參考資料 Cancer Site-specific Factors Coding Manual (癌症部位特定因子編碼手冊) NCCN Bladder Cancer Guidelines AJCC (7th ed.,2010) TNM Staging System Campbell

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1 膀胱癌特定因子分期及診療指引高雄榮總泌尿外科袁倫祥

2 參考資料 Cancer Site-specific Factors Coding Manual (癌症部位特定因子編碼手冊) NCCN Bladder Cancer Guidelines AJCC (7th ed.,2010) TNM Staging System Campbell-Walsh Urology 10th ed.

3 Bladder Cancer 90% urothelial origin, most common malignancy of urinary tract system 5% squamous < 2% adenocarcinoma & others

4 Risk Factors Environmental toxin exposure (dye, chemicals) Smoking Inflammation/Infection Chinese herbs (aristolochic acid) Ground water (arsenic) Male: Female = 2~3:1

5 Clinical Symptoms of Bladder Cancer Painless gross hematuria Frequency/Urgency/ Dysuria Flank pain or bone pain

6 Relative Risk of Occupations Associated with Urothelial Cancer Formation Occupation RR Occupation RR Glassmakers 1.31 Miners 1.31 Rubber workers 1.29 Launderers 1.27 Bus drivers 1,29 Machine tool setters 1.27 Tailors 1.28 Hairdressers 1.23 Blacksmiths Motor mechanic Writer & artists Chemical workers Leather workers Painter

7 Diagnostic Tools Urinalysis Images IVU/Sono CT MRI Urine cytology (high specificity/low sensitivity) Cystoscopy TURBT (transurethral resection of bladder tumor) pathology

8 NMIBC (Non-Muscle Invasive Bladder Cancer) v.s. MIBC (Muscle Invasive Bladder Cancer)

9 Non-Muscle Invasive Bladder Cancer (NMIBC) Clinical Significance of Different Non-Muscle-Invasive Urothelial Cancer Categories in WHO 2004 Grading System PAPILLOMA PAPILLARY NEOPLASM OF LOW MALIGNANT POTENTIAL (PUMLMP) LOW-GRADE PAPILLARY CARCINOMA HIGH-GRADE CARCINOMA (PAPILLARY AND CIS) Recurrence (%) Grade progression (%) N/A Stage progression (%) Survival (%)

10 Carcinoma in Situ (CIS) Normal urothelium Misnomer Non-papillary, flat, high grade tumor Severe nuclear atypia, nonadhesive structure Carcinoma in situ

11 Bladder Cancer Grading System Malignancy Grading of Bladder Carcinoma: Old and New System WHO 1973 Papilloma WHO/ISUP 1998 Consensus WHO, 2004 Papilloma TCC grade 1 Papillary urothelial neoplasm of low malignant potential (PUNLMP) TCC grade 1 Urothelial carcinoma, low grade TCC grade 2 Urothelial carcinoma, low-grade or high-grade TCC grade 3 Urothelial carcinoma, high grade

12 AJCC TNM Staging Primary Tumor (T) Tx T0 Ta Tis T1 T2 pt2a pt2b T3 pt3a pt3b T4 T4a T4b Primary tumor cannot be assessed No evidence of primary tumor Noninvasive papillary carcinoma Carcinoma in situ: flat tumor Tumor invades subepithelial connective tissue Tumor invades muscularis propria Tumor invades superficial muscularis propria Tumor invades deep muscularis propria Tumor invades perivesical tissue Microscopically Macroscopically (extravesical mass) Tumor invades adjacent organs or pelvic/abdominal wall Tumor invades prostatic stroma, uterus, vagina Tumor invades pelvic wall, abdominal wall

13 AJCC TNM Staging Regional Lymph Nodes (N) Nx Lymph nodes cannot be asscessed N0 No lymph node metastases N1 Single lymph node metastases in true pelvis (hypogastric, obturator, external iliac, or presacral lymph node N2 Multiple regional lymph node metastases in true pelvis N3 Lymph nodes metastases to the common iliac lymph nodes All other lymph nodes above the aortic bifurcation are considered distant lymph nodes

14 AJCC TNM Staging Distant metastases (M) M0 No distant metastases M1 Distant metastases

15 AJCC TNM Staging Anatomic stage/prognostic groups Stage 0a Ta N0 M0 Stage 0is Tis N0 M0 Stage I T1 N0 M0 Stage II T2a T2b N0 N0 M0 M0 T3a Stage III T3b N0 N0 T4 Stage IV Any T Any T N0 N1-3 Any N M0 M0 M0 M0 M1

16 78 y/o F, T3N0M0->T4aN0M0

17 48 y/o M, ct3n0m1

18 52 y/o M, ct1n0m0 ->ctan0m0

19 84 y/o M, ct2n0m0-> ct1n0m0

20 Surgical Intervention Non-Muscle Invasive Bladder Cancer (Tis,Ta, T1) TURBT (transurethral resection of bladder tumor) Detrusor muscle in specimen Muscle-Invasive Bladder Cancer Radical cystoprostatectomy Anterior exenteration (+/- neoadjuvant C/T) (+/- neoadjuvant C/T) Extended lymph nodes dissection Bladder preserving regimen (R/T + C/T)

21 TURBT

22 TURBT Adequate resection with muscle in specimen Repeated TURBT within 6 weeks if Incomplete initial resection No muscle for high grade disease Large or multi-focal lesions Any T1 lesion

23 TURBT Specimen Detrusor muscle must present in TURBT specimen!

24 Intravesical Treatment Based on probability of recurrence and progression Immediate intravesical C/T (epirubicin/mitomycin) within 24hrs after TURBT Not given if extensive resection Induction intravesical C/T or BCG 3-4 wks after Maintenance therpay is optional

25 Neoadjuvant/Adjuvant C/T DDMVAC (dose-dense methotrexate, vinblastine, doxorubicin, cisplatin Gemcitabine & cisplatin (G+C) Survival benefit for neoadjuvant C/T for MIBC Survival benefit for adjuvant for T3,T4 or N+ at cystectomy

26 Extended Lymph Nodes Dissection More lymph nodes removed predict lymph nodes metastases (N) and improve survival

27 Radiation Therapy MIBC and poor cystectomy candidate Concurrent C/T + R/T + maximal TURBT

28 Initial Evaluation NMIBC Imaging of upper urinary tract CT TURBT Suspicious high grade Mapping biopsies TUR biopsies of prostate Suspicion of of urothelial urothelial carcinoma Urinalysis Cystoscopy Cytology MIBC Imaging of upper urinary tract CT CXR WBBS TURBT

29 NMIBC Management cta low grade cta high grade If incomplete resection, or no muscle in specimen, repeat TURBT Observation Single dose intravesical C/T within 24 hrs Induction C/T ct1 low grade ct1 high grade Any Tis Strongly advise repeat TURBT or Cystectomy for high grade BCG

30 MIBC Management ct2 Negative nodes CT or MRI Radical cystectomy ± neoadjuvant cisplatin-based C/T or Partial cystectomy (selected Pt) ± neoadjuvant cisplatin-based C/T or Maximal TURBT followed by concurrent C/T + RT or Poor surgical candidate TURBT alone RT + C/T C/T alone Positive nodes Treat as T4b

31 Locally Advanced Disease Radical cystectomy ± neoadjuvant cisplatin-based C/T or ct3, ct4a Negative nodes CT or MRI Maximal TURBT followed by concurrent C/T + RT or Poor surgical candidate TURBT alone or RT + C/T or C/T alone Positive nodes See as T4b flow chart

32 Locally Advanced Disease Negative nodes on biopsy or CT or MRI Chemotherapy or Chemotherapy + RT Negative nodes ct4b CT or MRI Re-evaluate?? Abnormal nodes Consider biopsies of nodes Positive nodes on biopsy or CT or MRI Chemotherapy or Chemotherapy + RT

33 Metastatic Disease See T4b charts Metastatic WBBS Chest CT or MRI Creatinine clearance Node only Consider biopsies of nodes Disseminated Chemotherapy

34 Non-Urothelial Carcinoma of the Bladder Type Mixed Pure Squamous Adenocarcinoma Any Small-cell Component (Neuroendocrine features) Urachal Carcinoma Primary Bladder Sarcoma Nature & management More aggressive & poor prognosis, TURBT or cystectomy Cystectomy, RT or agents commonly used with SCC Radical cystectomy, RT or C/T Neoadjuvant C/T with small-cell regimens + cystectomy or Primary C/T Complete urachal resection + cystectomy Treat as sarcoma

35 膀胱癌 Bladder Cancer C67.0-C67.9 C67.0 Trigone of bladder C67.1 Dome of bladder C67.2 Lateral wall of bladder C67.3 Anterior wall of bladder C67.4 Posterior wall of bladder C67.5 Bladder neck C67.6 Ureteric orifice C67.7 Urachus C67.8 Overlapping lesion of bladder C67.9 Bladder, NOS

36 SSF 1 WHO/ISUP 分級 (Grade) 欄位敘述: 記錄膀胱癌個案病理報告中呈現之World Health Organization (WHO)/International Society of Urological Pathology (ISUP) 分級收錄目的: 預後評估編碼指引: 僅適用於病理組織為泌尿上皮癌(Urothelial carcinoma M-code 範圍: , ) 泌尿系統原發癌症中若病理報告呈現 Low grade 或 High grade 時此分級系統視為WHO/ISUP分級

37 SSF1 WHO/ISUP 分級 (Grade) 編碼指引: 原發部位無病理檢查或病理組織非為泌尿上皮相關癌症者請編碼為988 如有2份以上之病理報告且有2種不同分級時請登錄病理報告數值高者非以WHO/ISUP分級者編碼為999 編碼定義低度分化泌尿上皮癌 (Low grade) 高度分化泌尿上皮癌 (High grade) 不適用: 原發部位無病理檢查或病理組織非為泌尿上皮相關癌症者不知WHO/ISUP分級病歷未記載

38 SSF 2 區域淋巴結夾膜外侵犯情形 Extranodal(Extracapsular) Extension of Regional Lymph nodes 欄位敘述: 記錄膀胱癌個案區域淋巴結夾膜外侵犯情形收錄目的: 預後評估編碼指引: 本欄位可參考病理報告或臨床記錄編碼若病理報告與臨床紀錄均呈現相關記錄以病理報告優先於臨床記錄編碼係指有區域淋巴結侵犯情形若病歷記錄僅呈現淋巴結侵犯(病理報告或臨床資訊) 但未提及是否有淋巴結夾膜外侵犯編碼為030

39 SSF 2 區域淋巴結夾膜外侵犯情形 Extranodal(Extracapsular) Extension of Regional Lymph nodes 編碼指引編碼定義 010 無區域淋巴結侵犯 020 區域淋巴結侵犯但無淋巴結夾膜外侵犯 030 區域淋巴結侵犯但不知淋巴結夾膜外是否有侵犯情形 988 不適用 999 不知區域淋巴結夾膜外是否受侵犯區域淋巴結夾膜外侵犯情形無法評估病歷未記載

40 國健局膀胱癌核心測量指標 (2013 草案) 項目保留指標類型診斷-2 膀胱癌之經尿道腫瘤切除術(transurethral resection of bladder tumor, TURBT)標本有描述並有看到固有肌肉層(muscularis propria) 分子: 分母中標本中有描述並看到固有肌肉層(muscularis propria) 分母: 膀胱癌接受經尿道腫瘤切除術(TURBT)的病人數在活體切片中組織的描述應詳載肌肉是否有受到侵犯關係到病患之預後指標名稱指標定義指標選取理由適用目的指標資料來源參考文獻品質監測病歷檔 NCCN guidelines

41 保留項目指標類型診斷-4 指標名稱病理報告中有描述分化程度指標定義指標選取理由適用目的指標資料來源參考文獻分子: 分母中有描述分化程度(low/high grade)的病人數分母: 非CIS或PUNLMP的膀胱癌病人有病理報告的人數組織病理報告品質關係到病人治療的預後品質監測 CR: (2.3)個案分類, (3.13)病理期別, (2.10) 分級/分化 NCCN guidelines

42 項目修訂指標類型治療-2 指標名稱接受膀胱根除性手術(radical cystectomy)的膀胱癌病人中病理報告呈現骨盆腔左右之淋巴結 8顆指標定義指標選取理由適用目的指標資料來源分子: 分母中病理報告呈現骨盆腔之淋巴結 8顆的病人數分母: 接受膀胱根除性手術(radical cystectomy)的膀胱病人數淋巴結侵犯數目和預後有關瞭解現況 CR:(2.3)個案分類, (2.14)區域淋巴結檢查顆數, (4.1.4) 申報醫院原發部位手術方式參考文獻 EAU guidelines, 98 全國CR分析修訂說明 1. 膀胱根除性手術為大型手術若淋巴摘除數量不足或根本沒拿確實不適當對病患之預後也不好 2. 分析98年全國資料執行膀胱根除性手術病患其淋巴摘除數量全國值50% 在8顆淋巴結數目原始指標接受膀胱根除性手術(radical cystectomy)的膀胱癌病人中病理報告有呈現骨盆腔左右之淋巴結分子分母人數中病理報告有呈現骨盆腔左右之淋巴結的病人數分母分母: 接受膀胱根除性手術 (radical cystectomy)的膀胱病人數

43 刪除項目指標類型追蹤-3 指標名稱非肌肉侵犯性膀胱癌病人合併有原位癌成分接受卡介苗 (Bacillus Calmette-Guerin, BCG)灌注分子: 分母中接受卡介苗 (Bacillus Calmette-Guerin, BCG)灌注之病人數指標定義指標選取理由適用目的指標資料來源刪除原因分母: 非肌肉侵犯性膀胱癌病人經切片或經尿道腫瘤切除術 (transurethral resection of bladder tumor (TURBT)後發現合併有原位癌成分的病人數 TURBT後再使用BCG能有效預防膀胱癌復發品質監測病歷檔 1.國內目前缺卡介苗 2. 目前無法由癌登資料呈現

一、口朊給藥護理技術操作標準

一、口朊給藥護理技術操作標準食道癌壹疾病導因一定義食道任何一處的組織細胞有了惡性的轉變發展出來的惡性腫瘤都叫做食道癌, 依細胞的來源又再區別為鱗狀上皮癌平滑肉癌等, 其中以由最內層黏膜上皮長出的癌最多再者, 食道上三分之二為由鱗狀上皮組成,

參考資料 Cancer Site-specific Factors Coding Manual (癌症部位特定因 子編碼 手冊) NCCN Bladder Cancer Guidelines AJCC (7th ed.,2010) TNM Staging System Campbell

參考資料 Cancer Site-specific Factors Coding Manual (癌症部位特定因子編碼手冊) NCCN Bladder Cancer Guidelines AJCC (7th ed.,2010) TNM Staging System Campbell