Bilharzial Bladder Cancer in Egypt A Review of 420 Cases of Radical Cystectomy

Transcription

1 Jap. J. Clin. Oncol. 1979, 9 (1), Bilharzial Bladder Cancer in Egypt A Review of 2 Cases of Radical Cystectomy A. EL-SAID, M.D., S. OMAR, M.D., S. IBRAHIM, M.D., H. TAWFIK, M.D., S. EISSA, M.D., I. ALI, M.D., S. DEMERDASH, M.D., S. BADAWI, M.D., H. MEBED, M.D. and M. MANIEH, M.D. Departments of Surgery, Pathology, Medical Statistics, Radiology and Clinical Pathology, Cancer Institute, Cairo University, Cairo Abstract Four hundred twenty patients with bilharzial bladder cancer were treated by radical cystectomy. The majority (8.9%) of these cases belonged to the clinically advanced stages T s and T. This was confirmed pathologically where P s accounted for 7.7% and P for 2.5% of the cases. There was a clinical error in staging of 133 cases (31.6%), with clinical understimation in 127 cases (3.2%). Pathological examination showed that the posterior wall was the commonest site of origin (61%), nodular fungating was the most frequent type and squamous cell carcinoma was encountered in 68.2% of cases. Multicentric tumors were present in 7% of cases. The rectal bladder was the commonest form of urinary diversion used (51%). This represents the general trend in the Cairo National Cancer Institute, since the rectal bladder is considered to be the most suitable method for Egyptian patients. Radical cystectomy was associated with 1% postoperative mortality and 3% postoperative morbidity. Septic complications were the main etiological factors. The actuarial survival rate was 61.7% by the end of the first year, dropping to 39% at the end of the third year. Local pelvic recurrence constituted the main cause of treatment failure (72.6%) and was responsible for 81.3% of the failures during the first year. Introduction ly of the squamous cell type, remaining localized in the pelvis for a long time and Carcinoma in the bilharzial bladder has being considered resistant to radiotherapy a special importance in Egypt. The available (El-Sebai, 1961; EI-Bolkainy et al., 1972). statistics for patients seeking treatment in the This study aims toward a better under- Cairo National Cancer Institute (C.N.C.I.) standing of the epidemiological and clinicoshow that carcinoma of the bladder forms pathological features of bilharzial bladdei 27.7% of all cancers in both sexes (Ibrahim, cancer. An attempt was made to evaluate 1978). the postoperative morbidity and mortality, This disease shows specific features that and the end results of treatment during a differ from nonbilharzial cancer, being usual- three-year follow-up period. Downloaded from at Pennsylvania State University on April 9, 216 Received February 19, Materials and Methods Reprint requests: Sherif Omar, M.D., Department of Surgery, Cancer Institute, Cairo...,, L-i. i University, 11, Bollus Hanna St. Dokky, Cairo, A of the 2 " P atlents had bilharzial Egypt bladder cancer and were treated by radical

2 118 EL-SAID et al. Jap. J. Clin. Oncol. June 1979 cystectomy at the C.N.C.I. between 1973 and The demographic and clinical data of these patients were analyzed. All patients were examined bimanually and the T.N.M. system of clinical staging was used. radical cystectomy in males and anterior pelvic exenteration in females were the only accepted lines of treatment in this series. The urinary diversions used included the rectal bladder, ureterocutanous, ileal conduit, Lowsley's operation and ileocecal bladder. The cystectomy specimens were studied pathologically and a correlation was made between the clinical staging (T) and the pathological stage (P). The postoperative Table 1 Presenting Symptoms in 2 Patients Subjected to Radical Cystectomy Symptom No. of Cases Burning micturition Hematuria Frequency Necroturia Pyuria Supra pubic pain Dysuria Incontinence 2.5 Retention 1.3 Table 2 Distribution of Cases According to Clinical Pathological Staging Clinical stage T, T a T, T< No. of Cases P! Pathological P P clinical error in 133 cases (31.6%) Clinical undentaging in 127 caief (3.2%) Clinical overataging in 6 cawa ( 1.%) / stage P* hospital stay, morbidity and mortality were analyzed. To avoid the bias introduced by irregular follow-up of patients living in distant provinces, we limited our follow-up study to patients resident in the Metropolitan Cairo area (162 patients). These patients were examined every two months in the first year and every three months in the next two years. Follow-up included clinical assessment of the patients to detect local recurrence, any evidence of renal impairment and late surgical complications. Radiological study was also made to assess renal excretion and morphology, in comparison with preoperative films, to detect any significant changes. Results The study included 336 males and 8 females, giving a male to female ratio of :1. Their ages ranged from 17 to 7 years with an average of 3.5 ± 9.2 years for males and 8.8 ± 1. years for females. There were 162 (38.6%) patients having a permanent residence in Cairo, Table 3 Primary Site of Bladder Cancer Site Posterior wall Anterior Vault Lateral walls Trigone Multiple Table No. of Cases Gross Appearance of Carcinoma Type No. of Cases Nodular fungating Ulcerative 11 2 Vermcous 2 1 Papillary 1 Downloaded from at Pennsylvania State University on April 9, 216

3 Vol. 9, No. 1 BILHARZIAL BLADDER CANCfiR 119 compared with 13 (3%) and 115 (27%) resident in upper and lower Egypt respectively. There were 28 (68.6%) farmers, and urinary bilharziasis was proved in 92% of them. A summary of the presenting systems is given in Table 1. Burning micturition, hematuria, frequency and necroturia were the most frequent. Table 2 shows the relative distribution of cases according to the clinical (T) and pathological (P) staging. The majority of cases (8.9%) were in the advanced T 3 or T< stage. The most frequent pathological stages were P a (7.7%) and P (2.5%). There was a clinical error in staging of 133 cases (31.6%) with clinical understimation in 127 cases (3.2%). Pathological examination showed that the most common site of origin was the posterior wall (61%) while the trigone was the rarest (5%). Multicentric tumors were elicited in 7% of the cases (Table 3). As shown in Table, the nodular fungating type was the commonest form (65%) while the papillary Table 5 Microscopic Appearance Growth Histological type S<njamous cell carcinoma Transitional Adenocarcinoma Anaplastic carcinoma Other of Malignant No.. of Cases % form was seen only 1% of cases. Squamous cell carcinoma contributed to the majority (68.2%) of the cases (Table 5). The lymph nodes were affected in 16.7% of cases and bilharzial ova were detected in 73% of cases. The different methods of urinary diversion used are presented in Table 6. The rectal bladder was the commonest method used (51%). The postoperative hospital stay ranged from 12 to 8 days with a mean of 2 days. Postoperative complications developed in 1 patients (3%). Table 7 shows that septic complications were the commonest cause of morbidity (71.5%). Postoperative mortality was encountered in 1% of the patients. The different causes of mortality are given in Table 8. The corn- Table 7 Postoperative Morbidity Wound sepsis 6 Burst abdomen 2 Pelvic collection 15 Adhesive intestinal obstruction 1 Reactionary hemorrhage 6 Secondary hemorrhage 5 Chest infection 1 Pyelonephritis 1 Septic sheck Average ftay in hospital 2 dayi 1 (3*) Downloaded from at Pennsylvania State University on April 9, 216 Table 6 Methods Used for Urinary Diversion Method of diversion Rectal bladder Urcterocutaneous Ileocecal bladder Heal loop conduit Lowsley's operation Ureterocolic No. of Cases % Table 8 Causes of Post Operative Peritonitis Renal failure Pulmonary embolism Heart failure Diabetic coma Septicaomia Faecal fistula Mortality (1%)

4 12 EL-SAID et al. Jap. 1. Clin. Oncol. June 1979 monest single cause was peritonitis (%"). Radiological follow-up showed that by the end of the first six months improvement of kidney function was observed in 5.9%, no significant change in 87.3% and deterioration in 6.8% of the cases. At the end of 12 months 5% showed improvement, 7% showed no change and 25% deteriorated. By the end of 18 months 2.7% showed improvement, 6.9% showed no change and deterioration occurred in 32.%. By the end of the first year the actuarial survival rate was 61.7%, dropping to 39% at the end of the third year (Table 9). During the follow-up period 95 patients (61%) died. Table 9 shows that treatment failures were more marked in the first year (6 patients, i.e. 61 A%) of the fatalities. Local pelvic recurrence accounted for failure of treatment in 72.6% of the fatalities. Discussion The male to female ratio of : 1 agrees with previous reports and with the general statistics of C.N.C.I. Male predominance could be explained by a higher exposure to bilharziasis among males working as farmers. This male predominance is lower in Cairo and its vicinity. This could be the result of bias due to traditional reluctance in far areas to transport female patients for treatment, a point which is also common for other forms of cancer (Ibrahim, 1978). The relatively younger age of our patients correlates with the age structure of the Egyptian population and the correspondingly short life expectancy. Early exposure to bilharzial infection may also play a role. The disease appears earlier in males than in females. The geographical distribution of cases in this study is not a proper indicator of the distribution of the bilharzial bladder cancer problem in Egypt. More centers are available in lower Egypt than in upper Egypt. However the high proportion of cases resident in upper Egypt may point to a rising prevalence of bilharzial infestation with the change of the method of irrigation in upper Egypt after the high dam was built. Analysis of the clinical presentation shows that the main presenting symptoms are similar to those of bilharzial cystitis and it takes some time before the patient appreciates a definite change in the symptoms that needs medical attention. Further delay usually occurs because of wrong diagnosis as cystitis or bilharzial ulcer, and subsequently more time is lost before the proper diagnosis is made and effective treatment starts. This may explain the high incidence of T, and T stages (8.9%) in this series. Nevertheless a high proportion of cases are still within the scope of operability because of the relatively low incidence of lymph node involvement and rare distant dissemination. El-Sebai (1961) reported that 85% of the cancers are considered Downloaded from at Pennsylvania State University on April 9, 216 Table 9 Follow-up of 162 Patients Duration of follow-up No. of Cases Mortality Local pelvic recurrence Other Actuarial survival rate - 6 months 6-12 months 12-2 months 2-36 months % 61.7% 9.7% 39.% 69 26

5 Vol. 9, No. 1 BILHARZ1AL BLADDER CANCER 121 to be operable when first seen, and a figure of 75% was reported by Ghoneim (197). The scope of resection and technical principles of the operative procedure are similar to those described by Paquin and Marshall (1956) and El-Sebai (1961). The commonest form of urinary diversion in our study was the rectal bladder (51%). This represents the general concept in the C.N.C.I. that this procedure is the most suitable for the majority of the Egyptian patients, who belong to the poor class. The ileal conduit is the method of choice in American and European centers. This method is considered to be the ideal method of diversion in regard to kidney function since being a conduit it avoids the potential risk of back pressure and infection to the kidneys. However, care of the ileostomy requires efficient appliances without which the ileal conduit can be troublesome to the patient. The majority of the bladder cancer patients in Egypt are farmers from the poor class. Reservoir methods, especially the rectal bladder, is more suitable for them from the socioecondmic point of view, since care of a colostomy without an appliance is much easier than that of an ileostomy without an appliance. Ghoneim and Ashamallah (197) showed the functional efficiency of the rectal bladder and reported the satisfactory social status of the patients. The ileocecal bladder (Khafagy et al., 1975) and the ileocecal bladder with perineal colostomy (El-Sayed et al., 1973) are promising procedures that can be used in selected cases. The pathological findings regarding the site of origin, pathological type, grading and lymph node involvement are consistent with the reports of other Egyptian workers on bilharzial bladder cancer (El-Sebai, 1961; El-Bolkainy et al, 1972). The overall error in clinical staging in this series was 31.6% with underestimation in 3.7%. This error is accepted in a deeply seated organ like the bladder, especially in lesions of the vault and anterior wall. Whitmore and Marshall (1962) gave a lower incidence of clinical error (22.7%). On the other hand a higher incidence of clinical error was reported by Marshall (1952) (36.7%), Kenny et al. (197) (56%) and El-Bolkainy et al. (1972) (37.2%). The high postoperative morbidity is essentially due to septic complications. Strict aseptic precautions, proper preparation of the colon, culture and sensitivity tests, with preoperative urinary antiseptics, may help to reduce this complication. However, the most important factor is the large raw area left in the pelvic and the unavailability of proper drainage of the pelvis. Regular penrose drains, suction drainage and closure without drainage were tried by different surgeons, with more or less the same result. Whitmore and Marshall (1956) gave a figure of 3% morbidity in their old series but more recently reported a figure of 53% (Whitmore and Marshall, 1962). The postoperative mortality of 1% is comparable with reports of Whitmore and Marshall in 1956 (17%) and El-Sebai in 1961 (15.5%). More recent reports by Whitmore and Marshall in 1962 and Ghoneim and Ashamallah in 197 give a mortality of 15% and 13.5% respectively. Thus there has been no reduction in the mortality figures in the different series in the past 2 years. The pattern of causes of mortality in the Egyptian series among different observations is similar, with septic complications as the leading cause, followed by renal failure, while cardiopulmonary complications are rare (El-Sebai, 1961; Ghoneim and Ashamallah, 197). On the other hand cardiopulmonary complications are more common in other reports (Whitmore and Marshall). This may be explained by the fact that the Egyptian patient is younger so is less susceptible to cardiopulmonary complication, yet his kidneys are more vulnerable to failure because of previous damage by urinary bilharziasis. A current computerized study on the results of treatment of carcinoma of the bladder is underway in the C.N.C.I. A preliminary Downloaded from at Pennsylvania State University on April 9, 216

6 122 EL-SAID et al. Jap. J. Clin. Oncol. June 1979 report of this series shows a drop in postoperative mortality rate to 8%. During the first six months of follow-up 118 patients (7.7%) were known to be alive and clinically free of the disease. This dropped to 61.7% by the end of the first year, to 9.7% by the end of the second year and to 39% by the end of the third year. Few reports of follow-up studies on bilharzial bladder cancer are available. El- Sebai (1961) reported a 3% five-year survival rate. In a recent study, Ghoneim et al. in a series of 62 patients reported 38.9% five-year survival (1976). Treatment failures and subsequent mortality were mainly due to local pelvic recurrence, which occurred in 69 patients during the follow up-period. This constituted 72.6% of the patients who died in the follow-up period. The majority of pelvic recurrences occurred during the first year (75%). From these figures and comparable figures given by El-Sebai in 1961 and Ghoneim in 197 we notice that over the past 2 years there has been no definite improvement in the survival rate. This suggests that radical surgical excision alone is not sufficient to prevent local pelvic recurrence in these cases because of the locally advanced condition of the disease. An adjuvant line of treatment directed to the pelvis may improve the results. Currently there is a prospective randomized study investigating the value of preoperative irradiation in the management of bilharzial bladder carcinoma in the C.N.C.I. A preliminary report shows that the twoyear disease-free survival rate was 6 ± 13% in the preoperative radiotherapy group compared to 2 ± 1% in the surgery alone group (Awwad et al., 1978). References Awwad, H., A. El-Said, O. Solima, S. Omar, S. El-Badawi, M. Barsom and N. El-Bolkainy, in press, El-Sayed, A., A. El-Said and I. Ali, Kasr El- Aini J Surg 1: El-Sebai, I., Kasr El-Aini J Surg 2: 183, El-Sebai, I., Cancer J Clin 27: 1, El-Bolkainy, M. N., M. A. Ghoneim and M. A. Mansour, Br J Vrol : 561, Ghoneim, M. A., Brit J Vrol 2: 29, 197. Ghoneim, M. A. and A. Ashamallah, Br J Urol 6: 511, 197. Ghoneim, M. A., M. N. El-Bolkainy, M. A. Mansour, S. M. El-Hamady, A. Ashamalla and E. H. Soliman, / Urol 111: Ibrahim, A. S., The National Cancer Institute Registry, Cairo: , in press, Kenny, C. M., I. J. Hardener and G. P. Murphy, J Urol 1: 72, 197. Khafagy, M., M. N. El-Bolkainy, R. S. Barsoum and S. EI-Tatawy, J Urol 113: 31, Marshall, V. F., / Urol 68: 71, Marshall, V. F., Cancer 9: 53, Paquin, A. J. and V. F. Marshall, Cancer 9: 585, Whitmore, W. F. and V. F. Marshall, Cancer 9: 596, Whitmore, W. F., Jr. and V. F. Marshall, / Urol 87: 853, Downloaded from at Pennsylvania State University on April 9, 216