Can We Preserve The Can We Preserve The Bladder In Bladder In Muscle Invasive Bladder Muscle Invasive Bladder Cancer? Cancer? Dr Manish Patel Dr Manish Patel Urological Cancer Surgeon Urological Cancer Surgeon Westmead Hospital Westmead Hospital University of Sydney University of Sydney
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Can We Preserve The Bladder In Muscle Invasive Bladder Cancer? Dr Manish Patel Urological Cancer Surgeon Urological Cancer Surgeon Westmead Hospital University.
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Can We Preserve The Bladder InCan We Preserve The Bladder InMuscle Invasive Bladder Cancer?Muscle Invasive Bladder Cancer?
Dr Manish PatelDr Manish Patel Urological Cancer Surgeon Urological Cancer Surgeon
Westmead HospitalWestmead HospitalUniversity of SydneyUniversity of Sydney
The Outcomes of Radical CystectomyThe Outcomes of Radical Cystectomy• Outcomes of RC are
very good.• Recurrences occur:• Median 12 months• 86% of recurrences
occur in first 3 years.• Local only recurrence
more likley in OC.• Most series- any
recurrence= death.• Even with LN+ve
disease, 30% likelihood of long term survival.
Stein et.al. Journal of Clinical Oncology, Vol 19, No 3 (February 1), 2001: pp 666-675
Upstaging is common with Bladder CancerUpstaging is common with Bladder Cancer• Based on TURBT, EUA, CT
– MRI with dynamic contrast enhancement and Fe particles may be better.
•TURBT and 65 Gy XRT•Tumour debulking (TURBT may be most important)•Assessment of response at 40Gy may be useful•CR to XRT- will have a good outcome.•60% invasive recurrence rate. Approx 50% cystectomy rate. •Co-existant CIS: High recurrence rate in bladder (70%).•Squamous differentiation may have poorer outcome
Radiation-ComplicationsRadiation-Complications
Early complications
• Diarrhea
• Bladder irritation (particularly if trigonal cancers)
Late complications (2-3 years later)
• Worse if heavily pretreated (TURBTS, BCG etc)
• Radiation cystitis (heamturia, frequency contracted bladder)
Neoadjuvant and Partial cystectomyNeoadjuvant and Partial cystectomy• Neoadjuvant chemotherapy (X3-4 cycles) followed by TURBT
staging.
• Then followed by partial cystectomy and pelvic lymph node dissection.
• Herr et.al (n=26). No Pt was eligible for PC alone.
– 19 had P0
– 7 yr median FU: 65% alive
54% with bladder
18% invasive recurrence
26% superficial recurrence
PC is a valid option in suitable patients, even with T3 tumours that are small.
Neoadjuvant and TURBTNeoadjuvant and TURBT• Neoadjuvant chemo (3-4 cycles).
• Restaging TURBT.
• Stenberg et.al (n=71). T2-T4a
– Median 54 months FU: 71% alive
57% bladder intact
After chemo: P0 or superficial disease, 5yr survival = 71%
Invasive disease 29%
MSKCC (n=111)
60(54%) achieved T0 status.- Most preserved bladders
56% recurrence in bladder (30% invasive)
25% of T0 is not P0.
Neoadjuvant chemotherapy and TURBTNeoadjuvant chemotherapy and TURBT• Srougi et.al. (n=30)
• TURBT, MVACX3.
– PR or no response > cystectomy (n=12)
– CR > all retained their bladder (n=14)
• 5 yrs, 71% (10) had local recurrences.
– 8 had radical cystectomy
• Survival of all CR pts was 79% @ 5yrs.
• All patients need close observation because of inadequate staging All patients need close observation because of inadequate staging and occurrence of new tumours.and occurrence of new tumours.