Urological malignancy Flashcards
What cells line the GU tract?
Transitional cells
What are the layers of the bladder?
- Urothelium
- Lamina propria
- Detrusor muscle
- Fat
- Peritoneum
What types of cancers occur in the bladder?
- Transtional cell carcinomas
- Squamous cell carcinoma
- Adenocarcinoma
- Secondary - bowel
What is the most common type of bladder cancer?
Transitional cell carcinoma- by a country mile!!! >90%
What are causes of bladder cancer?
PACSS
- Pelvic irradiation
- Aromatic amines
- Chronic cystitis
- Shistosomiasis
- Smoking - commonest cause
What type of bladder cancer is schistosomiasis most commonly associated with?
Squamous cell carcinoma
Where does exposure to aromatic amines most commonly occur?
Working in the rubber industry
What is thought to be protective against bladder cancer?
Diet rich in fruits and vegetables
What are symptoms of bladder cancer?
- Painless haematuria
- Recurrent UTI’s
- Sterile pyuria
- LUTS
- Anaemia - rare
- Abdominal pain
What proportion of bladder cancer patients present with painless haematuria?
>80%
Why should everyone with haematuria undergo cystoscopy?
Approximately 80% of those with bladder cancer present with painless haematura
Why do individuals with bladder cancer get cystitis with sterile pyuria?
Urothelium around cancer becomes inflammed - leads to frequency and pain on voiding
Why might someone with bladder cancer have abdominal pain (if the most common presenting symptom is painless haematuria)?
- Mass effect - pressing on local structures.
- May also have retention
What physical signs might you see in someone with bladder cancer?
Usually none, but can rarely have:
-
Palpable mass
- Urachus cancer - between synphisis and umbilicus
- Lower limb oedema - lymphatic/venous obstruction
How would you investigate someone with painless haematuria/symptoms of bladder cancer?
- Flexible cystoscopy +/- biopsy
- Urine - microscopy/cytology
- CT urogram
- Bimanual EUA
- MRI/Lymphangiography
What does automated flow cytometry look at when doing cytology of urine?
Measures the muclear/cytoplasm ratio in large numbers of cells - it is useful for detecting higher grade tumours, esp. CIS
What can CT urogram be used for in terms of investigation?
- Diagnosis
- Staging
What is MRI/lymphangiography used for when investigating for bladder cancer?
Pelvic node spread
What does the stage Tis/Cis mean?
Carcinoma in situ
What does the stage Ta represent in bladder cancer?
Tumour confined to epithelium/papillary carcinoma
What does the stage T1 stand for in someone with bladder cancer?
Tumour in submucosa or lamina propria
What does the stage T2 mean when staging bladder cancer?
Invading muscle
What does the stage T3 stand for in bladder cancer?
Invading perivesical tissue/fat
What does T4 stand for in staging bladder cancer
Invading adjacent organs
What does the prefix of p stand for in the staging of bladder cancer (e.g. pT2a)?
Histologically confirmed
How would you manage a bladder cancer Tis/Ta/T1?
- Diathermy vira transurethral cystoscopy/TURBT
- Intravesical BCG - stimulates non-specific immune response
- Consider mitomycin/epiribicin/gemcitabine as alternative chemos
How would you manage stage T2-T3 bladder cancers?
- Radiotherapy - consider salvage cystectomy if fails
- Radical cystectomy - gold standard
What is CIS?
Malginantly transformed cells which have not breach the basement membrane. It is highly aggressive and potentially life-threatening
How would you manage someone with stage T4 bladder cancer?
- Palliative chemo/radiotherapy
- Chronic catheterisation/urinary diversion
With bladder cancer, what is the general length of time for follow-up for high grade tumours?
Every 3 months for 2 years, then every 6 months lifelong
With bladder cancer, how long should you follow someone up for if they had low-grade disease?
First follow up cystoscopy at 9 months, the yearly after that
What are complications of bladder cancer?
- Sexual/urinary dysfunction
- Massive bladder haemorrhage
Why is intravesical BCG used in bladder cancer?
Induces a local immune response in the bladder, which reduces the progression of the bladder cancer and can cure high risk disease and CIS
What can occur in response to radiotherapy?
- Cystitis/proctitis like symptoms
- Fibrosed bladder - smaller
