UROLOGY - BLADDER CANCER

Question 1

Who’s most likely to get bladder cancer? Men or women

Answer 1

M:F 4:1

Question 2

How common is bladder cancer?

Answer 2

4th mmost common cancer in men
11th in women

Question 3

What are the risk factors for bladder cancer?

Answer 3

Smoking increases risk by up to 6 times
Occupation paint, hair dye, textiles and pesticide industries (aniline dyes)
Drugs like phenacetin and cyclophosphamide
Pelvic irradiation
Heavy alcohol use
Extended dwell times of urine in bladder also linked

Question 4

What are some risk factors specific for bladder squamous cell carcinoma?

Answer 4

Chronic UTI
Schistosomiasis in Middle East (also for adenocarcinoma)

Question 5

How does bladder cancer present?

Answer 5

Haematuria
Irritation lower urinary tract sympotms e.g. frequency and urgency
Recurrent UTI
Mucusuria (in adenocarcinoma but this is rare)
Weight loss, lethargy

Question 6

How does advanced/metastatic bladder cancer present?

Answer 6

Weight loss and lethargy
Bone pain and fractures
Pelvic pain
Lower limb or genital oedema from pelvic lymphadenopathy

Question 7

Whats the most common bladder cancer?

Answer 7

Uroepithelial aka transitional cell carcinoma 90%

Question 8

What are the cells that line the luminal surface of the uroepithelium?

Answer 8

Umbrella cells - these stretch to allow for the expanding bladder

Question 9

What are the 2 main mechanisms for transitional cell carcinomas?

Answer 9

Mutation in P53 causing urothelial cells to grow horizontally and invade tissues

Or non-p53 mutation related where papillary tumours grow outwards from the uroepithelim - less aggressive

Question 10

What are the 2 types of non-uroepithelial bladder cancers?

Answer 10

Squamous cell carcinomas - 4%
Adenocarcinomas - 2%

Question 11

Outline the pathogenesis of squamous cell carcinoma?

Answer 11

Chronic irritation e.g. recurrent UTI or schistosoma infection cause cells of urothelium to undergo meta plasma to form squamous cells and if left unchecked can develop into neoplasia

Question 12

Whats the most common bladder cancer in patent with bladder exstrophy?

Answer 12

Adenocarcinomas

Question 13

Where does adenocarcinoma derive from?

Answer 13

Glandular tissue

Question 14

Outline the staging of bladder cancer?

Answer 14

Tis - in situ
Ta - non-invasive papillary carcinoma
T1- limited to laminate propria
T2 a - superficial muscle involvement
T 2b - deep muscle involvement
T3- extends beyond bladder wall
T4 a- invades neighbouring structures e.g. vagina. Ureter, prostate
T4b - involvement of rectum or fixed to epelvic wall

Question 15

How do we investigate bladder cancer?

Answer 15

Cystoscopy
CT/MRI for staging

Question 16

Whats the initial treatment for bladder cancer?

Answer 16

Transurethral resection of bladder tumour - this removes the primary tumour and allows formal histologically grading and staging

Question 17

What proportion of bladder cancers are muscle-invasive from the outset?

Answer 17

25%

Question 18

How do we manage low-grade non-muscle invasive bladder cancer?

Answer 18

Cystoscope surveillance

Question 19

How do we manage high-grade non-muscle invasive bladder cancer?

Answer 19

Intravesical chemotherapy with mitomycin C
Intravesical immunotherapy with BCG which activates immune destruction of cells

Question 20

How do we manage muscle invasive bladder cancer?

Answer 20

Radical cystectomy or radiotherapy

Question 21

How do we manage metastatic bladder cancer?

Answer 21

Palliative chemotherapy and palliative radiotherapy for symptom control

Question 22

Whats the prognosis for bladder cancer stage 1?

Answer 22

5 year survival 80-90%

Question 23

Whats the prognosis for bladder cancer stage 2+?

Answer 23

5 years <50%

Question 24

What are the 2 potential reasons why bladder cancers re-occur so frequently?

Answer 24

Field effect - entire bladder was exposed to cause so each cell has the sam chance of mutating
Implantation theory - tumour cells detach form 1 location and float through the urine to reattach to another location on the bladder

Question 25

Whats the reoccurrence rates for bladder cancer?

Answer 25

5-year recurrence rates of approximately 65% in patients with non-invasive or in situ tumors
73% in patients with slightly more advanced disease at first diagnosis.