Bladder cancer April 2016 Bladder cancer Introduction Bladder

Bladder cancer April 2016

Bladder cancer: Introduction • Bladder cancer (BC): Heterogeneous disease • Although disease may occur in young persons >90% of new cases occur in persons ≥ 55 yr of age • 70% of patients presenting with superficial tumours, which tend to recur but are generally not life threatening • 30% presenting as muscle-invasive disease associated with high risk of death from distant metastases Kaufman DS, et al. Lancet 2009; 374: 239– 49/ Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.

Rawal S. Indian J Urol. 2008; 24(1): 60.

Epidemiology • 2 nd most common genitourinary malignancy after prostate cancer (PC) • 9 th most common cancer in the world • Globally, incidence of bladder cancer varies significantly, with Egypt, Western Europe and North America having highest incidence rates & Asian countries the lowest rates • 430, 000 new cases diagnosed worldwide, male to female ratio: 3: 1 (2012) • Men: 7 th most common cancer • Women: 17 th most common cancer Kaufman DS, et al. Lancet 2009; 374: 239– 49/ Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.

Males Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.

Females Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.

A high fluid intake is associated with decreased risk of BC in men Michaud DS, et al. NEJM. 1999; 340: 1390 -7.

Divergent molecular pathways of oncogenesis in superficial & muscle invasive urothelial carcinoma of urinary bladder Zhao M, et al. Chin J Cancer Res 2016; 28(1): 92 -98.

Bladder cancer: Clinical Presentation • Main presenting symptom of all bladder cancers: Painless haematuria • Diagnosis established by: Urinary cytology & transurethral tumour resection Kaufman DS, et al. Lancet 2009; 374: 239– 49.

Guidelines: Primary assessment of NMIBC Babjuk M, et al. EAU 2015.

Guidelines on non-invasive bladder cancer (Ta, T 1 and CIS) Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. EAU 2015.

Guidelines for TURB and/or biopsies, tumour classification & pathology report Babjuk M, et al. EAU 2015.

Bladder diagram Babjuk M, et al. EAU 2015.

Structure of urinary bladder wall & urothelium Zacche MM, et al. Research and Reports in Urology 2015: 7 169– 178.

2009 TNM classification of urinary bladder cancer Babjuk M, et al. EAU 2015.

WHO grading: 1973 & 2004 Babjuk M, et al. EAU 2015.

WHO grading: 2004 Babjuk M, et al. EAU 2015.

Colombel M, et al. Eur Urol Suppl. 2008; 7: 618– 626.

Summary of main urinary markers Babjuk M, et al. EAU 2015.

Photosensitizing agent 5 -aminolevulinic acid (5 -ALA) is used to induce red fluorescence under exposure to blue light using cystoscopy to identify cancerous and precancerous lesions Lerner SP, et al. Cancer. 2015; 121: 169 -78.

Optical coherence tomography (OCT) can resolve layers of bladder & distinguish benign from malignant characteristics Lerner SP, et al. Cancer. 2015; 121: 169 -78.

Weighting used to calculate disease recurrence & progression scores Babjuk M, et al. EAU 2015.

Probability of recurrence & disease progression according to total score Babjuk M, et al. EAU 2015.

Risk group stratification Babjuk M, et al. EAU 2015.

Algorithm for selection of treatment method Smith ZL, et al. BJUI. 2013; 112: 13 -25.

Smith ZL, et al. BJUI. 2013; 112: 13 -25.

Recommendations for adjuvant therapy in Ta, T 1 tumours and for therapy of CIS Babjuk M, et al. EAU 2015.

Summary of key steps & mediators in mechanism of action of BCG immunotherapy Fuge O, et al. Research and Reports in Urology 2015: 7 65– 79.

Guidelines on non-invasive bladder cancer (Ta, T 1 and CIS) Guidelines for follow-up in patients after TURB of NMIBC Babjuk M, et al. EAU 2015.

Management options for side effects associated with intravesical BCG Babjuk M, et al. EAU 2015.

Treatment strategy: Primary/recurrent tumour(s) without previous BCG* Babjuk M, et al. EAU 2015.

TURBT

Categories of unsuccessful treatment with intravesical BCG Babjuk M, et al. EAU 2015.

Treatment strategy in recurrence during or after intravesical BCG* Babjuk M, et al. EAU 2015.

Invasive Bladder Cancer • For muscle-invasive tumours, radical cystectomy with pelvic lymphadenectomy has been the gold standard for the past several decades • Complication & perioperative mortality rates have been declining, with reported rates as low as 17% to 32% and 2% to 3%, respectively Yafi FA, et al. Can Urol Assoc J. 2009; 3(5): 409– 412.

Radical cystectomy

Results of radical cystectomy

Results of radical cystectomy Stage Recurrence-Free 5 y. 10 y. Overall Survival 5 y. 10 y. T 2 N 50 78 41 62 29 50 33 77 52 64 40 49 24 44 26 T 3 a T 3 b T 4 a N+ NN+ NN+ Stein JP, et al. J Clin Oncol. 2001; 19(3): 666 -75. 89 50 76 37 61 29 45 33 87 57 52 44 26 29 12 23 20

Treatment recommendations in Ta, T 1 tumours and CIS according to risk stratification Babjuk M, et al. EAU 2015.

Treatment recommendations for BCG failure & recurrences after BCG Babjuk M, et al. EAU 2015.

Intravesical chemotherapy in non-muscle invasive BC Porten SP, et al. Indian J Urol. 2015; 31(4): 297– 303.

Instillation regimes for intermediate-risk tumors Jokisch JF, et al. Indian J Urol. 2015; 31(4): 304– 311.

High-risk tumors and its treatment Jokisch JF, et al. Indian J Urol. 2015; 31(4): 304– 311.

Muscle invasive BC: Key trials supporting current neoadjuvant, adjuvant & metastatic chemotherapy regimens Knollman H, et al. Ther Adv Urol. 2015; 7(6): 312 -330.

Key molecular pathways, therapeutic targets & drugs under investigation in urothelial carcinoma Knollman H, et al. Ther Adv Urol. 2015; 7(6): 312 -330.

PUTTING CANCER IN CHECK