Bladder Carcinoma

Bladder Carcinoma

The urinary bladder is a hollow organ in the lower abdomen (pelvis). It collects and stores urine produced by the kidneys. Bladder cancer affects the urinary bladder and is more common in men than in women. Cancer develops in the inner cell lining of the urinary bladder.

The inner lining of the bladder is called the urothelium or transitional epithelium. Urothelial carcinoma (also called transitional cell carcinoma) accounts for about 95 % of all bladder cancers develops from these lining cells.

Squamous cell carcinoma, adenocarcinoma and small-cell carcinoma make up the other 5% of bladder cancers. They are all very rare.

Epidemiology

Bladder cancer is the fourth most frequently occurring cancer in males, but is less common in women. More than 50,000 men and 16,000 women are diagnosed with this disease every year. The disease is more often detected at an advanced stage in women than in males. Bladder cancer is found to occur more in whites than in other ethnic groups.  Bladder cancer is more frequent in people over 50 years of age, although the disease can develop at any age.

Risk factors

  • Smoking
  • Occupational exposure to aromatic amines or aniline dyes
  • Occupations associated with diesel exhaust, petroleum products, solvents, dyes and other organic chemicals
  • Previous exposure to radiation
  • Treatment with cyclophosphamide (a chemotherapeutic drug)
  • Presence of long-term indwelling catheters due to spinal cord injuries
  • Presence of schistosomiasis, a parasitic infection found in the Middle East and Africa
  • Chronic bladder irritation due to urinary infections, kidney and bladder stones
  • Personal history of cancer in other parts of the urinary tract
  • Rare in-born defects of bladder due to the abnormal presence of urachus (a connection between the belly button and the bladder)
  • Family history of bladder cancer (mutations in Rb1 and PTEN genes) and a genetic condition called hereditary non-polyposis colorectal cancer (HNPCC) syndrome
  • Arsenic contamination in water

Signs and symptoms

Bladder cancer does not show many symptoms unless it reaches an advanced stage. The general symptoms listed below may not strongly indicate bladder cancer. These symptoms are the following:

  • Hematuria, which means blood in the urine. The blood may not be visible. It is important to note that most people with blood in the urine do not have cancer.
  • Pain or burning during urination (dysuria). This is usually not due to cancer.
  • Feeling of urgency or a strong urge to urinate without producing much urine. This is usually not due to cancer.

Diagnosis

Medical history and physical exam: It is very important that the doctors have information about the medical history of anyone with these symptoms. Doctors will examine a patient with these symptoms. Depending on the person’s age and symptoms, various procedures may be done.

Urine tests:  Firstly, the urine is examined for blood as well as infection. When someone has the above symptoms and the urine appears to be infected, the infection will be treated first.

If urine cancer is suspected, the person will probably be referred to an expert in the urinary tract.

If cancer is suspected, the presence of cancer cells in urine may be detected with the help of urine cytology. NMP22 and BTA tests are done i\on urine samples. These are tumor markers, which can be detected in the urine if the person has bladder cancer.

 

Cystoscopy: In this procedure, a slender tube-like instrument called cytoscope is inserted through the opening of the urethra into the bladder. Sterile saline is injected through the cytoscope to have a better view of the bladder.

Biopsy: Cells or tissues removed from the affected tissue are examined under a microscope in the laboratory to check for signs of cancer. A pathologist in the laboratory does this. A biopsy can show how deeply the cancer has invaded into the bladder wall

Intravenous pyelogram (IVP): This radiological procedure gives a view of abnormalities in the kidneys or urinary system. X-ray contrast media is injected into a vein, which enters the kidneys. X rays are taken at specific time intervals, which give information on the anatomy of kidney and its function. Better results can be obtained if this process and a CT scan machine is combined. The combined technique is called CT urogram.

CT (computerized tomography) scan: A CT scan is a combination of special X-ray equipment with sophisticated computers to produce multiple cross- sectional images of the bladder. A small amount of radiation is injected which is harmless. The scan takes 10–30 minutes and is painless.

MRI: The imaging technique is based on the use of a strong magnetic field and radio waves. The images can be viewed on a computer screen and ACC can be detected.

Ultrasound imaging: This is done with sound waves. An ultrasound may help to analyze whether the suspected region has a cyst or a tumor. A cyst is not cancerous. Biopsies can be done when guided by ultrasound.

Bone scan: A bone scan is an imaging test used to determine if cancer has spread to the bones. A radioactive substance is injected into a vein in one arm before the scan begins.

Chest x-ray: A chest x-ray may be done to look for tumors in the lungs that might be the spread from a bladder cancer.

Staging

Staging is based on the results of the diagnostic tests. The staging is done both by the TNM staging method and by the overall staging method denoted by Roman numerals.

Treatment

Surgical treatment is usually performed. Even when the cancer is removed, there is still a chance another tumor will develop, so that chemotherapy or radiation is also needed.

Surgery: Surgery is done when the cancer is detected at an early stage. Doctors recommend a transurethral resection (TUR) or transurethral resection of the bladder tumor (TURBT) for early stage or superficial bladder cancers. It is done by inserting a resectoscope (a kind of cystoscope) through the urethra. This surgery is not performed for invasive bladder cancer. In such cases, the bladder and surrounding tissues are removed by completely, which is called a radical cystectomy. After surgery, a new area is provided to store urine.

Intravesical therapy: With this treatment, a chemotherapy drug is administered directly into the bladder with the help of a catheter. This therapy can be of two types: immunotherapy and chemotherapy.

Intravesical immunotherapy:  Initial stages of the disease can be treated with Bacillus Calmette-Guerin (BCG), a bacterium that is placed in the urinary bladder with a catherer. The immune cells infiltrate and becomes activated in the bladder in response to the bacterium. This affects the bladder cancer cells. BCG is administered once a week for 6 weeks.

Interferons are proteins, which are synthesized and released by host cells in response to pathogens to stimulate the immune system. They can be synthesized artificially and used as medicine. Interferon-alpha is used for intravesical treatment of bladder cancer.

Intravesical chemotherapy: Anticancer chemotherapeutic drugs are put directly into the bladder through a catheter to kill cancer cells of the bladder. Mitomycin and thiotepa are commonly used for this purpose.

Chemotherapy

Chemotherapy can be used before surgery to reduce the size of tumor or can be given after surgery and sometimes after radiotherapy to kill cancer cells that remain after surgery and/or radiotherapy. This reduces chances of recurrence. Chemotherapy has been shown to enhance the results of radiotherapy.

Radiation therapy

Bladder cancers are treated with external beam radiation therapy. Most often, radiation treatments are given 5 days a week for several weeks. It is the main treatment for unoperable conditions. It can also be used after surgery for reducing recurrences or before surgery to reduce the size of tumor. It is also used at an advanced stage of the disease to increase the time of survival of the patient. Radiation therapy is more effective when combined with chemotherapy.

Prognosis

The earlier the disease is diagnosed better the prognosis. Stage I patients have 5 year survival rate of 88%. However, prognosis becomes poor as the disease progresses and invades deeper layers of urinary bladder (from innermost to outermost). Stage IV cancer patients only have a 5 year survival rate of 15 %.

References

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  6. This article was originally published on September 3, 2012 and last revision and update was 9/4/2015.