Carcinoma in Situ of the Bladder

Central to the earlier detection and effective treatment of bladder cancer is the understanding of the basic principle that in situ cancer, evolving from epithelial atypia or hyperplasia, is the early phase in the development of invasive bladder cancer. While it may be asymptomatic, irritative bladder symptoms such as frequency, urgency, and dysuria irrespective of bacteriuria are usually evident and should be evaluated with exfoliative urinary cytology to detect the presence of this cancer. Properly collected and skillfully interpreted cytologic examination of the urine is probably the most accurate screening test for this and other important varieties of bladder cancer. Improved technologic features of cystoscopy have aided in the identification of in situ cancer, particularly when multiple random cold biopsy specimens of all quadrants, including the trigone, of the bladder and of the prostatic urethra are employed. Such investigative methods recognize that in situ cancer is a generalized urothelial malignancy that very often involves ureteral, prostatic as well as all bladder mucosa. Despite the pathologic observation that this cancer shows an intense cellular activity, the temporal aspect of its transition from a superficial cancer to an invasive one remains unpredictable, although clearly finite. Treatment is controversial. Radical cystectomy should effect cure if recommended early and before it becomes clinically apparent that the disease is already invasive in some urothelial locations. If the cancer appears to be localized to a relatively small (5 cm) area of the bladder and the patient's symptoms are not excessive, intravesical chemotherapy using such preparations as Thio-tepa, mitomycin, Adriamycin, or epodyl may result in a temporary, sometimes complete, remission.