Bladder Flashcards
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Tis Ta T1 Staging
Tis -> Carcinoma In Situ
Ta -> Noninvasive papillary carcinoma
T1 -> Invades Lamina Propria
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T2 Staging
T2a -> Invades superficial muscularis propria
T2b -> Invades deep muscularis propria
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T3 Staging
T3a -> Microscopic perivesical fat invasion
T3b -> Macroscopic perivesical fat invasion
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T4 Staging
T4a -> Invades vaginal wall, prostate, seminal vesicles or uterus
T4b -> Invades pelvic side wall or abdominal wall
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N Staging
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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M Staging
M1a -> Distant metastasis to lymph nodes beyond common iliacs
M1b -> Non-LN distant metastasis
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Stage I
T1 N0 M0
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Stage II
T2 N0 M0
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Stage III
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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Stage IV
Stage IVa -> T1-4b N0-3 M0-1a (T4b, M1a)
Stage IVb -> T1-4b N0-3 M0-1b (M1b)
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NMIBC Low Risk
- PUNLMP
- solitary LGTa <3cm
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NMIBC Intermediate Risk
- LGTa >3cm
- Multifocal LGTa
- Recurrent LGTa (within 1 year)
- LGT1
- solitary HGTa <3cm
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NMIBC High Risk
- HGTa >3cm
- Multifocal HGTa
- HGT1
- CIS
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NMIBC Very High Risk
- BCG unresponsive
- Variant histology
- Lymphovascular invasion
- Prostatic urethral invasion
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Bladder Mass Workup
- 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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NMIBC repeat TURBT
- HG Ta
- HG T1
- Visually incomplete resection
- High- volume tumor
- No muscle in specimen
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Low Risk NMIBC Treatment
- Surveillance
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Int Risk NMIBC Treatment
- Intravesical Gemcitabine or Mitomycin (p)
- Surveillance
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High Risk NMIBC Treatment
- BCG (p)
- Cystectomy
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Very High Risk NMIBC Treatment
- Cystectomy (p)
- BCG
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BCG unresponsive or intolerant treatment
- Cystectomy (p)
- Intravesical chemotherapy
- Pembrolizumab (select pts)
- Nadofaragene firadenovec-vncg (select pts)
- Nogapendekin alfa inbakicept-pmin + BCG (select pts)
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Positive cytology with negative cystoscopy workup
- 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)
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Positive cytology with negative workup treatment
- Follow up at 3 month intervals, then longer
- If prior BCG, continue with maintenance
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MIBC Workup
- CT C/A/P
- Bone scan if indicated
- Labs (including alkaline phosphatase)
- Estimate eGFR
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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)
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Stage IIIa Treament
- NAC then radical cystectomy
- Cystectomy alone (cisplatin ineligible)
- Trimodal therapy (maximal TURBT, chemoRT)
- RT or Maximal TURBT (TMT ineligible)
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Definitive bladder preservation therapy follow up
- 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
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Adjuvant therapy s/p cystectomy
- 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
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Stage IIIb or Stage IVa Treatment
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
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Stage IIIb or Stage IVa response to treatment
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
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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)
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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
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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
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post-BCG Irritative LUTS
Short-term (2-3 days)
* Antispasmodics, bladder anesthetics, NSAIDs
* peri-instillation FQ
Long-term (1 week or more)
* UCx (treat if +)
* Bladder biopsy (granulomatous cystitis)
* Isoniazid (NIH) 300mg PO qD and pyridoxine (vitB6) 25mg PO qD x3 months
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BCG Sepsis
- Blood culture
- Urine culture
- ICU
- IV abx
- Prednisone (shock)
- Isoniazid (INH)
- Rifampin (watch for drug interactions)
- Ethambutol
- Pyridoxine (Vit B6)
Recurrence rates after BCG
20-45% within the first 3 years
25-33% at 5 years
