Urinary Bladder Cancer

Urinary Bladder Cancer

1. Hematuria

   • More than 3 RBCs in centrifuged urine per high-power field microscopy on properly collected urine specimen (>3 RBC/HP)
     • Classification
       • Color
         • Microscopic
         • Gross
       • Source
         • Urologic:
           • from peripheral calyces to external meatus
         • Nephrologic
           • glomerular origin
     • Etiology
       • Urological:
         • neoplasm, BPH, urolithiasis, infection, trauma, iatrogenic, vascular
       • Nephrological
         • Post-strep GN, SLE, HUS, Subacute bacterial endocarditis, necrotizing papillitis, periarteritis nodosa
       • Hematological
         • Hemophilia, VW diseases, ITP, sickle cell trait, DIC, anticoagulant therapy
       • Miscellaneous:
         • Exercise hematuria, diseases of adjacent organs like the appendix, idiopathic

2. ANATOMY AND HISTOLOGY OF URINARY BLADDER

   • Blood supply
   • Innervation
   • Histology
     • three layers of smooth muscle, and a transitional epithelium.
     • The mucosa is heavily folded - this helps to accomodate for large volume changes.
     • The transitional epithelial lining can stretch until it looks like stratified squamous epithelium.

3. PHYSIOLOGY OF micturition

   • Micturition is the process by which the urinary bladder empties when it becomes filled.
     • 2 main steps
       • Filling stage
         • the bladder fills progressively until the tension in its walls rises above a threshold level;
       • Micturition reflex
         • empties the bladder or, if this fails, at least causes a conscious desire to urinate
       • The micturition reflex is completely autonomic spinal cord reflex but it can be inhibited or facilitated by centres in the brain

4. Signs and symptoms

   • Blood or blood clots in the urine.
   • Pain or burning sensation during urination.
   • Frequent urination.
   • Feeling the need to urinate many times throughout the night.
   • Lower back pain on 1 side of the body.

5. Risk Factors

   • Smoking
   • Increasing age
   • Exposure to certain chemicals
   • Previous cancer treatment
   • Chronic bladder inflammation
   • Personal or family history of cancer

6. Staging of bladder cancer

7. Investigations

   • Cytology
     • most helpful in diagnosing high-grade tumors and carcinoma in situ (CIS).
       • cytology is the most reliable urine test for detecting bladder cancer, a positive cytology finding should be treated as indicating cancer until proven otherwise.
         • If cystoscopy findings are negative in the setting of positive cytology findings, further evaluation of the urinary tract is required.
           • The upper urinary tract should be evaluated with contrast imaging. Cystoscopy with bilateral retrograde pyelography and bilateral ureteral washings should be performed.
       • CIS exfoliates cells that have an unusual appearance and are easy to identify via cytologic examination, prompting further evaluation.
     • high grade papillary urothelial carcinoma
   • culture sensitivity test
     • Helps to find the right anti-biotic to kill an infecting organism. This test determines the sensitivity of a colony of bacteria to an antibiotic.
       • The efficacy of an antibiotic can be demonstrated under suitable conditions by its inhibitory effect on micro organisms.
         • Sensitivity analysis is a useful tool to help quickly determine if bacteria are resistant to certain drugs.
   • Prostate specific antigen
     • is a protein that is produced by the cells of the prostate gland and enters the bloodstream.
       • Raised PSA levels can indicate several different disorders involving the prostate, one of which is prostate cancer.
         • PSA testing is not 100% accurate. Some men who have prostate cancer will not have elevated PSA levels (it is not 100% sensitive). Other (noncancerous) conditions that cause the cells of the prostate to produce higher levels of PSA include benign prostatic hyperplasia (BPH), urinary tract infections, and prostatitis.
   • An intravenous pyelogram (IVP)
     • 1- round shadow on the right side of the urinary bladder later seen to be a bladder cancer(LEFT).
     • 2- benign prostatic hyperplasia. White = bladder , black = benign enlargement of the prostate, pushing down on the inferior bladder. (RIGHT)

8. Transitional cell carcinoma

   • Malignant tumor arising from the urothelial lining of the renal pelvis, ureter, bladder, or urethra
     • Risk factors
       • Cigrette smoke
       • naphthylamine, azo dyes, and long-term cyclophosphamide or phenacetin use.
     • Arises via two distinct pathways
       • Flat- develops as a high-grade flat tumor and then invades; associated with early p53 mutations
       • Papillary-develops as a low-grade papillary tumor that progresses to a highgrade papillary tumor and then invades; not associated with early p53 mutations

9. SQUAMOUS CELL CARCINOMA

   • Malignant proliferation of squamous cells, usually involving the bladder
     • Arises in a background of squamous metaplasia (normal bladder surface is not lined by squamous epithelium)
     • Risk Factors
       • chronic cystitis (older woman)
       • Schistosoma hematobium infection (Egyptian male)
         • S. haematobium: eggs are laid in small venules of the vesical & pelvic plexus
           • eggs make their way from the venules to bladder lumen for S. haematobium
         • Painless terminal haematuria
         • Chronic cystitis with frequency of micturition & dysuria
         • Generalised hyperplasia & fibrosis of the bladder mucosa with a granular appearance (Sandy patch)
         • Formation of bladder stones due to deposition of oxalate & uric acid crystals „
         • Hydronephrosis
         • Granuloma formation around schistosoma eggs is a result of delayed hypersensitivity reaction mediated by T-cell immune response
       • long-standing nephrolithiasis

10. ADENOCARCINOMA

    • Malignant proliferation of glands, usually involving bladder
      • Arises from a urachal remnant (tumor develops at the dome of the bladder), cystitis glandularis, or exstrophy (congenital failure to form the caudal portion of the anterior abdominal and bladder walls)

11. Management

    • Intra-vesical therapies are used in two general contexts: as an adjuvant to a complete endoscopic resection to prevent recurrence
    • invasive is to control of the primary tumor and, depending on the pathologic findings at surgery, systemic chemotherapy to treat micro-metastatic disease
    • Radical cystectomy - bladder-sparing approach
      • Chemotherapy Alone is inadequate (radical cystectomy or radiation therapy)
      • complete endoscopic resection
      • partial cystectomy
      • combination of resection, systemic chemotherapy, and external beam radiation therapy

12. prognosis is affected by

    • stage
    • type
    • tumors size
    • age and general health

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