Bladder, Renal, and Testicular Cancer

Editor's Notes

1. Instructions: Select speaker icon in upper left-hand corner to begin presentation.Slide 1: No Notes
2. SLIDE 2: A 66 YEAR-OLD MALE (PATIENT CASE)00:00:06A 66-year old male presents to his primary care physician with the chief complaint of urinary frequency. During the work-up, a urinalysis reveals microscopic hematuria. Urine cytology demonstrates suspicious cells. A cystoscopy found a suspicious lesion that was biopsied. The biopsy showed transitional cell carcinoma that invades the subepithelial connective tissue (T1 lesion), node negative (node-), and had no metastatic disease (M-).WHAT THERAPY SHOULD HE RECEIVE AT THIS POINT?SLIDE 3: BLADDER CANCER (PATHOPHYSIOLOGY) 00:00:35When you look at the bladder cancer and pathophysiology, the majority of bladder cancer is of transitional cell histology, and we’re obviously going to focus on that subtype when we talk about therapy today, which is what our patient had.
3. SLIDE 3: BLADDER CANCER (PATHOPHYSIOLOGY) 00:00:35When you look at the bladder cancer and pathophysiology, the majority of bladder cancer is of transitional cell histology, and we’re obviously going to focus on that subtype when we talk about therapy today, which is what our patient had.
4. SLIDE 4: NATURAL HISTORY OF BLADDER CANCER00:00:50 As for the natural history of bladder cancer, if you look at the handout—which is provided to you as for some background on the epidemiology, etiology, and risk factors—it will go through some of that data for you. For instance, males have a greater incidence than females. Smoking and certain chemical exposure will increase your risk of bladder cancer, so refer to the handout for review of that.If you look at the natural history of bladder cancer, though, 70-80% of patients will present with a superficial tumor. The depth of the tumor is one of the primary prognostic factors for these patients.Grade III tumors are more likely to recur than Grade I or II tumors. If untreated, 50% of carcinoma in situ’s (CIS) will develop into invasive disease within five years. Most common sites of metastatic disease are lymph nodes, liver, lung, and the bone, which is through direct extension of disease.
5. SLIDE 5: WHAT STAGE IS OUR PATIENT?00:01:50SO WHAT STAGE IS OUR PATIENT?Our patient was T1, node negative, no metastatic disease, so he would be a Stage I (or sometimes called non-muscle invasive disease).
6. SLIDE 6: TREATMENT OPTIONS FOR SUPERFICIAL DISEASE00:02:02He would receive a transurethral endoscopic resection—or a TURBT procedure—and he would follow that with adjuvant therapy. The question of what kind of adjuvant therapy will answer next.Most people would do an intravesicular BCG (which would be considered standard of care based on the data presented on this slide). You can see with BCG there was a progression free survival (PFS) of 63% versus 37% on the control arm. There is a subset of patients where observation may be an option. If you have Ta disease, which is a little bit smaller disease, you can give a single dose of intravesicular chemotherapy—most of the time doxorubicin—instead of the BCG vaccine.
7. SLIDE 7: TREATMENT (SUPERFICIAL BLADDER CANCER)00:02:46And when you compare the BCG to doxorubicin given intrasticularly (?), you can see the data here showing why BCG was the standard of care: It had a higher disease free survival at 5 years in [both] Ta, T1, and in-situ tumors.
8. SLIDE 8: BASED ON THIS INFORMATION00:03:06Based upon this information, our patient undergoes a transurethral endoscopic resection followed by intravesicular BCG.
9. SLIDE 9: TREATMENT OPTIONS FOR MUSCLE INVASIVE DISEASE00:03:17Now if he had Stage II or higher disease, greater disease which is muscle invasive disease—which is also T2 to T4a lesions—therapy would obviously be changed.For organ-confined disease, radical cystectomy is recommended. However, if surgery is contraindicated, then radiation therapy can be used. (And obviously, when you think of surgery as an option, you want to look at neoadjuvant therapy to see if it plays a role in therapy.THE ROLE OF ADJUVANT THERAPY IN THERAPY SHOULD ALWAYS BE CONSIDERED WHEN CONSIDERING SURGERY AS AN OPTION.
10. THE ROLE OF ADJUVANT THERAPY IN THERAPY SHOULD ALWAYS BE CONSIDERED WHEN CONSIDERING SURGERY AS AN OPTION.SLIDE 10: NEOADJUVANT COMBINATION CHEMOTHERAPY IN BLADDER CANCER00:03:49So [looking] at neoadjuvant treatment for these patients, here is a trial of CMV—which is cisplatinum, vinblastine, and methotrexate—for three cycles in a neoadjuvant approach. You can see no difference compared to control.