W. Hassen - Bladder cancer - Guidelines

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W. Hassen - Bladder cancer - Guidelines

  1. 1. Bladder Cancer GuidelinesA Brief ReviewWaleed A. Hassen M.D.Chairman of UrologyTawam HospitalAssistant ProfessorJohns Hopkins Medical Institutions
  2. 2. Estimated new cancer cases.10 leading sites by gender, US, 2000 38 300 14 900
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. Understanding Pathology Pathologic Reporting
  7. 7. 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
  8. 8. Staging• Initial suspicion of TCC – Office cystoscopy – Cytology• Suspect NMIBC – Image upper tracts – Pelvic CT before TURBT – EUA – Mapping biopsies if indicated
  9. 9. 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
  10. 10. 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
  11. 11. Management• cTa (low grade) – Complete resection – Observation vs single dose intravesical chemotherapy*
  12. 12. Management• cTa (high grade) – Complete resection – Re-resection if no muscle in specimen* – Induction Immunotherapy – Chemotherapy only if unable to tolerate BCG
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. Impact of Progression
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. Role of Lymphadenectomy
  21. 21. Survival based on Number of LNs(MSKCC N=637)Node Negative Node Positive PatientsPatients
  22. 22. SEER Database (N = 1923) Konety et al, 2003
  23. 23. Extent of Dissection Overall Distribution Single Positive Node
  24. 24. 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
  25. 25. Management– cT3/T4 • Strongly consider neoadjuvant chemotherapy • Radical Cystectomy
  26. 26. DSS 1.66 in favor of chemo (p=.002, Overall Survival 1.33 in favor of chemo p
  27. 27. Adjuvant TrialsSeries Chemo N SurvivalRichards 5FU/Dox 129 NoFreiha CMV 55 NoStuder Cisplatin 77 NoStockle MVAC 49 YesSkinner CAP 91 Yes
  28. 28. 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%
  29. 29. 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
  30. 30. Management– Bladder cancer is a lifelong disease– Attention to published surveillance protocols– Attempt multi-disciplinary care whenever possible– Do not forget about upper tracts

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