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epidemiology, staging, management of bladder cancer including intravesical chemotherapy, chemoRT and surgery
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BLADDER CANCER
Dr. Amina Abdul RahmanJunior Resident
Dept of RadiotherapyMedical College, Calicut
EPIDEMIOLOGY
EPIDEMIOLOGY
• Disease affecting the elderly• Median age of Diagnosis is 70 yrs• Male : Female ratio is 3:1• More for whites than Africans or Hispanics
ETIOLOGY
Etiology
• Cigarette Smoking• Industrial Chemicals :Dye workers, Dry Cleaners, Hair Dyeso-aminophenol is the carcinogenSlow acetylators have more risk• Schistosoma hematobium• Chronic Bladder infection
Etiology
• Bladder calculi• Long term indwelling catheter• Past history of upper urothelial cancers• Chlorinated municipal water• Radiation Exposure• Use of Cyclophosphamide
ANATOMY
PATHOLOGY
Pathology
• Most Common Type is Transitional Cell Carcinoma 93%
Papillary Flat Benign Dyspalsia Malignant Cis Invasive Cancer
Pathology
• Squamous Cell Carcinoma• Adenocarcinoma• Small Cell Cancer• Rhabdomyosarcoma• Lymphoma• Melanoma• Secondaries frm other sites• Primary UB Pheochromocytoma
STAGING
Nodal Staging
N1 : single first echelon lymph node
N2 : multiple first echelon lymph nodes
N3 : second echelon lymph nodes
MOLECULAR GENETICS
Molecular Genetics
• LOH of TS on Ch 9 - earliest• The loss of TS gene p53 on Ch 17 for NIBC to
MIBC• P53 accumulation in nucleus is an
independent bad prognostic factor• Aneuploid DNA content in NIBC, more risk for
progression• IHC for microvessel density, marker for Tr
angiogenesis
MULTIFOCAL TUMORS
Metachronous / Synchronous Disease
Field Cancerisation
Whole urothelium exposed to carcinogen
Transforms independent separate groups of cells
Multiple tumors which are genetically unrelated
Metachronous / Synchronous Disease
Clonality
Single carcinogenic insult to a single cell
Clones from this cell spread thro out the UB
Topographically distinct lesions but genetically related
CLINICAL FEATURES
Clinical Features
• Painless gross hematuria 75%
• Symptoms of Bladder irritation
• Advanced disease : pelvic pain, ureteral obstruction, HUN, Rectal obstruction
INVESTIGATIONS
Investigations
• Urine cytology • Cystoscopy and TURBT
• If sessile lesion , perform further imaging of the pelvis as lesion likely invasive
• If papillary, go ahead with resection
Imaging of the pelvis
• To assess extravesical spread and pelvic LN• MRI is better than CT• Imaging of the upper pelvis : CT urogram for
ruling out synchronous lesions• Chest Xray/ CT Thorax to rule out mets• Bone scan if symptomatic or raised ALP• FDG PET for LN mets or Distant mets
TURBT
TURBT
• Bimanual examination under anesthesia before and after
If mass palpable : invasiveMobile mass : T3Fixed mass : T4• Sample muscle within the area of tumor to assess
invasion• Sample biopsies from multiple sites and prostatic
urethra to r/o CIS only if high grade/sessile/in bladder neck
TURBT
Pathologist should comment on:1. If muscle is present in the sample or not2. If muscle is invaded or not3. If CIS is present4. If LVI is present
CLASSIFICATION
Classification
• NMIBC : Ta, Tis, T1
• MIBC : T2 onwards, any N
• Metastatic disease : M1
NON MUSCLE INVASIVE BLADDER CANCER
Ta
Low grade• 15% risk of recurrence and 0.2% risk of
progression• TURBT f/b immediate single intravesical
instillation of mitomycin within 24 hrs• Repeat at 6 weeks if high risk for recurrence• Cystoscopy 3 monthly
Ta
• High gradeIntravesical induction therapy with BCG 1-2 weeks after resection (upto 2 inductions)Cystoscopy at 3 monthly intervalsMaintainence therapy is recommended 3 weekly instillations for a year
T1
• After T1 disease is diagnosed from a TURBT, a second TURBT is strongly recommended
• But if the following factors are present:1. Multifocal lesions2. LVI3. Recurring after BCG Directly do cystectomy and not repeat TURBT
T1
Second TURBT
residual disease no residual disease
Intravesical BCG Intravesical BCG or or Cystectomy Mitomycin
Tis
• Considered high grade with high risk for progression
• Treated with intravesical BCG
INTRAVESICAL CHEMO/IMMUNOTHERAPY
Immunotherapy
• Bacillus Calmette Guerin, attenuated form of M. bovis
• Acts as immune stimulant• stimulates cellular response releasing
cytokines IL-1,2,6,8,TNF and IFN gamma• S/E : Urinary frequency ,dysuria, hematuriaArthralgia, rash, feverPneumonitis, hepatitis, prostatitis, sepsis
Intravesical BCG
• Given 1-2 weeks after resection• Patient is dehydrated over night• Urine is voided completely • 50 mg of TICE in 50cc of 0.9% NS is instilled via
catheter• Patient is asked to void urine after 2 hours• Weekly for 6 weekly• Maintenance is 3 weekly for a year for high risk
and CIS
Intravesical chemotherapy
• Mitomycin is the recommended chemo agent• Dose is 40mg in 20cc sterile water• Given immediately after resection and then 6
weeks later• Other agents : doxorubicin, epirubicin,
valrubicin, thiotepa• Interferon Alfa2b
Intravesical chemotherapy
• CI : bladder perforation, myelosuppression
• S/E : skin rash, irritative bladder symptoms, myelosuppression
Intravesical therapy CHEMOTHERAPY IMMUNOTHERAPY
Directly kills tumor cells Stimulates patient’s immune response to fight the tumor
Increasing dose increases cell killing
Increasing dose will only suppress patient’s immune response
Penetrates bladder by diffusion
Attaches by receptors
When given within 6 hours of resection prevents tumor seeding
Immediate immunotherapy is very toxic
Low grade tumor more responsive to chemo
High grade tumors are more responsive
PROGNOSIS
SURVEILLANCE
Surveillance
• Use cystoscopy and urine cytology• Low grade Ta Cystoscopy at 9 months, then annually thereafter• High grade Ta and T1:Cystoscopy at 3-6 monthly intervals for 2 years, then at increasing intervals
MUSCLE INVASIVE BLADDER CANCER
MIBC
• Start treatment after full metastatic work up• Treatment options:Radical CystectomyPartial CystectomyNeoadjuvant/Adjuvant ChemotherapyDefinitive ChemoRT
RADICAL CYSTECTOMY
Radical Cystectomy
Cystoprostatectomy + Urinary diversion procedure + Pelvic Lymph Node DissectionAdvocates of Surgery argue that:1. There is good long term survival rates2. Morbidity and mortality due to surgery have
now decreased3. Provides for accurate pathological T and N
staging
Radical Cystectomy
• Males :Urinary Bladder, Prostate, Seminal Vesicles, Visceral peritoneum, perivesical adipose tissue and lower ureter• Females:Bladder, uterus, cervix, vaginal cuff, FT, ovaries, anterior peritoneum Followed by a Urinary diversion procedure
Urinary Diversion
• Incontinent :
Ileal conduit : 15 cm of distal ileum to which both ureters are anastomosed, stoma is attached to the ant abd wall
Ileal Conduit
Incontinent urinary diversion
Urinary Diversion
• Continent :1. Stomal reservoir that require intermittent
catheterisationIndiana pouchKoch pouch2. Orthotopic NeobladderAnastomosed to remaining distal urethra
Indiana Pouch
Orthotopic Neobladder
Pelvic LN Dissection
• Extended pelvic LN dissection is beneficial• Remove all first echelon nodes the
hypogastric, obturator, int and ext iliac, pre sciatic and presacral LN
• Also extended to incl common iliac, lower para aortic, paracaval, intr aortic LN
Complications of Surgery
Early• Urinary Leakage• Lymphatic LeakageLate• Recurrent UTI• Stomal infarction/strictures/retraction• Parastomal Hernia• Ureteric ischemic stricture
Metabolic problems of Urinary Diversion
• Hyperchloremic Metabolic Acidosis• Hypokalemia• Hypocalcemia• Hypomagnesemia • Abnormal Drug Kinetics
Partial Cystectomy
• Done when invasive tumor can be removed with a 2 cm margin of normal mucosa without compromising continenence or capacity
• MC site where it can be done is Dome• CI at neck and trigone• LN dissection should also be done
NEOADJUVANT CHEMO
Neoadjuvant Chemotherapy
Advantages :1. Invivo drug sensitivity testing2. Shrinks down tumor for easier surgery3. Delivers full dose of systemic chemotherapy
upfront thus addressing micrometastatic disease early
Neoadjuvant Chemotherapy
• Supported by Two large RCTs• Grossman et al studied 317 pts with T2 to T4a
disease
Surgery alone MVAC x 3 cycles
Surgery• Duration of Follow Up : 11 years
SWOG MVAC Trial
• Chemo regimenMethotrexate 30mg/m2 D1, D15, D22Vinblastine 3mg/m2 D2, D15, D22Doxorubicin 30mg/m2 D2Cisplatin 70mg/m2 D2• Median survival 77 months in the chemo arm
vs 46 months in the surgery alone arm• 38% had complete pathologic response
BA06 30894 CMV Trial
976 patients with T2-T4a disease
CMV x 3 cycles Surgery or ChemoRT
Surgery or ChemoRT• Duration of follow up : 8 years
BA06 30894 CMV Trial
• Chemo RegimenMethotrexate 30mg/m2 iv bolus D1, D8Vinblastine 4mg/m2 D1 D8Cisplatin 100mg/m2 D2• Statistically significant 16% reduction in risk of
death
MVAC Vs DD- MVAC
• DD-MVAC Q14daysMethotrexate 30mg/m2 iv push over 2-3 min D1Vinblastine 3mg/m2 slow iv push D1Doxorubicin 30mg/m2 slow iv push over 15min D1Cisplatin 70mg/m2 inf over 4 hrs D1Pegfilgrastim 24-48 hrs later• Grade 3 or 4 toxicity in only 11%• Complete response of 43%
ADJUVANT CHEMOTHERAPY
Adjuvant Chemotherapy
• Not enough evidence supporting adj chemo in UB cancer
• It is justified in patients with high risk for relapse, if neoadj chemo was not given
1. T3 or more2. Node positive3. LVI present4. >20% cells are positive for p53
Adjuvant RT
• No strong evidence supporting RT in the adj setting
• Maybe given in cases of high risk for locoregional relapse :
1. Positive surgical margins2. Tumor spillage• 40-45 Gy ± Cisplatin , if no NAC was given
DEFINITIVE CHEMO RT
Definitive ChemoRTRationale:1. Micrometastases is common early in the
disease history2. This is the optimal time to treat potential
micromets during RT, before gross mets appear
3. RT induces vascular sclerosis decreasing access of chemo to tumor later
4. CCRT acts as radiosensitisers5. Post op patients may not tolerate CCRT due to
surgical morbidity
Ideal Candidates for CCRT
1. T2 to T3a2. Node negative3. No HUN/ disease at or near ureteric orifice4. No trigone involvement5. Unifocal dis6. No extensive CIS7. Complete TURBT8. Good bladder function
Definitive CCRT
Complete TURBT
40 Gy CCRT with 2 cycles Cisplatin Q3wkly
Cystoscopy ( 3wks later)
Disease No Disease
Cystectomy 25 Gy with 1 cycle Cisplatin
RTOG 89-03 Shipley et al
• 123 pts with cT2 to T4a MIBC• 3 cycles MCV f/b definitive CCRT Vs definitive CCRT alone• OS was similar in both arms 49%• CR of 77%
Analysis of Definitive CCRT Trials
• 4 major RTOG trials• Complete response rate ranging from 59% to
81%• 80% of long term survival maintained intact
bladder• Low rates of grade 3 toxicity, no late grade 4
toxicity
RTOG 05-24
• Ongoing Study• Continuous – course chemoradiation instead
of split course RT • Rationale : to prevent time gap for tumor cells
to repopulate
Simulation
• Patient supine with bladder empty• Foley’s catheter is inserted and 30 ml of
contrast injected• Rectum should be empty, Rectal tube with
barium to visualize the rectum• 2 phases used, first whole pelvis with nodes
f/b boost to tumor
Radiation Fields
• 4 field technique
• AP-PA field:Superior border : L5-S1Inferior border : bottom of obturator foraminaLateral border : 1.5 – 2 cm lateral to bony pelvis
AP - PA
Radiation fields
• Lateral fieldsAnterior border : anterior bladder with a margin with 1.5 – 2cmPosterior border : 2-3 cm posterior to bladder
Lateral Fields
Boost Fields
• For treating the tumor site alone• Exact location of tumor should be obtained
from Pre TURBT imaging• Full bladder is preferred to min dose to bowel
and remaining bladder
Boost Field
Radiation Toxicity
• Acute effects:DysuriaUrgencyFrequency Diarrhoea
Radiation toxicity
• Late effects:Chronic irritative cystitisHemorrhagic cystitisBladder contractureRectal strictureSmall bowel obstruction
79% of patients had normal bladder fn at 10 yrs
PALLIATIVE CHEMOTHERAPY
Palliative Chemotherapy
• Benefits only those with good PS, no visceral mets
• 2 commonly used regimens are 1. DD-MVAC2. GC• GC is not inferior to MVAC, with more toxic
deaths in MVAC
PALLIATIVE RT
Palliative RT
• Beneficial for pain or hematuria• Short high dose per fraction schedules for ill
patients with large disease burden• For better GC patients, longer schedules
concurrent with chemotherapy maybe tried
Summary
• NMIBC (Ta, Tis, T1)TURBTIntravesical therapyClose follow upCystectomy in selected cases
Summary
MIBCT2, T3, T4a :• Neoadj chemo f/b cystectomy• Adj chemo/RT in selected cases if no NAC was
given• Definitive ChemoRT• Patients with poor PS : TURBT alone,
ChemoRT, chemo alone
Summary
• T4b or Node positive Neoadj Chemo, assess for response, then give further chemo or RT/ cystectomy
THE END