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 – Smoking – Age – Radiation exposure – Previous urothelial carcinoma – Analgesics – Cyclophosphamide

Has Haematuria Screening Been Useful?

•

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 Renal Cell Carcinoma Urothelial cancer Urolithiasis Glomerular causes Nephritis AV Malformation Renal infarction Renal vein thrombosis Polycystic kidneys • • • • • • • • • • Lower Urinary Tract 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, non invasive, 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 Upper Tract Imaging: CT Urogram or IVP + US Lower Tract Investigation: Cystoscopy (Flexible or Rigid) Dysmorphic cells on microscopy Nephrologist Evaluation Low Risk Exclude UTI (MSU) Urine cytology X3 Upper Tract Imaging: US only.

Lower Tract Investigation: Cystoscopy (Flexible)

Case

• Mr KS has • Normal CT IVP • Urine cytology: suspicious for malignancy • Has cystoscopy

Cystoscopy

High Grade Urothelial Carcinoma Carcinoma in-situ Lamina Propria Invasion

Staging of Bladder Cancer

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.

• 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 •

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 50-59 60-69 70+ 0.7ng/ml 0.9ng/ml 1.4ng/ml 1.7g/ml 0-2.5ng/ml 0-3.5ng/ml 0-4.5ng/ml 0-6.5ng/ml

PSA and Risk of Prostate Cancer in Asymptomatic Men.

PSA Levels PCPT Trial Values Normal DRE 1-1.99

2-2.99

3-3.99

4-10 10+ 17% 24% 27% 29% 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.

Male 50-70 >10 year life expectency Algorithm for PSA Testing Male 40-70 >10 year life expectency Family Hx or other high risk Male 40-70 Symptomatic

Discuss Pros and Cons of PSA testing Normal : Rpt in 1 year Test PSA and DRE No bicycle riding, UTI (6 weeks), recent surgery or manipulation

Normal PSA TEST

Abnormal Normal but Above median

Calculate PSA Velocity

Mildly Abnormal OR

Repeat PSA in 6 weeks With F/T% DRE Abnormal Refer to Urologist 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.

• Follow-up: • Continent @ 4weeks • Potent @ 3 months • No PSA recurrence at 2 years.

Questions