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A 65-year-old patient presents to his GP with a 3-month history of intermittent abdominal pain. Over the last week he has noticed discoloration of his urine and yesterday he had an episode of visible haematuria. He denies any lower urinary tract symptoms and has not noticed any significant weight loss. He admits to smoking 20 cigarettes a day and working in textile factory for the last 40 years. Abdominal examination is unremarkable. Blood tests show normal full blood count (FBC), renal function tests and prostate-specific antigen (PSA) 2.2 ng/mL.
1. Where is the pathology likely to be located in this patient?
A few possible differential diagnoses exist in this case: renal colic, bladder cancer and prostate pathology. However, this patient’s renal function is normal and PSA is within normal limits for this patient’s age and therefore rules out the former and latter. Urinary tract infection is also unlikely, as the patient does not report any changes in urinary symptoms. Bladder cancer is likely to be the cause in this case.
2. What is the relevance of his previous medical history?
This patient is a heavy smoker and his occupational history of working with textiles are likely to be significant risk factors for bladder cancer. Other risk factors include aromatic amines in dyes, paints, solvents, leather dust, inks, combustion products and rubber. In the Middle East, schistosomiasis is a significant risk factor causing 80% of cases of bladder cancer. Squamous cell carcinoma can develop from chronic inflammation due to stones or indwelling catheters. Radiation to the pelvis and cyclophosphamide are also risk factors.
3. What are the next steps in further investigating this patient’s symptoms?
This patient should be referred for urological investigations. He should have urinalysis sent for cytology and microscopy, culture and sensitivity to look for malignant cells and rule out infection. A CT and/or MRI should then be performed to examine for disease within the bladder and any evidence of distant disease. This should be followed by cystoscopy to directly visualise any tumour and allow for a biopsy to be taken.
Urinalysis does reveal malignant cells. MRI revealed a suspicious mass in the bladder. Cystoscopy showed an irregular papillary mass 4 cm in size and a biopsy was performed. A biopsy sample was taken. The patient was diagnosed with G2pTa cancer.
4. How should this patient be managed?
This patient has an intermediate risk bladder cancer. This can be managed with transurethral resection of bladder tumour (TURBT) with a 6-week cycle of intravesical mitomycin C. For lower risk cancer, TURBT and one dose of intravesical mitomycin C can be given. For higher risk, non-invasive bladder cancer, intravesical bacillus Calmette–Guérin (BCG) or radical cystectomy should be discussed. For higher risk muscle invasive bladder cancer, neoadjuvant chemotherapy using a cisplatin combination regimen should be offered before radical cystectomy or radical radiotherapy.
5. How should this patient be followed up?
This patient should have regular cystoscopic follow-up at 3, 9 and 18 months, and once a year thereafter. Should there be any sign of recurrence, further staging and biopsy should be performed to determine further management.