NON MUSCLE INVASIVE BLADDER CANCER 2.pptx

Non—muscle-invasive bladder cancer (NMIBC) is a heterogeneous subclassification of urothelial carcinoma with significant variation in individual risk of recurrence and progression to muscle-invasive disease.

1. DR NAJMI ASYRAF NON MUSCLE INVASIVE BLADDER CANCER

2. CASE STUDY 1 55 YEARS OLD MALAY GENTLEMAN REFER TO UROLOGY CLINIC FOR MICROSCOPIC HAEMATURIA

3. WHAT TO DO NEXT? PATIENT HISTORY SIGN AND SYMPTOMS PHYSICAL EXAMINATION

4. On further hx Non-visible haematuria Incidental finding upon kk follow up Repeated multiple times still got microscopic haematuria Occupation-works in agricultural field P atient is a smoker 2 packs/year No hx of trauma , stone before On Examination patient appears alert conscious, pink , abdomen no mass, bladder not palpable, prostate not enlarged

5. Aetiology Risk factor Tobacco smoking (50%) Occupational exposure to aromatic amines, polycyclic aromatic hydrocarbon and chlorinated hydrocarbon (10%) Family history Exposure to ionizing radiation

6. Imaging That We Can Do X-RAY KUB ULTRASOUND KUB CYSTOSCOPY CTU & IVU

7. XRAY KUB

8. ULTRASOUND KUB Utrasound maybe performed as and adjunct to physical examination Per abdomen

9. CTU AND IVU

10. OTHER THINGS THAT WE CAN DO FOR DIAGNOSTIC PURPOSE CYSTOSCOPY URINE CYTOLOGY PHOTODYNAMIC CYSTOSCOPY URINARY MOLECULAR MARKER TEST*

11. CYSTOCOPY

12. Cystoscopy

13. Photodynamic cystoscopy *fluorescene cystoscopy*

14. CASE STUDY 2 60 years old malay gentleman presented at ED complaining of haematuria for 1/12 He claim it was painless

15. INSERTED CBD-GROSS HAEMATURIA NEEDED BLADDER IRRIGATION What is your plan in ED?

16. Ward Management Imaging? – USG / CT CE under LA?

17. In Acute Setting TURBT is both Diagnostic and Therapeutic

18. Transurethral Resection Bladder Tumour Goal of TURBT is to make correct diagnosis and completely remove all visible lesions and to get T-staging Complete resection is essential to achieve a good prognosis

19. Common Question for TURB Why we do under GA Lateral wall tumour -obturator jerk Why we don’t do biopsies under LA? Hameturia obscured view

20. HPE REPORT

21. Staging Of bladder cancer

22. WHO Grading

23. Second Resection Significant risk of residual tumour after initial TURB of TaT1 lesion has been demonstrated Second TURB can increase recurrence free survival , improve outcomes after BCG treatment and provide prognostic information Second resection is recommended in selected case 2-6 weeks after initial resection

24. Intravesical Chemotherapy Single, immediate, post operative intra vesical instillation of chemotherapy Act by destroying circulating tumour cell after TURB and ablative effect on residual tumor at the resection site and small overlooked tumour Example: Mitomycin C, Epirubicin /Pirarubicin SI + TURB > TURB in reducing recurrence rate Administered within 24 hours Contraindications: Suspect Bladder Perf / Gross heamaturia / Suspect MIBC

25. Intravesical Bacillus Calmette-Guerin (BCG) Immunotheraphy BCG after TURB is superior to TURB alone or TURB + Chemotheraphy for preventing the recurrence of NMIBC BCG was less effective in patient > 70 years of age BCG intravesical treatment is associated with more side effects compared to intravesical chemotherapy. However, serious side effects are encountered in < 5% of patients and can be treated effectively in almost all cases Bacillus Calmette- Guérin should be used with caution in immunocompromised patients Presence of leukocyturia, nonvisible haematuria or asymptomatic bacteriuria is not a contraindication for BCG application, and antibiotic prophylaxis is not necessary in these cases

26. Absolute Contraindication of Intravesical BCG During the first two weeks after TURB Patients with visible haematuria After traumatic catheterisation Patients with symptomatic urinary tract infection

27. Side Effects of Intravesical BCG Cystitis Haematuria Symptomatic Granulomatous Prostatitis BCG Sepsis Allergic Reactions Athralgia / Athritis

28. Radical Cystectomy Some patient with NMIBC experience diseases progression to muscle-invasive disease Prognosis in patient experience disease progression is worse than those who present with primary muscle invasive In Patient in whom RC is performed before progression to MIBC,the 5 years DFS exceeds 80%

29. Follow up

30. Thank you!