Diagnosing bladder cancer - Amazon Web Services…5 The Royal Marsden Diagnosing Bladder Cancer 22...
Transcript of Diagnosing bladder cancer - Amazon Web Services…5 The Royal Marsden Diagnosing Bladder Cancer 22...
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The Royal Marsden
1
Diagnosing bladder cancer
Mr Pardeep Kumar
Consultant Urological Surgeon
The Royal Marsden
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 2
Presentation overview
– Bladder Cancer
– The Haematuria Clinic
– Evidence
– Cases
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The Royal Marsden
Bladder Cancer
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 4
Bladder cancer
– In 2010
– 10,300 new diagnoses
– 4,900 deaths
– 7th most common cancer
– Most expensive cancer to treat overall
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 5
Bladder Cancer (C67): 2008-2010 Average Number of New Cases Per Year and Age-Specific Incidence Rates per 100,000 Population, UK
Prepared by Cancer Research UK - original data sources are available from http://www.cancerresearchuk.org/cancer-info/cancerstats/
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 6
Bladder cancer - Grade
Good specimens + uropathologist
WHO grading
1973 vs. 2004
Grade 1, 2 and 3 vs. Low/High grade
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 7
Bladder cancer - Stage
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The Royal Marsden
The Haematuria Clinic
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 9
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A cause is usually found for Haematuria in x number of cases
1. 10%
2. 40%
3. 70%
4. 95%
10
10%
40%
70%
95%
23%
7%
29%
41%
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Malignancy is the commonest cause of Visible Haematuria?
A. Yes
B. No
11
Yes
No
93%
7%
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Analysis of 1930 patients attending a haematuria clinic
• 1194 Men, 736 Women
• Age 17 – 96 years (Mean 58 years)
• 61% No cause for haematuria found
• 12% Bladder cancer
• 13% UTI
• 2% stones
Khadra et al. J Urol 2000
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Malignancy is more likely with visible haematuria?
A. Yes
B. No
13
Yes
No
0%0%
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 14
Analysis of 4020 patients attending a haematuria clinic
• 2627 Men, 1393 Women
• Macroscopic 46.8%. Macroscopic 53.2%
• Malignancy in 12.1%
• Macroscopic 18.9%
• Microscopic 4.8%
Edwards et al. BJU Int. 2006
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Analysis of 778 patients attending a haematuria clinic
• At least one episode of macroscopic haematuria
•Age > 40 years
•Urinary Tract Infection excluded
•Use CT scanning as a first line investigation
•20% pick up rate of bladder cancer
•Reduce local anaesthetic cystoscopies by 17%
Blick et al. BJU Int. 2012
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Are you less likely to have a malignancy if a UTI is proven on urine culture?
A. Yes
B. No
16
Yes
No
64%
36%
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The Royal Marsden
Cases
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 18
– 69 yr old man
– Jan ’12 - TURP for LUTS - focal CIS
Case One
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– 69 yr old man
– Jan ’12 - TURP for LUTS - focal CIS
– Mar ’12 - ‘Urgent’ relook
– G3pT2 at least bladder base
– LVI
– Foci CIS in prostate chips
Case One
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– Fit – walks 10 miles per day
– Performance status 0
– Neoadjuvant chemotherapy
– 3 cycles of Gem/CIS
– Planned lap cystoprostatectomy and conduit
Case One
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Case One
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– Cancelled day before surgery – unfit
– Treatment dose LMWH
– Advised re: DXT
– Patient seeks second opinion…
Case One
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 24
– Surgery or DXT
– Management of DVT/PE
– Management of urethra
Case One
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Case One
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– Robot assisted cystoprostatourethrectomy and intracorporal ileal conduit
– Enhanced recovery pathway
– Treatment dose LMWH day 2
– Bowels opening day 5
– Filter removed day 8
Case One
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– 14 day admission – wound infection
– Readmission 10 days post op - lymphocoele
– G3pT3a – margins negative
– 0/14 lymph nodes involved
– CIS lower right ureter
– Urethra no malignancy
Case One
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Case One
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– 50 yr old woman
– 18/12 dysuria – 8 courses of antibiotics
– Micro proven UTI (E. coli)
– Macro haematuria prompted referral
Case Two
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Case Two
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 31
– Locally reported as squamous cell
– G3pT2 TCC squamous and plasmacytoid differentiation
– No LVI
– No CIS
– Performance status 0
– Long term smoker
– Left hip dysplasia – hip resurfacing
– Appendectomy via pfannenstiel
Case Two
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Case Two
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 33
Case Two
– Neoadjuvant chemo – Gem/CIS x 3
– Surgery vs. DXT?
– Reconstructive options?
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– 43 yr old woman, heavy smoker
– Sept 2011 – Emergency attendance with vaginal discharge and pain
– Oct 2011 – Urine cytology positive
– Feb 2012 – First hospital OPA
– May 2012 – Symptoms worse – Urodynamics
Case Three
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The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 35
– June 2012 – VCMG attendance – alarm bells
– Ulcerated lesion anterior vaginal wall
– EUA and cystoscopy – Bladder neck/proximal urethral tumour. Invasion into vagina
– Emergency referral
Case Three
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– June 2012 – VCMG attendance – alarm bells
– Ulcerated lesion anterior vaginal wall
– EUA and cystoscopy – Bladder neck/proximal urethral tumour. Invasion into vagina
– Emergency referral
Case Three
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– In pain, catheter in situ.
– Histo – Poorly diff carcinoma consistent with TCC with focal squamous maturation
– CT Chest Abdo Pelvis
Case Three
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Case Three CT
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– Further investigation?
Case Three
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Case Three
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– Further investigation?
– Minimally invasive surgery?
– Surgical approach?
Case Three
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– Kidney – G3pT2 TCC
– Bladder G3pT4, ? Urethral origin
– Negative margins, No involved lymph nodes
Case Three
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Case Three
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Summary
– Refer all macroscopic Haematuria
– Refer persistent microscopic haematuria in those over 40 yrs
– Diagnose and treat UTI but still consider referral
– Beware persistent storage urinary symptoms
– Consider nephrology when Haematuria investigations negative