• Urinary cytology. Reasonable sensitivity [80%] and high specificity [90-95%] for high grade disease. Poorer discrimination for lower grade disease. An adjunct to cystoscopy

• Tumor markers. Several candidate markers studied in the past few years. Sensitivity and specificity aid in detecting lower grade lesions, but specificity is affected [lowered] by inflammation and hematuria reducing their role in screening, BTA trak, NMP-22
  • Hyaluronic Acid-Hyaluronidase [HA-HAase] may be less effected
  • Tissue base antigen markers [Immunocyte] may bolster cytology evaluation
  • Genomic based markers: microsatellite analysis, and FISH analysis may be unaffected by inflammation
• Transurethral Resection of bladder tumor [TURBT]
  • Lesion excised by classic electrocautery
  • Attempt to sample true detrusor
  • Repeat TUR useful in complete staging of T1 lesions
  • Role of random biopsies unclear
  • Value in biopsy of suspect areas and prostatic urethra

  Jewitt Staging for Bladder Cancer

  History:

  Originally proposed by H.J. Jewett in 1946; revised by Marshall in 1956. Also called Jewett-Marshall Staging and AUS (American Urologic System).

  Criteria:

  Histologic staging based on depth of invasion through the bladder wall. It does not consider grade of tumor, local recurrence rate or multicentricity of tumors. It's important to have a deep resection.

  Categories:

  Stage A	Submucosal invasion but no involvement of muscle
  Stage B	Bladder wall or muscle invasion, subdivided B1 superficial and B2 deep
  Stage C	Extension through serosa into perivesical fat (around bladder)
  Stage D	Lymph node and distant metastases, subdivided D1 regional nodes and D2 distant nodes and other distant metastases

  Guidelines for Jewett Staging:

  • It is important to have a good surgical or biopsy specimen so that muscle layers can be seen and assessed.
  • The prognostic dividing line is between B1 and B2, so be mindful of the description of the depth of muscle invasion.
  • AJCC Tumor notation T1 to T4 parallels Jewett stages A, B, C, D; N (node) and M (metastases) are part of Jewett stage D.

References

• Droller MJ: Bladder: Anatomical overview in surgical management of urologic disease: An anatomic approach, MJ Droller, St. Louis, Mosby Yearbook, p 575, 1992.
• Herr HW, Schwalb DM, Zhang ZF, et al: Intravesical bacillus Calmette-Guerin therapy prevents tumor progression and death from superficial bladder cancer: Ten-year follow-up of a prospective randomized trial. J Clin Oncol 13:1404, 1995.
• Lamm DL: Complications of bacillus Calmette-Guerin immunotherapy. Urol Clin North Am 19:565, 1992.
• Malkowicz SB: Superficial bladder cancer: The role of molecular markers in the treatment of high-risk superficial disease. Semin Urol Oncol 15:169-178, 1997.
• Messing EM, Catalona W: Urothelial tumors of the urinary tract. In: Campbell's Urology 7th ed. PC Walsh, AB ED Vaughan, AJ Wein, Vol 3, Chap 77, 2327, 1998.
• Spruck CH, Ohneseit PE, Gonzalez-Zulueta M, et al: Two molecular pathways to transitional cell carcinoma of the bladder. Cancer Res 54:784-788, 1994.

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