Bladder CA Flashcards by Kevin Chu

Give me the TNM for bladder CA

Tis: CIS
Ta: superficial
T1: invades lamina propria
T2: invades muscular wall (a: inner, b: outer)
T3: invades perivesical fat (a: micro b: macro)
T4: (a)adjacent structures/(b)pelvic wall

N1: 1 node near bladder
N2: more than one node near bladder
N3: node in abdomen

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What are risk factors for bladder CA?

Male > female, age, tobacco abuse, schistomiosis, radiation, chemical exposure (aromatic compounds), cyclophosphamide

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What metastatic imaging must have been performed in all bladder CA patients?

Upper tract imaging (CT preferred, but a lot will have had it done as part of hematuria workup)

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What is risk stratification for bladder CA

Low risk: LG Ta</= 3cm, PUNLMP

Medium risk: recurrent LG Ta within one year, LG Ta > 3cm, HG Ta </=3cm, multifocal LG Ta, LG T1

High risk: HG Ta >/= 3cm, HGT1, recurrent HG Ta, CIS, BCG failure in HG patient, variant histology, LVI, or HG prostatic involvement

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What are some variants?

micro papillary, sarcamatoid, nested, plasmacytoid

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What are important things to do for variant histology bladder CA?

Review with a GU pathologist.
Re-TURBT in 4-6 weeks if planning bladder sparing approach vs up front cystectomy

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What are the different types of urine biomarkers for bladder CA, and what are they useful for?

NMP22
BTA
FISH
ImmunoCyt
CxBladder

Mainly useful for IR and HR disease, to assess response to intravesical BCG (FISH), and for equivocal cytology (ImmunoCyt and FISH)

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When should re-resection be performed?

incomplete resection
high risk HGTa or HGT1

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When should mitomycin C be given?

in patients with LR or IR disease after TURBT

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What are chances for low risk disease to recur?

30-40%

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What are some BCG side effects?

sepsis, granulamtous prostatitis (and cystitis / orchitis), dysuria, hematuria, irritative voiding symptoms (tx with NSAID, anticholinergics, Pyridium)

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How to treat BCG sepsis?

Steroids + NSAIDs + RIPE
pyridoxine prevents peripheral neuropathy

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What happens if only persistent fever or UTI after BCG?

isoniazid x 3 months

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Which patients is BCG not good for?

Patients that don’t have an intact immune system (patients on chronic steroids for RA or mAB) - can use mitomycin C for these patientsW

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What to treat patient that is BCG refractory CIS and HR disease, but not surgical candidate?

Valrubicin

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What chance for recurrence in HR disease?

60-70%

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How long for maintenance therapy in patients of IR and HR?

IR - 3 weeks at 3,6,12 moths for a year
HR - 3 weeks every 3,6,12,18,24,30,36 for 3 years

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Which patient should get a second try at BCG if the first one had recurrence?

Ta or CIS
can be either six week induction or three week maintenance

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What about persistent disease in a patient with HR T1 disease?

How soon is high grade recurrence to show up where you don’t offer anymore BCG?

Two cycles of BCG, within 6 months

What to do if recurrence within 12 months?

clinical trial enrollment (if not cystectomy eligible) or try intravesical gemcitabine/docetaxel

What about recurrence for CIS in 12 months?

pembro or intravesical valrubicin

What is surveillance for each?

LR - cysto - 3 months, 6-9 months later, than yearly (up until 5 years)
IR and HR - cysto/cyto - q3 months for two years, q6 months for 2 years, then yearly

For IR and HR - upper tract imaging ever 1-2 years

What should you do every time you do a TURBT?

EUA - check to see if it is fixated disease

If found to have MIBC, what staging do you need to do?

CBC, CMP, Alk Phos, LFT, CXR (or Chest CT), CT A/P w/ IV contrast

What are you looking for on imaging?

extent of local disease to safely remove bladder, hydronephrosis, lymph nodes, distant mets, and upper tract disease

What are general ideal characteristics for a patient to undergo bladder preservation strategies for MIBC?

unifocal disease, can be fully resected, no hydronephrosis, LIMITED CIS remember, must get all team involved - med Onc, rad Onc, and urology

What must effects on QoL must you talk to patients for MIBC treatment?

sexual function, fertility, continence, metabolic dysfunction, bowel function (can have ileus, recurrent infections etc)

What are some contraindications for NAC?

poor ECOG >/= 2 hearing loss in one ear poor CrCL < 60 severe heart failure peripheral neuropathy

How soon to do cystectomy after NAC?

about 12 weeks

What happens if you are identified to have pT3/T4 or N disease after surgery?

For those who did not get NAC, get adjuvant chemotherapy or immunotherapy. For those who did get NAC, get adjuvant immunotherapy (nivolumab)

What do you counsel patient between bladder preservation vs cystectomy?

That the 5 year, 10 year survival rates are better with cystectomy. 28% vs 47%.

Can you preserve female reproductive organs?

If maintaining fertility is important, and cancer can be controlled, can do uterine / ovarian / vagina (anterior wall) sparing. If not important to maintain fertility, but still want to spare uterus, should still perform salpingectomy.

When do you do urethrectomy?

if the apical urethral margin is positive (can be immediate or delayed). Must always check for negative margin in neobladder patients.

What are contraindications to continent channels?

Poor hepatic and renal function (GFR < 45) Short bowel length Poor dexterity or psychological issues Postive urethral margin significant urethral stricture disease

If neobladder to be considered, what needs to be confirmed

negative urethral margin for females - if palpable mass (T3b) - then needs urethral AND vaginal margins

What else must you do to prepare patients for cystectomy?

Ostomy teaching!!!

What are boundaries of PLND?

Limited - genitofemoral, node of cloquet, obdurate nerve / external iliac, common iliac bifurcation (external iliac + obdurator nodes) Standard - common iliac bifurcation, bladder, obdurate / external iliac, node of cloquet (external iliac, obdurator, internal iliac (hypogastric)) - need at least 12 nodes

Which types of bladder CA are not ideal for bladder sparing?

cannot resect entire tumor, T3/T4, multifocal CIS, hydronephrosis

What kind of chemo is radiosensitive and good for trimodal therapy?

cisplatin or 5FU + mitomycin C or gemcitaibine

How should you survey?

Just survey like HR disease

What is surveillance / follow up after cystectomy?

chest imaging and CT A/P every six months for 2-3 years Labs - CMP every 3-6 months for two years then annually afterwards. consider B12 if heavy terminal ileum use cytology is not verified for use

What is chance for urethral recurrence

10% Monitor with urethral washes - cytology and physical exams, as needed

What are some metabolic derangement post urinary diversion?

Stones, electrolyte abnormalities, hepatic issues (ammonia), metabolic acidosis, short bowel syndrome

What do you counsel patients on continence with a neobladder?

Daytime continence is fine Nightlight continence is around 50% (due to loss of afferent input)