Muscle-Invasive Urothelial Carcinoma
Overview
Muscle invasive bladder cancer (MIBC) is a cancer that spreads into the detrusor muscle of the bladder. The detrusor muscle is the thick muscle deep in the bladder wall. This cancer is more likely to spread to other parts of the body.
In the U.S., bladder cancer is the third most common cancer in men. Each year, there are more than 83,000 new cases diagnosed in men and women. About 25% of bladder cancers are MIBC. Bladder cancer is more common as a person grows older. It is found most often in the age group of 75-84. Caucasians are more likely to get bladder cancer than any other ethnicity. But there are more African-Americans who do not survive the disease.
Symptoms
How do you know that you may have bladder cancer? Some people may have symptoms that suggest they have bladder cancer and others may feel nothing at all. Some symptoms should never be ignored. You may need to talk to a urologist about your symptoms. A urologist is a doctor who focuses on problems of the urinary system and male reproductive system. Talk to your doctor if you have these symptoms: Blood in the urine is the most common symptom of bladder cancer. It is often painless. Often, you cannot see blood in your urine without a microscope. If you can see blood with your naked eye, you should tell your health care provider right away. Even if the blood goes away, you should still talk to your doctor about it. Blood in the urine does not always mean that you have bladder cancer. There are a number of reasons why you may have blood in your urine. You may have an infection or kidney stones. Very small amounts of blood might be normal in some people. Frequent urination and pain when you pass urine (dysuria) are less common symptoms of bladder cancer. If you have these symptoms, it is still important to see your health care provider. He/she may perform more tests to find out if you have something such as a urinary tract infection or something more serious, like bladder cancer.
Symptoms You Should Not Ignore
Causes
People can get bladder cancer when they come into contact with tobacco or other cancer-causing agents. There also are some risks linked to genes and certain types of infections. One more known risk factor is treatment with radiation given to the pelvis.
Smoking is a Big Risk Factor
You are more likely to get bladder cancer if you smoke or breathe in tobacco smoke. Smoking tobacco may be the cause of half of all bladder tumors. If you smoke, you are more likely to get bladder cancer than those who have stopped.
Workplace Exposure is Another Known Cause
Some things in the workplace may put you at a greater risk for bladder cancer. Contact with chemicals used to make plastics, paints, textiles, leather and rubber may cause bladder cancer.
Diagnosis
If your health care provider believes you have MIBC, you may be referred to a urologist. Your urologist may perform a full medical history and physical exam. Further tests may be needed to form a diagnosis. If you are diagnosed with bladder cancer, you may need more tests. These tests will find out the stage of your disease. It will also give your doctor an idea of what treatment is best for you.
Tests for MIBC
These tests may be done to see if you have bladder cancer:
- Urine cytology: The color and content of your urine will be checked. This test will also look at body cells under a microscope.to test for cancer cells.
- Blood tests: A comprehensive metabolic panel (CMP), which includes kidney and liver function tests, will be among the blood tests your doctor will order.
- A Computerized tomography scan (also known as CT or CAT scans).
- Cystoscopy: A doctor will use a thin tube that has a light and camera at the end of it (cystoscope) to pass through the urethra into the bladder. It allows your doctor to see inside the bladder. Your doctor will likely use a flexible cystoscope and a local anesthetic for your exam in the office to see if there is a growth in the bladder.
If any of these tests suggest you have bladder cancer, the next step is to do a transurethral resection of a bladder tumor (TURBT), as described below. You will likely be put to sleep for this procedure. The scope the doctor uses when you are put to sleep to perform a TURBT is not flexible like the one used in the office, but rigid. This means it is straight and does not bend. This cystoscope is bigger, has a light at the end, and surgical tools can pass through it. During a TURBT, the doctor will both try to remove all visible tumors and take tissue. The tissue sample will be sent to a lab where they will find out vital information about your cancer. They will also see whether the cancer has spread. This will help with choosing the right treatment.
- Transurethral resection of bladder tumor (TURBT): This is a very important procedure for accurate tumor typing, staging and grading. Your doctor can look inside the bladder, take tumor samples and resect (cut away) what he/she sees of your tumor.
- Blue light cystoscopy with TURBT: For this test, your doctor uses a catheter to place an imaging solution into your bladder through your urethra. The solution is left in the bladder for about an hour. The doctor then uses the cystoscope to check the bladder with a white light and then with blue light. Bladder cancer cells show up better with blue light.
Other Imaging Tests
These tests may help your doctor diagnose and stage bladder cancer.
- Retrograde pyelogram: This test uses x-rays to look at your bladder, ureters and kidneys. The test is done during a cystoscopy.
- Magnetic resonance imaging (MRI): These tests use a strong magnetic field, radio waves and a computer to make detailed pictures of the inside of your body.
- Positron emission tomography (PET) scan: If your chest, abdomen or pelvic image results are not normal or if your doctor cannot get a lymph node biopsy, your doctor may order a PET scan. For this, you will be given a special drug (a tracer) through your vein or you may swallow the drug. Your cells will pick up the tracer as it passes through your body. When the scanner passes over the bladder, the tracer allows your doctor to better see where and how much the cancer is growing.
Treatment
Knowing you have cancer can be scary. Still, your doctor and health care team are there to help you. Your health care team will discuss what you must know about all the treatment choices. They will tell you about possible risks and the side effects of treatment on your quality of life.
Choices for Treatment
Treatments for muscle invasive bladder cancer include:
- Bladder removal (cystectomy) with chemotherapy or without chemotherapy
- Chemotherapy with radiation, in addition to TURBT
Chemotherapy
Chemotherapy uses drugs to kill cancer cells. For MIBC, chemotherapy will most likely be given before radical (total) cystectomy. Bladder removal with chemotherapy raises survival rates for bladder cancer patients. Neoadjuvant chemotherapy (given before cystectomy) should include the drug cisplatin. Adjuvant chemotherapy means the drug is given after surgery. Your doctor may offer this treatment if it is right for you.
Chemotherapy drugs are mostly given by vein (intravenous). The drugs enter the bloodstream and travel throughout your body.
Most often, doctors offer chemotherapy before bladder removal for best survival rates. But not all people are able to have chemotherapy. You may not get chemotherapy if you have poor kidney function, hearing loss, heart problems or other health issues. Some patients may choose not to get chemotherapy before surgery. But some may still need to have it after surgery based on the tumor stage. You will likely have your bladder surgery about 6-8 weeks after you have finished chemotherapy.
You may have your chemotherapy treatment in an outpatient part of the hospital, at the doctor’s office or at home. Rarely, you will need to stay overnight in the hospital. Chemotherapy is sometimes given in cycles. Each cycle often has a treatment period followed by a rest period.
There are side effects to chemotherapy. The side effects depend on which drugs are given and how much is given. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells, such as:
- Blood cells: If chemotherapy drugs lower the levels of healthy blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, you may need to stop the chemotherapy or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
- Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment. But your hair color and texture may be different.
- Cells that line the digestive system: Chemotherapy can cause a poor appetite, upset belly and vomiting, loose stools, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems. Symptoms most often go away when treatment ends.
- Nerve cells: Some drugs used for bladder cancer may cause tingling or numbness in your hands and feet. Your healthcare team can suggest ways to control these side effects.
Surgery to Remove the Bladder (Cystectomy)
FFor MIBC, because the cancer has grown into the muscle, in most cases the whole bladder is removed (in some cases only part of the bladder is removed). As mentioned, before your bladder is removed, you will most likely be given neoadjuvant cisplatin-based chemotherapy. Bladder cancer can spread to the lymph nodes. When the bladder is removed, a pelvic lymph node dissection is also done to remove the fatty tissue surrounding the pelvic blood vessels. A pelvic lymph node dissection is thought of as standard of care. Standard of care means that this is the usual treatment.