Armando Hasudungan
Biology and Medicine videos

Bladder Carcinoma

Mainly focusing on Transitional cell tumours

bladder-carcinoma2

Overview

Three main types of bladder carcinoma
Transitional cell carcinoma (Most common)
Squamous cell carcinoma
Adenocarcinoma (Rare)

Overview Transitional cell tumours can affect any part of the urinary epithelium. It is the second most common urological malignancy (Renal Adenocarcinoma is the most common, bladder adenocarcinoma is rare) and is one of the most common cause of cancer related death. Bladder cancer occurs most commonly from the fifth to seventh decades of life and is more common in men. Transitional cell tumour is also known as urothelial carcinoma and has a broad spectrum of morphology from low grade, sea weed looking, superficial papiliferous growths to invasive, solid mass.

Definition
Transitional endothelial cells:
Endothelial cells that can change shape
Transitional cell Tumours (TCT):
Spectrum of disease from benign superficial growths to invasive carcinomas. TCTs may affect any part of the urinary epithelium (bladder, ureter).

overview

Side note Transitional epithelial cells are found in the bladder, ureter and part of the kidneys and urethra. Therefore transitional cell carcinoma can occur in any of these areas.

Bladder Anatomy and Physiology

An empty urinary bladder sits behind the pubic symphysis, when filled the bladder rises and is higher and can be readily palpated and percussed. In children the urinary bladder sits higher normally.

Extending of the dome of the bladder to the umbilicus is the median umbilical ligament, a fibrous cord that represents the obliterated urachus.

Layers of the bladder 

  • Urotherlium (transitional cells)
  • Basement membrane
  • Lamine propria (Connective tissue)
  • Detrusor muscle (inner and outer layer)
  • Adventitia (fat)
  • Visceral peritoneum

Detrusor muscle is made up of smoother muscle fibers arranged at random in a longitudinal, circular and spiral manner without any layer formation or orientation. However at the internal meatus, the detrusor muscle forms three specific layers:

  • Inner longitudinal
  • Middle circular
  • Outer longitudinal

Arterial Supply

  • Superior vesical artery
  • Middle vesical artery
  • Inferior vesical artery
  • Obturator artery
  • Inferior gluteal artery

In females the uterine and vaginal artery also send some blood supply

Venous drainage Surrounding the bladder is a rich venous supply that drains essentially to the internal iliac veins → common iliac veins → IVC

Lymphatic Drainage

  • Vesical lymph nodes
  • Common iliac lymph nodes
  • Internal iliac lymph nodes (hypogastric)
  • External iliac lymph nodes

Innervation

  • Parasympathetic nerves (S2, S3, S4) → promotes urination
  • Sympathetic nerves (T11, T12, L1, L2) → inhibits urination
  • Somatic nerves (voluntary control) → controls external sphincter (holding in urine)

Micturition Physiology

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Watch Video Physiology of Micturition

Risk Factors

Risk Factors
Age >40 years old
Smoking (main factor)
Aromatic amines
Cyclophosphamide
Schistosoma haemotabium (squamous cell carcinoma)
Chronic irritation (squamous cell carcinoma)
Aristolochic acid

Signs and Symptoms

Remember The most common presentation of bladder cancer is painless haematuria

Painless haematuria: Microscopic (invisible) or macroscopic

Irritative symptoms

  • Dysuria (Painful micturition)
  • Frequency
  • Urgency
  • Renal colic due to blood clot

Obstructive symptoms

  • Feeling of incomplete voiding
  • Double voiding

Signs and Advanced disease

  • Constitutional signs and symptoms
    • fever
    • weight loss
    • night sweats
  • Suprapubic palpable mass

sands

Remember >40 year old presenting with painless haematuria is bladder malignancy (+/- risk factors) until proven otherwise
Side note All patients with macroscopic haematuria or persistent microscopic haematuria should be referred to a urologist for evaluation.

Investigation

  • Urine cytology (urine cell analysis) – Checks for malignant cell. If present likely to be malignancy. If not present can still be low-grade tumour and needs cystoscopy to confirm
  • Cystoscopy – carried out by flexible cystoscope and can visualise the bladder lining. It is gold standard

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Classification and Staging

WHO Grading of transitional carcinoma
Urothelial papilloma
Papillary urothelial neoplasms of low malignant potential (PUNLMP)
Low-grade papillary urothelial carcinoma (PRESENTS MOST COMMON)
High-grade papillary urothelial carcinoma

Staging  uses MRI and CR scanning to detect local or systemic spread

staging

Side note To make it easy think of Low-grade as being non-muscle invasive and high grade as muscle invasive

Pathology

70% are superficial in nature at diagnosis, being confined to the mucosa. Transitional cell carcinoma must be differentiated from other forms of bladder cancer

Bladder Carcnoma Pathological change
Transitional cell carcinoma (most common) papiliferous growths “seaweed” to solid, invasive looking tumour
Squamous cell carcinoma
Adenocarcinoma (rare)

Transitional carcinoma can invade the muscle layer of the bladder and this will tailor management:

  • Nonmuscle invasive bladder cancer
  • Muscle invasive bladder cancer

Management

Bladder Carcnoma Management
Transitional cell carcinoma (most common) Transurethral resection +/- Chemotherapy +/- Radical cystectomy
Squamous cell carcinoma Cystectomy or radiation therapy
Adenocarcinoma (rare) Cystectomy or partial cystectomy + Chemotherapy
  • Nonmuscle invasive bladder cancer can be treated endoscopically
  • Muscle invasive bladder cancer best treated with cystectomy

mgx

Follow-up

  • Postcystectomy patients require 6 monthly contrast enhanced abdominal and pelvic CT scans and chest X-ray (or CT).
  • Renal function should also be monitored as strictures can occur in the anastomosis between ureter and ileal conduit or neobladder.

Complications and Prognosis

Complications

  • Prostatic urethral transitional cell carcinoma
  • Hydronephrosis
  • Urinary retention
  • Complications of Surgery

Prognosis

  • 30% develop muscle-invasive disease
  • 5 year survival rate for muscle-invasive is 50%
  • Metastatic TCT has poor prognosis with a medial survival of 13months

References

Best Practice
Sharma, S, Ksheersagar, P & Sharma, P 2009 Diagnosis and treatment of Bladder Cancer, American Family Physician, vol.  80, no. 7, pp. 717-723.