Source: Cancer Resource Room

What is Bladder Cancer?
Any cancer that starts in the bladder is called bladder cancer. Transitional cell cancer is the most common bladder cancer. Cancer is a disease caused by a group of abnormal cells that grow and multiply without stopping. As these cells grow and multiply, they form a tumor or lump. The tumor cells replace the normal cells of an organ. Tumor cells crowd out the normal cells. This leaves fewer healthy cells to do the job of that organ. Tumor cells can grow from one organ into nearby tissues and other organs. They can also travel through the blood and lymph to other parts of the body and form more tumors. These tumors are called metastases.

Bladder cancers start in the cells that line the inside of the bladder. The lining tissue is made up of two types of cells, transitional cells and squamous cells. Cancers that start from transitional cells are called transitional cell cancers. More than ninety percent of bladder cancers start in these cells. Tumor cells grow in the bladder lining, invade through the layers of the bladder, and spread to lymph nodes and other tissues near the bladder.

What is the bladder? What does the bladder do?
The bladder is a hollow organ in the lower abdomen just behind the pubic bone.

It is made up of three main layers of tissue.

1. The inside or lining layer is called the mucosa. It is made up of transitional cells and squamous cells. Under the lining are thin layers of cells that support the mucosa. These are the submucosa and the lamina propria.
2. The next major layer of the bladder is the muscle layer. The muscles contract to squeeze the bladder when it gets full.
3. The outer layer is called the serosa. It covers part of the muscle layer and separates the bladder tissues from the surrounding organs. Some parts of the bladder are covered by a fat layer called the perivesical fat.

The bladder is the storage part of the urinary system. It stores the urine made by the two kidneys. The kidneys make urine all the time. In the middle of each kidney is a small space called the renal pelvis. As the kidney makes urine, it collects in the renal pelvis. Urine flows from the renal pelvis to the bladder through a long tube called the ureter. Each kidney has its own ureter. The two ureters attach to the back of the bladder.

The bladder is about the size of a small orange when it is empty. The bladder tissues stretch as the bladder fills with urine. It stretches until it is full enough to send a signal to the brain that the bladder needs to be emptied. When it is full, the muscular wall of the bladder squeezes. This empties the urine through a tube called the urethra. A set of circular muscles called sphincters control the emptying of the bladder. Control over emptying the bladder is called continence; not having control is called incontinence.

Are all bladder cancers the same?
There are about 54,000 new cases of bladder cancer diagnosed in the United States each year. About 90 percent of bladder cancers are transitional cell cancers. The other types of bladder cancer are called squamous cell cancer and adenocarcinoma of the bladder. The name of the cancer describes the type of cells that started the disease.

How is bladder cancer diagnosed?
Diseases are diagnosed by putting together several bits of information. Some information comes from the patient, like symptoms, or how the patient feels. Other information comes from the patient’s medical history, or what medical problems the person has had in the past. Information also comes from the doctor’s examination of the patient. Technical information comes from blood tests and xrays or other imaging studies. When all the pieces of information are collected, a likely diagnosis can be made.

Sometimes the diagnosis needs to be proved by doing a biopsy. A biopsy means taking a small sample of tissue or cells to look at under a microscope. This is the only way to know the exact diagnosis of a disease.

Bladder cancer is diagnosed by the patient’s symptoms, medical history, physical exam, blood tests, xrays, and special tests of the urinary organs. Sometimes bladder cancer is discovered from a urine test done as part of a medical check-up. A urine test that shows microscopic amounts of blood in the urine can be a sign of bladder cancer.

Symptoms of bladder cancer—What does the patient feel or notice?
Bladder cancer starts in the lining layer of the bladder. It grows larger and deeper, spreading to nearby tissues and lymph nodes. The bladder can keep working normally even though a cancer has started in one part of it. This means a bladder cancer can get quite large or deep before it is found. Bladder cancers are more likely to cause changes that the patient feels than others tumors in the urinary system.

Symptoms caused by bladder cancer are from the tumor bleeding or from the tumor growing through the tissues of the bladder into the nearby tissues. A tumor can cause a blockage or obstruction so the urine cannot pass from the ureters to the bladder. This usually does not cause pain, but does make the ureter look different than normal on a special xray called an IVP. The cancer tissue bleeds easily. The bleeding can be seen in the toilet when the person urinates (pees). Some symptoms are caused by cancer cells growing into other tissues or putting pressure on nerves.

When symptoms occur they include:

• Blood in the urine
• Pain in the side or back
• Pain when urinating
• Needing to urinate frequently
• Feeling the need to pee with little or no results

These symptoms can occur with more common illnesses. They should be checked by a doctor.

Patient’s history—What should the doctor know?
A patient’s medical history and physical exam are the first steps in making a diagnosis of any disease. In the case of bladder cancer, the patient’s history may include information about:

• Tobacco use or exposure to second-hand smoke
• Work in the rubber, chemical, or leather industries
• Work as a printer, painter, machinist, hairdresser, or trucker
• Infection with a parasite (in tropical climates)
• Treatment for other illnesses with cyclophosphamide or arsenic
• Radiation treatment in the pelvis or abdomen
• Other family members with bladder cancer
• Previous bladder cancer

Physical exam—What will the doctor look for?
The physical exam has two purposes. One is for the doctor to examine the patient for any lumps (masses) in the abdomen or pelvis that may be caused by a bladder cancer. The examination should include a rectal exam, and for women, a vaginal exam. The other purpose of the physical exam is to learn about the patient’s overall health. The doctor will listen to the person’s heart and lungs, feel the abdomen for tender places, any lumps, or for an enlarged liver, and check for bone pain in the spine, arms and legs.

Blood tests:
There are no blood tests that can diagnose bladder cancer, but some blood tests give information about the general health of the patient. These can alert the doctor to a problem. Some common blood tests are:

• CBC—blood count to check for anemia (low red blood cell count)
• LFT’s—liver tests that can be abnormal if cancer spreads to the liver
• Alk Phos—alkaline phosphatase, a bone enzyme that can be abnormal if cancer spreads to the bones
• BUN/Creatinine—check for normal kidney function

Urine tests:

• Urine specimen—tested for small amounts of red blood cells, bacteria, white blood cells, sugar, proteins and crystals
• Urine cytology—tests for abnormal cells in the urine that may be from a bladder cancer

Xrays and other imaging tests:

• Chest xray—This may show cancer spread to the lungs.
• IVP (IntraVenous Pyelogram)—An IVP uses dye to outline the inside of the kidneys, ureters, and part of the bladder. A special dye, called contrast, is put into the blood through an arm vein. The contrast dye travels in the blood to the kidneys where it is filtered out. The filtered dye flows in the urine to the bladder. This special dye can be seen in xrays. A series of xrays are taken as the dye flows in the urine through the kidneys, renal pelvis, ureter and into the bladder. The xrays show the outlines of the inside of the urinary organs. Any change in the smooth shape or size of the kidneys, ureters, or bladder will show on the xrays.
  An IVP is done in the radiology department. It requires an IV in the hand or arm for the contrast dye and fluid. The patient needs to lie on an xray table for twenty to sixty minutes. Some people are allergic to the dye used in this test. If you have any allergies at all, especially an allergy to shellfish, you should tell the radiology staff.
• CT scan—A CT scan is a series of xrays showing cross-sections of a body region. An abdominal CT scan shows both kidneys in cross-section pictures from top to bottom. The images will show the inside of the kidneys, the ureters, and the bladder. A CT scan is a good way to find a tumor, to see what size it is, and to see whether or not it has spread to nearby lymph nodes or other tissues.
  CT scans are not painful, but do require lying on a table for about 30 minutes. If contrast dye is used, it is given through an IV. The dye can make a person feel very warm for a short time, and it causes the sensation of needing to pee urgently. Both feelings pass quickly. Some people are allergic to the dye used in this test. If you have any allergies at all, especially an allergy to shellfish, you should tell the radiology staff.
• MRI—This test is like a CT scan except it uses magnets instead of xrays to make the cross-section pictures of the body. MRI may be used in bladder cancer to check if the disease has spread into the muscle of the bladder or into the nearby tissues, organs, or lymph nodes. Contrast dye is given through an IV just as it is for a CT scan.
• Bone scan—A bone scan makes a picture of the entire skeleton. A small amount of fluid with a radioactive substance in it is injected into a patient’s arm vein. The fluid has to travel through the body for about two hours before the scan can be done. The scan is painless, and requires the patient to lie on a radiology table for about twenty minutes. The scanner moves slowly over the patient’s body, from head to foot, recording a picture of the skeleton. Anything that changes normal bone tissue (arthritis, infection, injury, cancer), shows up as a dark spot on the scan. If a spot is seen on a bone scan, regular Xrays and a CT or MRI scan can be done to show what caused the changes. A bone scan is done to look for any possible spread of cancer to the bones.

Special tests:

• Cystoscopy— Cystoscopy is an important test for finding bladder cancer. A cystoscope is a tool for looking inside the bladder. The cystoscope is a narrow tube, about the size of a pencil. It has a tiny camera in the end that sends pictures to a TV for the doctor to look at. The cystoscope is passed through the urethra. It starts from where urine comes out, and goes into the lower part of the bladder. This is not usually painful, but a numbing gel can be used if needed. The doctor can look at the lining of the bladder for any signs of tumors. If any abnormal tissue is seen, samples can be taken out through the cystoscope. Urine is collected to look for cancer cells. Small pieces of tissue are taken from normal-looking areas inside the bladder. These are looked at for possible early, or precancerous, changes in the bladder cells. If many tissue samples (biopsies) are going to be taken, or if tumors are found that need to be removed, then this procedure will be done under general anesthesia in an operating room.
• Retrograde pyelography—This test is done during cystoscopy. The cystoscope is used to find the openings of the ureters into the bladder. A tube is placed into the ureter through that opening, and contrast dye is injected up into the ureter. Xrays are taken to show the inside shapes of the ureters and kidneys. These pictures are clearer than those from an IVP, but require cystoscopy.
• Antegrade pyelography—This is another test that uses dye to show the inside of the kidneys and ureters. The kidney is located using ultrasound or a CT scan, and dye is injected into the kidney through a needle. Local anesthetic (like Novocain) is used to numb the skin where the needle is put in. Like the retrograde pyelogram, the xrays are clearer than in an IVP, but this test does not require cystoscopy.

Biopsy—What it is and what it means to the patient
A biopsy takes a small sample of tissue or cells to look at under a microscope. This is the only way to know the exact diagnosis of a disease. Biopsies for bladder cancer are done during a cystoscopy (see description above in the “Special tests” section). Small pieces of tissue are taken from the lining of the bladder. A pathologist looks at the samples of tissue to tell whether or not the tissue is normal. Several biopsies can be done during one cystoscopy.

If a small tumor is seen in the lining of the bladder during cystoscopy, the doctor can remove the whole thing. When the biopsy removes the whole tumor, it is called an excisional biopsy. All the tissue is looked at by a pathologist who can make a diagnosis and tell how far into the bladder lining the tumor has grown.

If the biopsy shows bladder cancer, the patient can have tests to tell how much cancer there is and whether or not it has spread beyond the lining of the bladder.

Stage and grade in bladder cancer

What is the “grade” of bladder cancer?
The grade of bladder cancer describes how abnormal the cancer cells look compared to normal bladder cells. When a pathologist looks at the biopsy tissue with a microscope, he/she is comparing that tissue to normal. The more abnormal the cells are in size, shape, and arrangement, the higher the grade of the cancer. Higher-grade cancers are often more aggressive and more likely to spread further than the bladder. The grade of a bladder cancer is important in deciding how to treat a person’s disease. Low-grade bladder cancers are called Grade 1. High-grade cancers are either Grade 2 or Grade 3.

What is the “stage” of bladder cancer?

Stage describes:

• How large the tumor is
• Whether or not the tumor cells have grown through the lining tissue into the muscle of the bladder
• Whether it has spread to tissues, blood vessels, and/or lymph nodes around the bladder
• Whether it has spread to lymph nodes and to other parts of the body, such as the lungs, bones, or brain

The stages are:

• Stage 0—cancer cells have formed a small lump on the surface of the bladder lining (papillary carcinoma) without growing any deeper. Or, cancer cells are growing on the surface of the bladder lining without making a bump (carcinoma in situ), and without growing any deeper.
• Stage 1—early cancer in the lining of bladder. Tumor cells may go through the lining layer, but do not go into the muscle layer.
• Stage 2—cancer cells have grown through the bladder lining and into the muscle layer. This stage may be described as 2a or 2b, depending on how deep into the muscle the cancer cells have grown.
• Stage 3—the cancer has grown into the fat layer outside the bladder muscle (perivesical fat), but not to any lymph nodes or other organs.
• Stage 4—the cancer has spread to nearby organs like the prostate, uterus, vagina, muscles of the abdomen, or pelvis. Or, cancer has spread to distant lymph nodes, bones, brain, lungs, or other organs.

The combination of stage and grade are used by cancer doctors to design the best treatment plan for each patient.

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