The second most common tumor of the genitourinary system, among all cancers, it is 4th in men and 8th in women, Male / Female ratio = 2.7, and is more common in white race than black race.
Although it can be seen at any age, it is usually middle age. It is more common in the elderly population, the average age of diagnosis is 69 in men and 71 in women, and the incidence increases with age. Well-differentiated tumors appear to be more common and have a better prognosis in adolescents and adults under 30 years of age.
Risk Factors:
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Chemical carcinogens
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Smoking
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Genetic predisposition
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Pelvic irradiation
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Cytotoxic chemotherapeutics
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Bacterial, viral, parasitic agents
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Chronic irritation
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Endogenous tryptophan metabolites
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Analgesic use
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Artificial sweeteners
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Coffee, tea?
Smoking is the most important risk factor.
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The incidence is 4 times higher than in non-smokers
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The risk increases in direct proportion to the number, duration and rate of inhalation of cigarette smoke
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It takes up to 20 years for the risk to return to normal after quitting smoking
CLASSIFICATION
1- Papilloma: mostly in young people, benign and growing towards the bladder
2-Transitional cell carcinoma: It is 90-95% of bladder cancers. They form the group that we will describe here under the name of bladder cancers.
3- Nontransitional cell carcinomas
-Adenocarcinoma
-Squamous cell carcinoma
-Undifferentiated carcinomas
-Mixed carcinoma
-Epithelial and nonepithelial carcinomas.
DIAGNOSIS:
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Patient history.
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Physical examination
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Routine tests (Urine and blood analyses)
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Imaging methods
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IVP, Ultrasonography, Computerized Tomography, Bone Scintigraphy.
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Cystoscopy
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Urine cytology
Beli rti and findings:
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Painless, intermittent hematuria (blood in the urine)
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Frequent urination, feeling of urgency to urinate , dysuria (burning during urination), nocturia
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Inability to urinate, suprapubic mass, flank pain
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Loss of appetite, weakness, weight loss, anemia.
Hematuria is one of the most important of these and is the complaint of consulting a physician in 85% of cases, its degree is not related to the extent of the disease, It is painless and intermittent. In almost all cases diagnosed with cystoscopically identifiable bladder cancer, at least microscopic hematuria (blood seen only in urine analysis) can be detected.
Of the imaging methods, the most frequently used and first applied in diagnosis is ultrasonography (US), which is the least invasive method. . IVP has an important place in the evaluation of hematuria and especially the upper urinary system. In addition to being able to show a bladder tumor, computed tomography (CT) may be important in terms of local spread, metastatic lymph nodes and distant organ metastases.
Cystoscopy: It is the gold standard in diagnosis, staging and follow-up. It is the gold standard in suspicious areas. It allows biopsy, but it is an expensive and invasive method.
Cytology: It is the search for cancer cells shed from the bladder epitheliumin urine or bladder wash water. Diagnostic value is low in low-grade superficial tumors.
STAGING:
- Tumors limited to the bladder mucosa and submucosal connective tissue are Superficial Tumors.
- Tumors that spread to the bladder muscle by passing through the submucosal connective tissue are Muscle Invasive Tumors.
- Tumors that spread to neighboring or distant organs are Metastatic Tumors. p>
Superficial tumors constitute 75-85% of all bladder cancers, they have a high probability of recurrence, but only 10% progress to muscle-invasive or metastatic disease.
Muscle Invasive Tm. They constitute 15-25% and distant metastasis occurs in 50%.
The treatment options for these three groups are completely different.
Extra-bladder spread first occurs through the lymph vessels and the lymph nodes around the bladder. and then travels to distant organs via blood. best The most distant organ metastases are 38% Liver, 36% Lung, 27% Bone, 21% Adrenal, 13% Intestinal.
TREATMENT IN BLADDER TUMORS:
Bladder tumor treatment purpose >ı:
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To reduce relapses, thus avoiding invasive procedures such as cystoscopy or TUR-MT
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To prevent tumor progression. Thus, reducing the need for more aggressive treatment
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Reducing the cancer-related death rate.
Initial treatment of all bladder tumors transurethral It is resection(TUR-MT), that is, the tumor in the bladder is scraped with a closed operation by entering through the urinary tract.
TUR-MT, in addition to its therapeutic role in superficial tumors, determines the tumor stage and tumor stage after pathological examination. It enables the treatment to be directed by precisely determining the degree of the disease. However, when TUR-MT is left as the only treatment, there are recurrence tumor rates that can reach 70%.
During the first TUR-MT, the entire bladder mucosa is systematically examined with appropriate degree lenses, and when a bladder tumor is detected, the upper part of the tumor and Its base (including the muscle layer) is scraped and sent to the pathology laboratory as separate samples, and the tumor base is completely cauterized. Biopsy is taken in other suspicious areas.
Treatment in superficial bladder tumors:
In tumors reported superficial as a result of pathology in the first TUR-MT;
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TUR-MT + Close Monitoring
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TUR-MT + Intravesical (inside the bladder) Chemotherapy
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TUR-MT + Intravesical Immunotherapy can be applied.
However, recurrence rates of up to 70% have been found in those who were monitored only by TUR-MT. The purpose of intravesical treatments after TUR-MT is to:
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To prevent implantation, that is, tumor transplantation to normal areas
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To eliminate small residual tumors that go unnoticed.
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To prevent and delay relapse or progression.
For this purpose, Mitomycin C is administered into the bladder. >Chemotherapeutic drugs such as doxorubicin, epirubicin, valrubicin or BCG, interferon Immunotherapeutic drugs such as , interleukin are administered.
Treatment in Muscle-Invasive Tumors:
The gold standard in the treatment of muscle-invasive bladder tumors is the Radical Cystectomyoperation. . In this operation, in men, the bladder, prostate, vesicula seminalis,
visceral peritoneum covering the bladder, fatty tissue around the bladder are removed, and in women, the bladder, urethra, uterus, ovaries, pelvic peritoneum, posterior vaginal cuff are removed, as well as pelvic lymph nodes up to a certain level. It is removed and urinary diversion is performed, that is, the urine is directed to another place instead of the excreted bladder.
Radical cystectomy is still the most effective and permanent method in the treatment of muscle-invasive bladder cancer. It provides accurate staging of the primary tumor and lymph nodes and thus reveals whether there is a need for additional chemotherapy.
5-year survival with Radical Cystectomy is around 50%. Radiotherapy and/or chemotherapy may be offered as an option for patients who are not medically suitable for cystectomy or who do not want surgery.
An important point after radical cystectomy is urinary diversions, that is, where the urine will be directed after bladder removal. . Options here:
1-Diversions opened to the incontinent skin: Ileal or colon conduits are in this group and the ureters are connected to a released piece of intestine and the other end of the intestine is opened to the abdominal skin. Urine accumulates in special bags applied to the skin area.
2-Continent rectal reservoir: ureters are directed to the sigmoid colon and urine is excreted through the rectum.
3-Continent skin reservoirs: a pouch formed from the intestine. It is attached to the skin with special mechanisms, and this mechanism prevents urine from leaking out. It is emptied by placing a catheter in this pouch at certain intervals.
4-Orthotopic neobladder: The new bladder created from the intestine is connected to the normal urinary tract, and the patient urinates normally.
Treatment in metastatic disease
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At least 50% of patients with muscle invasive disease die from metastatic disease within 2 years
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The probability of clinically determined distant metastasis at initial diagnosis is 5%
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The average life expectancy is 12-14 months with chemotherapy.
Combined treatments containing cis-platinum are applied, they are highly toxic treatments. The complete response rate is between 5-18%.
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