Friday, May 17, 2024

Bladder Cancer Carcinoma In Situ

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Treating Stage I Bladder Cancer

Understanding Bladder Cancer Carcinoma In-Situ (CIS)

Stage I bladder cancers have grown into the connective tissue layer of the bladder wall , but have not reached the muscle layer.

Transurethral resection with fulguration is usually the first treatment for these cancers. But it’s done to help determine the extent of the cancer rather than to try to cure it. If no other treatment is given, many people will later get a new bladder cancer, which often will be more advanced. This is more likely to happen if the first cancer is high-grade .

Even if the cancer is found to be low grade , a second TURBT is often recommended several weeks later. If the doctor then feels that all of the cancer has been removed, intravesical BCG or intravesical chemo is usually given. If all of the cancer wasn’t removed, options are intravesical BCG or cystectomy .

If the cancer is high grade, if many tumors are present, or if the tumor is very large when it’s first found, radical cystectomy may be recommended.

For people who arent healthy enough for a cystectomy, radiation therapy might be an option, but the chances for cure are not as good.

Erbb2 Expression As Potential Risk

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The Following Stages Are Used For Bladder Cancer:

Stage 0

In stage 0, abnormalcells are found in tissue lining the inside of the bladder. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is divided into stages 0a and 0is, depending on the type of the tumor:

  • Stage 0a is also called noninvasive papillary carcinoma, which may look like long, thin growths growing from the lining of the bladder.
  • Stage 0is is also called carcinoma in situ, which is a flat tumor on the tissue lining the inside of the bladder.

Stage I

In stage I, cancer has formed and spread to the layer of connective tissue next to the inner lining of the bladder.

Stage II

In stage II, cancer has spread to the layers of muscle tissue of the bladder.

Stage III

Stage III is divided into stages IIIA and IIIB.

  • In stage IIIA:
  • cancer has spread from the bladder to the layer of fat surrounding the bladder and may have spread to the reproductive organs and cancer has not spread to lymph nodes or
  • cancer has spread from the bladder to one lymph node in the pelvis that is not near the common iliac arteries .

Stage IV

Stage IV is divided into stages IVA and IVB.

  • In stage IVB, cancer has spread to other parts of the body, such as the lung, bone, or liver.
  • Also Check: Shortness Of Breath And Loss Of Bladder Control

    What Are The Risk Factors For Bladder Cancer

    Some factors increase the risk of bladder cancer:

    • Cigarette smoking is the biggest risk factor it more than doubles the risk. Pipe and cigar smoking and exposure to second-hand smoking may also increase ones risk.
    • Prior radiation exposure is the next most common risk factor .
    • Certain chemotherapy drugs also increase the risk of bladder cancer.
    • Environmental exposures increase the risk of bladder cancer. People who work with chemicals, such as aromatic amines are at risk. Extensive exposure to rubber, leather, some textiles, paint, and hairdressing supplies, typically related to occupational exposure, also appears to increase the risk.
    • Infection with a parasite known as Schistosoma haematobium, which is more common in developing countries and the Middle East.
    • People who have frequent infections of the bladder, bladder stones, or other diseases of the urinary tract, or who have chronic need for a catheter in the bladder, may be at higher risk of squamous cell carcinoma.
    • Patients with a previous bladder cancer are at increased risk to form new or recurrent bladder tumors.

    Other risk factors include diets high in fried meats and animal fats, and older age. In addition, men have a three-fold higher risk than women.

    Treatment Of Stage Iv Bladder Cancer

    Small Cell Carcinoma of Bladder with overlying Urothelial

    For information about the treatments listed below, see the Treatment Option Overview section.

    Treatment of stage IV bladder cancer that has not spread to other parts of the body may include the following:

    Treatment of stage IV bladder cancer that has spread to other parts of the body, such as the lung, bone, or liver, may include the following:

    • External radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
    • Urinary diversion or cystectomy as palliative therapy to relieve symptoms and improve quality of life.
    • A clinical trial of new anticancer drugs.

    Use our clinical trial search to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done. General information about clinical trials is also available.

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    What Are The Types Of Bladder Cancer Tumors That May Form

    Three types of bladder cancer may form, and each type of tumor can be present in one or more areas of the bladder, and more than one type can be present at the same time:

    • Papillary tumors stick out from the bladder lining on a stalk. They tend to grow into the bladder cavity, away from the bladder wall, instead of deeper into the layers of the bladder wall.
    • Sessile tumors lie flat against the bladder lining. Sessile tumors are much more likely than papillary tumors to grow deeper into the layers of the bladder wall.
    • Carcinoma in situ is a cancerous patch of bladder lining, often referred to as a flat tumor. The patch may look almost normal or may look red and inflamed. CIS is a type of nonmuscle-invasive bladder cancer that is of higher grade and increases the risk of recurrence and progression. At diagnosis, approximately 10% of patients with bladder cancer present with CIS.

    Principles Of Bcg Immunotherapy

    Animal studies and subsequent extensive clinical experience have elucidated several factors of importance in optimizing the response to BCG immunotherapy:

    Tumor Burden–Animal studies have demonstrated that the antitumor response to BCG is limited by tumor burden , and therefore, all visible tumor should be resected or fulgurated prior to initiation of BCG treatment.

    Lowest Effective Dose–Also, optimal response requires a sufficient number of viable organisms and direct juxtaposition of BCG and tumor cells. Although a sufficient number of colony-forming units is required for response, the dose-response curve for BCG immunotherapy, like most biologic-response modifiers, is bell shaped .Dose reduction has clinical relevance because Morales et al have shown that it significantly decreases the toxicity of intravesical BCG .

    Surprisingly, data collected by Pagano and associates have suggested that 75 mg of Pasteur BCG is not only less toxic but also more effective than the standard 150-mg dose . In their randomized trial involving 183 evaluable patients, low-dose Pasteur BCG resulted in a 40% improvement in 5-year disease-free status when compared with standard-dose BCG. A multicenter protocol is currently underway in the United States and Canada to evaluate reduced-dose Connaught BCG.

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    Treatment Of Stages Ii And Iii Bladder Cancer

    For information about the treatments listed below, see the Treatment Option Overview section.

    Use our clinical trial search to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done. General information about clinical trials is also available.

    Intravesical Bcg Plus Ifn

    Histopathology Bladder Transitional Carcinoma-in-situ

    Prior investigators have reported use of BCG and Interferon alpha therapy after BCG failure and have shown a 5060% complete response rate . In a subsequent large phase II trial on this combination therapy, 45% of patients with BCG failure and 59% of patients naïve to BCG remained disease free at a median of 24-month follow up . Unfavorable factors that were significant for recurrence after BCG and INF therapy included multifocality, large size , presence of T1, and prior BCG failure more than once .

    However, combination therapy with INF should not be used as first-line therapy as it has not been shown to be effective. A multicenter, prospective study randomized 670 patients who were BCG naïve with NMIBC to receive BCG or BCG plus INF. At 24-month median follow up, there was no difference in recurrence-free survival between the two groups . There is also limited efficacy for CIS after two BCG failures and it is important to note that patients with significant unfavorable risk factors mentioned earlier are most difficult to deal with, as combination therapy with INF is the least effective.

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    Smoking Can Affect The Risk Of Bladder Cancer

    Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer not having risk factors doesn’t mean that you will not get cancer. Talk to your doctor if you think you may be at risk for bladder cancer.

    Risk factors for bladder cancer include the following:

    • Using tobacco, especially smoking cigarettes.
    • Having a family history of bladder cancer.
    • Having certain changes in the genes that are linked to bladder cancer.
    • Being exposed to paints, dyes, metals, or petroleum products in the workplace.
    • Past treatment with radiation therapy to the pelvis or with certain anticancer drugs, such as cyclophosphamide or ifosfamide.
    • Taking Aristolochia fangchi, a Chinese herb.
    • Drinking water from a well that has high levels of arsenic.
    • Drinking water that has been treated with chlorine.
    • Having a history of bladder infections, including bladder infections caused by Schistosoma haematobium.
    • Using urinarycatheters for a long time.

    Older age is a risk factor for most cancers. The chance of getting cancer increases as you get older.

    Stage Groups For Bladder Cancer

    Doctors assign the stage of the bladder cancer by combining the T, N, and M classifications .

    Bladder cancer

    Stage 0a: This is an early cancer that is only found on the surface of the inner lining of the bladder. Cancer cells are grouped together and can often be easily removed. The cancer has not invaded the muscle or connective tissue of the bladder wall. This type of bladder cancer is also called noninvasive papillary urothelial carcinoma .

    Stage 0is: This stage of cancer, also known as a flat tumor or carcinoma in situ , is found only on the inner lining of the bladder. It has not grown in toward the hollow part of the bladder, and it has not spread to the thick layer of muscle or connective tissue of the bladder . This is always a high-grade cancer and is considered an aggressive disease because it can lead to muscle-invasive disease.

    Stage I: The cancer has grown through the inner lining of the bladder and into the lamina propria. It has not spread to the thick layer of muscle in the bladder wall or to lymph nodes or other organs .

    Stage II: The cancer has spread into the thick muscle wall of the bladder. It is also called invasive cancer or muscle-invasive cancer. The tumor has not reached the fatty tissue surrounding the bladder and has not spread to the lymph nodes or other organs .

    Stage IV: The tumor has spread into the pelvic wall or abdominal wall, or the cancer has spread to lymph nodes outside of the pelvis or to other parts of the body.

    Recurrent cancer

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    After Bladder Cancer Has Been Diagnosed Tests Are Done To Find Out If Cancer Cells Have Spread Within The Bladder Or To Other Parts Of The Body

    The process used to find out if cancer has spread within thebladder lining and muscle or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

    Postcontrast Acute Kidney Injury And Contrast


    There is an ongoing debate around occurrence, causes, screening strategies and management of PC-AKI. Please seeChapters 28 and29 for a discussion of this topic in the context of the pathophysiology and management of AKI. For clarification, we describe the terms as in the American College of Radiology Manual on contrast media.45

    PC-AKI.: a deterioration in renal function occurring within 48 hours following intravascular administration of iodinated contrast, regardless of the cause of the worsening of renal function. PC-AKI is a correlative diagnosis.

    CIN: a subset of PC-AKI in which the intravascularly administered contrast is the cause of the deterioration of renal function. CIN is a causative diagnosis and is a subgroup of PC-AKI.

    The diagnosis of PC-AKI is made if any of the following occurs within 48 hours of contrast injection:


    A percentage increase in serum creatinine level of 50% or higher , or


    Urine output reduced to 0.5â¯mL/kg/h or less for at least 6 hours

    Hillary L. Copp MD, Linda D. Shortliffe MD, in, 2010

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    Treatment Of Cis Versus Tcc

    The diagnosis of bladder carcinoma in situ is established by a combination of cystoscopy, urine cytology, and histologic evaluation of multiple bladder biopsies. Biopsies are performed on suspicious/abnormal areas in the bladder detected by cystoscopy or by white light, photodynamic, or narrow-band imaging. Biopsies obtained in areas adjacent to an identified tumor may reveal unsuspected CIS. A study of a noninvasive test using urine samples from patients with hematuria showed an 88% sensitivity and 99.8% negative predictive value.

    Treatment of bladder CIS differs from that of papillary transitional cell carcinoma . Endoscopic surgery, which is the initial treatment of papillary cancers, is not effective for CIS because the disease is often so diffuse and difficult to visualize that surgical removal is not feasible. When a combination of papillary tumor and CIS is present, the papillary tumor is removed before treatment of the CIS is initiated.

    Carcinoma In Situ Vs Precancerous Cells Vs Dysplasia

    There are many terms describing the spectrum of normal cells and invasive cancer cells. One of these is dysplasia. Dysplasia can run the spectrum from mild dysplasia in which the cells are barely abnormal appearing, to carcinoma in situ, which some pathologists describe as severe dysplasia involving the full thickness of the epithelium. The term precancerous cells may also be used to describe cells on this continuum between normal and cancer cells.

    These terms are also used in different ways depending on the sample analyzed. For example, cells visualized on a pap smear may show dysplasia , but since the cells are “loose,” nothing can be said about whether carcinoma in situ is present or not. With cervical dysplasia, a biopsy is required before the diagnosis of CIS is made. A biopsy sample provides a view of the cells as they occur in relation to the basement membrane and other cells, and is needed to understand if abnormal cells seen on a pap smear are concerning.

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    Five Types Of Standard Treatment Are Used:


    One of the following types of surgery may be done:

    • Transurethral resection with fulguration: Surgery in which a cystoscope is inserted into the bladder through the urethra.A tool with a small wire loop on the end is then used to remove thecancer or to burn the tumor away with high-energy electricity. This is known as fulguration.
    • Radical cystectomy: Surgery to remove the bladder and anylymph nodes and nearby organs that contain cancer. This surgery may bedone when the bladder cancer invades the muscle wall, or when superficialcancer involves a large part of the bladder. In men, the nearby organs that areremoved are the prostate and the seminal vesicles. In women, the uterus, theovaries, and part of the vagina are removed. Sometimes, when the cancer hasspread outside the bladder and cannot be completely removed, surgery to removeonly the bladder may be done to reduce urinarysymptoms caused by the cancer.When the bladder must be removed, the surgeon creates another way for urine toleave the body.
    • Partial cystectomy: Surgery to remove part of thebladder. This surgery may be done for patients who have a low-grade tumor thathas invaded the wall of the bladder but is limited to one area of the bladder.Because only a part of the bladder is removed, patients are able to urinate normally afterrecovering from this surgery. This is also called segmental cystectomy.
    • Urinary diversion: Surgery to make a new way forthe body to store and pass urine.

    Radiation therapy


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