Urothelial Cancer
Urothelial cancer includes bladder cancer (90%), ureter cancer (5-7%), and renal pelvis cancer. It is a malignant disease that affects men 3-4 times more often than women, with an average age of onset at 73 years. Risk factors include smoking, diseases of the urogenital tract, and certain medications. The causal link between smoking and bladder cancer development is evidenced by the higher rates of the disease in active smokers compared to former smokers and those who have never smoked.
Urothelial cancer most often presents with specific symptoms, the primary one being macroscopic hematuria. Simply put, the patient notices blood during urination, which usually prompts them to visit their Urologist, leading to a diagnosis.
Transurethral biopsy during cystoscopy is the method by which the Urologist examines the patient's bladder, identifies the lesion, and collects a sample. A particularly important aspect of accurate diagnosis is obtaining a portion of the muscular layer. This part of the histological report is crucial for determining the patient's prognosis. The presence of muscle layer invasion in the bladder or ureter distinguishes between muscle-invasive and non-muscle-invasive localized cancer.
The histological diagnosis includes urothelial carcinomas (90%), squamous cell carcinomas (5%), adenocarcinomas (2%), and small cell carcinomas (1%).
Localized Urothelial Cancer
As mentioned earlier, the distinction between non-muscle-invasive and muscle-invasive urothelial cancer is crucial, both for prognosis and for the therapeutic approach to the patient.
Non-Muscle-Invasive
In non-muscle-invasive cancer, the complete removal of the lesion via cystoscopy is of paramount importance and is carried out in collaboration with the Urologist. In cases of recurrent lesions and high-grade malignancy, patients may receive intravesical instillations.
Muscle-Invasive Cancer
The presence of invasion in the muscular layer is the key factor in recommending surgical intervention, such as cystectomy and/or nephroureterectomy, for patients whose physical condition permits it, aiming for complete cure. At this stage of the patient's treatment, close collaboration between the Urological Surgeon and the Medical Oncologist is essential, highlighting the complexity of the disease. Often, the patient may need to receive chemotherapy either before surgery (neoadjuvant) or after surgery (adjuvant) to achieve the maximum possible benefit. Additionally, radiotherapy plays a primary role in the treatment plan, especially in cases where radical surgery cannot be performed or is not chosen by the patient.
Metastatic Disease
The presence of metastases marks the stage of diagnosis where the patient must receive systemic treatment, either through chemotherapy or immunotherapy. Recent advancements in oncology have highlighted urothelial cancer as a key player in modern developments, with the administration of immunotherapeutic agents showing very positive results. Furthermore, the presence of an FGFR3 gene mutation has opened the door to targeted therapy options.
Future Developments
The combination of immunotherapy with targeted therapies and other molecules suggests a particularly promising future for patients diagnosed with urothelial cancer.