Bladder cancer, bladder carcinoma
Summary With 2-3 per cent of the cancer-diseases, the cancer (carcinoma) of the bladder is rather rare, but stands on place two in the smoker-conditional cancer-diseases after the lung-cancer, however.
The bladder-carcinoma stands as well over 24.000 new-diseases per year on place 5 of the frequency-scale of cancer-diseases in Germany. 230.000 people in Germany are circa or were affected by bladder-cancer once. Approximately 7.000 people die of the bladder-carcinoma per year in Germany. This is to big extent because the concerned go to late to the doctor although symptoms of the disease make themselves noticeable already in an early stage. It often is prevented a successful therapy and a complete cure by it. Men as frequently as women are well 3-once involved, although emerged in the last years, that also women more frequently sicken.
Concerned men therefore are more frequent than women and the disease-frequency rises with the 60.-year of life. Already often sicken member from risk-groups earlier, however. Risk factors are: The occupation-encumbrance had an influence on chemicals, tobacco-consumption, excessive alcohol-consumption, hair-stain, and in tropical regions the bilharziasis. Symptoms like bloody urine and pains only late rarely occur. With the lowest indications of problems at the urination or pains with it or in the lower abdomen, an urologist immediately should be consulted. The diagnosis becomes this, through sonography (ultrasound), the microscopic urine-examination (cytology), the urine-examination of the tumour marker NMP22 and the cystoscopy (bladder-reflection), executes. All excrescences in the bladder are cancer that subdivides itself into many stages. The successful therapy improves an early diagnosis and treatment considerably! For that reason, a preventive examination is after cancer, especially with risk-groups very important. - Below more of it.
A micro-hematuria (not with free eye visible blood in the urine) is determined at routine-examinations, should take place further examination.
The method of the election with existence of a bladder-carcinoma is the transurethral resection (TUR) with which the tumor is removed by means of an endoscope through the urethra and the withdrawal of tissue-tests to the histological examination.
Through the histological (microscopic) examination, the penetration-depth can and is determined the tumor-stage with it. Superficial tumors can be taken away over the urethra, so-called TUR. Whether the cancer encroached already on adjacent organs, is determined with CT or MRT. With advanced stages, there are two therapy-approaches: The radical operation with bladder-distance or a TUR (transurethral resection) with subsequent irradiation and chemotherapy. A follow-up treatment is meaningful in every case by means of an instillation-therapy with mitomycin or BCG, because bladder-cancer has a Reside - inclination of approximately 70 per cent. Definition The bladder is a concave-organ, in which the urine transports from the kidney over the ureters and is stored until the secretion. The bladder-cancer takes its origin of the so-called passage-epithelia (urothelium) of the bladder - this is the mucous membrane that lines the bladder.
One distinguishes two types from bladder-cancer: The superficial bladder-cancer: this form is more or less limited the mucous membrane and a relatively benign type. It represents 80 percent of the bladder-cancers.
The aggressive type, that grows into the bladder-wall and into the muscular system.
The first is marked in that it can perform again (relapse-inclination) after the therapy. The second, aggressive type frequently shows, if is not operated radically, a firm growth.
One understands a vicious tumor that is created in the bladder, by a bladder-carcinoma (bladder-cancer). This tumor is created in the urothelium. The urothelium is the lining of the bladder of interior, to some extent the inner-skin of the bladder.
Division (1)
Approximately 70 per cent of all bladder-tumors, so-called superficial tumors are at the time of the diagnosis-position that is called limited on the mucous membrane and the Lamina propria situated directly under it, the connective tissue-work period between mucous membrane and bladder-muscular system. The remaining is already in the deep work periods of the bladder (bladder-muscular system) as well as outgrown over it. one calls it locally advanced bladder-carcinomas. The symptoms are even still advanced if already metastases appeared. Consequently, one can subdivide the simpler survey the bladder-carcinoma half in three main-groups: the superficial carcinomas, the locally progressed carcinomas and the metastasis carcinomas. In accordance with leaves itself divide also the coarse direction of the therapy, namely into transurethral resection plus adjuvant therapy, radical cystectomy (bladder-distance) and systemic chemotherapy.
Division (2)
The division of the tumor-expansion happens after the TNM-System, with what T for tumor, N for lymph nodes ("node") and M for metastases stands. The expansion of the primarily-tumor with the corresponding uppercase letters becomes on that occasion plus addition and the Grading with the uppercase letter "G" and the figures 1 - 3 marked. The small senior letter of "p" then means that the stage was determined by the pathologist. All pTaG1-3 and pT1G1-3 tumors and the carcinoma in situ (Cis) belong to the superficial bladder-tumors.
Risk factorsNumerous elements are held responsible for the emergence of the bladder-cancer:
Occupational hazards
Altogether, over 50 differently chemical substances are known for an emergence of this disease. Among them also chemicals that are used in the rubber or magenta-industry, like the b-Naphthalin and diaminodiphenyl. Step with employed persons, with whom a more professionally chronic contact with these chemicals is proved, a bladder-carcinoma on, so this is recognized as occupation-disease.
Avoidable risks
The smoking is regarded as a risk factor for bladder-cancer, however not so influential for the lung-cancer or the vicious tumors in the oral cavity or the pharynx. However, bladder-cancer is the second-most frequent smoker-cancer after the bronchial-cancer. This is also the reason that the disease-numbers increase with the women since the share of the smokers increased strongly since the World War II in the population.
Newest studies showed, this also an excessive alcohol-consumption and here especially the periodic consumption of high-percent alcohol (schnapps) of the bladder-cancer can lead, since the urothelium (bladder-inner-wall) is attacked here.
Since newest, also content-materials are brought causally with the emergence of bladder-cancer in hair-stains in context what can also be proclaimed an increase of involved women.
Also more regularly frequent use of Phenacitin (an analgesic) can have to do causally with the emergence of a bladder-carcinoma.
Bilharziasis (schistosomiasis)
An infection is one of the most important risk factors world-wide with single-educational, the Schistosoma. These bacteria live in tropical countries in water-cochleae and penetrate through contact with the water in the human being one, in which these water-cochleae live. In some regions of Africa, all inhabitants virtually sickened because they swim in infested fluxions or seas, as well as use the infested water as drinking water. Approximately 300 million people are from this disease, the schistosomiasis as well as Bilharziasis involved. The bladder-carcinoma often is a rare late consequence if no therapy against these causes takes place. Since very poor countries, that an inclusive medical care, enlightenment and provision often lack, usually are about yielding a return at the concerned countries, no treatment often is carried out and the concerned find the red urine and blood normal in the chair.
Through the tourism in these countries, the schistosomiasis is one frequent also in Europe in the vacation of acquired disease. In failure-disease, bloody chair, red urine, pains and problems at the urination after a tropics-residence, one later should think also months and years of this disease.
Because of the completeness, viruses are called here, the human papilloma-viruses, that participation is also repeated with the emergence of vicious tumors in principle.
Symptoms and diagnostics As there are not any unequivocally specific trouble, that points out this disease with high likelihood, with most vicious tumors also with the bladder-carcinoma. For that reason, every abnormal symptoms should, like pains, bloody or unusually dark urine, undefinable woolly pieces in the urine (often with pains with the urination) excessive urine-urge problems at the urination, by a doctor is clarified. A low blood-addition in the urine (a red-coloring) already frequently exists early. However, this blood-addition (micro-hematuria) occurs in the bladders and kidney-system in almost all disease. First clearly bloody urine (macrohematuria) worries the patients. A farther progressed carcinoma however often consists of this case. Pains also very late originate first in far advanced stages or if an ureter (from the kidney to the bladder) or the urethra are transferred by the tumor. The pains can be in this case also in the edges or in the back, because of the congestion or inflammation in the concerned kidney. Symptoms can be also frequent or painful urination.
In principle, it is applicable to the urologist that every unclear micro-hematuria, that bloody urine is called, without fevers or clear urine-way-infection - until as evidence (from the German broad outlines to the bladder-carcinoma) the opposite on a bladder-carcinoma can remind.
A microscopic examination of the urine (urine-cytology) often is little helpful because the tumor-cells are to rarely be found in the urine. only with particular bladder-carcinomas (low differentiated), the marksmanship is higher. If no tumor-cells are therefore found in the urine, this is no evidence against the existence of a bladder-carcinoma.
For that reason, a Tumor-marker provision with NMP22 should take place additionally before the urine-cytology, that under consideration of the exclusion-criterions, a present bladder-cancer more certainly can prove.
The most important examination at the first visit with the urologist is the sonography (ultrasound-examination) of the bladder and the prostate gland where the first results can be put fast gentle for the patient on the existence of a bladder-carcinoma.
The additional examination is the reflection of the bladder (cystoscopy), that is performed in an urological clinic or with the urologist. Under local anaesthesia or anaesthesia, a flexible tube is put forward by the urethra into the bladder. Over optics, the inside of the bladder can be looked at. If the urologist sees a tumor in the bladder-wall, he can appraise which wall-work periods the tumor penetrates and also tests take, that then are examined microscopically. The doctor can see also the orifices of the two ureters and can recognize, whether blood comes from one of the two ureters. Over a cystoscopy, also a tumor-operation can take place if the tumor still is sufficiently small as well as is. The tumor with an electric loop is taken away on that occasion, shreds and later rinses, or by means of laser-ray becomes desolate. This operation is called (TUR) transurethral resection.
With the diagnostic action is a phase among other things - division of the bladder-carcinoma important, because the further therapy depends on the stage. Also here, the best examination is the cystoscopy and sampling (TUR).
A computerized tomography (CT) or magnet-resonance-tomography (MRT) are carried out with each patient afterwards. Regarding the stages - division however clearly was defeated the bladder-reflection (cystoscopy) she/it, because both examinations cannot represent the different work periods of the bladder-wall satisfactorily. From the participation the deceased work periods the bladder-wall is the stages namely - division decisively dependent. By the MRT and CT, a participation of adjacent organs (intestine, uterus, prostate gland, seminal vesicles, pelvic floor-muscular system or lymph nodes - attacks) can be determined. In this situation, however, already a far progressed carcinoma is metastases (daughter-lumps in liver or lung) before and with high likelihood. This participation of the adjacent organs is not recognized with a bladder-reflection. TherapyAll superficial bladder-carcinomas should with the basis-therapy, namely the transurethral resection is treated. An endoscope is introduced in it by the urethra in anaesthesia into the bladder and the tumor with an electro-loop is "planed" down there. The planed down tissue then is given to the pathological examination and the pathologist certain both the expansion-degree of the tumor (the stage) in the TNM-System and the size of the maliciousness (Grading).
The superficial bladder-carcinomas have a high relapse-quote that is called in up to 70 per cent of all cases appears tumor again sooner or later after the operation. For that reason, a so-called adjuvant therapy is recommended broadly today. This happens through in-flushes of medications into the bladder. After placing a disposable catheter, the medication is injected into the bladder. There, it can then effect the mucous membrane and the tumor-endangered areas. The therapy of the bladder-carcinoma depends however decisively on the stage, in which he/it was recognized.
The superficial bladder-carcinomas
Most bladder-carcinomas (approximately 80 per cent) are discovered in a very early phase (in the tumor-stage T1 or Tis). This means in this case that the tumor restricts itself to the most internal work periods of the bladder-wall and the muscular wall of the bladder doesn't involve. In these cases, a relatively small operation suffices over the bladder-reflection (cystoscopy and TUR). It becomes to this, how above described, executed a reflection of the bladder over the urethra. one can introduce operation-instruments additionally and can take away the tumor under view. The urologist even can partially take away the bladder over this way if that is necessary because of the expansion. It can be meaningful in certain situations, one, to execute therapy additionally. For example a local chemotherapy or local immune-therapy can be applied in that the corresponding medication is given into the bladder and works only in the bladder-inside.
After this therapy, however, a renewed bladder-carcinoma occurs in more than half of the cases (50-70 per cent) within 5 years. For that reason, a periodic control is necessary by means of the cystoscopy. In 60-70 per cent of the cases, the originally superficial bladder-carcinoma can be had command of by the repeated TUR long-term.
The deeply infiltrating bladder-carcinomas
Only approximately 20 per cent of the bladder-carcinomas is at the time of the first diagnosis of the advanced phase that is called with participation of the muscle-work period of the bladder-wall. These are named - deeply infiltrating bladder-carcinomas. In these cases, the above described TUR doesn't suffice. Several therapy-possibilities of the disposal stand:
The cystectomy
That is a complete operative distance of the bladder and the prostate gland, with subsequent or synchronized bladder-substitute. This is to be marked as the best method, with which achieving the highest absolute cure-chances is and that has the highest survival rate (approximately 70-80 per cent after 5 years) for the concerned. Often, one can a "Neo - bladder" from one piece of small bowel, that then takes over the function of the bladder, produces. If the urethra is not concerned, it can often be gotten also as natural urine-excretory-organ so that no artificial exit must be put what the quality of life influences positively in the future. With this operation, also parts of the lymph nodes of the surrounded area are taken. These become, how supplied also the other taken out tissue of a histological examination in order to finally be able to determine, whether metastases are likely, and a subsequent chemotherapy is advised.
A TUR (operative distance of the tumor over a bladder-reflection like above described) with subsequently irradiation and chemotherapy will only rarely be effective and comprises the danger of later metastases.
An exclusive one high-measured chemotherapy with several medications, possibly combined with an immune-therapy is executed only with patients, with whom a cystectomy is not possible from medical view.
One would recommend more final possibility however only when the tumor is available in the highest stage, if it therefore grew in adjacent organs and the likelihood of metastases is very high with it.
The TUR and radiotherapy
The exclusive radiotherapy is one in form shrink with the bladder-carcinoma through the danger of the side effect - bladder or a chronic bladder-inflammation restricts. For that reason, the radiotherapy is applied normally in combination with another law case. In principle, it can be appointed also before or after an operation. The most, an irradiation proved itself in combination with a relatively mild chemotherapy (Cisplatin) against a TUR. It becomes on that occasion, how above described, over a bladder-reflection the tumor or a part of the bladder removes. This should happen as in a way as possible that no microscopic tumor-remains are to be seen at the cut-fringes. The irradiation becomes subsequent over approximately daily 5-6 weeks executed. In the first and last week of the irradiation, chemotherapy takes place under stationary conditions.
The results regarding the cure and the 5-yearly-survival rate are at least just as good opposite the radical distance of the bladder. As advantage of this approach would be to be named that in 1st the bladder can be gotten. 2. In the case of a whereabouts of rest-tumor or a radical bladder-distance can still be carried out then a return of the carcinoma with good results.
Chemotherapy
The exclusive chemotherapy-approaches with several Chemo - medications is very side-effect-rich, therefore the usage-possibilities are left only younger patients for exception clauses because of their better constitution.
However, milder approaches stand by the relief with very far advanced stages to the disposal. Then, it becomes usually only one Chemo - medication started, or it is executed a local chemotherapy or immune-therapy. The medication is given directly into the bladder on that occasion.PrognosisMost bladder-carcinomas (approximately 80 per cent) are discovered in very early stages (in the tumor-stage T1 or an initial stage of T1 like the Tis or Ta).
After a TUR, therefore the operative tumor-distance between the bladder-reflection, steps in more than half of the cases (50-70 per cent) within 5 years a bladder-carcinoma renews on. For that reason, a periodic control is necessary by means of the cystoscopy. In 60-70 per cent, the originally superficial bladder-carcinoma can be had command of by the repeated TUR long-term.
With 20 per cent of these patients steps within 5 years a bladder-carcinoma renews, then however in a higher stage on. These patients then must be supplied equally a radical blister-distance or a combined radiation-chemotherapy like the patients, who had from start at a deeply infiltrating carcinoma, in the connection with a TUR. With both, the 5-yearly-survival rate is proceeding between 60 and 70 per cent.
If a radical distance of the bladder is carried out, the bladder must usually be replaced with turned off small bowel*-loops. In 80 per cent, this bladder-substitute works well. The patient is in 10 per cent durably incontinent (urine flows into the washing), the patient is incontinent in wider 20 per cent only at night. In 10-20 per cent, another operation must come after the bladder-substitute because of complications.
If radiotherapy is carried out after TUR, a long-term bladder-receipt can be achieved in 70-80 per cent. In approximately 10 per cent of the cases, the patients have side effects that impair the bladder-function. Low side effects would be a slight bladder, for example, - shrinkage with the consequence, frequent waters', to have to leave, (pollakiuria) respectively frequent nightly urine-urge (nycturia). Heavy side effects are chronic bloody bladder-inflammations or a massive shrinks - bladder that then leads to a cystectomy in the extreme-case, however. In approximately 10-15 per cent, a radical bladder-distance (cystectomy) must take place because of a renewed bladder-carcinoma within 5 years. In these unfavourable cases, one can still 5-yearly-survive, according to tumor-stage, between 30 and 60 per cent is reached.
With the existence of distant metastases (far away-housing projects, daughter-lumps), however, the forecast is bad. Distant metastases usually are found in the lung or in the liver. The medium survival-time then amounts usually less than one year.
Also the proof of lymph node-metastases, therefore daughter-lumps in the lymph nodes of the basin, is a sign bad prognostic because the likelihood of distant metastases is very high. This 5-yearly-survive-in the time of then lies with approximately altogether 20%. It must be roofed that the likelihood of a lymph node-affection rises in the basin with the stage of the tumor. As soon as a deeply infiltrating carcinoma is diagnosed, the likelihood of a lymph node-affection is between 10 and 20 per cent even if this cannot be diagnosed with the MRT or CT. As soon as adjacent organs are concerned, it even is up to 45 per cent; therefore almost half of all patients.
PreventionAs there is also this connection with the avoidable toxicants with the lung-cancer, with which the smoking is an avoidable risk factor, with the bladder-carcinoma.
With a professionally conditional contact with magenta or naphthalene over longer time, both urologist and patient should think of red discoloured urine at bladder-carcinoma at the appearance early.
The smoking and the uncritical use of analgesics should be avoided, as well the periodic consumption of a high-percent liquor and an excessive use of hair-stains. To this please read also the corresponding articles about these topics.
Another article occupies itself with newest examinations in the USA after Coffee-and tea-enjoyment decreases the bladder-cancer-risk.
In tropical and subtropical countries, swimming in seas and fluxions should be avoided. In many places, the bilharziasis is also pointed out publicly expressly to it. After a vacation-residence in these countries must think at the bilharziasis at the appearance of bloody urine or blood in the chair and a corresponding therapy is introduced.
In principle, it is applicable to the urologist that every unclear micro-hematuria, that bloody urine is called without fevers or clear urine-way-infection, until can remind the opposite on a bladder-carcinoma as evidence. In this case belong the cytology, the Tumor-marker - provision with NMP22, the sonography and bladder-reflection to the absolute routine of the diagnostics.
Author: Detlef Höwing - © 2005
On Basis of the German article 2002 in www.selbsthilfe-harnblasenkrebs.de
|
Federation of bladder cancer Patients - FbcP
