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The Royal Marsden
1
Diagnosing bladder cancer
Mr Pardeep Kumar
Consultant Urological Surgeon
The Royal Marsden
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 2
Presentation overview
– Bladder Cancer
– The Haematuria Clinic
– Evidence
– Cases
The Royal Marsden
Bladder Cancer
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 4
Bladder cancer
– In 2010
– 10,300 new diagnoses
– 4,900 deaths
– 7th most common cancer
– Most expensive cancer to treat overall
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 5
Bladder Cancer (C67): 2008-2010 Average Number of New Cases Per Year and Age-Specific Incidence Rates per 100,000 Population, UK
Prepared by Cancer Research UK - original data sources are available from http://www.cancerresearchuk.org/cancer-info/cancerstats/
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 6
Bladder cancer - Grade
Good specimens + uropathologist
WHO grading
1973 vs. 2004
Grade 1, 2 and 3 vs. Low/High grade
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 7
Bladder cancer - Stage
The Royal Marsden
The Haematuria Clinic
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 9
A cause is usually found for Haematuria in x number of cases
1. 10%
2. 40%
3. 70%
4. 95%
10
10%
40%
70%
95%
23%
7%
29%
41%
Malignancy is the commonest cause of Visible Haematuria?
A. Yes
B. No
11
Yes
No
93%
7%
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 12
Analysis of 1930 patients attending a haematuria clinic
• 1194 Men, 736 Women
• Age 17 – 96 years (Mean 58 years)
• 61% No cause for haematuria found
• 12% Bladder cancer
• 13% UTI
• 2% stones
Khadra et al. J Urol 2000
Malignancy is more likely with visible haematuria?
A. Yes
B. No
13
Yes
No
0%0%
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 14
Analysis of 4020 patients attending a haematuria clinic
• 2627 Men, 1393 Women
• Macroscopic 46.8%. Macroscopic 53.2%
• Malignancy in 12.1%
• Macroscopic 18.9%
• Microscopic 4.8%
Edwards et al. BJU Int. 2006
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 15
Analysis of 778 patients attending a haematuria clinic
• At least one episode of macroscopic haematuria
•Age > 40 years
•Urinary Tract Infection excluded
•Use CT scanning as a first line investigation
•20% pick up rate of bladder cancer
•Reduce local anaesthetic cystoscopies by 17%
Blick et al. BJU Int. 2012
Are you less likely to have a malignancy if a UTI is proven on urine culture?
A. Yes
B. No
16
Yes
No
64%
36%
The Royal Marsden
Cases
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 18
– 69 yr old man
– Jan ’12 - TURP for LUTS - focal CIS
Case One
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 19
– 69 yr old man
– Jan ’12 - TURP for LUTS - focal CIS
– Mar ’12 - ‘Urgent’ relook
– G3pT2 at least bladder base
– LVI
– Foci CIS in prostate chips
Case One
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 20
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 21
– Fit – walks 10 miles per day
– Performance status 0
– Neoadjuvant chemotherapy
– 3 cycles of Gem/CIS
– Planned lap cystoprostatectomy and conduit
Case One
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 22
Case One
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 23
– Cancelled day before surgery – unfit
– Treatment dose LMWH
– Advised re: DXT
– Patient seeks second opinion…
Case One
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 24
– Surgery or DXT
– Management of DVT/PE
– Management of urethra
Case One
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 25
Case One
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 26
– Robot assisted cystoprostatourethrectomy and intracorporal ileal conduit
– Enhanced recovery pathway
– Treatment dose LMWH day 2
– Bowels opening day 5
– Filter removed day 8
Case One
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 27
– 14 day admission – wound infection
– Readmission 10 days post op - lymphocoele
– G3pT3a – margins negative
– 0/14 lymph nodes involved
– CIS lower right ureter
– Urethra no malignancy
Case One
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 28
Case One
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 29
– 50 yr old woman
– 18/12 dysuria – 8 courses of antibiotics
– Micro proven UTI (E. coli)
– Macro haematuria prompted referral
Case Two
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 30
Case Two
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 31
– Locally reported as squamous cell
– G3pT2 TCC squamous and plasmacytoid differentiation
– No LVI
– No CIS
– Performance status 0
– Long term smoker
– Left hip dysplasia – hip resurfacing
– Appendectomy via pfannenstiel
Case Two
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 32
Case Two
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 33
Case Two
– Neoadjuvant chemo – Gem/CIS x 3
– Surgery vs. DXT?
– Reconstructive options?
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 34
– 43 yr old woman, heavy smoker
– Sept 2011 – Emergency attendance with vaginal discharge and pain
– Oct 2011 – Urine cytology positive
– Feb 2012 – First hospital OPA
– May 2012 – Symptoms worse – Urodynamics
Case Three
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 35
– June 2012 – VCMG attendance – alarm bells
– Ulcerated lesion anterior vaginal wall
– EUA and cystoscopy – Bladder neck/proximal urethral tumour. Invasion into vagina
– Emergency referral
Case Three
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 36
– June 2012 – VCMG attendance – alarm bells
– Ulcerated lesion anterior vaginal wall
– EUA and cystoscopy – Bladder neck/proximal urethral tumour. Invasion into vagina
– Emergency referral
Case Three
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 37
– In pain, catheter in situ.
– Histo – Poorly diff carcinoma consistent with TCC with focal squamous maturation
– CT Chest Abdo Pelvis
Case Three
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 38
Case Three CT
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 39
– Further investigation?
Case Three
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 40
Case Three
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 41
– Further investigation?
– Minimally invasive surgery?
– Surgical approach?
Case Three
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 42
– Kidney – G3pT2 TCC
– Bladder G3pT4, ? Urethral origin
– Negative margins, No involved lymph nodes
Case Three
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 43
Case Three
The Royal Marsden Diagnosing Bladder Cancer 22 02 2016 44
Summary
– Refer all macroscopic Haematuria
– Refer persistent microscopic haematuria in those over 40 yrs
– Diagnose and treat UTI but still consider referral
– Beware persistent storage urinary symptoms
– Consider nephrology when Haematuria investigations negative