Bladder cancer

Question 1

Define bladder cancer

Answer 1

Malignancy of bladder cells

Over 90% of cancers of the urinary bladder are urothelial carcinoma (previously termed transitional cell carcinoma).

Non-muscle-invasive tumours are most common.

Question 2

State the risk factors for bladder cancer

Answer 2

• Tobacco exposure
• Male gender
• Age >55 years
• Exposure to chemical carcinogens-
  
  • aromatic amines (rubber and dye industries)
  • polycyclic aromatic hydrocarbons (aluminium, coal, and roofing industries)
  • exposure to arsenic in drinking water
• Pelvic radiation
  
  • ​commonly used in prostate cancer
• Systemic chemotherapy
  
  • ​cyclophosphamide
• FHx positive for bladder cancer
• Chronic inflammation, Schistosoma infection, and chronic indwelling catheters
• T2DM (moderate risk)
  
  • use of pioglitazone, a thiazolidinedione, is associated with an increased risk

Question 3

State the epidemiology of bladder cancer

Answer 3

• 2% of cancers- 9th worldwide incidence
• incidence varies globally- commonest in Egypt, Western Europe, and North America
• 2nd most common cancer of the genitourinary tract
• 2-3 x more common in MALES
• 70% of patients are >65 years of age

Question 4

Recognise the presenting symptoms of bladder cancer

Answer 4

Most commonly presents with gross (commonly) or microscopic painless haematuria

• Gross haematuria is characteristically intermittent
• Leads to incorrect conclusion that an intervention such as antibiotic administration has been effective.

Irritative/storage symptoms:

• Dysuria- in absence of UTI is highly suggestive of carcinoma
• Frequency
• Urgency
• Nocturia
• Voiding irritability
• Recurrent UTIs

Question 5

Recognise the signs of bladder cancer on physical examination

Answer 5

Absence of any symptom or finding on physical examination is common and illustrates the importance of screening urine for microhaematuria.

Bimanual examination may be performed as part of disease staging

Question 6

Identify appropriate investigations for bladder cancer

Answer 6

• Cystoscopy - allows visualisation, biopsy or removal - cystoscopy + biopsy is diagnostic
• Urine microscopy/cytology – malignancy can cause sterile pyuria (<33% positive in low grade TCC)
• FBC- if the appearance of the tumours at cystoscopy indicates they are likely to be muscle-invasive. May show mild anaemia
• Chemistry profile (including alkaline phosphatase)
  
  • If the appearance at cystoscopy indicates tumours are likely to be muscle-invasive
  • If elevated/bone pain, should go for a bone scan
• Renal and bladder ultrasound- bladder tumours and/or upper tract obstruction may be seen. Less detail than CT urogram or intravenous pyelogram.
• CT urography
  
  • ​images the urinary tract with contrast during the excretory phase
  • shows the urinary tract well and has the advantage of better imaging of the renal parenchyma and soft tissue of the abdomen and pelvis, including lymph nodes.
• CT/MRI abdo/pelvis
  
  • ​useful in patients at high risk of metastatic disease
  • (e.g., those with muscle invasion and lymphovascular invasion)

Question 7

Treatment for bladder cancer

Answer 7

small-volume, low-grade, stage Ta disease

• Ta = non-invasive papillary carcinoma
• single instillation of intravesical chemotherapy (mitomycin) within 6 hours of transurethral resection.

Large-volume or multifocal, low-grade, Ta disease

• Transurethral resection (TURBT) is first-line therapy.
• BCG immunotherapy or mitomycin chemotherapy every week for 6 week

T1 = tumour invades subepithelial connective tissue, i.e., the lamina propria