Bladder cancer (URO) Flashcards
What type of cancer is the majority of bladder cancer?
Transitional cell carcinoma AKA urothelial carcinoma (90%)
Rarely, cancers may be squamous cell carcinomas associated with chronic inflammation e.g. schistosomiasis
What is the most causative risk factor for bladder cancer?
Smoking
Describe the epidemiology of bladder cancer. (2)
- M>F
- > 65 years
What do non-invasive bladder cancers include? (3)
- papillary tumours confined to the epithelial mucosa (Ta)
- tumours invading the subepithelial tissue i.e. lamina propria (T1)
- carcinoma in situ (Tis)
What do muscle-invasive bladder cancers include? (3)
- organ-confined tumours: invade muscularis propria (T2a/T2b)
- non-organ-confined tumours: invade perivesical fat (T3a/T3b)
- tumours invade adjacent organs: prostate stroma, seminal vesicles, uterus, vagina, pelvic wall, abdominal wall (T4a/T4b)
What chromosomes are involved in bladder cancer?
- loss of heterozygosity in chromosome 9q is common in non-invasive tumours (favourable prognosis)
- loss of tumour suppressor genes Rb + p53 is associated with invasive tumours (unfavourable prognosis)
What are some general risk factors for bladder cancer? (9)
- smoking
- exposure to chemical carcinogens (aromatic amines in rubber/dye industries, polycyclic aromatic hydrocarbons in aluminium)
- age>65
- pelvic radiation
- systemic chemotherapy
- Schistosoma infection
- male sex
- chronic bladder inflammation
- genetic predisposition
What are some risk factors for transitional cell carcinoma of the bladder? (7)
- smoking
- aniline dye (printing/textile industry e.g. 2-naphthylamine and benzidine)
- rubber manufacture
- cyclophosphamide
- pelvic radiation
- chronic UTIs
- positive Fx
What are some risk factors for squamous cell carcinoma of the bladder? (3)
- Schistosomiasis (endemic in Middle East)
- long-term catheterisation (>10y)
- smoking
Which occupations are high risk for bladder cancer? (2)
- painters
- hairdressers
What are the clinical features of bladder cancer? (3)
- painless haematuria (gross/microscopic) - intermittent episodes, Abx failed to treat, often macroscopic
- dysuria (painful urination) - associated with aggressive bladder cancer
- irritative/storage Sx –> urinary frequency and urgency
What is the first-line investigation for bladder cancer?
Urinalysis (bedside Ix) - haematuria and pyuria (WCC >10/mm3)
What investigation is key to diagnosing bladder cancer?
Cystoscopy and biopsy - visualises bladder tumours and enables pathological diagnosis
Which investigations are done for staging bladder cancer? (5)
- renal and bladder US - may see hydronephrosis due to tumour causing obstruction
- CT/MRI abdomen and pelvis
- imaging of upper urinary tract collecting system for non-invasive disease (Ta, Tis)
- IV urography - may show filling defects indicative of tumour, but small tumours often not visible
- CXR - for muscle invasive/lung metastases
What scan do we do to look for metastases in bladder cancer?
CXR - check for lung metastases / muscle-invasive cancer
What urinary biomarkers may be present in bladder cancer? (4, low yield)
- bladder tumour antigen (BTA)
- nuclear matrix protein 22 (NMP22)
- ImmunoCyt/uCyt+
- UroVysion
What is the next step for a >60y with unexplained non-visible haematuria and either dysuria or raised WCC on blood test?
Referred via 2WW suspected cancer pathway to exclude bladder cancer
What are some differential diagnoses for bladder cancer? (10)
- BPH (enlarged prostate DRE)
- haemorrhagic cystitis (acute onset)
- prostatitis (men<55)
- UTI
- nephrolithiasis
- renal cell carcinoma
- renal urothelial carcinoma
- gynaecological/pelvic cancers
- radiation cystitis
- diverticulitis
Describe the TNM staging for bladder cancer.
- T0: no evidence of tumour
- Ta: non-invasive papillary carcinoma
- T1: tumour invades sub-epithelial connective tissue (lamina propria)
- Tis: carcinoma in situ
- T2a: tumour invades superficial muscularis propria (inner half)
- T2b: tumour invades deep muscularis propria (outer half)
- T3: tumour extends to perivesical fat
- T4: tumour invades - prostatic stroma, seminal vesicles, uterus, vagina
- T4a: invasion of uterus, prostate or bowel
- T4b: invasion of pelvic sidewall or abdominal wall
- N0: no nodal disease
- N1: single regional lymph node in true pelvis
- N2: multiple regional lymph nodes in true pelvis
- N3: lymph node metastasis to common iliac lymph nodes
- M0: no distant metastasis
- M1: distant disease
How is non-muscle invasive and low risk bladder cancer managed?
Transurethral resection of bladder tumour (TURBT)
Plus immediate post-operative intravesical chemotherapy
How is muscle-invasive (T2) bladder cancer managed?
Radical cystoprostatectomy - removal of bladder, prostate and seminal vesicles, with bilateral pelvic lymph node dissection
How is metastatic (or locally advanced T4b or N2-3) bladder cancer managed?
Palliative systemic chemotherapy
2nd line - immunotherapy (delayed BCG, pembrolizumab, atezolizumab)
What are some complications of bladder cancer? (4)
- prostatic urothelial carcinoma
- upper tract (renal/ureteral) urothelial carcinoma
- hydronephrosis (tumour of trigone, urethral orifice or ureter can obstruct and cause renal damage)
- urinary retention (tumours at bladder neck can cause outlet obstruction)
What is the survival rate for non-invasive bladder cancer?
High
What is the survival rate for metastatic bladder cancer?
12%
Describe the TNM staging for bladder cancer.
- T0: no evidence of tumour
- Ta: non-invasive papillary carcinoma
- T1: tumour invades sub-epithelial connective tissue (lamina propria)
- Tis: carcinoma in situ
- T2a: tumour invades superficial muscularis propria (inner half)
- T2b: tumour invades deep muscularis propria (outer half)
- T3: tumour extends to perivesical fat
- T4: tumour invades - prostatic stroma, seminal vesicles, uterus, vagina
- T4a: invasion of uterus, prostate or bowel
- T4b: invasion of pelvic sidewall or abdominal wall
- N0: no nodal disease
- N1: single regional lymph node in true pelvis
- N2: multiple regional lymph nodes in true pelvis
- N3: lymph node metastasis to common iliac lymph nodes
- M0: no distant metastasis
- M1: distant disease
Describe the prognosis of different TNM stages of bladder cancer.
- T1 = 90%
- T2 = 60%
- T3 = 35%
- T4a = 10-25%
- any T, N1-N2 = 30%
