Muscle Invasive Bladder Cancer : Bladder conservation protocols
Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe)...
-
Upload
bennett-warner -
Category
Documents
-
view
226 -
download
2
Transcript of Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe)...
![Page 1: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/1.jpg)
Bladder Cancer
R. Zenhäusern
![Page 2: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/2.jpg)
Bladder cancer:
Epidemiology• Incidence: 20/100000/year (Europe)• Mortality: 8-9/100000/year
• Fourth most common cancer in men– Incidence: 31.1 mortality: 12.1
• Seventh most common cancer in women– Incidence: 9.5 mortality: 4.5
• At diagnosis >70%: > 65 y of age
![Page 3: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/3.jpg)
Bladder cancer: Histology
• 90-95% transitional-cell carcinoma
• 3% squamos-cell carcinoma
• 2% adenocarcinoma• <1% small-cell carcinoma
![Page 4: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/4.jpg)
Bladder cancer: Entities
• 75-85% superficial bladder cancerpTa, pTis, pT1
• 10-15% muscle-invasive bladder
cancerpT2, pT3, pT4
• 5% metastatic bladder cancerN+, M+
![Page 5: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/5.jpg)
Bladder cancer: Stage and Prognosis
Stage TNM 5-y. Survival
0 Ta/Tis NoMo >85%
I T1 NoMo 65-75%
II T2a-b NoMo 57%
III T3a-4a NoMo 31%
IV T4b NoMo 24%each T N+Mo 14%each T M+ med. 6-9 Mo
![Page 6: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/6.jpg)
Superficial Bladder Cancer
pTa, pT1, Tis
• Standard of care=intravesical Therapy transurethral resection
• Relapse rate: 70% adjuvant therapy
![Page 7: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/7.jpg)
Superficial Bladder Cancer
• Histological grading is important
G1 G2 G3
Relapse rate 42% 50% 80%
Progression rate 2% 11% 45%
![Page 8: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/8.jpg)
Superficial Bladder Cancer
Adjuvant Therapy• Reduces relpase rate by 30-80%
– Doxorubicin weekly 6-8 w. / monthly 6-12
– Mitomycin C weekly 6-8 w. / monthly 6-12
– BCG weekly 6-8 w. /Mo 3 and 6
![Page 9: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/9.jpg)
Invasive bladder cancer
• Standard of care = Radical cystectomy with pelvic lymphadenectomy
Only about 50% of patients with high-grade invasive disease are cured
![Page 10: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/10.jpg)
Results of radical cystectomy
Stage Recurrence-Free Overall Survival5 y. 10y. 5 y. 10y.
T2 N- 89 87 77 57N+ 50 50 52 52
T3a N- 78 76 64 44N+ 41 37 40 26
T3b N- 62 61 49 29N+ 29 29 24 12
T4a N- 50 45 44 23N+ 33 33 26 20
Stein et al JCO 2001;19:666
![Page 11: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/11.jpg)
Results of radical cystectomy
Stage Recurrence-Free /Overall Survival 5 years
Organ-confined (<pT2pNo) 73% 62%
non-organ-confined (>pT2pNo) 56% 49%
Positiv lymph nodes (pT1-4, pN+) 33% 24%
Madersbacher et al JCO 2003;21:690
![Page 12: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/12.jpg)
Chemotherapy for bladder cancer
• Bladder cancer is a chemosensitive disease
• Active single agents.
RR– Cisplatin 30%– Carboplatin 20%– Gemcitabine 20-30%– Ifosfamide 20%
![Page 13: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/13.jpg)
Chemotherapy for bladder cancer
Combination chemotherapy.
RR CR
– MVAC 40-75% <20%– Gemzar / Cisplatin 40-70% 5-15%– Gemzar / Carboplatin 65% 5%– Taxol / Carboplatin 20-40%
![Page 14: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/14.jpg)
Adjuvant chemotherapy
• Six randomised trials have compared CT with observation after cystectomy or RT
• 4x no survival benefit• 2x benefit from adjuvant CT no standard of care
– node positive disease, lymphovascular invasion, positive margins
![Page 15: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/15.jpg)
Neoadjuvant chemotherapy
• Meta-analysis of ten randomised trials (2688 patients)
13% reduction in risk of death5% absolute benefit at 5 yearsOS increased from 45% to 50%
ABC Meta-analysis Collaboration. Lancet 2003;361:1927
![Page 16: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/16.jpg)
Combined Radio- and Chemotherapy
CR 5y.OS
• Radiotherapy 57% 47%
• RT and cisplatin 85% 69%
• RT and carboplatin 70%57%
Birkenhake et al. Strahlenther Onkol 1998;174:121
![Page 17: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/17.jpg)
Bladder-sparing therapy for invasive bladder cancer
• High probability of subsequent distant metastasis after cystectomy or radiotherapy alone (50% within 2 years)
• Radiotherapy im comparison with cystectomy has inferior results (local control 40%)
• muscle-invasive bladder cancer is often a systemic disease
combined modality therapy
![Page 18: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/18.jpg)
Bladder-sparing protocol
Transurthral resection
Induction Therapy: Radiation + chemotherapy
(cisplatin, paclitacel)
Cystoscopy after 1 month
no tumor tumor
Consolidation: RT + CT cystectomy
![Page 19: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/19.jpg)
Bladder-sparing protocol
Shiply et al. Urology 2002;60:62
T2: 5y / 10y OS: 74% / 66%
T3-T4a: 5y / 10y OS: 53% / 52%
![Page 20: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/20.jpg)
Results of bladder-sparing therapy and cystectomy
Bladder-sparing n Pat. 5y. OS 5y. Survivaltherapy % with Bladder %
Houssett 1997 120 63 NASauer 1998 162 55 44Shipley 1998 123 49 38Shipley 2002 190 54 45Rodel 2002 415 50 42
Cystectomy
Dalbagni 2001 181 36 NAStein 2001 633 48 NA
![Page 21: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/21.jpg)
Combined-modality treatment and organ preservation in invasive
bladder cancer
Rödel et al. JCO 2002;20:3061
415 patients with T1 high-risk, T1-4, No-1
Treatment: 1. Transurethral resection
2. RT (n=126), RCT (n=289) RT median 54 Gy, CT cisplatin week 1,
5
3. Restaging-TUR
![Page 22: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/22.jpg)
Combined-modality treatment and organ preservation in invasive
bladder cancer
• Rödel et al. JCO 2002;20:3061
• Complete remission 72%• Local control after CR 64% (10 y.)
• distant metastasis 35% (10 y.)
• Disease-specific survival 42% (10 y.)
• Preservation of bladder >80%
![Page 23: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/23.jpg)
Local control Distant metastasis
Rödel et al. JCO 2002;20:3061
![Page 24: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/24.jpg)
Disease-specific survival for patients after salvage cystectomy
50%45%
21% 18%
Rödel et al. JCO 2002;20:3061
![Page 25: Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe) Mortality:8-9/100000/year Fourth most common cancer in men.](https://reader035.fdocuments.us/reader035/viewer/2022062314/56649d885503460f94a6dcd6/html5/thumbnails/25.jpg)
TUR and adjuvant Radio-Chemotherapy
• 5 year Survival 50-65%
• Preservation of Bladder38-43%