Bladder cancer

Question 1

Describe bladder cancer?

Answer 1

• Develops from the lining of the bladder
• Most common tumour of the urinary system
• More common in men (3:1)
• Most are superficial, => good prognosis

Question 2

What are the subtypes of bladder cancer?

Answer 2

• Transitional cell carcinoma (80-90%)
• Squamous cell carcinoma
• Adenocarcinoma (rare)
• Sarcoma (rare)

Question 3

How can bladder cancer be further classified?

Answer 3

• Non-muscle-invasive bladder cancer (80%)
  
  • Does not penetrate into the deep layers of the bladder wall
• Muscle-invasive bladder cancer
  
  • Penetrates into the deeper layers of the bladder wall
• Locally advanced/metastatic bladder cancer

Question 4

Describe the anatomy of the bladder wall?

Answer 4

• 4 layers (important for classification):
  
  • Transitional epithelium (urothelium) - inner lining
  • Lamina propria (connective tissue) - second layer
  • Muscularis propria (muscle) - third layer
  • Fatty connective tissues - outer layer

Question 5

What are the risk factors for bladder cancer?

Answer 5

• Smoking
• Increasing age
• Exposure to aeromatic hydrocarbons
• Schistosomiasis infection
• Previous pelvis radiation

Question 6

Describe the clinical features of bladder cancer?

Answer 6

• Painless haematuria
• Recurrnet UTIs or LUTS
  
  • Frequency, voiding, urgency
• Pelvic pain, bone pain, weight loss, lethargy

Question 7

Describe the staging of bladder cancer?

Answer 7

TNM staging

Question 8

Differentials for bladder cancer symptoms?

Answer 8

• UTIs
• Renal calculi
• Prostate or renal cancer

Question 9

Describe the investigations which should be performed in someone who is suspected of bladder cancer?

Answer 9

• Urgent cystoscopy
  
  • Initially via flexible cystoscopy under LA
  • If lesion is found then rigid cystoscopy under general for definitive assessment
• CT scan if suspected muscle-invasive bladder cancer
• Urine cytology

Question 10

Describe the management of non-invasive bladder cancer?

Answer 10

• Carcinoma in-situ or T1 tumours:
  
  • Resected via TURBT
• Higher risk disease:
  
  • Adjuvant intravesical therapy
    
    • BCG
    • Mitomycin C
• No response to treatment:
  
  • Radical cystectomy
• ** High rate of recurrence: regular surveillance via cytology and cystoscopy

Question 11

Describe TURBT?

Answer 11

• Transurethral resection of bladder tumour
• Resecetion by diathermy during rigid cystoscopy
• Intravesical treatments may be instilled into the bladder following the procedure

Question 12

Describe the treatment of muscle-invasive bladder cancer?

Answer 12

• Radical cystectomy (complete removal of bladder)
  
  • • neoadjuvant chemoterhapy (cisplatin combination therapy)
• Following cystectomy, patients require urinary diversion:
  
  • Ileal conduit formation
  • Bladder reconstruction
• Regular follow-up CT

Question 13

Describe ileal conduit formation?

Answer 13

Urine drains via urostomy

Question 14

Describe bladder reconstruction?

Answer 14

• Reconstruction from segment of small bowel (neobladder)
• Urine drains urethrally or via catheter

Question 15

Describe the treatment for locally advanced / metastatic bladder cancer?

Answer 15

• Chemotherapy
  
  • Cisplatin based regimen OR
  • Carboplatin + gemcitabine regimen
• Symptom management

Question 16

For a patient presenting with new visible haematuria, what is the recommended first-line investigations (after routine bloods and urine dipstick testing)?

Answer 16

CT scan KUB + flexible cystoscopy

Question 17

In a patient who has undergone an ileal conduit formation, what is the most likely cause of their macrocytic anaemia?

Answer 17

B12 deficiency