A Systematic Approach to Diagnose and Treat Bladder Cancer with Precise and Personalized Surgery Based on the Experience of Department of Urological Oncology at Shanghai General Hospital

Link of the Original Article:

https://mp.weixin.qq.com/s/LhNcFvfgHmJlCU5ldHiHtA

Recently, Popular Medicine had an interview with Dr. Xiang Wang, Director of the Department of Urological Oncology (North)and Deputy Director of Urology Center, Shanghai General Hospital. He explained in detail the current cutting-edge and common bladder cancer treatment techniques, the trilogy of "initial battle", "continuing battle" and "duel" to protect the bladder.

Chapter One 

Initial Battle: Identify the Enemy and All should be Cleared

According to whether the tumor invades the bladder muscle layer, bladder cancer can be divided into two categories: non-muscle invasive bladder cancer (NMIBC) and muscle invasive bladder cancer (MIBC). About 75% of bladder cancers are early stage, i.e. non-muscle invasive bladder cancer, which is better treated and usually does not require removal of the bladder. Most patients only need to undergo endoscopic surgery via the urethra. However, 30% to 50% of patients with early-stage bladder cancer will have a recurrence within 2 years after surgery. Therefore, it is especially important to win the "first battle".

1.1 Identifying the Enemy and Us and Making Precise Diagnosis

There are many diseases that can cause hematuria. Patients with kidney stones may have hematuria after exercise, and patients with serious urinary tract infections may also have hematuria, but if there is painless visual hematuria throughout the whole process, it is likely to be a sign of bladder cancer. Of course, red urine is not always a sign of hematuria. Red urine may also occur after consuming certain fruits (such as red dragon fruit) or medications, and routine urinalysis can help identify this.

Urinalysis is simple, non-invasive and one of the most important methods for bladder cancer diagnosis and post-operative follow-up. Detecting cancer cells in patients' urine through urine exfoliation cytology is one of the qualitative diagnostic methods for uroepithelial cancers such as bladder cancer, renal pelvis cancer and ureteral cancer. With the development of technology, urinalysis nowadays can not only provide basic information such as red blood cells and white blood cells in urine, but also detect tumor cells shed in urine and bladder tumor markers, such as nuclear matrix protein 22 (NMP22) and bladder tumor antigen (BTA).

Ultrasonography is the most commonly used non-invasive and radiation-free examination method for diagnosing bladder cancer, and it can also examine the kidney, ureter, prostate, pelvis, retroperitoneal lymph nodes and other organs at the same time. Shanghai General Hospital was the first in China to carry out ultrasonography, which further improves the detection rate of bladder cancer and allows assessment of its depth of infiltration.

CT examination (plain scan + enhanced scan) can detect early bladder cancer of 1-5 mm in diameter, and is of great value in assessing the extent of its infiltration, whether it invades adjacent organs, and whether distant metastasis has occurred, etc. CT urography (CTU) is a special enhanced CT examination, which can show the upper urinary tract, lower urinary tract and its surrounding by collecting the excretory phase of contrast agent in the urinary tract to complete urinary tract reconstruction. It can reveal the upper and lower urinary tract and its surrounding lymph nodes and adjacent organs, and has largely replaced the traditional intravenous pyelogram (IVU).

Magnetic resonance imaging (MRI) is used to assess the invasion of adjacent organs and is often used to determine the stage of bladder cancer.

1.2 Surrounding and Sweeping all Tumors That Need to Be Removed

"Cystoscopy + biopsy" is the "gold standard" for bladder cancer diagnosis. In clinical practice, Dr.Xiang Wang's team found that if there is a conclusive tumor-like lesion in the bladder detected by imaging examination, cystoscopy can be omitted and the tumor can be directly resected diagnostically after it is found by careful examination through transurethral electrodesiccoscopy. For patients with non-muscle invasive bladder cancer, doing so can achieve the purpose of obtaining tumor specimens for pathologic diagnosis and at the same time completely remove the tumor, which can save patients from the pain of secondary surgery.

For bladder cancer that is too malignant or too large or multiple to be excised in one visit, a second excision is required 2 to 6 weeks after the first treatment to remove the tumor to a deep muscle layer in order to further remove the tumor and obtain a more precise pathological diagnosis.

This is the "first battle" in the systematic treatment of bladder cancer. Next, patients still have to continue the battle with the cunning bladder cancer.

Chapter Two

Continuing Battle: Internal and External Approaches 

Bladder cancer is prone to recurrence, relapse, progression and metastasis, and is known as "one of the most expensive cancers". The recurrence rate of bladder cancer within 5 years after surgery is as high as 24%~84%. Therefore, even if the "first battle is successful", patients should not let down their guard and need comprehensive treatment and regular follow-up. 

2.1 Perfusion Therapy and Cystoscopy to Prevent the Risk of Recurrence

All patients with non-muscle invasive bladder cancer require immediate postoperative bladder irrigation chemotherapy or regular bladder irrigation therapy to reduce the risk of recurrence, as recommended by authoritative national and international guidelines.

Immediate postoperative infusion chemotherapy kills intraoperatively disseminated and trauma residual tumor cells, significantly reducing the recurrence rate. Thereafter, patients can undergo regular bladder infusion chemotherapy: once a week for 8 weeks, followed by once a month for 12 months.

Bladder perfusion immunotherapy is mainly BCG bladder perfusion therapy. Both national and international guidelines recommend that patients with intermediate to high-risk non-muscle invasive bladder cancer or bladder cancer in situ be treated with BCG bladder perfusion after transurethral resection of the tumor, usually starting 2 to 4 weeks after surgery. Maintenance BCG bladder perfusion therapy for 3 years in patients with high-risk bladder cancer and 1 year in patients with intermediate risk is effective in preventing recurrence.

It is worth mentioning that among non-muscle invasive bladder cancers, carcinoma in situ is a special type with poorly differentiated cells, which is highly malignant and has a high risk of muscle infiltration. It was found that BCG infusion for in situ cancer had a significantly higher complete remission rate (72%-93%) than bladder infusion chemotherapy (48%) and significantly reduced the risk of tumor recurrence and progression. Therefore, patients with bladder carcinoma in situ should be treated with BCG infusion after surgery.

Along with instillation chemotherapy, patients should also undergo regular (usually every 3 months) cystoscopy. If suspicious lesions of the bladder mucosa are found, they should be biopsied to clarify the pathological findings or removed at the same time.

2.2 Multi-pronged Approach to Further Reduce the Risk of Recurrence 

In order to further reduce the risk of recurrence of bladder cancer, the Department of Urological Oncology adopts a multidisciplinary (MDT) and multi-method treatment model to develop individualized and customized treatment plans for bladder cancer patients, for example, for bladder cancer patients with a higher risk of recurrence, bladder artery interventional chemotherapy, local bladder radiotherapy, immunotherapy and targeted therapy are used to reduce the recurrence rate and improve the overall treatment effect. Recently, Shanghai General Hospital has developed bladder cancer photodynamic therapy technology, which can effectively treat tumors that are "latent" in the bladder and not easily detected.

This comprehensive treatment can be applied not only to patients with early-stage bladder cancer, but also to patients who have a strong desire to preserve their bladders but cannot undergo total bladder removal, such as initial limited muscle-invasive bladder cancer and recurrent high-risk non-muscle-invasive bladder cancer.

Chapter Three

The Duel ---Preserving the most Important Organ and making the Urine Flow Diversion

The main reason why bladder cancer is "cunning and vicious" is that it is "easy to progress and metastasize". 20% to 30% of non-muscle layer invasive bladder cancer may progress. The first time a patient is seen, it is already a muscle-invasive bladder cancer. 

3.1 Total Cystectomy in Treatment of Muscle-infiltrating Bladder

The principle of treatment for muscle-infiltrating bladder cancer is radical total cystectomy and urinary diversion after neoadjuvant chemotherapy (or combined immunotherapy). Patients with locally progressive bladder cancer are treated with local surgery combined with preoperative or postoperative systemic systemic therapy. Patients with advanced metastatic bladder cancer are treated with systemic systemic therapy combined with supportive therapy.

It is worth mentioning that the specific treatment plan for muscle-invasive bladder cancer needs to be decided jointly by the patient and the physician after full communication. As a doctor, when the tumor threatens the patient's life, he or she must provide professional and reasonable treatment advice and inform the patient of the advantages and disadvantages of different surgical procedures. As a patient, he or she should cooperate and trust the medical staff and carefully learn the postoperative stoma care or functional training of the in situ neobladder. Only with the cooperation of both doctors and patients can we overcome bladder cancer.

3.2 Maintaining Life and Well-being  

In recent years, cystectomy with preservation of sexual function (SPC) is receiving increasing attention. Especially for some male bladder cancer patients with high demand for sexual function, if the tumor is limited and there is no tumor in the prostate, prostatic urethra and bladder neck, cystectomy with preservation of sexual function can be chosen. In female patients, if the tumor does not invade the anterior vaginal wall, cervix and ovaries, preservation of neurovascular bundle, uterus, vagina and ovaries can be chosen. Of course, surgery to preserve sexual function should be performed to ensure the radical effect of the tumor and regular postoperative follow-up.

This article was published in the August on Popular Medicine

Editor: Shishi Cai, Publicity Office