Bladder Cancer

The first professional observation of tumours occurred at the end of the 19th century and it was the bladder which focussed attention on environmental cancer as a result of the high incidence of the pathology amongst people working in dyestuff industries.
Doctors have sought to identify a relationship between the onset of cancer and environmental and occupational circumstances ever since.

Incidence

In the United States approximately 100,000 people contract bladder cancer each year.
This type of cancer causes approximately 10,200 deaths mostly amongst men.
In recent years the number of sufferers amongst women and young people has increased.
Bladder cancer is more common in densely populated and industrialised areas.

Etiopathogenesis

People most at risk are those working in the following sectors:
dyestuffs, plastics, leather and skins, textile industries, hairdressers and painters.

Substances suspected of causing bladder cancer
Auramine (manufacturing), benzidine, cyclophosphamide, phenacetin, N-phenyl-2-2-naphthylamine, isoniazid, 2-napthylamine, tar, soot and lead.

Smoking

Twin action
direct: as a result of carcinogens such as 2-naphthylamine contained in cigarette smoke
indirect: due to interference on the metabolism of tryptophan inhibition of conversion of 3 hydroxyanthranilic acid into n-methylnicotinamide and therefore accumulation of intermediate metabolites (ortho phenol) occurs in the urine.

The revelation of topical carcinogenic action on the urothelium by these agents confirms the link between smoking and bladder neoplasm, just as the increased incidence amongst women and young people is linked to a different attitude to smoking.
The incidence of this type of tumour is 4 times greater in smokers than non-smokers.
The risk is linked to the number of cigarettes consumed, the duration of smoking and the level of inhalation. There is reduced incidence amongst ex-smokers compared to smokers.

Classification and anatomical pathology

A total of 95% of bladder tumours involve the transitional epithelium cells which reproduce the epithelium of the urinary tract. Criteria for diagnosis of malign tumours: Increase in cellularity, multiplication of nuclei, cellular polarity modification, changes to the volume of nuclei and chromatin, anomalous mitosis.

A) Transitional cell papilloma
Delicate fibrovascular stroma papillary tumour, covered by an epithelium superimposable over the normal one. Macroscopically speaking it is a vegetating form with a small peduncle.
B) Transitional cell carcinoma
This is the traditional urothelial carcinoma with clear signs of anaplasia and invasive action.
Microscopically speaking there are:

  • papillary structures
  • sessile structures (with a wide system base and tenaciously secured to the bladder wall)
  • ulcerating and infiltrating structures

C) Epidermoid carcinoma: consisting of cells producing keratin
D) Adenocarcinoma: can secrete mucous, originates from the urachus and grows mainly on the dome.
E) Undifferentiated carcinoma: cannot be recognised and classified.

Grade:
G0-G1-G2-G3
The pT stage: indicates the extension (ta-t1-t2-t3-t4)
The N stage: indicates growth into the lymph nodes
The M stage: indicates metastasis

Clinical outline

Haematuria (gross or microscopic): this is the main symptom, even though it is manifested in many urological disorders, and is the first symptom in 60 to 75% of cases.
Bladder irritation: urinary frequency, urinary urgency, burning sensation and pain during urination,
usually indicates spreading of the pathology in terms of depth and is linked to ischemia and ulceration of the bladder wall and may be accompanied by bacterial infection.
Aching hips: may be linked to neoplastic ureteral obstruction.

Diagnosis

Screening: urography, cytology, ultrasound, cystoscopy, CAT scan.
Cytology: This is a simple process which can be repeated, useful for patients at risk and those already treated.
Urography: Above all the cystographic stage is useful showing a filling fault in the bladder cavity.
Supra-pubic ultrasound: This is an excellent screening process for patients with suspected neoplasm and those at risk.
Cystoscope: This is useful in the diagnosis of bladder cancer, enabling detection of very small structures and low-grade anaplasia which may not be picked up during urography and cytology.
Fluorescence cystoscopy: PDD (photo dynamic diagnosis) approximately 60 minutes following instillation of a photo dynamic drug in the bladder, porphyrin accumulates inside the cells on the lesions of the bladder wall. The porphyrin is fluorescent and emits a red light when energised by blue light. Therefore the preneoplastic and neoplastic lesions emit a red light on a blue background.

This method enables detection of 30% more cases of papillary neoplasm than the standard cystoscopy and 95% more in the event of carcinoma in situ (CIS), enabling much earlier and appropriate treatment.

Transurethral biopsy: Provides information concerning the anatomical and pathological features of the lesion (capillary, invasive, histologically malign).
CAT scan: enables detection of 3 categories

  • Non-infiltrating neoplasm
  • Lesions invading muscular tissue
  • Affecting the perivesical area

Treatment

Transurethral endoscopy
Traditional surgery (partial or total)
Endocavity antiblastic therapy (after conservative surgery)
Radiotherapy
System antiblastic therapy