Bladder cancer!

Bladder Tumors (Urinary Bladder Tumors) Bladder (urinary bladder) cancer is malignant tumors arising from the tissues that make up the wall of the bladder. 90% of bladder cancers are tumors originating from cells lining the inner surface of the bladder, called transitional cell carcinomas. It is the fourth most common cancer in men after prostate, lung and colon cancers. It constitutes approximately 10% of cancer cases in men. It is the eighth most common cancer in women and accounts for 4% of all cancer cases. Bladder cancer can occur at any age, including childhood. The average age of occurrence is 65-70. Two-thirds of cases occur in people 65 and older. It is rare under the age of 35, but with the rapid industrialization, the age limit for these tumors is gradually being lowered. Men get bladder cancer 2-3 times more often than women. At the time of diagnosis, 85% of the cancers are limited to the bladder, and 15% of them have spread to surrounding tissues or distant organs. Bladder cancer is one of the most common cancers among men today after prostate cancers (it is the second most common cancer of the genitourinary system).

Its incidence increases with age. Tumors seen at younger ages generally have a better histological structure and show a better course. The frequency of bladder tumors varies according to regions and countries. Risk Factors in Bladder Cancer? Causes that increase the likelihood of developing any disease are called risk factors.

 Exposure to chemical agents (petroleum, paint, leather industry workers, etc.)

 Smoking

 Advanced age, male and Caucasian race

 Excessive consumption of fatty and fried foods

 Genetic predisposition

 Radiation therapy to the lower abdomen (radiotherapy)

 Chemotherapy applications

 Infections

 Bladder stones, long-term irritation

 Excessive use of painkillers The most important risk factors for the development of bladder cancer are smoking, gender and diet.

Causes Today, it can be mentioned that there is a genetic predisposition of superficial and slowly progressing bladder tumors. It has been reported that inactivation of many tumor suppressor genes plays a role in the formation of bladder cancer. Today, the most important tumor suppressor genes shown to be related to the formation of bladder cancer are TP53 and cell cycle inhibitors RB, P21, P27 and P16. Apart from genetic predisposition in its etiology, occupational carcinogens, smoking, chronic bladder inflammation, bladder stones, foreign bodies, radiation therapy, Some painkillers, artificial sweeteners, chemotherapeutic drugs and foods can be counted. Smoking is one of the most important causes of bladder tumors, bladder development is 4 times higher in smokers. Occupational carcinogens, chemicals, paint, rubber, leather industry workers, dry cleaners, paper industry, It is more common in those working in the petroleum industry, cosmetic industry, dental technician, gas and aluminum industry.

It is more common in those who have recurrent urinary tract infections, those with long-lasting bladder stone disease, those who have long-term catheter or catheterization, and those who use phenacetin painkillers for a long time. High-dose radiation therapy to the bladder region increases the incidence of cancer 4 times. Cyclophosphamide, a chemotherapy drug, bladder tumor poses a risk for its development. . Signs and Symptoms The most common finding of bladder tumor is painless clotted bleeding in the urine. Painless and intermittent bleeding in the urine is seen in approximately 85% of the patients. The bleeding may be visible or in the form of bleeding that can be seen microscopically. In some patients, symptoms such as cystitis may be present, complaints such as frequent urination, burning during urination, and difficult urination are the first signs of bladder tumor. may have symptoms. With bleeding, clots can also come from the urine. There may be pain due to spread, fatigue, weight loss, bone pains, back and headaches, bloody sputum, jaundice, which can be seen in other cancers in advanced stages. Pain in the lumbar region may accompany these complaints. As an examination finding, patients usually do not have a typical examination finding. However, in the advanced stage, it can be felt in the abdomen. Enlargement of the liver and a gland on the shoulder may be palpable. .

Diagnosis Urinalysis plays an important role in diagnosis. The presence of blood cells (erythrocytes) in the urine in the complete urinalysis should reveal the suspicion of a tumor. Urine Cytology is a method based on the examination of urine by a pathologist and the detection of cancer cells. Urine cytology is a method with low sensitivity in low-grade tumors and 80% in high-grade tumors. It is more effective in high-grade tumors. But its effectiveness is weak in low-grade tumors. The fact that cytology is not very sensitive has prompted researchers to search for more sensitive tests. Some tests used in diagnosis today are BTA stat and NMP22, which are also used in our country.

However, their sensitivity is low for small tumors and well-grade tumors. Others are ImmunoCyst and UroVision DNA FISH tests. ImmunoCyst probably has the highest sensitivity for small and low-grade cancers, while UroVision DNA FISH has the highest specificity. Flow cytometry detects 80% of bladder tumors, but is more sensitive in high-grade tumors as in cytology, but this test is more reliable than cytology. Cystoscopy is the most important diagnostic method for bladder tumors. It is the easiest and safest method for definitive diagnosis when a bladder tumor is suspected. By entering the urinary tract (urethra) with an optical instrument, the inside of the urinary bladder can be seen with 8-10 times magnified images. Flexible cystoscopy is a simple but very valuable diagnostic method that can be performed even with local anesthesia. Imaging Methods The simplest imaging method in the diagnosis of bladder tumor is abdominal ultrasonography (Abdominal Ultrasonography). Tumors reaching a certain size can be visualized by ultrasonography, but newly started tumors may not be visualized. Medication imaging should be performed in patients with hematuria (bleeding in the urine), IVP and computed tomography can be used as drug imaging. Other methods Computed tomography (CT/CT), Magnetic Resonance (MRI) ) and Intravenous Urography (IVP).

In addition, Positron Emission Tomography (PET) is very useful in showing the extent of the disease. Staging The bladder wall consists of 3 main layers. 1) Mucosa and Lamina propria 2) Muscularis propria (muscle layer) and 3) Serosa. Bladder tumors are staged according to the involvement of these layers, it is very important for the type and follow-up of the treatment to be staged. Ta tumors are limited to the mucosa, papillary tumor. T1 tumors are tumors that have infected the lamina propria. The superficial muscle layer is involved in T2 stage and the deep muscle layer is involved in T3 stage. T3a exceeded deep muscle layer microscopically, T3b exceeded bladder wall macroscopically. Tumors called carcinoma in situ (Cis) are also high-grade cancers located in the mucosa, but can be dangerous for the patient if appropriate treatment is not performed on time. If T4 has involved adjacent organs, there is also microscopic staging that determines the behavior of the tumor, apart from the clinical stage described above. Better behavior is expected in low-grade tumors, while a more aggressive course is expected in high-grade tumors. Treatment When a bladder tumor is suspected, it should be treated by scraping the tumor by entering the urinary tract under general/spinal (waist) anesthesia (Transurethral Resection: TUR). Tumor tissues scraped with a special wire with the help of electrocautery should be sent for pathological examination. In some cases, a piece should be taken from the normal and suspicious areas of the urinary bladder and sent to pathology. There are many treatment options in bladder tumors. It is better to go to treatment by staging,

TREATMENTS ACCORDING TO STAGES IN BLADDER CANCER Stage 0 bladder cancer (Carcinoma in situ) Treatments that can be applied in cases of stage 0 bladder cancer in the bladder:

• Transurethral resection (TUR)

• Regional biologic therapy or chemotherapy into the bladder after TUR and
• Segmental (partial) cystectomy

• Radical cystectomy Stage 1 bladder cancer

• Transurethral resection (TUR)

• Regional biologic therapy or chemotherapy into the bladder after TUR and

• Segmental (partial) cystectomy

• External (external) radiotherapy or radiotherapy with radiation nuclei alone Stage 2 bladder cancer

• Radical cystectomy and removal of lymph nodes

ı • Chemotherapy with radical cystectomy

• External (external) radiation therapy combined with chemotherapy


• Segmental (partial) cystketomy Stage 3 bladder cancer

• Radical cystectomy and removal of lymph nodes

• Chemotherapy with radical cystectomy • External radiation therapy combined with chemotherapy Stage 4 bladder cancer

• Radical cystectomy

• (palliative) radiotherapy to reduce complaints

• (palliative) cystectomy to reduce complaints

• Systemic chemotherapy With early diagnosis, the chance of treatment is high. While some treatment methods are still standardized treatments used for clinical treatment, some treatments are under evaluation for clinical applications.

The treatment is as follows
1-Transurethral Resection (TUR): Removal of bladder tumor using cystoscope.

2-Intravesical Treatment: It is a treatment based on killing cancer cells by injecting drugs into the bladder.



5-Cystectomy: Surgical removal of the bladder In superficial tumors (Ta, T1), TUR can provide a permanent cure. Some bladder tumor types cannot be completely removed by surgical procedures such as TUR. These tumors are usually high-grade tumors seen in more than one site and tumors larger than 4 cm. After the surgical procedure, the remaining tumor cells in the bladder can be destroyed by administering special medical drugs into the bladder so that the tumor cells that remain in the bladder do not reproduce and form a tumor and do not move to the deeper layers of the bladder and spread to the surrounding tissues. All of these treatments are called intravesical treatments. It is usually done in the hospital. A thin catheter is inserted into the bladder. The drug administered is either “chemotherapeutic” drugs that kill cancer cells or a tuberculosis vaccine called “BCG”. After the drug is given to the bladder, it is waited for a while without urinating so that it can affect the cancer cells in the bladder. After intravesical drug administration, the residence time of the drug in the bladder should be 1-2 hours. Treatment given into the bladder is often applied once a week for 6 weeks. After this weekly treatment, you should come for control at the times that will be recommended to you and continue your preventive treatments. After the treatment, you should have your cystoscopy and urine cytology examinations performed every 3 months.

The most commonly used drugs for intravesical treatment today are Mitomycin-C, Thiotepa, Doxorubicin, Bacillus Calmette-Guerin (BCG). If the tumor has invaded the muscle layers (T2, T3), the most ideal treatment method is to completely remove the bladder (Radical Cystectomy) and then to perform the bladder from the intestine, especially in young patients with good general condition. This postoperative orthotopic bladder (intestinal bladder connected to the urinary tract) is the best method in terms of patient comfort in suitable patients. In patients who are not suitable for this, ileal loop (the method in which the bladder is carried in the abdomen) should be performed. These surgeries are now performed laparoscopically or even robotically. What Is Cystectomy And How Is It Performed? It is a treatment method used in patients with disease that has spread to the bladder muscle layer but not to distant tissues. It can also be used in patients who have spread to distant tissues but have excessive bleeding due to tumor.

Cystectomy is performed in 2 ways;

Partial (partial) cystectomy: Patients with a tumor that has spread to the bladder wall in the side or dome of the bladder or patients with a tumor within the bladder diverticulum are candidates for partial cystectomy. It is based on the removal of a part of the bladder.

After partial cystectomy, patients may not accumulate enough urine in their bladder. While this condition is temporary in most patients, it can sometimes be permanent. Radical cystectomy: Surgical removal of the entire bladder. It is applied in patients with high-grade, high-stage cancer. In men; bladder and surrounding fat tissues, peritoneum adjacent to the bladder, prostate and seminal vesicles, in women; The bladder and surrounding adipose tissue, the peritoneum adjacent to the bladder, the cervix (cervix), the uterus (uterus), the anterior vaginal wall, the urinary tract (urethra) and ovaries (ovaries) are resected. Since the uterus was removed in women who underwent radical cystectomy; Since the prostate and testes (seminal vesicles) are removed in men, they cannot have children because semen cannot be discharged into the urinary tract. If a man has cancer in the urinary tract passing through the prostate, the entire urinary tract should be removed along with the bladder. Chemotherapy and radiotherapy Chemotherapy is used in patients who have spread that cannot be treated with surgery or who have spread to the body after surgery. Distant metastases are seen at a rate of 30-40% after radical cystectomy (complete removal of the bladder) or radical radiotherapy (ray treatment) in patients with extension to the bladder muscle layer. If these patients are not treated, their life expectancy is quite limited. It is another treatment option in bladder cancer. Radiation energy kills cancer cells. This effect is dose dependent. Radiation therapy can be used alone or in combination with chemotherapy or before surgery. The doctor planning the treatment will prepare a plan for you. This planning is prepared by considering your illness and health condition.

Radiation is applied directly to the bladder and thus other areas are less affected. Follow-up in Bladder Cancer There is always a risk of recurrence of bladder tumors, so patients should be followed up periodically at intervals recommended by the physician. Bladder cancer patients are called for control at regular intervals. Patients with superficial bladder tumors whose bladder has not been removed are followed up with cystoscopy for 3 months in the first year, 6 months in the 2nd year, and annually after the 3rd year. Patients with cystectomy are followed up with a computed tomography of the abdomen once a year and a chest x-ray and blood tests every 6 months after the surgery. In patients with bone pain, bone scintigraphy may be requested to evaluate the spread of cancer to the bone. Follow-up is a very important part of the treatment applied to the cancer patient, so that if it recurs, it is possible to treat it immediately. There is also a small possibility of tumor formation in the channels through which it is transmitted. For this reason, kidneys should also be examined every 2 years.

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