Urinary Bladder Cancer Flashcards
What is urothelial cancer?
It is defined as cancer that begins in the urothelium lining the renal pelvis, ureters and urinary bladder
What is another name for urothelial cancer? Why?
Transitional cell cancer
This is cancer due to the fact that the urothelium consists of transitional epithelial cells
What is the main urothelial cancer?
Bladder cancer
What are the six risk factors of bladder cancer?
Age, with individuals over the age of 55 having an increased risk
Gender, with males having an increased risk of bladder cancer
Family History, with individuals having an increased risk if their family members have received a diagnosis of bladder cancer or hereditary nonpolyposis colorectal cancer (HNPCC)
Smoking
Chemical Exposure, such as to aniline dyes, arsenic and 2-naphylamine
Previous Cancer Treatment, with cyclophosphamide and radiation therapies aimed at the pelvis increasing the risk of bladder cancer
What is the main risk factor of bladder cancer?
Smoking
Why does smoking increase the risk of bladder cancer?
This is due to harmful chemicals accumulating in the urine and thus damaging the lining of the bladder
Why do harmful chemicals increase the risk of bladder cancer?
This is due to the fact that the kidneys have a role in filtering harmful chemicals from the bloodstream into the bladder, which can therefore damage its lining.
What are the six clinical features of bladder cancer?
Haematuria, which is the presence of blood within urine.
Polyuria, which is an increased urine output > 3L per 24hrs
Urinary Urgency
Nocturia, which is clinically defined as waking up at night on more than one occasion to micturate
Dysuria, which is defined as painful or difficulty in urinating
Recurrent UTIs, which is defined as more than four urinary tract infections per year
What are the three types of haematuria?
Visible
Microscopic
Dipstick positive
What type of haematuria tends to present in bladder cancer?
Painless visible (frank) haematuria
Therefore, patients present with the appearance of pink-coloured urine
What four investigations are used to diagnose bladder cancer?
Cystoscopy
Ultrasound Scan
CT Urogram
Urine Cytology
What is the gold standard investigation used to diagnose urinary bladder cancer?
Cystoscopy
What is a cystoscopy?
It involves the clinician inserting a cystoscope camera through the urethra and into the bladder
This allows the examination of these structures for evidence of disease
During cystoscopy, a biopsy can be collected which can then be analysed histologically for the presence of cancerous cells.
What is fluorescent cystoscopy?
It involves intravesical instillation of a photosensitising agent
This is followed by cystoscopy with a fluorescent blue light source
What photosensitising agent is used in fluorescent cystoscopy?
5-ALA
How can fluorescent cystoscopy be used to diagnose bladder cancer?
Rapidly metabolising cells will result in reflected red light instead of blue
How is an ultrasound scan used to diagnose bladder cancer?
It is used to identify evidence of bladder cancer and to stage the cancer – by determining its size and the presence of metastases
What is a CT urogram?
An investigation using a CT scan and contrast medium to look at the urinary system
The contrast medium allows the urinary system to appear more clearly
How is a CT urogram used to diagnose bladder cancer?
It is used to identify evidence of bladder cancer and to stage the cancer – by determining its size and the presence of metastases
What is a urine cytology?
It involves the analysis of urine under a microscope – allowing cancerous cells to be identified
What two investigations are used to definitively diagnose bladder cancer?
CT urogram
Ultrasound scan
When do we conduct bladder cancer investigations when patients over the age of 50 present with visible haematuria?
Within 2 weeks
When do we conduct bladder cancer investigations when patients over the age of 50 present with microscopic or dipstick haematuria?
Within 4-6 weeks
What is grading?
The assessment of the cancer’s aggressiveness
What is grading based on?
It is based upon the cancer’s histological differentiation and therefore requires a bladder biopsy to be determined
What is grading used to determine?
Prognosis outcome
To guide treatment
How do we grade bladder cancer?
Low grade (G1)
High grade (G3)
What is low grade bladder cancer?
It is defined as a well differentiated tumour, in which cells are closer in appearance and organisation to normal cells
How do low grade bladder cancers grow and metastasise?
They grow slowly
They rarely invade the muscular wall of the bladder
What is high grade bladder cancer?
It is defined as a poorly differentiated tumour, in which the cells appear abnormal and lack any resemblance to normal-appearing tissues
How do high grade bladder cancers grow and metastasise?
They grow more aggressively
They tend to spread to the muscular wall of the balder and other organs
What is a carcinoma in-situ?
It is a pre-cursor for muscle invasive cancer, in which cells appear abnormal however are not invasive yet
It is a very aggressive type of cancer that requires different form of treatment
What is staging?
The assessment of a cancer’s spread
What is staging based on?
It is based upon clinical and radiological assessment
What is staging used to determine?
Prognosis outcome
To guide treatment
What two methods are used to stage bladder cancer?
Localised Bladder Cancer Staging
TNM Staging
What is bladder cancer stage zero?
It is defined as a tumour (stage 0a) or carcinoma in-situ (stage 0is) contained within the mucosa lining of the bladder lining
What is bladder cancer stage one?
It is defined as a bladder tumour involving the lamina propria bladder layer
What is bladder cancer stage two?
It is defined as a bladder tumour involving the superficial muscle bladder layer
What is bladder cancer stage three?
It is defined as a bladder tumour involving the deep muscle bladder layer
What is bladder cancer stage four?
It is defined as a bladder tumour which has metastasised to other organs and structures within the body.
What is T stage in TNM staging?
It considers how big the tumour is and how far it has spread
What is N stage in TNM staging?
It considers whether the cancer cells have spread into the lymph nodes
What is M stage in TNM staging?
It considers whether the tumour has spread anywhere else in the body
How do we determine the M stage in TNM staging?
CT scan of chest, abdomen and pelvis
How do we treat bladder cancer?
Surgical treatment
Chemotherapy treatment
Radiotherapy treatment
What three surgeries are used to treat bladder cancer?
Transurethral Resection of Bladder Tumour (TURBT)
Cystectomy
Neobladder Reconstruction
When is TURBT used to treat bladder cancer?
When the cancer is confined to the inner layers of the bladder, therefore those that are non-muscle invasive
What is TURBT?
A surgeon passes an electric wire loop through a cystoscope and into the bladder
The electric current in the wire is used to cut or burn away the cancer
What is cystectomy?
A surgical procedure in which all or part of the bladder is removed
What is a partial cystectomy?
It involves the clinician removing only a portion of the bladder that contains the cancerous tumour
What is a radical cystectomy?
It involves the clinician removing the entire bladder and surrounding lymph nodes
What is neobladder reconstruction?
After a radical cystectomy, a new conduit for urine to leave the body must be created
What are the two types of neobladder reconstructions?
Incontinent Conduit
Continent Conduit
What is an incontinent conduit?
It involves the surgeon creating a tube using the ilium
The tube runs from the ureters into a urostomy bag in the abdomen
What is a continent conduit?
It involves the surgeon using the intestine to create a reservoir to hold urine
The urine is drained from the reservoir through a suprapubic catheter a few times each day
What occurs after a neobladder reconstruction? Why?
Chemotherapy is injected into the bladder
This destroys any remaining cancer cells and prevents reoccurrence
What chemotherapy treatment is given to low grade cancer patients after neobladder reconstruction? What is given if the patient has a bad prognosis?
A one-time injection of mitomycin C is usually prescribed
However, if the patient has a bad prognosis, a prolonged chemotherapy course of six weeks is usually recommended
What chemotherapy treatment is given to high grade cancer and CIS patients after neobladder reconstruction?
A weekly injection of intravesical BCG for three weeks
When is chemotherapy used to treat bladder cancer?
It is used as a neoadjuvant treatment for muscle invasive bladder cancers, followed by radical surgery or radical radiotherapy
What three chemotherapy agents are used to treat bladder cancer?
Mitomycin C
GC Regimen (Gemcitabine & Cisplatin)
MVAC Regimen (Methotrexate, Vinblastine, Adriamycin & Cisplatin)
When is radiotherapy used to treat bladder cancer?
It is usually combined with chemotherapy to treat muscle-invasive cancer in cases where patients are unsuitable for surgery
What is the cause of squamous cell carcinoma of the bladder?
Schistosomiasis
What drug increases the risk of bladder cancer?
Pioglitazone
How is localised spread of bladder cancer determined?
MRI scan of pelvis
