Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 Bladder Cancer Incidence is Decreasing in NSW 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) Bladder Cancer Staging Tis Superficial Invasive Bladder Cancer Cell Types • Transitional Cell Carcinoma (TCC) >90% – 70% are superficial • Squamous Cell Carcinoma 5% • Adenocarcinoma 0.5-2% Progression of Urothelial Cancers P53/ INK4A mutations Normal Urothelium Papillary High Grade Hyperplasia Chromosome 9 P53/ INK4A mutations CIS >40% 80% Progression <4% Muscle Invasive Papillary Low Grade Cancer of the Bladder Signs and Symptoms Signs and Symptoms Painless Hematuria Vesical Irritability Flank pain or Kidney Failure Lower extremity swelling Pelvic Mass Weight Loss Abdominal or Bone Pain Percent of All Patients 85 40 20 10 10 8 5 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. Algorithm for Bladder Cancer Treatment First Occurence TCC Superficial Disease Ta, T1 Intravesical Therapy TURBT Follow-Up Invasive Disease T2 Progression Metastatic Invasive Chemotherapy XRT or Cystectomy Recurrence Treatment by P/P Preference Instillation of BCG Reduces Recurrence and Progression of High Grade Bladder Cancers Instillation of Single Dose Intravesical Chemotherapy Reduces Recurrences of Superficial Bladder Cancer Early Cystectomy for Patients with HG Bladder Cancer Refractory to Intravesical Treatments Improves Survival Extended Lymphadenectomy At Radical Cystectomy Improves Survival Greater Number of Lymph Nodes Retrieved Results In Greater Survival The Quality of Surgery Affects Survival 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. Improvements in Neobladder Results Ureters • Better QoL • Day-time continence Pouch 96% • Night-time= 82% • Females=38% ISC • Males=5% ISC Urethra Outcomes Following Radical Cystectomy Chemotherapy and Bladder Cancer MVAC was the standard of care:- Very toxic Gemcitabine 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. Patterns of Recurrence: Invasive Disease Site Local Distant •Bone •Lung •Liver Risk Factors P3/4=34%, LN+ve=32% P1/2=20% P3=60% P4=70% LN+ve=40% Median time 8-18 months 90% recur in first 3 years. Upper Tracts Generally 2-4% Ureteral Ca= 30% 17% after RC 6% after neobladder Up to 45% if TCC in prostate 22-40 months Urethral 1-3 years Follow up Schedule After Cystectomy Evaluation Year 1 Year 2 Year 3-5 Year 6+ History+ Exam 3mthly 6mthly 6mthly 12mthly CXR 3mthly 6mthly 6mthly 12mthly Abdo/Pelvic CT 6mthly 6mthly 6mthly 12mthly FBC/UEC LFT 3mthly 6mthly 6mthly 12mthly Urethral Wash 6mthly 6mthly 6mthly 12mthly Uppertract cytology 3mthly 6mthly 6mthly 12mthly 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. Follow Up Schedule After Superficial Disease Likely Likelyhood hood of of progression recurrence Low Grade 4% 90% High grade Ta=40% T1=52% CIS >50% 95% 90% 90% 1st Year 2-5 years 6+ years 6 monthly if 1st check clear 3 monthly 6 monthly yearly 3 monthly 6 monthly 3 3 monthly monthly 6 monthly Diagnosis, Treatment and Follow-Up of Kidney Cancer The Incidence of Kidney Cancer is Increasing 3.1% of male Cancers and 2.4% of female cancers Approx 50% mortality in NSW. SIZE MIGRATION Conventional RCC 1983-1997 9 8 7 6 Mean size5 (cm) 4 3 2 1 0 8.3 7.8 7.1 6.6 5.5 83-85 86-88 89-91 Year 92-94 95-97 Risk Factors General • Smoking • Obesity • Haemodialysis • ?Diabetes Mellitus • ? Hypertension Genetic • VHL • Tuberous Sclerosis • Burt-Hogg-Dube • Familial Papillary • Familial Leimyomatosis Most Patients are Incidentally Diagnosed. • Relatively asymptomatic until large/advanced. • 25% Metastases at presentation. • • • • Flank pain Haematuria Mass Paraneoplastic 10-30% 50% <5% 10% • Paraneoplastic symptoms – – – – – – – – Anaemia Weight loss Fever Hypercalcaemia Hepatic Sx Amyloidosis Enteropathy Myopathy 30% 33% 30% 10% 5% 5% 3% 3% MALIGNANT RENAL CELL NEOPLASMS HeidelbergClassified by Cytogenetics Type Occurrence Features Conventional Clear Cell 69% Common, aggressive. VHL and familial. Papillary 14% Often multiple and bilateral Less aggressive. Assoc. T.S. Oncocytoma 12% Benign. Chromophobe 5% Less aggressive. Collecting Duct Rare Very aggressive. Medullary Rare Very aggressive. 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. TNM Staging of Renal Cell Carcinomas T1 <7cm Confined to Kidney T3b/c Renal Vein or IVC T2 >7cm T4 Outside Gerotas Fascia T3a Adrenal or Gerotas Fat involved N: Nodes involved M: Distant Mets. Survival: Renal Cell Carcinomas TNM Stage T1 T2 or T3a T3b/c, T4 N or M The Work Up For A Patient With Suspected Kidney Mass Haematuria: US+/- IVP Mass Incidental Mass High Quality Imaging CT Abdomen +/- IV contrast Surgery Localised Staging: Chest XR/CT B.S. if high risk Possible Cytoreduction Interferon Tx Metastatic Give Choices Pain/Mass Palliation Clinical Trial 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. 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. 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 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 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. 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. Recurrence Patterns Site Risk Symptoms Lung* 3-16%, 54% of all metastases. Bone 2-8%, 20% of all metastases. Cough, haemoptysis, dyspnea Back, hip rib pain. Brain <2%, 5% of all metastases. Neurologic symptoms. Liver* 4% LFTs, CTs Contralater 1-2% (usually new primary) al Kidney* Abdo CT. Local * 10% Recurrence Abdo CT, loin/back pain. *Worthwhile screening as amenable to surgical therapy Follow Up Protocol Risk Group History+Exam CXR FBC, UEC LFT, Ca Abdominal CT Low Yearly Yearly 2 yearly. Intermediate 6 monthly, then yearly after 2 years 3 monthly for 2 years, then 6 monthly. 6 monthly, then yearly after 2 years 3 monthly for 2 years, then 6 monthly. 2 yearly High 6 monthly for 2 years, then yearly. Isolated Renal Fossa, Lung or Liver Recurrence • Surgical therapy • Medical therapy • No therapy 50% survival 14% survival 12% survival Dr Manish Patel Urological Oncologist Senior Lecturer, University of Sydney Suite 12a Westmead Private Hospital Westmead NSW 2145 (Ph) 9633 2088 Suite 3, 2 Redleaf Ave. Wahroonga NSW 2076 (Ph) 9924 1777