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Urological malignancies have a high incidence among newly diagnosed cancers annually in Australia with prostate (55.9/100,000), kidney (14.4/100,000) and bladder (9.3/100,000) featuring high on the list. The focus on prostate cancer results in bladder cancer often being overlooked as significant contributor to the urological-based disease mortality and morbidity.
Bladder cancer is 3-4 times as common in males as in females and median age at diagnosis is 65-70 years. The excess of bladder cancer in men is not fully explained by any differences in known risk factors such as smoking and occupational exposure. Mortality is also different between the sexes with between 2-10 deaths/100,000 males a year and 0.5-4 deaths/100,000 females a year.
Symptoms and signs of bladder cancer may be subtle or synonymous with presentations in other bladder diseases. Clinical symptoms include painless haematuria, urgency, nocturia and dysuria. On occasions, a delay in diagnosis may occur after an initial treatment for presumed urinary tract infection. Severity of symptoms and signs in bladder cancer is usually related to tumour size and stage both being greater at late presentation.
Radiological modalities in diagnosis of early urothelial carcinoma are usually non-contributory and cystoscopy, bimanual examination and biopsy/transurethral resection are the optimum techniques for diagnosis and staging of urinary bladder cancer. Urine cytology also plays a role as positive cytology often indicates the presence of a urothelial tumour somewhere in the urinary tract.
Bladder sampling results in the second most common pathological specimen (secondary to prostate) submitted to uropathologists. Urothelial carcinoma accounts for between 80% and 90% of bladder cancer and non-invasive tumours constitute most of bladder neoplasms at initial diagnosis.
These are separated into two distinct categories – flat and papillary – which may be seen separately or in combination. Reporting of bladder cancer is based on histological examination with specific criteria applied to determine tumour grade and stage.
Urothelial carcinoma in situ (CIS)
Flat urothelial lesions contain cytologically malignant cells, are devoid of papillary structures and are reported as urothelial carcinoma in situ (CIS). The pure form of (CIS) accounts for 1-3% of all urothelial neoplasms but is commonly seen in conjunction with high grade papillary urothelial carcinoma and associated with 45-65% of invasive tumours.
Involvement of the bladder surface is usually multifocal and sometimes diffuse. Disease can extend to involve the distal ureters and the prostatic urethra.
Non-invasive papillary urothelial carcinoma
Assessment of papillary carcinoma is based on epithelial architecture and cytological morphology of individual cells serving as a prognostic indicator for recurrence and progression in non-invasive tumours. Low-risk lesions include urothelial papilloma and papillary urothelial neoplasms of low malignant potential which have essentially normal urothelium and mild architectural distortion.
Risk of progression then increases subsequently from low-grade urothelial carcinoma to high grade urothelial carcinoma with high-grade disease stratifying management and therapeutic decisions. Multifocal tumours in the bladder or involving other regions of the urothelial tract (ureters and urethra) also represent increased risk factors for recurrence and progression.
Invasive Urothelial Carcinoma
Once determined that the urothelial carcinoma is invasive (extends beyond the basement membrane of the urothelium), this becomes the most seminal prognostic factor, designated as the T stage on pathology reports.
Tumours invasive into lamina propria (T1) have better survival than tumours invading into the muscularis propria/detrusor muscle (T2) with poor survival outcomes for tumours with extravesical extension or invasion into pelvic structures (T3 and T4).
On pathological assessment of trans-urethral biopsy specimens, it is possible to determine the presence of T1 and T2 disease (dependant on detrusor muscle presence in the specimen), giving the treating clinical team valuable information regarding the subsequent treatment pathway. Assessment of T3 and T4 status is usually only determined on examination of definitive resection (cystectomy) specimens.
Bladder cancer is a recurrent and often progressive malignancy and although we must maintain focus on the more commonly occurring urological cancers, recognition of the role bladder cancer plays in men’s health should enable early referral, detection and pathological diagnosis, giving clinicians the best opportunity to manage this recalcitrant disease.
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