.