GU Cancer: Bladder Cancer

Question 1

Definition

Answer 1

Transitional cell carcinoma in the bladder arises from the endothelial lining (urothelium). The majority are superficial (not invading the muscle) at presentation.

Question 2

Risk factors

Answer 2

• Smoking
• Increased age = 73
• Aromatic amines = used in dye and rubber industries but have been heavily regulated or banned for many years (painter, hairdresser, mechanic working with tyres)
• Chemo + radio
• Schistosomiasis causes squamous cell carcinoma of the bladder in countries with a high prevalence of the infection.

Question 3

TOM TIP

Answer 3

The typical presentation to look out for in your exams is a retired dye factory worker with painless haematuria. Whenever an exam question mentions a patient’s occupation, it is almost certainly relevant and will tell you the diagnosis. Dye factory workers get transitional cell carcinoma of the bladder. Patients with asbestos exposure get mesothelioma. Outdoor workers with significant sun exposure get skin cancer.

Question 4

Types of cancer

Answer 4

• Transitional cell carcinoma (90%)
• Squamous cell carcinoma (5% – higher in areas of schistosomiasis)
• Rarer causes are adenocarcinoma (2%), sarcoma
• Small-cell carcinoma

Question 5

Signs and Symptoms

Answer 5

Aged over 45 with painless haematuria without UTI or persisting after treatment for a UTI
Aged over 60 with microscopic haematuria (+ve on dipstick) PLUS:
- Dysuria or
- Raised white blood cells on a FBC

Question 6

Staging

Answer 6

The TNM staging system:
- T (tumour),
- N (lymph node)
- M (metastasis) stages.
There is a clear distinction between:
- Non-muscle-invasive bladder cancer (not invading the muscle layer of the bladder)
- Muscle-invasive bladder cancer (invading the muscle and beyond)
Non-muscle-invasive bladder cancer includes:
- Tis/carcinoma in situ: cancer cells only affect the urothelium and are flat
- Ta: cancer only affecting the urothelium and projecting into the bladder
- T1: cancer invading the connective tissue layer beyond the urothelium, but not the muscle layer

Invasive bladder cancer includes T2 – 4 and any lymph node or metastatic spread.

Question 7

Diagnosis

Answer 7

GOLD STANDARD = Flexible Cystoscopy

Question 8

Treatment

Answer 8

Conservative = support e.g. specialist nurse
Medical = chemo/radio
Surgery = transurethral resection of bladder tumour or cystectomy