Transitional cell carcinoma of the bladder
Transitional cell carcinoma (TCC) is the most common primary neoplasm of the urinary bladder, and bladder TCC is the most common tumour of the entire urinary system.
This article concerns itself with transitional cell carcinomas of the bladder specifically. Related articles include:
- general discussion: transitional cell carcinoma of the urinary tract
- TCCs in other locations:
- other histologies:
Epidemiology of transitional cell carcinomas of the renal pelvis are similar to those of the rest of the urinary tract: please refer to TCCs of urinary tract for further details.
Haematuria is the most common presenting complaint, which may be macroscopic or microscopic. A tumour located at the vesicoureteric junction may result in ureteral obstruction and hydronephrosis, which may present with flank pain. Additionally a tumour near the urethral orifice may result in bladder outlet obstruction and urinary retention.
Occasionally patients only present once systemic symptoms of metastatic disease are present.
Diagnosis and local tumour staging is, usually, achieved with cystoscopy and full thickness biopsy 4.
As is the case elsewhere along the urinary tract, transitional cell carcinomas of the bladder fall into two broad macroscopic groups 4:
- superficial: 70-80%
- most are papillary 70%
- high-grade carcinoma in situ: 30% (see grading of TCCs)
- invasive: 20-30%
The bladder is by far the most common site of transitional cell carcinomas, 50 times more common than TCC of the renal pelvis, and 100 times more common than TCC of the ureter 1. Bladder TCCs are the most common tumour of the entire urinary tract.
- cyclophosphamide (chemotherapy agent) increases the risk of bladder transitional cell carcinoma with a dose-response pattern 8
- aromatic amines in tobacco smoke
- arylamines used in rubber and plastic manufacturing
- polycyclic aromatic hydrocarbons in industrial combustion processes (such as smelting)
Imaging of bladder transitional cell carcinomas has a number of roles:
- incidental discovery the tumour
- tumour staging (see staging of transitional cell carcinoma of the bladder)
- tumour staging of locally advanced masses
- evaluation of distant metastases and nodal status
Ultrasound has a limited role to play in either diagnosis or staging transitional cell carcinomas of the urinary tract in general.
Bladder transitional cell carcinomas appear as either focal regions of thickening of the bladder wall, or as masses protruding into the bladder lumen, or in advanced cases, extending into adjacent tissues. Care should be taken in assessing bladder wall thickness as this changes with the degree of bladder distension and varies from patient to patient, e.g. patients with bladder outlet obstruction due to benign prostatic hypertrophy. In general, however, asymmetric mural thickening should be viewed with suspicion.
The masses are of soft tissue attenuation and may be encrusted with small calcifications.
Although unable to distinguish between T1, T2 and T3a (microscopic extravesical spread), CT is able to distinguish T3b tumours (stranding/nodules in perivesical fat) and T4 tumours (direct extension into adjacent structures/loss of normal fat plane) 4.
Care should be exercised when interpreting stranding or nodularity following transurethral resection or even biopsy, as these changes may be postoperative 4.
Nodal metastases are common, seen in 30% of T2 tumours and 60% of T3 and T4 tumours 4.
CT or conventional urography
When tumours are large and of papillary morphology, contrast filling the interstices between papillary projections can lead to a dappled appearance referred to as the stipple sign 2.
MRI is superior to other modalities in locally staging the tumour and is in some instances able to distinguish T1 from T2 tumours on T2 weighted images.
- T1: isointense compared to muscle 4
- T2: slightly hyperintense compared to muscle
- T1 C+ (Gd): shows enhancement
Unfortunately, FDG is excreted into the urine and thus accumulates in the bladder, making it unsuitable for diagnosis of urinary tract tumours. It does have a role to play in the assessment of nodal or distant metastases.
Treatment and prognosis
Treatment is strongly influenced by tumour stage.
Superficial tumours can be treated with local transurethral resection +/- intravesical therapy. Ta tumours can be treated solely by resection. Carcinoma in situ or T1 tumour usually require both resection and intravesical therapy (bacille Calmette-Guerin (BCG) or chemotherapy, e.g. mitomycin C) 6.
Invasive tumours require radical cystectomy +/- chemotherapy and/or external beam radiotherapy 5.
A critical part of management of patients with TCCs is an awareness of the high rate of recurrence due to field effect on the entire urothelium. Approximately 2-4% of patients with a bladder TCC will go on to develop one or more TCCs of the renal pelvis or ureter 3-4.
Superficial tumours (which account for 70-80% of all cases) although having in themselves excellent prognosis, with almost no risk of metastases, have a predilection for recurrence (70% recur within 3 years) and these recurrences are more likely to be invasive. This is especially the case with carcinoma in situ 4.
Invasive tumours on the other hand, have poorer prognosis demonstrating both local invasion of perivesical tissues, lymphatic spread to local nodes and eventual haematogenous metastases 4.
Overall bladder transitional cell carcinomas have a 5-year survival of 82%, contributed mainly by the large proportion of superficial tumours (5-year survival of 94%). Patients with metastatic disease in contrast have poor prognosis (5-year survival of 6%) 4.
General imaging differential considerations include:
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