• Tumor progression is not linear form atypia to muscle invasive disease. Genetic correlates of progression have been discovered, but are insufficient to explain the behavior of all tumors or the individual behavior of a lesion. General patterns of behavior and clinical response can be estimated with greater confidence.
• Superficial disease. 70% of all lesions, with a 10-20 progression rate. Lifetime risk of recurrence is approximately 70%. Progression is correlated to grade and stage with low grade Ta lesions with a 1-3 % risk while high grade T1 lesions may progress in 30-45% of cases. Tumor size, multifocality, associated CIS and time to first recurrence are associated with behavior.
• Carcinoma in situ [CIS] flat lesion without polarity and poor cell adhesion. Felt to be precursor lesion of muscle invasive disease. P53 and RB alterations common. Progression rate 20-50 percent in patients with pure CIS
• Muscle invasive disease. 80-90 % mortality rate in 3 years if left untreated. Survival correlated to stage. Roughly 50% five year survival after cystectomy. Node positive disease still curable [20-35%] if low volume.
• Pattern of progression. 5-15% local recurrence rate after cystectomy. General spread is to lung, liver and bones. Usually occurs 18-24 months after surgery.

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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