educational purpose

1. BLADDER CANCER
BY
CHU EMMANUEL NDZE
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2. OUTLINE
• Introduction
• Anatomy of the bladder
• Understand bladder cancer
• Understand the types and classification of bladder cancer
• Risk factors and causes of bladder cancer
• Signs and symptoms
• Preventive measures of bladder cancer
• Method of diagnosis
• Staging
• Grading
• Treatment options
• Side effect of treatment
• Management of side effect
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3. INTRODUCTION
• Bladder cancer is a common type of cancer that
begins in the cells of the bladder. The bladder is a
hollow muscular organ in your lower abdomen
that stores urine.
• Bladder cancer most often begins in the cells
(urothelial cells) that line the inside of your
bladder. Urothelial cells are also found in your
kidneys and the tubes (ureters) that connect the
kidneys to the bladder. Urothelial cancer can
happen in the kidneys and ureters, as well, but it's
much more common in the bladder.
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4. ANATOMY OF THE BLADDER
• In humans, the bladder is a hollow muscular organ situated
at the base of the pelvis. The bladder can be divided into a
broad fundus, a body, an apex, and a neck.
• Apex – located superiorly, pointing towards the pubic
symphysis. It is connected to the umbilicus by the median
umbilical ligament.
• Body – main part of the bladder, located between the apex
and the fundus
• Fundus (or base) – located posteriorly. It is triangular-
shaped, with the tip of the triangle pointing backwards.
• Neck – formed by the convergence of the fundus and the
two inferolateral surfaces. It is continuous with the urethra.
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5. • The bladder has three openings. The two
ureters enter the bladder at ureteric orifices,
and the urethra enters at the trigone of the
bladder. These ureteric openings have mucosal
flaps in front of them that act as valves in
preventing the backflow of urine into the
ureters, known as vesicoureteral reflux.
Between the two ureteric openings is a raised
area of tissue called the interureteric crest. This
makes the upper boundary of the trigone.
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6. • The walls of the bladder have a series of ridges, thick
mucosal folds known as rugae that allow for the
expansion of the bladder. The detrusor muscle is the
muscular layer of the wall made of smooth muscle
fibers arranged in spiral, longitudinal, and circular
bundles. The detrusor muscle is able to change its
length. It can also contract for a long time whilst
voiding, and it stays relaxed whilst the bladder is
filling. The wall of the urinary bladder is normally 3–
5 mm thick. When well distended, the wall is
normally less than 3 mm.
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7. Blood and lymph supply
• The bladder receives blood by the vesical
arteries and drained into a network of vesical
veins. The superior vesical artery supplies blood
to the upper part of the bladder. The lower part of
the bladder is supplied by the inferior vesical
artery, both of which are branches of the internal
iliac arteries. In females, the uterine and vaginal
arteries provide additional blood supply. Venous
drainage begins in a network of small vessels on
the lower lateral surfaces of the bladder, which
coalesce and travel with the lateral ligaments of
the bladder into the internal iliac veins.
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8. • The lymph drained from the bladder begins in
a series of networks throughout the mucosal,
muscular and serosal layers. These then form
three sets of vessels: one set near the trigone
draining the bottom of the bladder; one set
draining the top of the bladder; and another set
draining the outer undersurface of the bladder.
The majority of these vessels drain into the
external iliac lymph nodes.
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9. Nerve supply
• The bladder receives both sensory and motor
supply from sympathetic and the
parasympathetic nervous systems. The
motor supply from both sympathetic fibers,
most of which arise from the superior and
inferior hypogastric plexuses and nerves,
and from parasympathetic fibers, which come
from the pelvic splanchnic nerves
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12. • The bladder wall is made of many layers,
including:
• Urothelium or transitional epithelium. This is
the layer of cells that lines the inside of the
kidneys, ureters, bladder, and urethra. Cells in this
layer are called urothelial cells or transitional
cells.
• Lamina propria. This is the next layer around
the urothelium. It’s a type of connective tissue.
• Muscularis propria. This is the outer layer. It’s
the thick muscle tissue outside the lamina propria.
• Fatty connective tissue. This covers the outside
of the bladder and separates it from other organs.
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13. DEFINITION OF BLADDER
CANCER
• Bladder cancer start when cells that make up the
urinary bladder start to grow out of control. As
more cancer cells develop, they can form a tumor
and, with time, spread to other parts of the body.
• The bladder is a hollow organ in the lower pelvis.
It has flexible, muscular walls that can stretch to
hold urine and squeeze to send it out of the body.
The bladder main job is to store urine. When you
urinate, the muscles in the bladder contract, and
urine is forced out of the bladder through a tube
called the urethra.
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14. TYPES OF BLADDER CANCER
• Urothelial carcinoma (transitional cell carcinoma):
is the most common type of bladder cancer. These
cancers start in the urothelial cells that line the inside
of the bladder. Urothelial cells also line other parts of
the urinary tract, such as the renal pelvis, the ureters,
and the urethra.
• Squamous cell carcinoma: this type make up about
1 to 2% of bladder cancer. Seen with a microscope,
the cells look much like flat cells that are found on
the surface of the skin. Nearly all squamous cell
carcinomas of the bladder are invasive.
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15. • Adenocarcinoma: only about 1% of bladder
cancers are adenocarcinomas. These cancer
cell have a lot in common with gland forming
cells of colon cancers.
• Small cell carcinoma: less then 1% of bladder
cancer are small cell carcinomas. They start in
nerve like cells called neuroendocrine cells and
they usually grow very fast.
• Sarcoma: they start in the muscle cells of the
bladder, but are very rare. they are treated a lot
like transitional cell carcinomas(TCCs)
especially in their early stages.
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16. CLASSIFICATION OF BLADDER
CANCER
• Bladder cancer can be classified according how far they
have spread and their nature of growth.
1. According to mode of spread:
• Invasive vs non-invasive bladder cancer
• Invasive cancers: this is when cancer have grown into
deeper layers of the bladder wall and are always harder
to treat.
• Non-invasive cancers: this is when cancers are only in
the inner layer of cells (the transitional epithelium).
They have not grown into the deeper layers. They are
also called sperficial or non muscle invasive.
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17. 2. According to their nature of growth
• Papillary vs flat cancer
• Papillary carcinomas grow in slender, finger-like
projections from the inner surface of the bladder toward
the hollow center. They are called non invasive
papillary cancer. Very low grade or slow growing are
types are called papillary urothelial neoplasm of low–
malignant potential (PUNLMP) and tent to have a very
good outcome.
• Flat carcinomas do not grow toward the hollow part of
the bladder at all. If a flat tumor is only in the inner
layer of the bladder cells, it`s known as a non-invasive
flat carcinoma or flat carcinoma in situ (CIS).
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18. RISK FACTORS/CAUSES
• Cigarette smoking: the duration of smoking and the umber smoke
per day impact on a person`s risk of developing bladder cancer.
• Exposure to carcinogenic chemicals in the environment, mainly
from textile or petrochemical industries , cars, paper, rubber
industries etc.
• A genetic predisposition in people born in some areas of Europe is
suspected
• Chemotherapy and radiation therapy: people undergoing chemo or
radiation therapy are vulnerable to developing bladder cancer.
• People infected schistosoma hematobium are at risk of developing
squamous cell carcinoma.
• Diabetes : individuals with type 2 diabetes have an increase rate of
developing bladder cancer.
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19. Signs and symptoms
• Blood in the urine (haematuria) often painless
• Feeling pain or burning on urination (dysuria)
• Frequent urge to urinate.
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20. METHOD OF DIAGNOSIS
• Clinical examination:
• Cystoscopy: is a technical examination where the doctor
inserts a lighted tube with a camera at the end through the
urethra to inspect the interior of the bladder and the urethra for
the presence of a tumor.
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21. • Urine cytology: this is a laboratory examination
performed to detect the presence of tumor in urine.
• Histopathological examination: is a laboratory
investigation of a tumor cell. The test is performed on
the tissue removed from the tumor during cystoscopy.
• Radiological examination:
 Computed tomography (CT) urography is used to
detect papillary tumors in the urinary tract, which can
be seen as filling defects or indicated by
hydronephrosis
 Ultrasound (US): helps in the detection of
hydronephrosis and visualization of intraluminal
masses in the bladder.
• urinary cytology: they examination of voided urine or
bladder-washing specimens for exfoliated cancer cells.
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22. Preventive measures
• Fluid intake: studies has been proposed that
fluid intake may reduce the risk of developing
bladder cancer in men.
• Fruit and vegetables: consumption of fruit and
vegetables is said to have protective effect
against bladder.
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23. Staging of bladder
• Staging of bladder cancer is base on Tumour, node, metastasis classification (TNM)
 T- primary tumor
• TX- primary tumour cannot be assessed
• T0- No evidence of primary tumour
• Ta- Non-invasive papillary carcinoma
• Tis- Carcinoma in situ: ‘flat tumor’
• T1- Tumour invades subepithelial connective tissue
• T2- Tumour invades muscle
• T2a- Tumour invades superficial muscle (inner half)
• T2b- Tumour invades deep muscle (outer half)
• T3- Tumour invades perivesical tissue
• T3a- Microscopically
• T3b- macroscopically ( extravesical mass)
• T4- Tumour invades the prostate, uterus, vagina, pelvic wall, abdominal wall.
• T4a- Tumour invades prostate, uterus, or vagina
• T4b- Tumour invades pelvic wall or abdominal wall.
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24.  N- lymph node
• NX- regional lymph nodes cannot be assessed
• N0- No regional lymph node metastasis
• N1- metastasis in a single lymph node in the true
pelvis (hypogastric, obturator, external iliac, or
presacral)
• N2- metastasis in multiple lymph nodes in the
true pelvis.
• N3- metastasis in common iliac lymph node(s)
 M- Metastasis
• MX- metastasis cannot be assessed
• M0- no distant metastasis
• M1- distant metastasis
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25. stages definition category
Stage 0a Non-invasive papillary carcinoma: the tumour is confined to the innermost
cell layers of the bladder lining the epithelium.
Non-muscle
Stage 0is Carcinoma in situ: ‘flat tumour: a high-grade tumour confined to the
innermost cell layers of the epithelium
invasive
Stage 1 The tumour invades the deeper connective tissue lining the lamina propria Bladder cancer
Stage 2 The tumour invades the muscles of the bladder . This stage is divided into 2
T2a- Tumour invades superficial muscle (inner half)
T2b- Tumour invades deep muscle (outer half)
Muscle invasive
bladder cancer
Stage 3 The tumour invades the tissues surrounding the bladder. This
stage is divided into 3
T3a- Microscopically.
T3b- macroscopically ( extravesical mass).
T4a- Tumour invades prostate, uterus, or vagina
Advance and
metastatic
Stage 4 T4- Tumour invades the prostate, uterus, vagina, pelvic
wall, abdominal wall. The tumour is accompanied by
metastasis.
disease
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26. Layers of the bladder wall showing the
mucosa and the muscle layer
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27. Grading of bladder cancer
• The grading of bladder cancer depends on the rate at which
they cells multiply and the degree to which they are
invasive. There are four different grades of bladder cancer.
1. Papilloma: a tumour composed of non- malignant cells.
2. Papillary urothelial neoplasm of low malignant
potential (PUNLMP): a tumour composed of non-
malignant cells typically covered with a thickened layer of
transitional epithelium.
3. Urothelial carcinoma low grade: a malignant tumour that
grows slowly and is unlikely to spread.
4. Urothelial carcinoma high grade: a malignant carcinoma
that grows faster and is more likely to spread.
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28. Treatment options for bladder
cancer
• The treatment will vary depending on whether the cancer is invasive
or not.
 Cystoscopy and transurethral resection:
• A cystoscope is used to cut the cancer out (transurethral resection)
under a general anaesthetic. The tissue removed will be sent to a
pathologist who will examine the specimen microscopically to
determine if the cancer is just in the lining of the bladder, partially
invading the wall of the bladder or more deploy invading the muscle
of the bladder wall.
 Intravesical chemotherapy or immunotherapy:
• In order to reduce the risk of recurrence and progression; all patients
that have had a TURBT are given one single intravesical instillation
with a chemotherapeutic agent such as mitomycin C or epirubicin
or doxorubicin immediately after surgery.
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29.  Intravesical immunotherapy with bacillus calmette-Guerin (BCG):
• For patients with certain risk profile, it recommended to give intravesical
treatment bacillus calmette-Guerin (BCG), a vaccine use to protect against
tuberculosis.
 Cystectomy: partial or complete removal of the bladder. Recommended to
patients with stage II, stage III ie for invasive cancers.
• Following cystectomy, the urine needs to be diverted in one of the
following ways;
a. Urine is directed through the intestinal tissue, known as an ileal conduit,
with an opening or stoma on the abdominal wall. The patient will wear a
pouch externally on the skin to collect urine.
b. An orthotopic neobladder is created. In this operation the patients bladder
is removed and replace with loops of their own bowel fashioned into a
pouch. There is no change to normal bowel function and the patient
passes urine naturally through the urethra.
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30. Side effect of treatment
Chemotherapy/ immunotherapy:
• The side effect of intraversical chemotherapy
include:
Feelings of urgency to urinate, pain in the bladder
and sometimes incontinence.
Nausea and loss of appetite.
Rarely there may be absorption into the blood
stream of the chemotherapy or immunotherapy
agents used, this may require specific treatments
like the use of long term antibiotics inn rare
circumstances.
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31.  Cystectomy:
• The side effect from bladder removal are substantial and life;
 Men face impotence and infertility due to the damaged on the nerve
that supply the penis and absence of the prostate will bring about
infertility.
 Women also face sexual dysfunction and sometimes infertility; due
to removal of part of the vaginal during radical cystectomy . In some
cases ovaries , fallopian tubes, and uterus are removed as well
leading to immediate menopause.
• Other side effect
 A hernia can develop alongside the ileal conduit/stoma that may be
unsightly and may repair.
 If a neobladder is constructed, it lead to urinary incontinence.
 Hair loss
 Fatigue
 Mouth sores
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32. Management of side effects
• Counter Chemo-Induced Fatigue With
Exercise.
• Take Medication to Quell Nausea and
Vomiting.
• Using a Cooling Cap to Minimize Hair Loss.
• Beat Mouth Sores With Ice Chips.
• Wash Your Hands Often to Avoid Infection.
• Tell Your Doctor About Tingling in Your
Hands or Feet.
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