Bladder Cancer

Case: Lady, 87 years old. Widow (2004). Non-smoker (active or passive). Alcohol: only occasionally (glass of wine, beer). Medical History: 1984 (car crash: ruptured diaphragm + pericardium + spleen (---> splenectomy), multiple hepatic lesions, fractured pelvis and ribs; laparotomy (wrong diagnosis of intestinal occlusion); 2003-2006: suspected TIAs + gait difficulties. Education: University. Hobbies: sculpture, Taï Chi Chuan, learning Chinese. Major complaint: urinary urgency/frequency and consequent chronic lack of sleep. Very tired and loss of weight (but both were first noted when looking after her husband during the 18 months that preceded his death; this included climbing up and down steep staircases multiple times everyday). Gait difficulties.  Occasionally, slight hematuria and/or cloudy urine; at other times, urine quite normal. [Note: peers consider that urinary frequency, hematuria and bacteruria should not necessarily be a cause for concern in the elderly.] Aetiology = ? 

Hospital: Department of Urology, St. Jean Hospital, Brussels, Belgium. 

Action taken:

1) Urinalysis: hematuria & bacteruria. Treatment: AB. Aetiology of infection: insufficient hydration, constipation or gynaecologic issues. First two possibilities most likely.

2) Recurrence of hematuria and bacteruria despite AB and persistence of urinary urgency/frequency ---> Ultrasound of urinary system.

3) US = intraluminal vesical mass and kidney cyst detected.

4) Direct (i.e. without previous cystoscopy) endoscopic transurethral resection of a macroscopically characteristic papilloma (40gr) on 19nth September 2006. Biopsy: papillary carcinoma T2. 

5) Aetiology of this cancer? Chronic "normal" urinary infection in the elderly...?... Other...?...

6) Treatment decision after internal discussion between a "classical" interdisciplinary team: application of EBM (Evidence Based Medicine) ---> cystectomy or 6 week radiotherapy. [Immunotherapy and chemotherapy: considered as inappropriate for T2 Bladder Cancer]. Period.

7) NewPOL Network rejects decision and EBM, favours the neuroimmunoendocrine approach and proposes to set up a CWIN for Bladder Cancer: CWIN 4-1 (see below). Urologist open to discussion and novel/innovative ideas. The Extended Interdisciplinary Team now consists of the patient, St. John's Hospital and the NewPOL Network = the CWIN 4-1 Team.  

8) The CWIN 4-1 Team waits for replies from the international scientific and medical community hoping to receive new innovative suggestions. In the meantime, the literature is screened for alternative treatments. The CWIN 4-1 Team has an idea: find a way to get through to and penetrate the detrusor muscle with intravesical chemotherapy. 

9) In the meantime, patient is given AB + Epilobium Parvoflorum (twice a day). AB discontinued. EP taken everyday.

10) i. Chemotherapy reconsidered: it is indeed technically possible to increase wall penetration of active principle. ii. Immunotherapy (BCG) reconsidered: BCG is able to penetrate deep within the detrusor muscle and has even been observed in pelvic lymph nodes after instillation, while chemotherapy is dependent on simple diffusion and penetrates to the depths of tumor extension poorly.:  

11) Globe ---> UKT (about two weeks) ---> Normal Bladder Function

12) Pelvic/abd scan negative (no adenopathy). 

13) 6th November 2006: intravesical mass detected (about 2cm) by US. Diagnosis = Either Possible recurrence of tumour or inflammatory reaction

14) 17nth November 2006: endoscopic TUR of localised mass (smaller than expected) + biopsy.  Diagnosis: macroscopic = ? / microscopic (histopathology) = inflammatory and no evidence of tumour. But no absolute guarantee that tumour has been totally eradicated: what of the bladder wall? Rest of bladder macroscopically satisfactory (superficially).

15) In the meantime, BCG immunotherapy rejected (not without risk; besides, the dose-response curve of BCG is bell shaped; excess BCG can reduce antitumor activity and even produce enhanced tumor growth. 

16) Paper on AGE (Aged Garlic Extract) discovered. Oral AGE Immunotherapy considered. Urologist suggests a nutritionist. Nutritionist is consulted. Joins the CWIN 4-1 Team.

17) Treatment Decision: immunotherapy [AGE (10 days) ---> Maïtake (10days) ---> Nothing (10days)]/ month + continued E. P. + alternative medicine + adequate diet + encouraging intellectually/physically stimulating activities to improve patient's well-being and quality of life. Gait difficulties: complete program launched when patient better. 

18) Follow-up: cystoscopy / other...?

19) Cystoscopy 8 February 2007: negative = no recurrence of tumour, superficially. Bladder has well healed from preceding surgical intervention. Still too early to decide whether patient is 100% cured, but the clinical outcome is definitely promising even though there is still some residual vesicular instability. Kidney US in two-three months. Perhaps another CT-Scan.

20) Nutrition: extra Vitamins A, B6, C & E. Patient still continues treatment as in 17) above.

21) Urinary System US 4 March 2007: negative (bladder) = no recurrence of tumour. Cyst (4cm) in kidney but so situated as not to cause any obvious kidney damage. Dimensions of kidneys: ok. Clinically: irregular persistence of urge/stress incontinence and nocturnal enuresis.

22) Now concentrating on novel global revalidation program (GRP). Main concern: gait difficulties and bradykinesia, suspected TIAs and complex hallucinations. The GRP is presently very difficult to complete each day because patient very tired: patent heart murmurs but no clear evidence of cardiac ischemia. We may switch to another CWIN since the GRP is not focussed exclusively on Bladder Cancer anymore.  

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It is to be noted that the above protocol [7 - 20] - even though theoretically sound - was purely experimental and offered no guarantee of success. 

The above not only illustrates the importance of interactive integrated interdisciplinary communication in finding novel and perhaps more appropriate treatments for patients but also suggests that established peer wisdom and EBM not always be blindly followed.

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