Most common tumour of the urinary system
3% of all cancers in the UK
Peak age >80yrs
More common in men than women 3:1
Most diagnosed bladder cancers are superficical like Ta, T1 or CIS with a good prognosis
What can bladder cancers further be classified into?
Non-muscle-invasive bladder cancer where they done penetrate into the deeper layers of the bladder wall.
Muscle-invasive bladder cnacer penetrating into the deeper layesr of the bladder wall
Locally advanced or metastatic bladder cancer spreading beyond the bladder and distally
How can the bladder wall be divided anatomically?
Inner lining of the bladder called transitional epithelium
Second layer which is a connective tissue layer called the lamina propria
Third layer is a muscular layer called muscular propria
Fourth layer is fatty connective tissue layer.
They are important when classifying bladder malignancies
Aromatic hydrocarbons like industrial dyes or rubbers
Previous radiation to the pelvis
Painless haematuria visible or non-visible.
Recurrent UTIs or LUTS like freq, urgency or feeling of incomplete voiding
If the bladder cancer obstructs the ureteric orifice, features of ureteric obstruction may be present.
If there is locally advanced disease pelvic pain might present
Metastatic disease weight loss or lethargy might present
Bladder cancer staging
TNM with further subtypes
Explain the TNM staging in bladder cancer
Explain the different T staging
Prostate or renal cancer
Suspected -> Urgent cystoscopy 2 week wait usually done as a flexible cystoscopy.
If a suspicious lesion is identified from an initial cystoscopy, a rigid cystoscopy might be done for more definitive assessment.
Any tumour identified will require biopsy and potential resection via transurethral resection of bladder tumour (TURBT)
Imaging should be done especially for CT staging
Urine cytology can be sent off as well.
Management of non-muscle-invasive bladder cancer CIS or T1 tumours.
Typically resected via TURBT as mainstay of management.
If deemed high risk disease adjuvant intravesical therapy like Bacille Calmette-Guerin BCG or Mitomycin C might be used in outpatient setting.
Radical cystectomy might be done in high-risk disease or limited response to initial treatment.
Regular surveillance and follow-up via cytology and cystoscopy is essential due to high risk of recurrence
Explain Transurethral Resection of Bladder tumours
TURBT involves resection of bladder tissue by diathermy during rigid cystoscopy.
It is usually done under general or regional anaesthesia and a biopsy sample is obtained for assessment of staging.
Management of muscle-invasive bladder cancer.
If fit for surgery -> Radical cystectomy leading to complete removal of bladder.
They will often also need neoadjuvant chemotheray with cisplatin combinatino
What is needed after radical cystectomy?
Urinary diversion either through
Ileal conduit formation with urine draining via a urostomy
Bladder reconstruction from a segment of small bowel and urine draining urethrally or via catheter.
These patients require regular follow-up with CT imaging to monitor local and distant recurrence
Management of locally advanced or metastatic bladder cancer
Chemotherapy with either cisplatin-based or carboplatin + gemcitabine-based regime.
Symptomatic relief + specialist advice and input through MDT
Palliative options and care should be discussed
High risk of upper urinary tract symptoms and urethral tumours
Superficial disease = 80-90% 5 year survival
Muscle invasive and metastatic disease = 30-60% and 10-15% respectively