BLADDER CANCER Bladder Cancer is a cancer that forms in tissues of the bladder.

Types

Transitional cell carcinomas (cancer that begins in cells that

normally make up the inner lining of the bladder) cells)

Squamous

cell carcinoma (cancer that begins in thin, flat

Adenocarcinoma (cancer that begins in cells that make and

release mucus and other fluids). Etiologic factors

N categories for bladder cancer NX: Regional lymph nodes cannot be assessed due to lack of information N0: No regional lymph node spread N1: The cancer has spread to a single lymph node in the true pelvis N2: The cancer has spread to 2 or more lymph nodes in the true pelvis N3: The cancer has spread to lymph nodes that lie along the common iliac artery M categories for bladder cancer M0: No signs of distant spread M1: The cancer has spread to distant lymph nodes, organs, or tissues (like the bones, lungs, or liver) Stages of bladder cancer Stage 0a: Ta, N0, M0 The cancer is a noninvasive papillary carcinoma. It has grown toward the hollow center of the bladder but has not grown into the muscle or connective tissue of the bladder wall. It has not spread to lymph nodes or distant sites. Stage 0is: Tis, N0, M0 The cancer is a flat, noninvasive carcinoma, also known as flat carcinoma in situ (CIS). The cancer is growing in the lining layer of the bladder only. It has neither grown inward toward the hollow part of the bladder nor has it invaded the muscle or connective tissue of the bladder wall. It has not spread to lymph nodes or distant sites. Stage I (T1, N0, M0) The cancer has grown into the layer of connective tissue under the lining layer of the bladder without growing into the thick layer of muscle in the bladder wall. The cancer has not spread to lymph nodes or to distant sites. Stage II (T2, N0, M0) The cancer has grown into the thick muscle layer of the bladder wall, but it has not passed completely through the muscle to reach the layer of fatty tissue that surrounds the bladder. The cancer has not spread to lymph nodes or to distant sites. Stage III (T3 or T4a, N0, M0) The cancer has grown completely through the bladder into the layer of fatty tissue that surrounds the bladder (T3). It may have spread into the prostate, uterus, or vagina (T4a). It is not growing into the pelvic or abdominal wall. The cancer has not spread to lymph nodes or to distant Exams and Tests These tests are also used to diagnose bladder cancers in people who are having symptoms. The following tests might be done if bladder cancer is suspected:

Environmental exposure Tobacco use/Smoking; risk proportional to number of packs smoked daily and number of years of smoking People living in urban areas Occupational exposure Aromatic amines or aniline dyes Numerous occupations associated with diesel exhaust, petroleum products, and solvents (eg, auto work, truck driving, plumbing, leather and apparel work, rubber and metal work) Organic chemicals and dyes, such as beauticians, dry cleaners, painters, paper production workers, rope and twine industry workers, dental workers, physicians, and barbers.

Medical risk factors Pelvic radiation therapy Chemotherapy with cyclophosphamide via exposure to acrolein Patients with spinal cord injuries who have long-term indwelling catheters Recurrent or chronic bacterial infection of the urinary tract

Bladder diverticula Hereditary

Manifestations Symptoms of bladder cancer can include: Abdominal pain Blood in the urine Bone pain or tenderness Fatigue Painful urination Urinary frequency Urinary urgency Urine leakage (incontinence) Weight loss Loss of appetite and weight T categories for bladder cancer Ta: Noninvasive papillary carcinoma Tis: Carcinoma in situ (CIS); noninvasive flat carcinoma T1: The tumor has grown from the layer of cells lining the bladder into the connective tissue below. It has not grown into the muscle layer of the bladder. T2: The tumor has grown into the muscle layer T2a: The tumor has grown into the inner half of the muscle layer T2b: The tumor has grown into the outer half of the muscle layer T3: The tumor has grown through the wall of the bladder and into the fatty tissue that surrounds it T3a: The tumor's spread to fatty tissue surrounding the bladder can only be seen by using a microscope T3b: The tumor's spread to fatty tissue surrounding the bladder is large enough to be seen on imaging tests or to be seen or felt by the surgeon T4: The tumor has spread beyond the fatty tissue and into nearby organs or structures. It may be growing into any of the following: the stroma (main tissue) of the prostate, the seminal vesicles, uterus, vagina, pelvic wall, or abdominal wall T4a: The tumor has spread to the stroma of the prostate, uterus, and/or vagina T4b: The tumor has spread to the pelvic wall or the abdominal wall

CT scan Pyelography: This is a series of x-ray films of your urinary tract taken after your have had a special dye injected into a vein (intravenous pyelography [IVP]) or into your urethra (retrograde pyelography). The dye highlights the organs of your urinary tract and makes the recognition of certain abnormalities easier. However, CT scanning with three-dimensional reconstruction is replacing pyelography in many centers in the United States.

Biopsy: Tiny samples of your bladder wall are removed, usually during cystoscopy Urine tests If a tumor is found in the bladder, other tests may be performed, either at the time of diagnosis or later, to determine whether the cancer has spread to other parts of the body.

Ultrasound Chest x-ray film CT scan Bone scan

Complications Complications of bladder cancer can include: Metastasis Urinary incontinence Anemia Hydronephrosis

 Urethral stricture Nursing Management 1. Encourage the patient to express feelings and concerns about the extent of the cancer. 2. To relieve discomfort administer ordered analgesics for pain as necessary. 3. Implement comfort measures and provide distractions that will enable the patient to relax. 4. As appropriate, implement measures to prevent or alleviate complications of treatment. 5. Monitor the patients intake and output. Question him regularly about changes in his urine elimination pattern to detect changes in his condition. 6. Observe the patients urine for signs of hematuria (reddish tint to gross bloodiness). 7. Monitor the patients laboratory tests, such as changes in white blood cell differential, indicating possible bone marrow suppression from chemotherapy. 8. If the patient is being given intravesical chemotherapy, watch closely for myelosuppression, chemical cystitis, and skin rash. 9. Instruct the patient and the family about the types of treatment that are being planned for him. 10. Teach the patient and family to recognize and to manage adverse effects of chemotherapy. 11. Stress the importance of notifying the doctor if the patient develops signs and symptoms of urinary tract infection or other sudden changes in his condition Collaborative Management (Surgical and Medical) Surgical Procedures: Surgery for early-stage bladder cancer Surgery to remove the tumor. Transurethral resection of bladder tumor (TURBT) is often used to remove bladder cancers that are confined to the inner layers of the bladder. During TURBT, your doctor passes a small wire loop through your urethra and into your bladder. The loop is used to burn away cancer cells with an electric current (fulguration). In some cases, a high-energy laser may be used instead of electric current. TURBT may cause painful or bloody urination for a few days following the procedure. Surgery to remove the tumor and a small portion of the bladder. During segmental cystectomy, sometimes called partial cystectomy, the surgeon removes only the portion of the bladder that contains cancer cells. Segmental cystectomy may be an option if your cancer is limited to one area of the bladder that can easily be removed without harming bladder function. Surgery for invasive bladder cancer If cancer has invaded the deeper layers of the bladder wall, one may consider: Surgery to remove the entire bladder. A radical cystectomy is an operation to remove the entire bladder, as well as surrounding lymph nodes. In men, radical cystectomy typically includes removal of the prostate and seminal vesicles. In women, radical cystectomy involves removal of the uterus, ovaries and part of the vagina. Cystectomy carries a risk of infection and bleeding. In men, removal of the prostate and seminal vesicles will cause infertility. But in most cases your surgeon can attempt to spare the nerves necessary for an erection. In women, removal of the ovaries causes infertility and premature menopause in women who haven't experienced menopause prior to this surgery. Surgery to create a new way for urine to leave your body. Immediately after your radical cystectomy, your surgeon works to create a new way for you to expel urine. Several options exist. Which option is best for you depends on your cancer, your health and your preferences. Your surgeon may create a tube (urinary conduit) using a piece of your intestine. The tube runs from your kidneys to the outside of your body, where your urine drains into a pouch (urostomy bag) you wear on your abdomen.

In another procedure, your surgeon may use a section of intestine to create a small reservoir for urine inside your body (cutaneous continent urinary diversion). You can drain urine from the reservoir through a hole in your abdomen using a catheter a few times each day. In select cases, your surgeon may create a bladder-like reservoir out of a piece of your intestine (neobladder). This reservoir sits inside your body and is attached to your urethra, which allows you to urinate normally. You may need to use a catheter to drain all the urine from your new bladder. Medical Management: Medicines through a vein (IV) M-VAC is a combination of methotrexate, vinblastine, doxorubicin, and cisplatin. Methotrexate slows or stops the growth of cancer cells in the body and is frequently used in combination with other chemotherapy medicines. Cisplatin is a heavy metal that causes cell death by interfering with the multiplication of cancer cells. Gemcitabine is an antitumor medication that interferes with how cells divide and stops the growth of the cancer cells. It is often combined with another drug called cisplatin for treating bladder cancer. Doxorubicin is an anthracycline antibiotic medicine. Epirubicin and valrubicin are also anthracycline antibiotics that may be used. Paclitaxel or carboplatin are antitumor medicines that slow or stop the growth of cancer cells in the body. Medicines through a catheter into the bladder Bacillus Calmette-Guerin (BCG) may stimulate an immune response or inflammation in the bladder wall to destroy cancer cells within the bladder. This is known as immunotherapy. Mitomycin is an antitumor antibiotic that interferes with the multiplication of cancer cells. When administered directly into the bladder, mitomycin may help prevent the recurrence of bladder cancer. Therapies: Biological therapy, sometimes called immunotherapy, works by signaling your body's immune system to help fight cancer cells. Biological therapy for bladder cancer is typically administered through your urethra and directly into the bladder (intravesical therapy). Biological therapy drugs used to treat bladder cancer include: An immune-stimulating bacterium. Bacille Calmette-Guerin (BCG) is a bacterium used in tuberculosis vaccines. BCG can cause bladder irritation and blood in your urine. Some people feel as if they have the flu after treatment with BCG. A synthetic version of an immune system protein. Interferon is a protein that your immune system makes to help your body fight infections. A synthetic version of interferon, called interferon alfa, may be used to treat bladder cancer. Interferon alfa is sometimes used in combination with BCG. Interferon alfa can cause flu-like symptoms. Biological therapy can be administered after TURBT to reduce the risk that cancer will recur. Chemotherapy uses drugs to kill cancer cells. Chemotherapy treatment for bladder cancer usually involves two or more chemotherapy drugs used in combination. Drugs can be given through a vein in your arm (intravenously), or they can be administered directly to your bladder by passing a tube through your urethra (intravesical therapy). Chemotherapy may be used to kill cancer cells that might remain after an operation. It may also be used before surgery. In this case, chemotherapy may shrink a tumor enough to allow the surgeon to perform a less invasive surgery. Chemotherapy is sometimes combined with radiation therapy. Radiation therapy uses high-energy beams aimed at your cancer to destroy the cancer cells. Radiation therapy can come from a machine outside your body (external beam radiation) or it

can come from a device placed inside your bladder (brachytherapy). Radiation therapy may be used before surgery to shrink a tumor so that it can more easily be removed. Radiation therapy can also be used after surgery to kill cancer cells that might remain. Radiation therapy is sometimes combined with chemotherapy.