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FRCR2 > bladder > Flashcards

bladder Flashcards

1
Q

What proportion of non-muscle invasive bladder cancer will become muscle invasive
and what proportion of non-muscle invasive bladder cancer becomes recurrent

A

20%, and 50% recurrent

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2
Q

What are the 2WW criteria for bladder cancer

A

> 45 years old - Visible haematuria that persists or recurs after successful treatment / exclusion of UTI
60 with unexplained non-visible haematuria and either dysuria/raised WCC on bloods

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3
Q

What are the investigations for a new bladder cancer diagnosis

A

CTCAP / KUB & thorax - to exclude synchronous upper urinary tract cancer
MRI abdomen / pelvis
Flexible cystoscopy
TURBT - to assess depth of invasion - aiming for complete removal of all visible lesions
EDTA / NM-GFR for renal function

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4
Q

How is non-muscle invasive bladder cancer defined by T stage

A

Ta or T1
Muscle invasive from T2 onward

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5
Q

How is a stage 1 bladder cancer defined
How is a stage 2 bladder cancer defined

A

1 = T1N0
2 = T2N0 (muscle invasive)

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6
Q

How is a stage 3 bladder cancer defined

A

3 = either T3 or T4a, or node positive

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7
Q

How is a stage 4 bladder cancer defined

A

4 = T4b or distant mets

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8
Q

How is the management of non-muscle invasive cancer categorised

A

Low risk
Intermediate risk
High risk
Very high risk

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9
Q

What is the management of low risk non-muscle invasive bladder cancer
How is low risk defined

A

Ta & Gr1
TURBT and single dose of intravesical MMC
Cystoscopic surveillance

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10
Q

What is the management of intermediate risk non-muscle invasive bladder cancer

A

Neither low nor high risk
Intravesical MMC for 1yr or 1yr full dose BCG (6x weekly instillations, then 3-weekly instillations at 3, 6 & 12mths)

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11
Q

What is the management of high risk non-muscle invasive bladder cancer
How is it defined

A

Any of T1, grade 3, CIS, multiple, recurrent and large
Intravesical BCG for 1-3 years or radical cystectomy

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12
Q

What is the management of very high risk non-muscle invasive bladder cancer
How is it defined

A

T1 G3 or high grade associated with concurrent CIS
multiple / large T1 / recurrent with CIS in the prostatic urethra

Radical cystectomy or 3yrs of intravesical BCG

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13
Q

What are the side effects of intravesical MMC
What is the contraindication

A

Bladder irritation, myelosuppression, rash, risk of fibrosis
CI for MMC: Suspected/confirmed bladder perforation

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14
Q

When is a radical cystectomy indicated for non-muscle invasive bladder cancer

A

High risk - Multiple high risk G3 pT1 tumours or Widespread CIS
Recurrence following BCG treatment
Progression to muscle invasive BC
Side-effects preventing completion of BCG treatment

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15
Q

What are the side effects of intravesical BCG
Contraindications

A

Side effects
Cystitis (70%), Fever (50%), Haematuria (25%)
Joint pain, lethargy, nausea & vomiting, anorexia, diarrhoea, allergic 
reactions, granulomatous prostatitis/epididymitis, TB

Absolute CI
<2 weeks since TURBT
Following difficult catheterisation
Symptomatic UTI or haematuria (both due to risk of systemic absorption)

Relative CI:
Immunosuppression, asymptomatic infection

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16
Q

What are the treatment options for muscle invasive bladder cancer

A

neo-adjuvant chemotherapy followed by radical cystectomy or RT
Radical cystectomy/RT followed by adjuvant chemotherapy

17
Q

What is the benefit of neoadjuvant chemotherapy in MIBC
And according to what
What does this bring the 5yr OS to

A

According to the ABC met-analysis, NACT has a 5% OS benefit

5yr OS 45 -> 50%

Surgery within 4-6wks of completing chemotherapy

18
Q

What are the exceptions where NACT would not be given

A

Hydronephrosis (pre-chemo) – straight to surgery

Pure squamous histology or adenocarcinoma - proceed to radical cystectomy without NACT

19
Q

What NACT regimen is given

A

Either 3-4 cycles of gem/cis, with MRI before cycle 4 (6 cycles if T4 disease)
Or MVAC if <70yrs and fit
Methotrexate, vinblastine, doxorubicin, cisplatin
With folinic acid and GCSF

20
Q

What are the indications for radical cystectomy

A

T2 -T4a disease (Muscle invasive)
Multiple lesions - Extensive CIS or Multifocal tumour
Histology: Sarcomatous, Adenocarcinoma, Squamous carcinoma

21
Q

When is adjuvant chemotherapy indicated for MIBC

A

Following surgery, in those who did not receive NACT, but found to have node positive disease or extravesical spread

22
Q

What is the dose and chemo regimens for radical CRT for MIBC

What is the 5yr survival

A

55Gy/20# with concurrent MMC & 5FU
-MMC given on day 1, 5FU pump runs over day 1-5

Or with BCON - carbogen and nicotinamide as radiosensitiser
SE - nausea and headache

5-yr OS: 48% for RT with MMC/5FU, according to BC2001 trial

23
Q

What are the RT options for someone not fit enough for radical CRT

A

RT alone - 55Gy/20#
21Gy/3# alternate days
36Gy/6#/6wks
8Gy single fraction or 20Gy/5# for symptoms

24
Q

What are the contraindications to radical chemoRT for MIBC

A

Irretrievable loss of bladder function after RT therefore organ preservation pointless - opt for cystectomy
Patient will not comply with regular check cystoscopy post CRT
IBD

25
Q

When should urethral volume be included in MIBC CTV
What volume of urethra should be included

A

Bladder base tumour or distant CIS present

Include 1.5cm of prostatic urethra in males and 1cm of urethra in females

26
Q

What is the CTV-PTV margin for MIBC

A

1.5cm, with 2cm if dome of bladder tumour

27
Q

What is the follow up after radical RT for MIBC

A

Most recurrences occur in first 2 years

Life-long surveillance is mandatory
Cystoscopy & urine cytology
3/12 -> year 1
6/12 -> year 2
Annually thereafter

CTCAP - Distant disease most common in lung, liver and bones
6, 12 & 24 months after CRT
Annually thereafter for 5 years

28
Q

What is the treatment for recurrence post radical RT

A

salvage cystectomy, but associated with poorer survival outcomes

29
Q

What is the prognosis of MIBC
locally advanced and metastatic

A

5-year survival:
T2: 60% with chemo
T3: 40% with chemo
T4: 20% with chemo
N+ (stage IV): 10% with chemo

Metastatic disease: mOS 14 months with chemo

30
Q

What is the first line management of metastatic bladder cancer

What is the second line management

A

Pt eligible:
Gem/cis 4-6 cycles - if no progression -> maintenance avelumab

If cisplatin contraindicated:
Gem/carbo
If PDL1>5%, single agent atezolizumab
If PDL1>1%, single agent pembrolizumab

Second line:
Pembrolizumab or Atezolizumab (independent of PDL1 status)
Must have had platinum before & not had any PD-L1 directed treatment

31
Q

How are upper urinary tract tumours categorised according to risk

A

Low & High

Low - unifocal, <1cm, low grade & no invasive features on imaging

High - >2cm, possible hydronephrosis, high grade disease, variant histology or previous radical cystectomy for bladder cancer

32
Q

What is the management of a low risk upper urinary tract tumour

A

Kidney sparing - endoscopic laser ablation

33
Q

What is the management of a high risk upper urinary tract tumour

A

Nephrectomy +/- single dose of MMC
Adjuvant carbo/cis + gem for 4 cycles
POUT trial demonstrated improved DFS

Or adjvuant nivolumab if Pt-chemotherapy ineligible

34
Q

When is nivolumab indicated in bladder cancer or upper urinary tract urothelial cancer

A

Adjuvant monotherapy after complete tumour resection in high risk muscle invasive urothelial cancer with PD-L1 expression of ≥1% and in whom adjuvant treatment with platinum-based treatment is unsuitable, for a maximum of 1 year

35
Q

What surveillance is required after upper urinary tract tumour treatment

A

Pts with upper tract cancer have 40% chance developing bladder tumour -> LIFE LONG cystoscopies

36
Q

What is the prognosis after upper urinary tract tumour treatment

A

5yr survival <50% for pT2-3 and <10% for pT4

37
Q

How should a small cell cancer of the bladder be treated

A

very chemo sensitive
give neoadjuvant cis/etopo followed by radical RT/cystectomy

FRCR2 (28 decks)

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