Urological Malignancy - Bladder Cancer Flashcards
Give 4 risk factors of Transitional Cell Carcinoma.
- Smoking.
- Increased Age.
- Amines, Polycyclic Aromatic Hydrocarbons, Arsenic, Tetrachloroethylene (hair dyes, industrial paints, rubber, motor, leather) 15-40 years later.
- Cyclophosphamide.
Give 2 risk factors of Squamous Cell Carcinoma in the Bladder.
- Schistomiasis (Snail Fever).
2. Long-Term Bladder Catheterisation (10+ Years).
What is Schistomiasis?
Snail Fever caused by parasitic flatworms to cause chronic bladder infection which can lead to bladder cancer.
Epidemiology of Bladder Cancer.
Most commonly affects males aged between 50-80.
Clinical Presentation of Bladder Cancer (5).
- Painless Haematuria.
- Frequency.
- Urgency.
- Dysuria.
- Urinary Tract Obstruction.
Stereotypical Patient.
Retired Dye Factory Worker, presenting with painless haematuria.
Types of Bladder Cancers (2).
- 90% Transitional Cell Carcinomas.
2. 10% Squamous Cell Carcinomas.
What is a Papillary Urothelial Carcinoma?
Malignant tumour (TCC) arising from the transitional epithelium with finger-like projections - usually superficial and better prognosis.
Classification of Bladder Cancers (3).
- Low-Risk = Superficial Bladder Cancers.
- High-Risk = Muscle-Invasive Bladder Cancers.
- Carcinoma-In-Situ (CIS).
Properties of Low-Risk Superficial Bladder Cancers (5).
- Do not invade beyond Muscularis Propria (Detrusor).
- Low-Grade.
- Papillary Architecture.
- Require : Regular Follow-ups (High Chance of Recurrence).
- Management : Removal using TURBT via Cystoscopy and Intravesical Chemotherapy post-TURBT.
Properties of High-Risk Muscle-Invasive Bladder Cancers (5).
- Invade Detrusor and beyond.
- High-Grade.
- Solid Tumours.
- Worse Prognosis - higher risk of spreading to regional lymph nodes and metastasis.
- Management : Radical Treatment - Cystectomy.
What is a Carcinoma in Situ of TCC?
A flat lesion (no mass) in which the urothelium contains cells that display the nuclear features associated with malignancy but no invasion through the basement membrane.
Investigation of CIS TCC.
- Cystocopy - Red patches - blue-light cystoscopy : HAL (Hexyl minolevulinate).
- Urine Cytology - Highly atypical cells are shed into urine.
Prognosis of CIS TCC.
Left-untreated : 40% turn into Muscle-Invasive High-Risk Cancer.
What mutations are associated with the 3 types of TCC?
- HRAS and FGFR3 - Superficial.
2. TP53 and RB1 - Muscle-Invasive and CIS.
What is the importance of visible haematuria?
Bladder cancer until proven otherwise.
What are the relevant 2-week wait rules?
- Anyone aged over 45 with unexplained haematuria without a UTI or persisting after treatment for a UTI.
- Anyone over 60 with microscopic haematuria and either dysuria or raised WCC on bloods.
Which patients should be referred non-urgently?
People over 60 with recurrent unexplained UTIs.
Investigations of TCC :-
- Staging.
- Grading.
- Diagnosis.
Diagnosis : Cystoscopy and Biopsy.
Staging : TNM - Locoregional : Pelvic MRI; Distant - CT.
Grading : 3 Tier System (1 - Well-Differentiated; 3 - Poorly-Differentiated).
Management of TCC (2).
- Non-Muscle Invasive : TURBT (Transurethral Resection of a Bladder Tumour) + Chemotherapy + Immunotherapy.
- Muscle-Invasive : Radical Cystectomy + Urostomy with Ileal Conduit.
Immunotherapy in Bladder Cancer.
Weekly treatments for 6 weeks - BCG vaccine is squirted into bladder via the catheter then every 6 months for 3 years - stimulates immune system to attack bladder tumour.
Options for Draining Urine Following Radical Cystectomy (4).
- Urostomy with Ileal Conduit.
- Continent Urinary Diversion.
- Neobladder Reconstruction.
- Uterosigmoidostomy.
Urostomy with an Ileal Conduit (3).
- Ileal Section anastomosed to ends of ureters and stoma on skin.
- Kidneys - Ureters - Ileal Conduit - Urostomy Bag.
- Fit tightly around urostomy to avoid urine coming into contact with skin.
