Bladder Flashcards
Nonmuscle invasive bladder cancer: low risk features are
Papillary urothelial neoplasm of low malignant potential
Low grade urothelial carcinoma
- Ta
<-3cm
Solitary
NMIBC intermediate risk
Low grade urothelial carcinoma
-T1 or >3cm or multifocal or recurrence within 1 year
High grade urothelial carcinoma
- Ta, <-3cm and solitary
NMIBC high risk features
High grade urothelial carcinoma
-CIS, T1, >3cm or multifocal
Very high risk features
- BCG unresponsive
-variant histologies: nested, micropapillary, lymphoepithelioma like, plasmacytoma, sarcomatoid, giant cell, lipid rich, clear cell
-lymphovascular invasion
Prostatic urethral invasion
Very high risk features of NMIBC that requires cystectomy
LVSI, prostatic urethral involvement, variant histology(micropapillary, plasmacytoid, sarcomatoid)
Chemotherapy schedule for neoadjuvant chemotherapy in bladder cancer
DDMVAC: dose dense methotrexate, vinblastin, doxorubicin, cisplatin
Methotrexate: 30 mg/m2 iv on D1,15,22
Vinblastine 3mg/m2 iv on D2,15,22
Doxorubicin 30mg/m2 iv D2
Cisplatin 70mg/m2 iv D2
Qw4
Gemcitabine and cisplatin:
Gemcitabine 1000mg/m2 iv day 1,8,15
Cisplatin 75mg/m2 day 1
Bladder preservation eligibility
Optimal candidates for bladder preservation with chemoradiotherapy include
patients with tumors that present without moderate/severe hydronephrosis, are without concurrent extensive or multifocal Tis, and are <6 cm. Ideally, tumors should allow for a visually complete or maximally debulking TURBT
Histopathological variant of bladder cancer.?
Transitional cell carcinoma (TCC)-90%
✔ SCC -8%
✔ Adenocarcinoma -1-2 %, most often in dome of bladder, urachal remnant
✔ Undifferentiated variants
o small cell ca
o Giant cell ca
o lymphoepithelioma
✔ Sarcoma (rhabdomyosarcoma)- common in children ✔ Melanoma
✔ Lymphoma
✔ Carcinoid tumors
Common site of bladder cancer
Trigone(inferiorly below uretero-vesical Junction)
✔ Lateral and posterior walls
✔ Bladder neck
Indication IVC in bladder
Multifocal CIS
✔ CIS associated with Ta or T1 tumor
✔ Any grade 3 tumor
✔ Multifocal tumor
✔ Whose tumor rapidly recur following TURBT ✔ Persistent abnormal or equivocal urine cytology ✔ Subtotal resection.
Agents used for IVC
Agents used:
✔ BCG(Bacillus Calmette Guerin) - 50-60 mg
✔ Gemcitabine (CAT 1 for IVC given within 24 hours) ✔ Mitomycin C
✔ Thiotepa
✔ Doxorubicin
✔ Interferon alpha and BCG
Complication ivc in bladder cancer
Complication of IVC:
✔ General - frequency, dysuria, irritative voiding symptoms. Long term effect- bladder contracture
✔ Specific for BCG: fever, joint pain, granulomatous prostatitis, sinus formation, disseminated TB and death.
✔ Thiotepa: myelosuppression
✔ Mitomycin: skin desquamation and rash, HUS
✔ Doxorubicin: GIT upset, allergic reaction
Curative dose of radiotherapy for bladder cancer
64 Gy in 32 fraction over 6 ½ weeks
- 55 gy in 20 fraction over 4 wks
Side effects of bladder radiotherapy
Acute side effects:
Bladder: dysuria, frequency, urgency, incontinence
Rectum: mucous discharge, flatulence, diarrhea, urgency
Late side effects:
Bladder: haematuria, pain, frequency
Rectum: bleeding, flatulence, mucous discharge, urgency
Prostate: dry ejaculation, urethral stricture
Vagina: stenosis, dryness
Impotence
Secondary malignancy
Structures of urinary bladder
Structures (outside to inwards): Serous muscular sub mucous mucous.
Serous coat – derived from peritoneum and incomplete.
Muscular coat- known as detrusor muscle (outer and inner longitudinal, middle circular). Middle circular layer forms the sphincter vesicae (involuntary)
Submucous coat – absent at trigone region, where mucous membrane is adherent to overlying muscle.
Mucous membrane – The mucosal lining of the bladder comprises a transitional epithelium that extends from the renal pelvis to the urethra. This layer is devoid of muscularis mucosae and mucous gland
Concurrent chemoradiation regimen for bladder cancer
Preferred regimens
• Cisplatin alone
• Low-dose gemcitabine
*5-FU and mitomycin
Other recommended regimen
• Cisplatin and 5-FU
• Cisplatin and paclitaxel
