Bladder Cancer: Diagnosis and Evaluation: Difference between revisions
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== Imaging == | == Imaging == | ||
=== | === Upper Urinary Tract === | ||
==== Indications ==== | ==== Indications ==== | ||
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==== Rationale (2) ==== | ==== Rationale (2) ==== | ||
# '''Identify other sources of hematuria''' | # '''<span style="color:#ff0000">Identify other sources of hematuria''' | ||
# '''Assess the extravesical urothelium because of the “field change” nature of urothelial carcinoma''' | # '''<span style="color:#ff0000">Assess the extravesical urothelium because of the “field change” nature of urothelial carcinoma''' | ||
#* '''In patients with a known history of bladder cancer, upper tract tumors occur in <5% of patients''' | #* '''In patients with a known history of bladder cancer, upper tract tumors occur in <5% of patients''' | ||
#** The overall incidence of significant findings with imaging of the upper tracts in patients with newly diagnosed bladder cancer is low but increases with tumors of the trigone, CIS, and high-risk disease. | #** The overall incidence of significant findings with imaging of the upper tracts in patients with newly diagnosed bladder cancer is low but increases with tumors of the trigone, CIS, and high-risk disease. | ||
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===== Fluorescent (blue light) cystoscopy[https://www.ncbi.nlm.nih.gov/pubmed/17499283][https://www.ncbi.nlm.nih.gov/pubmed/17499291] ===== | ===== Fluorescent (blue light) cystoscopy[https://www.ncbi.nlm.nih.gov/pubmed/17499283][https://www.ncbi.nlm.nih.gov/pubmed/17499291] ===== | ||
* '''<span style="color:#ff0000">A photosensitizing agent, 5-aminolevulinic acid (ALA) or hexyl aminolevulinic acid (HAL), is instilled into the bladder</span>''' | |||
====== Rationale ====== | |||
* '''<span style="color:#ff0000">Improves detection of both small papillary tumors and CIS</span>''' | |||
====== Mechanism of Action ====== | |||
* '''<span style="color:#ff0000">A photosensitizing agent, 5-aminolevulinic acid (ALA) or hexyl aminolevulinic acid (HAL), is instilled into the bladder and subsequently</span>''' '''<span style="color:#ff0000">metabolized to protoporphyrn IX by tumor cells,</span> emitting a red fluorescence under blue light''' | |||
* | |||
====== Efficacy ====== | |||
* Sensitivity for CIS 87% compared to 83% with white light | |||
* '''Relatively high false-positive rate''' | |||
* Reduces the rate of residual tumour by 20% compared to white light cystoscopy | |||
* '''<span style="color:#ff00ff">NCT02560584</span>''' | * '''<span style="color:#ff00ff">NCT02560584</span>''' | ||
** Population: 304 patients with a history of multiple, recurrent or high grade bladder tumors undergoing first surveillance cystoscopy | ** Population: 304 patients with a history of multiple, recurrent or high grade bladder tumors undergoing first surveillance cystoscopy | ||
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**** 20% of recurrences seen only with blue-light flexible cystoscopy | **** 20% of recurrences seen only with blue-light flexible cystoscopy | ||
** [https://pubmed.ncbi.nlm.nih.gov/29203268/ Daneshmand, Siamak, et al.] "Efficacy and safety of blue light flexible cystoscopy with hexaminolevulinate in the surveillance of bladder cancer: a phase III, comparative, multicenter study." ''The Journal of urology'' 199.5 (2018): 1158-1165. | ** [https://pubmed.ncbi.nlm.nih.gov/29203268/ Daneshmand, Siamak, et al.] "Efficacy and safety of blue light flexible cystoscopy with hexaminolevulinate in the surveillance of bladder cancer: a phase III, comparative, multicenter study." ''The Journal of urology'' 199.5 (2018): 1158-1165. | ||
*'''<span style="color:#ff00ff">PHOTO''' | |||
**Population: 538 patients with a suspected first diagnosis of NMIBC at intermediate or high risk for recurrence | |||
**Randomized to white light cystoscopy vs. blue light cytoscopy | |||
**Primary outcome: time to recurrence at 3 years of follow-up | |||
**Results | |||
***Time to recurrence: no significant difference | |||
***No significant difference in progression | |||
**[https://pubmed.ncbi.nlm.nih.gov/38319866/ Heer, Rakesh, et al. "A randomized trial of PHOTOdynamic surgery in non–muscle-invasive bladder cancer." ''NEJM evidence'' 1.10 (2022): EVIDoa2200092.] | |||
* '''Prospective studies have shown that blue light cystoscopy decreases recurrence rates, despite a trend in decreasing progression rates and prolong time to progression, current data is inconclusive, and impact on oncologic outcomes other than recurrence remains unclear''' | * '''Prospective studies have shown that blue light cystoscopy decreases recurrence rates, despite a trend in decreasing progression rates and prolong time to progression, current data is inconclusive, and impact on oncologic outcomes other than recurrence remains unclear''' | ||
** '''Most clinical trials testing BLC have not used single dose chemotherapy at the time of TURBT, so the impact of combining both interventions remains uncertain.''' | ** '''Most clinical trials testing BLC have not used single dose chemotherapy at the time of TURBT, so the impact of combining both interventions remains uncertain.''' | ||
* | *HAL is approved for use both in Europe and the United States, but currently does not have Health Canada approval | ||
====== Indications ====== | |||
* '''2021 CUA: can increase tumour detection at first TURBT and reduce recurrence risk.''' | |||
* '''<span style="color:#ff0000">2024 AUA:</span> in a patient with NMIBC, blue light cystoscopy <span style="color:#ff0000">should be offered at the time of TURBT, if available,</span> to increase detection and decrease recurrence''' | |||
====== Technique ====== | |||
* The photosensitizing agent is instilled into the bladder 1-4 hours before the procedure | |||
===== Narrow band imaging (NBI) ===== | ===== Narrow band imaging (NBI) ===== | ||