Bladder cancer

Question 1

How common is bladder cancer?

Answer 1

7th most common in the UK.

9th in worldwide cancer incidence.

Question 2

What is the most common bladder cancer?

Answer 2

Over 90% of cancers of the urinary bladder are urothelial carcinoma.
Non-muscle invasive tumours are most common (75-80%).

Question 3

Gold standard investigations for bladder cancer

Answer 3

Cystoscopy and urinary cytology are key to making the diagnosis.
Screening for haematuria appears to markedly improve the prognosis of bladder cancer.

Question 4

What is the primary symptom of bladder cancer?

Answer 4

Frank painless haematuria

Question 5

———- are papillary and generally easy to visualise.

Answer 5

Low-grade tumours.

High-grade tumours are often flat or in situ and can be difficult to visualise.

Question 6

Treatment of muscle-invasive tumours?

Answer 6

Radical cystoprostatectomy is usually advised.

Question 7

Aetiology of bladder cancer

Answer 7

Smoking is the most important causative factor.
Second-hand smoke, occupational exposure to chemical carcinogens such as aromatic amines used in rubber and dye industries.
People with T2DM may be at an increased risk.

Question 8

What increases the risk of squamous cell carcinoma of the bladder?

Answer 8

Chronic inflammation, Schistosoma infection and chronic indwelling catheters.

Question 9

Classification of bladder cancer

Answer 9

TNM is used for the staging of bladder tumours.
Based on biopsy results, physical examination, and imaging studies, bladder tumours are staged according to their level of invasion.
The most widely used and universally accepted staging system is the tumour-node-metastases (TNM) system.

Question 10

T in TNM for bladder cancer

Answer 10

T: primary tumour
TX: primary tumour cannot be assessed
T0: no evidence of primary tumour
Ta: non-invasive papillary carcinoma
Tis: carcinoma in situ: ‘flat tumour’
T1: tumour invades subepithelial connective tissue (lamina propria)
T2: tumour invades muscularis propria:
T2a: tumour invades superficial muscularis propria (inner half)
T2b: tumour invades deep muscularis propria (outer half)
T3: tumour invades perivesical tissue:
T3a: microscopically
T3b: macroscopically (extravesical mass)
T4: tumour invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina, pelvic wall, abdominal wall
T4a: tumour invades prostatic stroma, uterus, or vagina
T4b: tumour invades pelvic wall or abdominal wall.

Question 11

N in TNM for bladder cancer

Answer 11

N: lymph nodes
NX: Regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: metastasis in a single lymph node in the true pelvis (hypogastric, obturator, external iliac, or presacral)
N2: metastasis in multiple regional lymph nodes in the true pelvis (hypogastric, obturator, external iliac, or presacral)
N3: metastasis in a common iliac lymph node(s).

Question 12

M in TNM for bladder cancer

Answer 12

M: distant metastasis
M0: no distant metastasis
M1a: non regional lymph nodes
M1b: other distant metastasis.

Question 13

Diagnosis of bladder cancer

Answer 13

Symptoms guide the workup:
Renal colic should prompt imaging studies with CT or plain X-rays for stone disease.
Acute onset of frequency and dysuria should prompt urine culture (with antibiotic treatment if indicated)
Failure to confirm either of these diagnoses should result in evaluation for bladder cancer with urinalysis, urine cytology and cystoscopy.

Question 14

Signs & symptoms of bladder cancer

Answer 14

-Haematuria (gross painless haematuria which is present throughout the entire urinary stream)
-Dysuria:
Typical of carcinoma in situ but also seen in high-grade urothelial carcinoma
Associated with aggressive bladder cancer
-Urinary frequency

Question 15

Risk factors of bladder cancer

Answer 15

Tobacco exposure (2-4 fold increased risk)
Chemical carcinogens
Age > 55 years (more than 90% of patients present after the age of 55)
Pelvic radiation
Systemic chemotherapy (cyclophosphamide increases the risk of bladder cancer)
Schistosoma infection
Male sex (fourfold greater risk)
Chronic bladder inflammation
Postive FHx

Question 16

Investigations for bladder cancer

Answer 16

Urinalysis 
Urine cytology
Cystoscopy 
CT urogram 
Renal and bladder ultrasound- bladder tumours may be seen
IV urogram- filling defects indicative of bladder tumour
FBC- usually normal 
Chemistry profile including ALP 
CXR
CT abdomen and pelvis 
Bone scan 
Urinary markers

Question 17

Differentials of bladder cancer

Answer 17

BPH
Haemorrhagic cystitis 
Prostatitis 
UTIs
Nephrolithiasis 
Renal cell carcinoma 
Renal urothelial carcinoma 
Gynaecological cancer or other pelvic cancers 
Radiation cystitis 
Diverticulitis

Question 18

Histology of the bladder

Answer 18

The bladder is lined by transitional epithelium (TE) which is made up of multiple layers of epithelial cells which can contract or stretch.
TE is usually found in the bladder, ureters and upper urethra.
Cells appear cuboidal when the organ is not stretched.

Question 19

Management of bladder tumour

Answer 19

Treatment is usually guided primarily by tumour grade and stage determined at initial resection.
Accurate staging, which requires resection into detrusor muscle is key.
Non-surgical candidates are treated with chemotherapy and radiation.

Question 20

Treatment of non-muscle invasive tumours

Answer 20

Low risk:
Transurethral resection + immediate post-operative intravesical chemotherapy (mitomycin usually used)
Immediate risk:
Transurethral resection + immediate post-operative intravesical chemotherapy (mitomycin usually used)+ delayed intravesical bacille Calmette-Guerin (BCG) immunotherapy or intravesical chemotherapy.
High risk:
Transurethral resection + immediate post-operative intravesical chemotherapy (mitomycin usually used)+ delayed intravesical bacille Calmette-Guerin (BCG) immunotherapy
2nd line: Radical cystectomy

Question 21

Treatment of locally invasive tumours

Answer 21

-Organ-contained T2a or T2b:
Radical or partial cystectomy with pelvic lymph node dissection
Preoperative chemotherapy (MVAC- methotrexate, vinblastine, doxorubicin and cisplatin)
Postoperative chemotherapy (MVAC) or chemoradiotherapy
2nd line: immunotherapy (atezolizumab, pembrolizumab)
-Non-organ contained T3a or T3b:
Radical cystectomy with pelvic lymph node dissection
Preoperative chemotherapy (MVAC- methotrexate, vinblastine, doxorubicin and cisplatin)
Postoperative chemotherapy (MVAC) or chemoradiotherapy
2nd line: immunotherapy (atezolizumab, pembrolizumab)
-Non-organ contained T4a or T4b:
Chemotherapy (MVAC)
Radiotherapy
Radical cystoprostatectomy
2nd line: immunotherapy (atezolizumab, pembrolizumab)

Question 22

Treatment of metastatic disease

Answer 22

1st line:
Chemotherapy (cisplatin, gemcitabine, paclitaxel) if CI then MVAC+ surgery or radiotherapy
2nd line:
immunotherapy (atezolizumab, pembrolizumab)

Question 23

Complications of bladder cancer

Answer 23

Prostate cancer
Hydronephrosis
Urinary retention

Question 24

What is the grading used for bladder cancer?

Answer 24

Grade 1: Least aggressive/well-differentiated histologically
Grade 2: Intermediate
Grade 3: Most aggressive/least well-differentiated histologically

Question 25

What does follow-up consist of?

Answer 25

History, examination and regular cystoscopy:
High-risk tumours: every 3 months for 2 years, then every 6 months.
-Low-risk tumours: first follow-up cystoscopy after 9 months, then yearly