Dr. Suzanne Merrill
speaker
74 appearances
1 recordings
1 series
first heard Aug 2024
last heard Aug 2024
Dr. Suzanne Merrill’s voice in public audio — every appearance, attributed to the second.
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The data really over time has shown us that blue light is a technology that should be offered to our patients, that it has good enough evidence behind it, that it can impact our patients course of disease and outcome.
Even back in 2013, there was a meta-analysis of nine studies, which ultimately showed that detection of TA and T1 lesions may be up to 25% greater, okay, with blue light cystoscopy and use of CISFU. than compared to white light.
And overall, this translated looking at really the raw data from this meta-analysis that the rate of recurrence with use of blue light can be reduced by about 11%, and it can certainly prolong the time to recurrence by about seven-ish months.
Yeah, of course. It's a lot more surprising when we're talking to our patients about how common bladder cancer is. So in 2024, it ranks as the fourth most common cancer in men and the sixth most common cancer in the U.S. for both men and women. And so superficial bladder cancer actually comprises of greater than 60% of all our new diagnoses that go on.
And when people get superficial bladder cancer, the main concern is that there is a high risk of recurrence. And that recurrence in just year one can be as high as 60 percent and obviously escalates going forward in time. So this discussion we're going to have today about diagnosing it, getting the right stage and grade done,
And fully taking care of it when we go in for that TURBT is absolutely critical for both our patients and getting them on the right track for treatment.
Yeah, of course. So really importantly with the risk stratification that our AUA outlines, which is low, intermediate, and high risk, and nowadays we're even talking about a very high risk group that some of us use to really specify patients that are in need of a more comprehensive talk about even entertaining invasive surgery such as cystectomy.
But what goes into the wrist ratification with patients is specifically the stage, so what we gain from that TRBT in terms of the depth of invasion, and then grade, as well as focality, so multiple tumors, and then the size of the tumor plays a role. For example, if we find CIS in a patient, that automatically, that stage, if you will, escalates the patient to certainly the high-risk group.
And then if we have a couple of features such as CIS, maybe also T1, if they have lymphovascular invasion, then a lot of us are thinking such patients should fit into even a higher escalation risk category, such as a very high risk group. And those are the patients that we're really concerned about, not only in terms of recurrence, but very much progression of disease.
So as you mentioned, definitely the cornerstone for diagnosis is that TURBT. And use of blue light cystoscopy combined with the optical imaging agent called cyst view, and it has a long kind of generic name or kind of chemistry name to it, which I'm not going to even go into here. But ultimately, you put this agent into the bladder, and it interacts with the heme biosynthetic pathway.
And it accumulates in these photoactive porphyrins. And it is these photoactive porphyrins which preferentially accumulate in malignant cells. And then when we use blue light illumination, it's these photoactive porphyrins that then, okay, which are accumulated in the cancerous cells, fluoresce bright pink, okay, under that blue light illumination. And so you're able to visually see that.
where these cancerous cells and conglomerations of these cancerous cells are, where they might not be apparent under white light, and really where this optical imaging agent has kind of shined, if you will, to use that. is in carcinoma in situ cases. So where we know that that disease specifically can be elusive under white light, we can miss it.
This agent really has shown to be uptake specifically in that superficial type of bladder cancer and allows us to visualize it, resect it, even see the margins of our resection to be able to fully resect and evacuate the cancer from the patients at the time of the TRBT.
Yeah, no, I think it's an important kind of topic to bring up. And it's certainly one of discussion and one of preference. But I will tell you that when this optical imaging agent rolled out, it was FDA approved in 2010. And so it's been around for quite some time.
And initially, we were using it really in patients that we knew already had a diagnosis of CIS, where it really has shown to detect that cancer, actually showing ultimately that it detects it, just to give you some hard data here, detects CIS tumors were found in 34.6%. patients compared to, for example, white light. The CIS tumors were only found in blue light up to 34.6% of the time.
And so initially people thought, well, maybe I should only use it for CIS patients. And ultimately, right, we only know a patient has CIS after that first TURBT. And so people would use it in that sort of situation. It was also felt to be a good use in people that had that positive cytology, but that white light surveillance cystoscopy didn't show anything abnormal.
And so you could use it there to see if we could see anything better under blue light illuminescence. But really, as we've used this technology more and more, we're finding that it really has more widespread applications. And it can be used for any resection, for any low-grade, high-grade patient or stage of disease.
I will tell you that when I don't think about using this is in your high volume tumor patients. So where you've gone in there cystoscopically, you know, the first time after the workup and there's just tumor everywhere. You have a hard time seeing normal urethelial walls. It's very hard to navigate kind of around the bladder. that is probably not a great time to use this technology.
But I can tell you, though, using that technology on that patient for the second resection is a great use to make sure that you've gotten all the tumor out of there, that you can see kind of your margins of resection. You know, I think we've all felt, and I'm sure you can agree, Suzette, that we do not do as good of a job with TRBTs as we think we do, right?
We train our residents, you know, very early on with doing TRBTs. Obviously, this is a cornerstone of urology. They need to know how to do them. But many times when we're doing TRBTs, we're with a junior resident, for example. This is kind of the junior resident case.
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