What is the appropriate diagnosis and treatment for a bladder mass?

Management of a Bladder Mass

Perform cystoscopy with transurethral resection of the bladder tumor (TURBT) immediately—this is both diagnostic and therapeutic, and must include separate submission of tumor base and edges to pathology to ensure adequate staging. 1

Initial Diagnostic Workup

When a bladder mass is identified on imaging, the following steps are mandatory:

• Cystoscopic evaluation with TURBT and bimanual examination under anesthesia is the definitive diagnostic procedure—bladder ultrasonography or CT can identify an intraluminal mass, but final diagnosis requires cystoscopy and histological evaluation 1

• Obtain CT abdomen/pelvis BEFORE TURBT if the cystoscopic appearance shows a solid (sessile), high-grade tumor, or suggests muscle invasion 2

• Skip pre-TURBT imaging for purely papillary tumors or suspected carcinoma in situ (CIS) 2

• Essential baseline studies include: complete blood count, creatinine, liver function tests, urine cytology, and upper tract imaging (CT urography or MRI urography) to exclude synchronous upper tract urothelial carcinoma, which occurs in 2.5% of patients 1, 2

• The resected specimen MUST contain lamina propria and detrusor muscle for accurate staging—absence of muscle leads to 49% understaging risk 1, 2

• Send tumor base and edges separately to pathology to ensure proper evaluation 2

Additional Biopsies During TURBT

• Take bladder biopsies from suspicious reddish areas or random biopsies from normal-appearing mucosa if urine cytology is positive or there is a history of high-grade non-muscle-invasive bladder cancer (NMIBC) 1

• Biopsy the prostatic urethra if the tumor is located at the trigone or bladder neck, or when evaluating positive cytology without visible bladder tumor 1

Risk-Stratified Management Based on Pathology

Non-Muscle-Invasive Disease (Ta, T1, Tis)

Low-Grade Ta Tumors (Low Risk)

• Administer single immediate intravesical chemotherapy (typically mitomycin C) within 24 hours of complete resection—this reduces recurrence risk by 11% and relative risk by 40% 1, 3, 2

• Avoid immediate intravesical treatment if TURBT was extensive or bladder perforation is suspected 2

• Follow-up schedule: cystoscopy at 3 months initially, then at increasing intervals 3, 2

High-Grade Ta Tumors (High Risk)

• Perform repeat TURBT within 2-6 weeks if the initial specimen contains no muscle—49% of patients without muscularis propria will be understaged 2

• Treat with intravesical BCG (preferred over chemotherapy) after TUR—BCG is superior based on 4 meta-analyses showing better prevention of recurrences 1, 2

• Alternative: intravesical mitomycin C if BCG is contraindicated 2

• Follow-up protocol: cystoscopy and urinary cytology at 3-6 month intervals for first 2 years, then at increasing intervals 2

• Upper tract imaging every 1-2 years for high-grade tumors 2

T1 Tumors (Subepithelial Invasion)

• Repeat TURBT within 2-6 weeks is mandatory for high-risk disease, especially if complete resection is uncertain, no muscle in specimen, lymphovascular invasion present, or inadequate staging suspected 2

• Treat with intravesical BCG after complete resection 1

• Consider early radical cystectomy for particularly high-risk T1 disease (multifocal lesions, vascular invasion, or recurrence after BCG) rather than repeat TURBT due to high progression risk 1, 2

• If no response to BCG, proceed to cystectomy due to high risk of progression 1

Carcinoma In Situ (Tis)

• Treat with complete endoscopic resection followed by intravesical BCG (6-week induction course) 2

• Reevaluate at 12 weeks (3 months) after start of therapy 2

• For persistent/recurrent disease at 12 weeks, give second course of BCG or mitomycin (maximum 2 consecutive induction courses) 2

• If residual disease persists after second BCG course, strongly consider radical cystectomy 2

Muscle-Invasive Disease (T2-T4a)

Standard Treatment Approach

• Radical cystectomy is the gold standard for muscle-invasive bladder cancer 1

• Administer cisplatin-based neoadjuvant chemotherapy before cystectomy for T2-T4a tumors—two large randomized trials and meta-analysis demonstrate 5% survival benefit at 5 years 1

• Surgical procedure: cystoprostatectomy in men or cystectomy with hysterectomy in women, including extended pelvic lymph node dissection 2

Alternative for Selected Patients

• Bladder-preserving approaches (complete TUR with radiotherapy ± concurrent chemotherapy) are reasonable alternatives for patients medically unfit for surgery or those seeking alternatives 1

• Ideal candidates for bladder preservation: initial T2 tumor <5 cm, no CIS, pT0 after second TURBT, no hydronephrosis, good performance status, proper bladder capacity and function 1

• External beam radiotherapy alone should only be considered when the patient is unfit for cystectomy or multimodality bladder-preserving approach 1

Post-Cystectomy Management

• Consider adjuvant chemotherapy in patients with high risk of relapse (pathologic T3-T4 or node-positive disease)—minimum 3 cycles of cisplatin-based combination 1, 2

• Surveillance schedule: every 3-6 months for 2 years with urine cytology, liver function tests, creatinine, electrolytes, chest radiograph, and abdominal/pelvic imaging 2

Locally Advanced or Unresectable Disease (T4b, Node-Positive)

• For unresectable disease (fixed bladder mass or positive nodes), consider chemotherapy alone or chemotherapy with radiotherapy 1

• If pelvic lymph nodes >2 cm on imaging, obtain biopsy to confirm nodal spread before treatment planning 1

• Treatment options for good performance status patients: chemotherapy ± radiotherapy; if complete response achieved, consider observation, radiotherapy boost, or cystectomy/lymphadenectomy 1

Common Pitfalls to Avoid

• Never accept a TURBT specimen without muscle—this leads to understaging in nearly half of cases and necessitates repeat resection 2

• Do not delay repeat TURBT in high-risk disease—perform within 2-6 weeks to ensure complete resection and accurate staging 2

• Avoid treating high-grade T1 or CIS with chemotherapy alone—BCG is superior and should be first-line 1, 2

• Do not perform immediate intravesical chemotherapy if extensive TURBT or perforation occurred—risk of systemic absorption and complications 2

• Never skip upper tract imaging in high-risk NMIBC—2.5% have synchronous upper tract disease 1, 2