Bladder carcinoma

They currently make up more than 2% of newly diagnosed malignancies.

Epidemiology

 * morbidity is still rising, mortality is decreasing, it affects men 3 times more often,
 * high incidence - in SW Europe, low in India and Japan,
 * the main occurrence is between 50 and 70 years.

Etiology

 * the main risk factor is smoking (mainly black tobacco smoking),
 * exposure to certain industrial pollutants -  'aromatic amines'  (benzidine, 2-naphthylamine,…),
 * chronic infection, in endemic areas - schistosomiasis (mainly squamous cell carcinoma).

Clinical manifestations

 * Hematuria and pollakiuria,
 * increased bladder irritation indicates an involvement of the neck, when the urethral orifice is affected, hydronephrosis and secondary pyelonephritis may occur,
 * sometimes it can be completely asymptomatic,
 * general symptoms (anorexia, weight loss, anemia) - are only in very advanced tumors.

Diagnosis

 * 1) Cystoscopy,
 * 2) endoscopic biopsy, eventually transurethral resection → this is necessary to determine the progress

Histopathology

 * 97% are urothelial carcinomas, rarely adenocarcinomas and undifferentiated carcinomas, squamous cell carcinoma is endemic (schistosomiasis),
 * macro - different appearance - papillary, infiltrating, probably in 1/4 they arise multicentricly (this is the cause of frequent recurrences),
 * they can start as ca in situ and then change to a papillary or infiltrating form,
 * initially the tumor grows in the mucosa, early into the submucosa, muscle and surrounding fat, metastasizes to the pelvic nodes, later paraaortic, more rarely hematogenously.

Treatment
The method of therapy depends on a careful evaluation of histology, degree of invasion, extent of the disease.

Surgical treatment

 * Non-invasive tumors can be treated with  transurethral resection (TUR) - it is relatively non-intrusive, it does not affect bladder function,
 * for the treatment of surface structures - coagulation or laser vaporization,
 * often, however, recurrence occurs within 1 year, so the five-year survival does not exceed 80%,
 * therefore it is recommended to supplement adjuvant intravesical CHT, intravesical application of IFN, BCG vaccine, adriamycin, irradiation,
 * if the tumor grows into muscle - partial cystectomy is determined,
 * the rationality of this procedure is questioned due to the multifocal origin of urothelial tumor
 * in addition, there is a risk of implantation metastases, so it is practically not performed today,
 * for larger tumors - "radical cystectomy with lymphadenectomy", in men with prostatectomy, in women with  hysterectomy,  adnexectomy,
 * it is a very demanding procedure and its indications must be carefully considered.

Radiotherapy

 * Most often as external irradiation, it is not used as a separate treatment, for numerous emergency services,
 * even as neoadjuvance no significant effect has been confirmed,
 * so far radiochemotherapy (RCHT) could have a good effect, but this is not based on studies,
 * however, it is irreplaceable as palliation (skeletal meta analgesia, suppression of hemorrhagic complications).

Chemotherapy

 * Served either locally or systemically,
 * 1) local - in diffuse in situ carcinomas, in superficial tumors after TUR and in papillary carcinomas (the most advantageous today seems  'mitomycin C' , which is practically not absorbed from the bladder and does not endanger toxicity),
 * 2) systemic - the main palliative treatment advanced forms, the tumor responds to a number of cytostatics,
 * most similar to - Pt derivatives, anthracyclines, ifosfamide,
 * adjuvant CHT - very useful especially for nodal involvement,
 * neoadjuvance - has many disadvantages, it is not done by default.

Photodynamic therapy

 * This can work in "in situ" carcinomas and in papillary carcinomas.

Immunotherapy

 * Mainly in the form of local application of BCG.

Prognosis

 * For non-invasive form, 5-year survival is 75-80%.

Related links

 * Kidney cancer
 * Kidney carcinoma