Bladder Cancer Flashcards
What is the etiology of bladder tumors
The established factors that increase the risk of bladder cancer are use of tobacco, cigarette smoking (carcinogenic arylamines in the smoke), occupational exposure to aniline dyes, phenacetin abuse, treatment with cyclophosphamide and schistosomiasis. In endemic areas, 30-40% of bladder cancer is associated with squamous cell carcinoma and 30% is associated with schistosomiasis. An inherent instability of the mucosa may also be a factor, hence multiple tumours and recurrences after treatment may occur.
What is the histological staging for bladder tumors
The depth of neoplastic invasion of the bladder wall (degree of invasion) has prognostic significance and is used for histo-logical staging of bladder tumours.
The term “invasive” implies that a bladder tumour has breached the basement membrane and tumour cells are, therefore, present in the stroma of the pedicle or in the bladder wall or in both. Generally, the incidence of metastases and extravesical extension varies directly with the depth to which the tumour has infiltrated the wall of the bladder.
The UICC staging is shown in Table 46-1 & Fig 46-3b.
Clinical staging is based on data obtained from the following studies:
1. Cystoscopy and a biopsy of the tumour that includes some underlying muscle.
2. Bimanual palpation of the bladder under G.A.
3. IVU or ultrasound for evidence of hydronephrosis from ureteric obstruction.
4. Chest X-ray for evidence of metastasis.
5. Radioisotope bone scan or skeletal survey for bony metastases.
6. Routine liver function tests.
7. Abdominal USG, CT scan and MRI will identify liver, pelvic and para-aortic nodal involvement as well as spread through the bladder wall.
What is the commonest bladder tumor
Transitional cell carcinoma
What is transitional cell carcinoma
It is the commonest bladder tumour. It may be pendunculated (papillary, villous) or sessile (solid, nodular). The papillary or villous type consists of a central core of connective tissue and blood vessels derived from the submucosa of the bladder. They vary both in the degree of cell differentiation and the degree of infiltration into the bladder wall. Generally, less well-differ entiated tumours tend to infiltrate deeply and metastasize. The well-differentiated tumour usually shows less infiltration and as a result tends to grow into the lumen of the bladder.
Conversely, the poorly-differentiated tumour shows less tendency to be papillary and may present as an ulcerated area on the vesical surface. The outgrowth of a papillary tumour may,
ata late stage, when considerable infiltration of the bladder wall has taken place, slough off giving the picture of an ulcerated solid or nodular tumour.
Transitional cell tumours are often multiple. There is also a tendency for new tumours to develop elsewhere in the bladder after an apparent successful treatment, even of stages Tis and Ta, suggesting generalized increased susceptibility of the mucosa (urothelium) to neoplastic proliferation, perhaps in response to carcinogens. This is true also of the renal pelvic and ureteric transitional cell tumours.
The risk of developing TCC of renal pelvis after diagnosis of TCC of bladder is 5% but the risk of TCC of bladder after diagnosis of TCCof renal pelvis is 40-70% suggesting possible implantation and field of change. Regular cystoscopy is therefore required in all cases of TCC of renal pelvis.
Spread is direct. Spread via the lymphatics is commoner than via the blood stream. The lymph nodes most frequently involved are the vesical, hypogastric, common iliac and lumbar. Blood spread is to the liver, lungs and bones.
Mention some cancers of the bladder
Transitional cell carcinoma
Anaplastic carcinoma
Carcinoma in situ of the urothelium
Squamous cell carcinoma
Adenocarcinoma
What is an anaplastic carcinoma of the bladder
It is fairly common and probably represents the extreme of malignant change in transitional cell carcinoma. The cells are immature without any attempt at differentiation. Infiltration is a feature.
What is a carcinoma in situ of the urothelium
Carcinoma in situ is found in every location of the urothelium. Its presence is not readily evident on endoscopy or gross examination of pathological specimens although slight changes of erythema and thickening may be noted. Careful microscopic analysis of urinary cytology specimens and of sections of bladder epithelium taken well away from known tumours has revealed a full range of changes from mild atypia to frank high-grade carcinoma in situ, an entirely intra-epithelial malignant tumour. This finding supports the concept of a widespread field of change caused by a carcinogen with a long latent period.
The condition is suspected in patients with nonspecific irritative symptoms of the bladder. Urine cytology and random biopsies of the bladder mucosa should, therefore, be carried out inevery patient with overt bladder tumour and transitional cell tumours of the upper tract.
What is a squamous cell carcinoma
It accounts for about 5% of vesical neoplasms, especially where schistosomiasis is uncommon; it is more common in Africa. In Ghana where schistosomiasis is endemic, squamous and transitional cell tumours of the bladder comprise 45% and 50% of cases respectively. It arises as a result of metaplasia of the transitional cell epithelium. It is variable in its degree of differentiation (from well-differentiated to anaplastic) and infiltration.
What is an adenocarcinoma
This is rare and arises (a) in urachal remnants, (b) in misplaced prostatic glands, (c) from an area of cystitis cystica and glandularis, or (d) spontaneously. The incidence is higher where schistosomiasis is endemic although squamous cell carcinoma occurs much more frequently.
Sarcoma of the bladder wall. It accounts for less than 3% of all bladder tumours. Various histological types are de-scribed.
- Rhabdomyosarcoma: It is rare and occurs mainly in male children and adolescents. It infiltrates widely, metastasizes early, and is usually fatal.
- Leiomyosarcoma, fibrosarcoma and myxosarcomas also occur very rarely.
Others
Primary malignant lymphoma, neurofibroma, small cell carcinoma carcinosarcoma and phaeochromocytoma are very rare. The latter may be associated with attacks of syncope and hypertension during voiding.
Secondary Tumours: They result from direct spread from the prostate and cervix.
What are some clinical features of bladder tumors
- Haematuria, total or terminal, is the first and principal symptom. It is at first nearly always painless and not associated with other symptoms. It is intermittent and may become profuse and cause clot retention. Advanced cases cause painful haematuria.
- When infection supervenes, symptoms of cystitis - burning, frequency and urgency - with haematuria occur.
- If the tumour invades and obstructs any ureteric orifice pain in the lumbar region occurs.
- Involvement of the bladder neck may lead to weak urinary stream and sometimes to complete urinary retention.
- The tumour may become necrotic and pieces of slough or fragments of papillary tumour may be passed in the urine.
- Local spread produces pain in the rectum or pelvis and fistula.
- Venous or lymphatic occlusion leads to unilateral oedema of the corresponding leg.
- Weight loss, malaise, severe anaemia and bone pain may
оссиг. - In early cases no abnormality may be found on physical examination. In late cases a suprapubic mass, which may be due to a large tumour or to urinary retention, may be present.
Palpable and tender kidneys from ureteric obstruction may be present. In the female, vaginal examination may reveal a mass at the base of the bladder. Less often, rectal examination may demonstrate an invasive mass in the region of the trigone.
Signs of metastases such as palpable abdominal masses (in-volved lymph nodes along the iliac vessels) and oedema of one or both legs may be present. From bimanual palpation (abdomino-rectal or abdomino-vaginal), best done under anaesthesia at the time of cystoscopy and biopsy, the size and extent of the growth can be estimated.
What are some investigations to make if bladder tumor is suspected
Investigations
1. Haemogram usually shows anaemia.
2. Culture of the urine may show infection.
3. Urine cytology may reveal tumour cells.
Flow cytometry, which measures DNA content of cells, is helpful in determining the malignant potential of the tumour.
Diploid tumours have favourable prognosis compared to aneu-ploid ones.
4. Renal function tests are usually normal unless there is bladder neck or ureteral orifice obstruction.
5. Imaging: i. IVU may show unilateral obstruction of the upper urinary tract and/or a filling defect in the bladder (Fig.
46-3c). Bone secondaries may be observed. Calcification in bladder wall is seen in schistosomiasis.
ii. Ultrasonic examination of the full bladder gives 80% accurate assessment of the degree of spread of the tumour through the bladder wall. Ultrasound of abdomen may demonstrate visceral metastases.
CTscan (Fig. 46-3d), MRI of abdomen and pelvis help to assess stage.
6. Cystoscopy (Fig. 46-3e):- The tumour should be observed with respect to the following:
(i) surface appearance - villous or not, haemorrhagic, pedunculated or sessile, ulcerated, incrusted;
(ii) position - base, wall, relationship to the ureters; (irl) size - estimated as accurately as possible. (iv) number ofmasses.
(v) condition of the mucosa adjacent to the tumour.
Biopsy of the tumour is done in two parts. First, the superficial portion is resected and sent separately for histologi-cal examination. The base with some underlying bundles of muscle is also resected and sent separately. These specimens will show the tumour type, grade and pathological stage.
Random biopsies from the mucosa adjacent to the tumour can be taken to rule out carcinoma-in-situ but this has potential for
tumour implantation of biopsy site.
What is the most satisfactory clinical method for determining the stage of local infiltration of the tumour and, therefore, the prognosis
Bimanual pelvic examination
What is bimanual pelvic examination
It is the most satisfactory clinical method for determining the stage of local infiltration of the tumour and, therefore, the prognosis. Bimanual palpation of the bladder, which in the male is abdomino-rectal and in the female abdomino-vaginal, is carried out under G.A. (for the relaxation of the abdominal muscles) and in an empty bladder.
Itinvolves careful bimanual palpation of the entire bladder and its infero-lateral ligaments and is done immediately before andafter cystoscopy and biopsy of the tumour. An assessment is made of (a) the presence/absence of any thickening or mass,
(b) size of mass, (c) mobility of mass, (d) the degree of fixation to other structures and (c) any co-existing pelvic pathology
