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
參考資料 Cancer Site-specific Factors Coding Manual (癌症部位特定因 子編碼 手冊) NCCN 2013.1 Bladder Cancer Guidelines AJCC (7th ed.,2010) TNM Staging System Campbell-Walsh Urology 10th ed.
Bladder Cancer 90% urothelial origin, most common malignancy of urinary tract system 5% squamous < 2% adenocarcinoma & others
Risk Factors Environmental toxin exposure (dye, chemicals) Smoking Inflammation/Infection Chinese herbs (aristolochic acid) Ground water (arsenic) Male: Female = 2~3:1
Clinical Symptoms of Bladder Cancer Painless gross hematuria Frequency/Urgency/ Dysuria Flank pain or bone pain
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 1.27 1.27 1.20 Chemical workers Leather workers Painter 1.19 1.27 1.17
Diagnostic Tools Urinalysis Images IVU/Sono CT MRI Urine cytology (high specificity/low sensitivity) Cystoscopy TURBT (transurethral resection of bladder tumor) pathology
NMIBC (Non-Muscle Invasive Bladder Cancer) v.s. MIBC (Muscle Invasive Bladder Cancer)
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 (%) 0-8 27-47 48-71 55-58 Grade progression (%) 2 11 7 N/A Stage progression (%) 0 0-4 2-12 27-61 Survival (%) 100 93-100 82-96 74-90
Carcinoma in Situ (CIS) Normal urothelium Misnomer Non-papillary, flat, high grade tumor Severe nuclear atypia, nonadhesive structure Carcinoma in situ
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
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
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
AJCC TNM Staging Distant metastases (M) M0 No distant metastases M1 Distant metastases
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
78 y/o F, T3N0M0->T4aN0M0
48 y/o M, ct3n0m1
52 y/o M, ct1n0m0 ->ctan0m0
84 y/o M, ct2n0m0-> ct1n0m0
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)
TURBT
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
TURBT Specimen Detrusor muscle must present in TURBT specimen!
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
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
Extended Lymph Nodes Dissection More lymph nodes removed predict lymph nodes metastases (N) and improve survival
Radiation Therapy MIBC and poor cystectomy candidate Concurrent C/T + R/T + maximal TURBT
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
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
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
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
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
Metastatic Disease See T4b charts Metastatic WBBS Chest CT or MRI Creatinine clearance Node only Consider biopsies of nodes Disseminated Chemotherapy
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
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
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:8050 8120-8124,8130-8131) 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
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 010 020 988 999 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
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010-030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
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
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
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
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
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