Bladder Cancer
Bladder cancer is the second most commonly treated cancer by an Urologist, and should therefore be considered common. Of course any time a person is informed that they harbor a cancer it is a frightening time, but it should be noted that the vast majority of cases of bladder cancer are low risk, and thus have a low likelihood of spread. Such cases are in many ways analogous to suspicious colon polyps that, if monitored by regular scope procedures and addressed at an early stage, can be very effectively managed with minimal impact on one’s life. However, perhaps 10-20% of cases of bladder cancer are far different and are aggressive. As such, these cases will need to be treated that way. The main risk factor for development of bladder cancer, or cancer of the lining of the urinary tract at any location, is smoking. However, not all patients with bladder tumors are smokers. It is largely accepted that environmental exposure to some chemicals also causes bladder cancer, but an exact list of all causative agents has not been completely outlined.
Nearly all bladder cancers present primarily with the finding of blood in the urine, or hematuria. This blood can be only microscopic, or at times can be seen by the patient when urinating (gross hematuria). It is because of this relationship between hematuria and bladder cancer that, when found, blood in the urine is nearly always referred to a Urologist, and a workup is performed. A hematuria workup will consist of a radiologic study that allows visualization of the entire urinary tract (such as a contrast CT scan), usually a urine test looking for cancer cells in the urine (such as a cytology test), and finally, direct visualization of the bladder called a cystoscopy. Other urine tests exist as well as an adjunct to cytology, and these may at times be utilized. The workup is not complete without all three tests being performed. We will send you to a radiologist for the CT scan and will ask that you return to us with your actual disc for another office appointment whereby we check the cytology result and perform a cystoscopy, which is a quick one-minute office procedure. It should be noted that most of these workups do not show bladder cancer, or may show other causes for hematuria such as kidney stones or an enlarged prostate. The goal here is simply to exclude cancer, not necessarily to determine a cause for the blood in the urine.
Almost all bladder cancers are called transitional cell carcinoma. Over 90% of such tumors will be formed in the bladder, but they can occur anywhere along the lining of the urinary tract including the ureter or in the kidney, or renal pelvis.
A typical bladder tumor
Bladder cancer almost always refers to a tumor of the lining of the urinary tract, or urothelium. The cells in this lining are called transitional cells, thus almost all bladder cancers are called transitional cell carcinoma. Over 90% of such tumors will be formed in the bladder, but they can occur anywhere along the lining of the urinary tract including the ureter or in the kidney, or renal pelvis. If a urothelial tumor is found in a location other than the bladder, traditionally this is managed by removal of the entire kidney and ureter on that side. In special circumstances, such tumors may be removed with scopes, or with removal of only part of the ureter. But, for the rest of this essay, we will discuss tumors of the bladder.
Bladder wall post-resection
When a bladder tumor is found, it is nearly always cancerous or malignant. However, two properties must be known about the tumor to know how dangerous it is, and what the management will be. We will first need to perform a relatively minor procedure called a TURBT, or trans-urethral resection of the bladder tumor. This will be a procedure, performed in a surgery center or hospital setting based on extent, whereby a scope called a resectoscope is placed into the bladder. This special scope allows us to shave off the tumor from the surface of the bladder wall, and to shave deep enough also to provide tissues from the deeper layers of the bladder called the lamina propria and the deep muscle layers. This procedure is done as an outpatient or at times will require an overnight stay. Aside from some annoyance with a urinary catheter, some irritative urinary symptoms afterward and blood in the urine, a TURBT carries with it the rare risks of bladder perforation or injury to the ureteral orifice, where the kidney connects to the bladder. The patient will come to our office to review the pathology report from their TURBT, and it is at that time that we will know what we need to know regarding the tumor. By definition, a CT scan will have already been performed that hopefully rules out spread or metastasis.
The pathology report will tell us about two main things: the grade of the tumor and whether the tumor is invasive or not. The grade will usually be called simply high grade or low grade. The higher the grade, the more aggressive the tumor is. However, the property that will have the biggest impact on risk, and affect treatment the most, is whether the tumor is invasive or not. Invasive tumors can metastasize, and with some exception, non-invasive or superficial tumors do not. There is a third finding that must be mentioned here as well called carcinoma-in-situ, or CIS. CIS is a very ominous finding, as although it is considered a pre-malignant lesion, it almost always will form a high grade, invasive tumor. Thus, ironically, much more would be made of a finding of a small area of CIS, even though it is pre-malignant, than a large, low grade, non-invasive bladder tumor. The finding of CIS will always warrant further treatment.
Removal of one’s bladder is a very involved, major operation done in specialized centers in most cases. Dr. Engel is one of a few Urologists in the area that performs complex urinary tract reconstruction to handle urination in a continent manner after bladder removal.
If a primary tumor is found to be deeply invasive, there is at least a 50% chance of metastasis that has occurred, even if it cannot be found. Such tumors that are invasive into the deep muscle will necessitate removal of the bladder. Contemporary thinking is that giving chemotherapy prior to bladder removal may be beneficial in such cases (neoadjuvant chemotherapy). Dr. Engel will always arrange a visit to an oncologist to be offered this approach, but sees logic in some cases in proceeding with surgery directly and offering chemotherapy after the surgery based on the pathologic findings (adjuvant chemotherapy). Removal of ones bladder is a very involved, major operation done in specialized centers in most cases. Dr. Engel performs such operations regularly. He is one of a few Urologists in the area that performs complex urinary tract reconstruction to handle urination in a continent manner after bladder removal. In men, Dr. Engel performs a Studer ileal neobladder, whereas in women his preferred reconstruction is called an Indiana pouch. Many patients will opt for a simpler approach called an ileal conduit whereby the urine will flow into an ostomy bag placed on the patient’s abdomen. In men, removal of the prostate is usually also performed when removing the bladder, but in selected cases Dr. Engel will perform a prostate sparing cystectomy in an effort to preserve erectile function and potentially retain ejaculation. Feel free to view a video of Dr. Engel performing such a surgery found in the common procedures section of this site.
Most tumors are superficial (not invasive) and low grade. These tumors are commonly only managed by performing regular cystoscopies and cytologies in the office, with removal when found.
But muscle invasive tumors are the exception, not the rule. Most tumors are superficial (not invasive) and low grade. These tumors are commonly only managed by performing regular cystoscopies and cytologies in the office, with removal when found. At times, we may recommend further treatment in the form of a course of instilling chemotherapy into one’s bladder (intra-vesical chemotherapy), but this is usually reserved for patients with recurrent disease. Such low risk tumors are often termed “nuisance tumors”, as they represent a nuisance but are not particularly dangerous. Low risk tumors do have a high recurrence rate, but they rarely progress to be a dangerous invasive or high grade tumor.
It is the high grade non-invasive tumor, or the early invasive tumor going into the lamina propria only, or when CIS is found that warrants treatment beyond simply surveillance cystoscopy. Such tumors, and especially CIS, not only have a high recurrence rate, but they also have a high progression rate. A tumor that is high grade and invasive to the lamina propria is especially dangerous. Such tumors can already have metastasized, and must be treated aggressively. These tumors are called T1G3 tumors. Some even advocate cystectomy when these are found, but more typical management involves automatic repeat resection to be sure that deeper invasion is not seen, along with a course of intravesical chemotherapy. CIS will always warrant intravesical chemotherapy, as do high grade tumors typically.
The two most common agents used for intravesical chemotherapy are called BCG and Mitomycin-C, although others sometimes employed after recurrence are interferon, valrubicin and others. Dr. Engel is currently involved in a clinical trial testing a new drug, already in use in Europe, called Eoquin. BCG is best described as a form of tuberculosis. It induces an immune response in the bladder and is best thought of as immunotherapy. Mitomycin-C is a standard chemotherapy agent. BCG is always given in the setting of CIS, and is most often given for T1G3 tumors and high grade tumors. Mitomycin-C is given in cases of lower risk tumor recurrence, but there is significant crossover with these agents and these are not fixed rules. BCG is given once a week in the office for six weeks, and at times as part of a “maintenance” protocol. The side effects of BCG are largely irritative symptoms in the bladder. A very rare risk of giving BCG is if it gets into the bloodstream. In such a case, as it is similar to tuberculosis, is can be a very severe infection even leading to sepsis. Mitomycin-C is given typically in the office every week for eight weeks. Side effects are also typically irritative and inflammatory in nature. Occasionally Mitomycin-C is given as a single dose at the time of tumor resection.
Dr. Engel is highly experienced in all areas of bladder cancer management and would be happy to discuss any of this further with you.
