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Bladder Cancer: Diagnosis and Evaluation: Difference between revisions

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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>''' before the procedure for 1-4 hours
 
** HAL is approved for use both in Europe and the United States, but currently does not have Health Canada approval
====== Rationale ======
* '''<span style="color:#ff0000">The photosensitizing agent is metabolized to protoporphyrn IX by tumor cells,</span> emitting a red fluorescence under blue light'''
* '''<span style="color:#ff0000">Improves detection of both small papillary tumors and CIS</span>'''
* '''<span style="color:#ff0000">Blue light cystoscopy improves detection of both small papillary tumors and CIS</span>'''
 
** Sensitivity for CIS 87% compared to 83% with white light
====== Mechanism of Action ======
** '''Relatively high false-positive rate'''
* '''<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'''
* Also reduces the rate of residual tumour by 20% compared to white light cystoscopy
 
====== 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.'''
* '''<span style="color:#ff0000">Guideline perspective on role of fluorescent (blue light) cystoscopy:</span>'''
*HAL is approved for use both in Europe and the United States, but currently does not have Health Canada approval
** '''CUA: can increase tumour detection at first TURBT and reduce recurrence risk.'''
 
** '''<span style="color:#ff0000">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'''
====== 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) =====
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