BLADDER CANCER PRESENTATION STAGING
Category: Urology
Abstract : Bladder cancer: presentation Symptoms - The most common presenting symptom
(85% of cases) is painless total haematuria. This may be initial or terminal if
the lesion is at the bladder neck or in the prostatic urethra. 34% of patients
>50 years and 10% <50 years with macroscopic haematuria have bladder
cancer. History of smoking or occupational exposure is relevant. -
Asymp
Bladder cancer: presentation
Symptoms
- The most common presenting symptom
(85% of cases) is painless total haematuria. This may be initial or terminal if
the lesion is at the bladder neck or in the prostatic urethra. 34% of patients
>50 years and 10% <50 years with macroscopic haematuria have bladder
cancer. History of smoking or occupational exposure is relevant.
-
Asymptomatic microscopic haematuria, found on routine urine stick-testing. Up to
16% of females and 4% of males have stick-test haematuria: less than 5% of those
<50 years, while 7 - 13% of those >50 years will have a malignancy.
-
Pain is unusual, even if the patient has obstructed upper tracts, since the
obstruction and renal deterioration arise gradually.
- Filling-type lower
urinary tract symptoms, such as urgency or suprapubic pain. There is almost
always microscopic or macroscopic haematuria. This so-called malignant cystitis
is typical in patients with CIS.
- Recurrent urinary tract infections and
pneumaturia due to malignant colovesical fistula, though less common than benign
causes (diverticular and Crohn's disease).
- More advanced cases may present
with lower-limb swelling due to lymphatic/venous obstruction, bone pain, weight
loss, anorexia, confusion, and anuria (renal failure due to bilateral ureteric
obstruction).
- Urachal adenocarcinomas may present with a blood or mucus
umbilical discharge or a deep subumbilical mass (rare).
Signs
General
examination may reveal pallor, indicating anaemia due to chronic renal
impairment or blood loss.
Abdominal examination may reveal a suprapubic mass
in the case of locally advanced disease. Digital rectal examination may reveal a
mass above or involving the prostate.
Although the likelihood of diagnosing
bladder cancer in patients <50 years is low, all patients with these
presenting features should be investigated.
Bladder cancer: diagnosis and
staging
After a urinary tract infection has been excluded or treated, all
patients with microscopic or macroscopic haematuria require investigation of
their upper tracts, bladder, and urethra. Usually, renal ultrasound and flexible
cystoscopy, performed under local anaesthetic, are first-line investigations. If
these fail to find a cause, an IVU or CTU and urine cytology are justified
second-line investigations. Patients with predominantly filling-type LUTS,
suprapubic pain, or recurrent UTI/pneumaturia should also have urine cytology
and cystoscopy.
CTU before and after IV contrast is becoming the
first-line radiological investigation of haematuria. It is faster and more
sensitive than ultrasound or IVU in the detection of renal (parenchymal and
urothelial) and ureteric tumours. However, it carries a higher radiation dose
and is more expensive. CTU also detects some bladder tumours, but may overcall
bladder wall hypertrophy as tumour and will miss flat CIS and urethral
pathology. Thus it cannot replace cystoscopy. If there is hydronephrosis in
association with a bladder tumour, it is likely that the tumour is causing the
obstruction to the distal ureter. This tends to be caused by muscle-invasive
disease rather than superficial TCC.
False -ve cytology is frequent (40 -
70%) in patients with papillary TCC, but more sensitive (90 - 100%) in patients
with high-grade TCC and CIS. False +ve cytology can arise due to infection,
inflammation, instrumentation, and chemotherapy.
If all investigations
are normal, consideration should be given to nephrological disorders that may
cause haematuria, such as glomerulonephritis. Cross-referral to a renal
physician is advised in patients with persisting microscopic haematuria,
especially those with associated proteinuria or
hypertension.
Transurethral resection of bladder tumour
(TURBT)
usually provides definitive histological diagnosis (see p.246). This
is usually undertaken under general or spinal anaesthesia; bimanual examination
is mandatory before and after bladder tumour resection, to assess size,
position, and mobility. The pathologist should report on the tumour type, grade,
and stage; in particular, the presence or absence of muscularis propria should
be noted, since its absence will preclude reliable T staging. Red patches are
biopsied separately; the prostatic urethra is biopsied if radical reconstructive
surgery is under consideration. Care is taken in resecting tumours at the dome,
since intraperitoneal bladder perforation may occur, especially in women with
thin-walled bladders.
Staging investigations
are usually reserved for
patients with biopsy-proven muscle-invasive bladder cancer unless clinically
indicated, since superficial TCC and CIS disease are rarely associated with
metastases.
- Pelvic CT or MRI may demonstrate extra-vesical tumour extension
or iliac lymphadenopathy, reported if >8mm in maximal diameter.
- Chest
X-ray
- Isotope bone scan (positive in 5 - 15% of patients with
muscle-invasive TCC) is obtained in cases being considered for radical
treatment.
- Staging lymphadenectomy (open or laparoscopic) may be indicated
in the presence of CT-detected pelvic lymphadenopathy if radical treatment is
under consideration.
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