Top Banner
Hematuria, Kidney & Bladder Cancer for the Primary Care Physician Shandra Wilson, MD June 4th,2013
76

Hematuria, Kidney & Bladder Cancer for the Primary Care Physician Shandra Wilson, MD

Feb 09, 2016

Download

Documents

spiro

Hematuria, Kidney & Bladder Cancer for the Primary Care Physician Shandra Wilson, MD. June 4th,2013. Overview. Hematuria – work-up Cases What’s new in bladder cancer What’s new in kidney cancer. Definition of Microscopic Hematuria. 3 or more RBC/ hpf 3 specimens 3 weeks. - PowerPoint PPT Presentation
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript

Hematuria, Kidney, Bladder Cancer for the Primary Care Physician

Hematuria, Kidney & Bladder Cancer for the Primary Care Physician Shandra Wilson, MD

June 4th,2013OverviewHematuria work-upCasesWhats new in bladder cancerWhats new in kidney cancer

2Definition of Microscopic Hematuria3 or more RBC/hpf3 specimens3 weeksAAFP.org, March 15, 2001AUA Best Practice Guidelines, 2001Definition of Microscopic HematuriaAAFP Best Practice guidelines No major organization currently recommends screening for microscopic hematuria in asymptomatic adults

USPTF Grade I 2012unclear of benefit of screening in asymptomatic population

AAFP.org, March 15, 2001AUA Best Practice Guidelines, 2001

Prevalence of Microscopic Hematuria0.18% - 18% of the population

Long-term Follow-Up Micro Hematuria1.2 million male and female adolescents Aged 16 to 25 years in IsrealUrine screening, 21 yrs of follow-up0.3% had isolated micro hematuriaESRD developed in 0.70% w/ micro hematuria, 0.045% w/o micro hematuria initially (HR =18.5; 95% CI 12.4-27.6)4.3% of all pts with ESRD had micro hematuriaVivante, et al JAMA. 2011;306(7):764-765

Title of article the time has come to recommend urine screening routinely6Dipstick Proteinuria and MortalityAlberta Kidney Disease Network920000 individuals in CanadaDipstick proteinuria (Tr or 1+) 7.8%HR of 2.1 for all-cause mortalityHR 2.7 doubling serum creatinine 1.7 for ESRD in pts with normal GFRMeta-analysis dipstick proteinuria of trace or greater 8% overall increased risk all-cause mortality, even in pts 65 yrs or youngerHemmelgarnBR, et al.JAMA.2010;303(5):423-429

Recommended if proteinuria positive albumin lever in urine tested

Clear evidence that starting an ACE inhibitor or Angiotensin 2 blocker early decreases ESRD here7Non-bloody red urineBeetsBlackberriesDrugs (pyridium)

Most Common Causes of HematuriaUTI BPH Nephrolithiasis Idiopathic Genitourinary cancer

Other Causes of HematuriaRadiation cystitisArteriovenous malformationMedical renal diseaseTraumaExercise-induced hematuriaCoagulopathyBenign familial/essential hematuriaPapillary necrosis

Odds of Finding Pathology40-90% of gross hematuria5-10% of microscopic hematuria

At least 40% of the time no etiology is found for asymptomatic microscopic hematuriaHistory of Present IllnessDysuria?Frequency?Recent respiratory infection?Menstruation?Previous episodes, work-upPast Medical Historyh/o stonesh/o XRTh/o bleeding disordersMedicationsPyridiumAnalgesic abuse

Social HistorySmokingExposure to dyes, chemicalsExercise patterns

Physical ExamAge (cancer)Hypertension (associated with nephritis)Edema (associated with nephrotic syndrome)Pain suprapubic, flank (infection)Possible DRE (BPH)

Laboratory EvaluationUA, microscopyUrine cultureConsider CBCConsider Creatinine

3 Rules to RememberSurvey upper & lower tracts (cytology 500mg/dl

Ideal Upper Tract StudyCT Urogram3 phasesNon-contrast to r/o calculiNephrogenic phase to evaluate parenchymaExcretion phase to evaluate GU lining

Lower Tract EvaluationDepends on age and risk factorsCystoscopy (CT misses CIS which is flat)Not necessary for non-smokers under 35yoCytology on all patientsBTA stat; NMP22; UroVysion unclear positioning in algorithm right nowCytology has accuracy issues tooFISH more expensive, objective

No Sx of Primary Renal Dz, AUA Age 35Cytology,Upper tract ImagingCystoscopyPositive: TreatNegative: Consider BP, cytol1 yr *Persistent hematuriaHTN, protenuriaEval for renal dzGross hematuriaAbnl cytolIrratative sx:Repeat complete eval* With complete work-up, the risk of missing malignancy is 28,000mg (HR 2.54)

Azoulay et al. BMJ 2012 344:e3645Life Time risk of Bladder Cancer1.17% of men 50-70yo develop TCC 0.34% women 50-70yo develop TCCOverall risk for all: 2.4% in the U.S.70%-85% do not require cystectomy

How are we doing?

Superficial Bladder CancerGreater than 98% of patients with bladder cancer have bleeding within 3 months of developing tumor (autopsy studies)Yet, recent SEER study evaluated 4,790 patients with NMI bladder cancer. Only 1 received appropriate treatment and follow-upA statistically significant survival advantage was seen in patients who received at least half of the recommended careSaigal, CK et al. Cancer 2012 118(5):1412-21

Quick Review-Superficial/NMISuperficial low grade disease: Strong survival (98%+), recurrence rates 30%Non-muscle invasive, high grade disease: Up to 20% require cystectomy; recurrence 60%+Multiple tumorsMany recurrencesLarge tumorsProgression in stage or gradeBCG intravesically (mounts immune response)Surveillance cystoscopy, maintenance treatments

FGFR3 Mutation Related to Favorable T1 disease132 patient with pT1 bladder cancer from 2 academic centersFGFR mutations in 37% of casesFGFR correlated with lower grade tumors Lack of FGFR mutation and CIS were significant for predicting progression in univariate analysis at 6.5 years (P =0.01)Van Rhijn J Urol 2012; 187(1):310

Decrease in bladder cancer recurrence with Hexaminolevulinate enabled Fluorescence551 participants, prospective studyRandomization between white light & blue light cystoscopy with Hex (5-aminolevulinic acid)Median time to recurrence 9.4 mos whiteMedian time to recurrence 16.4 mos 5ALA/blueCystectomy 7.9% whiteCystectomy 4.8% 5ALA/blue (p=0.16)$850 and 2 hours prep for 5-ALA wash5-ALA is a component of heme synthesis and is taken up by cancerous cells most effectively

Grossman HB; J Urol 2012 188(1):58-62http://www.youtube.com/watch?v=0aa-6WQLaPM

Invasive Dz:National Cancer Database40,388 patients with muscle invasive TCCStage 2-4; Age 18-99Patients treated with cystectomy: 42.9%Patients treated with radiation: 16.6%Both figures are stable between 2003-2007Average survival without treatment: 15 mos. U Fedili; J Urol 2011 185(1):72-8

Review: Ileal Conduit DiversionAdvantages of Ileal ConduitShorter operative timeQuicker recoveryEase of care by othersLess reabsorption of urinePreferred for radiation patients

Disadvantages Ileal ConduitExternal applianceHernia at least 25%Skin irritation

Continent Cutaneous DiversionAdvantages of continent cutaneous diversionDoes not use urethraMinimal change in external body imageNo appliance requiredDisadvantages of a continent cutaneous diversionNeed for regular catheterizationRisk for reoperation for complicationsNitrogen absorption

Orthotopic Continent DiversionAdvantages neobladderNo need for external applianceHigh daytime continence rate (93%)Least change in lifestyle

Disadvantages of a neobladderPossible need for regular catheterization (5-20%)Nocturnal incontinence 10-30%Reabsorption of nitrogen

How much has gone on in your world in the last 10 years?NCI website, 201056What are we doing differently? Griffiths G. JCO 2011;29(16):2171-7

57This article presents the long-term results of the international multicenter randomized trial that investigated the use of neoadjuvant cisplatin, methotrexate, and vinblastine (CMV) chemotherapy in patients with muscle-invasive urothelial cancer of the bladder treated by cystectomy and/or radiotherapy. Nine hundred seventy-six patients were recruited between 1989 and 1995, and median follow-up is now 8.0 years. National Trends, Cont.% receiving chemotherapy: 27% 2003 34.5% 2007Our data: 8.3% 2005 24.6% 2010Now recommended by EORTC w level 1 evidence

U Fedili; J Urol 2011 185(1):72-8National Trends Cont.Shifting medical climate to outcomesComplication rates of cystectomy becoming more defined and range from 40-80%Peri-operative mortality rate 2.6%Mortality higher at low volume hospitals (OR 1.7)Eur Urol 57(2): Feb 2010, 274-282

KM plots describing 5-year survival among patients undergoing cancer resection at low-, medium-, and high-volume hospitals, based on data from the SEER-Medicare linked database, 1992-2002; JD Birkmeyer, Annals of Surg 2007. 245(5):777-83Bladder 4%Colon 3%Esophagus 17%Lung 6%Pancreas 5%Stomach 6%Survival and High v. Low Volume HospitalsROBOTICS! Our world is changing!

Now Our New World

oooo Introduced in 2000 in Europe and USLaparoscopic surgery using a robotic interface5:1 and 10:1 magnification 3D visualizationNormal surgical manipulationFinger tip instrument controlScreen-in-screen technologyFluorescence technologyTremor reducing technology

Robotics History

Robotics History

Robotic cystectomyRobotic Open p value Mean EBL(ml) 258 575