Bladder Flashcards
pathophysiology -3
transitional cell carcinoma TCC 90-95%
T stage -4
superficial (Tis, Ta, T1) (70-80% of pts)
carcinoma in-situ (if untreated 60-70% will progress), ->NEED TO TX
papillary
muscle invasive (T2-T4) (20-30% of pts) (high-grade)
superficial (Tis, Ta, or T1) primary tx -5
WHAT IS TOC?
SURGERY + ADJUVANT
TURBT (transurethral endoscopic resection)
adjuvant intravesicular BCG x 6wks
—10 yr PFS 62 vs 37%
can do observation and just one dose of BCG without surgery for Ta dz (NOT COMMON)
BCG better than doxo
superficial (Tis, Ta, or T1) primary tx - BCG failure OR can not receive BCG -3
mitomycin (NCCN cat 1, first line)
BCG +interferon
valrubicin (anthracycline derivative)
BCG ADR - important to manage sx to give entire course (3pts)
flu: (phenazopyridine, APAP, NSAIDs)
#cystitis and infx: urine and b cx to r/o infx. usually higher and prolonged fever than in flu-like sx
(1-34%) usually self limiting,
HOLD BCG until resolves,
usually 2nd, 3rd, or 4th dose
muscle invasive (T2 to T4a) primary tx -4
WHAT IS TOC?
NEOADJ + SURGERY IS TOC
organ confined -> radical cystectomy unless contraindx, THEN CAN GIVE XRT.
can also use combined chemoXRT surgery to preserve bladder in select cases
neoadj x 3 cycles: CMV or M-VAC
adj chemo NO OS ADVANTAGE, some MD’s may give for T3 disease
muscle invasive (T2 to T4a) primary tx -neoadj CMV
cisplatin, methotrexate, vinblastine x3 cycles
10 yr OS: 36 vs 30%
muscle invasive (T2 to T4a) primary tx -neoadj M-VAC
MTX, vinblastine, doxorubicin, cisplatin x3 cycles
median OS 77 vs 46 mo (p=0.06)
muscle invasive (T2 to T4a) primary tx -neoadj concepts
3 cycles appear beneficial
need combo tx (no benefit from single agent cis)
muscle invasive (T2 to T4a) primary tx -adj concepts
NO OS advantage
for T3 or above 3 cycles may be used to delay recurrence (especially if neoadj not given)
stage IV primary tx -5
WHAT IS SOC?
M-VAC used historically but toxic
cis-gem is TOC: OS pretty close (13.8 vs 14.8mo), much less tox.
carbo-gem (only other phase III trial) (give if can not have cisplatin in M-VAC or cis-gem)
pac-carbo
pac-gem (give if can not use platinum at all)
M-VAC ADR -3
sepsis 12%
grade III-IV mucositis 22%
BOTH MUCH HIGHER THAN CIS-GEM
stage IV M-VAC principle
if use instead of cis-gem give in dose dense manner (inc PFS with same tox) NCCN req- LOOK UP