Bladder cancer

Bladder Cancer / Bladder Tumors

Bladder cancer is an abnormal growth or tumor arising from the lining of the bladder. The technical term for most bladder cancers is "transitional cell carcinoma."

The normal bladder has a flat, smooth, shiny, watertight lining consisting of layers of cells tightly connected with each other. The lining of the bladder can be imagined to be similar to the lining in the oral cavity (mouth). Underneath this lining is the muscle tissue of the bladder. The muscle is responsible for pushing out the urine at the time of voiding.

Bladder tumors almost always arise from the shiny bladder lining. The cells grow abnormally fast causing a tumor to sprout up from the flat lining into a growth projecting into the interior of the bladder cavity. In general, tumors at this stage are not life-threatening. They usually do not cause any symptoms and remain unnoticed until an episode of bleeding into the urine. After an episode of bleeding into the urine, the patient should undergo an evaluation by a urologist. The urologist is usually called upon to look into the bladder with a cystoscope (a telescope that can be inserted into the bladder). The urologist may also order various types of X-ray studies. This type of testing is very successful at finding bladder tumors. After diagnosis, the patient usually undergoes biopsy and/or removal of the tumor. This procedure, called "transurethral resection of bladder tumor," is accomplished using cystoscopes; therefore there are no surgical incisions. Depending on the amount of tissue that is removed as well as other factors, the procedure is either done on an outpatient basis or with a short hospital stay.

Stage and Grade

The tissue that is removed is examined by the pathologist under the microscope. The pathologist must assign a "stage" and a "grade" to the tumor tissue. The stage is an indication as to where the tumor was physically located. Stage has two general groupings: "superficial" and "invasive." Superficial tumors involve only the lining of the bladder. In other words, a tumor sprouted up out of the flat surface of the bladder into the cavity of the bladder. Invasive tumors are more dangerous. By definition, an invasive tumor is growing into the layers of the wall of the bladder rather than sprouting up into the interior of the bladder cavity. Tumors growing into the layers of the wall of the bladder are more dangerous because cells can break off and spread to distant organs. The pathologist also provides a tumor grade. This is simply an estimate of the speed of growth of the tumor based on what the cells look like under the microscope.

The urologist and the patient then discuss the pathology findings from the transurethral resection of the bladder tumor taking into account the stage and grade of the tumor. These discussions may lead to decisions regarding further treatment of the disease.

Superficial Tumors

As mentioned above, low grade, superficial tumors are relatively innocuous. Low grade, superficial tumors are analogous to some skin cancers in that they recur frequently but are usually not very dangerous to the patient. These tumors are usually cured by simple removal with the cystoscope and they often do not require further treatment. However, they have a very high rate of recurrence, so the patient must be monitored closely by the urologist for several years. Monitoring is accomplished in several different ways. The urologist usually recommends checking the bladder every 3 or 4 months with the cystoscope in an effort to diagnose tumors even before they cause symptoms such as bleeding. Also, urine may be sent off to the laboratory to check for abnormal cells. Finally, the patient who smokes should be encouraged to stop. Smoking is a well known risk factor in causing bladder cancer because the carcinogens in cigarette smoke pass from the lungs into the blood stream, and are concentrated by the kidneys into the urine. Thus the interior of the bladder is constantly exposed to these carcinogens at high concentration.

In some situations, the risk of recurrence may be judged to be excessively high. In these situations, the urologist may recommend a form of therapy unique to bladder cancer called "intravesical chemotherapy" or "intravesical immunotherapy." This form of treatment consists of instillations of liquid substances into the bladder using a catheter. These substances are designed to kill existing tumors or prevent the development of new tumors. These treatments are almost always administered on an outpatient basis on various time schedules. For example, the urologist may recommend once per week treatments for a period of one or two months followed by repeat cystoscopy to check the results.

Invasive Tumors

The pathology results from the transurethral resection of the bladder tumor may reveal that the tumor is either high grade (fast growing) or that its stage is "invasive." In this situation, the tumor is considerably more dangerous and potentially life threatening because it has the biological potential to spread to other areas of the body.

Depending on the depth of invasion into the bladder wall, the grade of the tumor, and other factors, the urologist may either recommend intravesical treatments as described above, or complete surgical removal of the bladder. If the latter option is chosen, the operation usually performed is called "radical cystectomy" and involves removal of the bladder and surrounding tissues (prostate in men and internal reproductive organs in women). The operation involves an abdominal incision and the patient usually stays several days in the hospital. The goal of this operation is complete remove of all tumor because, if the tumor is invasive, the transurethral resection alone usually leaves some tumor behind. Urologists in the Department of Urology at Wayne State University and the Karmanos Cancer Institute have extensive experience in this procedure and have performed a very large number of radical cystectomies over the last 10 years. In fact, the Department of Urology at Wayne State University and the Karmanos Cancer Institute is a referral source for other urologists who do not routinely perform radical cystectomy.

Urinary Diversion

During the operation to remove the bladder, the urologist must create a new method for elimination of the urine because the kidneys continue to excrete urine and the bladder has been removed. This surgical reconstruction is called urinary diversion, and it is accomplished by building a new system out of the patients own intestinal segments. These segments are removed from the intestinal stream without disturbing their blood supply, and then refashioned by the surgeon into a new urinary tract.

Urologists in the Department of Urology at Wayne State University have special expertise and experience in performing various types of urinary diversion. We now routinely recommend and perform "continent urinary diversion." In this type of diversion, a new "bladder" is created out intestinal segments, and the urine is collected in the new bladder inside the body without the need for an external bag or collection device. The patient can void through the urethra in the same way as before surgery. This option is available for both men and women. Your urologist can help you decide on the best type of urinary diversion for you if you must undergo radical cystectomy for bladder cancer.

Metastatic Bladder Cancer

This is the most advanced stage of bladder cancer. Cells from invasive bladder cancer can break off from the original tumor and spread throughout the body in the blood stream or through the lymphatic system. If these cells begin to grow in locations apart from the bladder (for example in the bone, liver, or lymph nodes), then the patient is diagnosed as having metastatic bladder cancer. Metastatic bladder cancer can develop in patients who have previously had bladder cancer at earlier stages. Unfortunately, metastatic bladder cancer may also be present the very first time a patient has any symptoms from bladder cancer. At Wayne State University and the Karmanos Cancer Institute, metastatic bladder cancer is treated by a multidisciplinary team of physicians including urologists, oncologists (who administer intravenous chemotherapy), and radiation oncologists (who administer radiation therapy). Usually, chemotherapy is required because this is the only form of treatment that can reach all cells of the body. Chemotherapy is often combined with other types of treatment such as surgery and radiation therapy. Traditional teatments with proven benefit are available to all patients at our institution. In addition, we have a number of newer types of multidisciplinary treatments that are being tested because we are hopeful that the long term results will be better than those obtained with standard treatments. At Wayne State University and the Karmanos Cancer Institute, our policy is to provide patients with explanations of the benefits and risks of all available treatments so that the patient can decide, together with the team of physicians, on the most appropriate course of action.