Bladder Flashcards
What is average age of bladder cancer?
70
What are major contributors to risk for bladder cancer in western world?
Smoking (66%) Occupational (20%) -truck driving -painting -aluminum, leather and textile work Cyclophosphamide Prolonged expsoure to bladder irritants (25 x) -indwelling foley -cystitis -renal calculi -neurogenic bladder
What are major contributors to risk for bladder cancer in non-western world?
schistosomiasis
Current recs for screening in bladder cancer?
Only in symptomatic patients
- macro or microscopic hematuria (very common), irritable bladder symtpoms, flank or pelvic pain, leg swelling, DVT
Two categories of bladder cancer according to WHO/ISUP? Based on?
Low grade
High grade
unclear aplasia and architectural abnormalities
What are pathologic subtypes of bladder cancer?
Transitional Cell Carcinoma (90%) Squamous Cell Carcinoma (3-5% in USA, high in non-western) Other (1-2%) -Adenocarcinoma -Small Cell Neuroendocrine
What 3 catergories of bladder cancer?
non-muscle invasive (superficial)
muscle invasive
metastatic
What should be performed prior to TURBT for non-invasive disease?
imaging of upper tract collecting system
CT urography, renal US or CT w/o contrast w/ retrograde pyelogram)
What appearance on cytoscopy pushes you to you perform CT abd/ pelvis with contrast?
lesions is sessile or high grade
What is work up for invasive bladder cancer?
CBC, Chemistry
Alk phos
- if elevated: Bone scan
CT C/A/P
staging summary for bladder cancer?
0-I: non invasive
II: muscle invasion
III: adipose invasion (a: microscopic, b: macroscopic)
IV: metastatic to regional nodes, or organs
N staging summary for bladder cancer?
N1: 5cm
What comprises non-muscle invasive tumors
Ta: low grade papillary
Tis: carcinoma in situ
T1: subepithelial tissue invasion
Why is it important to important to evaluate with CT prior to TURBT for high grade, solid or muscle invasive disease on inital cystoscopy?
Eval local tumor extent, abd lymph nodes, as well as synchronous and metachronous upper tract lesions (1-4%)
Difference between initial cystoscopy and confirmatory TURBT?
Cysto gives likely diagnosis based on experience and visualization whereas TURBT gives pathologic confirmation.
In what situations is a TUR likely insufficent for non-invasive bladder cancer?
Tumor > 3cm, multifocal lesions, adjacent CIS and recurrence within 2-3 months of resection
What is BCG?
bacillus Calmette-Guerrin , a live attenuated strain of Mycobacterium bovis
When and why is BCG used?
Adjuvant for high grade Ta, TIS or T1, to reduce risk of recurrence. (can pass for low grade Ta only)
What is dose of induction BCG? Data?
120mg intravesicularly for 6 weeks
Herr eta al JCO 1995, showed 10 survival advantage of 75% versus 55%.
Maintenance BCG? Data
weekly for 3 weeks every 6 months over 2-3 years superior to induction alone.
Malmstrom et al Eur Urology 2009
What is most common side effect in patients receiving BCG? When is one concerned for systemic infection?
- self-limited localized BCG cyctitis with increased urinary frequency, low grade fever and hematuria
- if symptoms persist beyond 48 hours
When is cystectomy recommended for non-invasive disease?
Failure to control CIS or recurrence of T1 tumor at 6-12 months despite standard therapy.
What T stages of muscle invasive disease is resectable?
T2:muscle invasion
T3:perivesicular fat invasion
T4a:pelvic organ invasion only (prostate, uterus, vagina)
What is recommended for those seeking bladder preservation despite muscle invasive disease? Most prolific author on this subject?
Agressive TUR followed by concurrent chemoradiation with cisplatin.
-Shipley
What is standard recommendation for muscle-invasive bladder cancer that is resectable?
neoadjuvant chemotherapy
- CMV (cisplatin, mtx and vinblastine)
- MVAC (+doxorubicin, phase III SWOG, 3 cycles, median OS 77% vs 46%)
What is median survival of metastatic bladder cancer with aggressive chemotherapy?
14 months
What is standard firstline therapy in metastatic bladder cancer?
MVAC
- mtx 30 mg/m2 day 1, 15, 22
- vinblastine 3mg/m2 day 2, 15, 22
- doxorubicin 30mg/m2 & cisplatin 70mg/m2 on day 2
What alternate regimen can be used first line for metastatic bladder cancer, if favorable saftey profile is desired? Data?
GC
-Gemcitabine 1000mg/m2 days 1, 8, 15
-Cisplatin 70mg/m2 day 2
Von der Maase JCO 2000 (similar RR (47% vs 46%), TTP (7.4 months) and MS (13.8 vs 14.8 months)
Does the addition of paclitaxel help GC?
overall and complete responses improved, but median survival was not statistically different (15.7 vs 12.8 months, p=0.1)
What is salavge therapy for metastatic bladder cancer?
No standard, single agents show 20% or less RR
