clinical case BLADDER CANCER Francisco M. Drugowick, Daniel Moser Silva Division of Urology, FCM-Unicamp
CLINICAL BACKGROUND Eighty three year old male has a history of intermittent episodic macroscopic hemat煤ria for 8 months. He denies lumbar or abdominal pain. He denies weight loss or lower urinary tract symptoms. He denies smoking. He has a history of shoemaker glue use for 30 years. 1) Physical exam : karnofsky performe status of 100%, flat abd么men, no palpable mass. 2) Labs : Hemoglobine 15,2d/dl; hematocrit 35,4%; urea 49mg/dl; creatinine: 1,2mg/dl; Albumine 4,5g/dl 3) Renal system ultrasound: Normal kidneys, no calculi, no hydronephrosis. Irregular solid lesions on right bladder wall measuring 1,5cm and 1,2cm with positive doppler perfusion. Prostate, volume: 25g.
MANAGEMENT: Lesions were ressected by TURb. Pathology: Urothelial carcinoma with scamous differentiation , grade 2+3 (UNICAMP) or high grade (OMS/SIPU). Pathological staging pT2. Radical cystectomy was proposed. However, since patient was elderly and there was an extreme concern regarding the surgical trauma and morbimortality Family denied surgical radical treatment. As an option, abdominal CT scan was performed followed by a novel TURb was performed 30 days after initial ressection.
-Abdominal computerized tomography :
Figure 1: Non contrast abdominal CT scan, axial cuts. No lesions in upper urinary tract.
Figure 2: Non constrast abdominal CT scan, axial cuts. Thin walled bladder, no evidente lesions.
During surgical procedure no recurrent lesions were noted and the รกrea of previous ressection was sampled. Pathology: Bladder fragments with muscle layer covered by urothelium, with giant cellular reaction (foreign body reaction). No signs of neoplasia. Patient was assymptomatic following the procedure. As pahtological staging showed a muscle-invasive non metastatic tumor and patient was selected for a non surgical treatment, a protocol of combined chemotherapy and radiotherapy was undertaken.
COMMENT - Ronaldo Dami達o - Danilo Sousa Lima da Costa Cruz
MULTIMODAL THERAPY AND THERAPEUTIC OPTIONS TO TREAT ELDERLY PATIENTS WITH UROTHELIAL MUSCLE INVASIVE BLADDER TUMORS.
Radical cystectomy remains the gold standard of care to treat urothelial muscle invasive tumors in most western countries 1. The search for a better quality of life in these patients has encouraged protocols with bladder preservation associated with adjuvant radio/ chemotherapy. Performance status and age are the main influencing factors for primary therapeutic choice as well as the type of urinary diversion.
There is an endless discussion regarding age and choosing the more adequate urinary diversion type. Cystectomy is associated with a significant reduction in cancer-specific and overall survival in patients over 80 years of age2. The largest retrospective study found that patients over 80 years showed higher post operative morbidity, with no increase in mortality3.
When a pT2 patient presents a downstaging to pT0 or pT1 during a second look ressection, he may be a candidate for a TUR-only treatment. However, about half of them will need cystectomy for recurrent muscle invasive bladder tumor with a cancer-specific mortality of 47% in this group4.
Currently, bladder sparing protocols combine bladder TUR, radiotherapy and chemotherapy 5. A pT0 status following an initial TURb and adjuvant radio and chemotherapy was shown to be associated with a more favorable prognosis and is essential to help deciding to proceed or not with a radical cystectomy6. A comparable survival rate of 50-60% in 5 years of follow up can be seen when analysing series of bladder multimodal preservation and radical cystectomy7. Multimodal approach can be offered as an alternative for selected patients especially those who are not good surgical candidates.
Suggested Literature:
1- World Health Organization (WHO) Consensus Conference in Bladder Cancer, Hautmann RE, Abol-Enein H, Hafez K, Haro I, Mansson W, Mills RD, Montie JD, Sagalowsky AI, Stein JP, Stenzl A, StuderUE, Volkmer BG. Urinary diversion. Urology 2007 Jan;69(1 Suppl):17-49. http://www.ncbi.nlm.nih.gov/pubmed/17280907 2- Miller DC, Taub DA, Dunn RL, et al. The impact of co-morbid disease on cancer control and survivalfollowing radical cystectomy. J Urol 2003 Jan;169(1):105-9. http://www.ncbi.nlm.nih.gov/pubmed/12478114 3- Figueroa AJ, Stein JP, Dickinson M, et al. Radical cystectomy for elderly patients with bladder carcinoma: an updated experience with 404 patients. Cancer 1998 Jul;83(1):141-7. http://www.ncbi.nlm.nih.gov/pubmed/9655304 4- Herr HW. Transurethral resection of muscle-invasive bladder cancer: 10-year outcome. J Clin Oncol 2001 Jan;19(1):89-93. 5- Weiss C, Wolze C, Engehausen DG, et al. Radiochemotherapy after transurethral resection for highrisk T1 bladder cancer: an alternative to intravesical therapy or early cystectomy? J Clin Oncol 2006 May;24(15):2318-24. 6- Solsona E, Iborra I, Ricós JV, et al. Feasibility of transurethral resection for muscle infiltrating carcinoma of the bladder: long-term follow-up of a prospective study. J Urol 1998 Jan;159(1):95-8; discussion 98-9. 7- Rödel C, Grabenbauer GG, Kühn R, et al. Combined-modality treatment and selective organ preservation in invasive bladder cancer: long-term results. J Clin Oncol 2002 Jul;20(14):3061-71. http://www.ncbi.nlm.nih.gov/pubmed/12118019
learning by image CRYOTHERAPY IN THE TREATMENT OF SMALL RENAL TUMORS Wilmar Azal Neto, Thiago Penachim, Fernandes Denardi Division of Urology, UNICAMP
CLINICAL MANAGEMENT Seventy year-old White male is referred to our clinic by the Nephrology team due to a diagnosis of renal chronic insuficiency and the finding of a large cyst and a solid nodule in the righ kidney as shown by abdominal CT scan. Patient is assymptomatic. Comorbidities are systemic hypertension and diabetes.
PHYSICAL EXAM:
Obese with good performance status. Not tender soft abdominal mass is palpable at right lower abdomen.
LABS: 1) Creatinine = 1,5 mg/dl, Creatinine clearence = 61 2) Abdominal computerized tomography (Figure 1)
Figure 1: Abdominal computerized tomography (dorsal position). Arrows show : a. Axial cut: arterial phase, arrow shows a large simple renal cyst and heterogenous nodular lesion at the posterior aspect of right kidney. b. Axial cut: excretion phase, arrow shows a fine septum inside the cyst and contrast inside the collecting system, no extravasation can be seen. c. Coronal cur: Arrow shows large renal cyst d. Sagital cut: arrow shows posterior nodular lesion at the back face of right kidney
DIAGNOSIS Class II chronic renal insuficiency with a large 19 cm Bosniak II renal cyst and a 2.7 cm solid renal nodule suggesting a primary renal neoplasia of the right kidney.
MANAGEMENT Percutaneous biopsy of nodular lesion: conventional clear cell carcinoma Furhman 1-2.
Focal treatment with CT and US guided cryoabaltion was performed (Figure 2).
Figure 2: Abdominal computerized tomography (ventral position). Arrows show: a. Axial cut: Arrow shows needle targetting the tumor b. Axial cut: Arrow shows “ice ball” and thermal ablation c. Axial cut: Arrow shows local aspect after ablation – note that the cyst was punctured and alcohoolized with complete regression. d. Coronal cut: arrow shows a J stent for complete cyst drainage
EDITORIAL COMMENT:
It is well known that despite the rising incidence of small renal masses detection and treatment, its mortality rate has not decreased (1) which may be related with a bias of excessive early detection that is currently common for prostate and renal cancer; the vast majority of patients may end up dying with their cancers and not because of them.
While the benefits of nephron sparring surgery regarding prevention of renal insufficiency and cardiovascular morbi-mortality continue to become more clear in the Literature (2, 3), issues related to selection biases, technical variations and lack of standardization, variations in tumor location and size make adequate evaluation of ablation techniques difficult to compare with partial nephrectomies. Besides, residual cancer cells may require several years before they become clinically detectable since the average anual growing rate of radiological detectable tumors may be as low as 0,13 cm/ year (2) with an uncommon but possible metastatic potential with need for long term follow up. Current data comparing cryoablation and partial nephrectomy although initial, do not show diferences in complication rates between the two approaches. However, although cryoablation shows a significant advantage in renal function preservation (6% versus 13% reduction in glomerular filtration rate) it is also associated with a higher c창ncer recurrence in multivariate analysis (hazard ratio=11,4, p=0,01) and lower disease free, c창ncer specific and overall survival rates (83,1%, 96,4% e 77,1% vs 100%, 100% e 91,7%, respectivamente) (4). Prospective, unbiased, randomized studies with technique standardization, as well as improvement in diagnostic ability to identify clinically significant tumors are utterly important to distinguish which renal masses do desserve to be treated and also which approach would prove more adequate for each case. The real questions to be addressed in the future are: when is ablation necessary? And safe? (5).
References:
1. Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK. Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst. 2006; 98: 1331-4. 2. Jewett MA, Mattar K, Basiuk J, Morash CG, Pautler SE, Siemens DR, et al. Active Surveillance of Small Renal Masses: Progression Patterns of Early Stage Kidney Cancer. Eur Urol. 2011 Jul;60(1):39-44. 3. Huang WC, Elkin EB, Levey AS, Jang TL, Russo P: Partial nephrectomy versus radical nephrectomy in patients with small renal tumors--is there a difference in mortality and cardiovascular outcomes? J Urol. 2009; 181: 55-61. 4. Tanagho YS, Bhayani SB, Kim EH, Figenshau RS. Renal cryoablation versus robot-assisted partial nephrectomy: Washington University longterm experience. J Endourol. 2013 Dec;27(12):1477-86. 5. Reis LO. Urological Oncology Survey. Int. Braz J Urol, 2011; 37: 270291.
Prof. Leonardo Oliveira Reis, MD, MSc, PhD - Professor of Urology, Head of Urologic Oncology, Pontifical Catholic University of Campinas, PUC-Campinas, São Paulo, Brazil - Researcher, University of Campinas, UNICAMP, São Paulo, Brazil - Johns Hopkins Medicine Fellow, Baltimore, USA - Columbia University Medical Center Fellow, New York, USA E-mail: reisleo.l@gmail.com
new technologies THE EFFECTS OF HYALURONIC ACID AND CARBOXYMETHYLCELLULOSE IN PREVENTING RECURRENCE OF URETHRAL STRICTURE AFTER ENDOSCOPIC INTERNAL URETHROTOMY: A MULTICENTER, RANDOMIZED CONTROLLED, SINGLE-BLINDED STUDY Jae Hoon Chung, Dong Hyuk Kang, Hong Yong Choi, Tae Yoong Jeong, U-Syn Ha, Jun Hyun Han, Ji Hyeong Yu, Jeong Man Cho, Tag Keun Yoo, Jinsung Park, Tae Hyo Kim, Seung Wook Lee - Journal of Endourology. June 2013: 756-762.
ABSTRACT Randomized controlled, double blind study and multicenter that evaluated the role of the administration of hyaluronic acid (HA) + carboxymethylcellulose (CMC) to prevent recurrence of stenosis after internal urethrotomy (IU). The urethrotomy is a procedure with a success rate of around 40% and high recurrence rates (23-80%). The purpose of applying the AH and the CMC is due to the fact that they are hydrophilic coating agents capable of cell membranes. This property would inhibit scar postoperative adhesion, which culminates with recurrence of stenosis. The intervention consisted of applying a combined solution of HA and CMC immediately after the urethrotomy within the light of the urethra between the mucosal surface and the Foley catheter. The Foley balloon was kept pulled on bladder neck and the urethral meatus remained occluded by gauze in the first 24h. One hundred and twenty patients who were enrolled in 2 groups: A - 60 patients underwent combined injection of HA / CMC; B - 60 patients as a control group (administered chlorhexidine gel as placebo). The group submitted the application of combined HA / CMC showed a lower rate of recurrent stenosis: 9.4% versus 22.9% in the control group (p = 0.029). At 24 weeks after the procedure, the maximum flow rate (Qmax) was 18.31 + 8:37 mL / sec for group A while group B was 14:55 + 5.67 ml / sec (p = 0.023).
Patients underwent instillation of HA / CMC had less pain and greater satisfaction through validated questionnaires. A limitation of the study was the follow-up period of 24 weeks, which is considered short as it is described recurrence of stenosis within 7-8 years after urethrotomy. Another interesting point would be a histological analysis comparing the scar tissue between the groups, the review authors cogitate on animal experimentation.
The real benefits of this therapy should be validated in longer studies to determine consistency of results. In any case, this work points to a new pespectiva to treat a common problem in urologic whose resolution is below the desired. Ricardo Souza Post Graduate Student of Urology UNICAMP
urology news
ON MAY 24 PROF. MARIA HELENA BAENA DE MORAES LOPES PERFORM EXAMS FOR FULL PROFESSOR AT THE FACULTY OF NURSING AT UNICAMP. THE TOPIC OF THE LECTURE WAS:
Urinary incontinence in women VAGINAL DELIVERY AND SAFE AND HEALTHY: IMPLICATIONS FOR NURSING CARE
from left to right: Prof. Dr. Yolanda Martinez Dora Évora, Prof. Dr. Ana Marcia Spanó Nakano, Professor. Maria Helena Baena de Moraes Lopes, Prof. Dr. José Guilherme Cecatti, Prof. Dr. Françoise Sophie Mauricette Derchain, Prof. Dr. Isília Aparecida Silva.
Congratulations to Professor Maria Helena for this achievement
MAKE EARLY REGISTRATION AND HAVE 25% DISCOUNT!! More information VIEW HERE ICS 2014, Rio de Janeiro - 20th - 24th October 2014
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