urology,

Bladder Tumour

May 10, 2020

Epidemiology

2nd most common. It most commonly affects males aged between 50 and 80 years of age. Those who are current, or previous (within 20 years), smokers have a 2-5 fold increased risk of the disease.

Pathology

  • Histology (cell type)
    • Transitional cell carcinoma TCC (>90% of cases) NB most have papillary pattern
    • Squamous cell carcinoma SCC ( 1-7%)
    • Adenocarcinoma (2%)
  • Morphology (appearance)
    • Papillary (70%) (better prognosis as less muscle invasion)
    • Sessile or mixed (20% worse prognosis)
    • Nodular

      Papillary TCC is the most common histopathological diagnosis

Risk factors:

  • Risk factors for transitional cell carcinoma of the bladder:
    • Smoking
    • Exposure to aniline dyes in the printing and textile industry: examples are 2-naphthylamine and benzidine
    • Rubber manufacture
    • Cyclophosphamide
  • Risk factors for squamous cell carcinoma of the bladder:
    • Schistosomiasis
    • Calmette-Guérin (BCG) treatment
    • Smoking

Presentation

  • Gross painless haematuria (in 85% of patients)
  • Haematuria can be microscopic (typically seen in females)
  • Symptoms of bladder irritation- dysuria, frequency and urgency

TNM Staging

   Stage       Description   
   T0       No evidence of tumour   
   Ta       Non invasive papillary carcinoma   
   T1       Tumour invades sub epithelial connective tissue   
   T2a    Tumor invades superficial muscularis propria (inner half)
   T2b    Tumor invades deep muscularis propria (outer half)
   T3       Tumour extends to perivesical fat   
   T4       Tumor invades any of the following: prostatic   stroma, seminal vesicles, uterus, vagina   
   T4a       Invasion of uterus, prostate or bowel   
   T4b       Invasion of pelvic sidewall or abdominal wall   
   N0       No nodal disease   
   N1    Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node)
   N2    Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis)
   N3    Lymph node metastasis to the common iliac lymph nodes
   M0       No distant metastasis   
   M1       Distant disease   

Staging

  • Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis and information relating to depth of invasion.
  • Local spread by MRI
  • Distant disease by CT scanning.
  • Nodes of uncertain significance by PET CT

Main prognostic groups

  • Low-grade proliferative lesions that develop into non-muscle invasive tumours (~80%)
  • Highly proliferative invasive tumours with a propensity to metastasise (high risk also of recurrence and progression)
  • Carcinoma in situ- which can penetrate the lamina propria and eventually progress

Management

  • Tis/Ta/T1 (non-muscle invasive)
    • TURBT
    • Intravesical BCG
    • Chemo with mitomycin, epirubicin, and gencitabine
  • T2-3 (muscle invasive)
    • Radical cystectomy is gold standard (better than radiotherapy)
    • Orthotopic reconstruction of the bladder using ileum is an option if baldder neck not involved
    • Neo-adjuvant and adjuvant chemo with M-VAC (MTX, VinB, Dox, Cis)
  • T4 (organ invasive)
    • Palliative chemo/radiotherapy
    • Long term catheter

Follow up cystoscopy

- Low risk non-muscle invasive bladder cancer: @ 3 months and 12 months after diagnosis
- Intermediate risk non-muscle invasive: @ 3, 9, 18 months and once a year thereafter
- High risk non-muslce invasive: @ 3 months for 2 years, 6 monthly for 2 years and once a year thereafter
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