Transcript Transitional Cell Carcinoma of the Urinary Tract

Transitional Cell Carcinoma of
the Urinary Tract
Manish Patel
Urology Registrar
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Epidemiology
•
•
•
•
•
•
Men >women
Incidence increasing in men
Mortality decreasing
Agemiddle aged and elderly
Race- blacks > whites
All symptomatic before death
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Etiology
•
•
•
•
•
Smoking
Occupational exposure
Analgesic abuse
Cyclophosphamide
?heredity
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Pathology
• Carcinoma insitu
• Superficial
• invasive
• Low grade
• Mod grade
• High Grade
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Natural History
• 75% superficial at presentation
2/3 well-mod diff.- 0nly 10% become
invasive or metastastic
1/3 high grade-50% become invasive
• 25% invasive- most are high grade
• CIS- 16% become invasive
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Natural History
• 40% muscle invasive TCC have occult distant
mets
• Nearly all Pts with mets die within 2 years
Spread
Lymphnodes, Liver, Lung, Bone, Adrenal
Local Complications
Bleeding, Pain, Ureteral Obstruction, Local invasion
surrounding structures/fistula.
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Diagnosis
• Microurine, urine cytology
• IVP, U/S, CT
• Cystoscopy and biopsy
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Staging
•
•
•
•
Biopsy
CT abdomen and pelvis
CXR
Bone scan
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Management superficial bladder TCC
Transurethral resection or fulgration
• 70% 5 year survival
• 10% will ultimately require more aggressive
Treatment
• Lamina Propria invasion has 46% muscle
invasion later
• multiple or recurrent TCC will respond to
intravesical chemo or BCG
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Management of Muscle Invasive TCC Bladder
• TURBT
• Partial Cystectomy
• DXRT with cystectomy salvage
35% 5 year survival
50-70% bladder recurence at 5 years
10% severe persistent complications
Only 8-15% are suitable for salvage
cystectomy- 40% 5 year survival
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Management of Muscle Invasive TCC Bladder
• Radical Cystectomy
Most effective form of cure
70% 5 year survival
45% 5 year survival outside bladder
• Complications-25%
infection, intestinal obstruction, hemorrage,
DVT, urine or faecal leak
• Mortality-1%
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Radical cystectomy
•
•
•
•
Ileal conduit
Neobladder
Continent urinary diversions
ureterosigmoidostomy
Adjuvant chemotherapy
Sig survival advantage for tumour outside
bladder and minor nodal involvement.
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Metastatic TCC
• 4 drug regimen MVAC used
• improves median survival from 8 months to
12 months.
• 6% mortality rate from toxicity
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
TCC of renal pelvis and ureter
• 10% or renal tumours, 5% of TCC
• Same risk factors as bladder TCC
• 30%-75% also have bladder TCC at some
stage
• Ureteral tumours more common at lower
end
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
TCC upper tract-symptoms & signs
• Haematuria, pain, metastatic disease,
incidental
Diagnosis
• IVP
• C/E RGP cytology and brushings
• CT
• U/S
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Staging
• Similar to bladder
• Most tumours are low stage, low grade
Treatment
• Nephroureterectomy
91% 5 years survival-superficial
43% 5 year survival -muscle invasive
0-23% advanced disease
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Treatment
Conservative excision
Only low grade +stage and renal disease
Endoscopic Treatment
Ureteroscope with laser or fulgration
Again only for low grade+stage/ renal
disease.
Major medical illness
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Carcinoma in-situ
•
•
•
•
•
No symptoms to frequency and dysuria
C/E normal or velvety erythema
High grade, 25% of HG TCC will have it
Often detected on urine cytology
>20% risk of developing invasive TCC or
already harbouring it.
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract
Carcinoma in-situ
• Best treatment is intravesical BCG
• Can also give other cytotoxic eg.
Mitomycin
Water Works By The Waves
Transitional Cell Carcinoma of the Urinary Tract