Bladder Cancer (Transitional cell carcinoma of the Bladder)

What is Bladder Cancer?

This animation brought to you by Blausen Medical Communications.
Contact Andrew Walbank.

A type of bladder cancer is Transitional cell carcinoma of the Bladder.The bladder functions as a waste storage system for urine. Urine is produced by the kidneys as they filter the blood, and then travels down the ureters into the bladder. The bladder expands and once it reaches a certain maximum volume, the urge to pass urine increases until urine is passed.The bladder is made up of an elastic type tissue which contains a layer of muscle. The bladder is lined with epithelium called transitional cells which are tall, thin cells that protect the underlying bladder from the urine contained therein. The membrane that the epithelium sits on is called the basal membrane.

Statistics on Bladder Cancer?

Bladder cancer is a relatively uncommon disease.
Bladder cancer incidence increases with increasing age.
Bladder cancer is twice as common in males as it is in females.
Bladder cancer is seen worldwide, but is more common in certain parts of Africa and the Mediterranean due to an infection caused by Schistoma (a parasite in that region).
90% of bladder tumours are of the transitional cell carcinoma type.

Risk Factors for Bladder Cancer

Cigarette smoking predisposes people to bladder cancer. Smoking cigarettes increases a persons risk of developing bladder cancer approximately 5 fold.Industrial exposure to certain chemicals such as analine in the dye industry increases the risk. Other organic chemicals used in rubber and other manufacturing processes can also increase the risk.Exposure to the chemotherapy agent Cyclophosphamide (occasionally used in younger people to treat either lymphoma or autoimmune diseases) is associated with a higher risk of developing bladder cancer.Chronic irritation of the bladder appears to provoke development of bladder cancer. The bladder can be irritated by reoccurring infections and bladder stones. In certain parts of Africa and in the Mediterranean area, a parasitic infection called schistosomiasis causes irritation of the lining of the bladder. The parasites that burrow into the bladder appear to stimulate the tumour.

Progression of Bladder Cancer

This type of bladder cancer tumour spreads by different mechanisms, depending on the type.Superficial transitional cell carcinoma (or superficial bladder cancer, bladder warts) tend to spread only within the bladder unless they are left untreated for a long period of time. They may spread along the lining of the bladder but not penetrate deeply into the bladder unless left.Invasive bladder cancer spreads via the lymphatics to the regional lymph nodes in either the groin or pelvis and then upwards into the abdomen. Blood borne spread is to the bones, lung, liver and occasionally brain.

Transitional cell carcinoma of the Bladder

Image courtesy of Mr. Tom Shannon (MBBS, FRACS).Click here to visit Mr. Shannon's external site, Hollywood Urology.

How is Bladder Cancer Diagnosed?

General investigations into bladder cancer may show anaemia, especially if haematuria (presence of blood in the urine) has been significant and prolonged. A raised alkaline phosphatase level may indicate either liver or bone involvement and in some cases the serum calcium may be raised in bone metastases. Abnormal kidney function (e.g raised creatinine or urea) may indicate that the bladder tumour, whether superficial or deep, is causing some blockage of the ureters where they enter the bladder.

Prognosis of Bladder Cancer

Superficial bladder cancer has an extremely good prognosis with a vast majority (greater than 90%) of people being alive and well after 5 years, with a majority of them being cured.Invasive bladder cancer however is different. If invasive bladder cancer is diagnosed early, the cure rate is still greater than 50% but if the tumour spreads to the regional lymph nodes this reduces survival to less than 50% over 5 years. Distant metastases is a bad sign as it means that the disease has spread and is obviously at a late stage in the tumours development.

How is Bladder Cancer Treated?

Radiotherapy has an important role in treating specific problems due to bladder tumours. In particular, painful bone metastases usually respond well to doses of radiation.Superficial Bladder Cancer:Superficial bladder tumours can be managed very effectively by repeated resection. After removal of these bladder tumours the surgeon will normally check inside the bladder on a regular basis from that point forward. Superficial bladder tumours tend to come back intermittently and may require resection on a repeated basis.Invasive Bladder Cancer:Invasive bladder cancer requires a more aggressive approach. In the early stages, the disease can be resected surgically either by partial or complete removal of the bladder (cystectomy). This can be fairly major surgery which will require the creation of an ileal conduit.If the disease has spread to the regional lymph nodes these may need to be removed during the same operation. If the bladder cacner tumour is found in the regional nodes, bladder cancer treatment may then be surgery plus radiotherapy or radiotherapy alone.A number of chemotherapy agents are active against bladder cancer and these may be given intravenously or instilled directly into the bladder (intra-vesical): Intravesical BCG.1) Chemotherapy protocols include:

MVAC
Methotrexate 30mg/m2 IV bolus days 1,15,22
Vinblastine 3mg/m2 IV bolus days 1,15,22 (vesicant)
Doxorubicin 30mg/m2 IV bolus day 2 (vesicant)
Cisplatin 70mg/m2 IV over 2 hours day 2- (Repeat every 28 days) Restage every 3 cycles

2) For bladder cancer patients unlikely to tolerate MVAC because of renal function, age or performance status:- Cisplatin 70 mg/m2 day 1 (or substitute carboplatin AUC 5)- Gemcitabine 1250 mg/m2 days 1+83) Concomitant chemo/radiotherapy.- Cisplatin 20mg/m2/daily x 5days with 1 litre N Saline hydration.- Cover during week 1 and 4 of radical radiation concomitantly.

Bladder Cancer References

eMEDiCINE.
Shah I; Gupta CL; Gupta R; Bardwajs Department of Urology, Acharya Shri Chander College of Medical Sciences and Hospital, Sidhra, Jammu, Jammu-180006 (India) Transitional cell carcinoma of bladder in young patients JK-Practitioner. 2001 Jul-Sep; 8(3): 181-2.

Warde P, Gospodarowicz MK: New approaches in the use of radiation therapy in the treatment of infiltrative transitional-cell cancer of the bladder. World J Urol 1997; 15(2): 125-33.