The inner wall of the bladder is lined with transitional cells that are responsible for most cancers of the bladder. The development and management depends very much on the invasiveness of the tumor. We distinguish cancer superficial bladder cancer invasiveness. If the cancer is superficial good prognosis, invasive cancer of the bladder is much more severe and requires aggressive treatment.
The bladder cancer is a tumor frequently. In 2000, 10,700 new cases were diagnosed in France, including one third of bladder cancers are related to smoking. The incidence of this cancer is the sixth largest in France by its frequency among cancers.
The factors most important are tobacco and some chemical carcinogens. As such the bladder cancer can be considered an occupational disease.
The main industrial chemicals in question are:
* Aromatic amines;
* Hydroxylated derivatives halogenated and sulphonated;
* Derivatives of aniline;
* Some polycyclic hydrocarbons;
* Industrial derivatives of tryptophan;
Also found at the origin of bladder cancer drugs (phenacetin, cyclophosphamide) or pelvic irradiation. The lesions of urinary bilharziasis may degenerate into malignant lesions like squamous cell carcinoma of the bladder, this parasite is found mainly in Egypt and West Africa.
There is also an endemic nephropathy tubulointerstitial pore water in the Balkan region, which may be complicated by urothelial cancer. This disease is caused by food poisoning by mycotoxin, ochratoxin A, produced by a fungus of cereals.
Several mutations in certain genes increase the risk of bladder cancer, including the p63 gene, the gene encoding the receptor for epidermal growth factor and other genes.
The clinical features suggestive of malignant tumor of the bladder are not specific. We note first the micro or macro-hematuria, dysuria, urinary signs of infection to clear urine, recurrent urinary infections. The alteration of the general condition and the pain often mark an advanced stage of disease.
Clinical symptoms require confirmation with achievement
* Finding a dipstick haematuria,
* Examination of urine cytology may confirm the presence of red blood cells and abnormal cells, but this has a low sensitivity,
* Cystoscopy to visualize the bladder lesions and perform at the same time for pathological studies of biopsies of lesions and confirmation of diagnosis. is an essential examination.
* Imaging examinations such as CT and MRI of the pelvis are helpful in staging. In this final stage, the injection of ferumoxtran-10 would detect lymph node metastases, even in small sizes, with very good sensitivity and specificity.
The bladder cancer develops from the inner lining of the bladder. In untreated, the disease spreads beyond the mucosa through the bladder wall, spreads through the lymphatics to the lymph nodes of the pelvis and through the veins throughout the body . Staging helps to know the exact stage of the disease, to apply the best treatment and to estimate the prognosis of the disease.
There are different pathological types of malignant tumor of the bladder. The term bladder cancer is the carcinoma of the bladder. There are three forms:
* The transitional cell carcinoma is the most common form. It represents 90% of bladder cancers.
* Squamous cell carcinoma is rare, it corresponds to 7% of cancers.
* Adenocarcinoma is rare, about 1%.
The non-cancerous lesions consistent with lymphoma, sarcoma and neuroendocrine tumeus bladder whose treatment differs carcinomas.
The TNM-UICC 2002
* Tx Primary tumor can be classified
* T0 tumor can not be classified
* Ta papillary superficial (respecting the basement membrane)
* Tis carcinoma in situ (plan, respecting the basement membrane)
* T1 Tumour invades subepithelial connective tissue
* T2 Tumor invades the muscle (or detrusor)
o T2a superficial muscularis
o T2b deep muscularis
* T3 tumor invading the bladder tissue died (fat)
o Achievement T3a microscopically
o Achievement T3b macroscopically
* T4 Invasion of adjacent organs
o Prostate T4a or uterus or vagina
o T4b pelvic wall or abdominal wall
N (regional lymph)
* Nx Lack of sufficient information
* N1 Metastasis in a single pelvic lymph node <2> 2 cm but <5> 5 cm
M (Distant metastasis)
* M0 No distant metastasis
* M1 Presence of distant metastases
Prognostic factors are:
* TNM stage;
* Histological grade;
* The presence or absence of hydronephrosis;
* The quality of transurethral resection for patients treated with combined radiation and chemotherapy.
The 5-year survival for localized tumors of the bladder is 60% irrespective T. It is independent of the type of local treatment. The 5-year survival of forms with pelvic lymph node is 5-25% depending on the size of the lymph node. The 5-year survival is 10-15% in patients treated with chemotherapy. Most deaths were observed within 2 years after diagnosis.
The metastatic disease have a very poor prognosis, with a survival time close to a year.
The treatment consists of either intravesical BCG immunotherapy (whose effectiveness remains controversial on the final outcome) or chemotherapy mitomycin C. Interferon alpha is being studied.
Chemotherapy may be used in several situations:
* Associated with radiotherapy.
* Before the surgery to try to reduce the size of the tumor and allow intervention. It is a neo-adjuvant chemotherapy. Several studies suggest an advantage to achieve this chemotherapy under certain conditions without his interest is formally established.
* After the surgery, it is called adjuvant chemotherapy whose goal is to reduce or delay relapse. In this situation also several studies suggest an advantage to this chemotherapy without his interest has been fully demonstrated.
For chemotherapy systemically effective molecules in bladder cancer are cisplatin, methotrexate, vinblastine, adriamycin, paclitaxel and gemcitabine. Today, the protocol used in the adjuvant and metastatic protocol GC (gemcitabine cisplatin). This protocol is equivalent to the MVAC protocol in terms of efficiency. It is less toxic. Vinflunine may be used in second line after failure of platinum-based chemotherapy.
Chemotherapy combined with radiotherapy can be combined cisplatin and 5FU.
See also Pancreatic cancer