Bladder Cancer |lower abdominal cancer | urinary bladder cancer

Bladder Cancer

Bladder cancer is usually transitional cell (urothelial) carcinoma. Patients usually present with hematuria (most commonly) or irritative voiding symptoms such as frequency and/or urgency; later, urinary obstruction can cause pain. Diagnosis is by cystoscopy and biopsy. Treatment is with fulguration, transurethral resection, intravesical instillations, radical surgery, chemotherapy, external beam radiation, or a combination.- (see also urinary tract infections)

 

Risk factors include the following:

·         Smoking (the most common risk factor, causing ≥ 50% of new cases)

·         Excess phenacetin use (analgesic abuse)

·         Long-term cyclophosphamide use

·         Chronic irritation (eg, in schistosomiasis, by chronic catheterization, or by bladder calculi)

·         Exposure to hydrocarbons, tryptophan metabolites, or industrial chemicals, notably aromatic amines (aniline dyes, such as naphthylamine used in the dye industry) and chemicals used in the rubber, electric, cable, paint, and textile industries

Types of bladder cancer include

Transitional cell carcinomas (urothelial carcinoma), which account for > 90% of bladder cancers. Most are papillary carcinomas, which tend to be superficial and well-differentiated and to grow outward; sessile tumors are more insidious, tending to invade early and metastasize.

Squamous cell carcinomas, which are less common and usually occur in patients with parasitic bladder infestation or chronic mucosal irritation.

Adenocarcinomas, which may occur as primary tumors or rarely reflect metastasis from intestinal carcinoma. Metastasis should be ruled out.

In > 40% of patients, tumors recur at the same or another site in the bladder, particularly if tumors are large or poorly differentiated or if several tumors are present. Bladder cancer tends to metastasize to the lymph nodes, lungs, liver, and bone. Expression of mutations in tumor gene p53 may be associated with both progression and resistance to chemotherapy.

 

In the bladder, carcinoma in situ is high grade but noninvasive and usually multifocal; it tends to recur.

 

Symptoms and Signs of Bladder Cancer

Most patients present with unexplained hematuria (gross or microscopic). Some patients present with anemia, and hematuria is detected during evaluation. Irritative voiding symptoms ( dysuria, burning, frequency) and pyuria are also common at presentation. Pelvic pain occurs with advanced cancer, when a pelvic mass may be palpable.

 

Diagnosis of Bladder Cancer

Cystoscopy with biopsy

Urine cytology

Bladder cancer is suspected clinically. If patients present with hematuria, workup is risk-stratified and involves a combination of diagnostic cystoscopy and imaging (CT urogram or renal ultrasound [ 1]). Urine cytology, which can detect malignant cells, should also be done. Cystoscopy and biopsy of abnormal areas or resection of tumors are required for diagnosis and clinical staging. Urinary antigen tests are available but are not routinely recommended for use in diagnosis. They are used sometimes if cancer is suspected but cytology results are negative.

 

Cystoscopy with blue light after intravesical instillation of hexyl-aminolevulinate can improve initial detection of bladder cancer as well as recurrence-free survival. Higher detection rates are expected to improve clinical outcomes by reducing future recurrences and by facilitating earlier recognition that certain tumors are unresponsive to therapy (thus, sparing some patients unnecessary treatments).

 

 

 

Metastatic and recurrent cancers

Metastases require chemotherapy, generally cisplatin based, which is frequently effective but rarely curative unless metastases are confined to lymph nodes. This can be followed by maintenance immunotherapy with avelumab. Combination chemotherapy may prolong life in patients with metastatic disease. For patients who are cisplatin ineligible or have progressed after receiving cisplatin-based regimens, newer immunotherapies using PD-1 and PD-L1 inhibitors are available, such as pembrolizumab and atezolizumab. The first targeted therapy, erdafitinib, is now available for use in patients with FGFR3 and FGFR2 mutations who have failed treatment with chemotherapy.

 

Treatment of recurrent cancer depends on clinical stage and site of recurrence and previous treatment. Recurrence after transurethral resection of superficial tumors is usually treated with a 2nd resection or fulguration. Early cystectomy is recommended for recurrent high-grade superficial bladder cancers.

Key Points

Risk of bladder cancer increases with smoking, phenacetin or cyclophosphamide use, chronic irritation, or exposure to certain chemicals.

Transitional (urothelial) cell carcinoma is > 90% of bladder cancers.

Suspect bladder cancer in patients with unexplained hematuria or other urinary symptoms (particularly in middle-aged or older men).

Diagnose bladder cancer via cystoscopic biopsy and, if there is muscle invasion, do imaging studies for staging.

Remove superficial cancers by transurethral resection or fulguration, followed by repeated bladder instillations of drugs.

If cancer penetrates the muscle, treat with neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy with urinary diversion or, less frequently, radiation plus chemotherapy.