Bladder Ca

Question 1

In patients who had TURBT - what investigations would you like to see?

Answer 1

1. Cystoscopy
2. Histopathology - looking for evidence of muscle invasive disease. Critical, as if stage T1 (no muscle invasion) - treatment is TURBT, but if muscle invasive, cystectomy may be required).
3. Staging CTCAP, PET.

What you want to establish is whether

a) Is there a muscle invasion
b) if not, does the patient has low, intermediate or high risk features
c) staging

Question 2

How would you classify non-muscle invasive bladder Ca? (3)

Answer 2

Ta: non-invasive papillary. Confined to urothelium, not penetrating basement membrane

Tis (CIS): severe dysplasia - high risk. Essentially treated as same as T1.

T1: by definition, it is invasive. But not involving muscularis propria.

Question 3

What are the features of high-risk disease in non-invasive bladder ca (not involving muscularis propria) -5

Answer 3

This depends on the risk profile of the tumour. Same as UC-dysplasia

1. Multifocal
2. Recurrent
3. Large
4. CIS or T1
5. High-grade.

Question 4

Management of non-muscle invasive bladder cancer depending on risk profile?

Answer 4

All need TURBT, which is required for diagnosis (all would have had it).

Low-risk: 1 instillation of intravesical chemo, followed by surveillance

Intermediate-risk: induction + maintenance intravesical chemo for 1 year with BCG or chemo.

High-risk: restaging TURBT in 2 months.

a) Radical cystectomy if indications present
b) if no indication/or not fit for radical cystectomy - intravesical BCG induction + _3 year_s of maintenance

Question 5

What are the indication of cystectomy for bladder Ca? (5)

Answer 5

Non-muscle invasive Ca who has appropriate performance status

1. Too extensive for TURBT to remove all
2. CIS involving prostatic duct
3. Pure SCC or Adenocarcinoma
4. Lymphovascular invasion
5. multifocal/diffuse/persistent lesions following TURBT

Question 6

Bladder cancer staging?

Answer 6

I: T1, no nodes.

II: T2 (invade musclaris propria), no nodes.

III: T3 (invades perivesical soft tissue) or Any T with Nodal involvement

IV: Metastatic.

Question 7

Management of Stage II, III, and IV bladder Ca?

Answer 7

II or III:

a) Surgical candidate + patient willing → radical cystectomy + platinum based chemo.
b) if not → combined TURBT + Chemo + RTx.

IV: Platinum based chemo.

Question 8

Important counselling points before sending patients for Cystectomy?

Answer 8

1. Change in lifestyle from ileal conduit/stoma or neobladder. Neobladder may require self-catheterisation to better empty it.
2. Risk of urinary incontinence
3. So do they have manual dexterity to perform self catheterisation, emptying the stoma bags?
4. Sexual changes - male: erectile dysfunction, female: ability to have orgasm. Less secretion.