Urothelial Cancer - TCC

Question 1

Where are most Transistional Cell Carcinomas found?

Answer 1

In the bladder

Question 2

Other than TCC what kinds of urothelial cancer can present?

Answer 2

Squamous CC - Mainly in countries where schistosomiasis is endemic

Adenocarcinoma - Rare Urachal malignancy

Question 3

Risk factors for TCC?

Answer 3

Smoking
Aromatic Amines (Hairdressers who use a lot of dyes in work)
Non-hereditary genetic abnormalities

Question 4

Risk factors for SCC?

Answer 4

Schistosomiasis
Chronic cystitis (UTIs, catheters & stones)
Cyclophosphamide
Pelvic RT

Question 5

How does Bladder cancer tend to present?

Answer 5

Mostly with Painless Haematuria.
Can have metastatic or invasive symptoms or Recurrent UTIs

Storage LUTS (frequency/dysuria/nocturia/urge/bladder pain) are also possible and suggest a carcinoma in situ.

Question 6

What main tests would you run for Bladder Cancer>

Answer 6

Painless Haematuria? Ultrasound & CT Urogram

Cystourethroscopy with Biopsy

Blood Pressure and Bloods

Urine culture - rules out UTI as cause of haematuria

Urine cytology - useful in high grade urothelial cancer

Question 7

What tests are used to stage Bladder Cancer?

Answer 7

CT/MRI
Bone Scan (if bone mets symptoms)
CT Urogram looking for upper tract tumours

Question 8

What are the major treatments for Bladder Cancer?

Answer 8

Endoscopic resection - TURBT
Fluorescent Cystoscopy - Good for CIS

• Intravesicle Chemo
• Intravesicle BCG Therapy
• Radical Surgery
• Radiotherapy

Question 9

What is BCG therapy?

Answer 9

Bacillus Calmette-geurin Therapy.
BCG is a germ similar to Mycoplasma Tuberculosis but doesn’t cause serious disease, its put into the bladder to stimulate the immune system.

Hence an immunotherapy

Question 10

How do we grade/stage bladder cancer?

Answer 10

Grade 1-3 based on how poorly differentiated and so how aggresive it is.

CIS - Non-muscle invasive but extremely aggresive

T staging based on whether its muscle invasive or not (detrusor specifically)

Question 11

Whats the prognosis for bladder cancer?

Answer 11

Non-invasive low grade cancer is good 90% 5 yr survival

Invasive high grade or CIS is bad - 50% 5 yr survival

Question 12

How would you treat a low grade non-muscle invasive cancer?

Answer 12

1) Endoscopic resection (TURBT)
2) Followed by 1 dose of intravesicle chemo (Mitomycin C)

Then endoscopic follow ups to monitor, if it recurs do 6 wks of intravesicle chemo

Question 13

How would you treat a high grade non-muscle invasive cancer?

Answer 13

Endoscopic (TURBT)

Followed by intravesicle BCG therapy (Weekly for 3 wks every 6 months for 3 yrs)

Question 14

What happens if a patient becomes refractory to BCG therapY?

Answer 14

Radical Surgery

Question 15

How would you treat a muscle invasive bladder cancer?

Answer 15

Neoadjuvant Chemo followed by either:
1) Radical RT + Extended Lymphadenectomy + radical cystoprostatectomy (men) or Anterior Pelvic Exenteration with Urethectomy (women)

2) Incontinent Urinary Diversion & Ileal Conduit

Question 16

What ares outside the bladder are mostly affected by TCC?

Answer 16

The renal pelvis or calyces

Question 17

How would a TCC in the pelvis or calyces present?

Answer 17

• Frank haematuria
• Unilateral Ureteric obstruction
• Flank or loin pain
• Metastatic symptoms incl. hypercalcaemia and bone pain

Question 18

How do you diagnose an upper tract TCC?

Answer 18

• CTU
• Urine cytology
• Ureteroscopy & Biopsy

Question 19

How is an upper tract TCC managed?

Answer 19

A nephro-ureterectomy (endoscopic resection only appropriate if low grade and unifocal)

Surveillance cystoscopies monitoring for synchronous bladder TCCs over the next 10 yrs