bladder cancer

see also:

• neoplasia / cancer / tumours
• http://info.cancerresearchuk.org/cancerstats/types/bladder/index.htm

• prevalence appears to be falling
• lifetime risk: 1 in 28 men, 1 in 91 women
• 90% are aged over 55yrs with average age at diagnosis being 73 yrs

• smoking
  • linear relationship between pack years and bladder cancer incidence and peak effect is at 15 cigarettes per day
  • risk of bladder cancer decreases by 30% within 1–4 years of cessation and continues to decrease by 60% at 25 years after smoking cessation
• opium consumption
  • 3x risk and 5x risk if also smoke tobacco
• occupational carcinogen exposure
  • accounts for ~30%
  • factory workers
  • bus drivers - diesel fumes
  • motor mechanics
  • leather workers
  • rubber and plastics manufacture
  • painters
  • hairdressers
• chronic bladder inflammation increases risk of SCCs mainly
  • schistosomiasis
  • possibly long term indwelling urinary catheters
• diet
  • arsenic
  • high consumption of animal fat and dietary cholesterol increases bladder cancer risk in men
  • Chinese herbal medications containing aristolochic acid
• radiation exposure
  • external beam radiotherapy (EBRT) for prostate cancer
• acquired somatic gene mutations
  • mutations in FGFR3, TP53, PIK3CA, KDM6A, ARID1A, KMT2D, HRAS, TERT, KRAS, CREBBP, RB1 and TSC1 genes may be associated with some cases of bladder cancer
  • deletions of parts or whole of chromosome 9 is common
  • loss of Y chromosome increases risk of bladder cancer in men as it allows cancer cells to evade immune system better, but it also makes them more treatable with immune checkpoint inhibitors ¹⁾
• inherited gene mutations
  • this are not thought to be a major factor
  • bladder cancer does not often run in families
• minor factors:
  • obesity

• cessation of smoking
• avoidance of carcinogens
• Mediterranean diet reduces risk
• possible other diet factors to reduce risk:
  • monounsaturated fat and plant-based oils in women
  • total dietary fiber and whole grains
  • drink lots of water
  • tea drinking although limited evidence
  • fruits and vegetables although limited evidence

• 95% are transitional cell carcinomas
  • 70% are papillary
  • 30% are non-papillary
• 5% are other types
  • SCC
  • adenocarcinomas
  • sarcomas
  • small cell carcinomas
  • secondary from other cancers

• 80-90% present with haematuria
• many have LUTS such as dysuria, frequency, urgency
• rarely, mucin-secreting tumors such as urachal adenocarcinoma may present with thick urine
• advanced features:
  • pelvic pain
  • bone pain
  • flank pain
  • abdominal mass (uncommon)
  • leg swelling

• local
  • may tether to local pelvic organs such as bowel, uterus or vagina
• metastatic spread
  • most common sites are lymph nodes, bones, lung, liver, and peritoneum.

• biopsy via cystoscopy
• if cystoscopy is not available, then other options may be of utility:
  • urine cytology - specific but not very sensitive for low grade tumours
  • various new biomarkers

• Ta - non-invasive papillary carcinoma
• Tis - carcinoma-in-situ
• T1 invades subepithelial connective tissue
• T2 invades detrusor muscle
• T3 invades perivesicle tissue
• T4 invades prostate, uterus or vagina
• T5 invades pelvic wall or abdominal wall
• N0 - no LNs
• N1 - single LN in true pelvis
• N2 - multiple LNs in true pelvis
• N3 - common iliac LNs
• M0 - no distant mets
• M1a - only to LNs outside of pelvis
• M1a - distant mets outside of pelvis

• Stage 0 (Ta or Tis, N0, M0) > 95% and accounts for 50% of diagnoses
• Stage I or II (T1 or T2, N0, M0) 63%, account for a third of diagnoses
• Stage III or IVA (T3 or T4 with any N and M0 or M1a) 35% and account for about 12% of diagnoses
• Stage IVB (M1B) 5% and account for 5% of diagnoses

• bimanual exam for tethering
• transurethral resection of bladder tumor (TURBT)
  • if invasive or high grade cancer is detected then:
    • MRI +/- CT of abdo pelvis
    • CT chest
    • LFTs - if raised AP without liver disease then bone scan