Editing Muscle-Invasive Bladder Cancer (section)

== Diagnosis and Evaluation ==
===<span style="color:#ff0000">UrologySchool.com Summary[https://pubmed.ncbi.nlm.nih.gov/28456635/ ★]</span>===
*'''<span style="color:#ff0000">History and Physical exam</span>'''
**'''<span style="color:#ff0000">Exam under anesthesia at time of TURBT for a suspected invasive cancer</span>''' 
*'''<span style="color:#ff0000">Imaging (2):</span>'''
*#'''<span style="color:#ff0000">Regional: CT abdomen/pelvis</span>'''
*#'''<span style="color:#ff0000">Distant: Chest (CT or CXR)</span>'''
*'''<span style="color:#ff0000">Labs (3):</span>'''
*#'''<span style="color:#ff0000">CBC</span>'''
*#'''<span style="color:#ff0000">Liver function tests</span>'''
*#'''<span style="color:#ff0000">Renal function</span>'''
* '''<span style="color:#ff0000">Other (1):</span>'''
*#'''<span style="color:#ff0000">TURBT pathology</span>'''
===History and physical exam===
*'''<span style="color:#ff0000">Examination under anesthesia</span>'''
**'''Performed at the time of TURBT for a suspected invasive cancer'''
**Provides 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 ===
* Goals of imaging in MIBC are to determine:
*#Feasibility and safety of removing of the bladder
*#Presence of hydronephrosis
*#Presence of upper tract disease
*#Local extent of the disease
*# Presence of pelvic or retroperitoneal lymph node metastases
*#Visceral/distant metastatic sites
*'''<span style="color:#ff0000">Regional</span>'''
** '''<span style="color:#ff0000">Cross-sectional imaging of the abdomen/pelvis with IV contrast</span>''' (if not contraindicated)
* '''<span style="color:#ff0000">Metastasis</span>'''
**'''<span style="color:#ff0000">Chest (CT or CXR)</span>'''
***'''Prior smokers may benefit from a chest CT;''' 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
***Indications (2):
***#Elevated alkaline phosphatase
***#Presence of bone pain symptoms
** PET imaging
***Indications (2):
***#Abnormal chest, abdominal, or pelvic imaging that requires further evaluation
***#Biopsy of a suspicious lymph node is not feasible
===Laboratory===
*'''<span style="color:#ff0000">CBC, liver function tests, and renal function</span>'''
**'''CBC: provides information regarding anemia and possible occult infection'''
**'''Liver function tests and renal function: 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.'''
*** Other than alkaline phosphatase, liver function tests not further specified.
****Liver function tests typically include[https://www.ncbi.nlm.nih.gov/books/NBK482489/]:
*****Alanine transaminase (ALT)
*****Aspartate transaminase (AST)
***** Alkaline phosphatase (ALP)
*****Gamma-glutamyl transferase (GGT)
*****Serum bilirubin
*****Prothrombin time (PT)
*****International normalized ratio (INR)
*****Total protein
*****Albumin
===Other ===
*'''<span style="color:#ff0000">TURBT pathology</span>'''
**Provides information on clinical staging, in addition to EUA
**'''If variant histology''' (e.g., micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, extensive squamous or glandular differentiation) '''is suspected OR if muscle invasion is equivocal, an experienced genitourinary pathologist should review the pathology'''
***Pathologic re-review of cystectomy specimens by experienced genitourinary pathologists may identify variants that alter treatment in up to 33% of patients