Bladder Cancer

Question 1

Aetiology of bladder cancer

Answer 1

90% of bladder cancers are lower urothelial carcinomas (known as transitional cell carcinoma)
Non-muscle-invasive tumours are the most common
Low-grade tumours are papillary
High-grade tumours are often flat or in situ and difficult to visualise

Carcinogens e.g. nitrosamines are concentrated and excreted in the urine where the urinary tract cells are exposed

‘Field effect’ = exposure of the urothelium to carcinogens at roughly the same concentration gives rise to an epithelium, from which occasional cells become initiated and give rise to independent clones of transformed cells

Question 2

Risk factors for bladder cancer

Answer 2

Smoking, tobacco exposure
Occupation exposure to chemical carcinogens e.g. Industrial dye exposure etc.*
Schistosoma infection (SCC bladder)
Arsenic exposure
Age >55
Pelvic radiation
Systemic chemotherapy
Male
Chronic bladder inflammation
Family history
T2DM

*aromatic amines used in rubber and dye industries; polycyclic aromatic hydrocarbons used in the aluminium, coal, and roofing industries; and exposure to arsenic in drinking water

Question 3

Symptoms and signs of bladder cancer

Answer 3

Gross haematuria (painless)
Dysuria
- Typical of carcinoma in situ OR high-grade urothelial carcinoma
- Associated with aggressive bladder cancer
- Rule out urinary infection
Urinary frequency

Gross/microscopic haematuria

Question 4

Investigations for bladder cancer

Answer 4

Urine dip: haematuria
Urinalysis: RBC casts and crenated red cells seen with glomerular bleeding
Urine cytology: +ve in 90% with high grade
Urinary markers: Bladder tumour antigen (BTA), NMP22

FBC: ?anaemia (before treatment)
U&Es
ALP: raised in mets

Renal/bladder US: visualise tumour/obstruction
CT urogram (excretory phase): visualise tumour/obstruction
IV urogram: visualise tumour/obstruction, filling defect
CXR
CT/MRI abdo/pelvis: ?stones, tumour
Cystoscopy

Question 5

Management for bladder cancer

Answer 5

Majority of bladder cancer on surface lining of bladder (in situ): TURBT
→ Enter remission
→ regular cystoscopy required (risk of recurrence)
→ immediate intravesical chemotherapy with mitomycin (30m-2h later)
→ intermediate-high risk: delayed (2 weeks) BCG immunotherapy for 6 weeks

Growth through surface lining into bladder muscle (ex situ)
Muscle invasion → radical cystoprostatectomy

±Chemotherapy | TURP | Radiotherapy | Radial cystoprostatectomy | Radical cystectomy + hysterectomy

Question 6

Describe the TURBT procedure and its complications

Answer 6

Trans Urethral Resection of Bladder (TURBT)

Cystoscope passed up urethra to bladder. Then, a tool is passed through cystoscope to remove bladder tumour.

Time: 30 minutes | Tissue may be examined by pathologist

Early Complications: haematuria, dysuria, UTI, septicaemia, DVT/PE, incontinence
Late complications: Bleeding (requires recatherisation), Urethral stricture (requires operation)

Question 7

Complications of bladder cancer

Answer 7

Prostatic urethral transitional cell carcinoma
Upper tract TCC
Hydronephrosis
Urinary retention

Question 8

Prognosis for bladder cancer

Answer 8

Depends on grade and stage
Most present with low grade, non muscle invasive bladder cancer: High risk of recurrence but low risk for disease progression and death.
50% survival if muscle invasion

High-grade NMIBC, especially if invasive into the lamina propria or associated with carcinoma in situ (CIS), is a risk for both recurrence and progression and is treated with cystectomy if intravesical therapy fails