Bladder Cancer

Question 1

How to classify bladder cancer?

Answer 1

Benign vs Malignant

Benign tumours are papillomas

Malignant tumours can be divided based on their histological subtype:
Transitional cell/urothelial carcinoma (most common, 90%)
Squamous cell carcinoma
Adenocarcinoma

Malignant tumours can also be classified as muscle invasive or non-muscle invasive

Question 2

What are the risk factors for transitional cell carcinoma?

Answer 2

Environmental factors:
Smoking
Occupational risk factors - exposure to aromatic amines and polyhydrocarbons from paint, dyes, rubber, textiles

Non-environmental factors:
Age
Male sex

Question 3

What are the risk factors for squamous cell carcinoma?

Answer 3

Infection e.g. schistosomiasis
Chronic inflammation e.g. long-term catheters
Pelvic irradiation

Question 4

How does bladder cancer present?

Answer 4

Painless macroscopic haematuria (and 5% of microscopic haematuria)
Lower urinary tract symptoms
Recurrent UTIs
Metastatic disease: FLAWS, bone pain

Examination is likely to be normal, but there may be a pelvic mass

Question 5

What are the differentials for haematuria?

Answer 5

UTI
Nephrolithiasis
Trauma
Interstitial cystitis

Question 6

How to investigate suspected bladder cancer?

Answer 6

Flexible cystoscopy
CT urogram to image the upper urinary tract
Urine cytology to pick up high grade cancer
Biopsy of bladder lesion

Staging investigations: bloods, CT CAP, MRI, bone scan

Question 7

How to stage bladder cancer?

Answer 7

TNM staging

Ta and T1 = non-muscle invasive
T2 - 4 = muscle-invasive

Question 8

How to grade bladder cancer?

Answer 8

G0 to G3 based on how differentiated the cancer is

G3 = highest risk of recurrence

Question 9

How to manage non-muscle invasive bladder cancer?

Answer 9

MDT

TURBT +/- intravesical mitomycin C
Specimen is analysed for muscle involvement (if the specimen doesn’t contain any muscle, a re-resection will be required within 6 weeks)

The remainder of the management depends on their grade/risk:

Low risk - follow-up flexible cystoscopy at 3 months and 12 months

Intermediate risk - consider 6 weeks mitomycin C, follow-up flexible cystoscopy at 3, 9, 18 months and then annually, consider discharge at 5 years

High risk - re-resected ASAP no later than 6 weeks, followed by intravesical BCG or radical cystectomy, follow-up flexible cystoscopies

Question 10

How to manage muscle invasive bladder cancer?

Answer 10

MDT

Offer radical cystectomy or radical radiotherapy +/- neoadjuvant chemotherapy (cisplatin-based)