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Gary Steinberg, MD
GarySteinbergMD (Physician - Urology (Verified) )| Communities: Prostate Cancer , Bladder and Urinary Cancer , Kidney and Renal Cancer , Testicular Cancer | Answers: 8 |
| Member Since: Jul. 2012 |
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Professional Statement
Dr. Steinberg has been on the faculty of the Department of Surgery/Urology at The University of Chicago Medical School since 1994, and is the Director of Urologic Oncology. He is actively involved in developing and performing innovative surgical procedures for patients with bladder, kidney, testicular and prostate cancer. He performs a large number of continent urinary reconstructions in men and women who have their bladder removed for cancer. He is also actively involved in a number of clinical trials testing newer treatments for urologic cancers, especially locally advanced bladder and kidney cancer.
Dr. Steinberg was born and raised in suburban Chicago. He attended Johns Hopkins as an Undergraduate and The University of Chicago Medical School. He received his surgical and urological training at the Johns Hopkins Hospitals and Medical School in Baltimore, Maryland. While at Johns Hopkins he was an American Cancer Society Clinical Fellow in urologic oncology.
Dr. Steinberg was born and raised in suburban Chicago. He attended Johns Hopkins as an Undergraduate and The University of Chicago Medical School. He received his surgical and urological training at the Johns Hopkins Hospitals and Medical School in Baltimore, Maryland. While at Johns Hopkins he was an American Cancer Society Clinical Fellow in urologic oncology.
Professional Info
Credential: MD
Primary specialty: Urology
Medical school: University of Chicago
Residency: Johns Hopkins University School of Medicine
Internship: Johns Hopkins University School of Medicine
Fellowship: Johns Hopkins University School of Medicine
Areas of expertise:
Bladder Cancer
Urologic cancers
Continent bladder reconstruction
Salvage surgery following radiation
Hospital affiliation: The University of Chicago Medical Center
Practice address:
5841 South Maryland Ave, MC6038
Chicago, IL
60637
Practice phone number: (773) 702-3080
GarySteinbergMD Activities
Platinum based chemotherapy i.e. Cis Platin is commonly used for the treatment of locally advanced and metastatic bladder cancer. In addition, Platinum based chemotherapy is used in the neoadjuvant (before radical cystectomy) and adjuvant setting (after radical cystectomy); however, presently there are no known biomarkers of disease response. Improving survival will require newer medications and moving beyond conventional histological staging and grading of tumors. Currently, chemotherapy for bladder cancer is the approach of “one size fits all”. However, we know that cancer is a diverse, complex heterogeneous process with multiple mutations and altered metabolic and genetic pathways. The goal of TCGA for bladder cancer is to perform complete genomic analysis of 500+ invasive bladder cancers to determine the various “genetic signatures” and altered metabolic pathways associated with bladder cancer. Ideally this will lead to new prognostic markers as well as therapeutic targets for novel and personalized drug development. Single gene markers such as p53, pRb, p16, p21, ERCC1, RRM1, hENT1, PTEN, pErb, Her2 Neu as well as microRNA markers have all been studied as prognostic predictors of survival as well as markers for chemotherapy responsiveness. To date clinical trials are ongoing to test agents that target the fibroblast, epidermal and vascular endothelial growth factor pathways. The goal is to augment cytotoxic chemotherapy with these targeted therapies; however, at present much work on the biology of bladder cancer is required.
New answer by GarySteinbergMD (Physician - Urology (Verified))
1
Answer |
10 months ago
The large majority of bladder cancers are urothelial cell carcinomas. The aggressiveness of bladder cancer is determined by the stage and grade of the tumor. The grade is what the tumor looks like under the microscope and consists of low grade or high grade. This is from the 2004 International Society of Urologic Pathologists; however, some pathologists continue to use grades 1, 2 and 3. In general grade1 and 2 are low grade and grade 3 is considered high grade. The 2004 classification also introduced papillary neoplasia of low malignant potential. In addition to urothelial cell carcinoma are a number of histological variants that are thought to be more aggressive. These include micropapillary, small cell, glandular differentiation, squamous, sarcomatoid, lymphoepitheloid as well as a few others.
Stage is the depth of penetration of the bladder cancer. There are 2 main categories i.e. non muscle invasive (NMIBC) and muscle invasive bladder cancer. Low grade NMIBC has a recurrence rate of approximately 50% but at most 2-4% risk of progression. High grade NMIBC such as Ta, T1 and carcinoma in-situ have a slightly higher risk of recurrence with approximately 30-40% risk of progression. A number of risk stratifications for NMIBC have been developed taking into account grade, stage, number and size of tumors as well as number of recurrences to classify patients as having low, intermediate and high risk of tumor recurrence and progression. Muscle invasive bladder cancer is always high grade and is associated with microscopic metastatic disease in up to 50% of patients at the time of diagnosis. To date there are no consistent molecular or genetic markers that are able to accurately stratify patients. Pathologic staging i.e. presence of extravesical invasion, involvement of adjacent organs such as the prostate or vagina or lymph node involvement are all associated with a poor prognosis. The Cancer Genome Atlas (TCGA) project will aid in the identification of prognostic biomarkers for bladder cancer.
Stage is the depth of penetration of the bladder cancer. There are 2 main categories i.e. non muscle invasive (NMIBC) and muscle invasive bladder cancer. Low grade NMIBC has a recurrence rate of approximately 50% but at most 2-4% risk of progression. High grade NMIBC such as Ta, T1 and carcinoma in-situ have a slightly higher risk of recurrence with approximately 30-40% risk of progression. A number of risk stratifications for NMIBC have been developed taking into account grade, stage, number and size of tumors as well as number of recurrences to classify patients as having low, intermediate and high risk of tumor recurrence and progression. Muscle invasive bladder cancer is always high grade and is associated with microscopic metastatic disease in up to 50% of patients at the time of diagnosis. To date there are no consistent molecular or genetic markers that are able to accurately stratify patients. Pathologic staging i.e. presence of extravesical invasion, involvement of adjacent organs such as the prostate or vagina or lymph node involvement are all associated with a poor prognosis. The Cancer Genome Atlas (TCGA) project will aid in the identification of prognostic biomarkers for bladder cancer.
New answer by GarySteinbergMD (Physician - Urology (Verified))
1
Answer |
10 months ago
In general in patients with NMIBC, multiple bladder tumors imply a greater risk of recurrence/progression. The entire urinary tract from the kidneys throughout the bladder, prostate and urethra is lined by urothelial cells. The carcinogenic exposure is typically greatest in the bladder and thus, urothelial carcinoma is much more common in the bladder than other locations. In general when one has multiple tumors there are more widespread cellular effect/alterations that are an increased risk factor.
New answer by GarySteinbergMD (Physician - Urology (Verified))
1
Answer |
10 months ago
All patients undergoing radical cystectomy for bladder cancer should have a pelvic lymph node dissection. We are currently participating in a National Cancer Institute sponsored intergroup randomized study through the Southwest Oncology Group (SWOG) comparing an extended versus standard pelvic lymph node dissection for patients with invasive bladder cancer. The hypothesis being studied is whether a more extensive lymph node dissection will lead to improved bladder cancer survival.
New answer by GarySteinbergMD (Physician - Urology (Verified))
1
Answer |
10 months ago
Intravesical therapy includes chemotherapy as well as immunotherapy. Intravesical therapy is for prophylaxis to prevent recurrences and/or progression of NMIBC and not necessarily as cytotoxic treatment. The goal standard therapy to decrease the recurrence rate and possibly the progression rate of high risk NMIBC is intravesical Bacillus Calmette Guerin (BCG) immunotherapy. After the patient has undergone a TURBT as well as repeat TURBT with removal of all visible high grade disease, an induction course of once weekly instillation of intravesical BCG for 6 weeks is performed. I also utilize one year of maintenance BCG which is 1/3 dose of BCG for 3 weeks after the 3, 6 and 12 month surveillance cystoscopy and cytology evaluation. Patients are evaluated every 3 months with cystoscopy and urinary cytology for 2 years and then every 6 months for 2 years and then yearly. Discontinuation of intravesical therapy and proceeding to radical cystectomy or alternative treatments is determined by response to BCG as well as timing of response to BCG. Patients that have recurrence and/or progression of their bladder cancer after 2 courses of BCG or within 1-2 years of diagnosis have an aggressive bladder cancer that will not respond to more BCG or BCG and interferon. Intravesical chemotherapy such as valrubicin, Mitomycin C or gemcitabine may be tried; however, only valrubicin has an FDA indication for BCG resistant/refractory carcinoma in situ. Alternatively these patients are recommended to undergo radical cystectomy.
A recent study assessed the potential benefit of combination intravesical BCG and interferon. The study enrolled approximately 600 patients at multiple centers and randomized patients with high risk NMIBC that were BCG naïve between BCG and the combination of BCG and interferon. There was no difference in outcome between the 2 groups and thus, the role of intravesical interferon is limited and of no benefit.
Some urologists advocate giving a single dose of intravesical chemotherapy after a TURBT for NMIBC. Long term studies performed in Europe demonstrate a decreased recurrence rate for patients with low risk but not intermediate or high risk NMIBC. Low risk disease is low grade, single occurrence, single tumor, 1-2 cm in size that is completely resected. There are side effects from chemotherapy especially if there is any bladder perforation and extravasation of the treatment after TURBT. In general I am not an advocate of single dose peri-TURBT intravesical chemotherapy.
A recent study assessed the potential benefit of combination intravesical BCG and interferon. The study enrolled approximately 600 patients at multiple centers and randomized patients with high risk NMIBC that were BCG naïve between BCG and the combination of BCG and interferon. There was no difference in outcome between the 2 groups and thus, the role of intravesical interferon is limited and of no benefit.
Some urologists advocate giving a single dose of intravesical chemotherapy after a TURBT for NMIBC. Long term studies performed in Europe demonstrate a decreased recurrence rate for patients with low risk but not intermediate or high risk NMIBC. Low risk disease is low grade, single occurrence, single tumor, 1-2 cm in size that is completely resected. There are side effects from chemotherapy especially if there is any bladder perforation and extravasation of the treatment after TURBT. In general I am not an advocate of single dose peri-TURBT intravesical chemotherapy.
New answer by GarySteinbergMD (Physician - Urology (Verified))
1
Answer |
10 months ago
Patients with bladder cancer typically present with hematuria, sudden change in voiding symptoms or pelvic pain. It is critically important that the patients are accurately diagnosed and staged. I start with a CT scan of the abdomen and pelvis with pre and post IV contrast films as well as delayed films and a CT Urogram. I also obtain either a chest X-ray or CT. Patients will then have a cystoscopy, urinary cytology and transurethral resection of the bladder tumor (TURBT) in the operating room. This will provide the urologist with the stage and grade of the tumor. The goal if possible is to completely resect all visible tumors and sample the bladder muscle layer. In patients with no evidence of metastases and high grade NMIBC I will perform a repeat TURBT in the operating room 6 weeks after the initial TURBT for diagnostic, prognostic, therapeutic and surveillance indications. In 30-40% of the patients there will be residual cancer on the repeat TURBT and upstaging in 20-30%. Recently Cysview and “blue light” cystoscopy has been approved in the United States. It has been used in Europe for approximately 5 years previously. Blue light cystoscopy may aid in the detection of bladder cancer making the TURBT more effective and improving diagnostic accuracy. Other physicians may obtain MRI scans rather than CT. There is limited data on the utility of PET/CT for the diagnosis and staging of bladder cancer. In patients with the diagnosis of muscle invasive disease and a CT scan and chest imaging no further workup is necessary. I rarely obtain bone scans for patients with bladder cancer.
New answer by GarySteinbergMD (Physician - Urology (Verified))
1
Answer |
10 months ago
Cancer development is generally a complex, multifactorial process with interplay of genetic, epigenetic, environmental and host factors. Despite numerous clinical, experimental and epidemiologic investigations that have identified etiologic environmental risk factors, 50% of patients have no known risk factors associated with their bladder cancer. The greatest risk factor is being a current smoker. This is associated with a four-fold increased risk and decreases to 2-3 fold for a former smoker. The causative agents are thought to be 4-aminobiphenyl, nitrosamines, polycyclic aromatic hydrocarbons, 2-naphthyamine, benzidine and other aromatic amines. Many of these agents are commonly used in industry and agriculture. Industrial exposure can be seen from the petroleum and petroleum products, steel mills, coal gasification, dry cleaning and leather and tanning. Other environmental risk factors are arsenic in the drinking supply, diesel exhaust, nitrates and nitrites in processed and smoked meats, polyaromatic hydrocarbons, ionizing radiation, chronic urinary tract inflammation, mmunosuppression, and some types of chemotherapy (oxazophosphorines). There may also be an association between chlorinated water, halogenated hydrocarbons, obesity, metabolic syndrome, diabetes and Pioglitazone and oral diabetes medication.
Bladder cancer is not thought to be a genetic cancer per se; however, inherited metabolism pathways that detoxify carcinogens and excrete the metabolic waste into the urinary tract are thought to increase ones predisposition to bladder cancer. Future research to identify biomarkers of risk for bladder cancer will be very informative in the future.
Bladder cancer is not thought to be a genetic cancer per se; however, inherited metabolism pathways that detoxify carcinogens and excrete the metabolic waste into the urinary tract are thought to increase ones predisposition to bladder cancer. Future research to identify biomarkers of risk for bladder cancer will be very informative in the future.
New answer by GarySteinbergMD (Physician - Urology (Verified))
1
Answer |
10 months ago
The most common presenting symptom of bladder cancer is hematuria or blood in the urine. The blood in the urine should be characterized as microscopic or gross, initial, terminal or total and associated with pain or painless. Bladder cancer must be ruled out for patients with total, gross painless hematuria. Many times the hematuria is intermittent and may resolve spontaneously. Approximately 33% of patients with gross hematuria will have an abnormal finding in the urinary tract with bladder cancer being most common. In addition, any sudden change in voiding symptoms such as frequency, urgency or dysuria should warrant an evaluation by a primary care physician or internist. Patients with microscopic hematuria detected during a urinalysis may also have bladder cancer.
All too often, patients will be treated for a presumed urinary tract infection after notifying their family physician about an episode of gross hematuria. At this time it is critically important that a urinalysis and urine culture is obtained prior to treatment as well as follow-up urinalysis to assess resolution of the blood in the urine.
Bladder cancer is more common in men than women and is a disease of aging with the mean age at diagnosis in the late 60’s to early 70’s; however, all patients with gross hematuria warrant a hematuria work-up which entails a CT scan of the abdomen and pelvis with IV contrast, delayed films and CT Urogram plus a cystoscopy and urinary cytology, preferably a barbotaged urine for cytology. This is routinely performed by a urologist.
All too often, patients will be treated for a presumed urinary tract infection after notifying their family physician about an episode of gross hematuria. At this time it is critically important that a urinalysis and urine culture is obtained prior to treatment as well as follow-up urinalysis to assess resolution of the blood in the urine.
Bladder cancer is more common in men than women and is a disease of aging with the mean age at diagnosis in the late 60’s to early 70’s; however, all patients with gross hematuria warrant a hematuria work-up which entails a CT scan of the abdomen and pelvis with IV contrast, delayed films and CT Urogram plus a cystoscopy and urinary cytology, preferably a barbotaged urine for cytology. This is routinely performed by a urologist.
New answer by GarySteinbergMD (Physician - Urology (Verified))
1
Answer |
10 months ago
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