A New Approach to the Treatment of Certain Bladder Carcinomas

Abstract

CARCINOMA of the bladder is a disease of relatively common occurrence, comprising about 0.4 per cent of all human tumors. The relative incidence is much higher in urologic practice, and in Young's Clinic 4 per cent of 12,500 cases were bladder tumors. They are nearly four times as common in men as in women, and, for practical purposes, occur between the ages of fifty and sixty-nine but from age sixty to sixty-four seems to be the period of most frequent occurrence. They may occur anywhere in the bladder but are slightly more common on the lateral walls than elsewhere. The trigone is the next most common region, the exact locations being as follows: As a general rule, the tumors occurring in the vault of the bladder are of the highest histologic grade of malignancy, namely, Grades 3 and 4, while in marked contrast, those involving the trigone, lateral wall, and neck of the bladder are commonly of histologic Grades 1 and 2. Based on the figures of the Carcinoma Registry of the American Urological Association, a tumor located on the lateral wall, the trigone, or the neck of the bladder has approximately an even chance to be either Grade 1 or 2, while 75 per cent of vault tumors will be Grades 3 or 4. From observations made upon dye workers, it seems likely that the malignant tumor originates in the basal layer of the epithelium about the terminal blood vessels and that it may reach considerable size before the superficial epithelium becomes involved. The tumor then usually follows the vascular supply into the deeper layers. If this concept is valid, it seems doubtful that we will ever be able to make an early diagnosis of bladder tumor, unless a cystoscopic examination becomes a routine procedure along with periodic health examination. Therefore, it is evident that hematuria, frequency, dysuria, pain, and retention are still our diagnostic signs; hematuria being the initial symptom in 75 per cent of all tumors. The hematuria of neoplasm begins without warning, is painless, begins and ceases without apparent cause or reason, and usually stops before the patient has had the courage to consult his physician. The following period is symptomless and the patient feels a sense of security. Knowing that his first attack ceased without treatment, the second attack of hematuria is regarded with less apprehension and this routine is repeated over and over until retention occurs, or until the hematuria is continuous. Only then does the physician see the patient, only to find a tumor so large that surgery is out of the question. The cystoscope reveals a picture varying with the numerous types of tumor which may be encountered. A simple papilloma presents itself as a pedicle from which delicate, translucent fronds wave to and fro in the cystoscopic fluid, while in a sessile papilloma, the fronds arise from a broad base and resemble a fragment of pink coral. These papillomas may be single or multiple.