Bladder cancer
What’s that?
Bladder cancer is a tumor formation of a malignant nature originating from the epithelial layer. It is one of the most common oncological diseases.
About the disease
Bladder cancer is the 7th most commonly diagnosed cancer in men and the 17th most commonly diagnosed cancer in women. The disease is slowly progressive and often characterized by a good prognosis. In the screening diagnosis of bladder tumors, a special place is given to ultrasound as a simple and accessible method. However, cystoscopy with biopsy is required for definitive diagnosis.
Treatment consists of surgical excision of the neoplasm, and in advanced cases, the bladder may need to be removed. Chemotherapy, immunotherapy, radiation therapy, and other methods may be used to prevent recurrence.
Types
TNM classification considers the primary tumor’s size and degree of invasion, the state of regional (nearest) nodes of the lymphatic system, and the presence/absence of distant metastatic foci. According to the belonging to each of the three signs, four stages of the oncologic process in the bladder are distinguished:
- Stage 1 – the tumor is localized only within the mucous layer, while the muscular layer is not affected, and there is no involvement of lymph nodes; that is, the tumor has not had time to spread beyond the primary focus.
- Stage 2 – mutant cells have gone beyond the epithelium into the thickness of the organ but still have not penetrated the lymphatic and circulatory system.
- Stage 3 – the tumor has spread to nearby urinary system organs, or some metastases do not exceed 2.5 cm in size.
- Stage 4 is a bladder cancer process in which there are metastases to lymphoid structures or other organs (often to the lungs) located at a distance from the primary focus.
In addition to TNM stage grading, morphologic classification is essential in determining prognosis. Thus, according to the degree of differentiation of malignant cells, tumors with high, medium, and low differentiation are distinguished. The more mature (differentiated) the cells, the better the tumor responds to treatment and the lower the risk of disease recurrence. The most frequent histologic type is adenocarcinoma (originating from glandular cell precursors), while squamous cell cancer (developing from cells of multilayered squamous epithelium) is less common.
In appearance, neoplasms can be flat focal (spread over the mucosa) and papillary (have the appearance of an outgoing formation in the lumen of the bladder).
Symptoms
Symptoms of bladder cancer in women and men may include the following:
- hematuria (presence of red blood cells in the urine) is one of the most frequent clinical signs;
- painful sensations in the pubic area;
- change in the nature and rhythm of urination – increased frequency, painfulness, uncontrollable urges.
The likelihood of bladder malignancy is increased in cases of recurrent cystitis that do not respond well to standard drug therapy.
With the progression and spread of the disease, the symptoms of bladder cancer are supplemented by the following manifestations:
- painful sensations in the projection of the lumbar region – associated with blockage of the ureteral orifices and violation of the outflow of urine from the kidney;
- painful sensations in the bones – caused by the penetration of tumor cells into the bone tissue;
- weakness, fatigue from minor work, rapidly developing weight loss, and poor appetite.
Reasons
Factors that increase the risks of malignancy in the bladder can be:
- Hereditary factors, which are associated with the activity of specific oncogenes;
- Tobacco smoking – almost every second case of bladder cancer is related to this factor (tobacco smoke contains proven carcinogens – aromatic amines and polycyclic hydrocarbons);
- Working at enterprises that produce paints and varnishes, process petroleum products, and produce metal;
- Drinking chlorinated water;
- Exposure to ionizing radiation;
- Schistosomiasis (a parasitic disease), especially repeated infections;
- Chronic cystitis and prolonged urethral catheter placement in the bladder.
Diagnosis
Objective diagnosis of bladder cancer primarily involves imaging techniques:
- ultrasound scan – usually the first method of assessing the urinary system;
- intravenous urography – injection of contrast into a vein and then a series of X-rays that help to identify filling defects at the level of different parts of the urinary system (kidneys, ureters, bladder);
- computed tomography with contrast – the most informative method of diagnosis, which also allows you to assess the state of regional lymph nodes;
- magnetic resonance imaging of the pelvis – a non-radiation diagnostic method with high informativeness;
- positron emission computed tomography allows you to accurately identify the tumor involvement in lymph nodes and other organs.
It should be noted that imaging methods are unsuitable for detecting the disease’s initial stage (cancer in situ). In some cases, urine cytological analysis can help remedy the situation – it determines the presence of sloughed cancer cells.
Cystoscopy with biopsy is recognized as the “gold” standard. The method allows you to study the state of the bladder mucosa under magnification and take the most altered tissue sample for histologic examination. The morphologist’s conclusion allows for the exclusion/confirmation of the diagnosis.
In some cases, UBC/BTA oncomarker tests may be helpful as part of a comprehensive examination. However, a negative result of such diagnostics does not unequivocally exclude a bladder tumor.
Bladder cancer treatment
The treatment program for malignant epithelial tumors of the bladder is based on surgical intervention, which allows the removal of the tumor mass. Chemotherapy (including intravesical), irradiation, and other methods may be performed as part of complex therapy, taking into account the stage and prevalence of the process.
Conservative treatment
Conservative treatment options include:
- systemic administration of chemotherapy drugs intravenously or orally;
- immunotherapy – immune drugs can destroy tumor cells;
- local chemotherapy – usually given after transurethral resection of the bladder to target urothelial malignant microfoci (this helps reduce the risk of recurrence in the future);
- radiation therapy – recommended in some histological types of tumors or total wall lesions (as an independent treatment option is used in the general severe condition of the patient when surgery is contraindicated);
Conservative therapy is used as an adjunct to surgery. It is not a radical treatment option in its own right, as all cases of bladder cancer require surgical removal of the primary tumor.
Surgical treatment
At the initial stages of the malignant process, it is possible to remove the tumor within the framework of transurethral resection. Not only the tumor is removed, but also the adjacent bladder wall. It allows to conduct objective histological diagnosis and establish the degree of cancer invasion, which is essential for postoperative staging of the pathological process and determining the program of further treatment.
Patients from the group of high oncological risk or with large tumors, cystectomy – partial or complete removal of the bladder – is most often indicated as the first line of surgical treatment. A medical board decides on the question of radical surgery. In surgical intervention, the removal of lymph nodes, which, according to PET-CT data, are affected by the malignant process (this stage of the operation is called pelvic lymph dissection).
All these treatment options are available in more than 900 hospitals worldwide (https://doctor.global/results/diseases/bladder-cancer). For example, cystectomy + bladder reconstruction is performed in 14 clinics across Israel for an approximate price of $12 K (https://doctor.global/results/asia/israel/all-cities/all-specializations/procedures/cystectomy-bladder-reconstruction).
Prevention
There are no effective methods of primary prevention. Patients at risk are recommended to visit a urologist for screening examinations.
After radical treatment of bladder cancer, patients should also be under the supervision of a specialist and undergo regular diagnostics. It is aimed at early detection of possible recurrences and subsequent correction. The dynamic follow-up program may include cystoscopic examination, urine microscopy, ultrasound scanning of the small pelvis and abdominal cavity, computed tomography to detect possible metastases, and magnetic resonance imaging of the small pelvis.
Rehabilitation
After transurethral resection (TUR), urine is drained through a urethral catheter for several days. During this time, it is recommended to increase fluid intake to allow lavage of the bladder and to speed up the sanitation of the surgical wound.
If a cystectomy has been performed to control the tumor, the second stage of treatment is to decide on the method of urine diversion. It can be external diversion with the formation of a stoma, the creation of an artificial reservoir for urine, or diversion into the intestine. The optimal method is selected based on the patient’s age and activity.
