Where are most Transistional Cell Carcinomas found?
In the bladder
Other than TCC what kinds of urothelial cancer can present?
Squamous CC - Mainly in countries where schistosomiasis is endemic
Adenocarcinoma - Rare Urachal malignancy
Risk factors for TCC?
Aromatic Amines (Hairdressers who use a lot of dyes in work)
Non-hereditary genetic abnormalities
Risk factors for SCC?
Chronic cystitis (UTIs, catheters & stones)
How does Bladder cancer tend to present?
Mostly with Painless Haematuria.
Can have metastatic or invasive symptoms or Recurrent UTIs
Storage LUTS (frequency/dysuria/nocturia/urge/bladder pain) are also possible and suggest a carcinoma in situ.
What main tests would you run for Bladder Cancer>
Patient presents with painless haematuria youd do a CT Urogram and US.
Also run BP & U&Es as standard
Followed by Cystourethroscopy & biopsy
What other tests can be done for bladder cancer?
Urine culture - rules out UTI as cause of haematuria
URine cytology - useful in high grade urothelial cancer
What tests are used to stage Bladder CanceR?
Bone Scan (if bone mets symptoms)
CT-U looking for upper tract tumours
What are the major treatments for Bladder Cancer?
Endoscopic resection - TURBT
Fluorescent Cystoscopy - Good for CIS
- Intravesicle Chemo
- Intravesicle BCG Therapy
- Radical Surgery
What is BCG therapy?
Bacillus Calmette-geurin Therapy.
BCG is a germ similar to Mycoplasma Tuberculosis but doesn’t cause serious disease, its put into the bladder to stimulate the immune system.
Hence an immunotherapy
How do we grade/stage bladder cancer?
Grade 1-3 based on how poorly differentiated and so how aggresive it is.
CIS - Non-muscle invasive but extremely aggresive
T staging based on whether its muscle invasive or not (detrusor specifically)
Whats the prognosis for bladder cancer?
Non-invasive low grade cancer is good 90% 5 yr survival
Invasive high grade or CIS is bad - 50% 5 yr survival
How would you treat a low grade non-muscle invasive cancer?
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
How would you treat a high grade non-muscle invasive cancer?
Followed by intravesicle BCG therapy (Weekly for 3 wks every 6 months for 3 yrs)
What happens if a patient becomes refractory to BCG therapY?
How would you treat a muscle invasive bladder cancer?
Neoadjuvant Chemo followed by either:
1) Radical RT + Extended Lymphadenectomy + radical cystoprostatectomy (men) or Anterior Pelvic Exenteration with Urethectomy (women)
2) Incontinent Urinary Diversion & Ileal Conduit
What ares outside the bladder are mostly affected by TCC?
The renal pelvis or calyces
How would a TCC in the pelvis or calyces present?
- Frank haematuria
- Unilateral Ureteric obstruction
- Flank or loin pain
- Metastatic symptoms incl. hypercalcaemia and bone pain
How do you diagnose an upper tract TCC?
- Urine cytology
- Ureteroscopy & Biopsy
How is an upper tract TCC managed?
A nephro-ureterectomy (endoscopic resection only appropriate if low grade and unifocal)
Surveillance cystoscopies monitoring for synchronous bladder TCCs over the next 10 yrs