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Uro Onc > 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 -> T3-T4a N0 M0 (T3-T4a)
T1-4a N1 M0 (N1)
Stage IIIb -> T1-T4a N2-3 M0 (N2-3)

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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
Q

BCa

Stage II Treament

A
  • 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
Q

BCa

Stage IIIa Treament

4

A
  • NAC then radical cystectomy
  • Cystectomy alone (cisplatin ineligible)
  • Trimodal therapy (maximal TURBT, chemoRT)
  • RT or Maximal TURBT (TMT ineligible)
27
Q

BCa

Definitive bladder preservation therapy follow up

4

A
  • 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
28
Q

BCa

Adjuvant therapy s/p cystectomy

3

A
  • 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
29
Q

BCa

Stage IIIb or Stage IVa Treatment Regimens

7

A

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

30
Q

BCa

Stage IIIb or Stage IVa response to treatment

7

A

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

31
Q

BCa

Stage IVb Treatment

A
  • 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)

32
Q

BCa

Second- and Third-line chemotherapy

A

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

33
Q

BCa

Enfortumab vedotin

A
  • 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
34
Q

BCa

post-BCG Irritative LUTS or allergic reaction

A

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

35
Q

BCa

BCG Sepsis or severe illness

A
  • Blood culture
  • Urine culture
  • ICU
  • IV abx
  • Prednisone (shock)
  • Isoniazid (INH) x6m
  • Rifampin (watch for drug interactions) x6m
  • Ethambutol x6m
  • Pyridoxine (Vit B6) x6m
36
Q

BCa

BCG Complications

A
  • 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

37
Q

BCa

BCG Sepsis

A
  • Blood culture
  • Urine culture
  • ICU
  • IV abx
  • Prednisone (shock)
  • Isoniazid (INH)
  • Rifampin (watch for drug interactions)
  • Ethambutol
  • Pyridoxine (Vit B6)
38
Q

EV Pembro 5y survival

A

In 45 patients, 50% of patients had durable response at 5 years

39
Q

Recurrence rates after BCG

A

20-45% within the first 3 years
25-33% at 5 years

Uro Onc (23 decks)

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