Bladder CA Flashcards
What is the most common presenting symptom in bladder cancer?
Painless haematuria
Seen in >80% of patients
What is the most common histology of bladder carcinomas?
Transitional cell carcinomas
Besides transitional cell carcinomas, what are the other histologies?
Lymphoepithelioma-like Sarcomatoid carcinomas Micro papillary or nested variants Primary squamous cell carcinomas Adeno carcinomas
What is the standard treatment of muscle-invasive bladder cancer?
Radical cystectomy with extended lymphadenectomy
What supports the use of CDDP-based neoadjuvant chemotherapy for bladder cancer?
Advanced Bladder Cancer Meta-analysis collaboration published in Eur Urology in 2005
A meta-analysis of 11 RCTs with 3000 patients
5% absolute increase in 5-year OS
9% absolute increase in 5-year DFS
This is compared with Radical cystectomy alone
What is the evidence for adjuvant chemotherapy for bladder cancer?
Leow et al. 2013 updated meta-analysis in Eur Urol 2014
Updated meta-analysis of 9 RCTs including 950 patients for usage of CDDP-based adjuvant chemotherapy
OS benefit with HR 0.8 and DFS benefit with HR 0.65
- DFS benefit more apparent in those with Positive lymph node involvement.
What are the clinical indicators that determine if a patient is suitable for bladder preservation?
Early tumor stage
- including high-risk T1 disease, T2
What are the 5 bladder tumor marker tests?
BTA-Stat BTA-TRAK NMP-22 uCyt+ UroVysion
Non shown to be superior to Urine cytology and cystoscopy
What are the risk factors for Bladder CA?
1) Age
2) Toxins
- Smoking
- Aniline-containing dyes, arsenic
- Phenacetin
- Arsenic
3) Chronic inflammation
- Chronic cystitis/UTI
- Schistosomiasis (S.Haematobium –> SCC)
4) Cytotoxic agents
- Pelvic RT
- Cyclophosphamde
Tell me about the bladder cancer staging for T.
Ta = Non-invasive papillary carcinoma
T1 = Tumor invades sub epithelial connective tissue
T2 = invades muscle
- T2a=invades superficial muscle (inner half)
- T2b=invades deep muscle (outer half)
T3 = invades perivesical tissue
- T3a=microscopically
- T3b=Macroscopically with extravehicular mass
T4=Tumor invades any of the following: prostate, vagina, pelvic wall/abdominal wall
- T4a=invades prostate, uterus, vaginalis
- T4b=invades pelvic wall/abdominal wall
Tell me about the N staging for bladder cancer
Regional LN are those within true pelvis.
All others are distant lymph nodes
N1 = mets in a single LN, 2cm or less
N2 = Single lymph node, >2cm, but 5cm or smaller; OR
- multiple LN, but none >5cm
N3 = Mets in a LN >5cm
How does completeness of TURBT relate to OS?
Completeness of TURBT is a strong prognostic factor for OS for both superficial and muscle-invasive disease
R0 = 10y OS 50% R1 = 10y OS 30% R2 = 10y OS 20%
What are the characteristics that are a/w higher chance of recurrence?
High Grade
Diffuse Tis alone or in a/w papillary tumors
>3 bladder lesions (any >3-5cm)
Vascular invasion
T1b - invasion of the deep portion of the lamina propria
Multiple recurrences within a short period of time (eg >2 in a year)
Incomplete resection due to diffuse bladder involvement or unfavorable location
Presence of tumor within 3-6 months after initial TUR
What is considered intermediate and high risk disease?
Multifocal Tis
G3 Ta or T1 with Tis
Rapidly recurring after TURBT
When do you treat with prophylactic intravesical chemotherapy ?
Immediately after TURBT (within 24 hours) for ALL superficial bladder cancer
What is the usual treatment for prophylactic intravesical chemo?
Usually Mitomycin-C
40mg in 40 Mls
Evidence comes from meta-analysis of 1500 patients of 7 RCTs over 3.5 years
- Sylvester 2004 in J Urol
What is the additional therapy for intermediate and high risk disease?
BCG most commonly used
Alternatives: Mitomycin C, or Epirubicin
Induction course of BCG once every week for 6 weeks–>
Intermittent maintenance cycles of e-week courses repeated Q3-6monthly –>
Q6-monthly up to 3 years
- This provides a 20% absolute reduction in recurrence rate
- Saint et al 2001 Urology
What are the agents used in intravesical treatment?
1) Intravesical BCG
2) Intravesical Chemotherapy
- Thiotepa
- Mitomycin-C
- Epirubicin/Doxorubicin
How would you monitor a patient after TURBT?
1) Cystoscopy
2) Urinary Cytology
3) Image upper urinary tract every 12-24 months as there is a 5% lifetime risk for development of upper tract tumor after Dx of bladder cancer
Cystoscopy/cytology:
- every 3 months for 2 years
- 6-monthly for 2 years
- yearly indefinitely
What are the side-effects of BCG?
Frequency (70%) Cystitis (70%) Fever (25%) Haematuria (25%) BCG-osis = BCG-sepsis (very rare, but can be fatal)