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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 4  |  Page : 628-631
Stage of urinary bladder cancer at first presentation

Hawler Medical University, Erbil, Iraq

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Date of Web Publication8-Jul-2009


The stage of urinary bladder cancer is an important factor in determining prognosis of the disease. This prospective study was performed to determine the stage of bladder cancer at first presentation at the Rizgary Hospital in the Erbil governorate in Iraqi Kurdistan. We evaluated 72 patients with bladder cancer. The grades and stages of bladder cancer of these patients were determined through physical examination and investigations. We found that 47.2% of patients had superficial cancer, 19.4% had tumor with invasion into the lamina propria and 30.6% of patients had tumor with invasion to muscle wall. Regional or distant metastases were found in 2.8% of patients. Well differentiated tumor was seen in 44.4% of the patients, moderately differentiated tumor was found in 38.9% and poorly differentiated tumor was found in 16.7% of the patients. Our study suggests that bladder cancer is diagnosed at a relatively early stage in the Erbil governorate. However, the situation can be further improved by adopting proper screening programs and performing appropriate investigations.

Keywords: Bladder cancer, Stage, Grade, Hematuria

How to cite this article:
Al-Bazzaz PH. Stage of urinary bladder cancer at first presentation. Saudi J Kidney Dis Transpl 2009;20:628-31

How to cite this URL:
Al-Bazzaz PH. Stage of urinary bladder cancer at first presentation. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2022 Jan 23];20:628-31. Available from: https://www.sjkdt.org/text.asp?2009/20/4/628/53253

   Introduction Top

Bladder cancer is the fourth most common cancer in men accounting for 6.2% of all cancers and the eighth most common cancer in women accounting for 2.5% of all cancers. It is also the second most common urogenital tumor. It is ge­nerally a disease of older men and the male to female ratio is 2.5:1. [1] ,[2]

Painless hematuria is the most common pre­senting symptom of bladder cancer and occurs in about 85% of patients. [3] Presentation with symp­toms of bladder irritability such as urinary fre­quency, urgency, and dysuria occurs in approxi­mately 25% of patients and is usually associated with diffuse carcinoma in situ or invasive bladder cancer. [4]

Factors that result in diagnosis being made at a more advanced stage of the disease include a possible under-reporting of superficial cancers, delayed diagnosis, and/or more frequent occu­rrence of more aggressive variants of transitional cell carcinoma in some people. [2] The vast majority of bladder cancers are transitional cell carcino­mas, although a high proportion of other bladder cancers such as squamous cell carcinoma and adenocarcinoma also occur. The relatively poor outcome of these tumors may explain some of the racial and sex differences in bladder cancer mortality. [5]

There is no uniformly accepted grading system for bladder cancer. The most commonly used systems are based on the degree of anaplasia of the tumor cells. [6] A strong correlation exists bet­ween tumor grade and stage, with most well­differentiated and moderately differentiated tumors being superficial and most poorly differentiated ones being muscle invasive. Stage for stage, there is a significant correlation between tumor grade and prognosis; however, the correlation between tumor stage and prognosis is even stronger. [7]

A papilloma (Grade-zero) is a papillary lesion with a fine fibrovascular core covered by nor­mal bladder mucosa. [8] Well-differentiated tumors (Grade-1) have a thin fibrovascular stalk with thickened urothelium containing more than seven cell layers, with cells exhibiting only slight ana­plasia and pleomorphism. [8] Moderately differen­tiated tumors (Grade-2) have a wider fibrovas­cular core, a greater disturbance of the base-to­surface cellular maturation, and a loss of cell polarity. Poorly differentiated tumors (Grade-3) have cells that do not differentiate as they prog­ress from the basement membrane to the surface. [9]

The most commonly used staging system allows for a precise and simultaneous description of the primary tumor stage (T stage), the status of lymph nodes (N stage), and metastatic sites (M stage) (American Joint Committee on Cancer, 1997). [10] Over-staging is relatively uncommon, but clinical under-staging may occur in up to 53% of pa­tients. [11] Ta refers to non-invasive papillary car­cinoma. T1 means that the tumor has invaded sub-epithelial connective tissues. In T2, tumor has invaded muscles, T3 refers to tumor that has in­vaded perivesical tissues and T4 is when the tumor has invaded the prostate, uterus, vagina, pelvic wall or abdominal wall.

As there are no previous studies from this region, this study was performed to determine the common stage of bladder cancer at first pre­sentation in the Erbil governorate in Iraqi Kur­distan. Also, the results were compared with the results of other studies.

   Patients and Methods Top

In this prospective study, we evaluated 72 pa­tients with bladder cancer hospitalized at the Department of Urology, Rizgary Teaching Hos­pital, Erbil, Iraq, from 2nd January 2006 till 30th June 2007. Detailed history and clinical exami­nation in addition to relevant investigations were carried out on these 72 patients in order to diag­nose bladder cancer and to determine its grading and staging. The investigations included micros­copic examination of the urine, urine cytology, plain x-ray of the abdomen, chest x-ray, ultra­sound of the abdomen and pelvis, intravenous urography and cystography, CT scan and/or MRI, cysto urethroscopy and histopathological exa­mination.

The data were analyzed and results were com­pared with a number of similar studies carried out in different countries.

   Results Top

During the study period, 72 patients were newly diagnosed as having bladder cancer and included 54 male patients (75%) with a mean age of 61.8 years and 18 female patients (25%) with a mean age of 57.9 years. The male to female ratio was 3:1. The most common age-group for occurrence of bladder cancer was 50 to 69 years accounting for 50% of cases.

Of the 72 patients with bladder cancer, 62 pa­tients (86.1%) presented with gross hematuria while ten (13.9%) presented with microscopic hematuria. All our study patients had transitional cell carcinoma as the type of bladder tumor.

Concerning the staging of the tumor, 47.2% (34/72) of the patients had superficial cancer (Stage Ta), 19.4% (14/72) had tumor with invasion into the lamina propria (T1) and 30.6% (22/72) of patients had tumor with invasion to muscle wall (T2). Regional or distant metastases were found in approximately 2.8% (2/72) of patients. There were no patients with carcinoma in situ

In our study, majority of the study patients (32/72, 44.4%) had well differentiated tumor (G1). Moderately differentiated tumor (G2) was found in 38.9% (28/72), while poorly differen­tiated tumor (G3) was found in 16.7% (12/72) of the study patients. [Table 1] shows the details of the grade and stage of bladder cancer in our study patients.

Stage Ta bladder cancer was the most commonly seen stage among all age-groups in our study, but this was more so in the age-group 50 to 69 years. T1 tumor existed mainly in the age-group 50 to 69 years, whereas T2 tumor was more common among patients in the age-groups 50 to 69 and 70 to 89 years as shown in [Table 2].

Similarly, Grade 1 bladder cancer was common among all age-groups but was mainly seen in the age-group 70 to 89 years. Grades 2 and 3 tumors were found mainly in the age-group 50 to 69 years as shown in [Table 3].

There were 22 patients with superficial well­differentiated tumors (Ta, G1) of whom 81.8% (18/22) presented with gross, painless hematuria, 9.1% (2/22) presented with gross painful he­maturia and another 9.1% (2/22) presented with painful microscopic hematuria.

The overall sensitivity of urine cytology was 22.2%. Positive results for Grade-1, Grade-2 and Grade-3 bladder cancers were 6.3% (2/32), 35.7% (10/28) and 33.3% (4/12), respectively. The spe­cificity of urine cytology was 100%. The details of these findings are shown in [Table 4].

   Discussion Top

The most common presenting symptom of bla­dder cancer in our study was gross, painless, in­termittent hematuria, seen in 78.6% of the pa­tients. This finding is in agreement with two other studies. [4] ,[12] Transitional cell carcinoma was the only histopathological type of bladder cancer seen in our study. While another study revealed the same result, [12] Epstein et al, [13] reported transi­tional cell carcinoma in 90% of the cases, which is probably due to the endemicity of schistoso­miasis among their study population.

At the time of diagnosis, 48 of our study patients (66.6%) had superficial lesions (Ta, or T1), 22 (30.6%) had muscle invasive lesions (T2/T3), and two patients (2.8%) had a locally metastasized tumor. There were no patients with carcinoma in situ, which is probably due to not taking random bladder biopsies. In another study, Rafique and Javed [12] reported from the Punjab in Pakistan, a higher incidence of muscle invasive lesions (75%), which is most probably due to the long history of using smokeless tobacco among people in the study region as well as the rural and un­educated nature of the study population that caused delayed presentation. On the other hand, Herr [3] reported a high incidence of superficial stages and a low percentage of muscle invasive lesions in the United States of America, which reflects a proper screening program for their population, early detection and early appropriate management.

Our study shows that well differentiated tumor (Grade-1) is most common among the study po­pulation (44.4%), which indicates the early de­tection of bladder cancer in this region. In contrast, Rafique and Javed revealed a high incidence of moderately and poorly differentiated tumors (86.8%). [12]

In our study, urine for cytological examination was obtained by bladder wash out. The test was positive (sensitivity) in 6.3%, 35.7% and 33.3% in Grade-1, Grade-2 and Grade-3 bladder can­cers respectively. In another study, Soloway and Morrison [14] reported positive urine cytology of 10%, 50% and 90% for Grade-1, Grade-2 and Grade-3 tumors, respectively. [14] Our results show lower sensitivity which may be due to improper interpretation of the cytology specimen and re­lative lack of experience of the person doing the examination. Thus, we cannot depend on cytology for definitive diagnosis of bladder cancer in this region. On the other hand, the specificity of urine cytology was 100% as there were no false po­sitive results.

   Conclusions Top

Generally speaking, patients with bladder cancer are diagnosed at a relatively early stage in the Erbil governorate. However, the situation can be improved further by adopting proper screening programs and initiating early management.

   References Top

1.Greenlee RT, Murray T, Bolden S, Wings PA. Cancer statistics, 2000. CA Cancer J Clin 2000; 50:7-33.  Back to cited text no. 1    
2.Lynch CF, Cohen MB. Urinary system. Cancer 1995;75:316.  Back to cited text no. 2    
3.Herr HW. Tumor progression and survival of patients with high grade, noninvasive papillary (TaG3) bladder tumors: 15-year outcome. J Urol 2000;163:60.  Back to cited text no. 3    
4.Varkarakis MJ, Gaeta J, Moore RH, et al. Superficial bladder tumor: Aspects of clinical progression. Urology 1974;4:414.  Back to cited text no. 4    
5.Dinlenc C, Siroky MB. Hematuria and other urine abnormalities. In: Siroky MB, Oates RD, Babayan RK.(eds). Manual of Urology, Diagnosis and The­rapy, 2nd ed. By Lippincott, Williams & Wilkins.  Back to cited text no. 5    
6.Grossfeld GD, Carroll PR. Cancers of the bladder, ureter, & renal pelvis. In: Jack McAninch, Emil Tanagho,(eds) Smith's General Urology 16th ed., by McGraw-Hill/Appleton & Lange (September 18, 2003). (September 18, 2003).  Back to cited text no. 6    
7.El-Bolkainy MN, Mokhtar NM, Ghoneim MA, Hussein MH. The impact of schistosomiasis on the pathology of bladder carcinoma. Cancer 1981; 48:2643.  Back to cited text no. 7    
8.Bernstein SA, Reuter VE, Carroll PR, Whitmore WF Jr. Primary signet ring cell carcinoma of uri­nary bladder. Urology 1988;31:432.  Back to cited text no. 8    
9.Mills SE, Wolfe JT 3rd, Weiss MA, et al. Small cell undifferentiated carcinoma of the urinary bladder. A light-microscopic, immunocytochemical, and ultrastructural study of 12 cases. Am J Surg Pathol 1987;11:606-17.  Back to cited text no. 9    
10.Murphy WM. Diseases of the urinary bladder, urethra, ureters, and renal pelvis. In: Murphy WM (ed): Urological Pathology. Saunders, 1989.  Back to cited text no. 10    
11.Jewett HJ, Strong GH. Infiltrating carcinoma of the bladder: Relation of depth of penetration of the bladder wall to incidence of local extension and metastases. J Urol 1946;55:366.  Back to cited text no. 11    
12.Rafique M, Javed AA. Clinico-pathological fea­tures of bladder carcinoma: Experience from a tertiary care hospital of Pakistan. Int Urol Nephrol 2006;38:247-50.  Back to cited text no. 12    
13.Epstein JI, Amin MB, Reuter VR, et al. The World Health Organization/International Society of Uro­logical Pathology consensus classification of urothelial (transitional cell) neoplasms of the urinary bladder. Bladder Consensus Conference Committee. Am J Surg Pathol 1998;22:1435-48.  Back to cited text no. 13    
14.Soloway MS, Morrison DA. Modalities used in the diagnosis, staging and evaluation of bladder cancer. AUA Update Series 1985;4:1.  Back to cited text no. 14    

Correspondence Address:
Pishtewan H Al-Bazzaz
Consultant Kidney Transplant Surgeon, Hawler Medical University, Erbil
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PMID: 19587505

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  [Table 1], [Table 2], [Table 3], [Table 4]

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