Bladder Cancer

Question 1

What type of cancer are the majority of bladder cancers?

Answer 1

1. > 90% transitional cell carcinoma (urothelial) in the UK >55yrs of age.
2. Adenocarcinomas and SCC less common in the west (schistosomiasis is a risk factor)

Question 2

What is the difference between low and high grade bladder cancer tumours?

Answer 2

1. Low grade - easy to visualise, negative cytology

2. High grade - hard to visualise (flat), positive cytology

Question 3

What are the risk factors for bladder cancer?

Answer 3

1. Smoking, aromatic amines used in rubber/dye industry.

2. Chronic cystitis, pelvic irradiation, M:F >4:1, schistosomiasis, thiazolidinedione’s

Question 4

What is this a presentation of?

Frank painless haematuria, microscopic haematuria, recurrent UTIs, dysuria, weight loss, night sweats, fever.

Answer 4

Bladder cancer

Question 5

How is a suspected bladder cancer investigated?

Answer 5

1. Urinalysis for haematuria
2. Urine cytology
3. Cystoscopy with biopsy is diagnostic
4. CT urogram can provide staging
5. If muscle invasive - FBc, ALP
6. Abdo/chest MRI before TURBT

Question 6

How is bladder cancer graded?

Answer 6

3-tier system to see how closely tumour resembles normal urothelial cells.

1. Low grade - 1 and most of 2
2. High grade - 3 and some of 2

Question 7

How is bladder cancer staged?

Answer 7

Asses extent of anatomical spread, TNM.

1. Tis (CIS)
2. Ta (no invasion), T1 (invasion into lamina propria)
3. T2 (detrusor invasion), T3 (perivesical tissue invasion), T4 (invasion into adjacent structures)

Question 8

How does bladder cancer spread?

Answer 8

1. Local - pelvic structures
2. Lymphatics - iliac and para-aortic nodes
3. Blood - liver and lungs

Question 9

What are the different classifications for bladder cancer?

Answer 9

1. Low risk - high chance of recurrence, less chance of progressing to high risk, TURBT, regular check-up.
2. High risk - risk of extensive invasion, solid not papillary, radical cystectomy.
3. Carcinoma in situ - precancer, high chance of progression to high risk, not through basement membrane, insert HAL into bladder before cystoscopy to visualise.

Question 10

What is the management of Tis/Ta/T1 bladder cancers?

Answer 10

1. Diathermy via transurethral cystoscopy
2. Or TURBT
3. Regime of post-op delayed intravesical BCG for multiple small tumours or high grade tumours
4. Alternative chemotherapy - mitomycin

Question 11

What is the management of T2/T3 bladder cancers?

Answer 11

1. Radical cystectomy is gold standard
2. Post-op chemotherapy and neoadjuvant chemotherapy improves survival
3. Urinary diversion formed - ileal conduit and urostomy, can reconstruct bladder if neck not involved.

Question 12

What is the management of T4 bladder cancers?

Answer 12

Invades adjacent organs - usually palliative chemo/radiotherapy

Question 13

What is the follow-up for bladder cancer?

Answer 13

1. High risk - cystoscopy every 3 months for 2 years, then every 6 months
2. Low risk - 1st cystoscopy after 9 months, then annually

Question 14

What is the prognosis of bladder cancer?

Answer 14

1. Tis/Ta/T1 - 95% 5-year survival

2. T2-3 - 60% if 65-75yrs, 40% if >75yrs