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Cases in Urological Oncology
Dr Manish Patel
MB.BS., MMed., FRACS, PhD
Urological Cancer Surgeon
Westmead Public and Private Hospital
Senior Lecturer, University of Sydney
A Case of Bladder Cancer
• Mr K.S. 63 year old man.
• Heavy smoker in the past.
• Father had bladder cancer
• Asymptomatic
Bladder Cancer Screening
• Risk Factors for Bladder Cancer
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Smoking
Age
Radiation exposure
Previous urothelial carcinoma
Analgesics
Cyclophosphamide
Has Haematuria Screening Been Useful?
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Only one good long term study
Not randomised
Men over age 50 years
Daily home dipstick test for a week
• 16.4% of the population had haematuria
investigated.
• 8.1% with haematuria had BC
• At 14 years no man with screen detected BC died.
• 20% of non screen detected BC had died
What Causes Haematuria?
• Upper Urinary Tract
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Renal Cell Carcinoma
Urothelial cancer
Urolithiasis
Glomerular causes
Nephritis
AV Malformation
Renal infarction
Renal vein thrombosis
Polycystic kidneys
• Lower Urinary Tract
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Urothelial cancer
Cystitis
BPH
Bladder stones
Prostate cancer
Prostatitis
Trauma
TB
Anticoagulation
Imaging
CT Urogram
• Helical CT abdomen and
pelvis
– With and without contrast,
with delayed phase
– 3D reconstruction.
• 100% sensitive, 97%
specific
• Identifies RCC, urothelial
tumours and kidney stones
as well as many other
abnormalities
• Choice of imaging
techniques
Imaging
Urinary Tract Ultrasound
• Cheap, quick, noninvasive, no contrast
• Sensitivity 60-70%,
specificity 90%
• Still inferior to CT.
Imaging
IVP
• Intravenous contrast
and tomograms
• Sensitivity 61%,
specificifty 92%
• Expensive and time
consuming
• Misses small renal
lesions – need US as
well
Algorithm for evaluation
Macroscopic
Haematuria
Microscopic
Haematuria
High Risk
Exclude UTI (MSU)
Urine cytology X3
Dysmorphic cells on
microscopy
Exclude UTI (MSU)
Urine cytology X3
Upper Tract Imaging:
US only.
Upper Tract Imaging:
CT Urogram or
IVP + US
Lower Tract Investigation:
Cystoscopy (Flexible or Rigid)
Low Risk
Nephrologist
Evaluation
Lower Tract Investigation:
Cystoscopy (Flexible)
Case
• Mr KS has
• Normal CT IVP
• Urine cytology: suspicious for malignancy
• Has cystoscopy
Cystoscopy
High Grade Urothelial Carcinoma
Lamina Propria Invasion
Carcinoma in-situ
Staging of Bladder Cancer
CIS
Tis
Superficial
Superficially Invasive
T2
Invasive
T3
What Next?
• BCG treatment for 6 weeks- intravesically
– Eradicated CIS (70%)
– Decreased recurrence and progression.
• Follow-up cystoscopy every 3 months for 2 years.
9 months later
• Muscle Invasive
• Staging CT, Bone scan normal.
A Case of Bladder Cancer
Underwent:
Nerve-sparing
cystoprostatectomy with
neobladder formation and
extended lymph node
dissection.
Ureters
Pouch
• Continent at 6 weeks.
• Erections at 5 months.
• Voids normally with a
little straining.
Urethra
A Case of Bladder Cancer
Considerations in FollowUp
• Cancer Recurrence:
– Regular urine cytology, CT scans abdomen and chest.
• Metabolic complications
– Hypochloraemic hypokalaemic metabolic acidosis.
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Vitamin B12 and bile acids
Urolithiasis
Pyelonephritis
Preservation of upper tracts.
Potency
A Case of Prostate Cancer
• Mr J.B. 57 year old.
• Mild LUTS
• Hypertension
• Asks his G.P. for a test for prostate cancer?
• What should the G.P discuss with him?
2 New Randomised trails of screening
PLCO trial highly flawed
30% were prescreened before entering the trial
52% in control arm had screening
85% only were screened in screening arm.
• 182,000 men aged 50-74
• Randomised to : PSA every 4 years or no
screening.
• PSA cut-off 3.0ng/ml and DRE
• 16.2% tests were positive
ERSPC DATA
• CaP incidence: 8.2% screened vs 4.8% control (p<0.05)
• CaP Death: decreased by 20% in screening arm at 9 years.
• When compliance and contamination was accounted for- 32%
diff.
• NNT = 48!!!
Summary
Potential
Benefits
• 20% reduction in death from
CaP
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Potential
Harms
Need to treat 48 men to
save one.
Need to discuss the individual benefits and risks
of screening with all male patients 50-70years.
A Case of Prostate Cancer
PSA Test: 3.0 ng/ml, F/T 9%
Is this normal?
Age
Median PSA
Normal Range
40-49
0.7ng/ml
0-2.5ng/ml
50-59
0.9ng/ml
0-3.5ng/ml
60-69
1.4ng/ml
0-4.5ng/ml
70+
1.7g/ml
0-6.5ng/ml
PSA and Risk of Prostate Cancer
in Asymptomatic Men.
PSA Levels
PCPT Trial
Values
Normal DRE
1-1.99
17%
2-2.99
24%
3-3.99
27%
4-10
29%
10+
45%
PSA Velocity
• Needs to be calculated with at least 3 PSA values
– 15% variability day-day
• PSA velocity of >0.35ng/ml/year is abnormal.
• If PSA velocity is abnormal and PSA is above the
median value – refer to urologist.
Free to Total (%) Does Help Specificity.
Algorithm for PSA Testing
Male 50-70
>10 year life expectency
Male 40-70
>10 year life expectency
Family Hx or other high risk
Male 40-70
Symptomatic
Discuss Pros and Cons of PSA testing
Test PSA and DRE
No bicycle riding, UTI (6 weeks), recent surgery or manipulation
Normal : Rpt in
1 year
Normal
DRE
Abnormal
PSA TEST
Abnormal
Normal but
Above median
Mildly Abnormal
Refer to Urologist
OR
Calculate PSA Velocity
Repeat PSA in 6 weeks
With F/T%
Exclude Other Causes of
Elevated PSA and then
Discuss Risk of CaP and
Need for Biopsy
A Case of Prostate Cancer
• Mr J.B has an abnormal
prostate exam.
• He has a prostate biopsy
– 2% Lignocaine pudendal
nerve block.
• Biopsy results:
• Gleason Grade 3+3=6
• In 6/12 cores involving
25%-50% of the cores.
• What are his options for
treatment?
Treatment options for low risk CaP
• Active surveillance
• Radical Prostatectomy
– Open
– Robotic
• Seed Brachytherapy (not HDR brachytherapy)
• External beam radiotherapy
• Experimental
– HIFU
– Cryothepy
A Case of Prostate Cancer
• Pathology:
– Adenocarcinoma, Gleason Grade 3+4
– Extracapsular extension
– Negative surgical margins.
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Follow-up:
Continent @ 4weeks
Potent @ 3 months
No PSA recurrence at 2 years.
Questions