Article Information

Md. Mashiur Arefin¹, Homayra Tahseen Hossain²

¹Assistant Professor, Department of Urology, Rajshahi Medical College, Rajshahi, Bangladesh

²Associate Professor, Department of Medicine, Popular Medical College, Dhaka, Bangladesh

^*Corresponding Author: Department of Urology, Rajshahi Medical College, Rajshahi, Bangladesh

Received: 14 June 2023; Accepted: 27 June 2023; Published: 13 July 2023

Citation: Md. Mashiur Arefin, Homayra Tahseen Hossain. Transitional Cell Carcinoma: Impact of Life Style on Grading of Tumor. Journal of Cancer Science and Clinical Therapeutics. 7 (2023): 141-145.

Abstract

Keywords

Transitional cell carcinoma, urothelial cancer, lifestyle, grading, correlation

Article Details

1. Introduction

Transitional cell carcinoma is a malignant tumor arising from transitional epithelial cells that line the urinary bladder [1]. Urothelial cancer is the 10th most common cancer and 2nd most common cancer among urological cancer worldwide, with approximately over 549,393 new cases and 199922 death per year [2]. The incidence of bladder cancer is more in men than women and approximately three-fourths of sufferers are male [3]. Bladder cancer strikes one in five persons worldwide before they are 75 years of age. It is estimated that the worldwide prevalence of this condition ranges from 1 in 10 in South and Central Asia and Middle Africa to 1 in 2.5 in Australia and New Zealand [4]. Ninety percent of all occurrences of bladder cancer are due to Transitional cell carcinoma (TCC), whereas only 5% are due to squamous cell carcinoma, and the remaining 5% include rare subtypes such as adenocarcinoma, sarcoma, and metastatic urothelial cancer [5]. It is very difficult to compare the data of underdeveloped nations that do not have functional cancer registries with developed countries with excellent technological support systems and functional cancer registries [6, 7]. So, the frequency of urological cancers shows significant variations in different parts of the world [8]. Kidney and bladder cancers show a statically significant positive association with socio-economic deprivation, on the other hand, prostate and testicular cancers show an opposite relationship [9]. Kidney and bladder cancers had a higher incidence rate in rural areas, while prostate cancers are higher in metro areas [10]. WHO classifies urothelial carcinoma as low-grade urothelial carcinoma (LGUC) and high-grade urothelial carcinoma (HGUC) based on its cell morphology and histological structure [3, 11]. Transitional cell carcinoma is strongly associated with tobacco consumption about 50-65% of all cases [5]. Other risk factors are exposure to polycyclic aromatic hydrocarbons, benzene products, phenacetin, certain chemotherapeutic agents like cyclophosphamide and similar products. The association is not clear but it’s implicated with Caffeine and artificial sweeteners [12]. 75% of urothelial bladder cancer is confined to the mucosa (non-muscle invasive bladder cancer: NMIBCa) and 25-30% are muscle invasive (muscle-invasive bladder cancer: MIBCa) at diagnosis [13].

Transurethral resection of the bladder tumour (TURBT) is the treatment of choice for NMIBCa and radical cystectomy is the choice for MIBCa and high-grade tumours. To prevent progression and recurrence, intravesical installations of chemotherapeutic agents or BCG along with TURBT are a choice. Despite the improvement of surgical and perioperative agents, long-term survival rates remained unchanged [13].

2. Materials and Methods

This descriptive and cross-sectional retrospective study focused on histologically proven cases of Transitional cell carcinoma (TCC) within urological malignancies at Rajshahi Medical College Hospital (RMCH) from January 2019 to January 2021. Patient records pertaining to the diagnosis of TCC in the urogenital system were retrieved from the Department of Urology at RMCH. Patient biodata, including age, sex, habits, symptoms, and affected organs, were extracted and analyzed. Statistical analysis was conducted using STATA 14. The study utilized anonymized data for statistical analysis, thereby waiving the need for patient consent regarding ethical considerations.

3. Results

During our study, we collected a total of 144 cases of Transitional cell carcinoma in the Department of Urology at Rajshahi medical college, Bangladesh, diagnosed by histopathology. The sex distribution of these cancers was male (112) 77.8% and female (32) 22.2%. The association between tobacco consumption and transitional cell carcinoma is very high (tobacco consumption rate 68.8%). In the case of TCC, the low grade is 85(59%) and the high grade is 59(41%) and males are more common (77.8%). Among all the TCC, upper tract TCC was seven in numbers and urethral was three, high-grade TCC is more common in male patients at age of 50 to 69 years who are smokers and reside in rural areas and cultivators. Male suffers more from high-grade tumour (46.4%) than female (21.9%). The mean age of a high-grade tumour is 59.5 years with a Creatinine level of 1.4 and haemoglobin is 10.5 gm/dl. The mean age of low-grade tumours is 65.5 years with a Creatinine level of 1.2 and haemoglobin is 10.6 gm/dl.

Pearson chi2(1) =6.2042 pr =0.013

Table 1: Grading of TCC among populations.

Figure 1: The low-grade tumour is more than the high-grade tumour.

Pearson chi2(3) =13.3568 pr =0.004

Table 2: Occupational Impact on TCC.

Figure 2: Cultivators are more sufferer.

Pearson chi2(1) =1.2501 pr =0.264

Table 3: Impact of habitant on TCC.

Figure 3: People living in rural areas suffer more.

Pearson chi2(1) =5.5386 pr = 0.019

Table 4: Association between tobacco consumption and grading of TCC.

Figure 4: Tobacco consumers have more TCC than non-tobacco consumers.

Pearson chi2(2) =9.7062 pr= 0.008

Table 5: Grading of TCC in the age group.

Figure 5: The age group (52-69) suffers more.

Table 6: Correlation between grading of TCC and age, haemoglobin & creatinine level of patients.

Figure 6: High-grade tumours average 59.5 years old with 1.4 Creatinine and 10.5 gm/dl haemoglobin. Low-grade tumours average 65.5 years old with 1.2 Creatinine and 10.6 gm/dl haemoglobin.

4. Discussion

Due to their worldwide frequency, urological malignancies are a real public health problem [14]. Urological malignancies are remarkably increasing in the ageing population [15].  Some lifestyle habits, such as smoking, physical activity, nutrition, sexual activity and personal hygiene are modifiable factors influencing the development and progression of urological cancers [16]. In GLOBOCAN 2020, Bangladesh shows prostate cancer ranks 17, bladder cancer 18, kidney cancer 20, ca-penis 27 and testicular cancer 30th position [2]. In this study, most of the sufferers are from the 50-69 years age group from rural areas with a habit of tobacco consumption and occupation by cultivation. Because this part of the country has the least industrial but more agricultural development. Among them, low-grade tumours are more common. But in the tobacco consumer group, high-grade tumours are common. Urothelial cancer is 4th most common cancer in men and 8th most common cancer in women in the Western world [17]. In Indian data, Genito-urinary systems formed 17.48% of all cancers in male patients, among them carcinoma prostate at 40.71% and urinary bladder cancer at 30.49% [18].  About 50-65% of all bladder cancers are due to tobacco consumption and 20% are for occupational and environmental toxins. Bladder cancer is a prime candidate for preventable cancer, with 81% of cases having known risk factors [5]. There are lots of etiological risk factors for bladder cancers i.e.: male gender, older age, hereditary and genetic factors, tobacco, environmental and occupational exposures, alcohol, red meat, obesity, pathogens like Schistosomiasis etc.

Beta-naphthylamine and polycyclic aromatic hydrocarbons, both found in tobacco, are known carcinogens. Inflammation induced by these particles ultimately leads to DNA adduction and permanent genetic mutation. In which oncogenes are activated or tumour suppressor genes are downregulated to promote carcinogenesis [5]. The second most common modifiable risk factor for bladder cancer is exposure to carcinogens in the workplace and the environment. Aromatic amines, polycyclic aromatic hydrocarbons, and chlorinated hydrocarbons are all known carcinogens that can be found in a wide range of commonplace materials like paint, metal, rubber, and petroleum products. Firefighters, cosmetologists, and farmers who use fungicides also face a higher risk [5]. According to the results of a large Chilean prospective observational study, being exposed to arsenic raises the risk of bladder cancer [19]. Other study indicated that the chance of developing bladder cancer was greatly enhanced by smoking in combination with exposure to extremely low amounts of arsenic (0.5 g/L) [20]. Nitrates and disinfection byproducts in municipal water supplies, as well as dietary elements like selenium and zinc, have all been linked to an increased risk of bladder cancer [21]. Chinese herbal products containing aristolochic acid found naturally in many plants belonging to the genus Aristolochia are a potent carcinogen for bladder cancer [22].

In our study all the urothelial cancers are transitional cell carcinoma, no other subtypes are detected. But in an Indian study [18], it was 97.71%. The male is more preponderance and the male-female ratio was 3.6:1, which is similar to China, Togo and the Western world [23, 8, 5]. But in India, it was 6.4:1 [18] and in Korea 5.68:1 [6]. There were significant differences in bladder cancer incidence rates in urban and rural areas. Incidence in rural areas is 59.7% is much higher than in urban areas 40.3% which is similar to a study by Adam John Gadzinski [10]. But in China [23] urban people suffer more. In this study, the most common age group is between 50 to 69 years of age and the mean age is 63 with a standard deviation of 12.1, which is similar to another study [17, 24, 5]. But a study from Africa [8] observes in much lower age group. Among the occupational status of the patients, cultivators are suffering more from urothelial cancer. This may be due to prolonged exposure to fungicides, arsenic and socioeconomic deprivation. Smokers are suffering more from urothelial cancer about 68.8%, among them 79.7% are high-grade tumours which is similar to other studies [5, 6, 18].

5. Conclusion

In this study, all of the urothelial malignancies are in the form of transitional cell carcinoma. Most of the sufferers are in the elderly age group at the age of 50-69 years age group who lived in rural areas and are tobacco consumers and cultivators. Men had a higher incidence rate than Women. In African countries, squamous cell carcinoma of the bladder is found due to the prevalence of Schistosomiasis and the affected are the younger age group. Most of the TCC is low grade and NMIBCa, and TURBT with intravesical therapy have a large impact on survival. But in the case of high-grade and MIBCa, radical cystectomy is the gold standard but is associated with morbidity and decreased quality of life. Metastatic TCC is a highly lethal disease with a limited survival rate. As most urological cancers are linked with modifiable risk factors, the incidence rate of these cancers can be reduced by improving public awareness and the healthcare system. Early diagnosis and treatment are the keys to improving urological cancer survival.

Conflicts of Interest

There are no conflicts of interest.

Financial Support and Sponsorship

Nil.

Informed Consent Statement

Not applicable.

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