Cases in Urological Oncology

1. Cases in Urological Oncology Dr Manish Patel MB.BS., MMed., FRACS, PhD Urological Cancer Surgeon Westmead Public and Private Hospital Senior Lecturer, University of Sydney

2. A Case of Bladder Cancer • Mr K.S. 63 year old man. • Heavy smoker in the past. • Father had bladder cancer • Asymptomatic

3. Bladder Cancer Screening • Risk Factors for Bladder Cancer • Smoking • Age • Radiation exposure • Previous urothelial carcinoma • Analgesics • Cyclophosphamide

4. Has Haematuria Screening Been Useful? • Only one good long term study • Not randomised • Men over age 50 years • Daily home dipstick test for a week • 16.4% of the population had haematuria investigated. • 8.1% with haematuria had BC • At 14 years no man with screen detected BC died. • 20% of non screen detected BC had died

5. What Causes Haematuria? • Lower Urinary Tract • Upper Urinary Tract • Urothelial cancer • Cystitis • BPH • Bladder stones • Prostate cancer • Prostatitis • Trauma • TB • Anticoagulation • Renal Cell Carcinoma • Urothelial cancer • Urolithiasis • Glomerular causes • Nephritis • AV Malformation • Renal infarction • Renal vein thrombosis • Polycystic kidneys

6. ImagingCT Urogram • Helical CT abdomen and pelvis • With and without contrast, with delayed phase • 3D reconstruction. • 100% sensitive, 97% specific • Identifies RCC, urothelial tumours and kidney stones as well as many other abnormalities • Choice of imaging techniques

7. ImagingUrinary Tract Ultrasound • Cheap, quick, non-invasive, no contrast • Sensitivity 60-70%, specificity 90% • Still inferior to CT.

8. ImagingIVP • Intravenous contrast and tomograms • Sensitivity 61%, specificifty 92% • Expensive and time consuming • Misses small renal lesions – need US as well

9. Algorithm for evaluation Macroscopic Haematuria Microscopic Haematuria High Risk Low Risk Exclude UTI (MSU) Urine cytology X3 Exclude UTI (MSU) Urine cytology X3 Dysmorphic cells on microscopy Upper Tract Imaging: US only. Upper Tract Imaging: CT Urogram or IVP + US Lower Tract Investigation: Cystoscopy (Flexible) Lower Tract Investigation: Cystoscopy (Flexible or Rigid) Nephrologist Evaluation

10. Case • Mr KS has • Normal CT IVP • Urine cytology: suspicious for malignancy • Has cystoscopy

11. Cystoscopy High Grade Urothelial Carcinoma Carcinoma in-situ Lamina Propria Invasion

12. Staging of Bladder Cancer CIS Tis Superficial Superficially Invasive T2 Invasive T3

13. What Next? • BCG treatment for 6 weeks- intravesically • Eradicated CIS (70%) • Decreased recurrence and progression. • Follow-up cystoscopy every 3 months for 2 years.

14. 9 months later • Muscle Invasive • Staging CT, Bone scan normal.

15. A Case of Bladder Cancer Underwent: Nerve-sparing cystoprostatectomy with neobladder formation and extended lymph node dissection. • Continent at 6 weeks. • Erections at 5 months. • Voids normally with a little straining. Ureters Pouch Urethra

16. A Case of Bladder CancerConsiderations in FollowUp • Cancer Recurrence: • Regular urine cytology, CT scans abdomen and chest. • Metabolic complications • Hypochloraemic hypokalaemic metabolic acidosis. • Vitamin B12 and bile acids • Urolithiasis • Pyelonephritis • Preservation of upper tracts. • Potency

17. A Case of Prostate Cancer • Mr J.B. 57 year old. • Mild LUTS • Hypertension • Asks his G.P. for a test for prostate cancer? • What should the G.P discuss with him?

18. 2 New Randomised trails of screening PLCO trial highly flawed 30% were prescreened before entering the trial 52% in control arm had screening 85% only were screened in screening arm.

19. 182,000 men aged 50-74 • Randomised to : PSA every 4 years or no screening. • PSA cut-off 3.0ng/ml and DRE • 16.2% tests were positive

20. ERSPC DATA • CaP incidence: 8.2% screened vs 4.8% control (p<0.05) • CaP Death: decreased by 20% in screening arm at 9 years. • When compliance and contamination was accounted for- 32% diff. • NNT = 48!!!

21. Need to treat 48 men to save one. Summary PotentialBenefits PotentialHarms • 20% reduction in death from CaP Need to discuss the individual benefits and risks of screening with all male patients 50-70years.

22. A Case of Prostate Cancer PSA Test: 3.0 ng/ml, F/T 9% Is this normal? Age Median PSA Normal Range 40-49 0.7ng/ml 0-2.5ng/ml 50-59 0.9ng/ml 0-3.5ng/ml 60-69 1.4ng/ml 0-4.5ng/ml 70+ 1.7g/ml 0-6.5ng/ml

23. PSA and Risk of Prostate Cancer in Asymptomatic Men.

24. PSA Velocity • Needs to be calculated with at least 3 PSA values • 15% variability day-day • PSA velocity of >0.35ng/ml/year is abnormal. • If PSA velocity is abnormal and PSA is above the median value – refer to urologist.

25. Free to Total (%) Does Help Specificity.

26. Algorithm for PSA Testing Male 50-70 >10 year life expectency Male 40-70 >10 year life expectency Family Hx or other high risk Male 40-70 Symptomatic Discuss Pros and Cons of PSA testing Test PSA and DRE No bicycle riding, UTI (6 weeks), recent surgery or manipulation DRE Normal : Rpt in 1 year Normal Abnormal PSA TEST Abnormal Normal but Above median Mildly Abnormal Refer to Urologist OR Calculate PSA Velocity Repeat PSA in 6 weeks With F/T% Exclude Other Causes of Elevated PSA and then Discuss Risk of CaP and Need for Biopsy

27. A Case of Prostate Cancer • Mr J.B has an abnormal prostate exam. • He has a prostate biopsy • 2% Lignocaine pudendal nerve block. • Biopsy results: • Gleason Grade 3+3=6 • In 6/12 cores involving 25%-50% of the cores. • What are his options for treatment?

28. Treatment options for low risk CaP • Active surveillance • Radical Prostatectomy • Open • Robotic • Seed Brachytherapy (not HDR brachytherapy) • External beam radiotherapy • Experimental • HIFU • Cryothepy

29. A Case of Prostate Cancer • Pathology: • Adenocarcinoma, Gleason Grade 3+4 • Extracapsular extension • Negative surgical margins. • Follow-up: • Continent @ 4weeks • Potent @ 3 months • No PSA recurrence at 2 years.

30. Questions