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Title: Optimalization of the diagnosis of tumors of the bladder using photodynamic diagnosis

Abstract:

Introduction Bladder Cancer is a serious problem of urological oncology. Bladder cancer is the fourth most common cause of cancer deaths in men and fifteenth in women. Transitional cell carcinoma is a heterogeneous disease. Seventy percent of bladder tumors present as non-muscle invasive bladder cancer - superficial disease and the rest as muscle invasive disease. 50% - 70% of the patients with non-muscle invasive bladder cancer suffer a local recurrence, whereas in 10-30% of the patients a progression is observed. The current standard for diagnosing bladder cancer is by white light cystoscopy. Macroscopic tumors are relatively easy to visualize but carcinoma in situ (Cis), dysplasia and small tumors of non typical location can be overlooked. It is connected with high rate of recurrence and because of it we are looking for new method, which could decrease an influence of surgeon for quality of TURBT and could allow of recognition all neoplastic lesions and in this way could increase range of TURBT, decrease recurrence rate, extend time intervals between TURBT procedure and recurrence of disease and decrease percentage of progression. Photodynamic Diagnosis grants above-mentioned criteria. PDD is based on the preferential accumulation of photoactive porphyrins in neoplastic cells, which fluoresce red under blue light illumination, enabling visualization of the tumor. Shining is caused interaction between proper length of wave - 405 nm and photosensitizer - 5-Aminolevulinic Acid. We can precisely resect visible lesions, because each lesion shines red in UV . Materials and Methods A total of 80. patients with known bladder cancer in stages Ta, Tis or T1 and grade G1-G3, half of the patients or suspected bladder cancer, half of the patients diagnosed by hematuria, ultrasonography, urography were recruited. Patients underwent bladder instillation with 50 ml of 8 mM solution of HAL hydrochloride in phosphate buffered saline Hexvix through a Foley catheter. The solution was retained for at least 1 hour before cystoscopy. Cystoscopy was performed using spinal or general anesthesia. After the HAL solution was evacuated the bladder was inspected by white light cystoscopy. Lesions or suspicious areas were classified and mapped onto bladder chart by blue colour. The bladder was then inspected by HAL fluorescence cystoscopy. Lesions or suspicious areas were classified and mapped onto bladder chart by red colour. Fluorescence cystoscopy was a supplementary procedure but not substitutional procedure. Biopsies were taken from all mapped areas. We took also biopsies from the tumours base for correct staging. Standard and HAL fluorescence cystoscopy was performed using the Storz D-light system and fluorescence-capable telescopes, which allows white and blue light bladder wall inspection. Video documentation additionally requires fluorescence-capable camera. The aim of the work The aim of the work was to determine influence Photodynamic Diagnosis’ with Hexvix on neoplastic lesions’ recognition in the bladder and estimate, how Photodynamic Diagnosis improve the TURBT in patients with non-muscle invasive bladder cancer. Results Of the 80. patients 52(65%) had transitional cell carcinoma or dysplasia. In 36. (45%) patients lesions were detected with white light cystoscopy and in 16. (20%) patients in fluorescence cystoskopy. There were together in white light cystoskopy and fluorescence cystoskopy: 12. patients with dysplasia, 9. patients with TaG1 tumours, 6. patients with TaG2 tumours, 12. patiens with T1G1 tumours, 6. patiens with T1G2 tumours, 4. patiens with T1G3 tumours and 3. patients with ca in situ. Analyzing, how many patients in fluorescence cystoskopy had more lesions on particular walls of the bladder. In fluorescence cystoskopy more lesions: on the right lateral wall had 13. patients, on the posterior wall had 12. patients, on the left lateral wall had 10. patients, in the trigone 6. patients, in the dome 4. ; patients, in the urethra 2. patients and on the anterior wall 1 patient. It was also analyzed, how many more lesions were detected in PDD. There were a total of 89. histologically verified dysplasia and neoplastic lesions. 54. ( 60,67%) lesions were identified using standard cystoscopy . There were : 2 (2,24%) – dysplasias, 18 tumours (20,22%) –TaG1, 6 tumours (6,74%) – TaG2, 16 neoplastic lesions (17,97%) – T1G1, 8 tumours ( 8,98%) – T1G2 and 4 neoplastic lesions (4,49%) – T1G3. All lesions seen using white light cystoscopy was also seen in fluorescence cystoscopy. 35 (39,33%) lesions were identified using only HAL fluorescence cystoscopy. There were: 19(21,34%) dysplasias, 4 tumours (4,49%) – TaG1, 3 tumours (3,37%) – TaG2, 2 tumours (2,24%) – T1G1, 2 tumours ( 2,24%) – T1G2, 2 neoplastic lesions (2,24%) – T1G3 and 3 carcinoma in situ - Cis ( 3,37%) . Analyzing the false-positive results. The false detection rate is the number of suspected lesions per technique that had negative histology divided by the total number of areas biopsied with that technique. The mean false-positive rate on biopsy for HAL was 41,66% compared with 25% for standard cystoscopy. It was analyzed the recurrence rate – RR. RR = number of recurrences/ number of months in observation x 100%. The mean recurrence rate in patients on TURBT in white light cystoskopy was 0,093 recurrence/month/patient and the mean recurrence rate in patients on TURBT in PDD was 0,073 recurrence/month/patient. Conclusions 1.Fluorescence cystoscopy improves the detection of neoplastic lesions and dysplasia in patients with bladder cancer compared with white light cystoscopy, leading to improved treatment in 32,5% patients. 2. PDD improves the detection of: a) Dysplastic flat leasions by 90,48%, which are hardly visible during white light cystoscopy and we must remember, that dysplasia is a premalignant lesion. This was statistically highly significant, p<0001. b) Carcinoma in situ lesions by 100%, which presence is a bad prognostic factor and increase the risk of recurrence and progression. This was statistically significant, p=0,029 c) TaG1 and T1G1 tumours, which are undetected during white light cystoscopy and which could be the source of early recurrences and progression. This was statistically highly significant, p<0001. 3. Fluorescence-controlled resection of lesions is more precise and radical procedure compared with white light TURBT. 4.Fluorescence-controlled resection of lesions decrease recurrence rates by 0,02/recurrence/month/patient. This was statistically highly significant, p<0001

Level of degree:

2 - studia doktoranckie

Degree discipline:

urologia ; onkologia

Degree grantor:

Wydział Lekarski

Promoter:

Wiesław Urbanowicz

Date issued:

2009

Format:

application/pdf

Identifier:

oai:dl.cm-uj.krakow.pl:772

Call number:

ZB-111781

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Location of original object:

Biblioteka Medyczna Uniwersytetu Jagiellońskiego - Collegium Medicum

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Last modified:

Jan 20, 2020

In our library since:

Nov 21, 2012

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