Bladder cancer: Difference between revisions
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<section begin="oncology" /><section begin="pathology" /><section begin="radiology" />'''Bladder cancer''' is the most common cancer of the urinary system. The most common histological type is urothelial carcinoma, previously called transitional cell carcinoma (90% of cases). The remaining cases are squamous cell carcinoma and adenocarcinoma.<section end="radiology" /> | |||
Urothelial carcinoma can occur anywhere there is urothelium, although it occurs most commonly in the bladder and renal pelvis and more rarely in the ureters and urethra. It's usually asymptomatic in early stages, and the most common presenting symptom is painless gross haematuria, which is present in 80% of bladder cancer patients. | Urothelial carcinoma can occur anywhere there is urothelium, although it occurs most commonly in the bladder and renal pelvis and more rarely in the ureters and urethra. It's usually asymptomatic in early stages, and the most common presenting symptom is painless gross haematuria, which is present in 80% of bladder cancer patients. | ||
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== Risk factors == | == Risk factors == | ||
Urothelial carcinoma is the second most frequent cancer in [[Smoking|smokers]], after [[lung cancer]] of course. This is because the urothelium is exposed to the toxins in the cigarette smoke after it has been excreted by the kidney. It’s also associated with occupational toxins | Urothelial carcinoma is the second most frequent cancer in [[Smoking|smokers]], after [[lung cancer]] of course. This is because the urothelium is exposed to the toxins in the cigarette smoke after it has been excreted by the kidney. It’s also associated with occupational toxins. Other risk factors include: | ||
* [[Lynch syndrome]] | * [[Lynch syndrome]] | ||
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== Pathology == | == Pathology == | ||
90% of bladder cancer cases are urothelial carcinoma, previously called transitional cell carcinoma. | 90% of bladder cancer cases are urothelial carcinoma, previously called transitional cell carcinoma. | ||
<section end="oncology | <section end="oncology" /> | ||
=== Classification === | === Classification === | ||
The new WHO classification of urothelial carcinoma distinguishes between flat and papillary urothelial lesions: | The new WHO classification of urothelial carcinoma distinguishes between flat and papillary urothelial lesions: | ||
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Less than 10% of low-grade cancers invade, but as many as 80% of high-grade cancers do. Invasion majorly affects the prognosis; 5-year survival is 90% in non-invasive cancer but only 10% in invasive cancer. The degree of which the urothelial tumor has invaded the bladder wall is important in the prognosis. Invasive tumors may extend not only into the bladder wall but to adjacent structures like the prostate, seminal vesicles, ureters and retroperitoneum. Haematogenous dissemination usually involves the liver, lungs and bone marrow. | Less than 10% of low-grade cancers invade, but as many as 80% of high-grade cancers do. Invasion majorly affects the prognosis; 5-year survival is 90% in non-invasive cancer but only 10% in invasive cancer. The degree of which the urothelial tumor has invaded the bladder wall is important in the prognosis. Invasive tumors may extend not only into the bladder wall but to adjacent structures like the prostate, seminal vesicles, ureters and retroperitoneum. Haematogenous dissemination usually involves the liver, lungs and bone marrow. | ||
<section begin="oncology | <section begin="oncology" /> | ||
=== Polychronotropy === | === Polychronotropy === | ||
Urothelial carcinoma shows ''polychronotropy'', which means that when one urothelial carcinoma is found it is very likely that other urothelial tumors are present or currently developing at other places of the mucous membrane. Because of this, urothelial carcinoma has a high risk of recurrence. | Urothelial carcinoma shows ''polychronotropy'', which means that when one urothelial carcinoma is found it is very likely that other urothelial tumors are present or currently developing at other places of the mucous membrane. Because of this, urothelial carcinoma has a high risk of recurrence. | ||
<section end="oncology | <section end="oncology" /> | ||
=== Pathogenesis === | === Pathogenesis === | ||
Carcinogenesis involves deletions of tumor-suppressor genes on chromosome 9p or 9q. The p16 or p53 genes are commonly involved. | Carcinogenesis involves deletions of tumor-suppressor genes on chromosome 9p or 9q. The p16 or p53 genes are commonly involved. | ||
<section begin="oncology | <section begin="oncology" /> | ||
=== Other histological types === | === Other histological types === | ||
Adenocarcinoma is rare and histologically identical to gastrointestinal adenocarcinomas. | Adenocarcinoma is rare and histologically identical to gastrointestinal adenocarcinomas. | ||
Squamous cell carcinoma is rare and related to chronic inflammation of the bladder | Squamous cell carcinoma is rare and related to chronic inflammation of the bladder. | ||
== Clinical features == | == Clinical features == | ||
The most common symptom is painless gross [[haematuria]]. There may also be symptoms of bladder irritation, like dysuria, pollakisuria, and urgency. <section end="pathology" /> | The most common symptom is painless gross [[haematuria]]. There may also be symptoms of bladder irritation, like dysuria, pollakisuria, and urgency. <section end="pathology" /> | ||
Some may present | Some may present with incidentally discovered microscopic haematuria (defined as 2+ or more on a urinanalysis on 3 separate urine tests with 1 month between the tests). | ||
Bimanual examination (one hand per rectum and the other in the vagina (women) or lower abdominal wall (men) can be used to palpate for evidence of local extension of bladder cancer, which is usually evident of muscle-invasive disease. | Bimanual examination (one hand per rectum and the other in the vagina (women) or lower abdominal wall (men) can be used to palpate for evidence of local extension of bladder cancer, which is usually evident of muscle-invasive disease. | ||
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[[Haematuria]] on [[urine analysis]] is seen in most cases of bladder cancer. Urine cytology may show cancer cells. | [[Haematuria]] on [[urine analysis]] is seen in most cases of bladder cancer. Urine cytology may show cancer cells. | ||
Patients suspected of having bladder cancer should be referred to [[cystoscopy]]. Cystoscopy allows for taking biopsy sample, cytology sample, or even resecting the tumour in its entirety in some cases. <section end="pathology" /> | Patients suspected of having bladder cancer should be referred to [[cystoscopy]]. Cystoscopy allows for taking biopsy sample, cytology sample, or even resecting the tumour in its entirety in some cases. <section end="pathology" />Photodynamic diagnosis (PDD) is often used in cystoscopy, where a fluorescent dye called hexyl aminolevulinate (HAL, Hexvix®) is administered into the bladder. Cancer cells absorb this dye and glow red or pink when special fluorescent light is shone from the cystoscope, making them easier to see. | ||
[[CT]] with contrast is the first choice imaging modality if bladder cancer is suspected based on cystoscopy. It allows for visualisation of the local spreading of the malignancy | [[CT]] with contrast is the first choice imaging modality if bladder cancer is suspected based on cystoscopy. It allows for visualisation of the local spreading of the malignancy. Because contrast is filtered by the kidneys, it enters the urinary tract, and a tumour may therefore produce a filling defect. If the tumour has invaded the bladder wall, it will appear thickened on the CT. CT urography also allows for examination of the entire urinary tract, as bladder cancer is often multifocal. CT abdomen and pelvis to look for metastasis is also indicated for staging. In Norway, CT of the abdomen is performed before cystoscopy (because positive findings may allow the patient to skip cystoscopy and proceed directly to TUR-B). | ||
<section begin="pathology" /> | <section begin="pathology" /> | ||
=== Stages === | === Stages === | ||
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Non-muscle invasive and muscle-invasive disease can only be distinguished by transurethral resection of the bladder or by MRi. CT cannot distinguish them. | Non-muscle invasive and muscle-invasive disease can only be distinguished by transurethral resection of the bladder or by MRi. CT cannot distinguish them. | ||
<section end="radiology | <section end="radiology" /> | ||
== Management == | == Management == | ||
Management for non-metastatic disease (stages I - III) involves either cystoscopic surgical removal of the tumour (TUR-B), complete surgical removal of the bladder (radical cystectomy), or radiotherapy + chemotherapy. For metastatic disease, only chemotherapy and/or immunotherapy is indicated. | Management for non-metastatic disease (stages I - III) involves either cystoscopic surgical removal of the tumour (TUR-B), complete surgical removal of the bladder (radical cystectomy), or radiotherapy + chemotherapy. For metastatic disease, only chemotherapy and/or immunotherapy is indicated. | ||
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=== Radical cystectomy === | === Radical cystectomy === | ||
Radical cystectomy is indicated for muscle-invasive disease. It involves removal of the bladder, prostate, seminal vesicles, uterus, and adnexae. Lymph node dissection should also be performed. Without a bladder, a bladder substitute should be made. There are multiple options: | Radical cystectomy is indicated for muscle-invasive disease. It involves removal of the bladder, prostate, seminal vesicles, uterus, and adnexae. Lymph node dissection should also be performed. | ||
Without a bladder, a bladder substitute should be made. There are multiple options: | |||
* An ileal conduit urinary diversion, also called a Bricker conduit. A new bladder is made from part of the ileum, with the ureters connected to one end, and the other end opens through the abdominal wall like an enterostoma. Urine is collected in a bag connected to the stoma. This is the most common option | * An ileal conduit urinary diversion, also called a Bricker conduit. A new bladder is made from part of the ileum, with the ureters connected to one end, and the other end opens through the abdominal wall like an enterostoma. Urine is collected in a bag connected to the stoma. This is the most common option | ||
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=== Radiotherapy === | === Radiotherapy === | ||
Radiotherapy may be part of bladder preservation therapy or be used palliatively for metastatic disease.<section end="oncology | Radiotherapy may be part of bladder preservation therapy or be used palliatively for metastatic disease.<section end="oncology" /> | ||
[[Category:Urology]] | [[Category:Urology]] | ||
[[Category:Oncology]] | [[Category:Oncology]] | ||