Treating Urothelial Bladder Cancer

128 Pages·2018·3.83 MB·English

by  Francesco Soria, Paolo Gontero

Treating Urothelial
Bladder Cancer
Francesco Soria
Paolo Gontero
Editors
123
Treating Urothelial Bladder Cancer
Francesco Soria • Paolo Gontero
Editors
Treating Urothelial
Bladder Cancer
Editors
Francesco Soria Paolo Gontero
University of Turin University of Turin
Torino Torino
Italy Italy
ISBN 978-3-319-78558-5 ISBN 978-3-319-78559-2 (eBook)
https://doi.org/10.1007/978-3-319-78559-2
Library of Congress Control Number: 2018950479
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Preface
Bladder cancer represents the most common genitourinary cancer in male
population after prostate cancer and the most common in women, with around
80,000 estimated new cases during 2016 only in the United States. It is mainly
a disease of the elderly, with the majority of new diagnoses occurring in the
decade between 75 and 84 years. Therefore, with the aging of population,
bladder cancer will become even more frequent and develop in an even bigger
public health challenge in the near future. This will lead to a mandatory mul-
tidisciplinary management, which will call in not only the urologist, medical
oncologist, and radiotherapist but also the general practitioner, geriatrician,
and public health manager.
Moreover, after many years, novel technologies and new therapeutic
agents are becoming a reality in the treatment of urothelial bladder cancer,
carrying the opportunity to change the natural history of the disease. This will
lead, as already happens for other cancers, to more and more individualized
treatments. Therefore, one of the major challenge will be the correct selection
of the right treatment for the right patient. All the figures which are taking
part in the management of bladder cancer will be involved in this challenging
process, and, to achieve these ambitious results, they must be open to change
and improve their approach to the disease.
The idea of writing a book focused on the treatments’ novelties in bladder
cancer management arose after the success of the first two editions of Global
Congress on Bladder Cancer. The great interest originated from the debate
between all the figures involved in bladder cancer management convinced us
that this would be the right time to publish a book that will be able to act as a
guide in these years of change.
The dissemination of effective new diagnostic technologies and the
improvement in minimally invasive radical surgery with robotic surgery
along with the advent of systemic immunotherapy make the present time
unique in the history of bladder cancer and open the premise for a breakthrough
in disease outcome.
Are we ready for the “new era of bladder cancer”?
Torino, Italy F. Soria
Torino, Italy P. Gontero

v
Contents
Part I B ladder Cancer Diagnosis
1 Imaging in Bladder Cancer: Can We Do Better? . . . . . . . . . . . 3
Giovanni Barchetti, Vincenzo Salvo, Davide Fierro, Maurizio
Del Monte, Isabella Ceravolo, and V. Panebianco
2 New Optical Improvements in Bladder Cancer Diagnosis:
Seeing Better for a Better Management? . . . . . . . . . . . . . . . . . . 11
Benjamin Pradère, Idir Ouzaid, and Evanguelos Xylinas
3 Enhancing the Quality of Transurethral Resection:
The Importance of a Complete TURB
and the En-Bloc Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Rodolfo Hurle and Carmen Maccagnano
4 Active Surveillance for Low-Risk Non-Muscle
Invasive Bladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Rodolfo Hurle, Carmen Maccagnano, and Giovanni Forni
Part II N on-muscle Invasive Bladder Cancer
5 How Good Are We at Predicting Outcomes
in Non-Muscle Invasive Bladder Cancer? . . . . . . . . . . . . . . . . . 37
Richard Sylvester
6 Adjuvant Treatment: Old and New Immunotherapy in Non-
Muscle-Invasive Bladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . 43
J. Palou and F. Pisano
7 The Role of New Experimental Conservative Therapies
for High Risk Non-Muscle Invasive Bladder
Cancer: Could We Trust Them? . . . . . . . . . . . . . . . . . . . . . . . . . 49
M. Allasia and F. Soria
Part III Muscle Invasive Bladder Cancer
8 Is There Still a Role for Radical Cystectomy? . . . . . . . . . . . . . . 55
M. Brausi
vii
viii Contents
9 Minimally Invasive Radical Cystectomy and Its Role
and Future in Treatment of Bladder Cancer
Patients. Myth or Reality? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Omar M. Aboumarzouk and Piotre L. Chlosta
10 Neoadjuvant vs. Adjuvant Chemotherapy:
Which Is Right?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Robert J. Jones
11 Radiotherapy for the Treatment of Muscle-Invasive
Bladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Barbara Alicja Jereczek-Fossa and Giulia Marvaso
12 Immunotherapy and New Combinations in Muscle-Invasive
Bladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Emmanuelle Kempf and Ignacio Duran
Part IV A View on the Future
13 The Role of Urologist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Mihai Dorin Vartolomei and Shahrokh F. Shariat
14 A View of the Future: The Role of Pathologists . . . . . . . . . . . . . 113
Eva Compérat
15 The Role of Medical Oncologist . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Robert J. Jones
16 The Future of Radiotherapy in Bladder Cancer . . . . . . . . . . . . 123
Nuradh Joseph, Rohan Iype, and Ananya Choudhury
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Part I
Bladder Cancer Diagnosis
1
Imaging in Bladder Cancer:
Can We Do Better?
Giovanni Barchetti, Vincenzo Salvo, Davide Fierro,
Maurizio Del Monte, Isabella Ceravolo,
and V. Panebianco
Introduction (20–25%) and are more often muscle invasive
and high grade, deriving from dysplasia or carci-
Bladder cancer is the most common malignancy noma in situ.
of the urinary tract, being the seventh most com-
mon cancer in men and the 17th in women.
Tobacco smoking is the most common recog- Controversial Aspects
nized risk factor, although in a minority of cases
occupational exposure to aromatic amine, poly- At present, imaging studies for bladder cancer
cyclic aromatic hydrocarbons and chlorinated are required after muscle-invasive bladder can-
hydrocarbons, ionizing radiation and schistoso- cer (MIBC) is diagnosed. The most important
miasis are considered the most important predis- information they are required to provide are:
posing factors. extent of local tumour invasion, tumour spread
The great majority of neoplasms are epithelial to lymph nodes, tumour spread to upper urinary
and among them more than 90% are urothelial tract and other distant organs such as liver, lungs
tumours, except in developing countries where and bones [1]. In clinical practice, the evalua-
squamous cell carcinoma is the most common tion of the extent of local tumour invasion means
histologic type due to the high prevalence of differentiating a T4 tumour, that is a neoplasm
schistosomiasis. Malignant, nonepithelial malig- that invades prostate stroma, seminal vesicles,
nancies are very rare. Morphologically, urothelial uterus or vagina from T3 or lower tumours.
tumours can be papillary or non-papillary. The Imaging cannot accurately differentiate a T2b
former are more common (80–85% of cases) and tumour invading the deep bladder muscle (outer
tend to be non-muscle-invasive, low grade, multi- half) from a T3 tumour that invades perivesical
focal tumours that arise from hyperplasic epithe- tissue. Improvement in magnetic resonance
lium. They have an overall good prognosis, imaging (MRI) technique could theoretically
though the recurrence rates can be as high as help in such distinction, even though at this time
50%. Non-papillary tumours are the minority the clinical significance of this kind of informa-
tion may be limited.
More importantly, imaging studies are cur-
G. Barchetti · V. Salvo · D. Fierro · M. Del Monte rently not considered in the initial diagnosis of
I. Ceravolo · V. Panebianco (*)
bladder cancer. The most important information
Department of Radiological Sciences, Oncology and
for treatment planning, that is differentiation of
Pathology, Sapienza University/Policinico Umberto I
of Rome, Rome, Italy non-muscle-invasive bladder cancer (NMIBC)
© Springer International Publishing AG, part of Springer Nature 2018 3
F. Soria, P. Gontero (eds.), Treating Urothelial Bladder Cancer,
https://doi.org/10.1007/978-3-319-78559-2_1
4 G. Barchetti et al.
from MIBC, is yielded by cystoscopy. According Imaging for Staging of MIBC: What
to recent literature, MRI could be able to distin- Do We Do?
guish invasive malignancies from superficial
ones with a possible improvement in patient The purpose of imaging studies is to provide useful
management. If MRI is demonstrated to be reli- information to accurately choose the correct treat-
able in classifying a neoplasm as invasive, the ment plan. According to the European Association
first diagnostic cystoscopy could be omitted. of urology (EAU) guidelines, Imaging parameters
Therefore, the urologist could directly perform a required for staging MIBC are the following:
TURB for definitive diagnosis and this could
greatly expedite radical treatment, whilst avoid- – Extent of local tumour invasion;
ing at the same time unnecessary invasive – Tumour spread to lymph nodes;
procedures. – Tumour spread to upper urinary tract and
other distant organs (e.g. liver, lungs, bones,
peritoneum, pleura and adrenal glands).
Bladder Cancer Diagnosis
and Staging Local staging can be achieved using equally CT
or MRI, as neither of those techniques is able to
Bladder cancer is most commonly suspected accurately differentiate tumour invasion of the
because of haematuria (80–90%) or other urinary outer half of the bladder wall from microscopic
symptoms such as urinary frequency, urgency, invasion of the perivesical tissue (e.g. T2b vs. T3a).
pelvic pain or weight loss, although it is increas- The goal of imaging studies is therefore to exclude
ingly diagnosed as an incidental finding during the presence of an extravesical mass (stage T3b or
other imaging studies. To confirm the clinical higher) as shown in Fig. 1.1. There is no definitive
suspicion, urinary cytology and diagnostic flexi- evidence about which technique should be used
ble cystoscopy are performed. The most crucial preferentially. According to literature MRI as has a
step at this stage is to differentiate between higher accuracy compared to TC for primary
NMIBC and MIBC. If NMIBC is diagnosed, a tumour staging thanks to its superior soft tissue
transurethral resection of the bladder (TURB) is contrast, with a reported sensitivity and specificity
performed, to completely remove all visible of 93–100% and 73–94% respectively in delineat-
lesions and to make the correct diagnosis. Upper ing extravesical extension (compared to a sensitiv-
urinary tract imaging to exclude synchronous ity and specificity of 85–89% and 63–95%
tumours is also recommended. Subsequent respectively for CT) [2]. MRI examination of the
patient management depends on patient’s and bladder includes axial and coronal T2-weighted
tumour’s characteristics, and often entails admin- fast spin-echo imaging; axial T2-weighted fat-satu-
istration of intravesical chemotherapy. rated imaging; axial T1-weighted dual-echo in-
If MIBC is diagnosed at cystoscopy, patient phase and opposed-phase imaging and
management greatly differs because imaging diffusion-weighted imaging (DWI). The collecting
studies are required for disease staging as treat- system can be delineated in detail with static-fluid
ment and prognosis of MIBC are determined by MR urography or with excretory MR urography
tumour stage and grade. If a bladder tumour has performed with a T1-weighted fat-suppressed 3D
been incidentally but unequivocally visualized in gradient-echo sequence with gadolinium contrast
previous imaging studies, such as computed excretion into the collecting system. T2-weighted
tomography (CT), ultrasound (US) or MRI, diag- images provide the optimal soft-tissue contrast. As
nostic cystoscopy can be omitted and the patient the detrusor muscle is seen as a hypointense band
can directly undergo TURB to obtain a complete against the hyperintense urine and perivesical fat,
histological diagnosis. TURB is mandatory to disruption of the hypointense layer is usually indic-
enable histopathological diagnosis and staging, ative of MIBC. On T2-weighted images, extravesi-
which requires resection of the bladder muscle to cal extension is seen as nodular soft tissue of
confirm or exclude tumour invasion. intermediate signal intensity projecting into