Urinary Bladder Cancer

Hematuria
1. More than 3 RBCs in centrifuged urine per high-power field microscopy on properly collected urine specimen (>3 RBC/HP)
  1. Classification
    1. Color
      1. Microscopic
      2. Gross
    2. Source
      1. Urologic:
        from peripheral calyces to external meatus
      2. Nephrologic
        glomerular origin
  2. Etiology
    1. Urological:
      1. neoplasm, BPH, urolithiasis, infection, trauma, iatrogenic, vascular
    2. Nephrological
      1. Post-strep GN, SLE, HUS, Subacute bacterial endocarditis, necrotizing papillitis, periarteritis nodosa
    3. Hematological
      1. Hemophilia, VW diseases, ITP, sickle cell trait, DIC, anticoagulant therapy
    4. Miscellaneous:
      1. Exercise hematuria, diseases of adjacent organs like the appendix, idiopathic
ANATOMY AND HISTOLOGY OF URINARY BLADDER
1. Blood supply
2. Innervation
3. Histology
  1. three layers of smooth muscle, and a transitional epithelium.
  2. The mucosa is heavily folded - this helps to accomodate for large volume changes.
  3. The transitional epithelial lining can stretch until it looks like stratified squamous epithelium.
PHYSIOLOGY OF micturition
1. Micturition is the process by which the urinary bladder empties when it becomes filled.
  1. 2 main steps
    1. Filling stage
      1. the bladder fills progressively until the tension in its walls rises above a threshold level;
    2. Micturition reflex
      1. empties the bladder or, if this fails, at least causes a conscious desire to urinate
    3. The micturition reflex is completely autonomic spinal cord reflex but it can be inhibited or facilitated by centres in the brain
Signs and symptoms
1. Blood or blood clots in the urine.
2. Pain or burning sensation during urination.
3. Frequent urination.
4. Feeling the need to urinate many times throughout the night.
5. Lower back pain on 1 side of the body.
Risk Factors
1. Smoking
2. Increasing age
3. Exposure to certain chemicals
4. Previous cancer treatment
5. Chronic bladder inflammation
6. Personal or family history of cancer
Staging of bladder cancer
Investigations
1. Cytology
  1. most helpful in diagnosing high-grade tumors and carcinoma in situ (CIS).
    1. cytology is the most reliable urine test for detecting bladder cancer, a positive cytology finding should be treated as indicating cancer until proven otherwise.
      1. 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.
    2. CIS exfoliates cells that have an unusual appearance and are easy to identify via cytologic examination, prompting further evaluation.
  2. high grade papillary urothelial carcinoma
2. culture sensitivity test
  1. 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.
    1. The efficacy of an antibiotic can be demonstrated under suitable conditions by its inhibitory effect on micro organisms.
      1. Sensitivity analysis is a useful tool to help quickly determine if bacteria are resistant to certain drugs.
3. Prostate specific antigen
  1. is a protein that is produced by the cells of the prostate gland and enters the bloodstream.
    1. Raised PSA levels can indicate several different disorders involving the prostate, one of which is prostate cancer.
      1. 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.
4. An intravenous pyelogram (IVP)
  1. 1- round shadow on the right side of the urinary bladder later seen to be a bladder cancer(LEFT).
  2. 2- benign prostatic hyperplasia. White = bladder , black = benign enlargement of the prostate, pushing down on the inferior bladder. (RIGHT)
Transitional cell carcinoma
1. Malignant tumor arising from the urothelial lining of the renal pelvis, ureter, bladder, or urethra
  1. Risk factors
    1. Cigrette smoke
    2. naphthylamine, azo dyes, and long-term cyclophosphamide or phenacetin use.
  2. Arises via two distinct pathways
    1. Flat- develops as a high-grade flat tumor and then invades; associated with early p53 mutations
    2. Papillary-develops as a low-grade papillary tumor that progresses to a highgrade papillary tumor and then invades; not associated with early p53 mutations
SQUAMOUS CELL CARCINOMA
1. Malignant proliferation of squamous cells, usually involving the bladder
  1. Arises in a background of squamous metaplasia (normal bladder surface is not lined by squamous epithelium)
  2. Risk Factors
    1. chronic cystitis (older woman)
    2. Schistosoma hematobium infection (Egyptian male)
      1. 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
      2. Painless terminal haematuria
      3. Chronic cystitis with frequency of micturition & dysuria
      4. Generalised hyperplasia & fibrosis of the bladder mucosa with a granular appearance (Sandy patch)
      5. Formation of bladder stones due to deposition of oxalate & uric acid crystals
      6. Hydronephrosis
      7. Granuloma formation around schistosoma eggs is a result of delayed hypersensitivity reaction mediated by T-cell immune response
    3. long-standing nephrolithiasis
ADENOCARCINOMA
1. Malignant proliferation of glands, usually involving bladder
  1. 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)
Management
1. Intra-vesical therapies are used in two general contexts: as an adjuvant to a complete endoscopic resection to prevent recurrence
2. invasive is to control of the primary tumor and, depending on the pathologic findings at surgery, systemic chemotherapy to treat micro-metastatic disease
3. Radical cystectomy - bladder-sparing approach
  1. Chemotherapy Alone is inadequate (radical cystectomy or radiation therapy)
  2. complete endoscopic resection
  3. partial cystectomy
  4. combination of resection, systemic chemotherapy, and external beam radiation therapy
prognosis is affected by
1. stage
2. type
3. tumors size
4. age and general health

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Urinary Bladder Cancer

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	Created by Fatma Shwaylia about 6 years ago