Urology: Bladder Cancer

Question 1

What is the most common type of bladder cancer?

Answer 1

TRANSITIONAL CELL CARCINOMA (90%)

• non-invasive papillary tumour protruding from mucosal surface
• CIS - flat area of abnormal high grade cells likely to grow fast, with high recurrence rate
• high grade T1 tumour - superficial cancers that invade the lamina propria
• solid non-papillary tumour that invades bladder wall and has high propensity for metastasis (originate from in situ dysplasia)

Question 2

Other than TCC, what types of cancer can be found in the bladder?

Answer 2

Squamous cell carcinoma (5%)

• usually invasive
• occur in response to chronic irritation (causing metaplasia from transitional cell to squamous cell), e.g. chronic inflammation from stones, Schistosomiasis (more common in developing countries)

Adenocarcinoma (1-2%)
- usually invasive

Sarcomas and small cell cancer (very rare)

Question 3

Suggest risk factors for bladder cancer.

Answer 3

1. Smoking - causes 50% cases (smoke contains aromatic amines and polycyclic aromatic hydrocarbons which are really excreted)
2. Increasing age
3. Occupational exposure to aromatic amines, polycyclic aromatic hydrocarbons and chlorinated hydrocarbons, e.g industrial plants processing paint, dye, metal and petroleum products (20 yr latent period)
4. Pelvic radiation and cyclophosphamide
5. Chronic inflammation from stones/indwelling catheter (squamous cell cancer)
6. Schistosomiasis (squamous cell cancer)

Question 4

What is the most common presentation of bladder cancer?

Answer 4

• Painless haematuria (gross in 80-90%)
• Advanced disease may cause voiding symptoms from bladder outlet obstruction (although these can also be caused by carcinoma in situ)

Question 5

How is bladder cancer diagnosed?

Answer 5

1. Urine cytology - doesn’t identify cancer or completely rule it out but may be helpful in finding larger and more aggressive cancers
2. Flexi-cystoscopy - direct inspection of bladder and biopsy of suspicious lesions
3. CT or MRI - also used for staging
4. Biopsy of prostatic urethra - recommended for cases of bladder neck tumour, suspected bladder CIS, positive cytology without evidence of bladder tumour or visible prostatic urethra abnormalities

Question 6

Describe how non-invasive bladder cancers are managed.

Answer 6

1. Solitary Ta/T1 papillary tumour: TURBT (trans-urethral resection of bladder tumour, inc. part of underlying muscle) + single dose intravesicle mitomycin c
2. Intermediate risk: TURBT + 6+ dose course of mitomycin c
3. High risk: intravesicle BCG or radical cystectomy

Question 7

Describe how invasive bladder cancers are managed.

Answer 7

Neoadjuvant chemotherapy (cisplatin combination regimen) + radical cystectomy OR radical radiotherapy

Question 8

Suggest possible complications of bladder cancer.

Answer 8

1. UTI
2. Urinary retention
3. Hydronephrosis
4. Tumour recurrence
5. Increased risk urethral TCC

Question 9

What is the prognosis of bladder TCC?

Answer 9

Recurrence rate for superficial TCC is high (70% within 5yrs) but good prognosis with 80-90% 5yr survival rates.

Patients with muscle-invasive cancer have 30-60% 5yr survival.

Only 10-15% 5yr survival rate for metastatic cancer.