Bladder cancer is one of the common tumors in urology, and its incidence is second only to prostate cancer. Compared with other malignant tumors, the fatality rate of bladder cancer is not outstanding, but its high recurrence rate makes patients very distressed. Will there be a recurrence of bladder cancer after surgery and how long will it take? Here are some domestic and foreign statistics, but only for reference. After all, statistical mathematics is only a probability, and it may be very different for everyone.
1. Reasons for easy recurrence after bladder cancer resection
The main clinical manifestation of bladder cancer is intermittent painless gross hematuria. Since most people are not indifferent to hematuria, they will actively go to the hospital for examination. If bladder cancer is found at this time, most of them are in the early stage of bladder cancer, that is, non-muscle. Layer invasive bladder cancer.
This kind of early bladder cancer accounts for 75% of the initial bladder tumors, of which the earliest stage Ta accounts for 70%, the remaining T1 stage accounts for 20%, and the carcinoma in situ Tis accounts for 10%.
Resection of bladder cancer is the first choice for early-stage bladder cancer, but as many as 45% (10%～67%) of patients have tumor recurrence within 1 year after surgery, and 55% (24%~84%) relapse within 5 years after surgery. .
2014 China Urology Diagnosis and Treatment Guidelines for Early Bladder Cancer 5-year Recurrence Rate
There are two peaks of postoperative recurrence.
The first peak occurred 100 to 200 days after surgery, but there are also a few patients who have relapsed within three months after surgery.
The second peak is 600 days after the operation, and there are still 4 months left after two years.
reported that 80% of recurrences occurred within two years after surgery. If you can persist for 2 years without recurrence, the chance of recurrence may not be large; and if you can persist without recurrence for 5 years, then congratulations, the chance of recurrence will basically disappear in the future.
Causes of bladder cancer recurrence:
The exact mechanism by which bladder cancer is prone to recurrence is still unclear. There are currently several theories:
1. Tumor cells are easy to spread and plant.
The tumor tissue floats in the urine of the bladder like a water plant. The tumor cells are like dandelion seeds, which fall off into the urine from time to time, and follow the urine flow to another part of the bladder, take root and sprout, and grow out of the naked eye. The small tumor that was detected gradually grew up after the operation.
2, the depth of resection during the operation is not enough.
Some tumors have deep roots. During the operation, if the doctor does not remove enough depth, new shoots may emerge from the deep root system after the operation.
3. Intraoperative planting.
During the operation, the tumor tissue removed was not completely necrotic for the time being, and some tumor cells fell on the surgical wound and lurked quietly.
4. Gene abnormalities.
Experiments have shown that the vast majority of bladder cancer patients with repeated recurrences have changes in the seventh, ninth and seventeenth pairs of chromosomes. The abnormalities of chromosomes promote the continuous growth of tumor tissues.
5. Toxic environment in the bladder.
If the human body is stimulated by toxic carcinogens for a long time, such as smoking, the carcinogenic toxic substances are metabolized by the kidneys, enter the urine, repeatedly stimulate the bladder, and induce cancer.
2. Classification of bladder cancer recurrence risk
According to the different risk of recurrence, early bladder cancer can be divided into the following three groups:
1. Low-risk non-muscular invasive bladder cancer.
must meet the following conditions at the same time to be a low-risk type:
△Single shot. There is only one tumor.
△Ta period. The earliest tumor.
△G1 (the pathological type is low-grade urothelial carcinoma, the best type of cancer).
△Diameter<3cm.
△There is no carcinoma in situ.
2. High-risk non-muscular invasive bladder cancer.
Any of the following four types are high-risk:
△T1 period.
△G3 (high-grade urothelial carcinoma).
△ Carcinoma in situ.
△Satisfies at the same time: multiple or recurrence, diameter>3cm, Ta, G1～G2.
3. Intermediate-risk non-muscular invasive bladder cancer
In addition to the above two types of other situations.
The low-risk recurrence risk is the smallest, followed by the intermediate-risk, and the high-risk recurrence is the largest.
The main bladder cancer is T1, G3 (high-grade urothelial carcinoma), which is a high-risk type of early bladder cancer and is relatively easy to recur.
Third, the risk of recurrence
The risk of recurrence was further quantified based on the European Cancer Treatment Research Organization Recurrence Score.
European Cancer Therapy Research Organization Bladder Cancer Recurrence Progress Score Sheet
The total score of risk of recurrence in the scoring table is 17 points. The higher the score, the greater the risk of recurrence.
The number of tumors: single 0 points, 2-7 3 points, ≥8 6 points.
Tumor diameter: <3cm0 points, ≥3cm3 points.
Number of previous recurrences: 0 points for the first time, 2 points for ≤1 relapse per year, 4 points for >1 relapse per year.
Stages: 0 points for Ta stage and 1 point for T1 stage.
Carcinoma in situ: There is no 0 point, there is 1 point.
Grading: G1 is 0 points, G2 is 1 point, and G3 is 2 points.
The subject of T1 stage scored 1 point, and G3 (high-grade urothelial carcinoma) scored another 2 points. The number and diameter of other tumors, and whether there is carcinoma in situ are not provided, and it is temporarily calculated as 3 points.
The picture below shows the 1-year and 5-year recurrence rates.
If the main assessment score is 3 points, the one-year recurrence rate is about 24%, and the 5-year recurrence rate is about 46%.
4. Measures to prevent recurrence
1. Resection of bladder tumor under NBI narrowband light imaging.
In NBI mode, bladder cancer lesions are displayed more clearly. Compared with resection under ordinary white light, it is conducive to the detection of small lesions and carcinoma in situ, and can significantly reduce the recurrence rate of bladder cancer patients after surgery.
But there must be a display system that supports NBI mode.
Mirror inside the bladder under NBI
2. Postoperative bladder infusion of drugs.
Bladder perfusion drug, the drug is not absorbed into the blood, has little toxic and side effects on the body, and plays a role in preventing tumor recurrence on the surface of the bladder mucosa. It is recommended for all patients.
①At present, there are two types of infusion drugs for bladder cancer:
△Chemotherapeutic drugs: Epirubicin, Mitomycin, Pirubicin, Gemcitabine
△Biological agents: including BCG, interferon
②After the operation, the bladder can be infused with drugs.
Within 24 hours after resection, bladder infusion chemotherapy can reduce the risk of recurrence.
However, it should not be used when the bladder is cut too deep and perforated during the operation or when there is obvious hematuria after the operation.
③Group perfusion scheme.
△For the low-risk group: a single dose of bladder infusion chemotherapy immediately after the operation, and subsequent bladder perfusion can be maintained without bladder.
△Intermediate risk group: bladder perfusion chemotherapy at immediate dose after surgery, followed by maintenance perfusion chemotherapy or BCG vaccine for one year.
△High-risk group: immediate-dose bladder infusion chemotherapy, followed by maintenance infusion chemotherapy or BCG for 1 to 3 years.
△High-risk recurrence group: If you are unwilling to remove the entire bladder, perform an electric resection again and perform hyperthermic perfusion chemotherapy. Heat the chemotherapy drug mitomycin perfusion solution to 42°C for one hour. Hyperthermic perfusion chemotherapy can still be used after BCG perfusion fails.
A doctor at the Medical Center of Nejmegen University in the Netherlands heated the bladder wall to 42 degrees Celsius with equipment. All 142 patients came from 11 cancer centers in Europe. In the hyperthermic perfusion chemotherapy group, patients received 6 months of hyperthermic perfusion chemotherapy. In the BCG vaccine group, patients also underwent intravesical BCG perfusion for 6 months. The primary endpoint of the trial is the patient's recurrence-free survival after 24 months. The test results proved that the hyperthermic perfusion chemotherapy group was better than the BCG vaccine group.
3, the second electric cut.
Secondary resection refers to the active resection of the basal part of the original tumor and other suspicious tumors after 2-6 weeks after the resection of early bladder cancer, regardless of the tumor recurrence.
Research shows that: the second electrosurgical resection can significantly reduce the recurrence rate and progression rate of patients, and improve the 3-year recurrence-free survival rate.
4. Regular review.
Regular review does not reduce recurrence, but recurring tumors can be detected in time.
5. What to do after recurrence
The subject was bladder cancer surgery in April last year. Now that the cystoscopy has a new organism, the possibility of recurrence needs to be considered.
As mentioned at the beginning, the fatality rate of bladder cancer is not outstanding, and the postoperative recurrence is not terrible.
The recurrence of early bladder cancer surgery can still be treated with resection.
The red arrow points to bladder cancer
Other drugs should be changed when chemotherapy drugs are injected into the bladder after surgery. For example, gemcitabine was used for perfusion before, but gemcitabine should not be used now. You can change pirarubicin, mitomycin, etc., or choose BCG infusion.
If there are repeated recurrences in the future, BCG infusion is recommended. If BCG is ineffective, use hyperthermic perfusion chemotherapy or radical total cystectomy.
references:
1, "Guidelines for Diagnosis and Treatment of Urological Diseases in China" 2014 edition.
2, "Bladder Cancer Diagnosis and Treatment Standards" (2018 edition).
3, "Expert Consensus on the Application of Narrow Band Imaging in Urology" 2016.
4, "Expert Consensus on Bladder Implantation Treatment for Non-muscle Invasive Bladder Cancer" 2019 edition.
5, "2019EUA Guidelines: Non-muscular Invasive Bladder Cancer TaT1 and CIS".
6, Kate Johnson, Chemohyperthermia shows promise in Nonmuscle BladderCancer.
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Early bladder cancer is generally not easy to spread and life-threatening, but the recurrence rate is relatively high. Not all early-stage bladder cancer will recur after surgery, and most people may not relapse. In the early stage of bladder cancer, 10% to 67% of patients will relapse within 12 months after resection, and 24% to 84% of patients will relapse within 5 years after surgery, which may be related to new tumors, tumor cell implantation or primary tumors. Tumor resection is not completely related. There are two peak periods for recurrence of non-muscular invasive bladder cancer after resection, which are 100-200 days after operation and 600 days after operation.
According to the condition of each patient, the recurrence of early bladder cancer can be predicted. Early bladder cancer is scored according to tumor size, number, recurrence, presence or absence of carcinoma in situ, pathological staging, and grade. Different scores correspond to different risks, and then correspond to different recurrence and progression rates. As shown below.
For example, the patient in the question, T1 stage tumor, high grade, here is 3 points, I don't know how big the tumor was at that time, how many, and whether there was carcinoma in situ. If none of these are present, at least there is a risk of recurrence of 3 points, at least intermediate risk, the 1-year recurrence rate is 24-38%, and the 5-year recurrence rate is 46-62%; and T1 high-grade urothelial cancer is definitely It is at high risk of progression. Within 5 years, 17-45% of patients may turn into muscle-invasive bladder cancer, which is also life-threatening bladder cancer. Therefore, T1 high-grade bladder cancer is a very dangerous type in early bladder cancer and requires more active treatment, such as BCG infusion, comprehensive treatment for bladder preservation, and even total cystectomy.
If it is stage Ta for low-grade bladder cancer, this kind of bladder cancer is actually a real early bladder cancer, and the prognosis is very good. We can see that if according to the above score, if all points are 0, then the 1-year recurrence rate is only 15%. The 5-year recurrence rate is only 31%. More importantly, if the risk of progression is also 0, then only 0.8% of patients will progress within 5 years, that is, less than 1 person in 100 people will progress and be life-threatening within 5 years.
Therefore, even if it is the same early stage bladder cancer, there are still considerable differences according to each person's situation. It is necessary to formulate the post-operative treatment and review plan according to the specific situation, instead of all bladder irrigation.
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