Cases in urological oncology
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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. A Case of Bladder Cancer. Mr K.S. 63 year old man. Heavy smoker in the past. Father had bladder cancer

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Cases in urological oncology

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


A case of bladder cancer
A Case of Bladder Cancer

  • Mr K.S. 63 year old man.

  • Heavy smoker in the past.

  • Father had bladder cancer

  • Asymptomatic


Bladder cancer screening
Bladder Cancer Screening

  • Risk Factors for Bladder Cancer

    • Smoking

    • Age

    • Radiation exposure

    • Previous urothelial carcinoma

    • Analgesics

    • Cyclophosphamide


Has haematuria screening been useful
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


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


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


ImagingUrinary Tract Ultrasound

  • Cheap, quick, non-invasive, no contrast

  • Sensitivity 60-70%, specificity 90%

  • Still inferior to CT.


ImagingIVP

  • Intravenous contrast and tomograms

  • Sensitivity 61%, specificifty 92%

  • Expensive and time consuming

  • Misses small renal lesions – need US as well


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


Case

  • Mr KS has

  • Normal CT IVP

  • Urine cytology: suspicious for malignancy

  • Has cystoscopy


Cystoscopy
Cystoscopy

High Grade Urothelial Carcinoma Carcinoma in-situ

Lamina Propria Invasion


Staging of Bladder Cancer

CIS

Tis

Superficial

Superficially Invasive

T2

Invasive

T3


What next
What Next?

  • BCG treatment for 6 weeks- intravesically

    • Eradicated CIS (70%)

    • Decreased recurrence and progression.

  • Follow-up cystoscopy every 3 months for 2 years.


9 months later
9 months later

  • Muscle Invasive

  • Staging CT, Bone scan normal.


A case of bladder cancer1
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


A case of bladder cancer considerations in followup
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


A case of prostate cancer
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?


2 new randomised trails of screening
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.


  • 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


Erspc data
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!!!


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.


A case of prostate cancer1
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



Psa velocity
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.



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


A case of prostate cancer2
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?


Treatment options for low risk cap
Treatment options for low risk CaP

  • Active surveillance

  • Radical Prostatectomy

    • Open

    • Robotic

  • Seed Brachytherapy (not HDR brachytherapy)

  • External beam radiotherapy

  • Experimental

    • HIFU

    • Cryothepy


A case of prostate cancer3
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.



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