Jeremy Perkins

Actos Side Effects : CAN CYTOLOGY BE USED INSTEAD OF CYSTOSCOPY TO RULE OUT BLADDER CANCER?

Urinary cytology is the examination of urine using special stains to look for cancer cells. These cells would have been those that have broken off (exfoliated) from the lining of the urinary tract. Voided urine is sent for analysis. First voided morning urine should not be used as there is a higher rate of cellular degeneration. To enhance the yield of cells, the bladder can be barbotaged (flushed). Cytology is most useful for high grade or aggressive tumors and for those with carcinoma in situ (CIS). In low to intermediate grade tumors, cytology may not be positive because these tumors may not exfoliate cells into the urine. In addition, if low grade tumor cells are exfoliated, they may appear to the pathologist to be identical to normal bladder cells. Due to the limitations of sensitivity of cytology, it is not a very good screening test, but proves to be valuable in following some individuals who have already been diagnosed and treated for bladder cancer.

Because a positive cytology is very specific for cancer, it is highly predictive of transitional cell cancer even if no tumor is visible during cystoscopy. Additional information can be obtained with urine cytology. The DNA content and measurement of the amount of abnormal DNA can be determined. In general, as the amount of abnormal DNA is increased, the prognosis is worsened.

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ARE THERE ANY OTHER URINE TESTS THAT ARE HELPFUL IN MAKING THE DIAGNOSIS?

There has been continued research and a subsequent array of urine tests to screen for bladder cancer. Some of these newer tests include:

Bladder Tumor Antigen (BTA): measures basement membrane protein antigen released into the urine, a protein from the bladder wall.

NMP22: measures nuclear matrix protein 22

Aura Teck FDP: measures fibrin, fibrinogen degradation

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Telomerase: measures the enzyme used to preserve telomeres (the ends of chromosomes required to continue cell division) Hyaluronic Acid, Hyaluronidase: substances which have a role in blood vessel growth in bladder tumors and tumor progression. ^[1] Research goes on and newer tests may prove to be both more sensitive (positive if cancer is present) and more specific (not positive for other reasons). At this time, none of the urine tests are sensitive enough to take the place of cystoscopy in the initial evaluation of an individual suspected to have bladder cancer. In general, cytology as an adjunct to cystoscopy is more helpful than any of the urine bladder cancer tests to date.

AS PART OF MY INITIAL WORK UP, MY PHYSICIAN HAS ORDERED A CAT SCAN. WHAT’S THE PURPOSE AND ARE THERE ANY ALTERNATIVES?

When an individual has gross hematuria or persistent microscopic hematuria, a complete assessment of the urinary tract is required. Although cystoscopy is the test of choice for examination of the bladder, imaging studies are required to make sure there is no disease in the upper tracts (kidneys and ureters). Bleeding can be caused from many different disorders including transitional cell carcinoma of the upper tracts, kidney or ureteral stones, or renal cell carcinoma (cancer of the parenchyma or fleshy part of the kidneys). Your urologist has a number of options to choose from. There are advantages and disadvantages of each.

Intravenous pyelogram (IVP) is accomplished by injecting a contrast agent into your vein and then obtaining X ray images. The contrast is excreted by your kidneys, subsequently filling the lumen of the kidneys, ureters and the bladder. The contrast allows one to see subtle filling defects within chambers of the urinary tract, possibly representing tumor, stone or blood clot. Tumors of the fleshy part of the kidneys can also be seen. The study also allows for an assessment of renal function. It is a sensitive test for renal obstruction, which can occur because of cancer. Disadvantages of the study include the possibility of an IV contrast agent allergy, which occasionally may be serious.

You will be asked whether you have a sea food allergy, a known allergy to iodine or to IV contrast. If this is the case, you may need to be premedicated prior to the exam to avoid a reaction. Although the study is quite useful at visualizing the upper tracts, it is not very good at picking up subtle tumors on the bladder surface. If your kidneys do not function well (you have renal insufficiency), the contrast may cause harm to your kidneys and the imaging will not be as good. For pregnant women, any X ray exam could be potentially damaging to the fetus and therefore, will not be performed.

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Ultrasonography can check for a kidney tumor, stone, or obstruction. Bladders filled with urine can be scanned. There is no contrast or X rays involved, and therefore the study can be accomplished in those with renal disease, contrast allergies or for women who are pregnant. Although larger tumors of the bladder are often visible, it is not a good study to rule out urothelial cancer (transitional cell cancer of the urinary tract lining) since smaller tumors or flat tumors in the lining are not visible. Also, other conditions such as enlarged folds in the bladder or enlarged prostates can be confused with bladder tumors. Ultrasound exams are generally fast, painless, and relatively inexpensive. An ultrasound combined with cystoscopy plus cytology (to rule out cancer cells) is a reasonable assessment for those with a low likelihood of having upper tract disease.

CT Scan or CAT (computerized axial tomography) provides a computerized cross sectional visualization of the abdomen and pelvis. X ray images are synthesized into exquisitely detailed images. The CT scan can be done with or without IV contrast, and therefore has the same limitations as IVP in those with allergies to contrast or renal insufficiency. These studies are excellent for finding renal cell cancers and stones within the kidneys and ureter, but not very good at delineating cancers of the lining. CT scan is often an important part of staging bladder cancer, determining whether the cancer has spread.

Magnetic Resonance Imaging (MRI) is a technology which uses strong magnets to provide detailed images of your internal organs. Like ultrasound, this study has no known harmful effects on the body. It does not require contrast injection like CT scan and can be done safely in patients with renal insufficiency. It is not generally used for initial screening. Many individuals find the test uncomfortable due to a loud noise heard throughout the test, in addition to the close quarters the machine requires, leading to feelings of claustrophobia. A mild sedative may be required if the test is necessary and the individual experiences these uncomfortable feelings.

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