Bladder cancer

Question 1

Subtypes of bladder cancer

Answer 1

• Transitional cell carcinoma - main type
• Squamous cell carcinoma
• Adenocarcinoma
• Sarcoma

Question 2

Classification of bladder cancer

Answer 2

• Non-muscle invasive - does not penetrate into deeper layers of bladder wall
• Muscle invasive - penetrates into deeper layers
• Locally advanced or metastatic bladder cancer - spreading beyond bladder distally

Question 3

Four layers of bladder wall

Answer 3

• Inner lining - transitional cell epithelium (urothelium)
• 2nd - connective tissue lamina propria
• 3rd - muscular layer muscularis propria
• Outer - fatty connective tissues

Question 4

RF for bladder cancer

Answer 4

• Smoking
• Increasing age
• Aromatic hydrocarbons eg industrial dyes/rubbers
• Schistosomiasis infection
• Previous radiation to pelvis

Question 5

Symptoms of bladder cancer

Answer 5

• Painless haematuria - visible or non-visible
• Recurrent UTIs
• Lower urinary tract symptoms eg frequency, urgency, incomplete voiding sensation

Question 6

Examination findings bladder cancer

Answer 6

• Early stage- nothing
• Locally advanced - pelvic pain
• Ureteric obstruction if obstructs ureteric orifice
• Cachexia if mets

Question 7

Staging of bladder cancer T staging

Answer 7

• Tis - in situ, contained within basement membrane
• T1 - through lamina propria into sub-epithelial connective tissues
• T2 - into muscularis propria
• T3 - invasion into perivesical tissues
• T4 - direct invasion into adjacent local structures

Question 8

TNM staging - N stage

Answer 8

• N0 - no nodes
• N1 - single node, <2cm
• N2 - single node, 2-5cm or multiple nodes all <5cm
• N3 - one or more nodes >5cm

Question 9

Initial investigation for ?bladder cancer

Answer 9

• Urgent cystoscopy - flexible under LA
• If suspicious lesion - rigid cystoscopy needed under GA with biopsy and potential resection of bladder tumour via TURBT - either initially or after biopsy results if appears invasive
• Urine cytology - poor sensitivity and specificity though

Question 10

Imaging for suspected muscle invasive bladder cancer

Answer 10

• CT staging
• Needed before TURBT

Question 11

Managament of non-muscle invasive bladder cancer

Answer 11

• T1 or carcinoma in situ can be resected via TURBT
• Higher risk - adjuvant intravesicle therapy eg BCG or Mitomycin C
• Radical cystectomy if high risk and limited response to initial treatment

Bacille calmette guerin

Question 12

Superficial bladder cancer recurrence?

Answer 12

• High rate
• Recurring within 3 years usually and more likely to be invasive
• Need regular surveillance via cytology and cystoscopy for patients who have had superficial cancer

Question 13

What is TURBT?

Answer 13

• Resection of bladder tissue via diathermy during rigid cystoscopy
• Under GA or regional anaesthesia
• Biopsy samples aid in assessment of stage of disease
• Intravesical treatments can be inserted into bladder during procedure

Question 14

Management of muscle invasive bladder cancer

Answer 14

• Radical cystectomy - with ileal conduit formation or bladder reconstruction
• Neoadjuvant chemotherapy - cisplatin
• Regular CT imaging to monitor for local and distal recurrence

Question 15

How is bladder reconstruction done?

Answer 15

• Using segment of small bowel and urine draining urethrally or via catheter
• B12 and folate levels should be checked at least annually due to resection of ileum during urinary diversion

Question 16

Management of locally advanced or metastatic bladder cancer

Answer 16

• If otherwise well, chemotherapy - cisplatin or carboplatin + gemcitabine
• Management of symptoms

Question 17

Prognosis of bladder cancer

Answer 17

• Increased risk of upper urinary tract and urethral tumours