Editing Muscle-invasive Bladder Cancer (2017) (section)

== Diagnosis and Evaluation ==

* '''UrologySchool.com Summary'''
** H+P, TURBT pathology, EUA, CT abdo/pelvis, chest imaging, CBC, LFTs, Cr

* '''History and physical exam'''
* '''Clinical Staging'''
** '''TURBT pathology'''
*** '''An experienced genitourinary pathologist should review the pathology of a patient when variant histology''' (e.g., micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, extensive squamous or glandular differentiation) '''is suspected OR if muscle invasion is equivocal'''
**** Pathologic re-review of cystectomy specimens by experienced genitourinary pathologists may identify variants that alter treatment in up to 33% of patients
** '''Examination under anesthesia at time of TURBT for a suspected invasive cancer'''
*** An exam under anesthesia (EUA) provides valuable information for the clinical staging and resectability of the primary tumor at surgery. This information contributes to the overall determination of clinical stage and assessment of potential benefit of neoadjuvant chemotherapy (NAC). Presence of a large/3-dimensional, residual mass after TURBT (cT3b), invasion of adjacent structures (cT4a), or fixation (cT4b) imply locally advanced clinical stage.
** '''Imaging'''
*** Attempts to determine:
***# Feasibility and safety of removing of the bladder
***# Presence of pelvic or retroperitoneal lymph node metastases
***# Presence of hydronephrosis
***# Presence of upper tract disease
***# Local extent of the disease
***# Visceral/distant metastatic sites
*** '''Primary'''
**** '''Cross-sectional imaging of the abdomen/pelvis with IV contrast''' (if not contraindicated)
*** '''Metastasis:'''
**** '''Chest'''
***** Prior smokers may benefit from a chest CT while non-smokers should have a minimum of a chest x-ray (with posterior-anterior and lateral images). Non-smokers also may benefit from CT imaging to evaluate for metastatic cancer.
**** Bone scan
***** In the absence of an elevated alkaline phosphatase, a bone scan need not be performed, but should be performed in patients with bone pain symptoms.
**** PET imaging
***** Should be reserved for patients with abnormal chest, abdominal, or pelvic imaging that require further evaluation, or if biopsy of a suspicious lymph node is not feasible.
** '''Laboratory: CBC, LFTs, alkaline phosphatase, and renal function'''
*** A CBC provides information regarding anemia and possible occult infection
*** The choice of urinary diversion in patients undergoing cystectomy is greatly influenced by metabolic abnormalities, such as acidosis or renal or hepatic insufficiency, and abnormal laboratory values may impact the ability to administer chemotherapy.