2016 Bladder Cancer Guidelines: two recommended ways to see tumors and prevent recurrence

2016 Bladder Cancer Guidelines: two recommended ways to see tumors and prevent recurrence
"Spotlight" by Blondinrikard Fröberg. Used with permission of a Creative Commons License here..

Bladder cancer has the highest rate of recurrence of any cancer at 50 to 80 percent. Researchers know that failure to see and remove all existing cancer during the initial surgery, called transurethral resection of bladder tumor (TURBT) is one reason for the high rate. If you can’t see the cancer, then you can’t remove it.

In the Spring of 2016, the American Urological Association and the Society for Urologic Oncology released updated guidelines for treating non-muscle invasive bladder cancer. You can read and download them here.  Among the 38 recommendations, two focus on enhanced cystoscopy:

"In a patient with NMIBC, a clinician should offer blue light cystoscopy at the time of TURBT, if available, to increase detection and decrease recurrence.

In a patient with NMIBC, a clinician may consider use of NBI to increase detection and decrease recurrence."

Many of us have had cystoscopies and TURBT performed with traditional white light imaging, which is widely available. Both blue light and NBI are newer technologies. Blue light requires both an FDA-approved chemical and a specific type of light, while NBI, narrow band imaging, is an optical filter.

The two technologies work differently to accomplish unique visual access to the inside of the bladder during cystoscopy.

Blue Light

This image was downloaded from the Cysview® site. The text below the left image reads: "Bladder image using white-light cystoscopy alone." Text below the image on the right reads: "Same image after using Blue Light Cystoscopy with Cysview® as an adjunct to white light."

This image was downloaded from the Cysview® site. The text below the left image reads: "Bladder image using white-light cystoscopy alone." Text below the image on the right reads: "Same image after using Blue Light Cystoscopy with Cysview® as an adjunct to white light."

The technical name for this is “photodynamic diagnosis” or “fluorescence cystoscopy.” It requires a chemical, HAL, to be inserted into the bladder and then the “blue light” setting on the Karl Storz D-Light C PDD system is used during cystoscopy.

Cancer tissue absorbs the chemical and turns pink or red under blue light, dramatically increasing the ability to see it. Cysview® is the brand name of the chemical and it must be used with the Storz® system.

Its primary use is for patients who are undergoing TURBT to remove a tumor. It offers surgeons much better visuals of tumors and CIS (a flat tumor on the bladder wall) than does white light, which improves their ability to remove all cancerous tissue and, thereby, prevent recurrence from cells left behind.

Two challenges of the approach are that the drug is instilled into the bladder and must be held there for an hour before the procedure and the process can’t be used repetitively.

Narrow Band Imaging

This is an NBI® image from the Olympus site . About this image: "Redness area around the primary tumor on NBI (right) was diagnosed as urothelial carcinoma, pTa, G2."

This is an NBI® image from the Olympus site
. About this image: "Redness area around the primary tumor on NBI (right) was diagnosed as urothelial carcinoma, pTa, G2."

NBI was approved by the FDA in 2015 and works alongside white light procedures. It is “a novel application that functions as an optical image enhancement tool” according to Richards, Smith, and Steinberg. You can read their article here.

It does this with light filter technology and without the use of dyes. NBI narrows the bandwidth of white light technology so that only blue and green light are used, which allows the camera to see “abnormal urothelium” more clearly. The narrow band light, according to , “is strongly absorbed by hemoglobin, thus enhancing the visibility of surface capillaries,” which are more common in cancerous tissue.

Get the Guidelines

If you have a chance to download a copy of the new guidelines, please do so. You and your doctor can use them to discuss your treatment. If your doctor or your local hospital do not have access to either of these technologies, find an NCI-approved hospital, which will have the newest technologies and the most skilled surgeons.

For more information about bladder cancer, the Bladder Cancer Advocacy Network is a wonderful organization. Their website is here.

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