Medical Journal of Babylon-Vol. 9- No. 2 -2012 مجلة بابل الطبية- المجلد التاسع- العدد s1

مجلة بابل الطبية- المجلد التاسع- العدد ال ثاني - Medical Journal of Babylon-Vol. 9- No. 2 -2012 201 2

Outcome and Prognosis of Patients with Bladder Cancer below 20 Years Old

Emad Hassan Mahmood College of Medicine, University of Babylon, Hilla , Iraq

Abstract Objective: evaluate the treatment and prognosis of the bladder mass in young patients less than 20 years old Patients and methods: twenty patients with bladder tumors (papilloma and transitional cell carcinoma)18 male and 2 female underwent this study from 2001-2011 all evaluated by abdominal ultrasound and cystoscopy. Results: the age of the patients between 18 months to 20 years, 18 male and 2 female. Hematuria is presenting symptoms in 15 patients, lower abdominal pain in 3 patients and irritative voiding symptoms in 2 patients. Histopathology was papilloma in one patient transitional cell carcinoma grade I in 16 patients, grade II in 2 patients and grade III in one patient. All patients treated by TUR of the tumor except 2 patients treated by open excision and fulguration and one patient by total cystectomy. Follow up period between 6 months to 10 years, mortality reported in one patient only. Conclusion: the bladder tumor in young patient carry good prognosis with low grade and stage at time of presentation ورام المثانة نتائج ومحصلت للمرضى الدين اعمارهم تحت العشرين سنة الخلصة الهداف: تقييم نتائج المرضى المصابين باورام المثانة الدين اعمارهم اقل من عشرين سنة ودراسة بعض العوامل المؤثرة. طريقة العمل: اشتملت الدراسة عشرين مريضا 18 دكر وانثيين تراوحت اعمارهم بين 18 شهر و 20 عاما في مستشفى الحلة التعليمي من سنة 2000-2011 اجريت لهم فحص الشعة الفوق الصوتية للبطن وناظور المثانة مع خزعة الورم وارساله للفحص النسيجي وكان العلج يتراوح بين قص ورفع الورم عن طريق الناظور, رفع الورم عن طريق فتح المثانة وعملية رفع المثانة الجدري. النتائج: التبول الدموي كان العرض السائد في 15 مريض والم البطن في 3 مرضى و اضطراب التبول في مريضين و نتيجة الفحص النسيجي سرطان المثانة الطلئي من الدرجة الولى في 16 مريض و الدرجة الثانية في مريضيين و الدرجة الثالثة في مريض واحد و كان العلج عن طريق استئصال الورم بالناظور في جميع الحالت ما عدا حالتين تم استئصال الورم عن طريق فتح المثانة و مريض واحد تم رفع المثانة الجدري له. الستنتاج: ان تصرف المرض في الفئة العمرية تحت العشرين سنة كان جيدة في الدراسة ونوع المرض من الدرجة الخفيفة و نتائج العلج كانت مشجعة.

Emad Hassan Mahmood 76 مجلة بابل الطبية- المجلد التاسع- العدد ال ثاني - Medical Journal of Babylon-Vol. 9- No. 2 -2012 201 2 study conducted in Hilla teaching patients is not different from adults in hospital from2001-2011. their 60s and 70s.[1,11-13]. All evaluated by abdominal A definite etiology for tumor ultrasound and cystoscopy with biopsy formation in the young is an enigma, and histopathological confirmation. based on the small number of cases, The methods of treatment were risk factors include older age, male transurethral resection of the sex, occupational exposure infection tumor(TUR-BT), vesicostomy and by schistosomiasis first hand cigarette tumor excision and cystectomy with smoking, a strong family history of ileal conduit.. transitional cell carcinoma of the Follow up by serial abdominal bladder, and exposure to other ultrasound(U/S), urine cytology and carcinogen. [14-17]. 75% present with cystoscopy accordingly. superficial bladder cancer and 25% with invasive bladder cancer [18,19] Results some contend the tumor in those who Age of the patients between 18 are in the first 2 decades of life are less months and 20 years table(1). aggressive and present at a low grade Hematuria is presenting symptoms in and stage and the staging depend on 15 patients, lower abdominal pain in 3 penetration to the bladder wall.[20-22]. patients and irritative voiding The likelihood of metastasis of symptoms in 2 patients table (2). transitional cell carcinoma depends on Histopathology was papilloma the stage and the grade of the tumor in one patient transitional cell not on the age of the patient. In the carcinoma grade I in 16 patients, grade present case, the probability of II in 2 patients and grade III in one metastasis is low. 5% of patients patient table (3). present with metastasis at time of All patients treated by TUR of the diagnosis [23]. tumor except 2 patients treated by open excision and fulguration and one Patients and Methods patient by total cystectomy. Twenty patients with bladder Follow up period between 6 tumors(papilloma and transitional cell months to 10 years, mortality reported carcinoma)18 male and 2 female age in one patient only. between 18 months and 20 years the

Table 1 Age distribution of the patients Age of patients Number of patients months 18 1 years 11 1 years 16 3 years 17 4 years 19 8 years 20 3

Table 2 Symptoms at time of presentation Symptoms of the patients number of the patients Gross hematuria 15 Suprapubic pain 3 Irritative Voiding symptoms 2

Emad Hassan Mahmood 77 مجلة بابل الطبية- المجلد التاسع- العدد ال ثاني - Medical Journal of Babylon-Vol. 9- No. 2 -2012 201 2

Table 3 grade of the tumor Grade Number of the patients Papilloma 1 Grade 1 16 Grade 2 2 Grade 3 1 some modification include Discussion Transurethral resection, suprapubic Because of the limited number of removal and open fulguration, and transitional cell carcinoma cases in partial cystectomy have been reported those under 20 years old and the varied as the most common therapeutic experience among reported cases, there approaches for transitional cell is controversy regarding the carcinoma of the bladder in children. aggressiveness of transitional cell [26,27] carcinoma in this age group compared In the present study Seventeen with older patients. Some contend that patients treated by TUR because their tumors in those who are in the first 2 age and stage were permissible and the decades are less aggressive and present tumor were resected totally while 2 at a lower grade and stage, while others patients treated by vesicostomy and believe there is no difference, excision of the tumor because their regardless of the age of the individual. age 18 months and 11 years and the None believe that transitional cell tumor can not be dealt by TUR. carcinoma is more aggressive or One patient age 20 years had G3 presents at a higher grade or stage in tumor and muscle invasion underwent the young. total cystectomy and ileal conduit. In this study 16 patients had grade 1 No additive post operative tumor 2 patients had grade 2 one treatment were required except the patient had grade 3 and one had patient with G3 and ( T2b) deep papilloma, so 17 patients had low muscle invasion treated by DXT and grade tumor which is consistant with chemotherapy after cystectomy. study of Benson and associate After initial treatment 50% to 70% evaluated 12 patients up to age 21 and recur in adult and 10% to 20% also contended that transitional cell progress to muscle invasion [28] so carcinoma in this population was less There is great controversy concerning aggressive, typically low grade, non best method of surveillance after tumor invasive and rarely recurrent [24]. removal, in this study neither Evaluation of the literature is recurrence nor muscle invasion occur, particularly problematic because many probably due to high percentage of low investigators included patients of grade tumor and early management various ages up to age 40, made play role. Although cystoscopy highly generalizations regarding transitional accurate, it is subject the patients to the cell carcinoma, and applied them to all potential morbidity of the younger adults. In addition, the number instrumentation and risk of anesthesia. of patients available for follow-up was Still, some consider cystourethroscopy highly variable and often too brief to mandatory.[29-31] make definitive conclusions All our patients followed up by The main treatment of superficial abdominal U/S and if its positive then bladder cancer is TUR, intravesical cystoscopy indicated, only one patient chemotherapy or BCG, photodynamic or radiotherapy [25] but in children

Emad Hassan Mahmood 78 مجلة بابل الطبية- المجلد التاسع- العدد ال ثاني - Medical Journal of Babylon-Vol. 9- No. 2 -2012 201 2 to previous studies mention cigarette need cystoscopy and the result were smoking as risk factor because our negative. patients too young in compared to Some recommend voiding urine other studies and history of smoking cytology, but recognize their limited for short period and low number of value in identifying low grade tumors cigarette. [32]. In our patients 3 of them were There was no definite history of followed up by urine cytology and all chemical contact or positive family were negative. history for bladder cancer. . Bladder ultrasound and voiding Investigators review of the cystourethrography have been literature, among 25 transitional cell recommended to reduce the frequency carcinoma occurring in the first decade of cystoscopic examination, [11]but we of life, 80% presented with did not use cystourethrography in macroscopic hematuria and this follow up the patients and depend on consistent with the present study were abdominal U/S and urine cytology if the macroscopic hematuria occurs in positive then cystoscopy indicated. 75% of the patients. Definite etiology for tumor Death occur in one patient due to formation in the young is not clear, distant metastasis and the tumor was based on small number of cases, there aggressive G3 with muscle appear to be an association between invasion(T2b) the patient were die first hand cigarette smoking, and after 6 months after radical exposure to carcinogen Benton and cystectomy. Henderson described 9 patients Morbidity was very low include severe between age 17 and 25 years with hematuria in one patient need blood transitional cell carcinoma of the transfusion and UTI in 3 patients. bladder 6 of 9 had firsthand or second Bladder cancer remains an important hand exposure to chemicals such as public health problem with no paint, solvents, cleaning solutions, improvement in incidence or resins, intermetallic compounds, glues associated mortality since 1975 [34]. and fuel oils [33]. In the studied patients the Conclusions environmental Factors were very 1.In this series of patients the important since the patients residence behaviors of the tumor were good with mainly in two locality in north and low morbidity and mortality. south of Hilla and rare in the center, 2.Good follow up were needed. these factors may probable risk factor 3.No definite etiological factors could for patients for developing bladder be identified. cancer in these area were vulnerable to 4.Treatment is same principle of older excessive explosion and to warfare patient except the instrumentation is chemicals this result was agreed with not feasible for all age group. that of national research council(2005), who stated that recent reviews of References studies of bomb survivors documented 1. Catalona WJ: Urothelial elevated risk of bladder cancer tumors of the urinary tract, in associated with ionizing radiation. Walsh PC, Retik AB, Stamey Two patients age 19,20 years had TA, et al (eds): Campbell's history of smoking with average Urology, ed 6. Philadelphia, cigarette smoking of 5-10 cigarette per WB Saunders, 1992, pp day for period less than 2 years and it 1094-1158. seem to be not a risk factor, in contrast

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31.Lalmand B, Avni EF, Verhest A, et 27.Curtis M, Schned A, Hakim S, et al: al: Transitional cell papillary papillary cell carcinoma of the bladder carcinoma of the bladder in a child. with lymphangietasia in 8 years old Pediatr Radiol 17:77-79, 1987. boy. J Urol 156(1) 202 1996 32.Benson RC, Tomera KM, Kelalis 28.Rossi MB, Wogalter H, Spatz M: PP: Transitional cell carcinoma of the Papillary transitional cell tumor of bladder in children and adolescents. J bladder in a 5 year old boy. J Urol Urol 130:54-55, 1983 97:88-89, 1967 33.Benson B. Hendersson BE: 29.Johnson AJ, Taylor JN: Papillary Environmental exposure and bladder tumor of bladder in a twelve year old cancer in young male. J Natl Cancer boy. J Urol 87:869-870, 1962. Inst 51:269-270,1973. 30.Quillin SP, McAlister WH: 34. Kaufman DS, Shipley WU, Transitional cell carcinoma of the Feldman AS, Bladder cancer. Lancet bladder in children: Radiologic 2009; 374:239-49. appearance and differential diagnosis. Urol Rad 13:107-109, 1991.

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