Epidemiology. The tumor is considered one of the most common malignant neoplasms (about 3% of all tumors and 30-50% of tumors genitourinary organs). Bladder cancer is 3-4 times more common in men. Most often recorded at 40-60 years of age. Incidence: 8.4 per 100,000 population in 2001.
Code according to the international classification of diseases ICD-10:
Causes
Etiology. The occurrence of bladder cancer is associated with tobacco smoking, as well as with the action of certain chemical and biological carcinogens. Industrial carcinogens used in rubber, paint, paper and chemical manufacturing have been implicated in bladder cancer. Bilharzia of the bladder quite often leads to squamous cell carcinoma. Other etiologic agents include cyclophosphamide, phenacetin, kidney stones, and chronic infection.
Morphology ( bladder tumors are most often of transitional cell origin). papillary. transitional cell. squamous. adenocarcinoma.
Classification. TNM .. Primary lesion: Ta - non-invasive papilloma, Tis - cancer in situ, T1 - with invasion into the submucosa connective tissue, T2 - with germination into the muscular layer: T2a - inner layer, T2b — outer layer, T3 - Tumor grows into peri-vesical tissue: T3a - determined only microscopically; T3b - determined macroscopically; T4 - with invasion of adjacent organs: T4a - prostate gland, urethra, vagina, T4b - pelvic and abdominal walls.. Lymph nodes: N1 - single up to 2 cm, N2 - single from 2 to 5 cm or damage to more than 5 nodes, N3 - more than 5 cm. Distant metastases: M1 - presence of distant metastases.
Grouping by stages. Stage 0a: TaN0M0. Stage 0is: TisN0M0. Stage I: T1N0M0. Stage II: T2N0M0. Stage III: T3-4aN0M0. Stage IV .. T0-4bN0M0 .. T0-4N1-3M0 .. T0-4N0-3M1.
Clinical picture
. Hematuria. Dysuria (pollakiuria, imperative urges). When an infection occurs, pyuria occurs. Pain syndrome does not always occur.
Diagnostics. Physical examination with mandatory digital rectal examination and bimanual examination of the pelvic organs. OAM. Excretory urography: filling defects with large tumors, signs of damage to the upper urinary tract. Urethrocystoscopy is the leading research method for suspected cancer and is absolutely necessary to assess the condition of the mucous membrane of the urethra and bladder. To determine the volume of the lesion and histological type, an endoscopic biopsy of the tumor is performed. Examine the mucous membrane. In the presence of carcinoma in situ, the mucous membrane is externally unchanged, or diffusely hyperemic, or resembles a cobblestone pavement (bullous change in the mucous membrane). Cytological examination of urine is informative as for tumor lesions severe, and with carcinoma in situ. Ultrasound: intravesical formations and the condition of the upper urinary tract. CT and MRI are the most informative for determining the extent of the process. X-rays of the chest organs and skeletal bones are performed to identify metastases. Bone lesions in highly malignant forms of cancer may be the first signs of the disease.
Treatment
Treatment depends depending on the stage of the disease, no clear standards for the treatment of bladder cancer have been developed.
. With carcinoma in situ, malignant transformation of the cells of the mucous membrane occurs. Local chemotherapy may be used. In the case of widespread damage (urethra, prostate ducts) and progression of symptoms, early cystectomy with simultaneous bladder plastic surgery or transplantation of the ureters into the intestines is indicated.
. Transurethral resection: used for superficial tumor growth without damage to the muscular lining of the organ. At the same time, relapses are quite frequent. Intravesical chemotherapy reduces the frequency of relapses of superficial bladder tumors. Doxorubicin, epirubicin and mitomycin C are effective. The drug is diluted in 50 ml of physiological solution and injected into the bladder for 1-2 hours. With the degree of differentiation G1, a single instillation immediately after transurethral resection is sufficient. For stage G1-G2 tumors, a 4-8 week course of instillations is carried out. Local immunotherapy with BCG reduces the frequency of relapses. External beam radiation therapy does not provide long-term remission (relapses within 5 years in 50% of cases). Interstitial radiation therapy is rarely used. Cystectomy is used to treat patients with diffuse superficial lesions if transurethral resection and intravesical chemotherapy fail.
. Invasive bladder cancer.. Intensive local treatment with cytostatics is prescribed to patients to eliminate a rapidly progressing tumor without metastasis.. Radiation therapy. For some tumors, irradiation at a total dose of 60-70 Gy to the bladder area has proven effective. Radical cystectomy is the method of choice in the treatment of deeply infiltrating tumors. Involves removal of the bladder and prostate in men; removal of the bladder, urethra, anterior vaginal wall and uterus in women. After radical cystectomy, urine is diverted using one of the following methods: ileal reservoir, intestinal stoma for self-catheterization, bladder reconstruction, or ureterosigmostostomy. For villous tumors and localized “in situ” tumors, treatment often begins with transurethral resection, adjuvant immunotherapy (BCG), and intravesical chemotherapy. If such tumors recur, it is necessary to decide on performing a cystectomy.
Postoperative follow-up. After transurethral resection, the first control cystoscopy is 3 months later, then depending on the degree of tumor differentiation, but not less than 1 time per year for 5 years in case of grade TaG1 and for 10 years in other cases. After reconstructive operations - ultrasound of the kidneys and urinary reservoir, biochemical blood test: the first year every 3 months, the second or third year every 6 months, from 4 years - annually.
Prognosis depends depending on the stage of the process and the nature of the treatment performed. After radical surgery, the 5-year survival rate reaches 50%
ICD-10. C67 Malignant neoplasm of the bladder. D09 Preinvasive bladder cancer
11.08.2017
Malignant tumor in the bladder is one of the few forms of the disease that can be detected at an early stage; accordingly, a favorable prognosis is possible in approximately 50% of cases.
Healing the doctor may suspectbladder canceralready at the stage of consulting the patient, having noticed the features manifestations pathology of the bladder against the background of predisposing factors in the anamnesis.
A tumor of any organ is a direct threat to life. As a rule, most of these neoplasms develop secretly, without any appear until it is too late to do anything. On last stage cancer is almost always incurable, and a person ultimately will die.
To minimize the number of deaths, doctors recommend a simple method - regular examinations to identify pathologyat an early stage. Unlike other neoplasms,bladder tumorcan be identified at the very beginning of development.
What causes bladder cancer?
Mark it preciselycauses of bladder cancerDoctors cannot, but they suggest minimizing a number of factors that can provoke cancer. AND research The following reasons are identified in this area:
Bladder cells can form different types tumors. Initiallyclassification of bladder cancertakes into account the degree of change in organ cells, that is, n how much they are different from healthy ones. Based on this it will be built diagnosis and forecast. There are the following types:
- transitional cell or well-differentiated cancer. It is this type that allows longer to live most of the sick. A tumor with such a favorable prognosis occurs in 98% of cases of all cancers in the bladder;
- low differentiated.For bladder cancerThis type of organ cells lose their healthy structure and change size. Based on their size, such tumors are divided into small and large cell. Cure cancer This type is difficult because the tumor grows quickly and metastasizes.
Symptoms of a malignant tumor
First symptomsare not too numerous, but still allow one to suspect oncology. If you suspectbladder cancer symptomswill be as follows:
- macrohematuria (blood in the urine appears from a growing tumor), which causes the color of urine to become reddish;
- There is no pain when emptying the bladder, which allows us to differentiatemain symptoms urolithiasis from cancer;
- dysuria (impaired urination). Mostly,first signs of bladder cancer in womenwill be manifested by frequent urge to go to the toilet, while very little urine is released. When it is suspectedbladder cancer symptoms in menurinary disturbances will be nocturnal (nocturia).
Listed abovesymptoms of bladder cancer in womenand men may be the only ones for many years with a slow course of the disease. Over time at a certainstages of bladder cancermay be added renal colic, urinary retention due to blockage of the ureter with coagulated blood. The pathology is like this degrees is rare.
Renal colic may manifest acute, requiring urgent hospitalization. The pain in the lower back is unbearable and worsens when walking. Reduce pain on thisstages of bladder cancerantispasmodics (No-shpa, Drotaverine) will help and combination drugs(Baralgin, Spazmalgon).
Additionally bladder cancer in womenand men are manifested by weakness for a long period, problems with sleep, low-grade fever for months, loss of body weight (1-2 kg per month). Such signs are characteristic of all stages, but are more pronounced in the third and third stages. fourth
Stands out when diagnosedbladder cancer stage 4 because they die from cancer precisely with this diagnosis. And if on 2 stages there are still chances that over time there will be no relapses, then Stage 3 and especially the fourth – this is practically a sentence. At 4 stage a number of additional symptoms appear, in addition to those listed above. Considering that the lymph nodes in the pelvic cavity are affected, in patients with belt severe swelling of the legs and perineum appears, covering male scrotum and labia in a woman. Determine how it manifests itself swelling, easy - press your fingers on the skin, hold for 3-5 seconds and release, observing the changes. If a dimple remains, which gradually levels out, this indicates swelling of the tissue.
Still on the third stage, closer to the fourth, cancer begins to grow in fatty tissue And neighboring organs. The growth of the tumor is felt by dull pain, which becomes stronger when urinating, physical activity. If upon diagnosisbladder cancer classificationclassified it as a low-differentiated type, its characteristic difference is metastases to different organs.
At the last stage, this is fraught with multiple organ failure, respiratory and heart failure. Any of these pathologies can cause a person to died , and if there are pathologies dv e and more, the fatal outcome is beyond doubt.
Diagnosis of bladder cancer
Early carried out on the basis of suspicion. The diagnosis can be confirmed or refuted using instrumental and laboratory studies. Unfortunately, serious tests are done only in major cities, private clinics. A regular blood and biochemistry test is not informative in this area,urine test for cancerdetects a tumor with a probability of 42%.
One of the available diagnostic methods is examination of urine sediment under a microscope to detect atypical cells. Will show l and this method, the presence of cancer depends on the form of the disease, since in a highly differentiated tumor the cells do not differ from healthy ones. There is anotherdiagnosis of bladder cancer- "BTA-TRAK". This is a test to determine tumor-specific substances in the urine. The test accuracy is 74%. The disadvantage of this method is the high price.
Among instrumental methods, the most accessible option is to explore bladder using ultrasound. On an ultrasound, the tumor will be visible as a darkened area of irregular shape. The technique is not fundamental, but allows the doctor to orient himself in the direction of thought for further research. No special preparation is required for an ultrasound; you just need to drink 1.5 liters of water a couple of hours before the examination and not urinate. A filled bubble is better visualized on the monitor, so it’s worth being patient to get an accurate picture.
The main way to confirm any forbladder stagecancer is cystoscopy. This is a procedure during which a cystoscope (camera and forceps) is inserted through the urethra into the bladder to examine the cavity and take tissue for analysis.
MRI and CT are used to determine the stage of cancer. These are highly informative studies that allow you to see in detail the structure of the bladder, the nearest fiber, The lymph nodes and other organs for the presence of metastases.
Treatment of cancer
Thanks to the development of urological technologies, new standards for the treatment of tumors have emerged, including when diagnosingbladder cancer treatmentcan be carried out in different ways. The doctor selects a specific treatment regimen taking into account the type of tumor and the degree of its development. Important factors the choices will be:
- safety of the chosen treatment method for the patient;
- minimum relapse rate.
In the initial stagestreatment of bladder cancer in menIt is carried out quickly, for this today they do not even make incisions on the skin - instruments are inserted through the urethra without injuring the mucous membranes. The tumor is removed, the wound is sutured, and the patient is left with rehabilitation andbladder cancer prevention. This minimally invasive method has been used for only 5-6 years, and it is called TUR (transurethral resection).
Considering that without removing the bladder there is a risk that the tumor will reappear, urologists have developed preventative method– BCG vaccine is administered through a catheter into the bladder. This procedure is carried out a month after tumor removal, the course lasts from 6 to 10 weeks. At an advanced second stage or in case of relapse, removal of the bladder is indicated, instead of which an artificial organ will function.
An alternative to TOUR on early stages Cancer treatment is brachytherapy - radioactive substances are injected into the bladder to destroy tumor cells. Recently, at a conference of urologists in Russia, it was proposed to try to treat a tumor with a new isotope that can break down tumor cells in a week. The technique is the most promising at the moment, but does not eliminate the risk of relapse. For stage 3-4 tumors, the doctor’s choice is chemotherapy or radiation.
In each individual case, the treatment method is selected individually, taking into account the patient’s desire to preserve the bladder. Thanks to modern advances, it has been possible to significantly improve the prognosis for tumors in the bladder, subject to timely diagnosis and therapy.
Prognosis and prevention
Upon diagnosisbladder cancer prognosisafter any treatment (except for surgery to remove an organ) comes down to a high risk of relapse. If the disease returns, it is recommended not to take any more risks, but to remove the organ. The 5-year survival rate for stage 1-2 tumors, taken as the standard, is guaranteed in 88-94% of cases. To say exactlyHow long do you live with bladder cancer?, is possible only in relation to a specific patient, and then only approximately, since the capabilities of the body cannot be predicted. According to statistics, the death of patients with stage 1-2 tumors is more often associated with complications after operations - colitis, urinary outflow disorders, than with relapses. For stage 3-4 cancer, survival rate is much shorter, depending on the malignancy of the process and the timing of treatment.
Upon diagnosis bladder cancer in men survival ratedepends not only on the therapy performed, but also on further monitoring of the patient. Patients should regularly visit the oncologist according to the schedule: in the first 2 years every 3 months, in the 3rd year - every 4 months, 4-5 years after treatment - every 6 months, and after the past 5 years it is enough to visit the oncologist once every year. According to practice, doctors claim that about 80% of patients stop coming to the clinic after 4 years have passed from the completed course of treatment. This behavior cannot be called responsible, since relapses can occur later.
To summarize, it can be noted that a bladder tumor will be less dangerous for the patient if diagnosed early.
The later cancer is detected, the less chance of a successful outcome. Even after successful treatment the risk of relapse is high, so it is advisable for the patient to visit the doctor with some regularity so as not to miss alarms and take action in time.
RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2012 (Orders No. 883, No. 165)
Bladder, unspecified part (C67.9)
general information
Short description
Clinical protocol"Bladder Cancer"
Urinary cancer bubble- one of the most common malignant tumors of the urinary tract. It ranks 17th in terms of frequency of occurrence among the population of Kazakhstan (Arzykulov Zh.A., Seitkazina G.Zh., 2010). Among all cancer patients, it accounts for 4.5% among men and 1% among women.
Protocol code:РH-S-026 “Bladder cancer”
ICD-X code: S.67 (S67.0-S67.9)
Abbreviations used in the protocol:
WHO - World Health Organization
SMP - specialized medical care
VSMP - highly specialized medical care
Ultrasound - ultrasound examination
CT - computed tomography
MRI - magnetic resonance imaging
ESR - erythrocyte sedimentation rate
PET - positron emission tomography
TUR - transurethral resection
RW - Wasserman reaction
HIV - human immunity virus
ECG - electrocardiography
CIS - carcinoma in situ
BCG - Bacillus Calmette-Guérin, BCG
ROD - single focal dose
Gr - Gray
SOD - total focal dose
Date of development of the protocol: 2011
Protocol users: oncologists, oncosurgeons, oncourologists, chemotherapists and radiologists at oncology dispensaries.
Disclosure of no conflict of interest: the developers signed a declaration of conflict of interest stating that they have no financial or other interest in the topic of this document, the absence of any relationship to the sale, production or distribution of drugs, equipment, etc. specified in this document.
Classification
International histological classification of bladder cancer:
1. Cancer in situ.
2. Transitional cell carcinoma.
3. Squamous cell carcinoma.
4. Adenocarcinoma.
5. Undifferentiated cancer.
TNM classification
(International Union Against Cancer, 2009)
T - primary tumor.
To identify multiple tumors, the index m is added to category T. To define the combination of cancer in situ with any category T, the abbreviation is is added.
TX - insufficient data to evaluate the primary tumor.
T0 - there are no signs of a primary tumor.
Ta is a non-invasive papillary carcinoma.
Tis - preinvasive carcinoma: carcinoma in situ (“flat tumor”).
T1 - the tumor extends to the subepithelial connective tissue.
T2 - the tumor has spread to the muscles.
T2a - tumor extends to the superficial muscle (inner half).
T2b - the tumor extends to the deep muscle (outer half).
T3 - tumor spreads to paravesical tissue:
T3a - microscopically.
T3b - macroscopically (extravesical tumor tissue).
T4 - the tumor has spread to one of the following structures:
T4a - The tumor has spread to the prostate, uterus or vagina.
T4b - the tumor has spread to the pelvic wall or abdominal wall.
Note. If histological examination does not confirm muscle invasion, then the tumor is considered to involve subepithelial connective tissue.
N - regional lymph nodes.
Regional to the bladder are the pelvic lymph nodes below the bifurcation of the common iliac vessels.
NX - it is not possible to determine the status of the lymph nodes.
N0 - metastases in regional nodes are not detected.
N1 - metastases in a single (iliac, obturator, external iliac, presacral) lymph node in the pelvis.
N2 - metastases in several (iliac, obturator, external iliac, presacral) lymph nodes in the pelvis.
N3 - metastases to one common iliac lymph node or more.
M - distant metastases.
MX - it is not possible to determine the presence of distant metastases.
M0 - there are no signs of distant metastases.
M1 - there are distant metastases.
Histological classification of bladder cancer without muscle invasion
WHO classification 1973
G - histopathological grading.
GX - degree of differentiation cannot be established.
1. G1 - high degree of differentiation.
2. G2 - average degree of differentiation.
3. G3-4 - poorly differentiated/undifferentiated tumors.
2004 WHO classification
1. Papillary urothelial tumor with low malignant potential.
2. Low-grade papillary urothelial cancer.
3. High-grade papillary urothelial cancer.
According to the 2004 WHO classification, bladder tumors are divided into papilloma, papillary urothelial tumor with low malignant potential, urothelial cancer of low and high degree malignancy.
Grouping by stages
|
Stage 0a Stage 0is |
Tis |
N0 | M0 |
| Stage I | T1 | N0 | M0 |
| Stage II |
T2a T2b |
N0 | M0 |
| Stage III |
Т3a-b T4a |
N0 N0 |
M0 M0 |
| Bladder | |
|
Ta Tis T1 T2 T2a Т2b T3 T3a T3b T4 T4a Т4b |
Non-invasive papillary Carcinoma in situ: “flat tumor” Spread to subepithelial connective tissue Muscle layer Inner half Outer half Beyond the muscle layer Microscopically Paravesical tissues Spread to other surrounding organs Prostate, uterus, vagina Pelvic walls, abdominal wall One lymph node ≤ 2 cm One lymph node > 2< 5 см, множественные ≤ 5 см Metastases to regional lymph nodes > 5 cm in greatest dimension |
Diagnostics
Diagnostic criteria
Clinical manifestations depending on the stage and location: hematuria, macro- or microhematuria, often painless hematuria; dysuric phenomena such as difficulty urinating, painful urination, imperative urges, pain in suprapubic region, weakness, night sweats, low-grade fever, weight loss.
Physical examination. On examination, local tenderness over the pubis may be noted. A bimanual examination is required to determine the condition of the rectum, prostate gland (in men), determination of ingrowth, mobility of these structures; in women, vaginal examination.
Lab tests: normal or decreased red blood counts; There may be minor, non-pathognomaniac changes (such as increased ESR, anemia, leukocytosis, hypoproteinemia, hyperglycemia, tendency to hypercoagulation, etc.).
Instrumental research methods:
1. Cystoscopy to identify the source of hematuria and the location of the tumor process in the bladder. Taking a biopsy from the formation and/or suspicious areas.
2. Cytological and/or histological confirmation of the diagnosis of malignant neoplasm.
3. Ultrasound of the pelvic organs to confirm the localization of the formation and the extent of the process.
4. X-ray research methods - if it is necessary to clarify the diagnosis (excretory urography, cystography, CT, MRI).
Indications for consultation with specialists:
1. Urologist, goal - consultation to exclude non-tumor diseases (tuberculosis, chronic cystitis, hemorrhagic cystitis, ulcers and leukoplakia of the bladder).
2. Cardiologist - to identify and correct the treatment of concomitant cardiac pathologies.
3. Radiologist - conducting x-ray examinations, describing x-ray examinations.
Differential diagnosis bladder cancer: acute or chronic cystitis, cystolithiasis, bladder tuberculosis, prostate adenoma, wasp. or xr. prostatitis, bladder diverticulum; conditions such as prostate cancer, rectal cancer, cervical cancer with invasion of the bladder.
Basic and additional diagnostic measures
Mandatory scope of examination before planned hospitalization:
Anamnesis;
Physical examination;
Bimanual examination, digital examination of the rectum, vaginal examination;
Laboratory tests: general urine test (if necessary cytological examination urine sediment), general blood test, biochemical blood test (protein, urea, creatinine, bilirubin, glucose), RW, blood for HIV, blood for Australian antigen, blood group, Rh factor;
Coagulogram;
Cystoscopy with tumor biopsy and from suspicious areas of the bladder mucosa;
Cytological or histological confirmation of the diagnosis of malignant neoplasm;
Ultrasound of the pelvic organs (for men - the bladder, prostate gland, seminal vesicles, pelvic lymph nodes; for women - the bladder, uterus with appendages, pelvic lymph nodes);
Ultrasound of organs abdominal cavity and organs of the retroperitoneal space;
X-ray of the chest organs.
List of additional diagnostic measures:
Transurethral, transrectal and/or transvaginal ultrasound;
CT/MRI of the pelvic organs to determine the extent of the process;
CT scan of the abdominal cavity and retroperitoneal space;
Laboratory tests: K, Na, Ca, Cl ions; and etc.;
Excretory urography with descending cystography;
Fibrogastroscopy and colonoscopy before radical cystectomy - according to indications;
Diagnostic laparoscopy;
Radioisotonic renography;
Osteoscintigraphy;
Consultations of related specialists and other examinations - as necessary.
Transurethral resection (TUR) of the bladder (category A) should be performed on all patients with a formation in the bladder for therapeutic and diagnostic purposes (except if there are obvious signs invasive process in case of verified diagnosis). For superficial tumors, during TUR, the exophytic part of the tumor is resected, then the base with a section of the muscular layer, 1-1.5 cm of the mucosa around and altered areas of the bladder mucosa.
For invasive tumors, the main mass or part of the tumor with a section of muscle tissue is resected. If radical cystectomy is planned, a biopsy of the prostatic urethra must be performed. The stage of the disease is established after histological examination based on data on the depth of invasion of the bladder wall (invasion of the basement membrane and muscle layer).
Treatment abroad
Get treatment in Korea, Israel, Germany, USA
Get advice on medical tourism
Treatment
Treatment goals for bladder cancer: elimination of the tumor process.
Treatment tactics
Non-drug methods:
mode 1 (general), diet - table No. 7.
Treatment tactics for bladder cancer depending on the stage of the disease
|
Stage diseases |
Treatment methods |
| Stage I (T1N0M0, TisN0M0, Ta N0M0) |
1. Radical operation, TUR* (category A) Intravesical BCG immunotherapy (category A) or intravesical chemotherapy 2. Bladder resection 3. Radical cystectomy** - with multifocal growth and ineffectiveness of previous treatment (category A) |
|
Stage II (T2aN0M0, T2bN0M0) |
1. Radical cystectomy (TUR* for T2a; resection of the bladder with lymph node dissection***) |
|
Stage III (T3aN0M0, T3bN0M0, T4a N0M0) |
1. Radical cystectomy 2. Chemo-radiation therapy - as a component of multimodal treatment or in case of contraindications to radical cystectomy |
|
Stage IV (T any N any M1) |
1. Chemoradiation therapy for palliative purposes 3. Palliative surgical interventions |
* In the absence of a TUR device, resection of the bladder can be performed. If this operation was performed in the urology department of a general medical network, it is necessary to obtain histological materials confirming the depth of invasion of the bladder tumor.
** Radical cystectomy should be performed in a specialized (urological oncology) department. This operation can be performed in dispensaries if there is a specialized department or beds, as well as if there are trained specialists.
*** Resection of the bladder is not a radical operation and should be performed only if there are contraindications to radical cystectomy.
Recommendations
1. There is evidence that radiotherapy alone is less effective than radical treatment(recommendation level B).
L Treatment of superficial bladder tumors
(stages Tis, Ta and T1)
Organ-preserving tactics (TUR - transurethral resection is mainly used). As an adjuvant treatment, a single intravesical instillation of chemotherapy drugs for 1-2 hours is carried out within 24 hours (preferably within the first 6 hours).
In case of diffuse unresectable superficial bladder cancer and recurrent tumors T1G3, poorly differentiated tumors with concomitant CIS, in case of ineffectiveness of the treatment, organ removal surgery (radical cystectomy) should be performed.
Radiation therapy is indicated: T1G3, multicentric growth (if radical cystectomy is refused).
Surgical treatment of superficial bladder tumors
Organ-preserving operations are possible using high-frequency currents (TUR) and a surgical scalpel (bladder resection).
Transurethral resection (TUR) is the mainstay of surgical treatment for superficial bladder tumors and tumors that invade the superficial muscle. At the same time, TUR is also a diagnostic procedure, as it allows one to establish the histological form and stage of the disease.
TUR involves removal of the tumor within healthy tissue with morphological control of the resection edges, including the bottom of the resection wound. The histological report should indicate the degree of differentiation, depth of tumor invasion and whether the material contains the lamina propria and muscle tissue (recommendation level C).
In the case where the primary TUR was incomplete, for example, with multiple or large tumors, if there are doubts about the radical previous TUR operation, or in the absence of the muscular membrane, as well as with a G3 tumor, it is recommended to perform a second TUR after 2-6 weeks (“second look”) ” - therapy). It has been shown that repeat TUR can improve disease-free survival (level of evidence: 2a).
5-year survival rate primary treatment RMP in the Ta-T1 stage through TUR alone is 60-80%. TUR completely cures about 30% of patients. Within 5 years, 70% develop relapses, and 85% of them within 1 year.
Resection of the bladder is a surgical method of organ-preserving treatment, used in the absence of a TUR device, or in the impossibility of performing a TUR for one reason or another. The requirements for resection are the same as for TUR - the presence of the muscularis mucosa must be present in the materials (wedge resection must be performed).
Adjuvant methods of influence:
A single immediate postoperative intravesical administration of chemotherapy drugs (mitomycin C, epirubicin and doxorubicin). A single immediate postoperative administration of chemotherapy should be carried out in all patients with suspected bladder cancer without muscle invasion after TUR. The timing of instillation is significant. In all studies, administration was carried out within 24 hours. Intravesical administration should be avoided in cases with obvious or suspected intra- or extraperitoneal perforation, which is very likely to develop with extended TUR.
Intravesical administration of chemotherapy drugs.
Intravesical chemotherapy and immunotherapy.
The choice between further chemotherapy or immunotherapy largely depends on the type of risk that needs to be reduced: the risk of relapse or the risk of progression. Chemotherapy prevents the development of relapse, but not progression of the disease. If chemotherapy is being administered, it is recommended to use drugs with an optimal pH and maintain their concentration during instillation by reducing fluid intake. Optimal mode and duration of chemotherapy remain unclear, but it should probably be given over 6 to 12 months.
Intravesical chemotherapy and immunotherapy can be used in combination with surgical treatment to prevent relapse and progression after surgery. Best effect noted with immediate (within 1-2 hours) intravesical chemotherapy in order to prevent the “dispersal” and “implantation” of tumor cells after TUR, and therefore reduce recurrence (category B).
Currently, the following chemotherapy drugs are used for intravesical administration: doxorubicin, mitomycin C, cisplatin and other chemotherapy drugs.
Intravesical chemotherapy regimens:
1. Epirubicin at a dose of 50 mg, diluted in 50 ml of saline solution, once a week, for 6 weeks, the first administration immediately after TUR.
2. Doxorubicin 50 mg in 50 ml of saline solution, intravesically, for 1 hour daily, for 10 days, then 50 mg once a month.
3. Doxorubicin 50 mg in 50 ml of saline solution, intravesically, for 1 hour weekly, for 8 weeks.
4. Mitomycin C 20 mg in 50 ml of isotonic sodium chloride solution, intravesically, 2 times a week, for 3 weeks.
5. Thiophosphamide 60 mg in 50 ml or 30 mg in 30 ml of 0.5% novocaine solution, intravesically, for 1 hour, 1-2 times a week, up to a total dose of 240-300 mg.
6. Cisplatin 60 mg in 50-100 ml of isotonic sodium chloride solution, intravesically, once a month.
7. Methotrexate 50 mg, once a week, No. 3-5
When using intravesical chemotherapy to prevent relapse after TUR for superficial bladder cancer, the same drugs are used in similar doses, but they are usually administered once a month for 1-2 years.
Intravesical BCG immunotherapy
Intravesical administration of BCG is indicated in the presence of unfavorable risk factors: tumors with a high degree of malignancy (T1G3), recurrent tumors, multiple tumors (4 or more), non-radical operations (foci at the cutting edges tumor growth), the presence of carcinoma in situ, aggressive course of pretumor changes in the urothelium, positive cytology of urinary sediment after TUR.
BCG (strain RIVM, 2 x 108 - 3 x 109 viable units in one vial).
BCG immunotherapy regimen:
3. Intravesical administration of BCG is carried out according to the following method: the contents of the bottle (2 x 108 - 3 x 109 viable units of BCG in one bottle) are diluted in 50 ml of isotonic sodium chloride solution and injected into the bladder for 2 hours. To facilitate contact of the drug with the entire surface of the bladder, the patient is recommended to change body position at certain intervals.
Unlike chemotherapeutic agents, BCG should not be administered immediately after bladder resection due to the possibility of severe systemic infection. BCG treatment usually begins 2-3 weeks after TUR. Excessive use of lubricants to lubricate the catheter during instillation may lead to a clinically significant decrease in the number of viable mycobacteria injected and poorer contact of BCG with the bladder mucosa. Therefore, a small amount of lubricant should be used for urethral catheterization. It is preferable to use catheters that do not require lubrication.
When performing intravesical BCG immunotherapy, both local and general reactions, the most common of which is fever. Any patient with a fever greater than 39.5°C should be admitted to hospital and treated as for BCG sepsis. If treatment is not started quickly, sepsis can lead to the death of the patient. Current recommendations for the treatment of BCG sepsis: prescribe a combination of three anti-tuberculosis drugs (isoniazid, rifampicin and ethambutol) in combination with high doses of short-acting corticosteroids.
Patients with a history of BCG sepsis should no longer receive BCG immunotherapy.
Contraindications to intravesical administration of BCG:
Previous tuberculosis;
A sharply positive skin reaction to the Mantoux test;
Diseases of an allergic nature;
Primary immunodeficiency, HIV infection;
Bladder capacity less than 150 ml;
Vesicoureteral reflux;
Heavy accompanying illnesses in the stage of decompensation;
Severe cystitis or gross hematuria (until symptoms disappear);
Traumatic catheterization or the appearance of blood after bladder catheterization are contraindications for BCG instillation on a given day.
Unlike chemotherapy, BCG immunotherapy, in addition to reducing the frequency of relapses, leads to a decrease in the incidence of tumor progression and increases survival of patients with superficial transitional cell carcinoma. BCG immunotherapy is indicated for patients with a high risk of relapse and progression of superficial bladder cancer (cancer in situ, stage T1, poorly differentiated tumors), as well as when intravesical chemotherapy is ineffective for well- and moderately differentiated Ta tumors.
L treatment of invasive bladder cancer
During initial treatment, an invasive tumor is detected in 20-30% of patients with bladder cancer, and 20-70% of them (depending on the stage and degree of malignancy) already have regional metastases, and 10-15% have distant metastases.
The gold standard treatment for invasive bladder cancer is radical cystectomy (category A). The following are various options surgical interventions.
Surgery
For invasive bladder cancer, organ-preserving (TURP for T2a and bladder resection) and organ-saving (radical cystectomy) operations are used. TUR can also be used as a palliative method to stop bleeding in advanced stages of bladder cancer.
Bladder resection. Resection of the bladder is not a radical operation and should be performed only if there are contraindications to radical cystectomy or if the patient refuses it.
Indications for resection of the bladder: a single invasive tumor within the muscular wall of the bladder, low-grade tumor, primary (non-recurrent) tumor, the distance from the tumor to the bladder neck is at least 2 cm, the absence of dysplasia and cancer in situ with a biopsy free of tumors of the bladder mucosa. During the operation, it is necessary to retreat from the visible edge of the tumor by at least 2 cm with complete exposure of the affected wall.
Resection of the bladder should be performed to its full depth, including removal of the adjacent part of the perivesical fat, with histological examination of the edges of the resection wound. The operation is combined with mandatory pelvic lymph node dissection. The latter includes removal of the external and internal iliac and obturator lymph nodes from the bifurcation of the common iliac artery to the obturator foramen. In case of metastatic disease of the lymph nodes, the scope of lymph node dissection can be expanded.
If histological examination reveals tumor cells at the edges of the resection wound (R1), a radical cystectomy is performed.
If the ureteric orifice is involved in the process after resection of the bladder and removal of the tumor, ureteroneocystoanastomosis is performed (in various modifications).
The optimal operation for invasive bladder cancer is radical cystectomy. The operation involves removal in a single block along with the bladder and perivesical tissue: in men - the prostate gland and seminal vesicles with adjacent fatty tissue, the proximal parts of the vas deferens and 1-2 cm of the proximal urethra; in women - the uterus with appendages and the urethra with the anterior wall of the vagina. In all cases, pelvic lymph node dissection is performed (see above).
During development renal failure, caused by a violation of the outflow of urine from the upper urinary tract, as the first stage in removing the bladder for temporary diversion of urine, as well as in inoperable patients, palliative surgery is performed - percutaneous nephrostomy.
All great amount Methods for urinary diversion after cystectomy can be roughly divided into three groups:
1. Diversion of urine without creating artificial reservoirs:
On the skin;
Into the intestines.
2. Diversion of urine with the creation of a reservoir and its removal onto the skin.
3. Various methods bladder modeling with restoration of urination (artificial bladder).
The simplest method of draining urine after removal of the bladder is to the skin (ureterocutaneostomy). This method is used in weakened patients with a high risk of surgical intervention.
Today, the most convenient method of urine derivation is to create a Bricker ileum conduit. At this method the ureters are anastomosed into an isolated segment small intestine, one end of which is brought out to the skin in the form of a stoma (Bricker operation). In this case, the ureters are anastomosed with a segment of the intestine, and the intestine itself is a kind of conductor for urine (Ileum Conduit). With this method of diversion, urine is constantly released onto the skin, so it is necessary to use special adhesive urinals. If it is impossible to use the small intestine as a conductor for urine drainage, the large intestine (usually the transverse colon) can be used.
Diversion of urine into a continuous bowel was considered a convenient method for patients, since there are no open stomas. Various techniques of ureterosigmoanastomosis were most often used. The main disadvantage of the method is scar deformities sites of anastomosis with hydronephrotic transformation of the kidneys, as well as the possibility of developing intestinal-ureteric reflux and ascending pyelonephritis. Frequent bowel movements and acute incontinence are additional side effects of this type of surgery. Patients, as a rule, die from chronic renal failure more often than from progression of the tumor process. Therefore, this technique has recently been used less and less.
The best option The operation is to create an artificial bladder from the small, large intestine and stomach with the restoration of the normal act of urination.
Indications for cystectomy are:
Possibility of performing radical cystectomy;
Normal kidney function (creatinine< 150 ммоль/л);
No metastases (N0M0);
Negative result of biopsy of the prostatic urethra.
Of the surgical methods, the most widely used are the methods of U. Studer and E. Hautmann.
Palliative operations in patients with bladder cancer
Indications for them are:
Life-threatening bleeding from a bladder tumor;
Impaired urine outflow from the upper urinary tract and the development of renal failure, acute obstructive pyelonephritis;
Concomitant diseases (diseases of cardio-vascular system, endocrine disorders, etc.).
To stop bleeding, the following are used: TUR of the tumor with stopping bleeding; ligation or embolization of the internal iliac arteries; stopping bleeding in an open bladder; palliative cystectomy.
If the outflow of urine from the upper urinary tract is impaired, the following is used: percutaneous puncture nephrostomy; open nephrostomy; ureterocutaneostomy; supravesical diversion of urine into an isolated segment of the small intestine (Bricker operation, etc.).
Radiation therapy for invasive bladder cancer
Confirmation of the diagnosis is required for radiotherapy. In the treatment of bladder cancer, radiation therapy can be used as independent method And How component combined and complex treatment before or after surgery.
Radiation therapy according to the radical program is indicated only if there are contraindications to radical surgery or if the patient is planning organ-saving treatment and if the patient refuses surgical treatment.
Radiation therapy according to the radical program is carried out using bremsstrahlung radiation from a linear accelerator or gamma therapy in the traditional dose fractionation regimen (single focal dose (SOD) 2 Gy, total focal dose (TLD) 60-64 Gy for 6-6.5 weeks ( irradiation rhythm - 5 times a week) in a continuous or split course. In this case, the entire pelvis is first irradiated up to an SOD of 40-45 Gy, then in the same mode, only the bladder area up to an SOD of 64 Gy. The best results of conservative treatment of bladder cancer are achieved when using chemoradiotherapy or when using radiomodifiers (electron-acceptor compounds, based on the oxygen effect, etc.).
External beam radiation therapy is carried out in the traditional mode: ROD 1.8-2 Gy to ROD 40 Gy. The effect of treatment is assessed after 3 weeks. When complete or significant tumor resorption is achieved, chemoradiotherapy continues until the SOD is 60-64 Gy. If resorption is incomplete or the tumor continues to grow, cystectomy can be performed (if the patient agrees to the operation and is functionally tolerant of the surgical intervention).
The indication for palliative radiotherapy is stage T3-4. Typically, lower doses of radiation are used (30-40 Gy) with a single dose of 2-4 Gy. Poor general condition (Karnofsky index below 50%) and a significant decrease in bladder capacity are contraindications to palliative radiotherapy. This treatment mainly has symptomatic effect, which is mainly limited to reducing the severity of gross hematuria. No effect on life expectancy is observed. After 3 weeks, cystoscopy and ultrasound are performed. If the effect is obtained, it is possible to continue radiation therapy up to an SOD of 60-64 Gy.
At the same time, in some patients the process becomes resectable and it becomes possible to perform radical surgery.
Symptomatic radiation therapy for bladder cancer is used as a type of palliative therapy to relieve individual manifestations of the disease and alleviate the patient’s condition (as a rule, this is irradiation of tumor metastases to reduce the severity of pain).
The use of radiation therapy after surgery is indicated for non-radical operations (R1-R2). A total focal dose of 60-64 Gy is used in the usual dose fractionation mode (2 Gy) with a five-day irradiation rhythm.
Contraindications to radiation therapy (except palliative): wrinkled bladder (volume less than 100 ml), previous pelvic irradiation, presence of residual urine more than 70 ml, bladder stones, exacerbation of cystitis and pyelonephritis.
Pre-radiation preparation using an ultrasound machine or using an x-ray simulator includes:
Position the patient on his back;
Empty bladder;
Mandatory recording of information obtained from CT and MRI;
Catheterization of the bladder with a Foley catheter with the introduction of 25-30 ml of contrast agent into the bladder and 15 ml into the balloon;
When planning irradiation from the lateral fields, rectal contrast is mandatory.
Irradiation technique
The radiation therapist is free to choose technical solutions (quality of radiation, localization and size of fields) provided that the radiation volumes are included in the 90% isodose.
I. Standard irradiation of the entire pelvis is carried out from 4 fields (anterior, posterior and two lateral).
Front and back margins:
Upper limit - upper limit of S2;
The lower border is 1 cm below the lower edge of the obturator foramen;
The lateral borders are 1-1.5 cm lateral to the outer edge of the pelvis (in greatest dimension).
Heads femur, the anal canal and rectum are protected as much as possible by blocks.
Side margins:
The anterior border is 1.5 cm anterior to the anterior surface of the contrasted bladder;
The posterior border is 2.5 cm behind the posterior wall of the bladder.
II. Targeted irradiation (boost) involves the use of two (opposite) or three (direct front and two lateral) fields.
The irradiation zone includes the entire bladder + 2 cm beyond it (if the tumor is not clearly defined). In case of good visualization of the tumor during pre-radiation preparation, the irradiation fields include the tumor + 2 cm beyond its borders.
Standard for planned radiation volume: 90% isodose includes the bladder and 1.5-2 cm beyond it.
Systemic chemotherapy
Chemotherapy may be used:
In the form of neoadjuvant chemotherapy before surgery or radiation treatment;
Adjuvant chemotherapy after radical surgical treatment or radiation therapy performed according to a radical program;
On its own for unresectable and metastatic bladder cancer as a palliative method.
The highest percentage of regressions is achieved by polychemotherapy regimens containing a combination of cisplatin and gemcitabine, as well as the M-VAC regimen. With almost identical indicators of objective effect and overall survival. The gemcitabine + cisplatin regimen has an undoubted advantage in terms of the frequency and severity of side effects, improved quality of life, and reduced costs of accompanying therapy.
Regimen: gemcitabine 1000 mg/m2, on days 1, 8, 15, cisplatin 70 mg/m2, on days 1, 8, 15.
Other polychemotherapy regimens may be used:
1. PG: cisplatin 50-60 mg/m2, intravenous drip, on the 1st day; gemcitabine 800-1000 mg/m2, intravenous drip, on the 1st and 8th day. Repeat the cycle after 28 days.
2. GO: gemcitabine 1000 mg/m2, IV, on day 1; oxaliplatin 100 mg/m2, 2-hour infusion on day 2. Repeat cycles every 2 weeks.
The occurrence of an oncourological tumor in the body of a woman or man is observed in old age. The male population is more susceptible to this pathology. Today, bladder cancer accounts for fifty percent of neoplasms in the urinary system. The causes of bladder tumors lie in risk factors. These include:
- Poisoning with carcinogenic substances (smoking, industrial hazards, consumption of hemomodified food);
- Long-term use of hormonal drugs;
- Congenital anomalies and hereditary genotype;
- Infectious, sexually transmitted diseases;
- Chronic inflammatory processes genitourinary system.
A malignant tumor of the bladder is preceded by precancerous diseases. These include: cystitis of various etiologies, leukoplakia, transitional cellular papilloma, adenoma and endometriosis.
The International Classification of Diseases 10 views includes neoplasms of urological localization. Of these, the following are distinguished:
- ICD 10, kidney tumor – C 64 – 65;
- ICD 10, ureter tumor - C 66;
- ICD 10, bladder tumor – C 67;
- ICD 10, tumor of unspecified organs of the urinary system - C 68.
The neoplasm in the bladder is of epithelial, muscular and connective tissue origin. Malignant tumors vary in form:
- Fibrosarcoma;
- Reticulosarcoma;
- Myosarcoma;
- Myxosarcoma.
Emergence benign tumor in the bladder, is a risk factor for its malignancy. Cancer can develop from a papilloma, cyst, or adrenal medulla (pheochromocytoma). The malignant process often occurs through the exophytic type of tumor growth, that is, into the cavity of the bladder. The neoplasm, depending on its morphological affiliation, has different shapes and pace of development. The tumor can slowly spread along the walls of the organ or be characterized by rapid infiltration, with germination of the membranes of the urinary tract and exit into the pelvic area. The most common cancer is the neck and base of the bladder. With infiltrative tumor growth, neighboring lymph nodes, tissues and other organs are involved in the malignant process. Damage to distant lymph nodes and organs occurs when late stage cancer. Metastasis of urinary carcinoma is observed in the third and fourth stages of tumor development. Localization cancer cells, which are carried by lymph and blood, are observed in the lymph nodes of the obturator and iliac vessels, as well as in the liver, spinal cord and lungs.
To obvious symptoms malignant process in the bladder include:
- Pain in groin area, sacrum, lower back, legs, perineum, scrotum in men;
- Increased body temperature;
- Impaired urinary function: pain, constant urge, incomplete emptying organ, the appearance of blood in the urine;
- General intoxication: pallor skin, lack of appetite, fatigue, weakness, loss of body weight.
It is not difficult to diagnose bladder pathology: ultrasound, cystoscopy, biopsy.
Treatment for bladder cancer involves removing the tumor. Surgery carried out according to the degree of the malignant process, localization and spread, stage of tumor development, metastasis and age of the patient. Before surgery, chemotherapy or radiation to cancer cells is often used to shrink the tumor. After surgery, treatment is continued with a comprehensive approach to combating the oncological process. Complete suppression of cancer cells, in order to avoid relapse, is achieved with cytotoxic drugs and radiation.
During a successful operation, the prognosis for the patient's life is favorable.
Video on the topic
Often, with advanced cancer, a tumor can be identified in women by bimanual palpation through the vagina and anterior abdominal wall, in men - through the rectum. Urine tests for bladder cancer show an increase in the number of red blood cells, and blood tests show a decrease in hemoglobin levels, indicating ongoing bleeding.
One way to diagnose bladder cancer is urine cytology, which is usually performed several times. The detection of atypical cells in the urine is pathognomonic for bladder neoplasm. In recent years another one has appeared laboratory method diagnostics, the so-called BTA (bladder tumor antigen) test. Using a special test strip, urine is examined for the presence of specific antigen bladder tumors. This technique usually used as a screening diagnostic method.
Of great importance in the diagnosis of bladder cancer is ultrasound diagnostics. Transabdominal examination can detect tumors larger than 0.5 cm with a probability of 82%. The formations located on the lateral walls are most often visualized. When the tumor is localized in the bladder neck, the use of transrectal examination may be informative. Neoplasms are not large sizes It is better to diagnose using transurethral scanning, carried out with a special sensor inserted through the urethra into the bladder cavity. The disadvantage of this study is its invasiveness. It must be remembered that an ultrasound of a patient with a suspected bladder tumor must necessarily include an examination of the kidneys and upper urinary tract in order to identify dilatation of the collecting system as a sign of compression of the ureteral orifice by the tumor.
Large tumors are detected by excretory urography or retrograde cystography. Sedimentary cystography according to Kneise-Schober helps to increase the information content of the study. Spiral and multislice computed tomography with contrast has great importance in the diagnosis of bladder cancer. Using these techniques, it is possible to establish the size and localization of the formation, its relationship to the orifices of the ureters, germination into neighboring organs, as well as the condition of the kidneys and upper urinary tract. However this method can be used if the patient is able to accumulate a full bladder and hold urine during the study. Another disadvantage of CT is the insufficient information content in identifying the depth of tumor invasion into the muscle layer due to the low ability to visualize the layers of the bladder wall.
Magnetic resonance imaging is also used in the diagnosis of bladder tumors. Unlike CT, tumor invasion into the muscle layer of the bladder or adjacent organs can be assessed with much greater accuracy.
Despite the informative nature of high-tech methods, the main and final method for diagnosing bladder cancer is cystoscopy with biopsy. Visualization of the tumor, a morphologist's conclusion about the malignant nature, structure and degree of differentiation of the bladder neoplasm are leading in the choice of treatment method.
Fluorescence cystoscopy can increase the information content of cystoscopy. The peculiarity of this technique is that after treating the mucous membrane of the bladder with a solution of 5-aminolevulinic acid during cystoscopy using light from the blue violet part of the spectrum, the tumor tissue begins to fluoresce. This is due to increased accumulation of fluorescent agent by neoplasm cells. The use of this technique makes it possible to identify small formations that often cannot be detected by any other method.
Loading...