Cancer - Bladder and Upper Tract (Urothelial Carcinoma/TCC)

Question 1

Where are most Transitional Cell Carcinomas found?

Answer 1

Bladder

Question 2

What other types of TCC can present despite urothelial carcinoma?

Answer 2

Squamous cell cacrinoma - in countries where schistosomiasis is endemic

Adenocarcinoma - Rare Urachal malignancy

Question 3

What is TCC?

Answer 3

Transitional cell carcinoma

Question 4

TCC risk factors?

Answer 4

Smoking
Aromatic Amines (Hairdressers using darker dyes)
Non-hereditary genetic abnormalities

Question 5

Squamous cell carcinoma risks?

Answer 5

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

Question 6

Typical bladder cancer presentation?

Answer 6

Painless haematuria
Can have mets/invasive symptoms
Recurrent UTIs
Storage LUTS suggest a carcinoma in situ

Question 7

What are the LUTS?

Answer 7

Lower UT symptoms - divided into storage/filling/irritative AND Voiding or obstructive symptoms

Question 8

What are the Storage LUTS?

Answer 8

Increased frequency
Dysuria and bladder pain
Nocturia
Increased urge

Question 9

What are the voiding/obstructive LUTS?

Answer 9

Poor stream
Incomplete voiding
Hesitancy
Terminal dribbling
Signs of urinary retention

Question 10

Bladder cancer investigations?

Answer 10

Patients who have painless haematuria - USS and C T urogram

Also BP and Us and Es as standard

Follow up with cysto-urethroscopy and biopsy

Question 11

Other tests for bladder cancer?

Answer 11

MSSU - rules out a UTI

Urine cytology - useful in high grade urothelial cancer

Question 12

What tests are used to stage bladder cancer?

Answer 12

CT/MRIs
Bone scans looking for mets
CT-Urogram looking for upper tract tumours

Question 13

Major treatments for bladder cancer?

Answer 13

Endoscopic resection - TURBT
Fluorescent cystoscopy

Intravesicle chemo
Intravesicle BCG therapy
Radiotherapy
Radical surgery

Question 14

BCG therapy?

Answer 14

Bacillus Calmette-geurin Therapy

A bacteria similar to M.tuberculosis but without the serious disease

Stimulates immune response which helps fight cancer

Question 15

How is bladder cancer staged?

Answer 15

Using classic TNM - T is if it is muscle invasive or non-MI/superficial

Question 16

How is bladder cancer GRADED?

Answer 16

G1 - well differentiated, less aggressive, commonly non-invasive

G2 - moderately differentiated - often non-invasive

G3 - Poorly differentiated, more aggressive and often invasive

CIS grading - carcinoma in situ = non-muscle invasive BUT very aggressive and has a different treatment plan

Question 17

What’s the prognosis for bladder cancer?

Answer 17

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

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

Question 18

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

Answer 18

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 19

What is a TURBT?

Answer 19

Transurethral Resection of Bladder Tumor

Question 20

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

Answer 20

Endoscopic TURBT

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

Question 21

What happens if a patient becomes refractory to BCG therapy?

Answer 21

Radical Surgery

Question 22

How would you treat a muscle invasive bladder cancer?

Answer 22

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

2) Incontinent Urinary Diversion & Ileal Conduit

Question 23

What areas outside the bladder are mostly affected by TCC?

Answer 23

The renal pelvis or calyces

Question 24

How would a TCC in the pelvis or calyces present?

Answer 24

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

Question 25

How do you diagnose an upper tract TCC?

Answer 25

• CT-U
• Urine cytology
• Ureteroscopy & Biopsy

Question 26

How is an upper tract TCC managed?

Answer 26

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

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