A diagnosis of bladder cancer begins with a discussion of the patient’s medical history. This is followed by a physical exam in which the doctor will feel the abdomen and pelvis for any physical signs bladder cancer tumors. The doctor may also include a rectal or vaginal exam. Study of a urine sample will determine if blood or cancer cells are present. In some cases the doctor will order an intravenous pyelogram. A harmless dye is injected into a vessel. The dye collects temporarily and improves the quality of the x-rays that follow.
Other imaging technologies such as computed tomography (CT) and magnetic resonance imaging (MRI) may be employed. Cytoscopy is common. This involves threading a thin tube through the urethra into the bladder. Miniaturized fiber optics provide light to allow the doctor to examine the bladder from within the cavity. Other miniaturized technology in the tube allows him to gather minute bladder tissue samples that will be sent to a pathologist who will study them for the presence of cancer cells.
Types of Bladder Cancer
Bladder cancers are characterized by type, stage and grade. This characterization will help determine the therapy that is most likely to be successful.
Transitional cell (urothelial) carcinoma - Transitional cell (urothelial) carcinoma has its origins in the transitional cells that line the bladder. These cells are also found in kidneys, ureters, and the urethra. About 90 percent of bladder cancers are transitional cell carcinoma.
Squamous cell carcinoma - Squamous cell carcinoma begins in thin flat cells that can be found throughout the body including the bladder. About 6 to 8 percent of bladder cancers are squamous cell cancers. Adenocarcinoma- Adenocarcinoma begins in glandular cells in other body organs and spreads to the bladder. Adenocarcinomas account for about 2% of bladder cancers.
Bladder tumors may take different forms. Superficial urothelial tumors may or may not be invasive. They seldom spread deeply into the bladder wall. Papillary urothelial tumors are slender projections resembling the arm of a cactus that grow from the bladder wall toward the center of the bladder. Those that grow only toward the center are called noninvasive papillary urothelial tumors. Papillomas are benign (non-threatening) urothelial tumors, the removal of which can usually be accommodated by simple surgical procedures such as transurethral resection of the bladder (TURB). These tumors can recur in the bladder or elsewhere in the urinary tract.
Patients who have experienced the removal of papillomas undergo re-examinations at regular intervals to check for recurrence. Papillary urothelial carcinoma is an abnormal papillary tumor. Its cells have irregular sizes, shapes and arrangements. When these abnormalities are slight, the tumor is called "low grade." They seldom invade the bladder wall but often return following removal. The risk of bladder wall invasion is greater when cells in these tumors show greater abnormal characteristics. Flat urothelial tumors (carcinoma in situ or CIS) affect only the cells in the interior bladder lining. In the great majority of instances, these cancers are limited to the lining. When they invade the muscle layer they are called flat invasive urothelial carcinomas.
Stage
Stage refers to the extent of the cancer. There are several staging systems. The most commonly used is the TNM system in which T stands for tumor, N stands for lymph node involvement and M stands for metastases or the spread of cancer cells to locations distant from the bladder. A more general staging system rates cancers as Stage 0 through Roman numeral IV. See Table.
Thus, a tumor graded as T2aN0M0 would indicate a tumor that reaches from the inner mucosa layer through the connective tissue and up to half way into the muscle wall but shows no evidence of lymph node involvement or metastases.
Grade
Pathologists "grade" the cancer according to nature of the cancer cells within the tissue samples they have received from biopsies. There are three grades: low grade or well-differentiated cells; middle-grade or moderately differentiated cells, and high-grade or poorly differentiated cells. These three categories are represented by the Roman numerals I, II, III. Low grade cells (Grade I) may vary in size but most look relatively normal. Only a few of these cells will be multiplying within a tissue sample. Middle grade (Grade II) are more uneven in both appearance and size. An increased ratio of these cells will be multiplying in a tissue sample. High grade cells (Grade III) comprise the most aggressive form of bladder cancer. They are distorted, vary greatly in size, and a significant number will be multiplying.
