cancer bladder surgery immunotherapy chemotherapy radiotherapy target therapy

1. Cancer Bladder, Arts of indications
By
Salah Mabruok
Khalaf, MD
South Egypt Cancer Institute
2018
Tumor borad
Medical Oncology department

2. Multidisciplinary Team
GOOD ONCOLOGY CARE

3. To know indications, you should know staging
Tumor (T) staging
•Ta - non-invasive papillary carcinoma
•Tis - carcinoma in situ, "flat tumor"
•T1 - invades subepithelial connective tissue
•T2 - invades muscularis propria
• T2a - invades superficial muscle (inner half)
• T2b - invades deep muscle (outer half)
•T3 - invades perivesical tissue
• T3a – microscopically
• T3b - macroscopically (extravesical mass)
•T4 - invades other organs
• T4a - invades prostatic stroma, uterus, vagina
• T4b - invades pelvic wall, abdominal wall

4. To know indications, you should know staging
Nodal staging
• N0 - none
• N1 - single LN metastasis in the true pelvis (Below common iliac)
• N2 - multiple LN metastases in the true pelvis (Below common iliac)
• N3 - metastases to the common iliac LNs

5. To know indications, you should know staging

6. Indications of Cystoscopy
1. Any gross or microscopic hematuria with a normal upper urinary tract
imaging
2. Unexplained or chronic lower urinary tract symptoms
3. Urine cytology that is suspicious for cancer
4. A history of bladder cancer with symptoms suggestive bladder disease
5. Follow up of bladder cancer after successful TURTB

7. Indications of CT Urography
• Diagnostic
1. Any patient with hematuria
2. History of bladder cancer, or positive cytology.
• For staging invasive bladder cancer or upper tract TCC:
1. Abnormally enlarged lymph nodes and visceral metastasis can be observed by CTU.
2. Local invasion into pelvic organs or tumor infiltration into the perivesical fat can also
be observed.
N.B. CT is not reliable for the detection of local invasion.

8. Indications of Urine Cytology
1. Follow-up of patients with a history of bladder cancer
2. Screening symptom-free patients who are exposed to environmental carcinogens
3. Evaluating patients with chronic irritative bladder symptoms before cystoscopy is
done.

9. Indications of NMP22 Antigen
• Nuclear matrix proteins (NMP): Instead of urine cytology if available as:
• Nuclear matrix proteins (NMP) make up the structural framework of the nucleus and
are important in gene expression
• Malignant urothelial cells contain up to 80 times higher concentration of NMP22
antigen than normal urothelial cells and release it upon cell death
• FDA approved for monitoring and diagnosis.
• Sensitivity for Detecting TCC (Grossman et al. JAMA 293:810-816, 2005)
• NMP22 Test = 57% versus Cytology = 16% (P < 0.001)

10. Muscle Non-invasive TCC

11. Indications of cystectomy in noninvasive TCC
• Tis
• Multifocal CIS (Tis) cannot be removed by TURT
• T1
• After failure of repeated TURT

12. Indications of Segmental resection (partial cystectomy) in noninvasive
TCC
1. Solitary tumor
2. Localized tumor to the bladder dome
3. Not associated with areas of CIS sought by multiple biopsies of urothelial mucosa
4. Able to be removed with a 2-cm margin of healthy tissue: far enough away from the
ureteral orifices and bladder neck
5. Bladder reconstruction is feasible as sufficient margin around the ureteral orifices and
bladder neck is preserved

13. Indications of Adj intravesical CTR or immunotherapy for noninvasive
TCC after TURT
• Immunotherapy
• Ta
• High-grade tumors: G3 (Immuno preferred to CTR)
• T1
• Any grade, after complete or incomplete TURT
• Chemotherapy
• Ta
• Low-grade G1-2
• High-grade tumors: G3
• T1
• Any grade, after complete or incomplete TURT

14. Indications of RT for noninvasive TCC
• Definitive RT is an alternative to surgery for patients refuse or unfit for radical
surgery
• Preoperative RT is seldom used. RT does not appear to improve expected
survival beyond that achieved by radical surgery alone, although local
recurrence is reduced.
• Postoperative radiation has no proved role

15. Indications of chemotherapy in non-invasive TCC
• No Chemotherapy in non-muscle invasive

16. Muscle invasive TCC

17. Indications of Neoadjuvant CTR
• T2
• T3
• T4

18. Indications of Neoadjuvant CCRT
• T2
• T3
• T4

19. Indications of Definite CCRT (bladder sparing)
Only for patients without hydronephrosis (NCCN, category 2B) followed by 2-3
cycles of adjuvant chemotherapy
• T2
• T3
• T4

20. Indications of radical cystectomy in fit patients
• Initial option
• T2
• T3
• T4a
• After definite CCRT
• Residual tumor
• After neoadjuvant CCRT or CTR
• T2
• T3
• T4a
• T4b (became resectable)

21. Indications of chemotherapy in invasive node –ve TCC
• Neoadjuvant for T2-4
• Adjuvant
• 2-3 Cycles after Definite CCRT (Bladder sparing)
• 6 cycles after radical cystectomy
• Palliative for unfit or inoperable T4b TCC

22. Indications of CTR, RT, Surgery in invasive node +ve TCC
• As shown from this plan of treatment
• CCRT OR 2-3 cycles of Chemotherapy THEN assessment of response:
• If complete response 
• Observation OR
• Cystectomy OR
• Boost with RT.
• If residual tumor 
• Cystectomy if resectable OR
• Chemo-RT if not received if unresectable or unfit patient OR
• Palliative TURBT OR
• Salvage CT if unresectable or unfit patient

23. Metastatic TCC

24. Chemotherapy for met TCC

25. CTR for metastatic TCC
• MVAC was the standard
• GC (Gemcitabine and Cisplatin) became the standard
• Carboplatin instead of cisplatin
• Neuropathy grade 3-4
• Poor renal function
• Gemcitabine/ paclitaxel is comparable to Gemcitabine and Cisplatin

26. Indications of Atezolizumab (Tecentriq)
• The Food and Drug Administration (FDA) on May 18 2016, approved for
• Locally advanced or metastatic urothelial carcinoma in patients who are
• Not eligible for cisplatin-containing chemotherapy, or
• Have disease progression during or following platinum-containing chemotherapy, or
• Disease progression within 12 months of neoadjuvant or adjuvant chemotherapy

27. Indications of Pembrolizumab (Keytruda)
• The Food and Drug Administration (FDA) on May 10 2017, approved for
• Locally advanced or metastatic urothelial carcinoma in patients who are
• Not eligible for cisplatin-containing chemotherapy, or
• Have disease progression during or following platinum-containing chemotherapy, or
• Disease progression within 12 months of neoadjuvant or adjuvant chemotherapy

28. Sq CC of bladder (rare)
• Surgery is only curative
• Radioresistent
• No adjuvnt RT or CTR
• Palliative CTR
• Epirubicine based CTR
• Cisplatin based CTR
• Taxines