Bladder cancer Flashcards
What type of cancer are most bladder cancers?
Transitional cell carcinomas - 90%
Squamous cell carcinomas - 10%
How common is bladder cancer? Who is most affected?
- Ranks ninth in worldwide cancer incidence.
- Europe, North America, Syria, Israel, Egypt, and Turkey have the highest incidence rates and SE Asian countries the lowest rates.
- More than 75 of new cases occur in people >65 years of age.
- M:F 3:1 but women tend to have a poorer prognosis as present with muscle invasive disease
What are the histological subtypes of bladder cancer?
Urothelial carcinoma (previously termed transitional cell carcinoma): >90%
Squamous cell carcinoma: approximately 5%
Adenocarcinoma: approximately 1%
What are the risk factors for bladder cancer?
- Tobacco - biggest RF x2-3
- Chemical carcinogens - (e.g. aromatic amines in rubber/dye industries, polycyclic aromatic hydrocarbond in aluminium, coal and roofing and arsenic exposure in drinking water, hairdressers, painters, medics)
- Age >55yrs
- Pelvic radiation
- Systemic chemotherapy
- Schistosoma infection → SCC subtype unlike the others
- Male sex
- Chronic bladder inflammation
- Positive FH
- T2DM
What are the clinical features of bladder cancer?
Painless haematuria (gross or microscopic) - present in over 80% of patients. Episodes typically intermittent (so often leads to wrong conclusion that Abx therapy was ineffective)
FUND (not HIPS)
- Dysuria - typical of carcinoma in situ
- Frequency - rarely the sole symptom
FLAWS - Fever, Lethargy, Appetite loss, Weight loss, Sweats (night)
5% of patients have metastatic disease, usually to lymph nodes, lung, liver, bone and CNS. Around 30% have involvement of the muscle layer.70% have superficial disease, of which 10% is carcinoma in situ.
When should you refer a patient urgently for urological assessment?
- Adult >45 with unexplained visible haematuria w/o UTI or one which recurs after successful UTI treatment
- Adults >60 with unexplained non-visible haematuria + dysuria +/- raised WCC on blood test
What investigations would you do for suspected bladder cancer?
Initial (e.g. GP setting):
- *Urinalysis - haematuria
- *Urine cytology - but -ve results do not exclude cancer. Positive in >90% of patients with CIS or high-grade tumours and in 33% of patients with low-grade tumour
- *FBC - exclude anaemia
- *U&Es
Refer to urology→
- *Flexible Cystoscopy - permits direct inspection of bladder and biopsy of suspicious lesions. + pathological diagnosis with TURBT.
- *CT urogram - filling defect
- *USS KUV - may show tumour or upper tract obstruction; use especially in non-visible haematuria
After resection:
- Bone scan - for metastases
- CT chest/abdo/pelvis for muscle-invasive cancer
What are the two groups of LUTS? (lower urinary tract symptoms)
Storage/irritative - FUND
- Frequency
- Urgency
- Nocturia
- Dysuria
Voididng/obstructive - HIPS
- Hesitancy
- Incomplete emptying
- Poor stream
- Straining
Others: terminal dribbling, overflow incontinence
A 75-year-old owner of a dye factory has experienced 4 episodes of ‘bright red’ blood in his urine over the past 2 weeks. He does not feel any pain when urinating. He has also noticed that he has lost weight recently despite not changing his eating habits or exercise levels. What is the most likely diagnosis?
A Pyelonephritis
B Glomerulonephritis
C Bladder Cancer
D Prostate Cancer
E Ureteric Stone
What is the management of bladder cancer?
Guided by tumour grade and stage determined at initial resection, usually extending to detrusor muscle.
Non-invasive disease:
- TURBT
- Intravesical chemotherapy (e.g. mitomycin, epirubicin) weekly for 6 weeks
- Intravesical BCG
Invasive disease:
- Radical cystectomy and node dissection
- Chemotherapy and radiation
- Immunotherapy with immune checkpoint inhibitors
Metastatic disease:
- Systemic chemotherapy (MVAC)
- Immunotherapy
- Radiotherapy - for symptom control
What are the complications of bladder cancer?
- Prostatic urothelial carcinoma
- Upper tract urothelial carcinoma
- Hydronephrosis
- Urinary retention
What is the prognosis with bladder cancer?
Most present with low grade tumours which are non-invasive but high risk of tumour recurrence after treatment
Once muscle invasion occurs survival is 50% even with radical cystectomy
Immunotherapy has revolutionised treatment of those with metastases
What % of patients with unexplained visible haematuria have malignancy?
20%
Non visible → 5% have cancer
What type of investigation is shown?
CT urogram
What type of investigation is shown?
CT urogram
What is the process for TURBT?
- GA or Spinal anaesthetic
- Resect Tumour incl muscle specimen
- +/- Intravesical Mitomycin
- 3 way catheter, irrigation
- Usually overnight stay in hospital
What follow up investigations should you do after TURBT?
CT urogram + CT chest
Summarise the staging for bladder tumours.
Simple: non-muscle invasive vs muscle invasive
Ta-T1 are non-muscle invasive.
T staging:
Ta - non-invasive papillary cancer
Tis – carcinoma in situ – high grade
T1 – tumour invades submucosa
T2a – superficial muscle
T2b – deep muscle
T3a – perivesical tissue microscopically
T3b – perivesical tissue macroscopically
T4a – prostate, uterus, vagina
T4b – pelvic wall or abdominal wall
What procedure is done after cystecomy? What are the complications of this procedure?
Ileal conduit → stoma
Complications: ileus, urinary leak, enteral leak, stoma problems
What are the differentials for haematuria?
Infection (UTI, schistosomiasis, TB)
Bladder cancer
Radiation cystitis
Calculi
Upper tract TCC
Renal cancer
Prostatic bleeding
Prostate cancer
Prostatic or other trauma
(categorise by anatomy)
