Pathology of bladder cancer

2021-01-30 12:00 AM

Bladder tumours often come back. The recurrence rate is about 52-73% between 3-15 years, so the follow-up regime of patients with bladder tumours is a lifelong monitoring regime.

 

Outline

Bladder tumours are the most common of all urinary tract tumours. According to the American Cancer Society, in 1994 there were about 51,200 new patients, and there were about 10,600 patients died. On average, about 10,000 patients die each year from bladder tumours. The death rate is lower in blacks than in whites.

The prevalence is more in men than in women, about 3: 1. In men, bladder tumours are ranked 4th among cancers, in women it is ranked 5th. Blacks have a bladder tumour rate of about half of whites.

In Vietnam, bladder tumours are increasingly discovered more and more. The disease is more common in adults aged 40-70 years (78%) and in men more often than in women.

There are two types of bladder tumours: benign and malignant; however, the cyst tends to become malignant easily. Therefore, bladder tumours need to be diagnosed early, with early and active treatment to have a good prognosis.

According to the world literature, the 5-year survival rate is 52-73% in agro-leaf tumours, reduced to 25-47% in the worm form.

Bladder tumours often come back. The recurrence rate is about 52-73% between 3-15 years, so the follow-up regime of patients with bladder tumours is a lifelong monitoring regime.

Reason

The following factors are believed to be at increased risk for bladder cancer.

Smoking

Currently, smoking is considered a cause of bladder cancer in humans. Smoking increases your risk of bladder tumours 2-5 times. The specific cancer-causing chemicals in cigarettes have not been precisely identified, although tobacco smoke contains carcinogens such as nitrosamine and 2 naphthylamines.

Work environment

Some of the chemicals that have been identified are known to cause bladder cancer:

  • Aromatic amines.
  • Aflatoxin.
  • Polycyclic hydrocarbon.
  • Benzidine.
  • 1 - amino - 1 - naphthol.
  • Heterocyclic amines.
  • N - nitrosamine compounds.
  • 2 - naphthylamine.
  • 4 – aminobiphenyl.

These chemicals are commonly found in the industries of dyeing, rubber, tanning, paint, chemicals ... Amino chemicals can enter the body through the nose, mouth and through the skin, from there the chemicals follow. blood sugar to the liver and converted to ortho aminophenol under the action of glucuronic acid, and is excreted by the kidneys into the bladder. Here the enzyme beta-glucuronidase hydrolyzes Orth aminophenol to release orthophenol which can stimulate cancer growth after absorption through the bladder mucosa.

Food

Coffee: Considered a substance that can cause occasional and poor bladder cancer.

Saccharin: Has been shown to cause cancer in the experiment. Drinking water with chlorine: Some studies have shown that drinking water with chlorine has a 1.6 to 2.0 times increased risk of bladder tumours.

Food: Eating foods high in fat and cholesterol can increase the incidence of bladder cancer.

Medicine

It has been found that people who use too many pain relievers containing phenacetin have an increased risk of bladder cancer. Cyclophosphamide can also cause bladder cancer.

Parasites and chronic diseases

Many authors have proven Schistosoma haematobium parasite as a higher incidence of cancer. This type of cancer is 85% squamous cell, different from the normal type is the transitional cell.

Bladder infections are thought to be related to the development of bladder cancer. In patients with long-term catheterization, 2 to 10% may develop bladder cancer.

Gene

P53 is thought to be a gene that is involved in the formation of bladder cancer.

Pathology

Classification of bladder cancer

The wall of the bladder has 3 layers:

  • Mucosa.
  • The muscular layer is smooth and smooth.
  • Serum layer.

In the mucous layer and muscle layer, there are many blood vessels, nerves and in the triangle, there are several glands. All of the above components can develop into different bladder tumours but 97% of bladder tumours are a type of bladder mucosal tumours. Distinguishing between benign or malignant mucosal tumours while the tumour is still in the mucosal layer is very difficult.

Depending on the nature of malignancy or beingness, tumours are called by different names.

  • Primary bladder tumour.
  • Growth of the tumour on the bladder mucosa

In the experiment, it has been proven that the development of bladder tumour progresses through 4 stages:

Overgrowth stage recovery

A few hours after exposure to the chemical, the two or three cell layers of the mucosa are swollen. Cells enlarge and lose the proportion of protoplasm. Chromatin appears in the nucleus of the cell, the number of nuclei increases, the blood vessels under the mucous layer are dilated and congested.

The bottom membrane has not been affected. At this stage, if the carcinogen is removed, the cell is restored.

The overgrowth  stage does not restore the nucleus or the thorns

If the oncogenic agent continues to affect the bladder mucosa, nocturia or papillae may appear.

In the mucosa there are many small blood vessels, surrounded by many cells that develop into small spines. The cell nucleus is abnormally large and has many nuclei.

These spikes tend to develop on the surface of the bladder wall to form a spiny phylogenetic pattern

Stage of papilloma

The growing spikes continue to form papilloma’s on the surface of the bladder mucosa and invasively develop through the basal membrane.

Melanoma stage

The basal membrane is damaged, possibly due to cancer cell dissolution, tumour cells are slightly smaller and the nucleus is round and enlarged.

Cancer continues to develop in-depth and spread in either side or in separate descends or metastasized blood or lymphatic lines to the lymph nodes 88%, liver (11%), lungs (34 %), bone 22%

Microscopic classification of bladder tumour

Usually, people evaluate the malignancy of bladder tumours in 2 ways:

Invasion depth.

Cell differentiation.

Classification according to the degree of tumour invasion

According to TMN (resolution 1997).

T (tumour).

Tx cannot identify the primary tumour.

T0 No evidence u.

I U papillae not infiltrated 

Tis Carcinoma topical.

T1 tumour infiltrates the submucosa.

T2 U infiltrates the muscle layer.

T2a U infiltrates the inner muscle layer.

T2b U infiltrates into the outer muscle layer.

T3 U infiltrates the perioral organ.

T3a Microbial infiltrates T3b Macroscopic infiltrates.

U T4 infiltrating one of the following agencies prostate, uterus, vagina, the pelvic, abdominal wall.

T4a U infects the prostate gland, or uterus or vagina.

T4b U infiltrates into the subframe wall or abdominal wall.

N (lymph nodes)

Nx Could not identify metastatic lymph nodes.

N0 No metastatic lymph nodes.

N1 Single grid (2cm).

N2 Single lymph nodes> 2cm, but (5cm, or multiple lymph nodes but no lymph nodes> 5cm).

N3 Metastatic lymph nodes> 5cm.

M (distant metastasis)

Mx the distant metastasis cannot be determined.

M0 There is no distant metastasis.

M1 Far metastasis.

Classification according to the differentiation of the cell

Grade I: The tumour is completely differentiated. The basal membrane is not invaded. Small tumours often papillae. Good endoscopic ablation treatment. There is no effect of radiation treatment

Grade II: tumours often papillae, cells are less differentiated and have eaten spread to the basal membrane but not to the muscle layer. Usually treated with endoscopic ablation and less sensitive to radiation.

Grade III and IV: The tumour has poor or undifferentiated cells. tumours are usually more nuclear than papillae. Surgical ablation is less effective and sensitive to radiation.

Differentiation classification

The classification table is both qualitative and quantitative.

Grade I: 0 - 25% atypical cells.

Grade II: 25 - 50% of cells are less differentiated.

Grade III: 50 - 75% of cells do not differentiate.

Grade IV:> 75% of cells do not differentiate.

Clinical symptoms and diagnosis

Clinical symptoms

Blood hematuria: This is the most common symptom (90-95%). Appears suddenly and also ceases suddenly. The hematuria is not painful and may be accompanied by blood clots, and hematuria is often recurrent. Repeated hematuria is for anaemia patients.

Disorders of urination: Usually appear when there is associated inflammation, patients may have urinary urgency, urination and in the elderly with fibroids, dysuria, and frequent urination.

Other symptoms: In the case of a progressive and large bladder tumour, the patient may present with hip pain due to obstruction of the ureter, swelling of the lower extremities, lump in the hypotonic region, weight loss, abdominal pain or bone pain.

Rectal: rectal does not detect anything, but if u can at depth (PT2 or higher) can see the bladder wall hard, non-portable, or palpable tumour. In the case of bladder tumours, it is necessary to have a combined rectal examination (vaginal exam in women) in conditions with pain relief, even anaesthesia.

Subclinical

In addition to the usual tests of urine and blood to evaluate inflammation, anaemia, kidney function ... tests that can contribute to the diagnosis of bladder tumours:

Urine tests for cells

This test is highly accurate (95%) in diagnosing highly differentiated cancers and in situ cancers, but is less valuable in diagnosing low-differentiated cancers (accuracy 10-50. %) morning urine collection, cryoscopic spin according to the Papanicolaou method can detect tumour cells. Many times, have to do many times.

Supersonic

Through an ultrasound of the abdominal wall or through the rectum, we can clearly see the image of the tumour, and can partly assess the tumour's invasion of the bladder wall. Good results are accurate (80-90%).

X-ray

Intravenous contrast urology (UIV) or bladder scan with contrast can detect the tumour or the stiffness (asymmetry) of the bladder wall due to tumour invasion of the less soft bladder wall. trade.

In addition, the kidney and ureter can be examined to detect tumours in the kidney or ureter. In this case, bladder tumours can be secondary to kidney tumours.

Computer tomography (CT scanner)

May allow detection of small tumours, or metastatic nodes of the tumour, around the bladder.

Count cells by line

This method allows measuring the amount of DNA of cells by fluorescence, to study the change in the number of DNA corresponding to the number of chromosomes of the dysplastic cell or the loss of ABO antigens. tumour cells.

Cystoscopy and biopsy

It is an important procedure that helps to accurately diagnose bladder tumours and tumour stages but must be done under sterile and cautious conditions. During cystoscopy should evaluate:

  • Tumour imaging.
  • Size.
  • Location.
  • A number of tumours.
  • Biopsy to assess tumour growth. The biopsy is carried out according to designated locations called  -Bladder mapping-.

Diagnosis confirmed

Based on the clinical and subclinical symptoms described above

Differential diagnosis

Cystitis

Cystitis can cause hematuria, urinary retention, and urinary retention. There is an infection syndrome. A test of red blood cells and white blood cells and a cystoscopy reveals no tumour inflammation.

Tuberculosis of the bladder or urinary tract tuberculosis

Do a BK test in urine? UIV can show tuberculosis kidney ulcers, cystoscopy does not see tumours, images of tuberculosis, bladder capacity of the baby.

Bladder stones.

Benign prostatic hyperplasia.

Cancer of the kidney or ureter.

Hematuria is usually complete and prolonged, lumbar pain may be, large kidney tumours can be found on large, stiff kidneys. A cystoscopy to rule out bladder tumours and locate bleeding. Intravenous contrast urology or ultrasound to detect tumours.

Symptoms

  • Bleed
  • Often caused by ulcers causing heavy bleeding.
  • Infection
  • Bladder infection is caused by an ulcerated bladder tumour. Patients with hematuria, burning and burning.
  • Urinary retention
  • When the tumour spreads to the bladder triangle, or because a large tumour blocks the bladder's neck opening, urinary retention
  • Renal fluid retention
  • When the tumour presses on the ureter, it can block the urine in the ureter and kidneys. Water retention can be one or both sides.
  • Perforation of the bladder or nearby organs

The tumour grows through the bladder to the surrounding organs: it causes perforation in the rectum, genital tract ...

The principles of treatment

Treatment of superficial tumours (pTa-pT1)

Laparoscopic ablation: The basic method for all types of superficial bladder cancer, the purpose is to take all visible tumours and undergo a pathological examination to get an accurate diagnosis. histopathology (a type of cell, degree of differentiation, degree of invasion of the bladder wall of the tumour). During surgery, the tumour must be cut to the muscle layer to remove all of the tumour's legs. For superficial bladder tumours, this alone is sufficient; however, 70% of cases will recur. Therefore, after endoscopic ablation, it is necessary to combine with chemotherapy or immunotherapy in place.

For tumours that recur and tend to develop invasive food and reduce differentiation, endoscopy alone is not enough, it is necessary to coordinate with chemotherapy or enhance local immunity.

Endoscopy + chemicals (Adriamycin, Mytomicine C ...).

Endoscopy + BCG: Thibaut and Camey used live BCG at 6 to 4 0 C and pumped into the bladder after the day of surgery (75mgBCG + 60mlNaCl 9% o).

Once a week for the first 6 months after endoscopy.

Once every 15 days for the next 3 months.

Once a month for the last 15 months.

Treatment of invasive tumours

Surgery

Partial cystectomy: N is less used today because the nature of the cyst is recurrent (70%), after eliminating the part of the bladder with cysts, the tumour will recur in another part of the time. . Therefore, indicative only for certain cases is that the tumour has only one unique site in the basal and lateral wall of the bladder.

Cut Bladder - TLT whole: A. This is surgery today is widely used for the treatment of invasive bladder tumours because it eliminates the root sprouts in bladder cancer. However, this is a relatively severe surgery so it only applies to patients in good condition. Two ureters will be inserted into the isolated ileum out of the abdominal wall (Bricker method) or inserted into a new bladder shaped from the intestine (Studer, Hautmann, Camey ...).

Radiation treatment

Applies to cancer that has metastasized and cannot be operated.

Body chemical treatment

Some anti-cancer chemicals have been used, but until now they are not highly effective and only apply the temporary treatment.

Patients after surgical treatment should be monitored and periodically checked ultrasound, cystoscopy, urine cells at least every 3 months. Lung x-ray at least 1/2 year.

Prognosis

52-73% recurrence from 3-15 years later. Therefore, it is necessary to have a lifelong patient monitoring regime, 6-12 months / clinical examination, urine test and ultrasound or cystoscopy. If a recurrence begins, get treatment immediately.