Key clinical points
NICE cancer referral guidelines for bladder cancer suggest the following:
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:
Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection.
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:
- aged 45 and over and have:
- unexplained visible haematuria without urinary tract infection or
- visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
- aged 60 and over and have unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test.
Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection.
Introduction
Bladder cancer is the second most common urological cancer.
Classification
Types
Transitional cell carcinomas may arise as solitary lesions, or may be multifocal, owing to the effect of 'field change' within the urothelium. Up to 70% of TCC's will have a papillary growth pattern. These tumours are usually superficial in location and accordingly have a better prognosis. The remaining tumours show either mixed papillary and solid growth or pure solid growths. These tumours are typically more prone to local invasion and may be of higher grade, the prognosis is therefore worse. Those with T3 disease or worse have a 30% (or higher) risk of regional or distant lymph node metastasis.
- Transitional cell carcinoma (>90% of cases)
- Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis)
- Adenocarcinoma (2%)
Transitional cell carcinomas may arise as solitary lesions, or may be multifocal, owing to the effect of 'field change' within the urothelium. Up to 70% of TCC's will have a papillary growth pattern. These tumours are usually superficial in location and accordingly have a better prognosis. The remaining tumours show either mixed papillary and solid growth or pure solid growths. These tumours are typically more prone to local invasion and may be of higher grade, the prognosis is therefore worse. Those with T3 disease or worse have a 30% (or higher) risk of regional or distant lymph node metastasis.
Epidemiology
- Incidence: 17.00 cases per 100,000 person-years
- Peak incidence: 70+ years
- Sex ratio: more common in males 2.7:1
| Condition | Relative incidence |
|---|---|
| Renal cancer | 1.24 |
| Bladder cancer | 1 |
| <1 | 1-5 | 6+ | 16+ | 30+ | 40+ | 50+ | 60+ | 70+ | 80+ |
Aetiology
Risk factors for transitional cell carcinoma of the bladder include:
Risk factors for squamous cell carcinoma of the bladder include:
- 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 include:
- Schistosomiasis
- Smoking
Clinical features
Symptoms
- Haematuria (85%)
- Difficulty passing urine (10%)
- Urinary urgency (10%)
Investigations
- Leucocytosis (15%): Bladder cancer is often associated with a raised white cell count
- Anaemia (10%)
Referral criteria
NICE cancer referral guidelines for bladder cancer suggest the following:
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:
Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection.
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:
- aged 45 and over and have:
- unexplained visible haematuria without urinary tract infection or
- visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
- aged 60 and over and have unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test.
Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection.
Investigations
Most will undergo a cystoscopy and biopsies or TURBT, this provides histological diagnosis and information relating to depth of invasion. Locoregional spread is best determined using pelvic MRI and distant disease CT scanning. Nodes of uncertain significance may be investigated using PET CT.
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 |
Management
Those with superficial lesions may be managed using TURBT in isolation. Those with recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy. Those with T2 disease are usually offered either surgery (radical cystectomy and ileal conduit) or radical radiotherapy.
Prognosis
| T1 | 90% |
| T2 | 60% |
| T3 | 35% |
| T4a | 10-25% |
| Any T, N1-N2 | 30% |