THE URINARY BLADDER TUMORSDr. Ali Kamal M. SamiM.B.Ch.B. M.A.U.A.F.I.B.M.S. M.I.U.A.
Ninety-five per cent of primary bladder tumoursoriginate in the epithelium; the remainder arise from connective tissueangioma, myoma, fibroma and sarcoma) .secondary tumours of the bladder from thesigmoid and rectum, the prostate, the uterus orovary,
PathologyBenign papillary tumours. The papilloma consists of a singlefrond with a central vascular corewith villi; it looks like a red sea-anemone .
Carcinoma arisingwithin the bladder maybe of three cell types:Transitional 90% Squamous 5% Adenocarcinoma 1-2%, which arises eitherfrom the urachalremnant.
Transitional cell carcinoma (TCC):Occupations which have been reported to have asignificantly excess risk of bladder cancer are shown belowOccupations with an excess risk of bladder cancer1. Textile workers2. Dye workers3. Tire rubber and cable workers4. Petrol workers5. Leather workers6. Shoe manufacturers and cleaners7. Painters8. Hairdressers9. Lorry drivers10. Drill press operators11. Chemical workers12. Rodent exterminators and sewage workersCigarette smoking is associated with a two to three-fold excess risk.In areas where S.haematobium is endemic bladder cancer is more common, and this tends to be squamous
Tumour staging and gradingStudy of the biological behaviour of transitional cell cancer of thebladder shows that they fall into the three following groups.• Non muscle invasive tumours (pTa) and (pT1) account for 70%. These tumours may be single or multiple. Histological examination mayreveal invasion of the lamina propria (pT1) but not of the muscle or noinvasion of lamina propria (pTa) .• Muscle invasive disease(T2)(T3)(T4) (accounts for 25 per cent of newcases). Such tumours carry a much worse prognosis as they are subjectto local invasion and distant metastasis.• Flat, noninvasive carcinoma in situ (CIS) accounts for 5%.
Superficial bladder cancer (pTa and pT1)These are usually papillary tumourswhich grow in an exophytic fashion into the bladder lumen.They may be single or multiple andmay appear pedunculated arising on a stalk with a narrow base, but if the’ tumours are less well differentiated they are more solid with a wider base. The most common sites forsuperficial tumours are the trigone and lateral walls of the bladder.
Muscle invasive transitional cell carcinomaThe tumour with muscle invasion is nearlyalways solid. These tumours are often large andbroad based, having an irregular, ugly,sometimes ulcerated, appearance within thebladder. The incidence of metastases, whetherfrom lymphatic invasion in the pelvis or blood-born to the lung, liver or bones, is much morecommon and will cause the death of 3 0—50per cent of patients.
In situcarcinoma The histologicalappearance of irregularlyarranged cells with largenuclei and a high mitotic index replacing the normally well ordered urothelium is known as carcinoma in situ.
Pure squamous cell carcinoma of the bladderSquamous cell tumours tend to be solid and arenearly always associated with muscle invasion. This isthe most prevalent form of bladder cancer in areaswhere bilharzia is endemic. Squamous cell tumoursmay be associated with chronic irritation caused bystone disease in the bladder as a result of metaplasia.
Pure adenocarcinomaThis accounts for approximately 1—2per cent of bladder cancer. It usuallyarises in the fundus of the bladder atthe site of the urachal remnant.
Clinical features1. Painless Intermittent haematuria is by far the most common symptom and should be regarded as indicative of a bladder carcinoma until proven otherwise.2. Constant pain in the pelvis usually heralds extravesical spread.3. There is often frequency and discomfort associated with urination.4. Pain in the loin or pyelonephritis may indicate ureteric obstruction and hydronephrosis.5. A late manifestation is nerve involvement causing pain referred to the suprapubic region, groins, perineum, anus and into the thighs.
Investigation•Urine.Urine should be cultured and examined cytologically for malignant cells. This is not agood screening test for patients with haematuria as, particularly with low-gradetumours, malignant cells may not be identified .•Blood tests like (Hb , S.electrolytes , B.Urea).•IVU.-The most common radiological sign is a filling defect.-Hydronephrosis may occur if a superficial tumour grows up the intramural ureter or ifdirect invasion of the ureteric wall occurs.•- Ultrasound scanning should be carried out if the kidney is nonfunctioning.•Cystourethroscopy.Cystourethroscopy is the mainstay of diagnosis and should always be performed onpatients with haematunia. It can be done with a rigid instrument under generalanaesthesia or with a flexible instrument under local anaesthesia. The urethra isinspected at the initial insertion of the instrument (urethroscopy) and the bladder isthen examined in a systematic fashion (cystoscopy).•Bimanual examination.A bimanual examination with the patient fully relaxed under general anaesthesiashould be performed both before and after endoscopic surgical treatment of thesetumours.
Noninvasive tumours•Endoscopic surgery (TURBT)(Trans Urethral Resection of Bladder Tumor)The tumour should be carefully resected in layers using a resectoscope. The baseof the tumour is sent separately for histological examination. Small biopsies aretaken near to and distant from the primary lesion to diagnose unsuspected CIS.The bimanual examination is repeated at the end of each endoscopic procedure.Follow-up. Most urologists agree that patients with a single, low- or medium-grade pTa tumour can safely be treated by resection alone and followed up bymeans of regular cystoscopies.The resection may be followed by a 6-week course of intravesical chemotherapywith mitomycin C, adriamycin or epirubicin.Others will treat such patients by means of endoscopic treatment followed byintravesical immunotherapy with intravesical bacillus of Calmette and Guérin(BCG).Follow-up cystoscopies are essential; they may be carried out by means of localanaesthesia with a flexible cystoscope on by means of general anaesthesia if theurologist feels that the patient has a high risk of recurrence.They are usually done in 3 months intervals in first year.6 months intervals in the second year.Yearly intervals for the next 3 years.
Intravesical chemotherapy andimmunotherapyVarious agents have been used aschemotherapy. These include•Thiotepa.•mitomycin C.•epirubicin.•adriamycin.Immunotherapy agent includes:BCG is now frequently used as intravesicalimmunotherapy
Open surgical excisionThis should be totally avoided. If by someerror a bladder containing a tumour isentered, then the tumour may be removedwith a diathermy needle and the basecoagulated and the bladder closed.Postoperative radiotherapy to the woundwill diminish the chance of tumourimplantation.
2.Invasive tumours•Radical cystectomy.•Radical radiotherapy.•Combination of the two.•Primary surgery(radicalcystectomy) followed bya combination of agentsusing cis-platinum, methotrexate, adriamycin and vinblastine(MVAC)
Radiotherapy Local radiotherapy. For small invasive lesions, local Deep external beam X-ray therapy. radiotherapy can beExternal beam radiotherapy is usually delivered by open given by means of high-powered placement of a linear accelerators. Radical radioactive tantalumradiotherapy giving 60 Gy over a 4— wire. It is used6-week period will produce a 40—50 infrequently today. per cent complete response.
SurgeryPartial cystectomy. This should be limited to thetreatment of small adenocarcinomas at the dome ofthe bladder.Radical cystectomy and pelvic lymphadenectomy. Thisis now standard treatment for localised pT2—pT3disease without evidence of secondary spread.OperationThe radical cystectomyNeeds diversion of urine by:•Ileal conduit.•Ureterosigmodostomy:Orthotopic ileal neobladder
LeukoplakiaThis condition is simply squamous metaplasia of the bladder. Profuseproduction of keratin may result in the passing of white particles in theurine. It cannot be treated easily. Localised areas may be resectedendoscopically.Diffuse leucoplakia of the bladder is premalignant and results insquamous bladder cancer. Careful cystoscopic assessment is required.The condition may require cystectomy.
EndometriosisEndometriosis within the bladder wall is rare, but can have theappearance of a vascular bladder tumour or a tumour which containschocolate-coloured or bluish cysts. The swelling enlarges and bleedsduring menstruation. If medical management fails, by means of danazolor luteinising hormone-releasing agonists (LHRH), further treatment isusually by means of partial cystectomy or full-thickness endoscopicresection, depending on its site. The condition may be part of morewidespread disease. Endometriosis is also a cause of ureteric stricture.