Malignant tumor of the urinary bladder (ca bladder)
Incidence The male-female ratio is 3-1 *Ca bladder is the 2nd most common cancer of the genitourinary tract. *The average age at diagnoses is 65yr. *at the time of diagnosis approximately 85% of the bladder ca. are localized to the bladder & 15% have spread to regional lymph node or distant sites.Risk factors & pathogenesis 1-Cigarette smoking. Smokers have 2-6 fold increase risk of bladder ca. than non smokers. Smoking is causative factor in up to 50% in men The causative agents alpha & beta naphthylamine which are secreted into the urine of smokers. 2-Occupational exposures. Pt who expose to organic chemical as aromatic amines, aniline dyes, B-naphthylamine, usually include people work in chemical, dye, rubber, petroleum, leather, & printing industries are at increased risk.
3-Cyclophosphamide (cytoxane). Drug used for management of various malignant diseases is also increase risk of ca bladder. 4- Physical trauma to the urothelium induced by chronic infection (schistomiasis), instrumentation, & calculi increase risk of malignancy. 5-diet: In general, a Mediterranean diet has the lowest urothelial cancer risk due to the increased ingestion of fruits and vegetables specifically citrus, apples, tomatoes, carrots
6-Genetic changes include activation of oncogenes & loss or inactivation of tumor suppressor genes. -loss of chromosome 9 appear to be consistent finding in all stages &grades of ca bladder. Suggest early events in ca bladder development. -More recent studies examining p53 tumor suppressor gene mutations in primary, recurrent, and upper tract tumors suggest that these tumors can have a single clonal origin
Staging.CIS—carcinoma in situ.Ta—epithelium not involve the lamina propria. T1—reaching the lamina propria.T2a—superficial detrusor muscle.T2b—deep detrusor muscle.T3a—microscopic invasion of perivesical tissue.T3b—macroscopic invasion of perivesical tissue. Extravesical mass.T4a—invasion of prostate, uterus, &vagina.T4b—invasion of pelvic wall, abdominal wall.
*superficial tumor—CIS, Ta, T1, T2a.*deep tumor—T2b, T3.Tumor grading.G1—well differentiated.G2—moderately well differentiated. G3—poorly differentiated.G4—undifferetiated.
HistopathologyNinety-eight percent of all bladder cancers are epithelial malignancies, with most being transitional cell carcinomas (TCCs).A. NORMAL UROTHELIUMThe normal urothelium is composed of 3–7 layers of transitional cell epithelium resting on a basement membraneBeyond the basement membrane is loose connective tissue, the lamina propria,in which occasionally smooth-muscle fibers can be identified.
These fibers should be distinguished from deeper, more extensive muscle elements. The muscle wall of the bladder is composed of muscle bundles coursing in multiple directions. As these converge near the bladder neck, 3 layers can be recognized: inner and outer longitudinally oriented layers and a middle circularly oriented layer.
B. PAPILLOMA papillary tumor with a fine fibrovascular stalk Papillomas are a rare benign condition usually occurring in younger patients. C. TRANSITIONAL CELL CARCINOMA Approximately 90% of all bladder cancers are TCCs. *Carcinoma in situ (CIS) is recognizable as flat, anaplastic epithelium.
D. NONTRANSITIONAL CELL CARCINOMAS 1. Adenocarcinoma <2% of all bladder cancers.They are mucus-secreting and may have glandular, colloid, or signet-ring patterns 2. Squamous cell carcinoma 5% and 10% of all bladder cancers in the United States and is often associated with a history of chronic infection, bilharzial infection, vesical calculi, or chronic catheter use. It is the most common type in eagpt and causing higher mortality rate in that countery
3. Undifferentiated carcinomas rare (accounting for <2%), have no mature epithelial elements. Very undifferentiated tumors with neuroendocrine features and small cell carcinomastend to be aggressive and present with metastases4. Mixed carcinoma— 4–6% of all bladder cancers and are composed of a combination of transitional, glandular, squamous, or undifferentiated patterns. The most common type comprises transitional and squamous cell elements
Clinical features 1-Hematuria is the presenting symptom in 85-90% of pt. with ca bladder. Usually intermittent may be gross or microscopic. 2-Frequency, urgency & dysuria may accompany the hematuria. Irritative voiding symptoms more common in pt with CIS.
3-Passing clot or necrotic tumor perurethra. 4-Suprapubic mass. 5-Obstructive uropathy. 6-Distant metastasis. usually symptoms of advanced disease include bone pain from bone metastasis or flank pain from retroperitoneal metastasis.
Investigations *GUE & urine cytology Usually reveal RBC in urine. Pyuria may be due to concomitant infection. *Hematology -Anemia, due to chronic blood loss or invasion of bone marrow. -Increase b.urea & s.creatinie
*Radiology -Ultrasonography. -IVU (filling defect in the bladder with or without hydronephrosis) -CT & MRI may be used to characterized the extent of the tumor & detect lymph nodes *Cystourethroscopy & tumor resection The diagnosis and initial staging of bladder cancer is made by cystoscopy and transurethral resection (TUR).
Treatment A-Superficial bladder tumor 1-Transurethral resection + intravesical Immunotherapy or chemotherapy. 2-Partial cystectomy. 3-Radical cystectomy. All give the same prognoses therefore treated by transurethral resection because it has less morbidity, & no need for urinary diversion as in cystectomy.
Radical cystectomy may indicated in superficial tumor if its 1-extensive, multiple superficial or large intracavity tumor. 2-high grade tumor, grade 3 & above 3-rapidly recurring tumor after resection, or recurring in high grade. 4-tumor anamenable to endoscopic resection eg tumor in the anterior wall.
B-Deep bladder tumor Usually treated by partial or radical cystectomy. Partial cystectomy is indicated in cases in which the tumor is single & located at the dome or fundus of the urinary bladder or at the lateral wall of the bladder which permit resection of 1-2 cm of normal tissue around the tumor
Radical cystectomy in male—include removal of bladder with its covering peritoneum & extrvesical fat, prostate, seminal vesicle &membranous urethra.In female—removal of the bladder with its covering peritoneum & extravesical fat, both ovaries, fallopian tubes, uterus, cervix, &anterior vaginal vault.*The most common urinary diversion is iliostomy. When both ureters anastmosed to one end of the ileal segment while the other end exteriorize by iloiocutaneous anastomosis.
Radiotherapy. Is an alternative to radical cystectomy in patients with 1-deeply infiltrating bladder cancer which is beyond surgery. 2-patients who are poor surgical candidates due to advanced age or significant comorbid medical problems. Treatment generally well tolerated but unfortunately local recurrence is common. Also may be used as palliative therapy after radical cystectomy with recurrence or debulking surgery.