Pathology report and incomplete staging

Jennifer (my wife), Chelsea (my daughter, a second year medical school student at GW), and I met with Dr. Hendricks this afternoon to hear about the pathology report and next steps.  Yesterday, GW Hospital issued a pathology report on the tumor that the doctor removed.  That report states:

"invasive urothelial carcinoma, high grade, lymphovascular invasion present, tumor involves smooth muscle, [but] it is difficult to determine if the smooth muscle represents hypertrophied muscularis versus muscularis propria."

In other words, the pathologist confirmed the cancer type and that it was in the muscle wall, could not tell how deeply into the muscle the cancer had penetrated.  The reference to "lymphovascular invasion present" refers to the lymph channels within the bladder.  There is no evidence that the cancer has actually travelled through the lymphovascular channels to the lymph nodes -- the CT scan suggests that it has not -- but the risk is there. 

Here's an email I sent to my extended family  reporting on these events:


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Jennifer, Chelsea and I just met with the doctor. The cancer is "highly aggressive" but appears to be localized to the bladder. The CT scan shows that there is no evidence of involvement by the lymph nodes, or metastazation. But the staging is inconclusive. The pathology report was not definitive.  The cancer is either stage 2a or 2b. Knowing this is necessary to determine the treatment. There will be another round of endoscopic surgery (probably in early Jan) to finish removing the remaining lesions (in situ), as well as closely examine the bladder wall to see if there is any remaining tumor in the wall (this will determine whether it is 2a or 2b). The doc is cautiously optimistic that the bladder can be saved; if so, I'll probably have follow-up chemo or other treatment. So things remain unsettled, but the news was not as bad as it could have been. Thank you for your faith and prayers - keep them going!

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In the past few days, I've learned that knowing how deep into the muscle wall the tumor has penetrated is important because the deeper the tumor into the muscle, the greater the chance it has spread.  In addition, the bladder doesn't work too well if there is a hole the muscle - when the bladder muscle squeezes, the part without the muscle will pop out like a balloon, which (to use a technical medical term) is really bad.  A staging of 2a means that the cancer is in inner half of the muscle, and a staging of 2b means that it is in the outer half of the muscle, close to or at the wall of the bladder.  When the tumor is all the way through the muscle wall, it's graded at T3.  This diagram helped me understand the stages better:  Diagram of bladder tumors


Here's what we know:

My cancer type is transitional-cell carcinoma, a muscle invasive bladder cancer (MIBC), stage T2. 
The tumor was approximately 5cm by 1.5cm (relatively large), and of a high grade or "very aggressive"
I have some tumor in situ (Tis) elsewhere in the bladder.
I have normal renal (kidney) function and no evidence of hydronephrosis (backed up kidney).
There is no evidence via CT scan of pelvic lymph node metastases, although the pathology report found lymphovascular invasion within the bladder.
Using the TNM system, I have T2+Tis,N0,M0 MIBC. 

Dr. Hendricks recommends that I wait several weeks for the bladder to heal itself, then schedule another TURBT.  He also recommended that I seek out second opinions, and recommended either Johns Hopkins or the Cleveland Clinic.  He said if this were him, he would want a second opinion, and that he would be willing to consult with anyone else I thought appropriate.  I am glad that he had brought that up, since I was intending to seek a second opinion in any event.