The Royal Marsden

1

Diagnosing bladder cancer

Mr Pardeep Kumar

Consultant Urological Surgeon

The Royal Marsden

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Presentation overview

– Bladder Cancer

– The Haematuria Clinic

– Evidence

– Cases

The Royal Marsden

Bladder Cancer

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Bladder cancer

– In 2010

– 10,300 new diagnoses

– 4,900 deaths

– 7th most common cancer

– Most expensive cancer to treat overall

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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/

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Bladder cancer - Grade

Good specimens + uropathologist

WHO grading

1973 vs. 2004

Grade 1, 2 and 3 vs. Low/High grade

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Bladder cancer - Stage

The Royal Marsden

The Haematuria Clinic

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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%

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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%

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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

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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

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– 69 yr old man

– Jan ’12 - TURP for LUTS - focal CIS

Case One

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– 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

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– Fit – walks 10 miles per day

– Performance status 0

– Neoadjuvant chemotherapy

– 3 cycles of Gem/CIS

– Planned lap cystoprostatectomy and conduit

Case One

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Case One

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– Cancelled day before surgery – unfit

– Treatment dose LMWH

– Advised re: DXT

– Patient seeks second opinion…

Case One

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– Surgery or DXT

– Management of DVT/PE

– Management of urethra

Case One

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Case One

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– 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

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– 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

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Case One

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– 50 yr old woman

– 18/12 dysuria – 8 courses of antibiotics

– Micro proven UTI (E. coli)

– Macro haematuria prompted referral

Case Two

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Case Two

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– 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

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Case Two

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Case Two

– Neoadjuvant chemo – Gem/CIS x 3

– Surgery vs. DXT?

– Reconstructive options?

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– 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

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– 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

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– 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

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– In pain, catheter in situ.

– Histo – Poorly diff carcinoma consistent with TCC with focal squamous maturation

– CT Chest Abdo Pelvis

Case Three

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Case Three CT

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– Further investigation?

Case Three

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Case Three

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– Further investigation?

– Minimally invasive surgery?

– Surgical approach?

Case Three

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– Kidney – G3pT2 TCC

– Bladder G3pT4, ? Urethral origin

– Negative margins, No involved lymph nodes

Case Three

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Case Three

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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