bladder cancer

Question 1

what are the main types of bladder cancer?

Answer 1

1. most are transitional cell carcinomas, there are 2 main types:

Papillary: the majority of cases, usually superficial with finger-like projections, often non-invasive and has a better prognosis

Flat: lie flat against the bladder tissue and are more prone to invasion, with a poorer prognosis

2. squamous cell carcinoma (1-7% in the UK) which is associated with chronic cystitis secondary to schistosoma haematobium infection
3. adenocarcinoma

Question 2

what are the risk factors for bladder cancer?

Answer 2

• increasing age
• male
• family history
• smoking (2-4 fold increase)
• occupational exposure to allanine dyes
• schitosomiasis infection-> which can cause chronic cystitis

Question 3

what are the signs and symptoms for bladder cancer?

Answer 3

• painless haematuria which can be microscopic or macroscopic
• increased frequency
• weight loss

on examination may have a palpable suprapubic mass
may have signs of anaemia if chronic bleeder

Question 4

which patients would you refer on a 2WW?

Answer 4

• > 45 with unexplained visible haematuria without UTI
• > 45 visible haematuria which persisits/reoccurs after succesful treatment of a UTI
• > 60 with unexplained microscopic haematuria AND dysuria OR raised WCC

Question 5

who would you consider for a non urgent referral to urology for suspected bladder cancer ?

Answer 5

> 60 with recurrent and persistent UTIs

Question 6

what are the primary investigations to do when suspecting a bladder cancer?

Answer 6

bedside:
- urinalyisis- to look for haematuria

bloods:

• FBC: look for HB and anaemia
• UandE- renal failure if there is an outflow obstruction
• LFTS and coagulation screen- may be derranged in metastatic cancer

imaging:
- flexioble cystoscopy- to confrim presence of tumour

Question 7

what secondary imaging investigatins would you do?

Answer 7

CT abdomen and pelvis (CTAP): assesses for distant metastasis for high-risk patients or suspected muscle-invasive disease on cystoscopy. Low-risk patients with non-muscle invasive disease do not need a CTAP (rarely alters management)

CT urogram: for imaging the urinary tract and better visualisation of the renal parenchyma

Pelvic MRI: often performed for local staging if cystoscopy suggests muscle-invasive disease

PET CT: usually performed if there are unclear findings 
on CT (e.g. lymph nodes of uncertain significance)

Bone scan: if suspecting bone metastasis; e.g. if bone pain or hypercalcaemia is present

Question 8

what is the management for non invasive bladder cancer?

Answer 8

Trans-urethral resection of bladder tumour (TURBT): rigid cystoscopy under general anaesthetic, with a post-operative dose of intravesical mitomycin C.

Further management will depend on the risk as determined by histology:

• Low risk: no further management
• Intermediate risk: 6 doses of intravesical mitomycin C
• High risk: intravesical BCG, or radical cystectomy if very high risk

Question 9

what is the management for bladder cancer invading the muscle wall?

Answer 9

Radical cystectomy with neoadjuvant chemotherapy; patients will require an ileal conduit (urostomy)

Radical radiotherapy with neoadjuvant chemotherapy is an alternative to surgery

Question 10

what is the management for locally advanced or metastatic bladder cancer?

Answer 10

Chemotherapy: cisplatin-based chemotherapy is generally offered

Palliative treatment: e.g. radiotherapy for bladder symptoms if curative treatment is not an option