Cancer ESMO Summit Africa 2019 Dr Benita Stoltz University of - PowerPoint PPT Presentation

Bladder Cancer ESMO Summit Africa 2019 Dr Benita Stoltz University of Pretoria Dr Riette Burger University of Stellenbosch

Case presentation • 52yr old male, • Social history: 20 pack year smoking • Symptoms: history, no alcohol Dysuria, macro- use, good family haematuria, urgency support. and dribbling. • Past medical history: HIV negative, no medical comorbidities.

Presentation Abdominal ultrasound Bladder mass causing left hydronephrosis  JJ stent was placed Examination: PS 1, unremarkable general examination Chest – clear Abdomen – no masses or organomegaly No distant lymph nodes, no pallor Cystoscopy: Bladder mass extending from the bladder neck covering both ureteral orifices, L>R.

TURBT Transurethral Resection of Bladder Tumour: • Histology: Infiltrating high grade urothelial carcinoma, muscularis propria invasion present • Sections from the prostatic urethra showed infiltration • Random bladder biopsies negative for carcinoma • No lympho-vascular invasion T2b

Investigations Blood Results: Na 134, K 5.0, Urea 5.1, Creatinine 154, normal FBC and LFT. Nuclear Medicine GFR Measurement: Corrected GFR 60ml/min CT Scan: Thickened bladder wall Lymphadenopathy: • right external (23mm) and internal iliac • left internal iliac • para-aortic (multiple, 8mm, loss of fatty hilum, all below renal vessels) Suspicious lung nodule left upper lobe 3,9 X 3,2mm

CT Scan

CT Scan Stage T2bN2M1a – Stage IVA OR T2bN2M1b – Stage IVB

Treatment Decision - Chemotherapy 3 Cycles Cisplatin / Gemcitabine, Cisplatin 70mg/ 𝑛 2 D1, Gemcitabine 1000mg/ 𝑛 2 D1 & D8 3-weekly Grade 1 side effects responding to medical management

Re-staging Investigation CT Scan: Less pronounced bladder wall thickening Significant reduction in size of iliac lymph nodes (near complete resolution) Para-aortic nodes also smaller and less in number Lung unchanged, most likely benign granuloma Stage T2bN2M1a – Stage IVA

CT Scan

CT Scan

Treatment - Surgery Radical cystoprostatectomy and lymph node dissection 3 X 3cm tumour of the trigone High grade invasive urothelial carcinoma Infiltrates lamina propria, but no residual tumour in deep muscle Tumour free margin > 2cm No LVI or PNI Normal urethra, prostate and seminal vesicles Lymph nodes dissection included pelvic and para-aortic nodal dissection: Left 0/7, Right 1/5 (external iliac node)

Questions Role of cysto-prostatectomy in stage IVA bladder cancer? Was para-aortic nodal dissection of benefit? Was adjuvant chemotherapy or chemoradiotherapy indicated? Role of PD-1 inhibitors?

Special Thanks Dr R Burger, consultant at Tygerberg Hospital as my supervisor, Prof H Simonds and the Department of Oncology at Tygerberg Hospital.

References Medscape Guidelines https://emedicine.medscape.com/article/438262-overview K Bowa, C Mulele, J Kachimba, E Manda, V Mapulanga, S Mukosa. A review of bladder cancer in Sub-Saharan Africa: presentation, assessment and treatment. Review article. 2018 Vol 17 .