Actos Attorney

Actos Attorneys:  Recent studies have shown the combination of BCG with Interferon results in greater efficacy in treating bladder cancer than either agent alone.^[1]A lower dose of BCG is mixed with Interferon and both are infused via a catheter into the bladder. Since a lower dose of BCG is used, the treatments are generally well tolerated. After an induction phase of 6 treatments, the patient is cystoscoped to determine response. If there is a good response, maintenance therapy with repeated treatments follow.

Laser therapy can be used to destroy superficial bladder cancers. It can prove particularly useful for treatment of tumors that cannot be reached with a standard resectoscope (such as tumors on the dome of the bladder in an obese individual). Generally, it is well tolerated with minimal bleeding. The disadvantage is the lack of pathologic specimen. Another modality, photodynamic therapy, was first reported in 1976. A photosensitizer is injected intravenously followed by whole bladder laser light therapy. Photofrin is approved by the FDA as a photosensitizer. It accumulates at a higher rate in rapidly dividing cells (the norm for cancer). When activated by light energy, the photosensitizer causes cell destruction. This therapy can eradicate superficial disease and CIS refractory to BCG therapy. Unfortunately, the therapy causes severe local inflammation and can lead to bladder contracture (shrunken bladder) in up to 20% of patients. It is accomplished under general anesthesia. Also, because the skin is also sensitized, the individual having treatment needs to avoid sun light or bright light for approximately 6 weeks. This therapy is available in only limited tertiary care centers. It may be justified as a last option in the hopes of avoiding cystectomy. Initial response rates may be as high as 50%.

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If you are still smoking, quit! Studies have shown those patients with bladder cancer that continue to smoke do worse than those who quit. Likewise, avoid exposure to any toxins which can lead to bladder cancer. Additionally, megadoses of vitamins in conjunction with BCG have been shown to reduce recurrence rates by as much as 40%, primarily in low grade, superficial disease.  Antioxidant vitamins in combination were used.

They present in an identical fashion as superficial bladder cancers. They may present with hematuria, irritative voiding symptoms, or can be found by accident on an ultrasound or X ray exam. On occasion, an individual may pass pieces of the tumor in his urine.  The vast majority do follow an initial presentation with superficial disease. However, approximately 25% of patients first present with serious invasive bladder cancer.  Invasive bladder cancers are almost always high grade. They are aggressive cancers and can spread rapidly. They are usually larger than superficial bladder cancers. These cancers can spread directly through the bladder wall, invading tissues outside the bladder and adjacent organs such as the prostate. They can spread via lymphatics, first to the pelvic lymph nodes and then throughout the body through the lymphatic system. More rapid spread to distant organs can occur through the venous system.

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Radical cystectomy will cure approximately 75% of patients whose cancer is confined to the bladder muscle. Although individuals with minimal spread of cancer beyond the bladder may at times be cured with surgical removal of the bladder, even minimal disease outside the bladder may also be accompanied by metastatic disease, which cannot be cured by surgery alone. Therefore, microscopic spread through the bladder wall is a very bad prognostic finding. In general, larger cancers which have spread beyond the bladder to contiguous areas have a worse prognosis than cancers confined to the bladder with early spread to the surrounding lymph nodes. The more nodes involved outside the bladder by cancer, the worse the prognosis.

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Actos Attorneys:  The exact mechanism(s) of BCG is still not fully understood. It is known BCG actually attaches to and enters cancer cells. BCG is thought to trigger an increased immune reaction in the bladder, thereby killing off cancer cells.  BCG is held in the bladder for two hours. One should not hold it longer as adverse reactions are increased. The individual should then void into a toilet at home, preferably in a seated position to avoid splashing. After voiding, the toilet is disinfected with bleach. Since BCG can be shed from the urethra after treatment for several days, condoms should be used or one should abstain from sexual relations for at least 48 hours after treatment.

Studies have shown an approximately 40% reduction in tumor recurrence in those treated with BCG as compared with those without treatment.For those with CIS, the reduction is even greater at approximately 70%. For individuals with residual tumors after resection, complete response is generally about 60%.Despite intravesical therapy, ultimately between 10-20% of individuals with superficial bladder cancer will develop muscle invasive disease.

After a 6 week induction course of weekly BCG, treatment is often repeated with 3 weekly treatments at 3 months, 6 months and then every 6 months for up to 3 years. This regimen was shown to decrease recurrences and increase complete responses as compared to induction treatment alone. Unfortunately, despite initial success, over long periods of time, many will experience disease recurrence and progression.Treatment regimens can be individualized based on the patient’s progress and his adverse reactions to treatment, which generally increase with repeated cycles.

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Adverse reactions are side effects of treatment. Approximately 95% of individuals will tolerate treatments well. Adverse reactions may be mild. Common reactions include cystitis (inflammation of the bladder characterized by burning on urination), hematuria, mild fever, malaise, and nausea. These symptoms generally pass without any treatment. For bothersome symptoms, various medications may prove helpful. Your physician can prescribe medication for burning or urinary frequency. For those with persistent cystitis, antibiotics can be utilized. For individuals experiencing severe symptoms lasting more than 48 hours, isoniazid, an anti-tuberculous drug can be prescribed. A short course of 3 days, starting the day before the next dose of BCG can be used to prevent severe side effects. Fortunately severe reactions resulting in sepsis, a life threatening condition characterized by high fever, chills and drop in blood pressure, is exceedingly rare. Sepsis would be treated in a hospital with triple anti-tuberculous drugs, steroids, and broad spectrum antibiotics.

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As treatment cycles progress, generally adverse reactions increase in severity, the most common being cystitis. Patients should not receive additional doses until they are asymptomatic. Studies have demonstrated increasing the intervals between treatments and reducing the dose of the BCG can still result in perhaps equal efficacy, but with reduced toxicity.  BCG therapy results in marked inflammation of the bladder wall. Cystoscopy done too soon after therapy would reveal a markedly reddened surface, making finding a bladder tumor difficult. Furthermore, microscopically, there will be severe reactive changes, complicating the pathologist’s job, as deciding between changes from the BCG and recurrent cancer, would be extremely difficult.

Recurrence of bladder cancer after the initial induction course, or relapse after complete response, would indicate failure of therapy. When two or more courses result in recurrence or when recurrence develops during the first six to twelve months after induction and maintenance therapy, patients generally are felt to have disease which is at higher risk for progression. A high percentage of patients who are complete responders remain tumor free for up to five years. However, with the passage of more time, additional patients will have late recurrences. For those with late recurrences (two to three years after therapy), most will respond to repeat BCG therapy.

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Actos Attorneys:  When an individual has diffuse, high grade cancer of the bladder, even when superficial, bladder removal may be warranted. Many may have widespread carcinoma in situ (CIS) in conjunction with papillary disease. One can expect a high rate of recurrence and a high rate of progression to invasive disease. Generally, intravesical therapy is tried first. If this therapy is unsuccessful, repeated therapy or alternate intravesical therapies can be tried. However, with failure of intravesical therapy, further trials may prove to be equally ineffective and lead to unnecessary delay for potentially definitive curative therapy. Many recommend removal of the bladder if two courses of six weeks of BCG are ineffective. Therefore, radical cystectomy is a treatment option for any individual who is thought to be at significant risk for progression to musclc invasive and potentially metastatic disease.

For individuals with recurrent disease despite tumor removal and intravesical therapy, progression to a more serious, muscle invasive disease is common. The patient at high risk for progression must consider radical cystectomy. If the individual is not a candidate for radical cystectomy because of poor health or the individual refuses cystectomy, radiation therapy can be considered. There are no good studies available and it is difficult to assess the efficacy of radiation alone since it is always combined with TURBT and the completeness of tumor resection is an uncertain variable. In general, radiation plays a minimal role in the treatment of superficial bladder cancer.

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For those individuals whose bladder tumors are at high risk for recurrence or progression, instillation of agents directly into the bladder can be worthwhile. The forms of therapeutic agents come in two groups: chemotherapy or immunotherapy. It is fortunate the bladder is readily accessible to these agents, allowing for direct action with minimal systemic side effects.

Those individuals at high risk for recurrence and or progression should be considered for this therapy. Individuals with multiple or diffuse superficial tumors, large tumors, high grade tumors, superficially invasive tumors, those with recurrence within one year, or individuals with CIS all should be considered for this treatment. In addition, those with positive cytology after resection or patients with persistent superficial tumors which could not be removed should also be considered.

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The agent is passed via a catheter into the bladder. The passage of the catheter generally takes just a few seconds in a woman, and perhaps ten seconds in a man. The urethral meatus (the outermost part of the urethra) is first cleansed with an antiseptic solution and then the catheter, which is made slippery with a sterile lubricant, is inserted up the urethra and into the bladder. On passage of the catheter, there is minor, short lived discomfort which may be reduced by an injection up the urethra with numbing medication. The various therapeutic agents are not painful during the infusion but may cause side effects afterwards. Depending on the agent instilled, the patient is asked not to void for a period of time afterwards to allow the agent to have its maximal effect on the bladder lining.

BCG is a living but attenuated form of tuberculosis bacteria. Similar to other living vaccines, it is used to create a heightened immunity. There are a number of precautions which must be taken to make sure the BCG is infused safely. BCG should not be infused immediately or shortly after tumor resection. Several weeks should be allowed to pass so the BCG does not gain access into open blood vessels. In addition, BCG should not be infused if the individual has a urinary infection, has active bleeding, or if the catheterization is traumatic and causes bleeding. It should not be used in patients whose immune system is seriously compromised or for those on steroids, which can decrease the immune system.

Our use of the term or terms Actos Attorneys is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Attorneys :  Bladder tumor “seeding” may occur during the procedure. As the tumors are resected, cancer cells are released into the irrigant which fills the bladder. These cells may implant in other areas of the bladder traumatized during the procedure. It should be understood that the bladder is generally filled with urine, and tumor cells can naturally implant at other locations even without surgery. Implantation can be lessened during surgery by avoiding injury to other bladder areas and by the use of adjuvant intravesical chemotherapy. There have been numerous studies over the past decade showing a number of chemotherapy agents can be effective in decreasing initial tumor recurrence, possibly by preventing seeding. Reduction in recurrence may however be short lived. Previously, it was common practice to obtain multiple random bladder biopsies at the time of initial tumor resection. This was recommended to rule out the possibility of hidden CIS. Understanding these biopsy sites may increase the possibilities of tumor recurrence by tumor seeding, biopsies are now often limited to areas adjacent to the tumors removed and suspicious appearing areas only. CIS can be ruled out by using cytology, or by obtaining biopsies during future cystoscopy after the tumor has already been removed. When dealing with low grade tumors, random biopsies of the bladder will rarely show cancer.

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After your procedure, depending on the level of anesthesia and the extent of surgery, you will be brought either to the recovery room or back to the area where you were first prepared for your procedure. You will be released to home only when you have fully recovered from you anesthetic and are doing well. The recurrence rate for superficial bladder cancer can be as high as 60-90%. Recurrences can cause bleeding and other difficulties and are best handled sooner rather than later. In addition, depending on the initial tumor grade and stage, progression to a more serious form of bladder cancer is an ongoing concern. Surveillance cystoscopy is therefore recommended. Cystoscopy is still the best means to check for recurrent disease. It is however, an invasive procedure and should be accomplished only as often as required. For solitary, low grade, non invasive disease, follow up cystoscopy can be accomplished with the flexible cystoscope if available. If negative at three months, further cystoscopic exams can be done yearly and eventually lengthened even further. For those with multiple tumors, large tumors, high grade tumors or those who also have CIS, frequent cystoscopies, initially every three months are called for. As long as there are no recurrences, the time between cystoscopies can be lengthened. Cytology can also be utilized to reduce the number of cystoscopies. If recurrence or progression does occur, heightened scrutiny is again called for.

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There are many medical conditions that may result in hydroureteronephrosis (swelling of the kidney and ureter), having nothing to do with bladder cancer. It is also true large bladder tumors may grow into the wall of the bladder and cause ureteral obstruction at the level of the bladder. When this is found, the prognosis is usually poor, as the tumors involved are usually high grade and deeply invasive. On occasion, a superficial low grade tumor may grow directly into the ureteral opening. In this situation, prognosis is not generally any worse, as the blockage has not occurred from an invasive tumor.

The urologist will determine if the cancer is superficial or invasive (growing deeper than the subepithelial connective tissue or stroma). Superficial disease is generally amenable to transurethral resection and treatment with intravesical BCG (Chapter 9), while deeply invasive disease often warrants radical cystectomy. A number of studies have shown individuals with high risk superficial disease should be closely monitored with yearly IVP or IVP after the development of a positive cytology. Those with high risk disease treated successfully with BCG are still at risk for upper tract disease and should be carefully monitored. For those with low risk disease, checking the upper tracts less frequently would be appropriate. Unfortunately, when upper tract disease develops, prognosis is markedly worsened, with many individuals eventually dying from their cancer.

Our use of the term or terms Actos Attorneys is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Attorneys: Photodynamic therapy may afford additional results. With this novel technique, a chemical is instilled into the bladder, sensitizing the cancer cells to light energy. The entire bladder is then illuminated with laser light via a cystoscope. This treatment is not widely available at the present time and it is most effective for small tumors.  There are potential risks and complications of any surgical technique. Bladder tumor removal via resectoscope is usually safe and complication free. However, potential problems may arise: Bleeding is usually present, but rarely severe. Some tumors are more vascular than others and will bleed more. In addition, the resection will involve the bladder wall and vascularity varies here as well. Transfusions are not generally required unless an individual starts with a low blood count from previous bleeding or medical condition. Bleeding can be an on going concern until the bladder completely heals weeks later. Catheterization and irrigation may be required. Just a small amount of blood will change the color of urine red. Urine that is punch colored or the color of rosé wine generally is not serious and will clear on its own. When the urine has large amounts of blood in it, the appearance generally looks like tomato juice, indicating serious bleeding requiring medical attention.

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Bladder perforation may occur, especially with large tumors or those located on the lateral bladder walls. During resection of tumors on the lateral walls, the obturator nerve, which runs alongside the outside of the lateral bladder wall, may cause a strong muscle contraction. This contraction can abruptly move the bladder during a resection, resulting in a perforation. During resection of a large tumor with solid base, the urologist proceeds with deep resection of the tumor to remove the entire tumor and also determine whether or not it is a high stage tumor with muscle invasion.

Bladder walls differ in size and integrity, and sometimes a perforation may occur. In addition, bladders which have previously been subject to some form of stress such as radiation or chemotherapy may have extremely poor integrity and are subject to pulling apart during a resection, resulting in a perforation. Bladder perforation is usually detected during the resection when the urologist sees fat (perivesical fat is located on the outside of the bladder). Sometimes, during a particularly bloody resection, the perforation may not be visible intraoperatively, but discovered when the lower abdomen becomes firm and distended (indicating that a large volume of fluid has passed into the abdomen). Small perforations are usually handled by stopping the procedure and maintaining a catheter for a week or more. Large perforations, especially those that communicate with the peritoneal cavity (the cavity that encases the bowels) generally require open surgical repair. Perforations can potentially spread cancer beyond the bladder.

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Ureteral injury may occur when a tumor covers the ureter in the bladder. The ureter may be obscured by a bladder tumor, and the urologist may inadvertently resect it along with the tumor. In general, cutting current to remove a bladder tumor does not usually lead to long lasting problems as compared to cauterization, which is more likely to cause permanent blockage or obstruction of the ureter. If the urologist is working in the area of the ureter, he should avoid cauterization as much as possible. He may ask the anesthetist to inject an intravenous coloring agent which will turn the urine blue and allow visualization of the ureter. If he knows a ureter may be in jeopardy, he may insert a stent (a small plastic tube that traverses the ureter) for several weeks to allow the ureter to heal in an open fashion.

Urethral injury is infrequent and is almost always in males. A stricture or narrowed area of the urethra may result from irritation or injury from the resectoscope pressing on the urethra. Individuals that develop strictures complain of difficulty urinating, experiencing a slow or split stream. Strictures are usually readily handled with a number of urologic procedures.

Our use of the term or terms Actos Attorneys is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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