Bladder

Question 1

What are the subtypes of urothelial cancer?

Answer 1

Transitional  cell carcinoma (90%)
Squamous cell carcinoma (5%)
Adenocarcinoma
Small cell carcinoma
Micropapillary
Metastatic (commonly from melanoma or lobular breast)

Question 2

What are the risk factors for bladder cancer?

Answer 2

Smoking
Dyes
Petro-chemicals
Paints
Arsenic
Radiotherapy
Cyclophosphamide chemotherapy
Bladder calculi (squamous)
Chronic cystitis (squamous)
Schistosomiasis (sqaumous)

Question 3

What is the clinical presentation of bladder cancer?

Answer 3

Haematuria - painless, gross, throughout micturition

Bladder irritability - frequency, dysuria, urgency

Question 4

How do you diagnose bladder cancer?

Answer 4

Cystoscopy is gold standard
Urine cytology (poor sensitivity)
Visualise upper renal tracts - CT or IVP
CT abdo/pelvis, consider CXR or bone scan if high risk

Question 5

What is the staging of bladder cancer?

Answer 5

Stage 1: non muscle invasive (Tis, Ta or T1)
Stage 2: muscle invasive
Stage 3: invades perivesicular tissue +/- pelvic organs
Stage 4: spread to pelvic wall, nodes or distant metastases

Question 6

What is most important risk stratification of bladder cancer staging?

Answer 6

Non muscle invasive vs muscle invasive

Non muscle invasive = low grade, recurs locally
Muscle invasive = high grade, disseminates easily

Question 7

What is management of non muscle invasive bladder cancer?

Answer 7

TURBT followed by intravesical therapy with either mitomycin or BCG depending on risk stratification

Question 8

What is the management of muscle invasive bladder cancer?

Answer 8

Standard of care is neoadjuvant chemotherapy followed by radial cystectomy
Neoadjuvant chemotherapy showed large OS benefit

Question 9

What is chemotherapy of choice in bladder cancer?

Answer 9

Sensitive to cisplatin
Use combination regimens
MVAC (methotrexate, vinblastine, doxorubicin, cisplatin)
Cis/Gem (cisplatin, gemcitabine)

Question 10

What is bladder preservation?

Answer 10

Alternative “curative” options for those unfit for surgery or who decline cystectomy
TURBT followed by radical chemo-radiation with mitomycin and 5-fluorouracil

Question 11

What is the treatment for metastatic bladder cancer?

Answer 11

Standard first line chemotherapy is MVAC or Cis/Gem, if patients can tolerate.
Other options include substituting carboplatin for cisplatin