Bladder cancer is the fourth most common cancer in men, after prostate, lung, and colorectal cancer, And is the 10th most common cancer in women. From 1985-2000, the number of patients diagnosed annually with bladder cancer increased by 33%. The recurrence rate for superficial transitional cell cancer of the bladder is high, and as many as 80% of patients have at least one recurrence. In developed countries, 90% of bladder cancers are TCC. In developing countries, 75% of bladder cancers are SCCs, and most of these cancers are secondary to S haematobium infection
The clinical course of bladder cancer carries a broad spectrum of aggressiveness and risk. Low-grade, superficial bladder cancers have minimal risk of progression to death; however, high-grade muscle-invasive cancers are often lethal.
Almost all bladder cancers are epithelial in origin. The urothelium consists of a 3- to 7-cell mucosal layer within the muscular bladder. Of these urothelial tumors, more than 90% are transitional cell carcinomas. However, up to 5% of bladder cancers are squamous cell in origin, and 2% are adenocarcinomas The World Health Organization classifies bladder cancers as low grade (grade 1 and 2) or high grade (grade 3). Tumors are also classified by growth patterns: papillary (70%), sessile or mixed (20%), and nodular (10%). Carcinoma in situ (CIS) is a flat, noninvasive, high-grade urothelial carcinoma. The most significant prognostic factors for bladder cancer are grade, depth of invasion, and the presence of CIS
The following is the TNM staging system for bladder cancer: CIS - Carcinoma in situ, high-grade dysplasia, confined to the epithelium Ta - Papillary tumor confined to the epithelium T1 - Tumor invasion into the lamina propria T2 - Tumor invasion into the muscularis propria T3 - Tumor involvement of the perivesical fat T4 - Tumor involvement of adjacent organs such as prostate, rectum, or pelvic sidewall N+ - Lymph node metastasis M+ - Metastasis
Laboratory Studies : Any patient with gross or microscopic hematuria should be urologically evaluated Urinalysis with microscopy Voided urinary cytology Newer molecular and genetic markers may help in the early detection and prediction of TCC. Newer, voided urine assays (ie, bladder tumor antigen [BTA-Stat, BTA-TRAK], nuclear matrix protein [NMP-22], fibrin/fibrinogen degradation products [FDP]) are being used for the detection and surveillance of TCC
The American Urologic Association Best Practice Policy recommends CT scanning of the abdomen and pelvis with preinfusion and postinfusion phases. This is ideally performed with a CT urography or followed by radiography of the kidneys, ureters, and bladder (KUB) to obtain images similar to those produced with intravenous pyelography (IVP). Two commonly used alternative studies are IVP and renal ultrasonography. The IVP is the traditional standard for upper-tract urothelium imaging; however, it is poor for evaluating the renal parenchyma. Ultrasonography is also commonly used; however, urothelial tumors of the upper tract and small stones are easily missed
To obtain biopsy samples of suspicious lesions during cystoscopy. And attempt to include the bladder muscle in the biopsy specimen. This allows the pathologist to determine whether the tumor is muscle invasive or not. Transitional cell tumors are typically papillary or sessile, and CIS may appear as an erythematous, velvety lesion.
invasive Ta T CIS More than 70% of all newly diagnosed bladder cancers are superficial, approximately 50-70% are Ta, 20-30% are T1, and 10% are CIS. Approximately 5% of patients present with metastatic disease
Superficial bladder cancer has a good prognosis, with 5-year survival rates of 82-100%. The 5-year survival rate decreases with increasing stage, as follows: Ta, T1, CIS – 82-100% T2 – 63-83% T3a – 67-71% T3b – 17-57% T4 – 0-22%
The risk of progression, defined as an increased tumor grade or stage, depends primarily on the tumor grade. The risk of progression increases with tumor grade, as follows: Grade I – 10-15% Grade II – 14-37% Grade III – 33-64% CIS alone, or in association with Ta or T1 papillary tumor, carries a poorer prognosis and a recurrence rate of 63-92%.
Endoscopic treatment Transurethral resection of bladder tumor (TURBT) is the first-line treatment to diagnose, to stage, and to treat visible tumors. Patients with bulky, high-grade, or multifocal tumors should undergo a second procedure to ensure complete resection and accurate staging. Approximately 50% of stage T1 tumors are upgraded to muscle-invasive disease. Electrocautery or laser fulguration of the bladder tumor is sufficient for low-grade, small-volume, papillary tumors. No further metastatic workup is needed for obviously superficial tumors. Because bladder cancer is a polyclonal field change defect, continued surveillance is mandatory.
The high rate of disease recurrence and progression in superficial bladder cancer underscores the need for careful follow-up studies. Surveillance for patients with superficial transitional cell bladder cancer includes cystoscopy and bladder wash cytologies every 3 months for 2 years, then every 6 months for 2 years, and then at least yearly.