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02. Urotelial Cancer (1375) > Bladder cancer > Flashcards

Bladder cancer Flashcards

1
Q

presentation - musc vs non musc inv, vs metastatic

A

75% non musc, 20% musc, 5% metastatic

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2
Q

cigaretter smoking dose threshold

A

dose dependent but 40 pk yrs is esp important. no risk plateau

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3
Q

4 things assd w bilateral upper tract ca

A

arsenic, balken nephropathy, bracken fern, aristolochia fangchi

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4
Q

2 polymorphisms confering higher suceptibility to environmental carcinogens

A
  1. slow acetylators, 2. glutathione s transferase M1 null
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5
Q

congential condition w higher risk of adnenoca

A

extrophy

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6
Q

iatrogenic condition w higher risk of adnenoca

A

ureterosigmoidostomy

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7
Q

signet cell adenoca significance

A

very bad

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8
Q

small cell/neuroendocrine markers - 3

A

synaptophysin, chromogranin, neuron speciic enolase

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9
Q

tx for small cell

A

VP-16 then cystectomy for ANY stage

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10
Q

3 premalignant lesions

A
  1. leikoplakia (20% risk of SCC), 2. cystitis glandularis (adenoca), 3. inverted papilloma (assd w TCC elsewhere)
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11
Q

benign lesions - 5

A

squamous metaplasia (50% females), nephrogenic adenoma (turbt), cystis cystica / follicularis, pseudosarcoma (spindle cell tumor), malacoplakia (rxn to chronic UTI)

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12
Q

significance of 9q loss

A

low grade tcc

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13
Q

significance of high p53, KI 67, matril metaloprotease

A

high grade

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14
Q

what is KI 67

A

marker of proliferation

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15
Q

tetraploidy significance

A

normal - found in umbrella cells

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16
Q

sig of low RB, e-cadgerin, p27

A

high grade

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17
Q

what is RB

A

“cell cycle brake” - loss promotes cancer proliferation

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18
Q

sig of high urokinase type pasminogen activator

A

high grade

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19
Q

nephrogenic adenoma sx

A

hematuria, dysuria, frequency

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20
Q

clinical stage for fixed vs palpable mass after turbt

A

fixed - T4, palpable - ct3

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21
Q

rate of understaging if no muscle in T1 specimen

A

50%

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22
Q

chance understaging in T1 with muscle in specimen or chance of leaving tumor behind

A

10-20% understaging, 30-50% residual tumor behind

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23
Q

retur?

A

all high grade T1 reduces understaging to < 10%

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24
Q

tumor in diverticulum - Ta vs T1

A

Ta - can be safely removed, T1 - may need partial cystectomy

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25
Q

2 situations where intraperitoneal perf can be managed conservatively

A
  1. small and late in TUR - switch to glycine, 2. large/ assd w bleeding or early in TUR - stop and retuen another time
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26
Q

absolute indication to e-lap in intraperitoneal bladder injury

A

bowel injury

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27
Q

LVI in T1 - prognostic sig - 3

A

88% chanc of understaging, increased occult LN mets, decreased survival

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28
Q

LVI mgmt in T1 - 2

A

early cystectomy with neoadjuvant chemo

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29
Q

risk of recurrence at 2 yrs vs 4 yrs for HG TCC

A

80% vs 20%

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30
Q

things primarily affecting recurrence - 4

A

prior recurrence > 1x/yr, multifocality, tumor > 3 cm, recurrence at 3 mo cysto

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31
Q

things affecting progression

A

CIS, stage (T1/CIS)

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32
Q

low risk bca - 3

A

low grade, solitary, Ta

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33
Q

progression risk for low risk

A

<5% @5 yrs

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34
Q

intermediate risk - 2

A

recurrent OR multifocal Ta/T1 low grade

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35
Q

progression risk for intermediate risk

A

10% at 5 yrs

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36
Q

high risk

A

any high grade (CIS, Ta, T1)

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37
Q

highest risk

A

multifocal T1G3+CIS

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38
Q

progression risk for high risk

A

25-50% @ 5 yrs

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39
Q

post TUR agents - 3

A

mitomicin, thiotepa, doxorubicin

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40
Q

when to give post TUR chemo

A

within 6 hrs

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41
Q

dwell time for post tur agents

A

30-60 minutes

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42
Q

what agent does not cause severe local tissue reaction/peritonitis with perforation

A

thiotepa

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43
Q

thiotepa risk with perf

A

myelosupression (lowest molecular weight)

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44
Q

benefit of post chemo agent

A

25-50% relative risk of recurrence, 15% absolute risk reduction

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45
Q

techniques for optimization of intravesical chemo (delayed) - 4

A
  1. relative dehydration, 2. empty bladder prior to instillation, 3. increase concentration (40 mg in 20 cc water), 4. alkalinize urine with po bicarb (reduces mitomicin degradation)
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46
Q

mitomycin toxicity

A

hypersensitivity, palmar rash, bladder contracture

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47
Q

thiotepa toxicity

A

myelpsupression- have to check weekly CBC

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48
Q

who is intravesical chemo best for

A

intermediate risk papillary, or if BCG is contraindicated

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49
Q

effect of intravesical chemo

A

recurrence only, no effect on progression

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50
Q

limitations of multidose chemo -3

A
  1. reduces recurrence only, 2. ineffective if prior bcg failure, 3. failure of 1 chemo agent increases failure likelyhood of another chemo agent
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51
Q

contraindications to BCG dose - 4

A
  1. traumatic cath, 2. recent gross hematuria, 3. unresolved UTI, 4. significant immunosupression or autoimmune disease
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52
Q

what are not contraindications to BCG - 4

A
  1. reflux, 2. hx treated TB, 3. positive PPD, 4. prosthetic devices
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53
Q

benefit to BCG

A

30% reduction in recurrence and progression

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54
Q

BCG MOA - 2

A
  1. T-helper type 1 immune response (inc IL2 and interferon gamma), 2. opposed by T helper type 2 response (increased IL-4 and IL-10)
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55
Q

1st steps to improve BCG tolerance

A

sx relieving drugs - antichol, pyridium

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56
Q

alternate methods of improving BCG toelrance - 3

A
  1. BCG dose reduction, 2. space tx out to 2 wks apart, 3. decrease dwell time to 30 mins
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57
Q

BCG sepsis meds - 2 steps

A

3-6 months with INH, or triple therapy (INH, ethambutol, rifampin) if severe case + steroids(!) in acute phase

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58
Q

supplementation with INH

A

B6, pyridoxine

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59
Q

mgmt of BCG prostatitis

A

anti tb meds

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60
Q

most common cause of BCG sepsis

A

traumatic catheterization

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61
Q

low, intermediate, high risk and chemo/BCG

A

low - postop chemo only, intermediate/high - postop chemo + 6 wk chemo or BCG + maintenance

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62
Q

indications for upfront cystectomy in nonmuscle invasive disease - 7

A

unfavorabel histology, LVI, bulky/incompletely resectable T1 HG, BCG failure x 2 in T1HG, prostatic stromal invasion, HGT1 in bladder diverticulum, bladder cripple with recurrent disease

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63
Q

unfavorable histology qualifying for upfront cystectomy

A

SCC, small cell, adenoca, nested or plasmacytoid, micropapillary

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64
Q

relative indications for RC

A

T1HG after repeat TUR, T1HG after BCG x 1, multifocal T1HG + CIS at presentation

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65
Q

upper tract studies - low risk, multifocal low risk, high risk

A

low risk - initial study only, multifocal low risk, every 2 yrs, high risk - q 1-2 yrs

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66
Q

delay in tx of small Ta with hx low/intermediate risk disesae

A

safe - 2 mm growth per mo

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67
Q

when is selective positive upper tract cytology unreliable

A

visible bladder tumor or bx + CIS - contamination

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68
Q

in female, if bladder workup negative for positive cytology

A

check gyn source

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69
Q

outcome if initial workup of positive cytology is negative

A

bladder source eventually in 80%

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70
Q

bcg failure vs chemo failure

A

bcg failure responds to 2nd line bcg (30-50% response) but not to chemo, chemo failure responds to bcg like untreated patient

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71
Q

most common cause of death in bladder ca

A

distant mets at the time of locoregional tx

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72
Q

what timeframe does progression of cancer happen after locoregional tx

A

within 2 yrs

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73
Q

small cell associated paraneoplastic syndromes - 3

A

ectopic ACTH, hypercalcemia, hypophosphatemia

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74
Q

T2a/b

A

Ta2 - inner muscle, b - outer muscle

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75
Q

T4a

A

t4b - prostate stroma (via SV, urethra, or bladder neck), vag, uterus, rectum. mobile. T4b - pelvic side wall, fixed

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76
Q

CIS of prostatic urethra or ducts and stage?

A

does not upstage as outcome is determined by primary bladder ca

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77
Q

most significant pathologic risk for progression

A

LN status

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78
Q

% upstaging from T1 at TUR to T2 at RC

A

40%

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79
Q

hydro on preop workup and cT stage

A

cT3

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80
Q

prostate prior to RC

A

always do prostate biopsies at 5/7 oclock. if neg, dont need to send urethral margin at RC

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81
Q

when to absolutely get CT chest other than abn cxr

A

T4, N+ on c stage

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82
Q

when to preserve uterus/vagina in F

A

better support when considering neobladder

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83
Q

when can a female not have orthotopic diversion

A

anterior vaginal wall invovlement b/c have to remove urethra

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84
Q

when not to preserve urethra in F and mgmt

A

poster based invasice ca. have to include a small strip of anterior vag for margin.

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85
Q

prostate/SV sparing RC

A

investigational as prostate is involved 40% of the time

86
Q

extended LN dissection and survival

A

no current evicence extended LN dissection (to IMA) improves survival.

87
Q

extended LN dissection and tumor involvement

A

involved in upto 50% of T3/4

88
Q

4 situations to abort cystectomy

A
  1. LN disease unresectable, 2. extensive periureteral disease, 3. fixation to pelvic side wall, 4. invading rectum
89
Q

when can you keep the urethra if there is tumor involvement

A

small, papillary tumors that have been resected

90
Q

recurrent urethral TCC risk and diversion type

A

lower with orthotopic vs cutaneous diversion

91
Q

how to preserve urethral innervation in female

A

limit dissection to above endopelvic fascia

92
Q

nerve sparin cystectomy?

A

only if no evidence of local extension intraoperatively. 40% achieve erections. age dependent

93
Q

CIS of ureter or prostate and outcome

A

not associated with poor outcome

94
Q

noncontiguous vs contiguous involvement of prostate and outcome

A

contiguous = very bad, T4 disease

95
Q

all of the following surgical LN characteristics impact survival: 5

A

LN, # LN positive, % LN positive, path stage of tumor, extranodal extension

96
Q

death and women

A

upto 50% higher risk of death

97
Q

timeframe to recurrence

A

most within 1st 3 yrs

98
Q

who needs annual upper tract monitoring post cystectomy - 3

A

urethral margin, + ureteral margin, CIS

99
Q

tumor location for partial cystectomy

A

dome of the bladder, away fro ureteral orifaces

100
Q

partial cystectomy outcome

A

poorer outcome.

101
Q

poor pronostic features in EBRT of bladder - 4

A

anemia, T3a> or T4, hydronephrosis, CIS (radioresistant)

102
Q

benefit of neoadjuvant chemo

A

5% overall survival benefit

103
Q

who benefits most from adjuvant

A

residual micromets

104
Q

FGFR3 mutation and tcc type

A

Ta papillary

105
Q

P53 chromosome location

A

short arm of 17

106
Q

P53 pathway

A

DNA damage –> inc P53 –> P21 –> cell cycle arrest (G1-S)

107
Q

RB gene location

A

chr 13q

108
Q

where are mets most likely after chemo and why

A

cns - privelaged site

109
Q

positive prognostic factors for chemo in mets - 2

A

LN only mets, asymptomatic

110
Q

mgmt of solitary mets post chemo

A

resect

111
Q

(absolute) criteria for neobladde - 5

A

live expectancy > 1 yr, manual dexterity (need for CIC), cr cl > 50 or cr < 2, normal bowel function, urethra not involved by cancer

112
Q

study to do before using colon in reservoir

A

colonoscopy

113
Q

who is not excluded from orthotopic neobladder - 3

A

> 80 yo, locally advanced disease, prior pelvic rsadiation

114
Q

absolute contraindication for neobladder in F

A

ca at bladder neck or posterior bladder. must retain distal 2/3 urethra for nl urinary function

115
Q

signifance of urinary retention in men post nb

A

likely suggests recurrence

116
Q

bowel segment to use for cutaneous diversion if prior pelvic radiation

A

transverse colon

117
Q

use fo turnbull stoma

A

eliminates risk of stomal stenosis

118
Q

what is hematuria/dysuria syndrome

A

reduced HCL secretion = loss of feedback on gastrin secretion –> peptic ulcers, hematuria

119
Q

cause of diarrhea after urinary diversion and mgmt

A

fat malabsorbtion and bile salt irritation of colon.

120
Q

mgmt of persistent diarrhea after colon conduit

A

metamucil –> antimotility drugs –> cholestyramine

121
Q

pathophys of increased renal calculi in diversion

A

decreased bile acids –> fat malabsorbtion and ca binding –> increased oxalate

122
Q

Post TURBT Algorithm NMIBC

A
123
Q

Genetic predisposition to NMIBC:

A

GSTM-1 and NAT-2

The most-studied genes associated with BlCa are N-acetyltransferase 2 and a deletion of glutathione S-transferase µ. Both of these genes are associated with the ability to metabolize aromatic amines and thus play an important role in the subset of individuals with environmental carcinogen exposure.

MSH2 (Lynch Syndrome)

Mismatch repair gene

LOH of ch. 9p, homozygous deletion of CDKN2A and loss of expression of p16

CIS → TP53, RB1, PTEN, oncogenes…

124
Q

Bladder cancer T staging:

A

Ta: non-invasive papillary

Tis: CIS

T1: invades lamina propria

T2: invades muscularis propria

T2a: superficial muscularis propria (inner half)

T2b: deep muscularis propria (outer half)

T3: invades perivesical tissue/fat

T3a: invades perivesical tissue/fat microscopically

T3b: invades perivesical tissue/fat macroscopically (extravesical mass)

T4: invades prostate, uterus, vagina, pelvic wall, abdominal wall

T4a: adjacent organs (uterus, ovaries, prostate stroma)

T4b: invades pelvic wall and/or abdominal wall

125
Q

N and M for bladder cancer

A
126
Q

Stages for TNM bladder cancer, 0a - IV b

A
127
Q

CSS in high-grade dz:

A

Ranges 70-85% at 10 years

128
Q

At time of TURBT, clinicians SHOULD document and perform cystoscopic exam of what? Additionally, they should perform what type of resection?

A

GUIDELINE STATEMENT 1

Entire urethra and bladder

Document tumor size, location, configuration, number, and mucosal abnormalities

GUIDELINE STATEMENT 2

A complete visual resection when feasable

129
Q

Define low risk NMIBC

A

Low risk

LG solitary Ta < 3 cm

PUNLMP

130
Q

Define intermediate risk NMIBC:

A

Intermediate risk:

Recurrent w/in 1 year, LG Ta

Solitary LG Ta > 3 cm

LG Ta, multifocal

HG Ta, < 3 cm

LG T1

131
Q

Define high risk NMIBC:

A

HG T1

Any recurrent, HG Ta

HG Ta, > 3 cm (or multifocal)

Any CIS

Any BCG failure in HG pt

Any variant histology

Any LVI

Any HG prostatic involvement

132
Q

Besides resection/cysto, what else SHOULD be performed as part of initial workup of bladder cancer patient?

A

GUIDELINE STATEMENT 3

Upper tract imaging (tumors <5%)

RGP, CT/MRI urogram, US

Risk stratified and generally w/in 6 mo of dx and every 1-2years (high risk)

133
Q

What SHOULD a clinician consider in a pt with NMIBC and normal cystoscopy and positive cytology?

A

GUIDELINE STATEMENT 4

prostatic urethral biopsies and upper tract imaging

consider enhanced techniques (blue light), URS, random bladder bx

134
Q

At each occurrence/recurrence, clinicians SHOULD:

A

GUIDELINE STATEMENT 5

assign clinical stage and classify risk category

135
Q

In variant histology results, what is recommend:

A

GUIDELINE STATEMENT 6

review of pathology by experience GU pathologist

(micro-papillary, plamacytoid, nested, neuroendocrine, sarcomatoid)

extensive squamous or glandular differentiation or presence of LVI

136
Q

If pt with variant histology (presumed non-invasive) considering bladder preservation, the clinician SHOULD perform and offer?

A

GUIDELINE STATEMENT 7

perform re-staging TURBT in 4-6 weeks

*r/o MIBC (high rate upstaging)

GUIDELINE STATEMENT 8

Offer radical cystectomy

137
Q

Is there a role of urinary biomarkers for surveillance of NMIBC?

A

GUIDELINE STATEMETN 9

NOT in lieu of cysto

cytology is mainstay despite drawbacks

5 markers are FDA approved

GUIDELINE STATEMENT 10

low risk cancer and normal cysto, do not routinely use biomarker or cytology for surveillance

138
Q

When are urine biomarkers recommended?

A

GUIDELINE STATEMENT 11

In NMIBC to assess response to BCG (UroVysion FISH) and to adjudicate equivocal cytology (UroVysion FISH and ImmunoCyt)

139
Q

What instances get a repeat TURBT?

A

GUIDELINE STATEMENT 12

incomplete initial resection (not all visible tumor)

GUIDELINE STATEMENT 13

high risk, HG Ta, consider repeat in 6 weeks (residual tumor up to 50% time, 15% upstaged)

GUIDELINE STATEMENT 14

T1, of primary tumor site to include muscularis propria in 6 weeks (upstage in 40-50% w/o muscle and 15-20% with muscle, improved BCG response, tx with mitomycin → lower recurrence and progression)

140
Q

In patient with suspected or known low- or intermediate risk bladder cancer, clinicians SHOULD:

A

GUIDELINE STATEMENT 15

administration of single post operative chemo (Gemzar 2g/100mL, mitomycin)

GUIDELINE STATEMENT 16

Low-risk → NO intravesical induction

GUIDELINE STATEMENT 17

Intermediate-risk → consider 6 week induction (such as mitomycin, gemcitabine, epirubicin, or docetaxel in leiu of BCG due to shortage)

141
Q

In high-risk newly dx CIS, HG T1 or high risk Ta, what SHOULD be done:

A

GUIDELINE STATEMENT 18

Induction 6 week BCG

**If not available, these patients and other high-risk patients may be given a reduced 1/2 to 1/3 dose, if feasible, if no supply, omit maintenance or limit to 1 year

Gemcitabine, epirubicin, docetaxel, valrubicin, mitomycin, or sequential gemcitabine/docetaxel or gemcitabine/mitomycin may also be considered with an induction and possible maintenance.

Insufficient evidence to support strain, strength, or combo BCG tx

142
Q

In intermediate-risk pt who responds to induction, may utilize:

A

GUIDELINE STATEMENT 19

Maintenance

Monthly for 6-12 mo

GUIDELINE STATEMENT 20

if given BCG and responds → maintenance 1 year (if supply)

143
Q

In high-risk patients who respond to BCG, maintenance:

A

GUIDELINE STATMENT 21

Continue for 3 years

3 weekly installments at 3, 6, 12, 18, 24, 30, 36 mo

144
Q

For persistent or recurrent disease or positive cytology following intravesical therapy, clinicians SHOULD consider:

A

GUIDELINE STATEMENT 22

prostatic urethral biopsy and upper tract evaluation before repeat intravesical therapy

*UC especially CIS considered “field-change” dz, entire urothelium at risk

Tumor recurrence involves prostatic urethra in 24-30% of NMIBC

Blue light cysto improves CIS detection by 20-40%

145
Q

Pt with persistent Ta or CIS dz after induction intravesical BCG SHOULD be offered:

A

GUIDELINE STATEMENT 23

A second course of induction

146
Q

In a patient with persistent/recurrent HG T1 dz after single induction of BCG, SHOULD be offered:

A

GUIDELINE STATEMENT 24

Radical Cystectomy if fit for surgery

147
Q

When is an additional course of BCG not appropriate?

A

GUIDELINE STATEMENT 25

Intolerance of BCG

Documented recurrence on TURBT of HG dz or CIS w/in 6 mo of 2 courses BCG or induction + maintenance

148
Q

What treatment can be offered for persistent or recurrent intermediate- or high-risk NMIBC w/in 12 months of completion of adequate BCG therapy?

A

GUIDELINE STATMENT 26

BCG (2 inductions or induction + maintenance)

radical cystectomy

unwilling or unfit for cystectomy → alternative intravesical agent (valrubicin, gemcitabine, docetaxel, combo)

clinical trials

Systemic immunotherapy with pembrolizumab for CIS

149
Q

Outline role of cystectomy in NMIBC:

A

GUIDELINE STATEMENT 27

Ta low- or intermediate- risk dz → DO NOT perform RC until bladder sparing modalities have failed

GUIDELINE STATEMENT 28

Persistent HG T1 on repeat resection, or T1 tumors with CIS, LVI, variant → offer RC

GUIDELINE STATMENT 29

High-risk with persistent or recurrent dz w/in 12 mo of appropriate BCG → offer RC

150
Q

What is the role of enhanced cystoscopy?

A

GUIDELINE STATEMENT 30

offer blue light cysto at time of TURBT if available → increase detection, decrease recurrence

Hexaminolevulinate (HAL) FDA approved for BLC

GUIDELINE STATEMENT 31

Consider use of narrow band imaging (NBI) to increase detection and decrease recurrence

151
Q

Discuss surveillance protocol for low- risk patient:

A

Reminder: LG solitary Ta < 3 cm, PUNLMP

GUIDELINE STATEMENT 32

first cysto in 3-4 mo

GUIDELINE STATEMENT 33

after first surveillance cysto neg, repeat cysto in 6-9 mo, then annually thereafter, after 5 year in absence of recurrence → SDM

GUIDELINE STATEMENT 34

Asx low-risk patient, should Not perform routine surveillance upper tract imaging

GUIDELINE STATEMENT 35

LG Ta and noted sub-cm papillary tumor (s), may consider in-office fulguration

152
Q

Describe surveillance protocol for intermediate risk dz:

A

Reminder: Recurrent w/in 1 year LG Ta, Solitary LG Ta > 3 cm, LG Ta, multifocal, HG Ta, < 3 cm, or LG T1

GUIDELINE STATEMENT 36

first surveillance cysto 3 mo

if neg, subsequent cysto and cytology every 3-6 mo for 2 years, q 6-12 mo for years 3-4, then annually after 5 years

GUIDELINE STATEMENT 38

intermediate- or high-risk patients should consider upper tract surveillance imaging at 1-2 year intervals

153
Q

Describe high-risk surveillance protocol:

A

Reminder: HG T1, Any recurrent, HG Ta, HG Ta, > 3 cm (or multifocal), Any CIS, Any BCG failure in HG pt, Any variant histology, Any LVI, Any HG prostatic involvement

GUIDELINE STATEMENT 37

first surveillance 3 mo

cystoscopy and cytology q 3-4 mo for 2 years, q 6 mo for years 3-4, and then annually

GUIDELINE STATEMENT 38

intermediate- or high-risk patients should consider upper tract surveillance imaging at 1-2 year intervals

154
Q

Recurrence rates of bladder cancer by stage:

A

pT2 → 20-30%

pT3 → 40%

pT2 → 70% (node pos dz)

155
Q

What is part of workup for suspected MIBC:

A

GUIDELINE STATEMENT 1

H&P, EUA at time of TURBT

GUIDELINE STATEMENT 2

full staging evaluation → CXR/Chest CT, A/P cross sectional imaging (IV contrast if possible)

Labs CBC, CMP (LFT, ALP, renal function)

156
Q

Goals of pre-operative imaging in MIBC:

A
  1. determine feasibility and safety of removing the bladder
  2. presence of pelvic LAN
  3. presence of hydronephrosis
  4. presence of upper tract dz
  5. possible visceral/distant mets
157
Q

What is recommended for pathologic review of MIBC?

A

GUIDELINE STATEMENT 3

experienced GU pathologist review when variant histology or if muscle invasion is equivocal (e.g. micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, extensive squamous or glandular differentiation)

158
Q

Prior to treatment at time of dx MIBC, clinicians SHOULD:

A

GUIDELINE STATEMENT 4

Discuss curative tx options before determining plan based on tumor, comorbidity, include multidisciplinary (chemo, rt, sx)

GUIDELINE STATEMENT 5

counsel patient regarding complications and implications of treatment on QOL (e.g. continence, sexual function, fertility, bowel dysfunction, metabolic problems)

159
Q

Prior to RC, what is recommended? If not possible due to factors or renal function, what is next recommendation?

A

GUIDELINE STATEMENT 6

offer cisplatin-based neo-adjuvant chemotherapy

*no validated predictive factors or clinical characteristics associated with response and benefit of NAC

*best regimen and duration not defined

*eligibility for NAC based on comorbidities and performance status, cardiac status and presence of peripheral neuropathy, healing loss, and renal dysfunction

160
Q

If patient is ineligible for cisplatin-based NAC, and has resectable cT2-T4N0 bladder cancer? is alternative NAC recommended?

A

GUIDELINE STATEMENT 7

Should NOT prescribe carboplatin-based NAC, if NO cisplatin → just proceed to sx

161
Q

When is the timing of RC after NAC?

A

GUIDELINE STATEMENT 8

ASAP following completion and recovery (ideally w/in 12 weeks if medically advisable)

162
Q

Patient s/p RC with pT2/T3 and/or N+ dz, who did not receive NAC, what is option?

A

GUIDELINE STATEMENT 9

Eligible patients who did not receive NAC s/p RC with non-organ confined dz → offer cisplatin-based adjuvant chemotherapy

163
Q

For MIBC who should be offered RC?

A

GUIDELINE STATEMENT 10

non-metastatic MIBC → RC and b/l PLND to eligible surgical candidates with resectable M0

164
Q

What is included in a radical cystectomy?

A

GUIDELINE STATEMENT 11

standard RC with curative intent remove: bladder, prostate, and SVs; female consider removal of adjacent reproductive organs base on dz and need for R0

(anterior vaginal wall, uterus, cervix, fallopian tubes, ovaries)

invasive cancer at margin → urethrectomy (immediate or delayed men, always women unless neobladder)

GUIDELINE STATEMENT 12

discuss and consider sexual function preservation in organ-confined dz and absence of bladder neck, urethral, and prostate (male) involvement

*nerve sparing, vagina sparing

165
Q

Which urinary diversions should be discussed? What are limitations/contraindications of certain types?

A

GUIDELINE STATEMENT 13

RC, discuss IC, continent cutaneous, and orthotopic neobladder diversions pros and cons

Contraindications to continent diversion:

  1. insufficient bowel length
  2. inadequate motor function or psych issue that limit self-cath
  3. inadequate renal or hepatic function increasing risk of metabolic abnormalities (GFR <45)
  4. cancer at urethral margins
  5. significant urethral stricture dz that is not correctable

GUIDELINE STATEMENT 14

orthotopic urinary diversion, must verify negative urethral margins

*in patients with palpable masses (_>_T3b) on bimanual, intraoperative frozen urethral and vaginal margins if considering neobladder

166
Q

Some key elements of pre-operative management for RC:

A

GUIDELINE STATEMENT 15

Optimize patient performance status (nutrition, smoking cessation, data shows no need for mechanical bowel prep, carb loading)

GUIDELINE STATEMENT 16

Peri-operative pharmacologic thromboembolic ppx given during RC (SCD, heparin)

prior to anesthesia and up to 4 weeks post op

GUIDELINE STATEMENT 17

ų -opioid antagonist therapy to accelerate GI recovery decrease LOS

GUIDELINE STATEMENT 18

Should received detailed teaching on care of diversion prior to d/c

167
Q

Discuss PLND during RC:

A

GUIDELINE STATEMENT 19

Clinicians should perform b/l PLND at time of sx with curative intent

GUIDELINE STATEMENT 20

B/L PLND should remove at minimum external, internal iliac, and obturator LN (goal >12)

168
Q

Discuss MIBC bladder preservation approach:

A

GUIDELINE STATEMENT 21

for new dx MIBC, pts who wish to retain bladder or w/comorbidities for whom RC is not tx not an option → bladder preserving tx (max TURBT, partial cystectomy and LND, primary RT, and multimodal tx)

GUIDELINE STATEMENT 22

pts considering bladder preservation → max debulking TURBT and assessment of multifocal dz or CIS should be performed

GUIDELINE STATEMENT 23

pts with MIBC who are medically fit and consent to RC SHOULD NOT undergo partial cystectomy or max TURBT as primary curative therapy

169
Q

Selection criteria for partial cystectomy or max TURBT:

A

accessible tumor location

size < 3 cm

no multi-focal CIS

no hydronephrosis

adequate bladder function

no residual T1 or higher dz

170
Q

Primary radiation for MIBC?

A

GUIDELINE STATEMENT 24

for patient with MIBC, SHOULD NOT offer radiation alone as curative tx

171
Q

Define multimodal bladder preserving therapy

A

GUIDELINE STATEMENT 25

MIBC → max TURBT, chemotherapy + EBRT

planned cystoscopic re-evaluation (mid course to ID non-responders)

*cytotoxic agents may sensitize tumor cells to RT, kills in synergistic fashion

GUIDELINE STATEMENT 26

Radiation sensitizing chemo should be included with curative intent

(cisplatin +/- 5FU, mitomycin C?, gemcitabine)

172
Q

After bladder preserving therapy, what should follow up be:

A

GUIDELINE STATEMENT 27

regular surveillance cystoscopy q 3 mo first year, q 4-6 the 2nd year q6-12 mo thereafter

CT scans (q6 mo for 1st year) and urine cytology

173
Q

Bladder preserving treatment failure options: residual or recurrent MIBC? non MIBC?

A

GUIDELINE STATEMENT 28

patients medically fit recurrent or residual MIBC → RC + b/l PLND

GUIDELINE STATEMENT 29

local measures (TURBT with intravesical tx) OR RC + b/l PLND

174
Q

Surveillance and f/up s/p RC for MIBC?

A

GUIDELINE STATEMENT 30

Chest and cross sectional A/P CT/MRI q 6-12 mo for 2-3 years, then annually

Evaluate: upper tract cancer, mc recurrence, progression, mets (pelvis, RP, liver, lungs, bones), and urinary diversion concerns like hydro

GUIDELINE STATEMENT 31

electrolytes and renal function q 3-6 mo interval for 2-3 years, then annually (hypokalemia, hyponatremia and/or hypokalemic hyperchloremic metabolic acidosis, B12)

GUIDELINE STATEMENT 32

Monitor urethral remnant for recurrence

175
Q

Guidelines in regards to survivorship:

A

GUIDELINE STATEMENT 33

discuss how patients are coping and recommend cancer support group or individual counseling

GUIDELINE STATEMENT 34

encourage pts to adopt healthy lifestyle habits, smoking cessation, exercise, healthy diet to improve long term health and quality of life

176
Q

What about variant histology f/up:

A

GUIDELINE STATEMENT 35

Unique clinical characteristics may require divergence from standard evaluation and management

177
Q

what is rationale for intravesical tx after TURBT?

A

recommended to reduce risk of recurrence (reduction 17%)

option for patients with papillary appearing tumor but no pathologic dx yet

destruction of residual microscopic tumor at site of TURBT and circulating cells, preventing re-implantation

Mitomycin C → alkylating agent inhibits DNA replication

Little systemic circulation

a/e dermatitis and irritative voiding sxs

178
Q

Risk factors for bladder cancer:

A
  1. tobacco
  2. Male > Female (3:1)
  3. Age (90% > 55 yo)
  4. Radiation
  5. chemical/occupational exposure → aromatic compounds (paint, dye, metal/petroleum)
  6. Phenacetin → analgesic
  7. Cyclophosphamide
  8. Pioglitazone (actos)
  9. Schistosomiasis (SCC)
  10. Chronic cystitis (SCC) → chronic UTI, foley, CIC, stones
179
Q

natural history of non MIBC? Ta, T1, CIS?

A

Ta → 50-70% recurrence, < 5 % progression

T1 → 70-80% recurrence, 50% progression

CIS → 80% recurrence after TURBT, 20-30% recurrence after BCG, 20% progress after complete BCG response

180
Q

factors that influence recurrence of non MIBC?

A

number of tumors

tumor grade and stage

tumor size > 3 cm

concomitant CIS

prior recurrence rate

tumor present at 3 mo cysto

181
Q

What factors influence muscle invasion for superficial UC (CIS, Ta, T1)?

A

tumor grade and stage

CIS

Tumor size > 3 cm

*if intravesical therapy fails, early cystectomy warranted

182
Q

What is the role of cytology in initial workup of microhematuria?

A

symptomatic (irritative voiding sxs in absence of infx)

risk factors for UC (smoking, dyes, exposures)

183
Q

What is the theory of BCG efficacy?

A

attenuated strain of mycobacterium bovis → immune response causes intense local inflammatory reaction of the bladder, activates T cells to attack abnormal urothelium and causes release of cytokines

184
Q

Why should BCG be postponed? When is it contrainidcated?

A

Postpone: recent resection (4 weeks), traumatic catheter, gross hematuria, cystitis, UTI/fever

contra: immunosuppression (HIV, lymphoma, leukemia, steroids), prior hypersensitivity rxn/sepsis, NOT if positive PPD

185
Q

What is an extended and a standard PLND?

A

Extended: common iliac, external iliac, obturator, hypogastric, and presacral LN (may include nodes up tot he level of the IMA if necessary)

Boundaries

  1. Genitofemoral nerves → lateral
  2. Bladder → medial
  3. Common iliac artery → proximal
  4. Femoral canal → distal

Standard: external iliac, obturator, hypogastric LNs

186
Q

Name the metabolic abnormalities for the various bowel segments that are used for diversion:

A

Stomach: hypochloremic hypokalemic metabolic alkalosis

Jejunum: hyponatremic hypochloremic hyperkalemic metabolic acidosis; tx: oral NaCL, HCO3, fluids

Ileum, Colon, Sigmoid: hyperchloremic hypokalemic metabolic acidosis; tx: oral Cl restriction, HCO3, oral/IV hydration, drain in cath

187
Q

How do you treat BCG sepsis?

A

After tx, high fever, shaking chills, hypotension

Admit right away

Early use of steroids, IVF, anti-Tb meds ASAP (UCx, BCx → bacteria, AFB), broad spectrum Abx (FQ)

INH 300 mg/day, pyridoxine (Vit B6 daily)

Rifampin 600 mg /day

Ethambutol 1200 mg/day

6 mo course of tx (check LFTs during INH tx)

NEVER give BCG again

188
Q

What are other side effects of BCG besides irritative voiding and BCG sepsis?

A

Granulomatous prostatitis: asx - no tx; sxs-tx INH/Rifampin 3-6 mo

Granulomatous orchitis/epididymitis

Cystitis: causes delay and dropout

189
Q

Describe regimens for multi-agent Cisplatin based chemotherapy and their major side effects:

A

GC (Gemcitibine, Cisplatin)

  1. Gemcitibine: thrombocytopenia and anemia
  2. Cisplatin: nephrotoxicity

(Older regimens)

MVAC (Methotrexate, Vinblastine, Doxorubicin, Cisplatin) *higher rate of neutropenia, sepsis, mucositis, alopecia, and fatigue

  1. Methotrexate: mucositis, myelosuppression
  2. Vinblastine: cardiotoxicity
  3. Doxorubicin: cardiotoxicity
  4. Cisplatin: nephrotoxicity
190
Q

When a patient has MIBC and family hx of colon cancer? What test is part of metastatic post TURBT workup? What other testing is indicated in further planning?

A

FOBT if + needs colonoscopy prior to considering diversion/tx

191
Q

What if grossly enlarged nodes are found at time of RC/PLND?

A
  1. Is it resectable? If yes, proceed with extended PLND, recommend adjuvant chemotherapy
  2. Abort case when:
    1. Bulk LAN not resectable
    2. Demoplastic peri-ureteral mets
    3. Rectal wall invasion
    4. Bladder fixed and unresectable
192
Q

Describe cystoprostatectomy in males?

A
  1. Midline incision
  2. Divide urachus and vasa
  3. Take down lateral pedicles of bladder and prostate
  4. Incise the peritoneum in the rectovesical cul-de-sac
  5. Incise the endopelvic fascia
  6. Preserve the neurovascular bundles
  7. Ligate the DVC
  8. Transect the urethra
193
Q

Likely sources of bleeding during RC?

A

DVC

Branches of internal iliac artery such as superior and inferior vesical arteries

External lilac and obturator vessels

pelvic sidewall

194
Q

What are QOL implications for RC?

A

Issue with continence

ED

Metabolic problems

Bowel dysfunction

Fertility

195
Q

Describe creation of neobladder (Orthotopic-Studer)

A
  1. 50-55 cm of ileum, 15-20 cm proximal to ileocecal junction
  2. 10-15 cm proximal end for ureteral reimplant
  3. Place single J stents
  4. Open anti-mesenteric side of distal 40 cm
  5. fold into sphere
  6. suprapubic tube is option
  7. anastomose to prostatic urethra
  8. place pelvic drain
196
Q

Describe creation of a continent reservoir (i.e. Indiana pouch):

A
  1. Right colon and 10 cm distal ileum
  2. Appendectomy
  3. Narrow catheterizable ileal segment with GIA stapler
  4. Imbricate or reinforce ileocecal valve with silk Lembert sutures or cecal wrap
  5. Colon folded into U-shaped segment and detubularized
  6. Ureteral-colonic anastomosis
  7. Place single J stents
  8. Sew catheterizable channel to abdominal wall and ensure easy passage of catheter
  9. Place pelvic drain
197
Q

Describe an anterior exenteration for females:

A
  1. Midline incision
  2. Divide urachus
  3. Take down lateral pedicles of bladder
  4. Ligate superior vesical artery
  5. Divide ovarian vessels (infundibulopelvic ligament)
  6. Divide cardinal and ureterosacral ligaments
  7. Incise the peritoneum in the pouch of Douglas
  8. Divide ureters at the level of the bladder
  9. Divide the urethra at bladder next and send margin for frozen
198
Q

Describe creation of an Ileal Conduit:

A
  1. Harvest 12-15 cm length of terminal ileum at least 15-20 cm from ileocecal valve
  2. Maintain vascular supply
  3. Perform enteroenterostomy
  4. Close mesenteric trap above conduit
  5. Pass left ureter behind sigmoid mesentery
  6. Close butt end of loop
  7. Ureteroileal anastamosis
  8. Tack butt end to RP ?
  9. Place single J ureteral stents
  10. Mature stoma
  11. Place pelvic drain
199
Q

What are indications for partial cystectomy?

A
  1. single primary tumor, no CIS (mapping bx)
  2. location suitable for bladder preservation (away from UOs, i.e. dome)
  3. High grade, focal, MIBC w/complete or partial response to chemo
  4. tumor amenable to complete excision with neg margins
  5. tumor only in diverticulum
  6. urachal adenocarcinoma → resect posterior rectus sheath, urachus, and dome (en-bloc)
  7. patients who have sufficient bladder capacity after sx (cystogram first)

**must perform b/l PLND

200
Q

Complications of partial cystectomy:

A

Tumor recurrence

Vesicocutaneous fistula

Ureteral obstruction

Urine leak

Reduced bladder capacity

Urge incontinence

201
Q

Discuss bladder preserving tx, components, amount, f/up?

A

medically unfit or refuse RC

complete TURBT, chemo, RT

XRT w/radio-sensitizing chemo (Cisplatin, 5FU)

45-55 Gy to bladder and LN with 20 Gy to tumor

22-47% proceed to RC

202
Q

Poor prognostic features for MIBC, when considering bladder sparing tx?

A

hydronephrosis

cT3b, cT4

low Hgb

CIS (does not respond to XRT)

residual dz after TURBT

203
Q

If you have a leak from a neobladder early post op, what is first steps? part of initial PE, labs, imaging?

A
  1. See patient, flush stents, foley, SPT (if present)
  2. UA, UCX, CBC, BMP, JP Cr
  3. Pouchogram and stentogram
  4. If leak, take JP off suction, manipulate away from anastomosis
  5. Consider PCNs
  6. If persistent, re-explore and repair
204
Q

List Intraop complications of RC?

A

hemorrhage

tumor spillage

rectal injury

vascular injury

nerve injury (obturator)

205
Q

List Post op complication of RC?

A

prolonged ileus

wound infection

urine leak

SBO

DVT/PE

intestinal leak

wound dehiscence

fistula

hemorrhage

urinary/renal obstruction

pyelonephritis

206
Q

What’s the treatment of choice for a 2 cm recurrence at the distal uretero-ileal anastamosis of an IC wit hydronephrosis? what if urethral cytology is positive?

A

PCN

Antegrade nephrostogram and stent, send cytology

Re-operation with excision of left distal ureter and re-anastomosis with negative urethral margins (consider URS and nephroureterectomy if multifocal)

urethrectomy

207
Q

what are risk factors for urethral recurrence s/p RC?

A

multifocal NMIBC

CIS

Bladder cancer stage

history of urothelial carcinoma of prostate

non-orthotopic urinary diversion

208
Q

What are indications for urethrectomy?

A

Men: diffuse CIS of prostatic urethra or ducts, tumor invasion to prostatic stroma, CIS or frank tumor at apical margin

Women: CIS or tumor at bladder neck/urethra, multifocal CIS, tumor involving anterior vaginal wall (T4)

209
Q

What are some metabolic complications of post-cystectomy urinary diversion?

A

Electrolyte abnormalities

AMS → increase ammonia levels

Altered hepatic metabolism

Pyelonephritis → proteus or pseudomonas MC

Metabolic acidosis → osteomalacia

Renal and reservoir calculi → struvite stones; mc associated with hyperchloremic metabolic acidosis

Adenocarcinoma → ureterosigmoidostomy ureteral anastomosis site at risk

Short bowel syndrome → B12 (neuro defects), bile salts, calcium and folic acid malabsorption

210
Q

How would you educate patients regarding incontinence following orthotopic urinary diversion?

A

80-90% continent during day

55-65% continent during night

Incontinence rate higher > 65 yo

Increased nocturnal incontinence is due to loss of afferent input from detrusor to the CNS, which perviously resulting in corresponding increase in urethral resistance with filling

02. Urotelial Cancer (1375) (11 decks)

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