Urinary Baldder Cancer

Epidemiology

Bladder cancer accounts for 7% of all cancers. The man is the 4th leading cause of illness (7%) after prostate, lung and colorectal. It is estimated a total of 136,000 new cases annually. The annual rate of incidence is 32 / 100,000 in men and 9 / 100,000 women and the mortality rate is 9 / 100,000.

In Romania the estimated incidence for 2000 was 16.47 to 100,000 inhabitants and the mortality rate 5.15 per 100,000 inhabitants.

Risk Factors

1. Smoking is responsible for about 65% in men and 30% women in cases of bladder cancer in the population in developed countries. The risk associated with cigarette smoking on smoking is due to the presence of aromatic amines including bezidine, 4-aminobiphenyl, 2-naphthylamine and 4-chloro-ortho-toluidine.

2. Occupational exposure to carcinogenic chemicals, rubber, organic dyes, processing metals and exposure to aromatic amines correlate with a high risk of bladder cancer. The risk attributed to exposure at work ranges from 10% -20%

 3. Drugs. Ciclofosfamide is an alkylating agent has been strongly linked to bladder cancer and consistent. Patients with non-Hodgkin lymphoma were treated with ciclofosfamide have had dose-dependent bladder cancer.

4. Chronic cystitis caused by Schistosoma hematobium plays an important role. The infection is responsible for about 10% of bladder cancer cases in developed countries and 3% of all cases of bladder cancer. The areas mainly affected are Iraq, Egypt and Southeast Africa. In these areas Schistosoma eggs are frequently found in association with squamous cell cancers than transitional cell cancers.

5. Diet rich in vegetables and fruits probably protect their against bladder cancer.

6. Balkan nephropathy is associated with an increased risk for tumors of the renal pelvis and ureters

Screening

Screening can be performed by urinary cytology. Early diagnosis programs were suggested for people at high risk (large smoking, occupational exposure) or the elderly, but there is evidence for efficacy.

Histological Types

1. Transitional cell carcinoma represents 90-95% of all bladder tumors

2. Carcinoma in situ has a poor prognosis and is rarely associated with well-differentiated superficial bladder tumors and then gives a high rate of recurrence. It is associated more often with infiltrative tumors with higher grading. It may be asymptomatic in the initial phase and the signs often cause bladder irritation. At endoscopy velvety red patches appear.

3. Squamous cell carcinoma is found in 5-10% in developed countries and 75% in Egypt. About 80% of them are associated with infection with Schistosoma haematobium.

4. The adenocarcinoma appears in 1-2%

Signs and symptoms:

– Velvety red spots endoscopy bladder.

– Hematuria, bladder irritation signs: urinary frequency, dysuria, bladder tenesmus.

In advanced disease pain occurs in the pelvis, lower limb edema due to lymphatic and vascular compression.

Paraneoplastic syndromes:

1. Systemic Fibrinolysis

2. Hypercalcemia

3. Neuromuscular Syndromes

Diagnosis

Bimanual examination is recommended for diagnosis of bladder, intravenous urography, cystoscopy and biopsy, cytology.

Cytology is useful in poorly differentiated tumors and carcinoma in situ (CIS) for diagnosis and follow-up.

Biopsy is any suspicious lesion and tumor. Tumor biopsy must include the bladder wall.

The diagnosis is confirmed by histopathological examination.

For staging is recommended:

– Clinical examination, history, bimanual exam of the bladder under anesthesia,

– Cystoscopy with tumor biopsy,

– Intravenous urography,

– Chest X-ray,

– HL, hepatic and renal function tests,

– Abdominal ultrasound

– Abdominal and pelvic CT and MRI in tumors larger than 5 cm.

TNM staging

T – primary tumor

Tx – primary tumor cannot be assessed

T0 – no evidence of primary tumor

Ta – non-invasive papillary carcinoma (limited to urothelial layer)

T1s – transitional cell carcinoma “in situ” (payment tumor)

T1 – tumor invades corion (lamina propria)

T2 – Tumor invades muscle

T2a – Superficial invasion (domestic 1/2)

T2b – deep muscle invasion (external 1/2)

T3 – tumor invades the fat perivesical

T3a – microscopic fat invasion perivesical

T3b – fat macroscopic invasion perivesical

T4 – Tumor invades the pelvic organs, pelvic or abdominal wall

T4a – tumor invades the prostate, uterus, vagina

T4b – tumor invades pelvic or abdominal wall

Lymph node N

Nx – regional lymph nodes cannot be assessed

N0 – no regional lymph node metastases

N1 – Metastasis in a single lymph node £ 2 cm

N2 – metastasis or lymph node in several one

ganglion> 2 cm and <5 cm

N3 – metastasis in a lymph node> 5cm

M- metastases

M0 – no distant metastases

M1 – there are distant metastases

Staging

Std. N0 M0 your 0a

Std. Tis N0 M0 0i

Std. T1 N0 M0 I

Std. T2 N0 M0 II

Std. T3 N0 M0 III

                                      T4a

Std. T4b N0 M0 IV

                                       M0 Any T N1,2,3

                                       Any T Any N M1

TREATMENT

Therapeutic Indication

A. The treatment of superficial bladder cancer Ta – T1, N0, Mo

The goal of treatment is to eradicate bladder lesions by endoscopic approach. Intravesical therapy is administered to prevent relapses and disease progression.