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W. Hassen - Bladder cancer - Guidelines
 

W. Hassen - Bladder cancer - Guidelines

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    W. Hassen - Bladder cancer - Guidelines W. Hassen - Bladder cancer - Guidelines Presentation Transcript

    • Bladder Cancer GuidelinesA Brief ReviewWaleed A. Hassen M.D.Chairman of UrologyTawam HospitalAssistant ProfessorJohns Hopkins Medical Institutions
    • Estimated new cancer cases.10 leading sites by gender, US, 2000 38 300 14 900
    • Understanding Pathology WHO/ISUP 1998 Consensus WHO 2004• Papilloma• Papillary urothelial neoplasm of low malignant potential (PUNLMP)• Urothelial Carcinoma low-grade• Urothelial Carcinoma high grade * – Previously classified grade 2 now high grade
    • Understanding Pathology Recurrence vs ProgressionPathology 5 yr Recurrence Prob. Muscle InvasionTa, Low grade 50% MinimalTa, high grade 60% ModerateT1, low grade 50% Moderate(rare)T1, high grade 50-70% Moderate-HighTis 50-90% High
    • Understanding Pathology Pathologic Reporting• Pathology report must comment: – Histologic grade – The presence of muscularispropria, and degree of involvement – Presence or absence of LVI – Presence or absence of CIS
    • Understanding Pathology Pathologic Reporting
    • Understanding Pathology Risk (NMIB)• Low risk – Initial Low grade, <3cm lesion• Intermediate – Low grade recurrent, multiple lesions, >3 cm• High – Any high grade or CIS
    • Staging• Initial suspicion of TCC – Office cystoscopy – Cytology• Suspect NMIBC – Image upper tracts – Pelvic CT before TURBT – EUA – Mapping biopsies if indicated
    • Staging• Suspect Muscle Invasive Disease – CBC, Chemistry including AlkPhos – CXR or CT Chest – Upper tract imaging – CT or MRI – Bone Scan if Alk. Phos elevated or symptoms
    • Transurethral Resection• Goals of TUR: – Complete resection of all visible tumor when possible – Adequate mapping of bladder if needed – Adequate staging by ensuring presence of muscle
    • Management• cTa (low grade) – Complete resection – Observation vs single dose intravesical chemotherapy*
    • Management• cTa (high grade) – Complete resection – Re-resection if no muscle in specimen* – Induction Immunotherapy – Chemotherapy only if unable to tolerate BCG
    • Management• cT1 (high grade) – Complete resection – Strongly advise re-resection – Consider early cystectomy especially if re- resection shows higher stage or volume disease – Induction BCG otherwise – Chemotherapy only if unable to tolerate BCG
    • Restaging TURBT• 150 cases who underwent re-staging TURBT • Residual disease found in 76% Patients • Upstaging to muscle invasive disease in 30% of patients who initially had superficial disease• Results are similar when same surgeon performs resection
    • Management• cTis – Induction Immunotherapy – If response consider maintenance BCG • (x 3 years) – Recurrent or persistent CIS, consider cystectomy after no more then 2 courses of BCG
    • Impact of Progression
    • 2nd Course of BCG Salvage up to 50% on non-responders # courses Progression % Rate Developing Risk of progression and Mets Mets increases as the # 1 7% 5% courses of BCG increases 2 11% 14% 3 30% 50%Catalona et al., J Urol, 137: 220-4, 1987
    • Management• cT2 – Radical Cystectomy remains treatment of choice – If positive nodes on CT- Biopsy – Partial cystectomy in SELECTED pts: • Solitary lesion (small) • Amenable location to resection with margin • No CIS • Lymphadenectomy should always accompany
    • Management– Cystectomy: • Positive margins tend to be lethal • Extended node dissection: – Common, internal, iliac, obturator nodes– Urinary Diversion • NeobladdervsIlial Conduit – Patient preference, co-morbidities – Tumor characteristics
    • Role of Lymphadenectomy
    • Survival based on Number of LNs(MSKCC N=637)Node Negative Node Positive PatientsPatients
    • SEER Database (N = 1923) Konety et al, 2003
    • Extent of Dissection Overall Distribution Single Positive Node
    • Management– cT2 • Radiation concomitant with chemo therapy – No hydronephrosis – Repeat TUR and boost to 65Gy if negative – Simulate/treat patient with empty bladder – High recurrence rate • Radiation alone in patients with extensive co- morbidities
    • Management– cT3/T4 • Strongly consider neoadjuvant chemotherapy • Radical Cystectomy
    • DSS 1.66 in favor of chemo (p=.002, Overall Survival 1.33 in favor of chemo p
    • Adjuvant TrialsSeries Chemo N SurvivalRichards 5FU/Dox 129 NoFreiha CMV 55 NoStuder Cisplatin 77 NoStockle MVAC 49 YesSkinner CAP 91 Yes
    • Neoadjuvant Chemotherapy plus Cystectomy and PLND Survival and Local Relapse analysis (N = 307) Dotan el al, ASCO 2005Treatment 5 year Survival Freedom from local relapseNeoadjuvant MVAC + >10 nodes 81% 91%Surgery alone >10 nodes 64% 90%Neoadjuvant MVAC <10 nodes 55% 73%Surgery alone < 10 nodes 39% 66%No cystectomy 11% 12%
    • Management– Metastatic Disease • Gemcitabine/Cisplatin preferred – Equivalent efficacy to MVAC • 3 drug regimens have not been shown to be more efficacious • Carboplatin is NOT a substitute for Cisplatin – Consider split dose cisplatin for borderline renal function • Consider Carboplatin or Taxane-based regimens for patients not candidates for Cisplatin
    • Management– Bladder cancer is a lifelong disease– Attention to published surveillance protocols– Attempt multi-disciplinary care whenever possible– Do not forget about upper tracts