Cancer - Haematuria and Bladder

Question 1

Haematuria: what types are there?

Answer 1

• Visible
• Non visible: dipstick and microscopic

Question 2

What is the differential for haematuria?

Answer 2

Urological

• Cancer:
  
  • RCC
  • Upper tract TCC
  • Bladder carcinoma
  • Advanced prostate carcinoma
• Other:
  
  • Stones
  • Infection
  • Inflammation
  • Large BPH

Nephrological:

• Glomerular:
  
  • Goodpasture’s syndrome (anti-GBM disease)
  • Vasculitis (eg Anca)
  • Lupus
  • IgA nephropathy
  • Alport syndrome (thin GBM disease)

Question 3

What Ix would you perform in someone how had haematuria?

Answer 3

• Primary care Ix: eGFR, albumin: Creatinine ratio, urine dip MSU before referral to urology
• Endoscopy: flexi cystoscopy
• Radiology: US of urinary tract (look for hydronephrosis, stones, masses)
• Cytology: urine

Question 4

What is the epidemiology of blader cancer?

Answer 4

• Decreasing incidence due to falling rates of smoking
  
  • M:F is 3:1
  • White > non-white
• Mortality: falling (but less so in women)

Question 5

Name some risk factors for bladder cancer?

Answer 5

• Smoking: increases risk by 4x
• Occupational exposure (20 year latent period) – rubber or plastics (arylamines), handling of carbon/crude oil/combustion/smelting (polyaromatic hydrocarbons), painters, mechanics, printers, hairdressers
• Upper urinary tract TCC (40% risk of spread)

Question 6

What are the main types of bladder cancer?

Answer 6

• 90% are TCC
• 10% are SCC
• Rare causes: adenocarcinoma, sarcoma, small cell

Question 7

What is the most common presentation of bladder cancer? How would you investigate this?

Answer 7

• Painless haematuria
• Flexible cystoscopy and biopsy

Question 8

Outline the TM classification for bladder cancer

Answer 8

• T: see picture
  
  • Tis: 5%
  • Ta-T1: 75% (non muscle invasive)
  • T2-4: 20% (muscle invasive)
• N0: no regional lymph node mets
• N1: mets in single LN (less than 2 cm)
• N2: mets in single LN (2-5cm) or multiple LN (<5cm)
• N3: mets in LN >5 cm
• M0: no distant mets
• M1: distant mets

Question 9

Treatment: TCC without muscle involvement

Answer 9

• Low risk non-muscle invasive TCC: regular cystoscopies +/- TURBT
• Intermediate/high risk non muscle invasive TCC: TURBT + intravesical chemotherapy (BCG) – fever SEs b/c is localised Tx

Question 10

Treatment: muscle invasive TCC

Answer 10

• Potentially curative: neoadjuvant chemotherapy + radical cystectomy or radiotherapy
• Palliative: palliative chemotherapy or radiotherapy

Question 11

Treatment: metastatic TCC

Answer 11

• Systemic chemotherapy (traditional): cisplatin blased chemotherapy (need good U+Es)
• Biological therapies: Atezolizumab and Pembrolizumab – target Programmed Cell Death Receptor 1 (PCDR) and can be given with poor eGFR
• Palliative chemotherapy

Question 12

What type of reconstruction can you have with a bladder cystectomy?

Answer 12

• Ileal conduit with urostomy: most common outcome
• Bladder reconstruction: in younger/fitter patients