Editing CUA: Muscle-invasive Bladder Cancer (2019) (section)

=== Clinical staging ===

* '''Based on (3):''' 
** '''TURBT pathology'''
** '''Exam under anesthesia'''
** '''Imaging'''

==== TURBT pathology ====
* '''MIBC should be diagnosed with a good quality TURBT including muscularis propria that confirms muscle invasion'''
** '''In those rare instances where''' evidence (radiographic or clinical (e.g. bimanual examination)) supports a clear-cut clinical diagnosis of MIBC and where '''(i) tumour size precludes safely performing a complete TURBT and/or (ii) complete TURBT is simply not feasible,''' '''tumour tissue should still be procured to establish a bladder cancer diagnosis and determine final histology'''
* '''Pathologic reporting of TURBT should include data on (5):'''
** '''T stage (depth of invasion)'''
** '''Histological type''' (i.e. urothelial, squamous cell, small cell carcinoma, etc), '''subtypes if there is mixed histology, and any divergent differentiation of urothelial carcinoma''' (e.g. urothelial carcinoma with squamous, glandular or sarcomatoid differentiation), '''including variant histology''' (i.e. micropapillary, plasmacytoid, nested variant, etc.) and an '''estimate of the proportion of variant histology'''
*** '''Pure non-urothelial histology (squamous, small cell)''' are more aggressive
*** '''Variant urothelial histology or extensive glandular/squamous differentiation is associated with more aggressive disease'''
**** '''Pathology review by a second pathologist, preferably a dedicated GU pathologist, is recommended for all cases of variant histology'''
** '''Grade'''
** '''Concomitant carcinoma-in-situ (CIS)'''
*** Concomitant CIS has been linked to higher rates of recurrence after RC and worse cancer-specific survival in patients with ≤pT2 disease at RC
*** '''CIS is associated with resistance to radiation'''
** '''Lymphovascular invasion (LVI)'''
*** LVI associated with more aggressive disease
*** Streeper NM, Simons CM, Konety BR, et al. The significance of lymphovascular invasion in transurethral resection of bladder tumour and cystectomy specimens on the survival of patients with urothelial bladder cancer. BJU Int 2009; 103:475-9.
*** Culp SH, Dickstein RJ, Grossman HB, et al. Refining patient selection for neoadjuvant chemotherapy before radical cystectomy. J Urol 2014; 191:40-7.

==== Examination under anesthesia ====
* '''Should be performed immediately after TURBT to accurately determine clinical stage and resectability(LE 3, moderate recommendation).'''

==== Imaging ====
* '''CT chest, abdomen and pelvis is the ideal treatment modality to stage localized MIBC and metastatic bladder cancer'''
** MRI is an alternative
** '''Chest imaging (CT or x-ray) should also be performed to rule out metastatic disease or concomitant lung cancer given the preponderance of smoking in urothelial carcinoma patients'''
* Bone scans are not considered mandatory but should be obtained in the setting of an elevated ALP, hypercalcemia or bony pain
* Currently, the role for PET CT in the staging of bladder cancer remains undefined