Bladder cancer 12 2012
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BLADDER CANCERAhmed ZeeneldinAssociate Professor of Medical Oncology
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INCIDENCE IN USA
¢ 4.5% of cancers¢ M: F: 2.5:1¢ Age: 6th-7th decade
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INCIDENCE IN EGYPT
¢ NCI males:¢ 1st , 16%
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INCIDENCE
¢ NCI combined:¢ 4th, 4.4%¢ M: F: 4:1¢ Median age:¢ M: 60¢ F: 58
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RISK FACTORS
¢ Occupational exposure:ó Aniline dyesó Leather, rubber and paint industries
¢ Schistosoma haematobium:ó Associated with squamous histologyó In Africa and middle east
¢ Smoking¢ Pelvic irradiation¢ Drugs: cyclophosphamide
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HISTOLOGY
¢ Urothelial (transitional cell) carcinoma TCC: commonest¢ In situó Papillaryó Flató With squamous metaplasiaó With glandular metaplasiaó With squamous and glandular metaplasia
¢ Squamous cell carcinoma (SCC)¢ Adenocarcinoma¢ Undifferentiated carcinoma
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HISTOLOGY IN EGYPT
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HISTOLOGY
¢ TCC: 90%¢ SCC: 6-8%¢ Adeno: 2%¢ Small cell: 1%
¢ TCC: 63%¢ SCC: 27%¢ Adeno: 3%¢ Undifferentiated: 2%
US EGY
systemic chemotherapy regimens used to treat TCC are ineffective in pure SCC or AdenoIf mixed tumor only TCC responds
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STAGES
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TNM STAGING 2010URINARY BLADDER
¢ T0: non-invasiveó Ta: Noninvasive papillary carcinomaó Tis: Carcinoma in situ “flat tumor”
¢ T1: mucosa or submucosa¢ T2: muscle
ó T2a: inner halfó T2b: outer half
¢ T3: outside muscle (adventitia)ó T3a: microscopic (histology, no
massesó T3b: macroscopic (mass)
¢ T4: surroiundingsó T4a: prostate, uterus, vaginaó T4b: pelvic or abdominal
¢ N1: regional LN+ó N1: Pelvic LNs (1)ó N2 : pelvic LNS (>1)ó N3: common iliac LN
¢ M1: Distant mets
T1
T2
T3
T4a
T4b
M1
N0 I II III III IV IVN1-3
IV IV IV IV IV IV
OR M1
SIMPLIFICATION-I: T1 -II: T2-III: T3/T4 a -IV: T4b OR LN+ OR M1
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STAGING
T0: non-invasiveTa: Noninvasive papillary carcinomaTis: Carcinoma in situ “flat tumor”
T1: sub-epithelial connective tissueT2: Tumor invades muscle
T2a: inner halfT2b: outer half
T3: Tumor invades perivesical tissueT3a: MicroscopicallyT3b: Macroscopically (extravesical mass)
T4: surroundingsT4a: prostate, uterus, vaginaT4b: pelvic wall, abdominal wall
N1: 1 pelvic LNN2: > 1 pelvic LN N3: common iliac LNM1: distant mets
Tis/0 T1 T2 T3 T4 M1=IV
N0 0 I II III T4a:III
T4b:IV
IV
N1-3 IV
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MANAGEMENT OF BLADDER CA
¢ Cystoscopy and biopsy:ó See lesionsó Biopsy and muscle should be includedó We will reach to a conclusion:ó MUSCLE IS INVADED OR NOT
¢ Not invaded àTURB¢ Upper UT imaging¢ CT if sessile or high grade T is suspected
¢ Invaded à CT: ¢ LN small (negative): T2,T3, T4a: cyatectomy¢ LN large: biopsy: negativeó Positive:
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NON MUSCLE INVASIVE
Grade Cyctectomy TURB IVsT+ Cystectomy Tis High No Yes BCG Resistent
/relapsedTa Low No Yes May (chemo, mito)
Once? After 6ms
//
Ta high No Yes BCG > Chemo //T1 Low No Yes BCG*
Mito**If residual//
T1 high May Yes BCG*Mito**
if residual//
+ not if extensive TURB or perforation* Whether residual or no residual** chemotherapy only if no residaul
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INTRAVESICAL CHMOTHERAPY
¢ Drugsó Chemotherapy
¢ Alkylating agents: thiotepa, mitomycin C (40mg in 20 cc stWater),
¢ Anthracyclines: doxorubicin (50 mg in 25 cc St water), epirubicin, valrubicin
¢ Value:ó Acts by diffusionó Prevent seeding and Reduce recurrence by 6%ó No reduction in disease progression or mortalityó Within 6 Hrs post TUR, Not if extensive TURB or
perforationó Overnight fast, empty bladder beforeó Keep for .5 hr (post TUR) or 2Hrs, supine and prone (air
bubble) ó Alkalanize urine with mitomycin
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INTRAVESICLA IMMUNOTHERAPY
ó Immunotherapy¢ BCG (81 mg for TheraCys and 50 mg for TICE, both in 50 cc
physiologic saline)ó Value:
¢ Acts by enhancing immune response, drawing lymphocytes and macrophages to the bladder and stimulating a cellular (TH1) immune response
¢ Not immediate (at least 1-2 wks post TUR)¢ Weekly x 6 w¢ Maintenance ¢ (3 app x q 3ms)¢ 3 weekly at 2, 6, 12, 18, 24, 30, 36 ms XXXX?¢ NOT WITH CIPRO
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MUSCLE INVASIVEN Cystectomy Chemotherapy Radiotherapy N- T2* Radical
PartialNo
Neoadj or adjuvantNeoadj or adjuvantCRT
NoMay be used instead of CT CRT
N- T3* Radical
No
Neoadj or adjuvant
CRT
No
CRTN- T4a If possible
1st or after Neoadj
CRT or chemo (Neoadj or adj)
CRT or chemo (Neoadj or adj)
N- T4b If possible after Neoadj
CRT or chemo (Neoadj or adj)
CRT or chemo (Neoadj or adj)
N+ If possible after Neoadj
CRT or chemo (Neoadj or adj)
CRT or chemo (Neoadj or adj)
M1 No Yes may
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PROGNOSTIC FACTORS
¢ Stage :ó depth of invasion
¢ Grade:ó Low grade: 1-2ó High grade: 3-4
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TREATMENT
ó Taó Tisó T1
¢ Treatment:ó Resection: Repeat TURó +/- intravesical therapy
¢ Grade¢ depth
¢ T2¢ T3¢ T4¢ Treat.ó Resection: cystectomy
¢ Partial or complete
ó Chemo: adjuvant/neoadjó RT:
Non-Muscle-invasive Muscle-invasive
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TREATMENT MODALITIES
¢ Resection:ó TURBT: ONLY FOR non-muscle invasiveó Cystectomy:
¢ Partial cystectomy : selected cases of muscle invasion¢ Radical cystectomy: standard treatment of muscle invasive
tumors and as salvage therapy¢ Drug therapy:ó Local (intravesical): ONLY FOR non-muscle invasive
¢ Immunotherapy: BCG or INF¢ Chemotherapy: MMC, Doxorubicin or Valrubicin, thiotepa
ó Systemic (IV) chemotherapy: ONLY for muscle invasive
¢ Radiotherapy: ONLY for muscle invasive
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TREATMENT: NON-MUSCLE INVASIVE
¢ Includes: Ta, Tis, T1¢ Tx:ó Repeated TURBó Post TURB intravesical therapy:
¢ depends on grade and depth of invasion that determines:¢ Bladder recurrence risk¢ Progression to muscle invasion risk
¢ Modes:¢ Adjuvant: to prevent bladder recurrence: MAINLY¢ Complementary: to eradicate residual disease: RARELY
ó Cystectomy: rare
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TREATMENT: NON-MUSCLE INVASIVE
¢ Tis (CIS), always high grade¢ Tx:ó TURBó Post TURB intravesical BCG
therapy Weekly x 6 ó Follow up: cystectoscopy +
cytology + imaging of upper Urinary tract q3 m x 24m, then increase intervals
ó Recurrence: ¢ TURB + ¢ Adjuvant intravesical therapy
according to grade and depth of invasion
¢ Follow up: cystectoscopy q3 m
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TREATMENT: NON-MUSCLE INVASIVE
¢ Ta (papilloma), low grade¢ Tx:
ó TURBó Post TURB intravesical therapy:
¢ None¢ Adjuvant intravesical
chemotherapy (Mitomycin C):¢ Single¢ Within 24 Hours form TURB
ó Follow up: cystectoscopy + cytology q3 m x 12 m, then increase intervals
ó Recurrence: ¢ TURB + ¢ Adjuvant intravesical therapy
according to grade and depth of invasion
¢ Follow up: cystectoscopy q3 m
¢ Ta (papilloma), high grade¢ Tx:
ó TURBó Post TURB intravesical therapy:
¢ None¢ Adjuvant intravesical BCG: ¢ Adjuvant intravesical
chemotherapy (Mitomycin C):¢ Single¢ Within 24 Hours form TURB
ó Follow up: cystectoscopy + cytology + imaging of upper Urinary tract q3 m x 24m, then increase intervals
ó Recurrence: ¢ TURB + ¢ Adjuvant intravesical therapy
according to grade and depth of invasion
¢ Follow up: cystectoscopy q3 m
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TREATMENT: NON-MUSCLE INVASIVE¢ Persistent or recurrent Ta and Tis
ó TURB+/- IVTà recurrence/persistence at W12à TURB+IVT à still recurrence or persistence at W 24
¢ Tx:ó Cystectomy is the first optionó TURB and Post TURB intravesical therapy may be considered to avoid cyctectomy
¢ Use different agents¢ Chemo: MMC, Valrubicin¢ BCG + INF a¢ Follow up: cystectoscopy + cytology + imaging of upper Urinary tract q3 m x 24m, then q 6m x 24
m¢ Recurrence/persistence: cystectomy
¢ Another scenario:ó TURB+/- IVTà recurrence/persistence at W12à TURB+IVT à CR:ó Maintenance BCG ó Follow up: cystectoscopy + cytology + imaging of upper Urinary tract q3 m x
24m, then q 6m x 24 m¢ Recurrence/persistence: TRUB + different IVT or cystectomy
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TREATMENT: NON-MUSCLE INVASIVE
¢ T1 , low riskó No high risk features
¢ Tx:ó TURBó Post TURB intravesical therapy:
¢ Adjuvant intravesical BCG:¢ Adjuvant intravesical chemotherapy
(Mitomycin C):¢ Single¢ Within 24 Hours form TURB
ó Follow up: cystectoscopy + cytology q3 m x 12 m, then increase intervals
ó Recurrence: ¢ TURB + ¢ Adjuvant intravesical therapy
according to grade and depth of invasion
¢ Follow up: cystectoscopy q3 m
¢ T1, high riskó multifocal lesions, ó vascular invasion, ó recurrence after BCG ó High grade.
¢ Tx:ó TURBó Post TURB intravesical therapy:
¢ Adjuvant intravesical BCG: ¢ Adjuvant intravesical chemotherapy
(Mitomycin C):¢ Single¢ Within 24 Hours form TURB
ó Cystectomyó Follow up: cystectoscopy + cytology
+ imaging of upper Urinary tract q3 m x 24m, then increase intervals
ó Persistence after conservative management : ¢ Cystectomy
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FOLLOW UP
¢ Low risk lesion: high risk lesions+ Cystoscopy and cytology Cystoscopy and cytology
¢ imaging upper tract¢ q3 m x 12 q3 m x24 ¢ Then increasing q 6m x 24
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TREATMENT: MUSCLE INVASIVE DISEASE
¢ Workup:ó Lab: CBC, chemistry, Alk phosó Cystoscopy, EAU/TRUBTó Imaging:
¢ Chest Xray¢ CT/MRI of abdomen and pelvis¢ +/- Bone scan
¢ Aim:ó Organ confined T2, N0, M0ó Non-organ confined T3, T4, N1, M0
ó Metastatic disease M1
Tis/0 T1 T2 T3 T4 M1=IV
N0 0 I II III T4a:III
T4b:IV
IV
N1-3 IV
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ORGAN CONFINED (T2) DISEASE
¢ Surgery (cyctectomy):ó Primary Txó radical : standard particularly in recurrenceó Partial (segmental)
¢ More in dome and solitary¢ Less in neck, trigone and multiple or associated Tis
¢ Chemotherapy:ó Cisplatin-based
¢ Neoadjuvant: in T3 or T2 or ¢ Adjuvant : pT3 and pT4 and LN+
¢ RT: ¢ Adjuvant: pT3 and pT4, LN+, SM+ or high grade
¢ Concurrent chemoradiotherapy (CCRT):ó Preoperative: in advanced diseaseó Definitive: in severe comorbidities and poor PSó If CCRT is not tolerable: chemo or radio can be given alone
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ORGAN CONFINED (T2 N0)
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NON-ORGAN CONFINED (T3, N0)
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NON-ORGAN CONFINED (T4 OR N1-3 OR M1)
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CYSTECTOMY
¢ Radical cystectomy: standardó Male:
¢ removes bladder, prostate, seminal vesiclesó Females:
¢ Removes bladder and maybe uterus, ovaries and tubesó Pelvic LND:
¢ decreases recurrence and ¢ increase OS
ó Urinary diversion or neobladder¢ Partial systectomy: selective
ó More in dome and solitaryó Less in neck, trigone and multiple or associated Tisó Recurrence after partial cystectomy:
¢ Consider as new cancer¢ Non-M invasive: TURB and IVT¢ M invasive: as usual but do not consider conservation
again
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NEOADJUVANT CHEMO
¢ Cisplatin-basedó MVACó CMVó Cis-Gemó Cis-adiaó Cis-Mtx
¢ 3 cycles¢ In T3 (category 1) or T2 (category 2A)
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NEOADJUVANT M-VAC CHEMO
¢ Grossman et al, N Engl J Med. 2003;349(9):859-66.
¢ MVAC x 3 q 28dó Mtx: 30 mg sm d1, 15, 22ó Vinblastine: 3 mg sm d2, 15, 22ó Adrai: 30 mg sm d2ó Cisplatin: 70 mg sm d2
¢ T2-T4a¢ Pathological CR: 38%
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ADVERSE EVENTS OF MVAC
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COMPLICATIONS AFTER SURGERY
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Figure 1. Survival among Patients Randomly Assigned to Receive Methotrexate, Vinblastine, Doxorubicin, and Cisplatin (M-VAC) Followed by Cystectomy or Cystectomy Alone, According to an Intention-to-Treat Analysis.
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OS in pT0 vs RD
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NEOADJ CIS-ADRIA OR CIS-MTX
¢ Sherif et al, Eur Urol 2004;45:297–303.¢ Combined analysis of 2 trials¢ Regimens:ó Cis 70 mg/sm & A 30 mg/sm q 3w x2 + RTó Cis 100mg/m & Mtx 250mg/sm q3w x 3 NO RT
¢ OS HR 0.80 (95% CI 0.64–0.99) in favor of neoadjuvanttreatment.
¢ 5 Y OS was 56% for neoadjuvant and 48% in the control group,
¢ 8% reduction in risk of death.
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OS
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NEOADJ CMV¢ 967 pts¢ 16% reduction in mortality with NACT
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NEOADJUVANT CHEMOTHERAPY FOR TRANSITIONAL CELLCARCINOMA OF THE BLADDER:
A SYSTEMATIC REVIEW AND META-ANALYSIS.
¢ Winquist et al, J Urol. 2004 Feb;171(2 Pt 1):561-9.¢ 11 trials (2,605 patients)¢ Conducted between 1984 and 2002¢ TCC stages II and III (T2-T4, Nx-N3, M0)¢ Pooled HR of death was 0.90 (95% CI 0.82 to 0.99, p =
0.02).¢ Absolute OS benefit of 6.5% (95% CI 2 to 11%) from
50% to 56.5%¢ PFS benefit consistent with OS benefit¢ CR rates: 14-38%, Major Pathological response: 43%¢ Major pathological response was associated with
improved OS in 4 trials
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REGIMENS
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NEOADJUVANT CHEMO
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CONCURRENT CHEMORADIOTHERAPY
¢ Improved local control of invasive bladder cancer by concurrent cisplatin and
preoperative or definitive radiation. The National Cancer Institute of Canada Clinical
Trials Group.
¢ Coppin et al, J Clin Oncol. 1996 Nov;14(11):2901-7.¢ RCT in 99 patients¢ T2 to T4b TCC¢ Randomized to CCRT or RTó (cisplatin 100 mg/m2 at 2-week intervals x 3 cycles
concurrent with pelvic radiation), or RT (radiation without chemotherapy)
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DESIGN
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CCRT VS RT IN TCC OF BLADDER
¢ Pelvis relapse significantly lower in CCRT¢ Distant relapse were similar¢ PFS better with CCRT (P 0.08)¢ 3 y OS rates 47% in CCRT and 33% in RT (P0.34)
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OS & PFS
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ADJUVANT CHEMOTHERAPY
¢ Non-urothelial CAó No data in any stage
¢ Urothelial CAó Conflicting dataó Many trials showing benefit are not randomizedó Metaanalysis of 6 trails
¢ 25% mortality reduction¢ But many limitations ¢ Regimens¢ GC¢ MVAC, MVEC¢ CAP
¢ No. of cycles: at least 3
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ADJUVANT CHEMOTERAPY FOR TCC OFBLADDER
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CHEMOTHERAPY IN METASTATIC TCC
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ADJ RT¢ Dat are scarce¢ Possible role in T3a, T3b, T4aó Due to High recurrence (30% that increase to 60% if
SM+)¢ May be given with concurrent cisplatin¢ Adj chemotherapy is also indicated in these cases¢ Adj RT and Adj CT are not give together
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BLADDER PRESERVATION
¢ Partial cystectomy alone¢ Chemotherapy then partial cystectomy¢ TUR alone¢ TUR followed byó Chemotherapy and radiotherapy (BEST)
¢ Cisplatin w1, 4 +/-8ó Chemo onlyó Radio only
¢ Indicationsó Urothelial caó Unfit ptsó Refusing pts