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• Most are transitional cell carcinomas
• Superficial tumours are usually low grade and associated with a good prognosis
• Muscle invasive tumours are of higher grade and have a poorer prognosis

Pathology

• Of all bladder carcinomas:
  • 90% are transitional cell carcinomas
  • 5% are squamous carcinoma
  • 2% are adenocarcinomas
• TCCs should be regarded a 'field change' disease with a spectrum of aggression
• 80% of TCCs are superficial and well differentiated
  • Only 20% progress to muscle invasion
  • Associated with good prognosis
• 20% of TCCs are high-grade and muscle invasive
  • 50% have muscle invasion at time of presentation
  • Associated with poor prognosis

Aetiological factors

• Occupational exposure
• 20% of transitional cell carcinomas are believed to result from occupational factors
• Chemical implicated - aniline dyes, chlorinated hydrocarbons
• Cigarette smoking
• Analgesic abuse e.g. phenacitin
• Pelvic irradiation - for carcinoma of the cervix

Schistosoma haematobium associated with increased risk of squamous carcinoma

Pathological staging

• Requires bladder muscle to be included in specimen
• Staged according to depth of tumour invasion

Tis	In-situ disease
Ta	Epithelium only
T1	Lamina propria invasion
T2	Superficial muscle invasion
T3a	Deep muscle invasion
T3b	Perivesical fat invasion
T4	Prostate or contiguous muscle

• Grade of tumour also important

G1	Well differentiated
G2	Moderately well differentiated
G3	Poorly differentiated

Presentation

• 80% present with painless haematuria
• Also present with treatment-resistant infection or bladder irritability and sterile pyuria

Investigation of painless haematuria

• Often performed in haematuria clinic
• Urinalysis
• Mid stream urine
• Serum urea and creatinine
• Ultrasound - bladder and kidneys
• KUB - to exclude urinary tract calcification
• Flexible cystoscopy
• Consider IVU if no pathology identified

Treatment of bladder carcinomas

Superficial TCC

• Requires transurethral resection and regular cystoscopic follow-up
• Consider prophylactic chemotherapy if risk factor for recurrence or invasion (e.g. high grade)
• Consider immunotherapy
• BCG = attenuated strain of Mycobacterium bovis
• Reduces risk of recurrence and progression
• 50-70% response rate recorded
• Occasionally associated with development of systemic mycobacterial infection

Carcinoma in-situ

• Carcinoma-in-situ is an aggressive disease
• Often associated with positive cytology
• 50% patients progress to muscle invasion
• Consider immunotherapy
• If fails patient may need radical cystectomy

Invasive TCC

• Choices are between radical cystectomy and radiotherapy
• Radical cystectomy has an operative mortality of about 5%
• Urinary diversion achieved by:
  • Valve rectal pouch - modified ureterosigmoidostomy
  • Ileal conduit
  • Neo-bladder
• Local recurrence rates after surgery are approximately 15% and after radiotherapy alone 50%
• Pre-operative radiotherapy is no better than surgery alone
• Adjuvant chemotherapy may have a role

Bibliography

Hall R R.  Superficial bladder cancer.  Br Med J 1994;  308:  910-913

Kaufman D C,  Shipley W U,  Feldman A S.  Bladder cancer.  Lancet 2009;  374:  239-249.

Whitehouse T H,  Persad R.  Radical cystectomy and bladder substitution.  Hosp Med 2000;  61:  336-340.

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