A Guide to the Diagnosis, A Guide to the Diagnosis, Treatment and Follow-Up of Treatment and Follow-Up of Bladder and Kidney Cancer. Bladder and Kidney Cancer. Dr Manish Patel MB.BS., MMed., Dr Manish Patel MB.BS., MMed., FRACS FRACS Urological Oncologist Urological Oncologist Westmead Hospital & Westmead Private Hospital Westmead Hospital & Westmead Private Hospital Senior Lecturer and Director of Urology – Senior Lecturer and Director of Urology – University of Sydney University of Sydney Scientific Director-Urological Cancer Scientific Director-Urological Cancer Organisation Organisation Urologist to the NSW Cancer Council Urologist to the NSW Cancer Council
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A Guide to the Diagnosis, Treatment and Follow-Up of Bladder and Kidney Cancer. Dr Manish Patel MB.BS., MMed., FRACS Urological Oncologist Westmead Hospital.
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A Guide to the Diagnosis, Treatment A Guide to the Diagnosis, Treatment and Follow-Up of Bladder and Kidney and Follow-Up of Bladder and Kidney
Senior Lecturer and Director of Urology – University of SydneySenior Lecturer and Director of Urology – University of SydneyScientific Director-Urological Cancer OrganisationScientific Director-Urological Cancer Organisation
Urologist to the NSW Cancer Council Urologist to the NSW Cancer Council
Bladder Cancer Incidence is Decreasing in NSW
Risk FactorsRisk Factors• Smoking
• Previous urothelial cancer.
• Exposure to carcinogens– Aromatic amines– Benzedine– Alanine dyes
• Transitional Cell Carcinoma (TCC) >90%– 70% are superficial
• Squamous Cell Carcinoma 5%
• Adenocarcinoma 0.5-2%
Progression of Urothelial Cancers
Normal Urothelium
CIS
Muscle Invasive
Papillary High Grade
Papillary Low Grade
Hyperplasia
P53/ INK4Amutations
80%Progression
Chromosome 9
P53/ INK4A mutations
>40%
<4%
Cancer of the Cancer of the BladderBladderSigns and Signs and SymptomsSymptoms
Signs and SymptomsSigns and Symptoms Percent of All Patients
Painless Hematuria 85Vesical Irritability 40Flank pain or Kidney Failure 20Lower extremity swelling 10Pelvic Mass 10Weight Loss 8Abdominal or Bone Pain 5
Screening For Bladder CancerHaematuria screening.
• Haematuria does preceed a diagnosis for bladder cancer by >2 years.
• Cystoscopy is often negative in these early cases.
• However:– In randomised studies of screening for haematuria, no
benefit has been demonstrated in survival from bladder cancer.
Algorithm for Bladder Cancer Treatment
First Occurence TCC
Intravesical Therapy
Recurrence
TURBT
Progression
InvasiveMetastatic
Treatment by P/P Preference
XRT or Cystectomy
Follow-Up
Superficial Disease Ta, T1
Invasive Disease T2
Chemotherapy
Instillation of BCG Reduces Recurrence and Progression of High Grade Bladder Cancers
Instillation of Single Dose Intravesical Chemotherapy Reduces Recurrences of Superficial Bladder Cancer
Early Cystectomy for Patients with HG Bladder Cancer Refractory to Intravesical Treatments
Improves Survival
Extended LymphadenectomyAt Radical Cystectomy
Improves Survival
Greater Number of Lymph Nodes
Retrieved Results In
Greater Survival
The Quality of Surgery Affects Survival
The Nerve Sparing Cystectomy
• For the preservation of erectile function.
• Similar principles to the preservation of cavernous nerves during radical prostatectomy.
• Only possible in selected patients.
• Pioneered at MSKCC and USC.
• Early results: up to 70% potency.
Improvements in Neobladder Results
• Better QoL
• Day-time continence 96%
• Night-time= 82%
• Females=38% ISC
• Males=5% ISC
Pouch
Ureters
Urethra
Outcomes Following Radical Cystectomy
Chemotherapy and Bladder Cancer
• Can give as Neoadjuvant or Adjuvant therapy to improve survival.
• In the metastatic setting, will improve survival.
MVAC was the standard of care:- Very toxicGemcitabine and Cisplatin shown to be equivalent:- much less toxic.
Patterns of Recurrence:Invasive Disease
Site Risk Factors Median time
Local P3/4=34%, LN+ve=32% 8-18 months
Distant
•Bone
•Lung
•Liver
P1/2=20%
P3=60%
P4=70%
LN+ve=40%
90% recur in first 3 years.
Upper Tracts
Generally 2-4%
Ureteral Ca= 30%
22-40 months
Urethral 17% after RC
6% after neobladder
Up to 45% if TCC in prostate
1-3 years
Follow up Schedule After CystectomyEvaluation Year 1 Year 2 Year 3-5 Year 6+