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A Guide to the Diagnosis, Treatment and Follow-Up of Bladder and Kidney Cancer. Dr Manish Patel MB.BS., MMed., FRACS Urological Oncologist Westmead Hospital.

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Presentation on theme: "A Guide to the Diagnosis, Treatment and Follow-Up of Bladder and Kidney Cancer. Dr Manish Patel MB.BS., MMed., FRACS Urological Oncologist Westmead Hospital."— Presentation transcript:

1 A Guide to the Diagnosis, Treatment and Follow-Up of Bladder and Kidney Cancer. Dr Manish Patel MB.BS., MMed., FRACS Urological Oncologist Westmead Hospital & Westmead Private Hospital Senior Lecturer and Director of Urology – University of Sydney Scientific Director-Urological Cancer Organisation Urologist to the NSW Cancer Council

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3 Bladder Cancer Incidence is Decreasing in NSW

4 Risk Factors Smoking Previous urothelial cancer. Exposure to carcinogens –Aromatic amines –Benzedine –Alanine dyes Urinary stasis (eg. Diverticulum) Chronic infection/irritation (eg. IDC, stone, UTIs)

5 Bladder Cancer Staging Superficial Invasive Tis

6 Bladder Cancer Cell Types Transitional Cell Carcinoma (TCC) >90% –70% are superficial Squamous Cell Carcinoma 5% Adenocarcinoma 0.5-2%

7 Progression of Urothelial Cancers Normal Urothelium CIS Muscle Invasive Papillary High Grade Papillary Low Grade Hyperplasia P53/ INK4A mutations 80% Progression Chromosome 9 P53/ INK4A mutations >40% <4%

8 Cancer of the Bladder Signs and Symptoms Signs and Symptoms Percent of All Patients Painless Hematuria85 Vesical Irritability40 Flank pain or Kidney Failure20 Lower extremity swelling10 Pelvic Mass10 Weight Loss8 Abdominal or Bone Pain5

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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.

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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

19 The Quality of Surgery Affects 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.

21 Improvements in Neobladder Results Better QoL Day-time continence 96% Night-time= 82% Females=38% ISC Males=5% ISC Pouch Ureters Urethra

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23 Outcomes Following Radical Cystectomy

24 Chemotherapy and Bladder Cancer Can give as Neoadjuvant or Adjuvant therapy to improve survival. In the metastatic setting, will improve survival. MVAC was the standard of care:- Very toxic Gemcitabine and Cisplatin shown to be equivalent:- much less toxic.

25 Patterns of Recurrence: Invasive Disease SiteRisk FactorsMedian time LocalP3/4=34%, LN+ve=32%8-18 months Distant Bone Lung Liver P1/2=20% P3=60% P4=70% LN+ve=40% 90% recur in first 3 years. Upper Tracts Generally 2-4% Ureteral Ca= 30% months Urethral17% after RC 6% after neobladder Up to 45% if TCC in prostate 1-3 years

26 Follow up Schedule After Cystectomy EvaluationYear 1Year 2Year 3-5Year 6+ History+ Exam3mthly6mthly 12mthly CXR3mthly6mthly 12mthly Abdo/Pelvic CT6mthly 12mthly FBC/UEC LFT3mthly6mthly 12mthly Urethral Wash6mthly 12mthly Uppertract cytology3mthly6mthly 12mthly

27 Other Considerations in FollowUp Metabolic complications –Hypochloraemic hypokalaemic metabolic acidosis. Vitamin B12 and bile acids Urolithiasis Pyelonephritis Preservation of upper tracts. Potency Support for stoma or self catheterisation. Psychological support.

28 Follow Up Schedule After Superficial Disease Likely hood of progression Likelyhood of recurrence 1 st Year2-5 years6+ years Low Grade4%90%6 monthly if 1 st check clear 6 monthly yearly High gradeTa=40% T1=52% 95% 90% 3 monthly 6 monthly CIS>50%90%3 monthly 6 monthly

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 cancers Approx 50% mortality in NSW.

31 SIZE MIGRATION Conventional RCC Mean size (cm) Year

32 Risk Factors General Smoking Obesity Haemodialysis ?Diabetes Mellitus ? Hypertension Genetic VHL Tuberous Sclerosis Burt-Hogg-Dube Familial Papillary Familial Leimyomatosis

33 Most Patients are Incidentally Diagnosed. Relatively asymptomatic until large/advanced. 25% Metastases at presentation. Flank pain 10-30% Haematuria 50% Mass <5% Paraneoplastic 10% Paraneoplastic symptoms –Anaemia30% –Weight loss33% –Fever30% –Hypercalcaemia10% –Hepatic Sx5% –Amyloidosis5% –Enteropathy3% –Myopathy3%

34 MALIGNANT RENAL CELL NEOPLASMS HeidelbergClassified by Cytogenetics TypeOccurrenceFeatures Conventional Clear Cell 69%Common, aggressive. VHL and familial. Papillary14%Often multiple and bilateral Less aggressive. Assoc. T.S. Oncocytoma12%Benign. Chromophobe5%Less aggressive. Collecting Duct RareVery aggressive. MedullaryRareVery aggressive.

35 Cyctic Masses Have Variable Risk of Harbouring Cancer: Bosniak Classification. Bosniak II: Internal septations: <5% malignant. Bosniak III: Enhancing rim: 45% Malignant Bosniak IV: Solid enhancing areas, coarse calcification 95%-100% Malignant.

36 TNM Staging of Renal Cell Carcinomas T1 T3b/c <7cm Renal Vein or IVC Confined to Kidney T2 T4 >7cm Outside Gerotas Fascia T3a N: Nodes involved Adrenal or Gerotas M: Distant Mets. Fat involved

37 Survival: Renal Cell Carcinomas TNM Stage N or M T3b/c, T4 T2 or T3a T1

38 The Work Up For A Patient With Suspected Kidney Mass High Quality CT Abdomen +/- IV contrast Staging: Chest XR/CT B.S. if high risk Surgery Give Choices PalliationClinical Trial Interferon Tx Incidental Imaging Haematuria: US+/- IVP Pain/Mass Mass Localised Metastatic Possible Cytoreduction

39 Open Radical Nephrectomy Pros Gold standard for cancer cure. Standard for large, complicated tumours. Least intraoperative complications. Improvements: Small, less invasive incision- lower complications.Cons Major operation with recovery period. Higher lung complications.

40 Laparoscopic Radical Nephrectomy Pros Less pain Quicker recovery Lower lung complications Cons Higher 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 age –Recurrent tumours –Kidney diseases. –Hyperfiltration More difficult surgery Slightly 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 tumours Applicable 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  standard of care % 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 VEGF –Thalidomide Gene therapy –Introduce normal genes which are defective in the cancer, to switch of the increased blood supply to these tumours.

45 Recurrence Patterns SiteRiskSymptoms Lung*3-16%, 54% of all metastases.Cough, haemoptysis, dyspnea Bone2-8%, 20% of all metastases.Back, hip rib pain. Brain<2%, 5% of all metastases.Neurologic symptoms. Liver*4%LFTs, CTs Contralater al Kidney* 1-2% (usually new primary)Abdo CT. Local * Recurrence 10%Abdo CT, loin/back pain. * Worthwhile screening as amenable to surgical therapy

46 Follow Up Protocol Risk GroupHistory+Exam FBC, UEC LFT, Ca CXRAbdominal CT LowYearly 2 yearly. Intermediate6 monthly, then yearly after 2 years 2 yearly High3 monthly for 2 years, then 6 monthly. 6 monthly for 2 years, then yearly.

47 Isolated Renal Fossa, Lung or Liver Recurrence Surgical therapy50% survival Medical therapy14% survival No therapy12% survival

48 Dr Manish Patel Urological Oncologist Senior Lecturer, University of Sydney Suite 3, 2 Redleaf Ave. Wahroonga NSW 2076 (Ph) Suite 12a Westmead Private Hospital Westmead NSW 2145 (Ph)


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