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Bladder Cancer – Causes, Symptoms, Diagnosis And Treatment

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Bladder Cancer – Causes, Symptoms, Diagnosis And Treatment

Bladder cancer is the most common malignancy of the urinary tract. The age group most affected is between 50-70 years. Is four times more common in men than in women.

Causes of bladder cancer:

The main factors that predispose to bladder cancer are:

  1. Occupational factors. Has been shown that workers in chemical industry, who are working with aniline dyes, which are composed of aromatic amines, will develop bladder cancer after a while. Latency period is about 6 to 20 years. These substances produce bladder cancer only if are excreted in urine.
  2. Food factors. Nitrites and nitrates in preserved foods would be considered having a carcinogenic role. Artificial sweeteners like saccharin by it’s content oh cyclohexylamine, can also cause bladder cancer.
  3. Chronic irritation of the bladder by lithiasis, chronic cystitis, schistosomiasis is a potential cause of bladder. In countries where infection with Schistosoma haematobium, a parasite, is endemic, bladder cancer is more common and occurs in young age. Bladder mucosal inflammatory changes associated with removing of the parasites eggs, lead to transformation of epithelial metaplasia.
  4. Has been shown that smoking in particular, but also drinking tea and coffee and analgesic abuse (phenacetin) can lead to the development of bladder cancer.

Bladder Cancer Morphopathology:

Bladder tumors are almost entirely (98%) malignant. They can be primitive or secondary.   Primitives bladder tumors are mostly epithelial (carcinomas) rarely mesenchymal (sarcomas). Secondary bladder tumors, are propagated from the neighboring organs (cervix, uterine body, prostate, rectum, sigmoid colon, appendix) to the wall of the bladder or are represented by metastasis  (gastric cancers, lung cancer).

Epithelial tumors include transitional cell carcinomas, the most common histological form (90%), epidermoid carcinomas (3-7%), adenocarcinomas (1%) or other rare forms.

Macroscopic, can be found two types of lesions:

  • Papillary lesion, with the growth into bladder cavity with narrow base of implantation, single or multi-center, variable size, sometimes presenting secondary changes like necrosis, haemorrhage and ulceration;
  • Infiltrative lesion with granular surface, which consists of a thickening of the lining, without producing an obvious intraluminal mass and includes areas of variable extention.

Both types of injury can take two forms:

  • Non invasive, superficial, without exceeding the basal membrane;
  • Invasive, exceeding the basal membrane with progressive infiltration of all layers of the bladder wall.
bladder Cancer

Bladder Cancer

Extension of bladder cancer occurs both locally, exceeding the bladder wall and invade nearby organs (into invasive forms) and distance by invading other organs like brain, lung, bone and liver.
Staging of bladder cancer:

To assess tumor invasion and the level of differentiation has been proposed the classification of bladder cancers after TNM (tumor, lymph nodes, metastasis) system:

Tumor:

  • Tis: in situ carcinoma;
  • T1: tumor limited to mucosa;
  • T2: tumor infiltrating bladder muscle;
  • T3: tumor infiltrating entire thickness of bladder;
  • T4: tumor infiltrating neighboring organs and fixes the bladder to the pelvic wall;

Lymph nodes:

  • No: without involving the regional lymph nodes;
  • N1:  involvement of a single lymph node with a diameter under 2 cm;
  • N2: involvement of a single lymph node , with a diameter between 2-5 cm or multiple lymph nodules less than 5 cm diametre;
  • N3 involving  lymph nodes with a diameter greater than 5 cm;
  • Nx: the invasion of lymph nodes can not be determined.

Metastasis:

  • Mo: without metastases;
  • M1: metastasis are present;
  • Mx: can not establish the existence of metastasis.

Symptoms of bladder cancer:

Hematuria is the most important clinical sign. It can be painless and capricious. Can appear events that occur frequently in cystitis: pyuria or hypogastric pain. Ureteral obstruction in cases of tumor invasion is present with low back pain, fever sometimes as a sign of infection. Rarely, patients can present symptoms of metastasis: abdominal pain, bone pain or weight loss.

Bladder Cancer Staging

Bladder Cancer Staging

 Diagnosis of bladder cancer:

Diagnosis of bladder cancer is put after symptoms and paraclinical examinations, which are represanted by:

  • Cystoscopy shows the tumor, her appearance (papilomatos or plan), location, size and  number;
  • Ultrasound examination, transabdominal, may reveal the tumor, but does not provide significant data about the local extension;
  • CT is useful in assessing the local extension of primary tumor and to establishing the presence of metasasis;
  • Urinary cytology, can show the existence of malignant cells. It is useful both for primary diagnosis and for monitoring the treated patients.

Evolution of bladder cancer:

All bladder cancers have a high potential for relapse.

Superficial bladder cancer have a long term evolution because the recurrences can be controlled and treated.

Invasive tumors that infiltrate the bladder wall have a severe evolution, characterized by relapses, lymph node invasion and early metastases, especially in the liver, lungs and bones.

Bladder Cancer

Bladder Cancer

Treatment of bladder cancer:

Bladder cancer is treated in a complex and difficult way. The treatment  must be based on proper and early diagnostic of the bladder cancer.

Superficial tumors ( stages Tis, T1, T2) benefit of transurethral resection (TUR). Survival beyond five years is about 70%. Adjuvant therapy after surgery is applied to prevent the relapse and the progression of the tumor. It consists of local or systemic chemotherapy or endovesical immunotherapy.

In the case of local chemotherapy are used endovesical instillation with various agents like : Epodyl, Mitomycin C and Doxorubicin. Systemic chemotherapy is using methotrexate-cyclophosphamide-cisplastin association.

Endovesical immunotherapy  is made with BCG vaccine instillation because it has a immunostimulant effect, or with interferon, which has antiproliferative and immunostimulant action.

Tracking of these patients is made by cystoscopy, urography and urine cytology every 3 months during the first year, every 6 months for the next two years, and then annually.

Invasive tumors (stages T2, T3) have radical surgery.

Surgery is major and is indicated in patients with bladder cancer and a good general condition. The best results are obtained in conditions of preoperative and postoperative radiotherapy. In these situations, the rate of survival beyond five years can reach 35-40%.

Transurethral resection may be a surgical alternative for bladder cancer. It is applicable to patients with small tumors, well differentiated, with superficial muscle invasion  and to those patients who have contraindications for radical intervention.

Bladder Cancer Treatment

Bladder Cancer Treatment

Neoadjuvant chemotherapy is especially useful for patients with bladder cancer and lymph node metastases. Good results are obtained with the combination of Methotrexate, Vinblastine, Adriamycin and Cisplatin.

In the case of bladder cancer with visceral metastases, palliative methods, chemotherapy and radiotherapy remain the only alternative.