Bladder cancer

Written by Ming Huay Chin

Last Reviewed: April 2019

Review Due: April 2020

 

DEFINITION

'malignant transformation and growth of the cells lining the bladder. 90% of bladder cancers are transitional cell carcinomas, but squamous cell carcinomas and adenocarcinomas can also occur'

 

AETIOLOGY

Smoking

Aromatic amines/hydrocarbons

Dye and rubber factories

Pelvic radiation

Chronic inflammation

Bladder stones

Long-term catheterisation

Schistosoma infection

SIGNS AND SYMPTOMS

Bladder tumours most commonly present with painless haematuria either microscopic or macroscopic.

Other symptoms include 

Dysuria

Urinary frequency 

Urinary urgency 

Patients may also present with signs of obstruction or retention.

Patients may also have systemic symptoms such as weight loss. 

 

PATHOPHYSIOLOGY

Carcinogens are concentrated and excreted in the urine. Collection of urine in the bladder causes the cells in the urinary tract to be exposed to these carcinogens, leading to malignant transformation of the cells lining the urinary tract.

 

Investigations

 

Urinalysis

Haematuria

Urine cytology

Malignant cells

Imaging

Cystoscopy: visualise bladder tumours

All patients with painless frank haematuria

CT urogram: detect upper tract involvement

CT (or MRI) abdomen and pelvis: staging (looking for metastasis)

TREATMENT

Treatment depends on the grade and extent of invasion of the bladder cancer. In most cases, an urgent transurethral resection of bladder tumour (TURBT) is carried out, and intravesical chemotherapy to reduce the risk of recurrence.

Low grade, non-muscle invasive bladder cancer (Ta)

TURBT + intravesical mitomycin C at the same time

Follow-up cystoscopy 3 months and then 12 months and discharge if no recurrence

If intermediate risk, follow-up cystoscopy at 3, 9, 18 months then yearly

If recurring <12 months, give course of 6 doses intravesical mitomycin C

High grade, non-muscle invasive bladder cancer (T1)

TURBT

Either intravesical BCG immunotherapy or radical cystectomy

Cystectomy if poor response to >2 sets BCG

Follow-up cystoscopy every 3 months for 2 years, then every 6 months for 2 years, then yearly

Muscle invasive bladder cancer (T2-T4)

Neoadjuvant chemotherapy

Radical cystectomy or radiotherapy

Follow-up: yearly imaging and monitoring of kidney function, cystoscopy every 3 months for 2 years, then 6 months for 2 years, then yearly

 

EPIDEMIOLOGY

Incidence in the UK is 800 cases per 100,000 people. Males are more commonly affected than females, where the M:F ratio is 2.5:1.

 

 
 

Prognosis 

Staging and Grading

Bladder cancer is staged using the TNM classification. T describes how far the tumour has invaded the bladder tissues. N describes if there is lymph node involvement, and M is used to describe if the cancer  has metastasised.

 

Bladder cancer is graded from 1-3. Grade 1 is well-differentiated and Grade 3 is poorly differentiated and most likely to progress to invasive disease.

 

Therefore, a bladder cancer may be described as T1G3, where the tumour has invaded the mucosa and histologically the cells are poorly differentiated.

 
 

REFERENCES

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