USMLE Step 3 CCS Case: Bladder Cancer
Case Presentation
68-year-old male presents to clinic with 2 weeks of painless gross hematuria.
Initial Orders (Day 1, Clinic Visit)
Immediate Laboratory Studies
- Complete blood count (CBC) - assess for anemia from chronic blood loss 1, 2
- Comprehensive metabolic panel (CMP) - evaluate renal function (creatinine clearance critical for future cisplatin eligibility) and liver function 1, 2, 3
- Urinalysis with microscopy - confirm hematuria and rule out infection 1, 2
- Urine cytology - high sensitivity (84%) for high-grade tumors and carcinoma in situ 1
Imaging
- CT urography of abdomen and pelvis with IV contrast - this is the gold standard imaging modality to evaluate the bladder mass and detect synchronous upper tract urothelial carcinoma, which occurs in 2.5% of patients 1, 2
Consultations
- Urology consultation - for cystoscopy with biopsy or transurethral resection of bladder tumor (TURBT) 1, 2
Patient Counseling (Initial Visit)
- Explain that painless hematuria in a 68-year-old male requires urgent evaluation for bladder cancer, which is the sixth most common malignancy in the United States 4, 5
- Discuss that 80% of bladder cancer patients present with painless hematuria 1
- Counsel on smoking cessation if applicable, as cigarette smoking is a major risk factor 4
- Explain the need for cystoscopy as the definitive diagnostic procedure 1, 2
Day 3: Review Results and Schedule Procedure
Results Review
- CBC: Hemoglobin 11.2 g/dL (mild anemia consistent with chronic blood loss)
- CMP: Creatinine 1.1 mg/dL, creatinine clearance >60 mL/min (cisplatin-eligible), normal liver function
- Urinalysis: Gross hematuria, no infection
- Urine cytology: Atypical cells present, suspicious for high-grade urothelial carcinoma
- CT urography: 3.5 cm mass in right lateral bladder wall, no hydronephrosis, no upper tract lesions, no lymphadenopathy
Orders
- Schedule TURBT with bimanual examination under anesthesia within 1 week 1, 2
- Pre-operative clearance: EKG, chest X-ray
- NPO after midnight before procedure
Day 10: TURBT Procedure
Intraoperative Orders and Documentation
- Perform bimanual examination under anesthesia - assess for extravesical extension or palpable mass (clinical staging for T3/T4 disease) 1, 2
- Complete TURBT with standardized protocol - document tumor size (3.5 cm), location (right lateral wall), configuration (papillary), and number (solitary) 2, 3
- Obtain separate pathology specimens:
Post-Procedure Orders
- Continuous bladder irrigation with three-way Foley catheter
- Monitor for hematuria and clot retention
- Pain control: Acetaminophen 650 mg PO q6h PRN, oxycodone 5 mg PO q4h PRN for severe pain
- Discharge when urine clear (typically 24-48 hours)
Day 12: Pathology Results
Final Pathology: High-grade urothelial carcinoma, pT1 (lamina propria invasion), no detrusor muscle invasion, focal carcinoma in situ (CIS) present, lymphovascular invasion absent
Risk Classification: High-risk non-muscle invasive bladder cancer (NMIBC) 1, 3
Day 14: Post-Operative Follow-Up
Additional Staging for High-Risk NMIBC
- CT chest with contrast - evaluate for metastatic disease 3
- Alkaline phosphatase level - screen for bone metastases 1
- Schedule repeat TURBT within 4-6 weeks - mandatory for high-risk disease to achieve complete resection, obtain adequate muscle sampling, and identify occult muscle-invasive disease (occurs in 10-30% of cases) 3
Multidisciplinary Planning
- Refer to medical oncology for treatment planning discussion 3
- Discuss case at multidisciplinary tumor board - include urologic oncology, medical oncology, and radiation oncology 3
Patient Counseling (High-Risk NMIBC)
- Explain that T1 high-grade disease with CIS represents high-risk bladder cancer with significant progression risk 1, 3
- Discuss two treatment pathways:
- BCG immunotherapy (bladder-sparing approach)
- Immediate radical cystectomy (definitive treatment)
- For BCG therapy: Explain the induction course consists of 6 weekly intravesical instillations starting 2-4 weeks after repeat TURBT, followed by maintenance therapy at 3,6,12,18,24,30, and 36 months 2
- For radical cystectomy: Discuss that this involves removal of bladder, prostate, and seminal vesicles with bilateral pelvic lymph node dissection, requiring urinary diversion (ileal conduit or neobladder) 1, 2
- Counsel on fertility preservation - recommend sperm banking before any systemic therapy if future fertility desired 3
- Emphasize smoking cessation - critical for reducing recurrence and progression risk 2, 4
- Discuss lifelong surveillance requirements regardless of treatment choice 2, 6
Week 6: Repeat TURBT
Procedure Orders
- Complete repeat TURBT - resect previous tumor bed and any residual disease 3
- Obtain deep biopsies including detrusor muscle from tumor bed 3
- Random bladder biopsies from areas of erythema or suspicious mucosa 1
Repeat Pathology: Residual high-grade urothelial carcinoma, pT1, CIS present, detrusor muscle present and uninvolved (confirms non-muscle invasive disease)
Week 8: Treatment Initiation (Patient Chooses BCG Therapy)
BCG Induction Course Orders
- Intravesical BCG 81 mg (TICE strain) in 50 mL normal saline - weekly instillations for 6 weeks 2
- Pre-treatment instructions:
- Restrict fluids 4 hours before treatment
- Empty bladder immediately before instillation
- Retain BCG in bladder for 2 hours, changing position every 15 minutes
- Void while seated after 2 hours
- Disinfect toilet with bleach after voiding for 6 hours post-treatment
- Monitor for BCG toxicity: fever, dysuria, hematuria, systemic symptoms 2
Concurrent Orders
- Upper tract imaging (CT urography) - baseline for surveillance, repeat every 1-2 years to detect metachronous upper tract disease 2, 7
- Smoking cessation program referral if applicable 2
Month 3: First Surveillance Cystoscopy
Orders
- Cystoscopy with bladder biopsies - assess for complete response 2, 6
- Urine cytology 2, 6
- If complete response: Proceed with BCG maintenance therapy 2
Result: Complete response - no visible tumor, negative cytology, negative biopsies
Month 3: BCG Maintenance Initiation
Maintenance Schedule Orders
- Intravesical BCG 81 mg - 3 weekly instillations at months 3,6,12,18,24,30, and 36 2
- Cystoscopy with cytology every 3 months for first 2 years, then every 6 months through year 5, then annually 1, 2, 6
- CT urography every 1-2 years for upper tract surveillance 2, 7
Ongoing Patient Counseling Throughout Treatment
BCG Therapy Education
- Explain that BCG is the most effective intravesical therapy for high-risk NMIBC, reducing recurrence and progression rates 2, 4
- Discuss common side effects: dysuria (90%), frequency (90%), hematuria (40%), low-grade fever (25%) 2
- Warn about serious complications requiring immediate evaluation: high fever >101°F, severe dysuria preventing voiding, persistent hematuria, systemic symptoms suggesting BCG sepsis 2
- Emphasize that maintenance therapy is critical - most benefit comes from completing the full 3-year maintenance protocol 2
Surveillance Importance
- Explain that lifelong surveillance is mandatory due to 50-70% recurrence risk even with BCG therapy 6
- Discuss that cystoscopy every 3 months is necessary to detect early recurrence when treatment is most effective 2, 6
- Counsel that upper tract imaging must continue long-term because upper tract tumors can develop years after bladder cancer diagnosis 7
BCG Failure Planning
- Explain that if cancer recurs despite BCG therapy (BCG-unresponsive disease), radical cystectomy becomes strongly recommended 2, 3
- Discuss that pembrolizumab (checkpoint inhibitor immunotherapy) is FDA-approved for BCG-unresponsive CIS in patients who decline or are ineligible for cystectomy 8
Quality of Life Considerations
- Address sexual function concerns - BCG therapy preserves bladder and sexual function compared to cystectomy 3
- Discuss impact on daily activities - BCG instillations require 2-hour retention and temporary activity restriction 2
- Provide psychological support resources - cancer diagnosis and chronic surveillance create significant anxiety 3
Alternative Scenario: Muscle-Invasive Disease (pT2)
If pathology showed muscle invasion (pT2 or higher), management would differ:
Staging for Muscle-Invasive Bladder Cancer (MIBC)
- CT chest, abdomen, and pelvis with contrast - evaluate for metastatic disease 1
- Bone scan if bone pain, elevated calcium, or elevated alkaline phosphatase 1
- PET-CT may be considered for equivocal findings 1
Treatment Orders for MIBC
- Neoadjuvant chemotherapy - cisplatin-based combination (gemcitabine-cisplatin or dose-dense MVAC) for 3-4 cycles before surgery, improves survival compared to surgery alone 1, 2
- Radical cystoprostatectomy with bilateral pelvic lymph node dissection after neoadjuvant chemotherapy 1, 2
- Urinary diversion: ileal conduit (urostomy bag) or orthotopic neobladder (internal pouch) 2
MIBC Patient Counseling
- Explain that muscle-invasive disease requires aggressive treatment with radical cystectomy to prevent metastasis and death 1, 2
- Discuss that neoadjuvant chemotherapy before surgery improves survival by approximately 5-8% at 5 years 2
- Counsel on urinary diversion options:
- Ileal conduit: external urostomy bag, simpler surgery, fewer complications
- Neobladder: internal pouch allowing voiding through urethra, preserves body image but requires intermittent catheterization in 20-30% of patients 2
- Address sexual function: nerve-sparing techniques can preserve erectile function in select patients, but most men experience erectile dysfunction requiring treatment 2
- Discuss fertility: sperm banking must occur before chemotherapy - chemotherapy causes permanent infertility 3
Key Clinical Pitfalls to Avoid
Diagnostic Pitfalls
- Never skip upper tract imaging - 2.5% of bladder cancer patients have synchronous upper tract tumors that require different management 1, 2, 7
- Always obtain detrusor muscle in TURBT specimen - absence of muscle prevents accurate staging and may necessitate repeat resection 1
- Do not rely on urine cytology alone - sensitivity is only 16% for low-grade tumors 1
Treatment Pitfalls
- Never omit repeat TURBT for high-risk NMIBC - 10-30% of patients have occult muscle invasion that changes management from BCG to cystectomy 3
- Do not start BCG therapy without adequate healing - wait 2-4 weeks after TURBT to prevent systemic BCG absorption and sepsis 2
- Never give BCG during active urinary tract infection or gross hematuria - risk of BCG sepsis 2
- Do not skip BCG maintenance therapy - most benefit comes from completing the full 3-year maintenance protocol 2
Surveillance Pitfalls
- Never discharge patients from surveillance - bladder cancer recurs throughout lifetime, requiring lifelong cystoscopy 2, 6
- Do not forget upper tract surveillance - continue CT urography every 1-2 years indefinitely for high-risk patients 2, 7
- Never delay cystectomy for BCG-unresponsive disease - persistent high-grade disease after adequate BCG therapy requires radical cystectomy to prevent progression and death 2, 3
Summary of Complete Order Set
Initial evaluation: CBC, CMP, urinalysis, urine cytology, CT urography, urology consultation 1, 2
TURBT procedure: Bimanual exam, complete resection with separate specimens (tumor edges, base, random biopsies, prostatic urethra) 1, 2
High-risk NMIBC staging: CT chest, repeat TURBT within 4-6 weeks, multidisciplinary consultation 3
BCG therapy: Induction (6 weekly instillations) followed by maintenance (3 weekly instillations at months 3,6,12,18,24,30,36) 2
Surveillance: Cystoscopy with cytology every 3 months for 2 years, then every 6 months through year 5, then annually; CT urography every 1-2 years 2, 7, 6
MIBC treatment: Neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy with lymph node dissection and urinary diversion 1, 2