Cancer - Bladder and Upper Tract (Urothelial Carcinoma/TCC) Flashcards
Where are most Transitional Cell Carcinomas found?
Bladder
What other types of TCC can present despite urothelial carcinoma?
Squamous cell cacrinoma - in countries where schistosomiasis is endemic
Adenocarcinoma - Rare Urachal malignancy
What is TCC?
Transitional cell carcinoma
TCC risk factors?
Smoking
Aromatic Amines (Hairdressers using darker dyes)
Non-hereditary genetic abnormalities
Squamous cell carcinoma risks?
Schistosomiasis
Chronic cystitis (UTIs, catheters & stones)
Cyclophosphamide
Pelvic RT
Typical bladder cancer presentation?
Painless haematuria
Can have mets/invasive symptoms
Recurrent UTIs
Storage LUTS suggest a carcinoma in situ
What are the LUTS?
Lower UT symptoms - divided into storage/filling/irritative AND Voiding or obstructive symptoms
What are the Storage LUTS?
Increased frequency
Dysuria and bladder pain
Nocturia
Increased urge
What are the voiding/obstructive LUTS?
Poor stream Incomplete voiding Hesitancy Terminal dribbling Signs of urinary retention
Bladder cancer investigations?
Patients who have painless haematuria - USS and C T urogram
Also BP and Us and Es as standard
Follow up with cysto-urethroscopy and biopsy
Other tests for bladder cancer?
MSSU - rules out a UTI
Urine cytology - useful in high grade urothelial cancer
What tests are used to stage bladder cancer?
CT/MRIs
Bone scans looking for mets
CT-Urogram looking for upper tract tumours
Major treatments for bladder cancer?
Endoscopic resection - TURBT
Fluorescent cystoscopy
Intravesicle chemo
Intravesicle BCG therapy
Radiotherapy
Radical surgery
BCG therapy?
Bacillus Calmette-geurin Therapy
A bacteria similar to M.tuberculosis but without the serious disease
Stimulates immune response which helps fight cancer
How is bladder cancer staged?
Using classic TNM - T is if it is muscle invasive or non-MI/superficial
How is bladder cancer GRADED?
G1 - well differentiated, less aggressive, commonly non-invasive
G2 - moderately differentiated - often non-invasive
G3 - Poorly differentiated, more aggressive and often invasive
CIS grading - carcinoma in situ = non-muscle invasive BUT very aggressive and has a different treatment plan
What’s the prognosis for bladder cancer?
Non-invasive low grade cancer is good - 90% 5 yr survival
Invasive high grade or CIS is bad - 50% 5 yr survival
How would you treat a low grade non-muscle invasive cancer?
1) Endoscopic resection (TURBT)
2) Followed by 1 dose of intravesicle chemo (Mitomycin C)
Then endoscopic follow ups to monitor, if it recurs do 6 wks of intravesicle chemo
What is a TURBT?
Transurethral Resection of Bladder Tumor
How would you treat a high grade non-muscle invasive cancer?
Endoscopic TURBT
Followed by intravesicle BCG therapy (Weekly for 3 wks every 6 months for 3 yrs)
What happens if a patient becomes refractory to BCG therapy?
Radical Surgery
How would you treat a muscle invasive bladder cancer?
Neoadjuvant Chemo followed by either:
1) Radical radiotherapy + Extended Lymphadenectomy + radical cystoprostatectomy (men) or Anterior Pelvic Exenteration with Urethectomy (women)
2) Incontinent Urinary Diversion & Ileal Conduit
What areas outside the bladder are mostly affected by TCC?
The renal pelvis or calyces
How would a TCC in the pelvis or calyces present?
- Frank haematuria
- Unilateral Ureteric obstruction
- Flank or loin pain
- Metastatic symptoms incl. hypercalcaemia and bone pain
How do you diagnose an upper tract TCC?
- CT-U
- Urine cytology
- Ureteroscopy & Biopsy
How is an upper tract TCC managed?
A nephro-ureterectomy (endoscopic resection only appropriate if low grade and unifocal)
Surveillance cystoscopies monitoring for synchronous bladder TCCs over the next 10 yrs
