1 A Guide to the Diagnosis, Treatment and Follow-Up of Bladder and Kidney Cancer. Dr Manish Patel MB.BS., MMed., FRACSUrological OncologistWestmead Hospital & Westmead Private HospitalSenior Lecturer and Director of Urology – University of SydneyScientific Director-Urological Cancer OrganisationUrologist to the NSW Cancer Council
6 Bladder Cancer Cell Types Transitional Cell Carcinoma (TCC) >90%70% are superficialSquamous Cell Carcinoma 5%Adenocarcinoma %
7 Progression of Urothelial Cancers P53/ INK4AmutationsNormal UrotheliumHyperplasiaChromosome 9Papillary High GradeP53/ INK4AmutationsCIS>40%80%ProgressionPapillary Low Grade<4%Muscle Invasive
8 Cancer of the Bladder Signs and Symptoms Percent of All PatientsPainless Hematuria85Vesical Irritability40Flank pain or Kidney Failure20Lower extremity swelling10Pelvic Mass10Weight Loss8Abdominal or Bone Pain5
11 Screening For Bladder Cancer Haematuria screening. Haematuria does preceed a diagnosis for bladder cancer by >2 years.Cystoscopy is often negative in these early cases.However:In randomised studies of screening for haematuria, no benefit has been demonstrated in survival from bladder cancer.
12 Cystoscopy, cytology, and urinalysis together do not detect 100% of all bladder cancers. This, coupled with a desire to avoid the need for frequent cystoscopy to detect recurrences, has led to the investigation of new urine-based bladder cancer tests and various tumor markers to aid in detection and monitoring of bladder cancer.This slide provides a summary of the average sensitivity and specificity of the various urine tests in detecting transitional cell carcinoma (TCC). Several of them (indicated with an asterisk) are approved by the US Food and Drug Administration. The majority of these tests are more sensitive, but less specific, than urine cytology.1-3 High rates of false-positive results have limited their use as single markers.References1. El-Gabry EA, Strup SE, Gomella LG. Superficial Bladder Cancer—Current Treatment Modalities and Future Directions. Parts I & II, AUA Update Series #20. Houston, Tex: American Urological Association, Office of Education; 2000.2. Mian C, Pycha A, Wiener H, Haitel A, Lodde M, Marberger M. Immunocyt: a new tool for detecting transitional cell cancer of the urinary tract. J Urol. 1999;161:3. Halling KC, King W, Dokolova IA, et al. A comparison of BTA stat, hemoglobin dipstick, telomerase and Vysis Urovysion assays for the detection of urothelial carcinoma in urine. J Urol. 2002;167:
13 Algorithm for Bladder Cancer Treatment Chemotherapy
14 Instillation of BCG Reduces Recurrence and Progression of High Grade Bladder Cancers
15 Instillation of Single Dose Intravesical Chemotherapy Reduces Recurrences of Superficial Bladder Cancer
16 Early Cystectomy for Patients with HG Bladder Cancer Refractory to Intravesical Treatments Improves Survival
17 Extended Lymphadenectomy At Radical Cystectomy Improves Survival
18 Greater Number of Lymph Nodes Retrieved Results In Greater Survival
20 The Nerve Sparing Cystectomy For the preservation of erectile function.Similar principles to the preservation of cavernous nerves during radical prostatectomy.Only possible in selected patients.Pioneered at MSKCC and USC.Early results: up to 70% potency.
24 Chemotherapy and Bladder Cancer MVAC was the standard of care:- Very toxicGemcitabine and Cisplatin shown to be equivalent:- much less toxic.Can give as Neoadjuvant or Adjuvant therapy to improve survival.In the metastatic setting, will improve survival.
25 Patterns of Recurrence: Invasive Disease SiteRisk FactorsMedian timeLocalP3/4=34%, LN+ve=32%8-18 monthsDistantBoneLungLiverP1/2=20%P3=60%P4=70%LN+ve=40%90% recur in first 3 years.Upper TractsGenerally 2-4%Ureteral Ca= 30%22-40 monthsUrethral17% after RC6% after neobladderUp to 45% if TCC in prostate1-3 years
26 Follow up Schedule After Cystectomy EvaluationYear 1Year 2Year 3-5Year 6+History+ Exam3mthly6mthly12mthlyCXRAbdo/Pelvic CTFBC/UEC LFTUrethral WashUppertract cytology
27 Other Considerations in FollowUp Metabolic complicationsHypochloraemic hypokalaemic metabolic acidosis.Vitamin B12 and bile acidsUrolithiasisPyelonephritisPreservation of upper tracts.PotencySupport for stoma or self catheterisation.Psychological support.
28 Follow Up Schedule After Superficial Disease Likely hood of progressionLikelyhood of recurrence1st Year2-5 years6+ yearsLow Grade4%90%6 monthly if 1st check clear6 monthlyyearlyHigh gradeTa=40%T1=52%95%3 monthlyCIS>50%
29 Diagnosis, Treatment and Follow-Up of Kidney Cancer
30 The Incidence of Kidney Cancer is Increasing 3.1% of male Cancers and 2.4% of female cancersApprox 50% mortality in NSW.
36 TNM Staging of Renal Cell Carcinomas T T3b/c<7cm Renal Vein or IVCConfined to KidneyT T4>7cm Outside GerotasFasciaT3a N: Nodes involvedAdrenal or Gerotas M: Distant Mets.Fat involved
37 Survival: Renal Cell Carcinomas TNM StageT1T2 or T3aT3b/c, T4N or M
38 The Work Up For A Patient With Suspected Kidney Mass Haematuria:US+/- IVPSurgeryMassLocalisedPossibleCytoreductionMassIncidentalImagingStaging:Chest XR/CTB.S. if high riskHigh QualityCT Abdomen+/- IV contrastInterferon TxMetastaticGive ChoicesPain/MassPalliationClinical Trial
39 Open Radical Nephrectomy ProsGold standard for cancer cure.Standard for large, complicated tumours.Least intraoperative complications.Improvements:Small, less invasive incision- lower complications.ConsMajor operation with recovery period.Higher lung complications.
40 Laparoscopic Radical Nephrectomy ProsLess painQuicker recoveryLower lung complicationsConsHigher intraoperative complications.Can not do large complicated tumours.New procedure- no L/T data.Less kidney conservation.
41 Partial Nephrectomy Preserves Renal Function Preservation of renal function.Old ageRecurrent tumoursKidney diseases.HyperfiltrationMore difficult surgerySlightly higher complication rate.Small tumours
42 New Technologys for Kidney Cancer RF ablation and cryoablation RF ablating or freezing tumours under CT guidance.Early results acceptable for small tumoursApplicable to elderly with small tumours.Depends on tumour location.No L/T data
43 Treatment for Metastatic Disease is Poor Kidney Cancer is Resistant to Chemotherapy and Radiotherapy.Interferon g- standard of care.10-15% have temporary response.Cytoreduction (removal of primary tumour)Can improve survival 4-16months in patients with good performance status and soft tissue mets.
44 Future of Advanced Disease Kidney Cancers are very vascular.Biological therapies aimed at the blood supply of tumours:Antibodies to VEGFThalidomideGene therapyIntroduce normal genes which are defective in the cancer, to switch of the increased blood supply to these tumours.
45 *Worthwhile screening as amenable to surgical therapy Recurrence PatternsSiteRiskSymptomsLung*3-16%, 54% of all metastases.Cough, haemoptysis, dyspneaBone2-8%, 20% of all metastases.Back, hip rib pain.Brain<2%, 5% of all metastases.Neurologic symptoms.Liver*4%LFTs, CTsContralateral Kidney*1-2% (usually new primary)Abdo CT.Local * Recurrence10%Abdo CT, loin/back pain.*Worthwhile screening as amenable to surgical therapy
46 Follow Up Protocol Risk Group History+Exam FBC, UEC LFT, Ca CXR Abdominal CTLowYearly2 yearly.Intermediate6 monthly, then yearly after 2 years2 yearlyHigh3 monthly for 2 years, then 6 monthly.6 monthly for 2 years, then yearly.