Bladder Cancer

Question 1

Epidemiology of bladder cancer

Answer 1

Fourth most prevalent malignant disease in men
Occurs four times more often in men than women
Incidence peaks in the seventh decade and the average age at diagnosis is 73

Question 2

Prognostic indicators bladder cancer

Answer 2

Tumour extent and depth of muscle invasion are important factors.
Tumour morphology is also important
- papillary tumours are usually low grade and superficial with a favourable prognosis
- infiltrating lesions are higher grade and typically have nodal involvement.

Question 3

Anatomy of bladder

Answer 3

When empty lies within the true pelvis.
The superior portion of the bladder is covered with the peritoneum.
The ureters pierce the wall obliquely and during contraction are compressed to prevent reflux.
Perivesical tissue: a layer of fat surrounding the bladder

Question 4

Trigone of the bladder

Answer 4

Is a triangular portion of the bladder that contains the ureter orifice as well as the urethra orifice.

Question 5

Lymphatics of the bladder

Answer 5

Form two plexus
1. in the sub-mucosa
2. in the muscular layer
they follow the blood vessels and ultimately end up in the internal iliac nodes. Some may find their way to the external iliac nodes.

Question 6

Clinical presentation of bladder cancer

Answer 6

Most patients (75-80%) present with painless hematuria. 
Almost all patients with carcinoma in situ experience frequency, urgency, dysuria and hematuria.

Question 7

Pathology of bladder cancer

Answer 7

98% are epithelial in origin.

• 92% are transitional cell carcinomas
• 6-7% are squamous cell carcinomas
• 1-2% are adenocarcinomas

Question 8

Morphology of bladder cancer

Answer 8

1. papillary (70%)
2. papillary infiltrating (25%)
3. solid infiltrating (25%)
4. non-papillary, non-infiltrating or carcinoma in situ (5%)

Question 9

Local extension of bladder cancer

Answer 9

Intraepithelial involvement of the distal ureters, prostatic urethra periurithelial prostatic ducts are most commonly found.

Question 10

Most common sites of distant metastasis bladder cancer

Answer 10

Lung
Bone
Liver

Question 11

Ta stage bladder cancer

Answer 11

Non-invasive papillary carcinoma

Question 12

T1 stage bladder cancer

Answer 12

Tumour invades subepithelial connective tissue

Question 13

T2 stage bladder cancer

Answer 13

Tumour invades muscle
T2a: tumour invades superficial muscle (inner half)
T2b: tumour invades deep muscle (outer half)

Question 14

T3 stage bladder cancer

Answer 14

Tumour invades perivesical tissue
T3a: microscopically
T3b: macroscopically

Question 15

T4 stage bladder cancer

Answer 15

T4a: tumour invades prostate, uterus, vagina
T4b: tumour invades pelvic wall, abdominal wall

Question 16

N1 stage bladder cancer

Answer 16

Metastasis in a single lymph node 2cm or less in greatest dimension

Question 17

N2 stage bladder cancer

Answer 17

Metastasis in a single lymph node >2cm but <5cm in greatest dimension
OR
Multiple lymph nodes none >5cm in greatest dimension

Question 18

N3 stage bladder cancer

Answer 18

Metastasis in a lymph node, more than 5cm in greatest dimension

Question 19

Treatment options for in-situ bladder cancer

Answer 19

Radical cystectomy is usually curative.
Although typically a less invasive approach is used.
For lesions <5 cm electrofulguration followed by chemotherapy is done.

Question 20

Treatment options for Ta and T1 bladder cancer

Answer 20

Transurethral resection and fulguration.
T1 patients that the tumour involves prostatic urethra, ureters and bladder neck are harder to treat locally and therefore usually require cystectomy.

Question 21

Partial cystectomy treatment use bladder cancer

Answer 21

Used for patients with relatively small, solitary, well-defined lesions with muscle invasion or superficial disease not suitable for transurethral resection.

Question 22

Radical cystectomy treatment use bladder cancer

Answer 22

Recommended for superficial lesions (Tis, Ta, T1) that have recurred after conservative management has been done.
For clinical stages T2, T3 and resectable T4a disease, radiation cystectomy is commonly used. Although pre-operative radiotherapy is not as commonly used it can be done for T3 or T4a disease that resectability is questionable. (45Gy in 25# has been shown to be effective for this purpose.

Question 23

EBRT (radical) treatment of bladder cancer

Answer 23

Ideal patients should have adequate bladder capacity without voiding problems or incontinence.
40% of patients have bladder free tumour after radiation dose alone.
Typical dose: 65Gy to 70Gy

Question 24

Chemoradiation for bladder cancer

Answer 24

Due to the high rate of local recurrence and the chance of distant mets this option can be beneficial.
Chemo can help sensitize the tumour as well as control metastatic spread.
Patients with T2 or T3 stage and muscle invasion are candidates.
Typically doses of 40-45Gy for larger fields include lymph nodes. Followed by a boost to the bladder for a total of 65Gy.

Question 25

Field borders for bladder cancer

Answer 25

Inf: caudal border of obturator foramen.
Superiorly: S1/L5 interspace
Laterally: 1.5cm laterally to the pelvic brim
Ant: 1cm anterior to the bladder or 1cm anterior the symphysis whatever is more anterior.
Post: 2cm posterior the most posterior portion of the bladder or tumour is seen on the CT scan.