Urothelial Cancers

Question 1

Where can Urothelial cancers occur

Answer 1

occur at any point from real callouses to the tip of the urethra

Question 2

What is the most common site for a Urothelial cancer

Answer 2

The bladder (90%)

Question 3

What is urothelial cancer also known as

Answer 3

Transitional cell carcinoma

Question 4

What is the 5 year survival rate of a Non-invasive, low grade bladder TTC

Answer 4

90%

Question 5

What is the 5 year survival rate of a invasive, high grade bladder TTC

Answer 5

50%

Question 6

What % of bladder cancers are TCC

Answer 6

90%

Question 7

What is the other cell type found in bladder cancer apart from TCC

Answer 7

Squamous cell carcinoma

Question 8

Where are Squamous cell carcinomas more common

Answer 8

In places where schistosomiasis is endemic

Question 9

Whats the risk factor for TCC bladder cancer

Answer 9

Smoking (accounts for 40% of cases)

Aromatic amines

Non-hereditary genetic abnormalities (e.g. TSG incl. p53 and Rb)

Question 10

What the risk factor for SSC in the bladder

Answer 10

Schistosomiasis (S. haematobium only)

Chronic cystitis (e.g. recurrent UTI, long term catheter, bladder stone)

Cyclophosphamide therapy

Pelvic radiotherapy

Question 11

Where are adenocarcinomas found (very rare)

Answer 11

The Urachal

Question 12

What is a urachal

Answer 12

A canal in the foetus that drains urine from bladder to belly button

Question 13

What the presenting symptoms for bladder cancer

Answer 13

Painless visible haematuria
Recurrent UTI
Storage bladder symptoms dysuria, frequency, nocturia, urgency +/- urge incontinence bladder pain

Question 14

What should you suspect if the patient presents with storage bladder symptoms

Answer 14

If present, suspect Carcinoma in Situ (CIS)

Question 15

What is carcinoma in Situ

Answer 15

Carcinoma in situ (CIS) is a group of abnormal cells that are found only in the place where they first formed in the body (see left panel). These abnormal cells may become cancer and spread to nearby normal tissue (see right panel).

Question 16

What investigations should you carry out for bladder cancer

Answer 16

Urine culture

Cystourethroscopy

Upper tract imaging

Urine Cytology
- Limited use in Dipstick haematuria
BP and U&E’s

Question 17

What the risk of malignancy if you find Frank haematuria and patient is >50

Answer 17

25-35%

Question 18

What the risk of malignancy if you find microscopic haematuria and patient is >50

Answer 18

5-10%

Question 19

What investigations should you do if patient has frank haematuria

Answer 19

Flexible cystourethroscopy within 2 weeks

Ct urogram & USS

Urine Cytology may also be useful (but not very sensitive nor specific)

Question 20

What investigations should you do if patient has microscopic haematuria

Answer 20

Flexible cystourethroscopy within 4-6 weeks

USS

Question 21

What procedures can be used to diagnose the bladder cancer

Answer 21

Cystoscopy and endoscopic resection (TURBT)

EUA to assess bladder mass/thickening before and after TURBT

Question 22

What procedures can be used to stage the bladder cancer

Answer 22

Cross-sectional imaging (CT, MRI)

Bone scan if symptomatic

CTU for upper tract TCC (2-7% risk over 10 years; higher risk if high grade, stage or multifocal bladder tumours)

Question 23

What is treatment for Low grade non-muscle invasive (i.e. Ta or T1)

Answer 23

• endoscopic resection followed by single instillation of intravesical chemotherapy (mitomycin C) within 24 hours
• prolonged endoscopic follow up for moderate grade tumours
• consider prolonged course of intravesical chemotherapy (6 weeks months) for repeated recurrences

Question 24

What is treatment for high grade non-muscle invasive or CIS

Answer 24

-very aggressive – 50-80% risk of progression to muscle invasive stage

endoscopic resection alone not sufficient

CIS consider intravesical BCG therapy (maintenance course, weekly for 3 weeks repeated 6 monthly over 3 years)

patients refractory to BCG – need radical surgery

Question 25

What is treatment for Muscle invasive bladder (T2 - T3)

Answer 25

neoadjuvant chemotherapy for local (i.e. downstaging) and systemic control; followed by either : ``` radical radiotherapy and/or; radical cystoprostatectomy (men) or anterior pelvic exenteration with urethrectomy (women); with extended lymphadenectomy ``` radical surgery combined with incontinent urinary diversion (i.e. ileal conduit), continent diversion (e.g. bowel pouch with catheterisable stoma) or orthotopic bladder substitution

Question 26

Where is the most common upper tract TCC located

Answer 26

Renal pelvis or collecting symptoms

Question 27

Where is the most least common upper tract TCC located

Answer 27

Ureter

Question 28

What is usually common for upper tract TCC

Answer 28

Tumours are often high-grade and multifocal on one side

Question 29

What are the presenting symptoms of upper tract TCC

Answer 29

Frank haematuria Unilateral ureteric obstruction Flank or loin pain

Question 30

What are symptoms of nodal or metastatic disease

Answer 30

Bone pain Hypercalcaemia Lung involvement Brain involvement

Question 31

What are Diagnostic investigations for upper tract TCC

Answer 31

CT-IVU or IVU Urine cytology Ureteroscopy and biopsy

Question 32

What is treatment for upper tract TCC

Answer 32

Most upper tract TCCs are treated by nephro-ureterectomy

Question 33

Why are upper tract TCC not treated endoscopically or by segmental resection

Answer 33

High risk of local recurrence if treated endoscopically or by segmental resection Difficult to follow up if treated endoscopically

Question 34

What do you do If unfit for nephro-ureterectomy or has bilateral disease with upper tract TCC

Answer 34

If unfit for nephro-ureterectomy or has bilateral disease - absolute indication for nephron-sparing endoscopic treatment (i.e. ureteroscopic laser ablation); needs regular surveillance ureteroscopy

Question 35

If uni-focal and low-grade disease

Answer 35

Relative indication for endoscopic treatment

Question 36

If endoscopic treatment is used for upper TCC then what should be done

Answer 36

In ALL cases, high risk of synchronous and metachronous bladder TCC (40% over 10 years); hence need surveillance cystoscopy