CONTEMPORARY TREATMENT OF BLADDER CANCER


by

Dr Foo Keong Tatt, MBBS, FRCS (Ed), FAMS (Urol),

and modified for the Internet by

Dr Peter Lim Huat Chye, AM(M'sia), MBBS, MMed(Surg), D.Urol(Lond), FICS, FAMS (Urol), M.I.Urol(Lond)(Hon), FCS (M'sia),

INTRODUCTION:

Bladder Cancer is the second commonest urological cancer & is the 9th commonest in the male, occurring usually after the age of 40 , predominating in the 6th decade of life. It is 5 times more common in males than in females with cigarette smoking implicated as a significant etiologic agent.

PRESENTATION & DIAGNOSIS:

Classically it presents as painless gross haematuria in 90% of cases. Signs are usually minimal, only in about 2% can a suprapubic mass be palpable. Initial diagnosis is predicated on a good Intravenous Urogram & Urinary Cytology with the former demonstrating a filling defect in 60% of cases. A cystoscopy follows during which any lesion discovered is resected as completely as possible whilst random biopsy of the apparently normal bladder mucosa is done to help plan definitive treatment after tissue diagnosis .CT Scanning & a bone scan imay be necessary if muscle invasion is suspected.

TREATMENT:

For purposes of prognostication & treatment, 2 main groups are identified, viz: the Superficial Bladder Cancer & the Muscle Invasive Bladder Cancer.

Superficial Bladder Cancer (Stage T-1):

These are usually papillary, low grade (well differentiated) tumours, confined to the urothelium or lamina propria & superficial to the bladder muscle. Except for those with associated carcinoma-in-situ, superficial bladder cancers have excellent prognosis & patients usually die from other causes. However 50-75% tend to recur with 20-30% becoming muscle invasive with worsen prognosis. Therefore, after transurethral resection, life long follow-up is mandatory with check-cystoscopies. If they have multiple recurrences and/or associated carcinoma-in-situ on mucosal biopsy, they are best treated with intravesical chemotherapy using Mitomycin-C or BCG.

Muscle Invasive Cancer (Stage T-2, T-3a &T-3b):

These are usually solid or ulcerative, high grade (poorly differentiated) tumours. They have poor prognosis & the 5 year survival is less than 40%. 50% of patients usually die within 2 years regardless of the modality of treatment. The mainstay of therapy is Radical External Beam Radiotherapy. However if the patient is fit & below 65 years of age, Radical Cystectomy with Construction of a Neobladder is preferred if CT Scan & a Bone Scan show no distant spread.

Locally Advanced Disease (Stage T-4):

For locally advanced disease, bulky tumours & those obstructing the ureters, a palliative total cystectomy with diversion may be required. Pre-operative downstaging with external beam radiotherapy or systemic chemotherapy may render an irresectable case operable.

Distant Spread (Stage with M +):

More recently, Systemic Chemotherapy with cis-platinum, methotrxate, adriamycin & vinblastine have been introduced in an attempt to improve survival of patients.