The internal wall of the Vessie is papered of transitional cells which are at the origin of the majority of the Cancers of the bladder. The evolution and the assumption of responsibility depend much on the invasive character of the tumor. One distinguishes surface cancer from the bladder of invasive cancer.

Epidemiology

Incidence

The cancer of the bladder is a not very frequent tumor. In 2000,10700 new cases were diagnosed. It occupies in France the sixth rank by its frequency among cancers.

Mortality

It accounts for 3,5% of cancer deaths.

Affected population

The Middle Age is 65 years. It touches 4 men for 1 woman, but this rate evolves/moves as of impact of the nicotinism at the woman is felt.

Risk factors

The supporting factors most important are the tobacco and unquestionable carcinogenic chemical. For this reason the cancer of the bladder can be regarded as an occupational disease.

The principal industrial substances in question are:

  • aromatic amines
  • their halogenous and sulfonic hydroxylated derivatives. (French table n°15 of the occupational diseases)
  • derivatives of aniline
  • certain polycyclic hydrocarbons
  • industrial derivatives of tryptophan

In addition one finds at the origin of the cancer of the bladder certain drugs (phenacetin, cyclophosphamide) or a pelvic irradiation. The lesions of urinary Bilharziose can degenerate into malignant lesions of type cancer épidermoïde of the bladder. This pathology is found mainly in Egypt and West Africa. There exists also an endemic tubulo-intertitielle nephropathy in the area of Balkans, which can becomes complicated in cancer urothéliale. This disease results from a food inoxication by a Mycotoxine, the Ochratoxine has, produced by a mushroom of cereals.

Diagnosis

Symptoms

The clinical elements evoking a cancerous tumor of the bladders are not very specific. One notes initially the Hématurie micro or macroscopic, the Dysurie, the signs of urinary infection to clear urine, the repeating urinary infections, the deterioration of the general state.

The clinical symptoms require a biological confirmation with realization

  • of a urinary strip finding the hématurie,
  • of a cytological examination of the urines confirming the presence of red blood corpuscles and of abnormal cells,
  • the Cystoscopie is the examination of choice to visualize the vesical lesions and to carry out in the same time of the biopsies for anatomopathologic studies of the lesions,
  • the examinations of imageries the such scanner and IRM of the basin are useful for the assessment of extension.

Assessment of extension

The cancer of the bladder develops starting from the internal mucous membrane of the bladder. In absence of treatment, the disease extends beyond the mucous membrane through the wall from the bladder, disseminates through the lymphatic vessels towards the ganglia of the small basin, and through the veins in the whole of the organization to form metastases. The assessment of extension makes it possible to know the stage exact of the disease, to apply the treatment best adapted and to estimate the forecast of the disease.

Anatomopathology

There exist different type anatomo-pathologiqques from malignant tumor of the bladder. The cancer term of the bladder corresponds to carcinome of the bladder. There are three forms:
  • transitional carcinome is the most frequent form. It accounts for 90% of the cancer of the bladder.
  • carcinome épidermoïde is rarer, it corresponds to 7% of cancers.
  • the adenocarcinomist is rarer, approximately 1%.

The noncarcinomatous lesions correspond to the lymphomas and sarcomes of the bladder whose treatment differs from carcinomes.

Classification

The rank G1 G2 G3

Classification TNM-UICC 2002

T (Tumor)
  • Tx Tumeur primitive which cannot be classified
  • T0 Tumeur which cannot be classified
  • Your surface papillary carcinome (respecting the basal membrane)
  • Tis in situ carcinome (plane, respecting the basal membrane)
  • T1 Tumor invading subepithelial conjunctive fabric
  • T2 Tumeur invading the muscle (or Détrusor)
    • T2a Musculeuse surface
    • T2b Musculeuse deep
  • T3 Tumor invading vesical perished fabric (grease)
    • microscopic T3a Reached
    • macroscopic T3b Reached
  • T4 Invasion of the adjacent internal organs
    • T4a Prostate or uterus or vagina
    • T4b pelvic Wall or abdominal wall
NR (regional Adenopathies)
  • Nx Absence of sufficient information
  • N1 Envahissement of only one pelvic ganglion <2 cm of largeer diameter
  • N2 Invasion of only one ganglion > 2 cm but <5 cm or several ganglia <5 cm
  • N3 Envahissement of a ganglion > 5 cm
M (remote Metastases)
  • M0 Pas of remote metastasis
  • M1 Présence of remote metastases

Classification of the surface tumors of the bladder

The committee of Cancerology of the French Association of Urology defined a surface classification of the tumors of the bladder. this classification makes it possible to distinguish three stages for which the risk of relapse at 5 years and death at 10 years are distinguished clearly.

The forecast

The prognostic Factors are:
  • stage TNM
  • the histological rank
  • the presence or not of a hydronéphrose
  • the quality of the résection transurétrale for the patients treated by association radio-chemotherapy.

Survival at 5 years of the forms located with the bladder is of 60% whatever the T. It is independent of the type of local treatment. Survival at 5 years of the forms with pelvic ganglionic extension is from 5 to 25% according to the importance of the ganglionic attack. Survival at 5 years is null in the metastatic forms. the majority of the deaths are observed in the 2 years following the diagnosis.

Therapeutic methods

Surgery

  • the résection transurétrale of bladder (RTUV) is the treatment of reference of the surface tumors of the bladder. the gesture can be renewed, in the event of repetition, in accordance with the recommendations.

  • the partial Cystectomie can be considered for the infiltrating tumors of the bladders, under precise conditions:
    • single
    • of small size
    • sitting on the mobile portion of the bladder
    • without carcinome in situ associated
    • leaving the sufficient post-surgical vesical capacity

  • total cystectomy (prostatectomy at the man, former pelvectomy at the woman), preceded by a clearing out ganglionic obturating, iliaque external and hypogastric with extemporané histological examination. It imposes the drainage of the urines by trans-intestinal way standard Bricker or a entérocystoplastie standard Camey or a derivation interns standard Coffey.

So during the intervention, the surgeon observes an important ganglionic invasion or an extension of the tumor to the bodies of vicinity, it is possible that the cystectomy is not carried out.

The external radiotherapy

It delivers by 4 beams of irradiation, 45 Gy in the pelvis then 20 Gy on the vesical cabin, into 6 to 7 weeks using a linear accelerator of 15 MV. Association radio chemotherapy combines the radiotherapy and a chemotherapy (containing cisplatine 25 mg/j and of 5-FU 1000 mg/j). The ARC seems higher than the radiotherapy alone in term of effectiveness. The vesical curiethérapie is practically abandoned.

The radiotherapy is also indicated on a purely antalgic basis on metastasis (S) osseous (S).

Chemotherapy and the immunothérapie

Endo-vesical treatment

The endovésical treatment includes/understands either a immunothérapie by BCG (the interféron alpha is being studied), or a chemotherapy by mitomycine C.

Systemic treatment

For chemotherapy by systemic way the effective molecules in the cancer of the bladder are the cisplatine, the méthotrexate, the vinblastine, the adriamycine, the paclitaxel and the gemcitabine. Today, the protocol of reference in metastatic situation is protocol GC (gemcitabine cisplatine). This protocol is equivalent to protocol MVAC in term of effectiveness. It is less toxic.

Protocol CG

  • gemcitabine 1250 mg/m ² J1-J8
  • cisplatine 70 mg/m ² J1
  • J1 = J21

Chemotherapy can be used in several situations:

  • associated with the radiotherapy, it acts of an ARC (association radio-chemotherapy)
  • before the surgery to try to reduce the size of the tumor and to allow the intervention. It is about an néo-auxiliary chemotherapy. Several studies seem to show an advantage with the realization of this chemotherapy under certain conditions without its interest being formally established.
  • after the surgery, it acts then of an auxiliary chemotherapy whose objective is to reduce or delay the relapses. In this situation also several studies seem to show an advantage with this chemotherapy without its interest being shown perfectly.

Therapeutic strategy

Surface tumors pTa-pT1-pTis

Tumors of weak risk according to the classification of the CCAFU

The treatment of reference is the trans-urethral résection of complete bladder. the monitoring includes/understands:
  • a cystoscopy with 3,6 and 12 months then every year during 5 years
  • in option: annual echography after 5 years in the absence of repetition.

Tumors of intermediate risk according to the classification of the CCAFU

The treatment of reference is the trans-urethral résection of complete bladder followed either of a intra-vesical chemotherapy post operational early or of an auxiliary endo-vesical instillation. the monitoring includes/understands:
  • a cystoscopy with cytology of washing to 3,6 and 12 months then every year during 15 years
  • a uroscanner at the time of the repetition if control is higher than 2 years.

Tumors of high-risk according to the classification of the CCAFU

The treatment of reference includes/understands a trans-urethral resection of possibly followed complete bladder biopsies of revaluation then of a intra-vesical immunothérapie by BCG (protocol 6+3 and desirable maintenance). The monitoring includes/understands:
  • a cystoscopy and a cytology of washing every three months during one year, every six months during two years, then once per annum until the fifteenth year.
  • a intravenous Urography every two years.
For the high-risk lesions the cystectomy must be considered in the event of reécidive early in spite of the instillations of BCG.

Infiltrating tumors localized

When the tumor is limited to the bladder and that there does not exist ganglionic invasion, the treatment of reference is the complete cystectomy. If the health condition of the patient does not allow to carry out this surgery, the surgery can be replaced by an association radio-chemotherapy.

Infiltrating tumors wide

The tumors extended beyond the bladder (T3 or T4) or accompanied by a ganglionic invasion N+ are worse forecast. There is no consensus as for their assumption of responsibility. That Ci depends on the health condition of the patient, of the extension of the disease, and the practices of chaques teams. If a surgery is possible, it can be preceded or followed by a chemotherapy containing platinum. If the surgery is not considered, it is necessary to propose to the patient an association radio-chemotherapy. If a chemotherapy first is proposed and that the tumor does not answer this first treatment the forecast is bad.

Metastatic tumors

The treatment of reference in metastatic situation is a chemotherapy of the gemcitabine-cisplatine type. This treatment makes it possible to prolong survival and to decrease the symptoms related to the disease among certain patients. signs associated with the local evolution with the disease, as the hématurie can sometimes be controls by the exérèse of the bladder, called " cystectomy of propreté" or a pelvic irradiion.

References

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