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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And unfortunately, the TRBT is so critically important for these patients as, again, it is one of their mainstays of treatment to get that cancer out fully, accurately stage and grade the patient, get them on that right journey. And there is a lot of data out there and we all know it that we do leave tumor behind.
There's reports up to, you know, 76% that residual tumor is left behind after the first TRBT. And that's a high number. And so again, this technology can really help to make sure that we do the best job we can for our patients, you know, at those TRBT settings, initial TRBT, repeat TRBTs, and getting all that cancer out that we can.
Yeah, that's very true. I think 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 patient's 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 with blue light cystoscopy and use of cis-fueled 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. So some pretty impactful evidence behind this technology.
Yeah, no, that's a really good point to bring up. You know, I think at least right now, evidence hasn't really kind of panned out, you know, in regards to it. Does it get picked up by more variant histologies such as small cells, such as micropapillary cells? sarcomatoid, which we all know can be seen. It's more rare, but can be seen certainly in the superficial setting.
These studies, these randomized studies, multi-center perspective in nature that really set this optical imaging agent up for FDA approval and use today didn't really sort out the variant histology, if you will. What we know is that certainly it does get picked up more by more aggressive type lesions like CIS, but can certainly still be used in the low-grade setting.
And as you mentioned, in our superficial bladder cancer, the mixed-grade heterogeneity is up to 30%. And so it's just very important to be able to ensure that we're capturing heterogeneity if you will, the truth about what is in a patient's bladder. Because, for example, with our intermediate risk category of the AUA, that contains patients that are low-grade, okay, as well as high-grade patients.
But the recommendations for patients that fall in that intermediate risk category is that the provider, you know, should consider intervesicle therapy. Or excuse me, it says it just should consider intervesicle. it doesn't actually recommend as strongly as if you're in the high-risk category to give intervesical therapy.
So it kind of leaves it up to the provider as to whether that patient should go on further with intervesical treatment or not. And the problem with that, if we've misclassified a patient
and they actually, for example, have a CIS lesion that we missed, or it was a predominantly low-grade papillary lesion that was visualized, but yet you miss that one smaller high-grade lesion sitting in the back of the bladder, smaller, then that patient might not be placed into the right risk category and therefore not receive the appropriate intervesical treatment going forward.
No. Very good point. You're right. It is actually 5% is only what is needed within the total specimen volume to deem that patient now is high grade.
Yeah, remarkable. Definitely. And, you know, I think that gets at the point, too, when we talk about the logistics of using this technology is that you do want to use technology.
both white light and blue light together, that you really should kind of not, you know, kind of only resect under blue light, for example, that you do want to use both kind of information gained from when you're doing your cystoscopy under white light, as well as the information gained under blue light. And that's where you're going to get the best accuracy.
Yeah, I mean, I guess there's certainly kind of a learning to it. But I think, again, white light is kind of what has been around historically and traditionally. And it's important that blue light again, how this technology works with SysView and this optical imaging agent and that it accumulates most preferential cancer cells.
It can also accumulate in areas of trauma and areas of inflammation, okay, where you have, again, this kind of increased kind of vascularity and heme biosynthesis taking place and these photoactive porphyrins in high accumulation. So, Ultimately, they've looked at with these pivotal studies kind of what the false positive rate is between, you know, use of blue light and white light.
And there really is not a significant difference between the two. But we do see, again, where the false positives are occurring are occurring at sites of, again, kind of trauma, potentially previous resection sites, especially on the margins. You can see this happen at the areas of scar. Certainly, if there is kind of active inflammation kind of infection is where this can happen.
So it is important to, again, kind of use your judgment compiled together from both the white light and the blue light as to whether or not you decide to take a biopsy, do a full scraping resection.
No, there shouldn't be. We can certainly talk about the logistics. It's important. But one of the things when you do, you take that patient into the OR, they have the SysView in their bladder still. You evacuate it after either if they come in with the catheter clamped or if they're holding it naturally.
evacuate it with the catheter, evacuate it with the scope, and then you should actually cycle the bladder with, again, your saline, wash it out, especially if it's sat in the bladder for longer than that recommended dwell time of an hour. It's definitely kind of accumulated more, so the blue light kind of gets a little bit challenging initially unless you cycle the bladder a couple times and look.
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