bladder Flashcards
What proportion of non-muscle invasive bladder cancer will become muscle invasive
and what proportion of non-muscle invasive bladder cancer becomes recurrent
20%, and 50% recurrent
What are the 2WW criteria for bladder cancer
> 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
What are the investigations for a new bladder cancer diagnosis
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
How is non-muscle invasive bladder cancer defined by T stage
Ta or T1
Muscle invasive from T2 onward
How is a stage 1 bladder cancer defined
How is a stage 2 bladder cancer defined
1 = T1N0
2 = T2N0 (muscle invasive)
How is a stage 3 bladder cancer defined
3 = either T3 or T4a, or node positive
How is a stage 4 bladder cancer defined
4 = T4b or distant mets
How is the management of non-muscle invasive cancer categorised
Low risk
Intermediate risk
High risk
Very high risk
What is the management of low risk non-muscle invasive bladder cancer
How is low risk defined
Ta & Gr1
TURBT and single dose of intravesical MMC
Cystoscopic surveillance
What is the management of intermediate risk non-muscle invasive bladder cancer
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)
What is the management of high risk non-muscle invasive bladder cancer
How is it defined
Any of T1, grade 3, CIS, multiple, recurrent and large
Intravesical BCG for 1-3 years or radical cystectomy
What is the management of very high risk non-muscle invasive bladder cancer
How is it defined
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
What are the side effects of intravesical MMC
What is the contraindication
Bladder irritation, myelosuppression, rash, risk of fibrosis
CI for MMC: Suspected/confirmed bladder perforation
When is a radical cystectomy indicated for non-muscle invasive bladder cancer
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
What are the side effects of intravesical BCG
Contraindications
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
What are the treatment options for muscle invasive bladder cancer
neo-adjuvant chemotherapy followed by radical cystectomy or RT
Radical cystectomy/RT followed by adjuvant chemotherapy
What is the benefit of neoadjuvant chemotherapy in MIBC
And according to what
What does this bring the 5yr OS to
According to the ABC met-analysis, NACT has a 5% OS benefit
5yr OS 45 -> 50%
Surgery within 4-6wks of completing chemotherapy
What are the exceptions where NACT would not be given
Hydronephrosis (pre-chemo) – straight to surgery
Pure squamous histology or adenocarcinoma - proceed to radical cystectomy without NACT
What NACT regimen is given
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
What are the indications for radical cystectomy
T2 -T4a disease (Muscle invasive)
Multiple lesions - Extensive CIS or Multifocal tumour
Histology: Sarcomatous, Adenocarcinoma, Squamous carcinoma
When is adjuvant chemotherapy indicated for MIBC
Following surgery, in those who did not receive NACT, but found to have node positive disease or extravesical spread (T3)
What is the dose and chemo regimens for radical CRT for MIBC
What is the 5yr survival
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
What are the RT options for someone not fit enough for radical CRT
RT alone - 55Gy/20#
21Gy/3# alternate days
36Gy/6#/6wks
8Gy single fraction or 20Gy/5# for symptoms
What are the contraindications to radical chemoRT for MIBC
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
When should urethral volume be included in MIBC CTV
What volume of urethra should be included
Bladder base tumour or distant CIS present
Include 1.5cm of prostatic urethra in males and 1cm of urethra in females
What is the CTV-PTV margin for MIBC
1.5cm, with 2cm if dome of bladder tumour
What is the follow up after radical RT for MIBC
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
What is the treatment for recurrence post radical RT
salvage cystectomy, but associated with poorer survival outcomes
What is the prognosis of MIBC
locally advanced and metastatic
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
What is the first line management of metastatic bladder cancer
What is the second line management
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
How are upper urinary tract tumours categorised according to risk
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
What is the management of a low risk upper urinary tract tumour
Kidney sparing - endoscopic laser ablation
What is the management of a high risk upper urinary tract tumour
Nephrectomy +/- single dose of MMC
Adjuvant carbo/cis + gem for 4 cycles
POUT trial demonstrated improved DFS
Or adjvuant nivolumab if Pt-chemotherapy ineligible & PDL1 >1%
When is nivolumab indicated in bladder cancer or upper urinary tract urothelial cancer
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, or have received neoadjuvant chemotherapy, for a maximum of 1 year
What surveillance is required after upper urinary tract tumour treatment
Pts with upper tract cancer have 40% chance developing bladder tumour -> LIFE LONG cystoscopies
What is the prognosis after upper urinary tract tumour treatment
5yr survival <50% for pT2-3 and <10% for pT4
How should a small cell cancer of the bladder be treated
very chemo sensitive
give neoadjuvant cis/etopo followed by radical RT/cystectomy
