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3 Annual Ellis Fischel Cancer Symposium: Gentiourinary ...
Transcript of 3 Annual Ellis Fischel Cancer Symposium: Gentiourinary ...
3rd Annual Ellis Fischel
Cancer Symposium:
Gentiourinary
Malignancies
Mark R Wakefield, MD, FACS
Chief, Division of Urology
No disclosures
ObjectivesReview top ten updates for the three most
common urologic malignancies
1. Prostate cancer: screening, diagnosis, risk
stratification, and treatment
2. Bladder Cancer: enhanced recovery and
new systemic therapies
3. Renal Cell Carcinoma: systemic and
minimally invasive treatments
Prostate Cancer
2. PSA Screening Remains Controversy
Early diagnosis at lower stage
Better cure with more options
Over-diagnosis with over-treatment
No survival benefit
Harm and side-effects from treatment
Prostate Cancer: PSAContradictions regarding utility in recent data
– PLCO (US screening trial)• Increased diagnosis of prostate cancer in screen
– 22% more by 7 years
• No identified survival benefit
• High cross-over
– Some details• 77,000 patients aged 55-74 (1993-2001; 2006)
• 52% of control had PSA and 40% had DRE
• 85% screened with PSA and 86% with DRE
• Increased death in screened group: 50 v 44 (ns)
NEJM 2009; 360:1310-1328
Prostate Cancer: PSA
Contradictions in recent data
– ERSPC (European screening and treatment trial)
• 162,000 55-69 year old men for 9 year median follow-up
• Screened group with PSA every 4 years
– 82% of men in screening group received PSA
– 16% with elevated PSA
– 17,500 biopsies
– 8.2% diagnosis in screened group and 4.8% in control
• 20% reduction in mortality (27% for those actually screened)
– 214 deaths in screened
– 326 deaths in control
• 1410 men screened per year for one death prevented
• 48 men require treatment to prevent one death
NEJM 2009; 360:1320-1328
Prostate Cancer: PSA• Recommendations:
– ACS and AUA : Offer annual DRE and PSA, greater than 50 (40) years of age and 10-year life expectancy
– ACP and AMA: Provide risk and benefit discussion; individualize screen based on patient
– USPSTF: Screening recommended based on individual assessment • C recommendation for men aged 55 to 69 (2018)
• Inadequate data to support: grade D (2012)
• Recommends against men over age of 75 (70 in draft)
(Annals of Internal Medicine, 149, 192-199; 2008)
Prostate Cancer
3. Better Tools for Diagnosis
Biopsies has significant risk
>150 targeted biopsies at Ellis Fischel
Prostate CancerMRI for identifying high risk prostate cancer
• 3Tesla multi-parametric
• Dynamic contrast enhanced
• Diffusion-eeighted images
• PI-RADS risk score
• Pre-biopsy tool– Sensitivity = 0.85 (95% CI 0.78-0.91)
– Specificity = 0.71 (95% CI 0.60-0.80)
Prostate Cancer
55 yo M, Gleason 7 (4 + 3) PZ
prostate cancer
Tumor extension to seminal vesicles
Looking for wall thickening, obliteration of lumina
A. Diffuse B. Focal
Prostate Cancer
4. Improved Risk Stratification
Identification of low risk disease
Active Surveillance
Identification of high risk disease
Multimodal therapy
Early identification of metastatic disease
Directed local and systemic therapy
Prostate Cancer Biomarkers
Tissue based
• Decipher
• Prolaris
• OncotypeDx
• ConfirmMDx
Liquid based
• PSA
• PCA3
• 4K score
• Prostate Health
Index
• Apifiny
Prostate Cancer Imaging
• Radio-nucleotide imaging
– Axumin
Fluciclovine F18
– PSMA-PET
Ga-68-PSMA-11
Prostate Cancer
5. Prostate Cancer Treatment Matures
Increased active surveillance
Application of robotic prostatectomy
Expansion of systemic treatments
Prostate Cancer: progressionSystematic therapies for metastatic disease
– Androgen Deprivation: intermittent versus continuous
– Secondary hormonal therapies
• Anti-androgens: uncertain role of earlier generations (bicalutamide)
• Newer: abiraterone, enzalutamide, apalutamide
- M0 castrate resistance: apalutamide and enzalutamide
- M1 castrate sensitive: abiraterone
– Taxol and similar therapies (cabazitaxel): promising and tolerated well• Primary treatment prior to castrate resistance for metastatic
disease
• Neo-adjuvant role
– Immunotherapy: Provenge
– Radiotherapy: Radium 223
Kidney Cancer
6. Increased incidence in US
– Demographic risk factors
– Small renal mass incidentally detected
7. Application of minimal invasive therapies
– Needle biopsy
– Active surveillance
– Ablative therapies
– Robotic assisted laparoscopy for partial
Renal Cell CarcinomaKunkle, DA, et al, Journal of Urology, 179: 1227; April 2008
• Incidentally detected renal mass
– Up to 70% of new diagnosis
– Earlier stage at diagnosis
– Increased surgical treatment
– Minimal change in overall surviva
• Imaging accurately diagnosis pathology
in most cases (95% PPV)
Renal Cell CarcinomaLipworth, L, et al, Journal of Urology, 176: 2353; December 2006
6. Suspected risk
factors• Cigarette Smoking
• Obesity
• Hypertension
• Analgesics
• Diet
• Alcohol
• Occupational Exposure
• Immunosuppression
Renal Cell CarcinomaLane, BR, et al, Journal of Urology, 179: 20; January 2008
7. Re-evaluation of the role of biopsy of renal mass– CT-guided, percutaneous biopsy
– 18 gauge true-cut
– 5% minor and major complication rate
– Insufficient biopsy material in 5-10%
– False negative biopsy 10-50%
– Indications:• Metastatic disease to kidney
• Metastatic renal cell
• Bilateral
• Contraindication to surgery
Renal Cell CarcinomaKunkle, DA, et al, Journal of Urology, 179: 1227-33, April 2008
Treatment options:
– Partial nephrectomy
• Laparoscopic/ robotic
• Open
– Open or laparoscopic or
percutaneous cryoablation
– Percutaneous
radiofrequency ablation
– Open or lap total
nephrectomy
– Surveillance
– HIFU
– Radiotherapy
Kidney Cancer8. Advanced disease at progression
– Vascular involvement: IVC thrombectomy
– Re-defining role of cytoreductive nephrectomy
– Neoadjuvant and adjuvant therapies
– Rapid expansion of therapies for metastatic disease
Bladder CancerTale of two diseases
– High prevalence due to recurrent non-invasive disease
– High mortality and morbidly for muscle invasive disease
9. Urinary diversion history and advances
10. Advanced recovery and robotic applications promise
improved recovery
Historical BackgroundBladder Substitution After Pelvic Exenteration
Surgical Clinics of North America, 1950
Eugene M. Bricker
Bladder Cancer: RC-TIGER
– Better prepared for surgery
– Shorter and safer hospital stay
• Less CV and VTE risk
• Shorter hospital stay: earlier recovery of bowel
function
• Better functional capacity upon discharge:
RIOT
• Lower infection rate
• Fewer complications and readmissions
• Improved patient satisfaction