Staging bladder cancer using the TNM system

Staging bladder cancer using the TNM system

Staging bladder cancer using the TNM system

Read Bladder Cancer First.

  • T0 ; No tumor in specimen collected
  • Tis ; Carcinoma in situ ( CIS)
  • Ta: Noninvasive papillary carcinoma
  • T1: Tumor invades lamina propria
  • T2: Tumor invades muscle
  1. T2a: Invades superficial muscularis propria
  2. T2b: Invades deep muscularis propria
  • T3: Tumor invades perivesical tissue
  1. T3a: Microscopic perivesical fat invasion
  2. T3b: Macroscopic perivesical fat invasion (extravesical mass)
  • T4
  1. T4a: Invades adjacent organs (uterus, ovaries, prostate stoma)
  2. T4b: Invades pelvic wall, abdominal wall

Invasive of nodal status:

  • N0 No nodal involvement
  • N1-3 Pelvic nodes
  • N4 Nodes above bifurcation
  • Nx Unknown

Invasive of metastatic status:

  • M0 No distant metastases
  • M1 Distant metastases
  • Mx Unknown

Symptoms of bladder cancer

There is painless urination with bleeding( hematuria)

  • Persistent blood in urine
  • Frequency of passing urine
  • Some patients will experience pain on passing urine ( dysuria)
  • Lower abdominal pain
  • Abdominal mass and swelling
  • Lymphedema
  • In severe cases, kidney failure as the cancer spreads to affect the kidneys
  • Nausea and vomiting
  • Metastatic spread to other sites such as the bones will cases pain at the affected regions

Diagnosing bladder cancer

The healthcare provider will perform a thorough medical history and examination in trying to find out how it started. You will be asked about the pain on passing urine, any change in color of urine, any frequency of passing urine and changes to it among others.

The healthcare provider will request for urine tests to rule out any infections such as TB, schistosoma cysts, and blood in urine

The definitive test for diagnosing bladder cancer is the Cystoscopy test. Most urologists will perform these diagnostic cystoscopies in an outpatient setting using a 16F flexible cystoscope and local Intraurethral lidocaine for topical anesthesia.

If a bladder neoplasm is detected, an outpatient transurethral resection (TUR) or biopsy is done with anesthesia.

Radiological tests such as intravenous pyelogram (IVP), retrograde pyelogram, or computed tomography (CT) or magnetic resonance (MR) urogram are used to identify additional tumors and obstruction of the upper urinary tract due to bladder cancer

Other tests done include the complete blood counts, blood indices, Fibrin Degradation Products (FDP) and bladder cancer tumor markers.

Treating Bladder cancer

There are several modes used in treating bladder cancer including, the use of drugs, radiotherapy or both. Most bladder cancers recur in the bladder, but can be managed with a combination of transurethral resection (TUR) and intravesical medications or immunotherapy. Here are some guidelines

  • Bacillus Calmette-Guérin (BCG) vaccine is the most effective agent for treating high-grade superficial lesions. The use of this vaccine leads to reduction in progression rates and increases survival
  • Radical cystectomy (removal of bladder) with diversion of urine bypassing the normal route is the most effective means to eliminate bladder cancer. Types of diversion include; orthotopic diversion with a neobladder.
  • Radiation therapy in combination with TUR and a drug such as cisplatin, has been shown to be effective in preserving the bladder
  • The use of medications using urinary catheters such as methotrexate, vinblastine, doxorubicin, and cisplatin, has shown high levels of toxicity with poor results.
  • New drugs such as paclitaxel and gemcitabine are active, and combinations of these agents with platinum-based compounds have better results with less toxicity.

Why cystectomy (bladder resection) is done

  • When there is a cancer within a bladder diverticulum
  • In cases of primary, and muscle-invasive or high-grade tumors that allow complete excision with adequate surgical margins
  • Patients in whom there is an inability to adequately remove tumor by TUR alone because of size or location
  • When there is a tumor overlying a ureteral opening that may require ureteral reimplantation
  • Patient refuses to have urinary diversion
  • In poor-risk patients where diversion is not possible

Bladder Cancer

Bladder Cancer

Bladder Cancer

Definition

Bladder cancer involves a group of cancers that range from non–life-threatening, low-grade, superficial papillary lesions to high-grade invasive tumors. There are various types of bladder cancer defined.

What are the types of bladder cancer?

The international Society of Urological Pathology Consensus had defined a mode of classification of bladder cancer as follows:

Normal

There is a normal bladder lining (urothelium) on physical and microscopic examination. Some cases of mild dysplasia may be classified here.

Hyperplasia

There is a flat bladder lining increased growth (urothelial hyperplasia) and papillary urothelial hyperplasia

Flat urothelial Lesions with atypia

  • Histological examination reveals a reactive (inflammatory) cell abnormality (atypia)
  • Histology may reveal cell abnormality (atypia) of unknown clinical significance
  • Microscopic cell examination shows low-grade bladder lining type of cancer or dysplasia (intraurothelial neoplasia)
  • There is a carcinoma in situ presenting with a high-grade intraurothelial neoplasia.

Papillary urothelial cancers

  • Urothelial papilloma
  • Inverted urothelial papilloma
  • Papillary urothelial neoplasm of low malignant potential
  • High grade papillary urothelial neoplasm
  • Low grade papillary urothelial neoplasm

Invasive urothelial neoplasm

  • Urothelial carcinoma with lamina propria invasion
  • Urothelial carcinoma with muscularis propria (affecting the detrusor muscle) invasion

What cause bladder cancer?

Bladder cancer is a potentially preventable disease associated with specific causative factors. Most of the causative factors also cat as risk factors . Continuous exposure to these leads to bladder cancer. Here are some of the causes:
  • Cigarette smoking
  • Occupational exposures to chemicals
  • Exposure to human papilloma virus type 16
  • Infections such as schistosomiasis, tuberculosis
  • Urinary calculi
  • Prolonged use of urinary indwelling catheters
  • Diverticula
  • Drugs such as cyclophosphamide
  • Radiation to pelvic structures
  • Exstrophy of bladder a congenital condition of being born with the abdominal wall open with the bladder muscle open
  • Females with endometriosis
  • Other congenital bladder abnormalities
  • Metastatic spread from other sites such as the colon and ovary

What are the risks of having bladder cancer?

Several factors play a role in having bladder cancer such as:
  • Extremes of age. There is an increased risk of bladder cancer especially among the aged population of over 65years. Close to 70% of these cancers are common among males of this age group and 75% among the females.
  • Cigarette smoking has been show to increase the risks of having bladder cancer among both sexes. Smokers have twice the risk of bladder cancer as nonsmokers. There is a twofold to threefold increase in risk of bladder cancer in subjects who smoke at least 10 cigarettes per day. Close to 50% of males who have bladder cancer are smokers while 30% of females are smokers.
  • Exposure to certain chemicals poses a risk to many. Occupational chemical exposure to substances such as arylamines and its derivatives which may also be found in cigarette smoke, O-toluidine, and benzidine-based dyes leads to cancer of the bladder. Other occupational risks include exposure to dyes, rubber, leather products, paint products, and drill press operators.
  • Drugs such as cyclophosphamide can cause bladder cancer if used on a long term basis.
  • Diet that are rich in beef, pork, and animal fat consumption increase risk of bladder cancer among both sexes.
  • Evidence suggests that consumption of non-beer alcoholic drinks can cause bladder cancer. The high levels of nitrosamines in beer has been implicated in causing bladder cancer
  • In populations living in swampy or stagnant waters and lakes, there are cases of infections with bilharzias (schistosomiasis) that can lead to bladder cancer.
  • Spinal cord injury is associated with increased risk for squamous cell carcinoma of the bladder.

How smoke increases the risk of bladder cancer

  • Tobacco Smoke Contains these Substances ;
  1. Aldehydes such as acetaldehyde, and acrolein
  2. Alkaloids such as nicotine
  3. Minerals & Elements such as aluminum; arsenic; cadmium ;Carbon Monoxide; Hydrocarbons; lead ; mercury; nitrogen oxides ; ozone; polynuclear aromatic hydrocarbons; radioactive polonium; lithium. Each cigarette contains 2 micrograms of Cadmium and more than 50% of this is absorbed through the Lungs.
  4. Tobacco smoke is the most significant source of environmental exposure to Cadmium.
  • Studies have shown that there is a twofold increased risk of bladder cancer in people smoking at least 10 cigarettes per day
  • Smokers who consume low-tar and nicotine cigarettes have a lower risk of developing bladder cancer when compared with those who consume higher tar and nicotine cigarettes.
  • Those who consume high numbers of unfiltered cigarettes and to some extent the passive smokers have a 50% increased risk of bladder cancer compared with those who smoke filtered cigarettes.
  • Those who smoke pipe have a lower risk of bladder cancer compared with cigarette smokers.

Substances that may increase the toxic effects of tobacco

  • Consumption of high levels of beta-Carotene supplements in concurrent with the use of tobacco has been shown to increase the risks of blade and other types of cancer. The intake of the beta carotenes in the presence of tobacco smoke in the lungs leads to oxidation of epoxides that can increase the binding of polynuclear aromatic hydrocarbon diolepoxides to the deoxyribonucleic acid (DNA) of the Lungs. This can cause mutations that lead to Cancer.
  • High consumption of caffeine among smokers leads to the craving for tobacco. The alkaloids found in the tobacco are responsible.
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