Bladder transitional cell carcinoma


Epidemiology
  • Ninth most common cancer in Singaporean males
  • Increasing incidence with age (80% diagnosed in patient >60 years old)
  • 4:1 male predominance


Pathology
  • TCC is the most common tumour of the bladder (>90%)


  • Thought to arise due to exposure to carcinogenic substances in the urine field change effect, thus urothelial tumours often occur multifocally


  • Other types of bladder tumours: adenocarcinoma (1%, arises from remnant of the urachus in the dome of the bladder), SCC (<5%, due to chronic irritation e.g. long term indwelling catheter or untreated bladder stone)


Risk factors
  • Industrial chemicals – naphthylamine, aniline-containing dyes, etc
  • Cigarette smoking
  • Occupational (hairdressers – exposure to hair dyes)
  • Analgesic abuse (phenacetin)
  • Chronic cystitis
  • Schistosomiasis
  • Radiation (pelvic)
  • Chemotherapy (cyclophosphamide)


Presentation
  • Haematuria is the most common presenting symptom (90%) – typically gross, painless, intermittent, occurring throughout the stream


  • LUTS – irritative symptoms (frequency, dysuria, urgency) suggestive of carcinoma in-situ, while obstructive symptoms (decreased stream, intermittent voiding, feeling of incomplete voiding, strangury) indicate a tumour at the bladder neck or prostatic urethra


  • Pain – in locally advanced or metastatic tumour flank pain due to urinary obstruction, suprapubic pain due to local invasion, bone pain due to metastasis


  • Constitutional symptoms – LOW, LOA, fatigue


Diagnosis
  1. Urine cytology for malignant cells
  2. Cystoscopy with cell brushings and biopsy
  3. IVU or CT urogram to detect synchronous lesions (3% chance of proximal tumour)


Staging
  1. CT abdo/pelvis for T, N and M staging


  1. Transurethral resection of bladder tumour (TURBT) with histopathology


Ta
Superficial, does not involve lamina propria
Tis
Carcinoma in-situ: “flat tumour”
T1
Superficial, involves lamina propria (up to muscularis propria)
T2a
Superficial involvement of muscularis propria – up to inner half of muscle
T2b
Deep involvement of muscularis propria – up to outer half of muscle
T3a
Microscopic extension outside bladder (from TURBT specimen)
T3b
Macroscopic extension outside bladder
T4a
Invasion of prostate, vagina, uterus
T4b
Invasion of lateral pelvic walls, abdominal wall


Generally can be divided into 2 main groups:
  1. Superficial tumour (70-80% of patients) – Ta, Tis, T1
  2. Muscle-invasive tumour (20-30%) – >T2


Management dependent on stage


Superficial tumour


  • Primary treatment is TURBT of the tumour


  • Intravesical therapy indicated in patients with high risk of tumour recurrence or tumour progression (high grade, multiple primary sites, multiple recurrences, tumour size >3cm, primary or coexisting carcinoma in-situ, prostatic urethral involvement)


  • BCG – 1 instillation per week for 6 weeks


  • Mitomycin C – single instillation within 24hrs of TURBT, or weekly/monthly treatments for up to 2 years


  • Follow-up:


  • 3

    Urine cytology with every cystoscopy

    -monthly cystoscopy for 1 year


  • 6-monthly cystoscopy for next 4 years


  • Yearly cystoscopy thereafter


  • IVU every 2 years


Muscle-invasive
  • Radical cystectomy
  • Radical cystoprostatectomy with pelvic lymphadenectomy in male
  • Anterior exenteration with pelvic lymphadenectomy in female


  • Ways of diverting urine output
    • Cutaneous ureterostomy (use ureters to create stoma, but easily stenosed due to small calibre; not continent)
    • Ileal conduit (a segment of ileum with ureters attached, as a stoma; not continent)
    • Neobladder construction using ileum (only if urethra not removed; continent, better quality of life)
    • Stoma with pouch construction under abdominal wall (not continent)


  • Radiotherapy (not as good as surgery)