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SUO > Bladder > Flashcards

Bladder Flashcards

1
Q

BCa

Tis Ta T1 Staging

3

A

Tis -> Carcinoma In Situ
Ta -> Noninvasive papillary carcinoma
T1 -> Invades Lamina Propria

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2
Q

BCa

T2 Staging

2

A

T2a -> Invades superficial muscularis propria
T2b -> Invades deep muscularis propria

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3
Q

BCa

T3 Staging

2

A

T3a -> Microscopic perivesical fat invasion
T3b -> Macroscopic perivesical fat invasion

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4
Q

BCa

T4 Staging

2

A

T4a -> Invades vaginal wall, prostate, seminal vesicles or uterus
T4b -> Invades pelvic side wall or abdominal wall

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5
Q

BCa

N Staging

3

A

N1 -> Single regional LN in true pelvis (perivesical, obturator, internal or external iliac or sacral lymph node)
N2 -> Multiple regional LNs in true pelvis
N3 -> Common iliac lymph nodes

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6
Q

BCa

M Staging

2

A

M1a -> Distant metastasis to lymph nodes beyond common iliacs
M1b -> Non-LN distant metastasis

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7
Q

BCa

Stage I

1

A

T1 N0 M0

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8
Q

BCa

Stage II

2

A

T2 N0 M0

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9
Q

BCa

Stage III

2

A

Stage IIIa -> T1-T4a N1 M0
Stage IIIb -> T1-T4a N2-3 M0

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10
Q

BCa

Stage IV

2

A

Stage IVa -> T1-4b N0-3 M0-1a (T4b, M1a)
Stage IVb -> T1-4b N0-3 M0-1b (M1b)

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11
Q

BCa

NMIBC Low Risk

2

A
  • PUNLMP
  • solitary LGTa <3cm
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12
Q

BCa

NMIBC Intermediate Risk

5

A
  • LGTa >3cm
  • Multifocal LGTa
  • Recurrent LGTa (within 1 year)
  • LGT1
  • solitary HGTa <3cm
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13
Q

BCa

NMIBC High Risk

4

A
  • HGTa >3cm
  • Multifocal HGTa
  • HGT1
  • CIS
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14
Q

BCa

NMIBC Very High Risk

4

A
  • BCG unresponsive
  • Variant histology
  • Lymphovascular invasion
  • Prostatic urethral invasion
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15
Q

BCa

Bladder Mass Workup

8

A
  • H&P
  • Office cystoscopy
  • Consider cytology
  • CTU
  • Smoking cessation
  • FH, consider germline testing
  • EUA with TURBT
  • Single dose intravesical chemotherapy within 24 hours (if non-invasive in apperance)
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16
Q

BCa

NMIBC repeat TURBT

5

A
  • HG Ta
  • HG T1
  • Visually incomplete resection
  • High- volume tumor
  • No muscle in specimen
17
Q

BCa

Low Risk NMIBC Treatment

1

A
  • Surveillance
18
Q

BCa

Int Risk NMIBC Treatment

2

A
  • Intravesical Gemcitabine or Mitomycin (p)
  • Surveillance
19
Q

BCa

High Risk NMIBC Treatment

2

A
  • BCG (p)
  • Cystectomy
20
Q

BCa

Very High Risk NMIBC Treatment

2

A
  • Cystectomy (p)
  • BCG
21
Q

BCa

BCG unresponsive or intolerant treatment

5

A
  • Cystectomy (p)
  • Intravesical chemotherapy
  • Pembrolizumab (select pts)
  • Nadofaragene firadenovec-vncg (select pts)
  • Nogapendekin alfa inbakicept-pmin + BCG (select pts)
22
Q

BCa

Positive cytology with negative cystoscopy workup

6

A
  • Rpt cytology in 3 months
  • Consider selected mampping biopsies including prostatic urethra
  • Cytology of upper tract
  • Consider ureteroscopy
  • Consider enhanced cystoscopy
  • Consider non-urinary source (vagina, cervix, rectum)
23
Q

BCa

Positive cytology with negative workup treatment

2

A
  • Follow up at 3 month intervals, then longer
  • If prior BCG, continue with maintenance
24
Q

BCa

MIBC Workup

4

A
  • CT C/A/P
  • Bone scan if indicated
  • Labs (including alkaline phosphatase)
  • Estimate eGFR
25
# BCa Stage II Treament
* NAC then radical cystectomy * NAC then partial cystectomy (select pts) * Cystectomy alone (cisplatin ineligible) * Trimodal therapy (maximal TURBT, chemoRT) * RT or Maximal TURBT (TMT ineligible)
26
# BCa Stage IIIa Treament | 4
* NAC then radical cystectomy * Cystectomy alone (cisplatin ineligible) * Trimodal therapy (maximal TURBT, chemoRT) * RT or Maximal TURBT (TMT ineligible)
27
# BCa Adjuvant therapy s/p cystectomy | 3
* pT3 or higher or pN+: adjuvant cisplatin based chemo (if not given previously) (p) or adjuvant nivolumab * ypT2 or higher or ypN+: consider nivolumab * pT3 or higher with positive margins: consider adjuvant RT
28
# BCa Stage IIIb or Stage IVa Treatment Regimens | 7
Downstaging systemic therapy * Pembrolizumab and enfortumab vedotin (p) (cisplatin eligible or ineligible) * Gemcitabine, cisplatin followed by avelumab maintenance * Nivolumab, gemcitabine, cisplatin followed by avelumab maintenance * ddMVAC followed by avelumab maintenance * Gemcitabine carboplatin (cisplatin ineligible) Concurrent chemoradiotherapy (M0 only) * Cisplatin alone * Low-dose Gemcitabine
29
# BCa Stage IIIb or Stage IVa response to treatment | 7
s/p Downstaging chemotherapy * CR: consolidation surgery, consolidation chemoRT or surveillance * PR: cystectomy, chemoRT or treat as metastatic * Progression: treat as metastatic s/p Concurrent chemoradiation * CR: surveillance * PR: NMIBC - BCG * PR: MIBC- consolidation surgery or treat as metastatic * Progression: treat as metastatic
30
# BCa Stage IVb Treatment
* Consider CNS imaging * Consider biopsy * Molecular testing Systemic Therapy +/- palliative RT * Pembrolizumab and enfortumab vedotin (p) (cisplatin eligible or ineligible) * Gemcitabine, cisplatin followed by avelumab maintenance * Nivolumab, gemcitabine, cisplatin followed by avelumab maintenance * ddMVAC followed by avelumab maintenance * Gemcitabine carboplatin (cisplatin ineligible)
31
# BCa Second- and Third-line chemotherapy
Post-platinum * Pembrolizumab (p) * Nivolumab * Avelumab * Erdafitinib * Enfortumab vedotin Post-ICI * Enfortumabd vedotin (p) * Gemcitabine cisplatin (cisplatin eligible) * Gemcitabine carboplatin (cisplatin ineligible) * Erdafitinib * ddMVAC (cisplatin eligible) Third-line * Erdafitinib * Enfortumab vedotin
32
# BCa Enfortumab vedotin
* PADCEV * antibody-drug conjugate * nectin-4 antibody (enfortumab) with microtubule inhibitor conjugate (vedotin) * SE: rash, peripheral neuropathy, fatigue, alopecia, weight loss, diarrhea, pruritis, decreased appetite, liver toxicity and nausea
33
# BCa post-BCG Irritative LUTS or allergic reaction 5
Short-term (2-3 days) * Antispasmodics, bladder anesthetics, NSAIDs * peri-instillation FQ Long-term or allergic reaction (1 week or more) * UCx (treat if +) * Bladder biopsy (granulomatous cystitis) * Isoniazid (NIH) 300mg PO qD and pyridoxine (vitB6) 25mg PO qD x3 months
34
# BCa BCG Sepsis or severe illness 9
* Blood culture * Urine culture * ICU * IV abx * Prednisone (shock) * Isoniazid (INH) x6m * Rifampin (watch for drug interactions) x6m * Ethambutol x6m * Pyridoxine (Vit B6) x6m
35
# BCa BCG Complications 11
* Fever 2.9% * Granulomatous prostatitis 1% * PNA/ hepatitis 0.7% * Arthralgia 0.5% * Hematuria 0.1% * Rash 0.3% * Ureteral obstruction 0.3% * Epididymitis 0.4% * Contracted bladder 0.2% * Sepsis 0.4% * Cytopenia 0.1% | JUrol 1992
36
# BCa Definitive bladder preservation therapy follow up | 4
* Reassess tumor status 2-3 months after treatment completion * s/p TMT: NMIBC - TURBT +/- intravesical therapy * s/p TMT: MIBC - consider cystectomy/ partial cystectomy or treat as metastatic * s/p RT only or TURBT only: systemic therapy or rpt TURBT +/- intravesical therapy or best supportive care
37
EV Pembro 5y survival
In 45 patients, 50% of patients had durable response at 5 years
38
Recurrence rates after BCG
20-45% within the first 3 years 25-33% at 5 years

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