Thank you for the overview. Let me know if you need any clarification or have additional questions.

1. Bladder Cancer Guidelines
A Brief Review
Waleed A. Hassen M.D.
Chairman of Urology
Tawam Hospital
Assistant Professor
Johns Hopkins Medical Institutions

2. Estimated new cancer cases.
10 leading sites by gender, US, 2000
38 300
14 900

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. Understanding Pathology
Recurrence vs Progression
Pathology 5 yr Recurrence Prob. Muscle
Invasion
Ta, Low grade 50% Minimal
Ta, high grade 60% Moderate
T1, low grade 50% Moderate
(rare)
T1, high grade 50-70% Moderate-High
Tis 50-90% High

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. Understanding Pathology
Pathologic Reporting

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. Staging
• Initial suspicion of TCC
– Office cystoscopy
– Cytology
• Suspect NMIBC
– Image upper tracts
– Pelvic CT before TURBT
– EUA
– Mapping biopsies if indicated

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. 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. Management
• cTa (low grade)
– Complete resection
– Observation vs single dose intravesical
chemotherapy*

12. Management
• cTa (high grade)
– Complete resection
– Re-resection if no muscle in specimen*
– Induction Immunotherapy
– Chemotherapy only if unable to tolerate BCG

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. 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. 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. Impact of Progression

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. 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. 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. Role of Lymphadenectomy

21. Survival based on Number of LNs
(MSKCC N=637)
Node Negative Node Positive Patients
Patients

22. SEER Database (N = 1923)
Konety et al, 2003

23. Extent of Dissection
Overall Distribution Single Positive Node

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. Management
– cT3/T4
• Strongly consider neoadjuvant chemotherapy
• Radical Cystectomy

27. DSS 1.66 in favor of chemo (p=.002, Overall Survival 1.33 in favor of chemo p

28. Adjuvant Trials
Series Chemo N Survival
Richards 5FU/Dox 129 No
Freiha CMV 55 No
Studer Cisplatin 77 No
Stockle MVAC 49 Yes
Skinner CAP 91 Yes

29. Neoadjuvant Chemotherapy plus Cystectomy and PLND
Survival and Local Relapse analysis (N = 307)
Dotan el al, ASCO 2005
Treatment 5 year Survival Freedom from local
relapse
Neoadjuvant 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%

30. 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

31. Management
– Bladder cancer is a lifelong disease
– Attention to published surveillance protocols
– Attempt multi-disciplinary care whenever
possible
– Do not forget about upper tracts