1. Cases in Urological Oncology Dr Manish Patel MB.BS., MMed., FRACS, PhD Urological Cancer Surgeon Westmead Public and Private Hospital 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? Upper Urinary Tract Renal Cell Carcinoma Urothelial cancer Urolithiasis Glomerular causes Nephritis AV Malformation Renal infarction Renal vein thrombosis Polycystic kidneys Lower Urinary Tract Urothelial cancer Cystitis BPH Bladder stones Prostate cancer Prostatitis Trauma TB Anticoagulation

6. Imaging CT 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. Imaging Urinary Tract Ultrasound Cheap, quick, non- invasive, no contrast Sensitivity 60-70%, specificity 90% Still inferior to CT.

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

9. Macroscopic Haematuria Microscopic Haematuria High RiskLow Risk Exclude UTI (MSU) Urine cytology X3 Exclude UTI (MSU) Urine cytology X3 Upper Tract Imaging: CT Urogram or IVP + US Upper Tract Imaging: US only. Lower Tract Investigation: Cystoscopy (Flexible or Rigid) Lower Tract Investigation: Cystoscopy (Flexible) Dysmorphic cells on microscopy Nephrologist Evaluation Algorithm for 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 Invasive Tis Superficial Superficially Invasive CIS T2 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. Pouch Ureters Urethra

16. A Case of Bladder Cancer A Case of Bladder Cancer Considerations 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. 20% reduction in death from CaP Need to treat 48 men to save one. Potential Benefits Summary Potential Harms 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? AgeMedian PSANormal Range 40-490.7ng/ml0-2.5ng/ml 50-590.9ng/ml0-3.5ng/ml 60-691.4ng/ml0-4.5ng/ml 70+1.7g/ml0-6.5ng/ml

23. PSA and Risk of Prostate Cancer in Asymptomatic Men. PSA Levels PCPT Trial Values Normal DRE 1-1.99 17% 2-2.99 24% 3-3.99 27% 4-10 29% 10+ 45%

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. 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 AbnormalNormal Refer to Urologist Exclude Other Causes of Elevated PSA and then Discuss Risk of CaP and Need for Biopsy PSA TEST Abnormal Mildly Abnormal Normal but Above median Repeat PSA in 6 weeks With F/T% Calculate PSA Velocity OR Algorithm for PSA Testing Normal : Rpt in 1 year

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