浸润性膀胱癌在男性与女性患者之间有无区别?

美国每年有10,000人死于膀胱癌,几乎均死于肿瘤的肌层浸润或转移。作者对101例膀胱癌患者行根治性膀胱切除术,手术适应症为:侵及肌层的膀胱癌(T_2,T_3,T_4),侵及前列腺导管的原位癌(CIS),TUR加腔内化疗后复发或持续存在的高分级肿瘤。该组患者中男74例,女27例;移行细胞癌(TCC)占80％,鳞状细胞癌(SCC)占14％,腺癌占 3％。通常鳞癌约占膀胱肿瘤的3～5％,而该组女性患者中鳞癌高达30％,男性为6％,两者比例为5:1。鳞癌是恶性度更高的肿瘤,多为侵润癌,5年生存率仅16～20％,该组女性鳞癌患     

膀胱部分切除术的价值

膀胱癌是泌尿系统最常见的恶性肿瘤,在我国其发病率居泌尿系统恶性肿瘤的首位.其中膀胱移行细胞癌(TCC)最为常见,占膀胱癌的90％以上.膀胱鳞状细胞癌比较少见,占膀胱癌的3％ ～7％.膀胱腺癌更为少见,占膀胱癌的比例＜2％.膀胱移行细胞癌的治疗方法取决于肿瘤的分期和细胞分级.表浅性肿瘤(SBC)占全部膀胱肿瘤的75％～85％,包括Tis、T0、T,期膀胱肿瘤,常采用保留膀胱手术方式;浸润性膀胱肿瘤是指肿瘤浸润肌层T2、T3、T4期肿瘤,其基本治疗是根治性膀胱切除术[1].     

膀胱鳞状细胞癌

目的分析膀胱鳞状细胞癌(SCC)的临床特点，提高对膀胱鳞状细胞癌的认识及诊治水平。方法回顾性分析10例该病患者的临床资料，结合国内外文献进行分析讨论。结果10例患者男8例，女2例，平均年龄61岁，行膀胱全切术2例，分别存活18、25个月。膀胱部分切除8例，2例术后1年内出现膀胱内复发，1年以上无复发者4例．2例失随访。本组患者生存时间6-72个月，平均生存16．4个月，1例膀胱鳞癌伴移行细胞癌(TCC)患者生存5年以上。结论膀胱鳞癌在诊断时临床分期较高，顸后差，对化疗不敏感，术前放疗和根治性膀胱切除可提高患者生存率。     

膀胱鳞状细胞癌的诊治

目的：探讨膀胱鳞状细胞癌的发病、诊断、治疗及预后。方法：回顾性分析8例膀胱鳞状细胞癌患者的临床资料,结合国内外文献进行分析讨论。结果：8例患者年龄44～7串岁。行膀胱全切术3例,膀胱部分切除5例。7例患者随访1～10年,2年和5年生存率分别为43％（3／7）和14％（1／7）。结论：膀胱鳞状细胞癌是一种高度恶性肿瘤,预后差,早期诊断和治疗对患者来说非常重要。膀胱根治性切除仍是目前较好的治疗办法。     

保留膀胱联合髂内动脉化疗治疗浸润性膀胱癌46例报告

目的：评价保留膀胱手术后联合髂内动脉介入化疗治疗浸润性膀胱癌的临床疗效。方法：2003年6月～2009年2月对46例浸润性膀胱移行细胞癌患者采用经尿道膀胱肿瘤电切或膀胱部分切除术联合顺铂＋吡喃阿霉素方案髂内动脉化疗进行治疗。结果：46例患者均获得随访,平均随访38（9～68）个月。33例无瘤生存,2例带瘤生存,11例死于肿瘤转移,5年生存率为75．76％;29例保留膀胱生存,10例行挽救性全膀胱切除,其中全膀胱切除术后死亡4例,5年膀胱保存率为73．32％;其中33例T2期患者5年生存率为83．21％;5年膀胱保留率为81．82％。全部患者对动脉化疗耐受良好,无严重全身和局部不良反应。结论：保留有功能的膀胱手术加髂内动脉灌注化疗为治疗浸润性膀胱移行细胞癌的有效方法之一,尤其是早期浸润性膀胱癌（T2期）患者,是保留膀胱治疗的最佳适应证。     

肾移植后膀胱恶性肿瘤的临床特征(附2例报告并文献复习)

目的：探讨肾移植后膀胱恶性肿瘤的临床特征。方法：报道经治的2例肾移植后膀胱癌患者的临床资料;并查阅中文数据库收集的国内50例肾移植后并发膀胱恶性肿瘤患者的临床与病理表现。结果：50例中,单一组织器官肿瘤34例,其中移行上皮癌33例,鳞状上皮细胞癌1例;多器官多组织起源肿瘤16例(32％)．同时性发生占81．25％(13／16)。膀胱肿瘤患者1年生存率为46．3％,5年生存率21．3％。结论：肾移植后膀胱恶性肿瘤的临床特征不同于非肾移植,多器官多组织起源肿瘤增多,近远期生存率低。     

膀胱鳞状细胞癌（附12例报告）

目的提高对膀胱鳞状细胞癌的诊治水平。方法回顾分析1980年1月至1999年7月收治的12例膀胱鳞状细胞癌临床资料,结合献进行讨论。结果12例中膀胱部分切除术6例,全膀胱切除术 尿流改道术4例,姑息性尿流改道术2例。随访1年生存率50％(6／12),5年生存率16．7％(2／12)。结论膀胱鳞状细胞癌浸润性强,恶性程度高,预后不良。早期诊断、严格掌握手术指征是提高膀胱鳞状细胞癌患5年生存率的有效措施。     

根治性膀胱切除治疗原发性膀胱神经内分泌肿瘤：美国南加州大学经验

原发性膀胱神经内分泌肿瘤临床罕见，作者报告采用根治性膀胱切除术治疗的经验，分析其组织病理学特点，评价临床治疗效果。1971年8月至2004年6月，2005例早期膀胱癌患者在南加州大学行根治性膀胱切除术，其中25例（1．2％）为膀胱神经内分泌癌，包括20例小细胞癌和5例大细胞癌。病理类型完全为神经内分泌组织者16例，     

膀胱混合癌的临床特征

目的:探讨膀胱混合癌的临床特征。方法:回顾性分析1990年6月~2004年8月收治的16例膀胱混合癌患者的临床资料,对该病的临床表现,诊断和治疗以及预后情况进行讨论。结果:膀胱混合癌16例,占同期230例膀胱恶性肿瘤的6.9%,其中移行、鳞状细胞混合癌7例,移行、腺细胞混合癌4例,移行、鳞状、腺细胞混合癌3例,鳞状、腺细胞混合癌2例。多数患者以膀胱刺激症为主要临床表现,治疗以膀胱全切为主,术后1、3和5年的生存率分别为81.3%、56.3%和12.5%。结论:膀胱混合癌以膀胱刺激症状为主要临床表现,恶性程度高,早期诊断困难。根治性全膀胱切除术有助于提高生存率。     

不同类型膀胱癌组织中环氧化酶-2的表达及意义

目的探时环氧化酶-2（COX-2）在不同类型膀胱癌组织中的表达及临床意义。方法应用免疫组化染色方法检测52例膀胱移行细胞癌组织（其中T，18例、T2 14例、T3 14例、T4 6例，G1 13例、G2 25例、G3 14例，肿瘤单发37例、多发15例）、20例膀胱腺癌组织、10例膀胱鳞状细胞癌组织及17例正常膀胱黏膜组织中COX-2蛋白表达情况，根据染色阳性细胞所占比例，分为（-）、（＋）、（＋＋）、（＋＋＋）4个等级，用等级资料x^2检验进行统计学分析。结果82例肿瘤组织COX-2蛋白表达率（82．9％，68／82）高于正常黏膜（23．5％，4／17）（P〈0．05），不同类型肿瘤COX-2蛋白表达率也有差别，鳞状细胞癌最强（100％，10／10），腺癌次之（90．0％，18／20），移行细胞癌相对较弱（76．9％，40／52）（P〈0．05）；在52例移行细胞癌标夺中，COX-2表达率与肿瘤分级、分期相关（P〈0．05）。结论COX-2在不同类型膀胱癌组织中呈岛表达，在鳞状细胞癌表达最强，可能成为膀胱癌化学预防的一个靶点。     

Surgical Treatment Results of Invasive Non-Transitional Cell Tumours of the Bladder

Although the majority of bladder cancers are transitional cell carcinomas (TCC), non-transitional cell tumours (non-TCT) have significant importance because of their aggressive clinical course. We evaluated the treatment results of invasive transitional and non-transitional bladder tumours treated in our department. Non-transitional cell tumours were demonstrated in 51 (9.6%) of 527 bladder cancer cases from 1992 to 1998 in our department. Radical cystectomy was performed in 177 invasive bladder cancer patients and of these 47 (26.5%) had non-transitional cell tumours. The majority of patients (92.15%) with non-transitional cell tumours of the bladder had invasive disease at the time of diagnosis. The distribution of non-transitional cell tumours was: 24 (51%) squamous cell carcinoma (SCC), 15 (31.7%) undifferentiated carcinoma (UC), 4 (8.5%) adenocarcinoma and 4 (8.5%) sarcoma. Overall 12 and 42 months disease specific survival rates for TCC patients were 69.37% and 47.22%, respectively, whereas overall 12 months survival rate for non-TCT patients was 47.61%. The survival rates after radical cystectomy for SCC, UC, adenocarcinoma and sarcoma were 35.8%, 41.5%, 37.5% and 75%, respectively. In the literature, the incidence of non-transitional tumours is 5%. However, in our department, we observed an incidence of 26.5% between 1992 and 1998. We also arrived at the conclusion that non-transitional tumours of the bladder tend to be more aggressive than invasive urothelial tumours and in most patients invasive disease was also present at the time of diagnosis. Early diagnosis and radical cystectomy are the most important factors that influence the survival in cases of invasive non-transitional cell tumours of the bladder.     

A case of transitional cell carcinoma with squamous differentiation which developed squamous cell carcinoma in situ in the clinical course

In August 2000, a 62-year-old woman presented to another municipal hospital with macroscopic Transurethral resection of bladder tumor (TUR-Bt) was performed. The pathological hematuria. diagnosis was transitional cell carcinoma (TCC), G2 > squamous cell carcinoma (SCC). TUR-Bt repeated in July 2003 indicated recurrence. The pathological diagnosis was TCC, G2. She was referred to our hospital in August 2003 because she desired bladder preservation. After cystoscopy and random biopsy, pathological diagnosis was TCC with squamous differentiation, G1-G2, pTis. She received 7 weekly intravesical bacillus Calmette-Guerin (BCG) instillations. In April 2004, TUR-Bt was repeated and multiple recurrences were found. The pathological diagnosis was TCC with squamous differentiation, G1-G2, pTa. She received 10 weekly intravesical Pirarubicin hydrochroride instillations. In August cystoscopy and random biopsy were performed for evaluation of the intavesical instillation treatment. Pathological diagnosis was atypical squamous cells. In November, cystoscopy revealed recurrence of a bladder tumor. After admission, a small papillary tumor and multiple flat lesion biopsies demonstrated SCC without obvious invasion. The patient underwent cystectomy. There were widespread areas of full thickness squamous atypia. Most of the bladder did not show appearance of typical TCC, but the final pathological diagnosis was TCC because the case developed from TCC and could not be diagnosed as pure SCC. The diagnosis of SCC in situ of bladder is difficult, and this may contribute to its rarity.     

Hexaminolevulinate-Guided Fluorescence Cystoscopy in the Diagnosis and Follow-Up of Patients with Non–Muscle-Invasive Bladder Cancer: Review of the Evidence and Recommendations

Context

Compared with standard white-light cystoscopy, photodynamic diagnosis with blue light and the photosensitiser hexaminolevulinate has been shown to improve the visualisation of bladder tumours, reduce residual tumour rates by at least 20%, and improve recurrence-free survival. There is currently no overall European consensus outlining specifically where hexaminolevulinate is or is not indicated.

Objective

Our aim was to define specific indications for hexaminolevulinate-guided fluorescence cystoscopy in the diagnosis and management of non–muscle-invasive bladder cancer (NMIBC).

Evidence acquisition

A European expert panel was convened to review the evidence for hexaminolevulinate-guided fluorescence cystoscopy in the diagnosis and management of NMIBC (identified through a PubMed MESH search) and available guidelines from across Europe. On the basis of this information and drawing on the extensive clinical experience of the panel, specific indications for the technique were then identified through discussion.

Evidence synthesis

The panel recommends that hexaminolevulinate-guided fluorescence cystoscopy be used to aid diagnosis at initial transurethral resection following suspicion of bladder cancer and in patients with positive urine cytology but negative white-light cystoscopy for the assessment of tumour recurrences in patients not previously assessed with hexaminolevulinate, in the initial follow-up of patients with carcinoma in situ (CIS) or multifocal tumours, and as a teaching tool. The panel does not currently recommend the use of hexaminolevulinate-guided fluorescence cystoscopy in patients for whom cystectomy is indicated or for use in the outpatient setting with flexible cystoscopy.

Conclusions

Evidence is available to support the use of hexaminolevulinate-guided fluorescence cystoscopy in a range of indications, as endorsed by an expert panel.     

T2a transitional cell carcinoma of the bladder: long-term experience with intravesical immunoprophylaxis with bacillus Calmette-Guerin

PURPOSE: In this prospective study we evaluate the effect of combined transurethral resection of early muscle invasive bladder cancer and immunotherapy with bacillus Calmette-Guerin (BCG) in patients unfit for radical cystectomy or refusing more aggressive therapies. MATERIALS AND METHODS: A total of 22 patients with a mean age 73.6 years were included in the study. Inclusion criteria were histologically proven muscle invasive transitional cell carcinoma of the bladder with a tumor-free second resection and negative staging examinations in patients unfit for radical cystectomy or refusing more aggressive therapies. All patients received 6 weekly instillations of 120 mg. BCG starting 14 to 21 days after the last transurethral resection of the tumor. Followup at 3 months included cystoscopy, urinary cytology, ultrasound of the abdomen and chest x-ray. Every 6 months computerized tomography of the abdomen and bone scans were performed. RESULTS: The overall 5-year survival rate was 69.1%, while the disease specific 5-year survival rate was 94%. One muscle invasive recurrence was noted at 69 months, which was again treated with the same regimen but ultimately led to radical cystectomy 21 months later. One patient died of progressive recurrence in the upper urinary tract. The 5-year recurrence-free survival rate was 46.5%. The only severe complication was BCG pneumonitis. CONCLUSIONS: The data show encouraging results for transurethral resection of bladder tumor with intravesical BCG therapy in select patients with T2a bladder cancer who are not candidates for radical cystectomy.     

Squamous cell carcinoma of the bladder: pathology, diagnosis and treatment

Squamous cell carcinoma (SCC) can occur in both nonbilharzial and bilharzial bladders; the two subtypes differ in epidemiology, pathogenesis and clinicopathological features. The nonbilharzial type occurs in Western countries and represents < 5% of all vesical tumours; it occurs most often in the seventh decade with a slight male predominance. The principal predisposing factor is prolonged indwelling urethral catheterization in patients with spinal cord injury and the main symptom is haematuria. Patients are usually diagnosed at an advanced stage and most of the tumours are of moderate and high grades. At cystoscopy tumours are predominantly ulcerative and commonly involve the trigone and lateral walls. Although distant metastasis is infrequent (8-10%) the prognosis is grave and most patients die after failure of locoregional control; radical cystectomy provides the best therapy. To avoid nonbilharzial SCC, patients with spinal cord injury should be free of catheterization if possible. The outcome can be improved by early detection with frequent cytology, cystoscopy and biopsy. Bilharzial SCC occurs commonly in the Middle East, South-east Asia and South America where schistosomiasis is endemic. In an Egyptian series SCC represented 59% of 1026 cystectomy specimens. The tumour is diagnosed in the fifth decade, and five times more common in men than women. Bladder carcinogenesis is probably related to bacterial and viral infections, commonly associated with bilharzial infestation rather than the parasite itself. The presentation is often with irritative bladder symptoms and haematuria, and many patients present at an advanced stage, although most tumours are of low and moderate grades. At cystoscopy tumours are predominantly nodular and usually arise from the upper vesical hemisphere. Lymph-node metastasis occurs in approximately 19% and significantly decreases survival; radical cystectomy remains the main treatment, giving a 5-year survival rate of 50%. Early detection improves the therapeutic yield and prevention is possible by combining snail control and mass therapy of the infested rural population by oral antibilharzial drugs.     

膀胱腺癌的诊断和治疗(附29例报告)

目的提高膀胱腺癌的诊断与治疗水平。方法29例中原发性膀胱腺癌18例，其中行全膀胱切除、尿流改道11例，膀胱部分切除7例；脐尿管腺癌9例，6例行扩大膀胱部分切除术，3例行全膀胱切除、尿流改道；印戒细胞癌2例，行全膀胱切除、尿流改道术。结果4例患者失访，25例患者随访时间为5个月一10年。生存1年者17例（64％），生存2年15例（60％），生存5年5例（20％），生存时间超过5年者均为早期患者。结论早期诊断、鉴别原发性膀胱腺癌与脐尿管腺癌、选择合适的手术方式是膀胱腺癌治疗的关键。     

Long-term risk of salvage cystectomy after radiotherapy for muscle-invasive bladder cancer

OBJECTIVES: To establish the long-term outcome for muscle-invasive transitional cell carcinoma of the bladder treated by radiotherapy with or without neoadjuvant cisplatin. METHODS: 159 patients with T2-T4a NX M0 bladder cancer were entered into a prospective randomized trial between June 1984 and June 1988. Follow-up was by 3-monthly cystoscopy in the first year, 6-monthly the next 2 years and yearly thereafter. Salvage surgery was performed at the discretion of the participating clinician. RESULTS: Minimum follow-up was 9 (median 11) years, at which time 29 patients (18%) remain alive. Median survival was 24 months with no difference between the treatment groups (chi(2) = 0.08, p = 0.77). Overall cystectomy rate was 24% (radiotherapy alone 20%, combined therapy 28%; p = 0.24). Median time to cystectomy from primary treatment was 12 months; range 56 days to 10 years. The risk of cystectomy was 11, 10 and 7% for the first, second and third years after radiotherapy respectively, and 8% in total after the third year. The proportion of patients alive in each successive year who had required a cystectomy was between 20 and 30% for 5 of the first 8 years after treatment. CONCLUSIONS: Salvage cystectomy is necessary in a quarter of patients after radiotherapy and this can be needed up to 10 years after treatment. During this time, multiple invasive procedures are likely to be performed, resulting in significant patient morbidity and cost. Patients should be fully counselled about the need for prolonged surveillance and the persisting risk of salvage surgery when deciding between primary cystectomy and radiotherapy.     

Endoscopic management of upper tract urothelial carcinoma in patients with a history of bladder urothelial carcinoma

PURPOSE: Endoscopic management of renal pelvis and ureteral urothelial carcinoma is gaining acceptance as a conservative treatment modality. Patients with a history of bladder urothelial carcinoma are at high risk for upper tract recurrence. We evaluate the role of endoscopic management of upper tract urothelial carcinoma in patients with a history of primary bladder urothelial carcinoma. MATERIALS AND METHODS: We retrospectively reviewed 90 patients with a history of primary bladder urothelial carcinoma who underwent endoscopic treatment of localized upper tract urothelial carcinoma between 1983 and 2004. RESULTS: Median patient age at diagnosis was 73 years (range 50 to 90). A total of 13 (14.4%) patients previously underwent cystectomy. With a median followup of 4.3 years (range 0.1 to 17), 105 upper tract urothelial carcinoma recurrences developed in 55 patients at a mean of 0.6 years (range 22 days to 5.9 years). Of these recurrences 76 were amenable to endoscopic management while 29 required nephroureterectomy. In 38 patients there were 91 bladder recurrences. At last followup 48 patients died, 17 of urothelial carcinoma at a median of 3.4 years (range 1 to 10). Cancer specific survival at 5 years for this cohort was 71.2%. Risk of death from urothelial carcinoma was significantly associated with stage (RR 3.23) and grade (RR 4.05) of upper tract urothelial carcinoma, imperative indication (RR 4.30), and treatment of bladder urothelial carcinoma with cystectomy (RR 3.34). CONCLUSIONS: Endoscopic management of upper tract urothelial carcinoma in patients with primary bladder urothelial carcinoma demonstrates a significant local recurrence rate. Furthermore, 5-year cancer specific survival is low. These patients represent a high risk cohort requiring strict ureteroscopic followup after endoscopic management is instituted.     

Prophylactic radical cystectomy for the management of keratinizing squamous metaplasia of the bladder in a man with tetraplegia

BACKGROUND/OBJECTIVE: To report a case of keratinizing squamous metaplasia of the bladder treated with radical cystectomy. DESIGN: Case report and discussion of management options. METHODS: Keratinizing squamous metaplasia of the bladder is a rare entity that can result from chronic irritative stimuli involving the bladder. It is considered a premalignant condition associated with invasive squamous cell carcinoma. A case report is presented describing the diagnosis and management of keratinizing squamous metaplasia of the bladder in a tetraplegic man with a chronic indwelling urinary catheter. RESULTS: Radical cystectomy with an Indiana continent reservoir was performed after cystoscopy with biopsy confirmed keratinizing squamous metaplasia. Final pathology revealed focal erosion and diffuse keratinizing squamous metaplasia of the bladder with prostatic adenocarcinoma as an incidental finding. CONCLUSIONS: Patients with spinal cord injury who use indwelling catheters for bladder management are at higher risk of developing keratinizing squamous metaplasia. Surveillance for early detection of this entity is recommended. Prophylactic cystectomy is sometimes warranted; however, observation and frequent cystoscopic surveillance to identify potential malignant transformation can be an alternative strategy. An interdisciplinary approach is recommended before consideration of bladder resection.     

膀胱非上皮性肿瘤的诊治

目的 总结膀胱非上皮性肿瘤的诊治经验。方法 对1953～2002年收治的28例膀胱非上皮性肿瘤患者的诊治情况进行总结、分析。结果 膀胱非上皮性肿瘤的主要临床表现为血尿、盆腔肿块、尿频、排尿困难等症状。主要辅助检查为B超、CT、膀胱镜检查及镜下活检。本组28例中,经术后病理检查,恶性肿瘤17例(占61．7％),有7种病理类型,分别为膀胱横纹肌肉瘤、膀胱小细胞癌、膀胱平滑肌肉瘤、膀胱恶性淋巴瘤、膀胱恶性纤维组织细胞瘤、膀胱脂肪肉瘤、膀胱黑色素瘤;良性11例(占39．3％),有4种病理类型,分别为膀胱海绵状血管瘤、膀胱壁纤维瘤、膀胱平滑肌瘤、膀胱嗜铬细胞瘤。11例良性肿瘤均完整切除或电灼、电切。17例恶性肿瘤中,膀胱部分切除术7例、膀胱全切除术9例、无法切除1例,有7例恶性肿瘤因复发多次行手术切除。17例恶性肿瘤患者均获随访,3年存活率47．0％(8／17)。结论 膀胱非上皮性肿瘤临床少见,病理类型复杂,恶性居多且预后较差,良性肿瘤预后较好。术前诊断率低,膀胱镜下深部活检可提高诊断率。手术是该病的主要治疗方法。良性肿瘤应完整切除,恶性肿瘤应争取广泛切除,结合其病理特点辅助放化疗可能提高疗效。