Bladder Cancer Flashcards
How common is bladder cancer?
Most common cancer of the renal system
What are the risk factors for bladder cancer?
- Age > 80yrs
- Men (3:1)
- Smoking
- Exposure to aeromatic hydrocarbons (e.g. industrial dyes or rubbers)
- Schistosomiasis infection (specifically causing the SCC subtype)
- Previous radiation to the pelvis.
What are the different types of bladder cancer & what proportion of cases do they make up?
- Transitional cell carcinoma (>90% of cases)
- Squamous cell carcinoma ( 1-7% - except in regions affected by schistosomiasis)
- Adenocarcinoma (2%)
- Sarcoma (rare)
What is a transitional cell carcinoma?
Cancer of the transitional epithelium (urothelium) of the bladder.
What are the 4 layers of the bladder wall (from inside to outside) ?
- Transitional epithelium (Urothelium)
- Inner lining of bladder
- Lamina propria
- 2nd layer made up of connective tissue
- Muscularis propria
- 3rd layer
- Fatty connective tissue
- Outer layer
How does TCC present?
- Painless haematuria (Visible / Non-visible)
- Recurrent UTIs
- Lower urinary tract symptoms (LUTS)
- Frequency
- Urgency
- Feeling of incomplete voiding.
- Systemic symptoms (e.g. weight loss or lethargy)
What signs may be present on examination of a patient with TCC?
In early disease examination is typically unremarkable can show signs such as:
- Urinary retention
In metastatic disease may present with
- Enlarged pelvic lymph nodes – lymphatic spread
- Hepatomegaly – liver metastases
- Bone pain – bony metastases
What are your differentials?
- UTIs
- Renal calculi
- Prostate / renal cancer
What investigations are used to investigate suspected bladder cancer?
- Usual haematuria work-up
-
Urgent flexible cystoscopy (under local anaesthetic)
* All cases of haematuria should be investigated with cystoscopy -
Rigid cystoscopy (after initial cystoscopy)
* For more definitive assessment under general anaesthetic -
Biopsy
* If tumour identified on rigid cystoscopy
+/- transurethral resection of bladder (TURBT)
- If found to be superficial
4. CT urogram - For any suspected muscle-invasive bladder cancer, prior to any resection performed at TURBT
5. Urine cytology - To identify cancerous cells (has poor sensitivity and so not routinely done)
Why is urine cytology not routinely done?
It has poor specificity & sensitivity
What is a CT urogram?
CT imaging with contrast used to evaluate urinary tract including kidneys, bladder, ureters
- · Different to CT KUB which doesn’t use contrast
When would you do TURBT on initial assessment vs. after biopsy?
If the growth is superficial - Do TURBT on initial assessment
If growth seems invasive - Do TURBT after biopsy results
What is a TURBT?
Resection of bladder tissue by diathermy during rigid cystoscopy
- To remove cancerous tissue
- Performed under general / regional anaesthetic
- Can be used for biopsy to stage disease
How is bladder cancer staged?
What is non-muscle-invasive bladder cancer?
Bladder cancer that does not penetrate into the deeper layers of the bladder wall (around 70-80% cases)
- TNM staging = Tis / Ta / T1
What is muscle-invasive bladder cancer?
Bladder cancer that penetrates into the muscular layers of the bladder wall (deeper)
- TNM staging = T2, T3
What is locally advanced / metastatic bladder cancer?
Bladder cancer that is spreading through the bladder wall to distal structures
(e.g. local / distant structures or to lymph nodes)
- TNM = T4 , N1/2, M1
How do you manage non-muscle-invasive bladder cancer?
-
TURBT
* For CIS or T1 tumours
+/- Adjuvant intravesical therapy (e.g. BCG / Mitomycin C)
- Cases with deemed higher risk disease, even in non-invasive
2. Radical cystectomy -
High-risk disease / limited response to initial treatments.
3. Routine follow-up with regular surveillance via cytology and cystoscopy.
What is the recurrence rate for superficial bladder tumours? & How does this impact management?
They have a high rate of recurrence with around 70% recurring within 3 years & these recurrences are more likely to be more invasive.
This is why all patients require regular surveillance w/ cytology & cystoscopy
How do you manage muscle-invasive bladder cancer?
- Radical cystectomy
with urinary diversion via:
- Ileal conduit w/ urine draining via urostomy
- Bladder reconstruction from a segment of small bowel (Neobladder)
-
Neoadjuvant chemotherapy
* Typically with a cisplatin combination regimen. -
Regular follow-up w/ CT imaging
* To monitor for local and distant recurrence.
What is radical cystectomy?
Surgical procedure in which bladder & surrounding organs removed:
- In men – bladder, prostate, seminal vesicles and surrounding lymph nodes are removed
- In women – bladder, ovaries, Fallopian tube, uterus, cervix and part of the vagina and surrounding lymph nodes are removed
What are the different types of urinary diversion?
- Ileal Conduit
* Allows urine to drain through stoma and into external bag affixed to abdomen - Continent diversion / Indiana pouch
* Harvested intestine used to form internal pouch that collects urine which is then drained using catheter through stoma (small opening) on abdomen - Neobladder
* Harvested intestine used to form internal pouch that collects urine which is voided normally though urethra
What are the 2 options for urine drainage after formation of a neobladder?
Urine can drain either:
Urethrally or via catheter
What follow up is essential with patients who recieve a neobladder? & why?
Routine bloods, B12 and folate levels should be checked at least annually
Macrocytic anaemia can develop due to B12 deficiency as resection of part of ileum will affect B12 absorption
