Bladder Cancer Flashcards
Initial workup
Thorough cysto and EUA
Complete resection + MMC if low risk
Upper tract imaging
If normal cysto but positive cytology, biopsy the prostatic urethra
Low risk bladder cancer risk category
Single TaLG <3cm
PUNLMP
High risk bladder cancer risk category (8)
Recurrent TaHG
TaHG >3cm (or multifocal)
T1HG
CIS
BCG failure in HG patient
Variant histology
LVI
HG prostatic urethral involvement
Intermediate risk bladder cancer category
TaLG recurrence within 1 year
TaLG >3cm
Multifocal TaLG
TaHG <3cm
T1LG
What should happen if variant histology?
Re-review path by GU pathologist
Management of variant histology
ReTURBT within 6 weeks if desires bladder sparing (be careful)
Upfront cystectomy (except small cell)
Do urine markers replace cysto
Na Brah
What is the role of urine biomarkers
BCG response and equivocal cytology (FISH)
When should a re-TUR be performed?
-6 weeks for variant histology desiring bladder preservation
-High risk TaHG, T1HG
Who should get intravesical chemo after TURBT?
Low or intermediate risk (gem or MMC)
-SKIP if perf
Management of index intermediate risk disease
Consider BCG or MMC is best
How to give MMC
Dehydrate
Alkalinize urine
Empty bladder first
Management of index high risk disease
BCG (any strain, any strength)
Can an intermediate risk patient get BCG maintenance after responding?
Yes - for 1 year
Can high risk BCG responders get maintenance?
Yes - 3 years
BCG –> persistent/recurrent Ta/CIS management
BCG induction #2
BCG –> persistent T1HG
Cystectomy
Clinical trial is optional
Pembro if CIS is optional
Can TaHG patients get Cystectomy?
Yes but only after everything else has been exhausted
Should blue light be offered?
Yes (or NBI)
When should the first surveillance cysto happen?
3 months after treatment
Low risk surveillance regimen
Cysto at 3 and 9 months, then annually for 5 years
No repeat upper tract imaging necessary
TaLG recurrence management option
Office fulg or TURBT
Intermediate risk surveillance
cysto at 3, 6, 12, 18, 24, then annually
Image upper tract every 1-2 years
High risk surveillance
Cysto every 3 months for 2 years, then every 6 months for 2 years, then annually
Image upper tracts every 1-2 years
Staging workup for MIBC
Cross-sectional imaging of the chest and abdomen with contrast
CBC, LFTs, AP, BMP
Bladder cancer T staging
Ta noninvasive papillary
Tis CIS
T1 Invades lamina propria
T2 invades muscularis propria
T3 invades perivesical tissue
-pT3a microscopic
-pT3b macroscopic
T4 local invasion
-T4a prostate, SVs, uterus, vagina
-T4b pelvic or abdominal wall
Bladder cancer N staging
N1 single node in true pelvis
N2 multiple nodes in true pelvis
N3 node in common iliac
M1a is node above common iliac (tricky!)
Cisplatin ineligible treatment for MIBC
Cx if candidate (e.g. skip carbo)
How much time should pass between NAC and Cx?
12 weeks or less
Management of cisplatin-naive pT3/pT4/N+ path on Cx
cisplatin adjuvant therapy
what should be removed at the time of cystectomy?
Men - bladder, prostate, SVs
Women - bladder, consider other organs
When should sexual function sparing surgery be done at the time of Cx?
No bladder neck, urethra, or prostate involvement
When planning an orthotopic diversion, what additional surgical step must be taken?
Urethral margin
What is the minimum LND for Cx?
external and internal iliac LNs
Obturator LNs
Bladder sparing treatment steps
Max TURBT
Check for CIS
Radiation sensitizing chemo
Surveillance for MIBC after treatment
CT q6months for 3 years then annually
Labs q3months
Monitor urethra for recurrence
Is chest imaging required for NMIBC?
Nope
Bladder cancer risk factors
Smoking
Male
Age
Radiation
Exposures (paints, dyes)
Phenacetin
Cytoxan
Pioglitazone
Schistosomiasis
Chronic cystitis (catheter, stones, etc)
Natural history of bladder cancer
Ta - 50% will recur, <5% will progress
T1 - 80% will recur, 50% will progress
CIS - 80% will recur, 20% will progress
What is mitomycin C
-Alkylating agent, inhibits DNA replication
-Better in alkaline urine
-Can cause contact dermatitis, bladder irritation
Treatment of CIS
Induction BCG
Contraindications to BCG
Immunosuppressed
Prior hypersensitivity reaction
Traumatic Foley
Recent resection (wait at least 2 weeks)
UTI or fever
BCG maintenance regimen
1 BCG per week for 3 weeks at 3 and 6 months, then every 6 months for 1-3 years
Preop considerations for cystectomy
Almivopam
Counsel on diversion options
Mark stoma
type and cross
antibiotics
Borders for extended lymph node dissection
Genitofemoral nerve lateral
Bladder medial
Common iliac artery proximal
Femoral canal distal
