urinary bladder cancer treatment diagnosis

Etiology

Above all, occupational exposure to chemical compounds (among others from the group of aromatic amines) is considered to be the factor leading to falling ill with cancer of the urinary bladder. Smoking tobacco is also mentioned (cancerogenic substances found in tobacco smoke such as nitrosamines, as well as tryptophane metabolites excreted in the urine). An additional risk factor, which may contribute to the development of more aggressive forms of cancer of the urinary bladder is a long exposure to foreign bodies and infections (mainly Schistosoma haematobium, it concerns African and Small Asia countries, as well as medicines – cyclofosphamide) and small pelvis irradiation due to another tumors in that area.

Genetic disturbances observed in the case of cancers of the urinary bladder are mainly the mutations within suppressor gene p53, oncogene erbB-2, p21, c-myc.

Symptoms

One of the most frequent symptoms of cancer of the urinary bladder, which forces the patient to visit a doctor is haematuria, sometimes with clots. With the advance of the tumor process disuric symptoms may take place, namely pain, bladder tenesmus, burning sensation during miction, sometimes  temporary retention of urine. Pain in the lumbar area as well as features of urinary tracts infection may appear during a stasis of urine in the upper urinary tracts. The pain in pelvis and around groin as well as swelling of the lower extremities usually accompany further symptoms of the disease. The first ‘signaling’ symptoms are the pains caused by metastatic changes in bones.

Urinary Bladder Cancer Diagnosis

Even one haematuria or earlier mentioned pain symptoms are an absolute indication for a patient to be examined in order to exclude the possibility of cancer of the bladder. Ultrasonography should be the first examination in the diagnosis of cancer of the urinary bladder, when the tumor change may be depicted, provided that it is big enough, the bladder is full and the place on the wall accessible during examination.

In contrast examination unevenness of bladder contour, filling defects and rigidity of infiltrated wall may be observed depending on the value and the degree of infiltration.

When a suspicious change is detected in bladder, the character of the change should be explained as soon as possible by the means of histopathologic examination. Having done bimanual examination (in order to find any out of bladder changes) cystoscopy is done. During the examination, segments are taken for histopathologic examination.

The urine cytology examination seems proper, nonetheless the negative result does not exclude the presence of a tumor process.

Apart from the above-mentioned examination, morphology, general urine examination, urography (the evaluation of urethers and kidneys) as well as small pelvis computer tomography (the evaluation of local infiltration and the invading stage of lymph nodes) are done. In the case of pain disorders, radiological examination and bone system scinigraphy seem advisable. Similarly to other tumors, chest RTG, gynecological examination in women and an evaluation of prostate’s state in men are recommended. From the prognosis perspective, determining the degree of histological tumor malignancy (basic prognostic factor apart from the state of primeval tumor determined according to TNM classification) seems vital. The following degrees of differentiation are distinguished: well-differentiated cancer (G1) – about 45% of detected cancers, moderately differentiated (G2), poorly differentiated (G3) and undifferentiated cancer (G4). The diagnostic value of BTA and NMP-22 markers is being checked and their determination does not constitute a norm as far as diagnostic methods are concerned.

urinary bladder cancer diagnosis treatment

Histological Classification of Urinary Bladder Cancer

Epithelial tumors

- transitional cell papilloma - transitional cell papilloma infiltrating the bladder wall - planoepithelial papilloma - transitional cell carcinoma - kinds of transitional cell carcinoma: " with planoepithelial transformation " with adenous transformation " with planoepithelial and adenous transformation - basal cell carcinoma - adenocarcinoma - anaplastic tumor

Non-epithelial tumors

- adenoma - fibroma - myxoma - myoma - angioma - lipoma - pheochromocytoma - sarcoma

Classification

In order to estimate the level of progression the TNM classification or modified system by Jewett and Marshall are applied.

TNM Classification

Pathological classification pT, pN corresponds to T, N clinical classification.

bladder cancer diagnosis

T - primary tumor

  1. Tx -  Primary tumour cannot be assessed
  2. T0 - No evidence of primary tumour
  3. Tis - Carcinoma in situ, preinvasive tumor with focusal anaplasy (G1, G2, G3) within epithelium
  4. Ta - Noninvasive papillary carcinoma
  5. T1 - Tumor invades subepithelial connective tissue
  6. T2 - Tumor invades muscle
  7. T3 – Tumor deeply infiltrates a part of muscular coat not exceeding it
    - (T3a) Tumor infiltrates the muscular coat
    - (T3b) Tumor invades perivesical tissue
    - T3aextracapsular extensions (unilateral)
    - T3b extracapsular extensions (bilateral)
    - T3c  Seminal vesicles infiltration
  8. T4 – Tumor invades other organs T4a - Tumor invades the prostate, uterus, vagina T4b - Tumor invades the pelvic wall, abdominal wall

N – regional lymph nodes

Nx - Regional lymph nodes cannot be assessed N0 - No regional lymph node metastasis N1- Regional lymph node metastasis N2 - Metastasis in a single lymph node, >2 cm but ≤5 cm in greatest dimension; or multiple lymph nodes, & 5 cm in greatest dimension N3 - Metastasis in a lymph node, >5 cm in greatest dimension

M – distant metastases

MX - Distant metastases cannot be assessed M0 - No distant metastases M1- Distant metastases M1a – lymph nodes other than regional M1b – bone(s) M1c – other organs

In Whitmor-Catalon’s classification A, B, C, D degrees correspond to T1, T2, T3 and T4 respectively in TNM classification.

Classification by Jewett and Marshall

  1. Stage 0: No tumor found in the specimen superficial tumour not invading the submucosa carcinoma
  2. Stage A: superficial tumour invading the submucosa
  3. Stage B: muscle invasive tumour
  4. Stage B1: superficial invasion (less than halfway)
  5. Stage B2: deep invasion (more than halfway)
  6. Stage C: invasion into the perivesical fat Stage D: Extra vesical disease, further specified in
  7. Stage D1: invasion of contiguous organ or regional lymph nodes metastases
  8. Stage D2: Extra metastases to distant organs

Treatment of Urinary Bladder Cancer

The choice of treatment for patients suffering from urinary bladder cancer depends on the degree of progression according to TNM classification, the level of tumor’s histological malignancy and the general state of the patient.

Surgical treatment of Urinary Bladder Cancer

Transurethral resection of tumor (TURT)

This method is used in the case of surface changes (Ta, T1, T2, as well as the multiple ones and when treating preinvasive tumor Tis, if the number of focuses is low and the atypy insignificant). TURT may be done also in the case of T3a tumors if the diameter of the base does not exceed 2 cm. In the case of advanced stages (T3, T4 ) it is sometimes used as paliative treatment.

Partial resection of urinary bladder

It is applied when a 3 cm microscope margin of healthy tissue is possible in big, individual focuses of T2 tumor and in the early period of T3.

Complete resection of urinary bladder (Cystectomy)

A two-stage surgery which consists in cutting out a bladder together with lymph nodes and recreating the possibility to drain the urine from the upper urinary tracts.

The operation concerns patients suffering from:

- poorly differentiated cancer (G3) - early recurrence after treatment using other methods - tumors invading the neck of urinary bladder, prostate urethra, bladder triangle when urine flow from kidneys is impeded - extended and multifocal pre-invasive tumors - bleeding from the bladder impossible to control

Cystectomy is also done among patients who underwent unsuccessful partial resection and after recurrences after radiotherapy.

Three ways of urine flow are applicable. One of them, known as the Bricker’s is about creating ileal conduit for the urine to flow to a bag stuck to the skin. The second option is the creation of an intestinal cistern, which when full is emptied by the patient by self catheterization through a skin fistula. The most comfortable way is the creation of a surrogate urinary bladder linked to the urethra (a patient urinates moving his/her stomach muscles).

Radiotherapy in Urinary Bladder Cancer

It is applied among patients who do not give their consent to the treatment or when a radical cystectomy is often impossible in their cases. Radiotherapy among patients in T2 to T4 progression stage creates a possibility of attaining a 5-year survival without disease recurrence among 35 to 45% of patients and a 5-year complete survival among 23-40%.

A 45 Gy dose is given for the pelvis and then a boost for bladder tumor is done up to 65 Gy dose. The introduction of conformal radiotherapy which consists in 3-dimensional planning system (3D CRT) into clinical practice in the recent years enables more effective application of radiotherapy in the radical treatment of urinary bladder cancer. Chemotherapy

In the case of urinary bladder cancer it is applied mainly as palliative treatment or together with surgical methods or radiotherapy.

bladder cancer blood urination

Inductive chemotherapy aims at reducing the size of tumor most often before the radiation.

Treatment Schemes of Urinary Bladder Cancer

Most often applied treatment schemes are:

M-VAC

Metotreksat 30 mg/m2 im Doksorubicine 30 mg/m2 iv Cisplatine 70mg/m2 iv Vinblastine 3mg/m2 iv The pause between the cycles 28 days

M-VC

Metotreksat 30 mg/m2 im Cisplatine 70mg/m2 iv Vinblastine 3mg/m2 iv The pause between the cycles 28 days

CISCA

Cyklofosfamide 650 mg/m2 iv Doksorubicine 50 mg/m2 iv Cisplatine 100mg/m2 iv The pause between the cycles 21 - 28 days

Paclitaxel (monotherapy)

Paclitaxel 250 mg/m2 iv 1 day, the cycles repeated every 21 days

Direct bladder treatment

Such a method is recommended in the cases of:

- tumors of T1 degree (multiple) - multifocal changes of Ta type - lesions of Tis character

Most often used drugs are: thipotepa, BCG vaccine, mitomycine, doksorubicine.

BCG therapy of the surface tumor has been more effective so far than direct bladder chemotherapy, as it decreases the risk of regional recurrence and, what is more, decreases probability of undergoing the disease process at invasive cancer stage.

Prognosis

In the case of urinary bladder cancer the prognosis depends on the level of progression as well as the choice of optimal treatment and the internal state of patients. A percentage of 5-year cure most often oscillates around 50-70% as for the I and the II degree, and 20-30% as for the III degree. Longer survival periods are rarely reported in the IV degree.

Home Remedies For Urinary Bladder Infections and Cancer

1. Drink plenty of water

Common wisdom and even doctors advise drinking more water to prevent as well as treat UTIs and bladder infections because it naturally increases the flow of urine and necessitates frequent voiding.

A few bacteria and fungi may be permanent residents in and around the urogenital tract, but they rarely cause any trouble unless their populations increase. This is usually prevented by many defense mechanisms of the body, including the elimination of the microbes along with urine. But recent research shows that the beneficial effect of drinking water has more to do with certain biochemical changes in the environment, rather than physical removal of the offending organisms.

Doctors have known for a long time that the pH of urine has a definite influence on urinary tract health, and there have been efforts to acidify or alkalinize urine with the object of treating kidney and bladder stones and UTIs. But, according to Prof. Jeffrey P. Henderson at the Washington University School of Medicine, urine closer to the pH of water is the best for fighting infections.

On doing extensive research into this subject, he found that the activity of a protein called siderocalin produced by our immune system is the most critical in restricting the growth of bacteria. This protein is highest when the urine pH is nearly neutral.

Drink plenty of water to produce water-like urine and give a hard time to those microbes. Dehydration, in general, stunts immune function, so, that gives you one more reason to stay well hydrated.

2. Empty your bladder frequently

If you’re drinking sufficient amount of water, you’ll have the natural urge to empty the bladder often. However, many of us have developed a tendency to hold in the water, sometimes out of necessity. This gives pathogenic bacteria more time to multiply and invade the lining of the bladder, in addition to the tissue damage caused by highly concentrated urine. Given enough time, the bacteria can make biofilms that resist even the strongest antibiotic. Even more dangerous is the spread of the infection up to the ureters and into the kidneys.

There are one-way flap valves in the ureters that connect the kidneys to the bladder, which normally prevent the backflow of urine. People with damaged flap valves may have a condition called vesicoureteral reflux, which makes them susceptible to kidney infections and eventual kidney damage. Holding in the urine until the bladder is too full can cause the valves to leak or fail, resulting in a similar situation. Your goal should be to void when the bladder is half full.

When you have UTI or bladder infection , it’s common to have an urge to go very frequently, but the urine output may be very little and the process rather painful. However, don’t try to fight the urge and try to hold in the urine. Drink more water to increase the output, and then go as often as you can. Use pain relieving measures to make it easier on you.

3. Take pelvic sitz bath

A warm pelvic sitz bath can relieve the pain and discomfort associated with bladder infections including UTIs. It involves sitting in a tub with water coming up to cover just the pelvic area, or upper thighs and lower abdomen as well. It is a common hydrotherapy treatment for several ailments, including local pain and cramping.

Warm sitz bath relieves pain, but a cold bath has an anti-inflammatory effect. You can have the best of both worlds by alternating both warm and cold baths. Start with water that is as warm as is comfortable for you. Drain the tub after 5-8 minutes and fill it with cold water or move to a cold water tub for 1 minute. Repeat the procedure until the pain subsides. A simpler variation is starting with a warm sitz bath and then letting the cold water tap run on low after 3 minutes. Let the water and your body cool gradually.

4. Use hot packs

If you don’t have the time and inclination for an elaborate sitz bath, hot packs around the lower abdomen will provide temporary relief form pain and the pressure-like sensation in the pelvic area. It can even reduce inflammation by promoting blood circulation in the area.

Use thick towels wrung out in hot water or a hot water bag. Moist heat is more soothing and effective, but it is cumbersome unless you have a gel pack that provides moist heat. Place the hot water bag or gel pack on your lower abdomen or lie on it while resting. They usually retain the desired amount of heat for about 25-30 minutes.

An electric heating pad will provide even warmth for a longer duration, but remember that dry heat can dry out the skin. Also, avoid using very high heat as it can cause skin burns.

5. Drink parsley tea

Parsley tea is a well known natural UTI remedy, but the actual tea recommended by natural healers involves the urine of the person with the infection. An ounce of the patient’s first voided urine is mixed with a quart of water and gently heated. A handful of parsley leaves is added, and the tea is simmered on the lowest setting for an hour. All of the tea has to be consumed on the same day but in divided doses.

Using the person’s urine for the brewing process is said to bestow certain immunologic benefits, but it is clearly not for everyone. Making a regular herbal tea by infusing just fresh parsley leaves in boiling water is an option you can try.

6. Drink good old cranberry juice

Cranberry juice used to be the ‘go to’ remedy and preventive measure for UTIs for long, but many people feel it’s not as effective as it’s made out to be. The medical world says there’s no conclusive evidence to support the claims, but none of the other natural remedies have gained medical acceptance either, despite many users vouching for them. Nevertheless, some clinical studies have found that pure cranberry juice (not the sweetened drink spiked with chemicals) indeed helps fight bladder infections, although it may cause intestinal and bladder irritation in some people, especially when taken in large amounts.

Going back to Prof. Henderson’s research, his team analyzed thousands of substances found in urine samples and found that certain molecules, referred to as aromatics, that come from food negatively affect the growth of pathogenic bacteria. Their main mode of action seemed to be binding with iron and depriving these microbes of this essential mineral. Not surprisingly, metabolites of cranberry juice were also there among the several beneficial aromatic compounds identified.

The researchers felt that the juice may be more effective if measures are taken to reduce urine acidity while drinking it, but that there might be individual variations. In other words, just try it and find out if it works for you.

7. Let garlic fight off the infection

Garlic’s antibacterial property is well known, but the challenge is to get the garlic compounds into the urinary bladder. The antimicrobial action is attributed to Allicin, a sulfur compound formed when the garlic cloves are crushed. If you ingest sufficient amount of garlic, you will produce garlic-smelling urine and even sweat. It’s unpleasant, no doubt, but it’s highly effective and immensely popular as a urinary tract infection or urinary bladder infection remedy. The typical smell of garlic comes from allicin, so there’s no point in trying to deodorize garlic.

You can mash up 3-5 cloves of garlic and mix it with butter or vinegar to make your garlic butter or salad dressing. If you don’t much care for the taste or garlic breath, swallow 5-6 smaller garlic cloves like a pill or cut up 2-3 larger ones and take them 2-3 times a day.

8. Make marshmallow root tea

Marshmallow root tea has a long history of being used for treating kidney stones as well as urinary tract infections. This mucilaginous drink has a long list of benefits; it can soothe the inflamed urinary tract lining; it reduces abdominal pain as well as pain during urination; it increases urine production; it modifies the pH of the urine and even clears up bloody urine. But more importantly, marshmallow tea is considered safe for babies and in pregnancy, which is a blessing because UTIs are all too common during pregnancy, and we’d want to avoid antibiotics during this.

To make the marshmallow root infusion, place crushed marshmallow root in a bowl and add lukewarm water in 1:4 ratio. Keep aside for 4-5 hours or overnight. Strain the thick, slimy tea and drink it several times a day.

9. Eat Cucumbers

Cucumbers have a high amount of water, which is a great way to get to get extra fluid through your system when you find yourself having a hard time drinking enough water.

10. Drink cranberry juice

Cranberry juice is jam-packed with anti-oxidants, which help build up the immune system.

It fights bladder infection developing resistants to toxicity of anti-bodies.

It also contains some compounds which help eliminate micro-organisms that cause UTIs.

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