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Bladder Cancer Diagnosis and Treatment

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Presentation on theme: "Bladder Cancer Diagnosis and Treatment"— Presentation transcript:

1 Bladder Cancer Diagnosis and Treatment
Albert McBride, MD, FICS

2 Epidemiology Incidence 74,690 new cases in 2014:
Men 56,390 Women 18,300 Mortality 15,580 deaths in 2014 Men 11,170 Women 4,410 2014 71,830 new cases of colo-rectal cancer 2020 Bladder cancer will be the 3rd most common malignancy in men

3 Epidemiology continued
90% of bladder cancers in the U.S. are urothelial cell tumors. Squamous cell carcinoma (7%) Adenocarcinoma (2%) Most common route of spread is local extension to surrounding tissues.

4 Risk Factors Risk Factors: Age Cigarette smoking: strongest RF
M: median – 72 F: median – 74 Cigarette smoking: strongest RF Attributable risk: 46% RR of death from Bladder CA Males: Current smokers = 3.3; past smokers = 2.1 Females: Current smokers = 2.2; past smokers = 1.9 Smoking cessation: can reduce risk up to 40% (ROLE OF PHYSICIANS!)

5 Risk Factors (continued)
RF’s continued… Chemicals: Aniline dyes (color fabrics) Cyclophosphamide Occupational: Aromatic amines (betanaphthylamine, 4-aminobiphenyl, and benzidine) Painting, leather industries, autoworkers, truck drivers, metalworkers, paper and rubber manufacturers, foundry workers, dry cleaners, dental technicians, hairdressers, and marine engineers 30-50 years after exposure Arsenic Northestern Taiwan (high water arsenic levels) Exposure to herb Aristolochia fangchi in Chinese herbal weight-reduction supplement There are over 60 known carcinogens and reactive oxygen species present, including 4-aminobiphenyl (4-ABP), polycyclic aromatic hydrocarbons, N-nitroso compounds and unsaturated aldehydes 

6 Risk Factors (continued)
Urinary tract infection - SCC Chronic irritation (catheters, bladder stones) -SCC Non-functional bladder – SCC Schistosoma haematobium (SCC, Egypt) Radiation

7 Lower risk: increased fluid intake (still controversial) Rationale:
Increased urine output Decreased contact time of carcinogens Dilution of carcinogen concentration Fruits and vegetables (still controversial)

8 Cost Analysis: Predicted life-time cost per patient: $99,270- $120,684(best case-worst case scenario) (Avritscher,et al, 2006) 5-yr net cost: $1B (7th highest all cancers)

9 Tumor Genetics

10 Diagnosis Signs and symptoms Asymptomatic Hematuria: MC (85%)
AUA’s Best Practice Policy Panel on Asymptomatic Microscopic Hematuria : at least 3 RBC’s/hpf from 2 of 3 properly collected specimens. Irritative voiding symptoms: frequency or dysuria Flank pain (hydronephrosis?, ureterovesical jxn tumor)

11 Cystoscopy Conventional or white light, “gold standard”
Disadvantage: flat lesions (CIS) -> incomplete resection -> recurrence Flexible: office procedure, w/w/o fulguration of small tumors Well-tolerated Fluorescent cystoscopy: [5-aminolevulinic acid (ALA)]: Visualization of tissue w/high metabolic rate Improves effectiveness of initial resection in superficial and early invasive CA Comparison vs conventional cystoscopy Single-center studies(Denzinger, et al 2007; Filbeck et al, 2002 ) : Increased recurrence-free survival Lower residual tumor rate Overall improved dx Multicenter study (Schumacher et al, 2010): No difference in terms of recurrence-free and progression-free survival Currently not included in the NCCN nor the updated AUA guidelines on management of non-invasive bladder cancer

12 Imaging Staging, pretreatment planning
CT: essentially replaced IVP in many centers MRI: patients with renal failure Risk of nephrogenic systemic fibrosis (NSF) from gadolinium More accurate staging 85% accuracy (non-invasive vs invasive) 82% accuracy (organ-confined vs nonorgan-confined) Disadv: overstaging Especially after recent biopsy or resection (edema and hyperemia)

13 CT scans Should include abdomen and pelvis, and be done with and without contrast. May demonstrate extravesical extension, nodal involvement, or metastases. Cannot differentiate depth of bladder wall invasion and may miss tumors <1cm in size. Replacing IVP as the procedure of choice. Previously included delayed images to identify defects in the collecting system, but with the use of CT urograms this is no longer an issue.

14 CT scan

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16 Fluorescence cystoscopy
Fluorescence cystoscopy uses an intravesical photoactive substance (such as 5-aminolevulinic acid, that is preferentially taken up by neoplastic tissue, allowing enhanced visualization between normal and neoplastic tissue using violet light( nm). Randomized trials have confirmed that fluorescence cystoscopy detects more tumors than white light cystoscopy. The drawbacks are that there is a slightly higher false positive rate and a higher cost. It remains investigational in the United States.

17 Fluorescence cystoscopy

18 Jacobs et al, 2010

19 PET (18-FDG): Detection of early mets or lymph node spread (adv over CT or MRI) Increased glycolytic activity in neoplastic cells with a high metab rate -> increased 18-FDG uptake

20 Combined PET/CT imaging (combined PET/CT device):
Functional findings on PET with anatomic structures shown on CT Diagnosis of metastatic disease Drieskens et al, 2005: Sensitivity: 60% Specificity: 88% PPV: 75% NPV: 79% Kibel et al, 2009: Prospective study on 43 muscle-invasive bladder cancer patients w/o mets on conventional CT or MRI: Sensitivity: 70% Specificity: 94% PPV: 78% NPV: 91% Conclusion: Lower recurrence-free, disease-specific, and overall survival in patients with positive 18-FDG PET/CT Scans

21 Staging Stage 0: noninvasive papillary carcinoma or CIS
Stage I: involves lamina propria. Stage II: invasion of muscularis propria or microscopic invasion of perivesical tissue. Stage III: macroscopic invasion of perivesical tissue or invasion of prostatic stroma/uterus/vagina. Stage IV: Involvement of pelvic wall/abdominal wall, or any lymph node involvement or metastases.

22

23 Staging

24 Bladder Cancer: Stage Distribution
Ta, Tis, TI 75% % of deaths T2-T4 15% N+, M+ 10% Progression 15-20% of patients with NMIBC will progress 18-45% of patients with MIBC will have metastatic disease 85% of deaths

25 Bladder Cancer: Stage and Prognosis
TNM 5-yr Survival Occult N+ Ta/Tis N0M0 95% 5% I TI 65-75% II Ta-b 57% 18-27% III T3a-4a 31% 45% IV T4b 24% T any N+M0 14% N any M+ Median OS <9 months

26 Treatment (General Principles)
TURBT (Transurethral resection of bladder tumor) Initial - Diagnostic, prognostic and often therapeutic 80 percent of patients with high-risk tumors recur within 12 months Repeat: to optimize staging, 2 to 6 weeks after initial 30 percent of T1 tumors will be under staged at initial TURBT Bulky high-grade Ta tumor Incompletely resected tumor Any T1 tumor especially if no muscle in resected specimen 34-76% with residual disease Divrik et al, 2006: initial only (+ MMC) vs repeat TURBT (+MMC) 3-yr recurrence free survival Later group had 30% higher survival rate

27 Treatment Non-muscle invasive
Goal: prevent recurrence and progression  decrease mortality Adjuvant intravesical therapy permits high local concentrations of a therapeutic agent within the bladder, potentially destroying viable tumor cells that remain following TURBT and preventing tumor implantation 2010 NCCN guidelines indicate use for: low grade Ta recurrences High grade Ta and T1 lesions CIS: Treatment of choice- Bacillus Calmette-Guerin (BCG) BCG is an attenutated National Comprehensive Cancer Network BCG is administered weekly for 6 weeks.

28 Tx: Non-muscle invasive
Goal: prevent recurrence and progression  decrease mortality Periop intravesical tx during TURBT 2007 Update AUA guidelines meta-analysis of 7 randomized trials comprising 1476 patients (Sylvester, 2004) 1 immediate instillation intravesical chemo vs TUR alone Outcome: recurrence median follow-up of 3.4 years Either epirubicin, MMC, thiotepa, pirarubicin: Immediately postop or within 24 hours No significant difference between chemo agents 37% vs 48% (p< ) Contraindications: Bladder perforation Extensive TURBT

29 Adjuvant intravesical therapy BCG immunotherapy
BCG shown to delay tumor progression to more advanced stage, decrease subsequent cystectomy and increase overall survival compare to TURBT alone 6 randomized trials that included 585 eligible patients with Ta or T1 disease TURBT plus BCG had significantly fewer recurrences at 12 months compared to those managed with TURBT alone (odds ratio 0.30; 95% CI ) BCG + IFN-alpha combination Still controversial results Not yet recommended in NCCN guidelines Shelley, M.D., Court, J.B., Kynaston, H., Wilt, T.J., Fish, R.G., and Mason, M. (2000). Intravesical Bacillus Calmette-Guerin in Ta and T1 Bladder Cancer. Cochrane Database Syst Rev CD

30 Failure rate (BCG): 20-40% recurrence rate
35% success rate after 2nd BCG cycle ~15% success rate after conventional chemo (Valrubicin)

31 Surveillance Nonmuscle-invasive Cystoscopy + Urine cytology:
1st 1-2 yrs: q 3mos 3-4 yrs: up to q 6months >4 years: annually Upper tract imaging: for high-grade tumors q1-2 years

32 Surveillance Muscle-Invasive Disease 1st 2 yrs:
Urine cytology, electrolyte and creatinine levels, chest xray, A/P imaging q 3-12 months Urethral washing q 6-12 mos Vitamin B12 level annually (continent diversion) Cystoscopy, urine cytology and/or bladder biopsies q3-6 mos x 2 years (bladder-sparing protocols) Bone scans: only indicated for patients with suspicious bone pains and advance disease (at least pT3 and pN+) After 2 years: as needed

33 Tx of Recurrence(Non-muscle invasive):
2007 Update AUA Guidelines Cystectomy : tx of choice Further intravesical therapy (patients who are poor surgical candidates)

34 Tx: Muscle-Invasive Radical Cystectomy Robotic Cystectomy
Urinary Diversion Periop Chemo

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37 Ileal Conduit Procedure
15-20 cm of small intestine (ileum) is separated from the intestinal tract Intestines are sewn back together (re-establish intestinal continuity) ~ cm of terminal ileum is preserved to prevent malabsorption of B12 The ureters that drain the kidneys are then sewn into one end of the ileum – either through bricker technique as shown or wallace And the other end is brought up to an opening on the abdomen as a stoma. The intestine naturally has a propulsive movement, almost like a snake, that normally would be moving food through the GI tract, but in this instance, is pushing the urine through the segment and out of the body. Figures from Campbell-Walsh Urology, Ninth Edition

38 Indiana Pouch Appendix removed
Right colon is opened lengthwise and folded down to create a sphere The Indiana Pouch is probably the most commonly used cutaneous reservoir. Here, the right colon and ileum are isolated. The appendix is removed. The right colon is opened lengthwise and folded down to create a sphere. Figures from Campbell-Walsh Urology, Ninth Edition

39 Modified Hautmann with Studer Chimney
Neourethra formation and folding and anastamosis

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41 Radical Cystectomy Organ-confined muscle-invasive Ca
5 year survival: % Operative mortality rate: up to 3% Complication rate: % (first month post op) Surgery alone (failure rates): pT2 : % pT3: % pT4: % Delay greater than 12 weeks associated with advanced pathologic stage and decreased survival concensus: should be done within 3 mos of dx of muscle-invasive disease Low- vs high-volume hospitals Low-vs high-volume surgeons Surgical margin status No of LN’s removed: higher -> better survival Minimum: nodes

42 Robotic cystectomy Potential advantages: Disadvantages:
Lower blood loss Less intraop fluid needs Smaller incisions Reduced bowel exposure Greater ergonomics Disadvantages: Less lymph nodes (controversial) Cost

43 Urinary Diversion Options: Factors in choosing method:
Neobladder (47%) Orthotopic neobladder (50-90% in some centers): No need for cutaneous stoma and urostomy appliance -> decreased physician reluctance and increased patient acceptance for early cystectomy Tissue-engineered neobladder: Still under research Uses autologous urothelial and smooth muscle cells cultured on biocompatible synthetic or naturally derived substrates Conduit (33%) Anal(10%) Continent cutaneous(8%) Incontinent cutaneous(2%) Factors in choosing method: safety (patient, cancer control) Complications (short , long term) Quality of life Physician experience

44 Perioperative chemotherapy
Rationale: 30-50% understaged clinically pT3/4 or node positive: >50% failure rate after cystectomy Goal: Downstage Eradicate micromets Reduce implantation of circulating tumor cells intraop Improve survival

45 Neoadjuvant Chemo Grossman et al, 2003: Intergroup 8710 trial
Cystectomy alone vs neoadjuvant MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) Neoadjuvant gp: Higher likelihood of eliminating residual cancer in the cystectomy specimen(pT0) Improved survival

46 Adjuvant chemo: Insufficient studies for inclusion in latest recommendations Theoretical advantages: Careful patient selection based on P staging Lack of delay to cystectomy Alleviation of patient anxiety Enhancement of chemotherapy against small-volume dse Disadvantages: Poor tolerance Delay in receiving postop chemo due to postop complications Donat et al, 2009: 30% of patients may have postop complications that might preclude or delay adjuvant chemo

47 Main disadvantages of chemo regimens: Toxic
MVAC: Severe granulocytopenia n/v Stomatitis Diarrhea/constipation Alternative regimens: G-MVAC (G-CSF + MVAC): no difference in survival GC (gemcitabine + cisplatin) Similar efficacy/survival rates but less toxicity Less neutropenia/mucositis/neutropenic fever

48 Cisplatin based chemo:
Contraindicated in patients with poor renal function Alternative: carboplatin Hussain et al, 2001: PCG (paclitaxel, carboplatin,gemcitabine) Higher response rate with median survival of 14.7 months

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50 Summary/Conclusions Bladder cancer is one of the most costly cancers from dx until death. Improvements in diagnosis and treatment of bladder cancer (tumor markers, fluorescent cystoscopy, PET/CT imaging, neoadjuvant chemo, extended lymph node dissection, use of orthotopic neobladder) A lot of room for improvement in management: Periop and adjuvant intravesical therapies remain underused (31%) Understaging at time of cystectomy (30-50%) High complication rates after cystectomy (25-57%) Improvement in imaging techniques and molecular markers to improve clinical staging Neoadjuvant chemo and extended LN dissection underused

51 References Jacobs, et al. Bladder Cancer in 2010: How Far Have We Come?. CA Cancer J Clin 2010; 60: 2010 NCCN Guidelines for Bladder Cancer 2007 Update of AUA Guidelines for Bladder Cancer Glenn’s Urologic Surgery, 7th ed Campbell-Walsh Urology, ninth edition UCLA State-of-the-Art Urology Symposium, March 2014


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