Squamous cell carcinoma (SCC) of the bladder is a type of malignant tumor developing from metaplastic squamous cells replacing the bladder urothelium as a result of prolonged urinary irritation (e.g. chronic infections, especially bilharzia or indwelling catheters). It accounts for a minority of bladder cancers, with the exception of more prevalent bilharzia associated type, common in Africa. Typically presenting with hematuria, bladder SCC is often diagnosed at a late stage with cystoscopy being the golden diagnostic standard and magnetic resonance imaging, the imaging technique of choice for staging.
Squamous cell carcinoma of the bladder is characterized by malignant proliferation of squamous cells replacing the urothelium, caused by prolonged bladder irritation. In areas endemic for schistosoma (Africa, Middle East, Southeast Asia and South America) the leading cause of bladder SCC is bilharzial cystitis   . This type of carcinoma accounts for 20 - 30 % of bladder cancers in these regions. It is discovered in the fifth decade of patient's life and is usually well differentiated  . Conversely, non-bilharzial SCC, occurring predominantly in the Western countries, is a rare type of bladder cancer (accounts for 5% of the cases) and is discovered later in life, usually during the seventh decade . It is mostly high-grade and often scattered throughout the bladder . This type of cancer is often seen in patients with spinal cord injury, indwelling catheters, neurogenic bladder and impaired flow of urine   . Common risk factors for both SCC types include smoking and cyclophosphamide therapy. Although more common in men, bladder SCC affects both sexes .
The most typical urinary finding is visible blood in the urine. Infrequently, it presents with microscopic hematuria. In either case, hematuria is usually painless. Other symptoms include increased frequency or urgency of urination and sometimes pain. A urinary tract infection may be simultaneously present. In advanced stages, patients may experience pelvic and/or back pain. Additionally, hydronephrosis might develop  . The fact that symptoms are intermittently present and may resemble those of urinary tract infection often postpones the diagnosis till the advanced stage of the disease .
Left Flank Pain
Case report A 72 year-old Caucasian lady was referred to our unit for further investigation of recurrent polymicrobial urinary tract infections (UTI) complicated by sepsis and associated with intermittent left flank pain. [f1000research.com]
The patient had extensive medical co-morbidities including chronic renal impairment, ischaemic heart disease with unstable angina, aortic stenosis and mitral regurgitation in addition to a previous cerebrovascular event (CVA) 8 years prior with residual [f1000research.com]
Given the late diagnosis of bladder SCC and the extent to which disease stage affects the prognosis, a high index of suspicion is warranted in all patients presenting with painless hematuria. Cystoscopy is the method of choice for tumor visualization and confirming the diagnosis . Additionally, bimanual examination and urinalysis aid the diagnosis, while contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) contribute to detection, localization and most significantly staging of the tumor.
Cystoscopy findings commonly show a nodular tumor mass protruding into the bladder lumen, although in some cases the tumor may be flat. The surface is necrotic with shed keratin fragments and signs of leukoplakia . This method permits cytologic washings and biopsy, providing samples for histological examination, grading and staging in respect to bladder wall invasion. Limitations include method's invasiveness and restricted ability to inspect the changes within bladder diverticula . A less invasive option, for detecting tumors with a diameter of 5 mm or larger, is virtual cystoscopy .
The urine culture may exclude urinary infections. Cytology shows high specificity and sensitivity in detecting carcinoma in situ (CIS), although negative findings cannot preclude the diagnosis of bladder SCC . Biomarkers, such as psoriasin, galectin 3 and forkhead box protein P3 (Foxp3) may contribute to early diagnosis   .
CT scan shows high accuracy in both local and lymph node staging. Limitations include overlooking microscopic metastases in non-enlarged lymph nodes, difficulty in discerning metastatic from benign lymphadenopathy and problems in distinguishing bladder wall thickening due to tumor progression from thickening of other etiologies (i.e. inflammation, radiation, biopsy etc.) . Dynamic, gadolinium-enhanced MRI is superior to CT scan in bladder carcinoma staging. T1 and T2 weighted imaging are used for staging and visualization of tumors spreading outside the bladder . Diffusion-weighted imaging shows high accuracy in discerning superficial from invasive tumors and higher accuracy than T2-weighted images in evaluating tumors at stage T2 or lower .
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