Dear Dr Goldstein,
I have been diagnosed with a tumour of the bladder after an episode of blood in the urine. The tumour is 1.5cm diameter and has an irregular wide base, with a negative doppler inside. There was not cancerous cells in the urine. PSA 2.57 AND PCR less than 0.50.
The wall of the bladder was well defined and without infiltrations or roots in the bladder wall. I am now in the waiting list for a transuretral resection of the bladder. I have been told by my doctor it is most likely to be grade I OR II. The waiting list can be up to three months and I am very concerned after I read that the prognosis is not so good for the grade ii if the operation is after 12 weeks of diagnosis. I would like your honest opinion, and do you think I should look for a private clinic and have the operation as soon as posible as the diagnosis was 4 weeks ago. Thank you
Andres, before answering your questions specifically, let me give you some background information I have written on bladder cancer.
Bladder cancer is the 4th most common cancer in men and the 8th highest in females. The incidence of this neoplasm increases with age and is 2-3 times more common in men than in women. This cancer originates in the lining of the urinary bladder and accounts for 90% of cancers that occur in the lining the entire urinary tract (the remainder are in the upper urinary tract). The patient will typically present with the gross passage of blood in the urine or with irritative urinary symptoms. The diagnosis is generally made by cystoscopic examination of the bladder which shows the typical cauliflower like tumor(s) on a pedicle of varying thickness. Some tumors may be more solid and broad based. These tend to be more aggressive and have a worse prognosis. Although the gross appearance is characteristic, biopsy is needed to confirm the diagnosis and to evaluate the grade and stage of the tumor. The GRADE is based on microscopic examination of the cancer cells and varies from one for the least to 4 for the most malignant. The STAGE measures the depth of penetration into the balder wall and is classified similarly. After the diagnosis is established, and depending on the grade and stage, other test may be needed to evaluate the extent of the tumor such as CT or MRI scans of the abdomen and pelvis. Low grade noninvasive tumor are usually cured by TUR (transurethral resection) of the tumor. High grade or stage tumors may require more intensive therapy such as radiation, chemotherapy or radical surgical removal of the bladder. Even low grade tumor have a tendency to recur so life long periodic evaluation is necessary to try and detect recurrences early. Sometimes, especially in a patient with multiple tumors on presentation or many recurrences, instillation of medication into the bladder is used to try and prevent such episodes. Some of the agents used for this include BCG, Mitomycin C, Thiotepa, Doxorubicin, Epirubicin, Valrubicin, and interferon alpha 2b. The latter agent has the added advantage of causing minimal bladder irritation.
That being said, a grade 1-2 tumor is considered low grade. The urinary cytology is typically negative in these cases so your cytology report is consistent with this. Although the size and gross appearance of the tumor suggests low grade. the "irregular wide base" is a bit disturbing. Such bases have an increased tendency to be associated with tumors that invade into the muscle (stage B). The lack of invasion noted on imaging studies is somewhat reassuring but this does not rule out microscopic invasion - only gross invasion.
Therefore, the safest course of action would be to have the tumor resected sooner rather than in 3 months. Be sure your urologist gets good samples of the muscle deep to the tumor for pathologic examination so that staging can be more accurate. Good luck and let me know how you make out.