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Case History

image A 70-year-old retired textile factory worker presents with recurrent haematuria and groin pain. Investigations confirmed the presence of a bladder tumour that is locally advanced and invading the lateral pelvic wall. Biopsies confirm multiple-site nodal involvement, including the retroperitoneum, but no visceral metastases. He has a good performance status.

What are the risk factors for bladder cancer?

Describe the clinical staging system used in bladder cancer. What are its prognostic implications?

Does palliative chemotherapy have a role in this setting?

What is the likely prognosis in this patient?

If the patient showed a good response to first-line chemotherapy would there be a role for second-line treatment on disease recurrence?


What are the risk factors for bladder cancer?

image Environmental factors are thought to account for most bladder neoplasms. Exposure to potentially toxic compounds, such as aromatic amines, accounts for up to 20% of all bladder cancer cases. The risk has been well documented. For employees in the aluminium, petrochemical and textile industries; more recent studies have suggested increased risk also for people constantly exposed to diesel fumes, such as professional drivers.

Smoking confers up to three times increased risk of developing a transitional cell carcinoma (TCC); this appears to increase approximately linearly with duration of exposure. Smoking cessation reduces it by about 40% within four years, but it never returns to baseline. Up to two-thirds of all bladder cancers could be directly attributable to smoking, due to its high prevalence.1

Chronic bladder inflammation, e.g. secondary to urinary stones or schistosomiasis, is also known to predispose to neoplasia, although in this setting squamous cell carcinomas are more common.

Radiotherapy to the pelvis and previous chemotherapy with cyclophosphamide-containing regimens have also been shown to be associated with secondary bladder malignancies with relatively short (image10 years) latency periods. The risk has been variously reported to range from 1.5 to 9 times the baseline risk.

Describe the clinical staging system used in bladder cancer. What are its prognostic implications?

The currently used staging system is based on the 2002 TNM classification,2 in which the clinical/pathological T stage has the most important role (Tables 15.1 and 15.2). This classification is still somewhat debated, with considerable inter- and intra-observer variability, especially for pT1 tumours. Substaging of the T2 and T3 categories also remains controversial, with several studies failing to find remarkable differences in survival or recurrence rates in subdivisions of the current stages.

Table 15.1TNM classification of bladder cancer

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