W1 Bladder Cancer And Urothelial Carcinomas (Joey) Flashcards
Bladder cancer intro and definitions
What are the two interchangeable names?
What are the 2 histologic subtypes?
Lower urinary tract urothelial cancer =
Upper urinary tract urothelial cancer =
UroThelial Carcinoma (UTC) is also known as Transitional Cell Carcinoma (TCC)
UroThelial Carcinoma, UTC (aka TCC) can be broken down into
2 histological subtypes:
—⭐️“Flat” Transitional Cell Carcinomas
—”Papillary” urothelial cancer (aka Papillary TCCs)
*tx is often similar
Urothelial cancer most likely presents in the bladder but it can present in the urethra, ureter and lining of the renal pelvis
Urothelial cancer of the bladder or urethra = lower urinary tract urothelial cancer
Urothelial cancer of the ureters or the lining of the renal pelvis are considered upper tract urothelial cancer
Clinical presentation
Regardless of the title or location, UTCs / TCCs most commonly present the same way:
⭐️______ ______ ______ ______
May also commonly present as ______ ( defined as ______ / hpf on UA w/ Microscopy )
Less common but still prevalent presentation is ______ — aka ______
Regardless of the title or location, UTCs / TCCs most commonly present the same way:
⭐️intermittent painless GROSS HEMATURIA ⭐️
May also commonly present as painless microscopic hematuria ( MH is defined as >3 RBC / hpf on UA w/ Microscopy )
Less common but still prevalent presentation is persistent irritation voiding — urgency
DUF triad: dysuria, urgency and frequency
Bladder cancer prevalence worldwide
Bladder Cancer in general is most common malignancy involving the urinary system in the world
Urothelial carcinoma risk factors
What increases the risk?
⭐️Smoking ⭐️ highly increases risk of bladder cancer c/t non-smokers (tobacco). A lot of metabolites are cleared in the urine. These toxins sit in the bladder for ~3 hours until you void!
Males
Advanced age
Urothelial Carcinoma Risk Factors
What are some occupational and environmental exposure risks ?
Occupational & Environmental Exposures:
—Various Solvents, Benzenes, Polyaromatic Hydrocarbons, Hair Dyes, Chlorinated, Water By Products, ? Agent Orange
Family hx somewhat > risk esp if 1* fam member dx’d < 60, more in smokers
Clinical presentation
UTCs aka TCCs most commonly present as: ⭐️________⭐️
Less common, but a prevalent presentation is persistent irritative voiding sx (a triad of persistent ______, ______, ______ - d/t bladder lining irritation — is also common in CIS)
UTCs aka TCCs most commonly present as: ⭐️intermittent painless GROSS HEMATURIA⭐️
Less common, but a prevalent presentation is persistent irritative voiding sx (a triad of persistent urgency, frequency, dysuria - d/t bladder lining irritation — is also common in CIS)
DUF (dysuria, urgency, frequency)
if you have bladder cancer, you have a DUF bladder
Bladder cancer — clinical presentation
Common site for metastasis? 4
—Bladder cancer presenting sx are similar to those of several common more benign disorders (like OAB, UTI, prostatitis, renal calculi / urolithiasis)
—Because of the sx overlap w/ other common diseases, diagnosis is often delayed, however sign of persistent microscopic hematuria is a feature you will often see holding true)
—More rarely, symptoms f/ upper tract disease (ex. abd pain f/ tumor invasion, flank pain f/ UT obstruction, etc), advanced disease, or metastases (SOB, bone pain) may be the initial presenting sx of dz
—Flank pain etc w/ lack of hematuria however is uncommon as a primary presenting symptom for TCC, and flank pain more likely 2/2 other urinary dz like UTI, stone, or a true renal mass like RCC
—Common primary sites of metastasis for UTC are LN, lungs, liver, bone (LLLB)
—May also see classic “Constitutional Symptoms” of cancer, including: Unintentional weight loss, fatigue, malaise, night sweats etc
Bladder cancer — initial workup
2 important ones
Confirmatory / updated UAs w/ microscopy (while you should always believe pts who say they had gross hematuria, confirmatory UA helpful if unsure if what pt is describing is hematuria or not )
BMP to assess renal function (important to know pt’s renal fnx prior to contrast )
Urine Cytology (looks for malignant CELLS in URINE under the microscope) — if it’s positive, most likely cancer
CystoURETHroscopy/cystoscopy/cysto:
—A cystoscopy is a transurethral assessment of the superficial urethra, bladder, & ureteral orifices
—A cysto alone does not assess the deeper layers of bladder
or the upper tracts (like ureters and lining of renal pelvis)
—need scans and biopsy
Delete
⭐️Bladder cancer — which imaging?
You would have done urine cytology and a cysto to view the lesions but then….
You need to do a ⭐️CT UROGRAM ⭐️
—triple phase CT, no contrast, as you’re injected contrast and watching how they’re clearing it, and also getting 3rd phase after it has cleared. In the non-contrast phase, you’re evaluating for stones, middle phase helps you look for black ages, and then third one, one to see if any areas have picked up the contrast, these areas could be malignant
Upper Tract Imaging:
In addition to a cysto, gross hematuria (GH) warrants imaging of upper urinary tracts: the ureters, renal pelvis, and renal parenchyma
—Almost always via a specialized CT A/P called a
“CT Urogram” aka CT Urography
Where is the bleeding coming from?
Hematuria at beginning of urination = urethral source
Bleeding noticed as a discharge = urethral meatus or anterior urethra
Hematuria at the end of voiding = bladder neck or prostatic urethra
Hematuria throughout voiding can originate anywhere
How do you know if a bleed is coming from the kidneys?
If not the kidneys or the bladder, what should I be thinking?
Bleeds from kidney tissue themselves, have a specific characteristics dysmorphic RBCs = bleed from kidney
Diagnosis of urothelial carcinoma?
⭐️Need TURBT to diagnose cancer of the bladder ⭐️
● Gold Standard: Biopsy ( you need tissue! )
This is typically performed as a cystoscopically aided biopsy called a
“TURBT” aka “Transurethral Resection of Bladder Tumor”
Just for recall
—urine cytology to see malignant cells
—cystoscopy to view the lesions
—CT urogram, scan to see the depth etc
—biopsy: TURBT: transurethral resection of bladder tumour
Urine cytology — how specific and how sensitive?
Has moderate sensitivity (varies on dz grade), but high specificity (~98%) for TCC:
SPPIN : specific, if positive, rules disease IN
SNNOUT: sensitive, if negative, rules disease OUT
When do you have to consider taking the bladder out with bladder cancer
When bladder cancer invades the muscularis propria, that considered a T2 lesion, this is when you need to consider taking the whole bladder out
Treatment for non-muscle invasion disease (T0-T1)
What is the intravesical topical therapy?
Intravesical (aka intravesicular) Bacillus Calmette-Guerin (aka “BCG”):
—BCG is specific strains of live attenuated Mycobacterium bovis
—BCG is used as an intravesical topical immunotherapy that is instilled into bladder
—MOA: specific mechanism still unclear, but generally suspect that the BCG causes an immune / inflammatory response to the bladder lining, leading to autoimmune mediated attack on the urothelial cells, killing the superficial UTC / cancer cells, which are then sloughed off into the urine, voided out, in hopes to treat the disease
Goal: create immune response to BCG while it’s sitting there. WBCs attack bladder lining and end up sloughing off bladder lining
Treatment, Surveillance, & Restaging: Serial / Repeat TURBTs for Lower Risk Disease (T0-T1)
Don’t memorize specifics timelines on this slide, just know the pts come back for reassessment and if dx markedly worse, repeat / addtnl tx options discussed
Muscle invasive disease — radical cystectomy
Very long, high risk surgery
Nephroureterectomy
When is it indicated?
● Nephroureterectomy:
○ Unilateral resection of the kidney and the ureter for upper tract disease
○ A NephroUx alone is a tx option when pts have suspected SOLELY UNILATERAL UPPER TRACT dz (no disease in bladder or other side)
○ Allows pt to remain continent! But does not remove any bladder disease…
○ Very rarely pt’s may undergo both a Cystx, and a unilateral NephroUx
■ There is a high risk / benefit analysis here given impacts on renal function, QOL, surgical difficulties, among others
○ Sometimes can do just resection of a segment of the ureter for very focal nureteral disease (called a partial ureterectomy)
● FYI: Urethrectomy also exists, sometimes used for sole urethral TCC
Post treatment and surveillance
Repeat Imaging: CT Urogram (or other imaging) q 3-12 mo, +/- Urine Cytology
When is bladder cancer not TCC? I.e which infection is common in E. Africa and Middle East that can cause non-TCC inflammation?
● *Schistosomiasis infx is common in East Africa & Middle East, chronic inflam associated w/ this can cause Non-TCC (may also cause mixed / UTC tho)
Upper tract transitional cell carcinoma
vs
true True Renal Cancer
What’s the difference in tumour attachment?
TCC: Tumor usually not attached to renal parenchyma
RCC: Tumor attached to renal parenchyma
Bladder cancer take homes
What is the number 1 risk factor?
Most important work up tool in gross hematuria?
What is the standard treatment for non-muscle invasive TCC of the bladder?
What is the gold standard treatment for muscle invasive bladder cancer?
Smoking is the number 1 risk factor for developing Bladder Cancer
Cystoscopy & Upper Tract Imaging (ideally CT Urogram) +/- cytology
CT Urogram is not the same thing as a standard CT A/P
Cysto / TURBT (resection), often + BCG (vs topical chemo) in general are the standard tx for non-muscle invasive TCC of the bladder
Radical Cystectomy is the Gold Standard Tx for Muscle Invasive Bladder Cancer
