Bladder Cancer

From Anvita Health Wiki

Contents 1 Etiology 2 Epidemiology 3 Pathology 4 Genetics 5 Clinical-manifestations 6 Laboratory 7 Complications 8 Differential-diagnosis 9 Management 10 More General Terms 11 Additional Terms 12 Internet Database 13 References

Etiology

• risk factors:

• occupational exposure to aromatic amines

• used in synthesis of plastics, rubber, dyes, printing
• automobile workers, painters, truck drivers, machinists, workers in textile & paper manufacturing

• tobacco smoking

• accounts for 1/3 of cases
• risk correlates with number of cigarettes smoked & years of smoking
• current smoking 2-fold risk relative to former smoker [6]

• phenacetin-containing analgesics
• cyclophosphamide, long-term use
• recurrent UTI

• especially with Schistosoma haematobium

• common infection in Middle East

• recurrent nephrolithiasis
• proposed risks unconfirmed or disproven

• caffeine
• artificial sweeteners
• excess alcohol
• tryptophan metabolites

Epidemiology

• 50,000 cases/year: 3% of all cancer deaths
• 2-3 times more common in men than women

• 4th leading cause of cancer among males

• after lung cancer, colorectal carcinoma, prostate cancer

• 8th most common cancer in women

• mean age of diagnosis: 67-70
• more common in industrialized nations & urban areas

Pathology

• morphology

• transitional cell carcinoma 90%, best prognosis
• squamous cell carcinoma 5%
• mixed cell cancer 5%
• adenocarcinoma is rare

• second malignancies occur in about 10% of patients
• metastases

• bone (26%)
• brain (7%)
• skin (5%)
• adrenal (35%)
• kidney (19%)

Genetics

• loss of part or all of chromosome 9 (55%)* FAM5A gene
• 17p deletion, +/- p53 (40%)
• 11p deletion (40%)
• 13q deletion (20%)
• down-regulation of BLCAP during progression
• somatic mutations can constitutively activate FGFR3
• S100A7 highly expressed in the urine of patients with squamous cell carcinoma of the bladder
• other implicated genes ACRBP, PBOV1, SPANXC, SAGE1, FMR1NB, HDAC9 BAGE1, BAGE2, BAGE3, BAGE4, BAGE5, LENG4, HRAS, NAT2, MDM2, RB1, BAT2D1, EREG, ZNF225

• * superficial recurrent carcinoma; other genetic aberrations associated with invasive carcinoma

Clinical-manifestations

• painless hematuria (75% of patients)
• signs of bladder irritation (25% of patients)

• dysuria
• frequency
• urgency

• signs/symptoms of advanced disease

• weight loss
• abdominal pain
• bone pain

Laboratory

• urine cytology
• cystoscopy with multiple biopsies
• urinary NMP22 ( point of care test) lacks positive predictive value
• intravenous pyelogram ( IVP)

• ureteral obstruction
• hydronephrosis
• bladder filling defect
• lack of bladder distensibility

• staging studies

• serum chemistries
• chest X-ray
• CT of abdomen & pelvis
• MRI generally no more useful than CT for staging

• urine telomeric repeat amplification protocol (TRAP) sensitivity 90%, specificity 88-94%

Complications

• 
  
• disease interaction(s) of cancer with Alzheimer's disease

Differential-diagnosis

• renal carcinoma

• IVP
• cystoscopy
• painless hematuria may be seen with both conditions

• nephrolithiasis

• generally painful hematuria
• IVP

• urinary tract infection ( UTI)

• pyuria
• positive urine culture

• prostatitis

Management

• depends upon staging
• superficial disease ( CIS - T1)

• endoscopic (transurethral) resection + intravesicular chemotherapy:

• doxorubicin, mitomycin, interferon, BCG

• laser surgery (not approved)
• 50-70% have superficial recurrences within 3 years
• 12% develop invasive or metastatic disease
• cystoscopy every 3 months for 2 years, then once a year

• recurrent disease: cystectomy +adjuvant chemotherapy
• invasive disease (T2, T3)

• cystectomy - simple or radical
• radiation - in conjunction with cystectomy
• chemotherapy
• 5 year survival is 40-50% regardless of mode of therapy
• surgical techniques that use small bowel as bladder reservoir

• Kock's pouch
• Indiana pouch
• Mainz pouch

• metastatic disease (T4, TxN)

• chemotherapy

• cisplatin, methotrexate, doxorubicin, cyclophosphamide, vinblastine or combination chemotherapy

• erythropoietin may alleviate myelosuppression during chemotherapy
• 30-70% of patients show initial response to therapy
• life expectancy is < 2 years

• screening

• may be useful in workers with history of exposure to aromatic amines
• not cost-effective in general population
• insufficient evidence to weight pros & cons [5]

More General Terms

• urologic malignancy (urologic cancer)
• bladder neoplasm

Additional Terms

• staging of bladder cancer

Internet Database

OMIM: 109800

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 563-65
2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
3. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 521, 592-93
4. Sanchini MA, Gunelli R, Nanni O, Bravaccini S, Fabbri C, Sermasi A, Bercovich E, Ravaioli A, Amadori D, Calistri D. Relevance of urine telomerase in the diagnosis of bladder cancer. JAMA. 2005 Oct 26;294(16):2052-6. PMID: [1]
5. Moyer VA on behalf of the U.S. Preventive Services Task Force Screening for Bladder Cancer: U.S. Preventive Services Task Force Recommendation Statement Ann Intern Med. 2011;155:246-251 <PubMed> PMID: [2] <Internet> [3]
6. Freedman ND et al Association Between Smoking and Risk of Bladder Cancer Among Men and Women JAMA. 2011;306(7):737-745 <PubMed> PMID: [4] <Internet> [5]
7. Bladder Cancer: NIH Institute and Center Resources [6]
8. National Guideline Clearinghouse Guideline for the management of nonmuscle invasive bladder cancer: (stages Ta,T1, and Tis): 2007 update. American Urological Association Education and Research, Inc. ngc-guideline: [7]
   - Screening for bladder cancer in adults: recommendation statement. (USPSTF) ngc-guideline: [8]
   - Use of neoadjuvant chemotherapy in transitional cell carcinoma of the bladder. (Program in Evidence-based Care) ngc-guideline: [9]
   - Pretreatment staging of invasive bladder cancer. American College of Radiology ngc-guideline: [10]
   - Follow-up imaging of bladder carcinoma. American College of Radiology ngc-guideline: [11]
   - Guidelines on bladder cancer: muscle-invasive and metastatic. European Association of Urology ngc-guideline: [12]
   - Guidelines on non-muscle invasive bladder cancer (TaT1 and CIS). European Association of Urology ngc-guideline: [13]

bladder cancer