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Hematology, oncology > Bladder cancer 2 > Flashcards

Bladder cancer 2 Flashcards

1
Q

Structures removed with radical cystectomy

A

men = remove bladder + prostate, followed by urinary diversion
women = typically remove bladder + uterus, followed by urinary diversion

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2
Q

accuracy of staging cystoscopy and TURBT for muscle invasive

A

Not very accurate, so patients are often upstaged after radical cystectomy

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3
Q

Contraindications to trimodality therapy for bladder preservation

A
  • extensive or multifocal CIS
    -tumor-related hydronephrosis
  • good pre-treatment bladder function
  • bunch of others….
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4
Q

What is Stage II anatomically?

A

The cancer has grown into the inner (T2a) or outer (T2b) muscle layer of the bladder wall, but it has not passed completely through the muscle to reach the layer of fatty tissue that surrounds the bladder.

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5
Q

Stage IIIA or IIIB implies

A

nodal involvement

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6
Q

what is MVAC?

A

methotrexate, vinblastine, adriamycin, cisplatin

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7
Q

clinical behavior of the variant histologies (squamous, adeno, micropapillary, nested, plasmacytoid, sarcomatoid)

A
  • more aggressive
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8
Q

T2 disease means

A

muscle invasive

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9
Q

Management of muscle invasive bladder cancer (T2 disease) generally speaking

A
  • neoadjuvant chemo then cystectomy
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10
Q

Management of patient with T1a disease who has TURBT and visually resected with path showing high grade NMIBC and negative margins

A
  • Repeat TURBT (need to ensure patient does not have component of muscle invasive disease)
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11
Q

Indications for BCG

A

Intermediate or high risk, non-muscle invasive bladder cancer:
1) cTa, high grade, intermediate risk
2) Tis, AUA high risk disease
3) cT1

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12
Q

management of urothelial cancer of the prostate with stroma invasion

A
  • cystoprostatectomy +/- urethrectomy +/- neoadjuvant chemotherapy
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13
Q

what is cystoprostatectomy

A

procedure in which the bladder and prostate gland are surgically removed,

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14
Q

Preferred perioperative regimens for MIBC + # of cycles

A

MVAC with GCSF x 3-4 cycles
Gem-cis x 4 cycles

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15
Q

T4a means

A

tumor outside bladder invading into surrounding structures (prostatic stroma, uterus, vagina, seminal vesicle)

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16
Q

T4b means

A

invading pelvic wall or abdominal wall

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17
Q

Evidence for carboplatin-based therapy in MIBC?

A
  • carbo has not demonstrated a survival benefit and should not be substituted for cisplatin
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18
Q

other RF’s for bladder cancer

A
  • aromatic amines and aromatic hydrocarbins
  • aristolochia fangchi (herb)
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19
Q

management of MIBC with small cell, neuroendocrine features

A
  • neoadjuvant cis-etoposide followed by XRT or cystectomy (need to use small cell lung cancer chemo regimen – cis-etoposide)
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20
Q

intravesical chemotherapy options for cTa + preferred option

A
  • gemcitabine (preferred) and mitomycin
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21
Q

management of superficial bladder cancers (T1 or less)

A

TURBT and intravesical chemo within 24 hours

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22
Q

Management of positive urine cytology with negative cystoscopy

A
  • cytology of the upper tract and ureteroscopy
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23
Q

Stage IIIA disease means in terms of N stage

A

N1 disease

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24
Q

Stage IIIB disease is in terms of nodal staging

A

> N1 disease

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25
Q

Management of N1 disease

A

Neoadjuvant cisplatin based combination chemo followed by cystectomy vs. concurrent chemoRT

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26
Q

Management of stage IIIB disease (multiple nodes involved)

A
  • downstaging systemic chemo or concurrent chemoRT
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27
Q

efficacy of gem-cis vs MVAC

A
  • equivalent OS and PFS benefit
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28
Q

preferred regimens for metastatic bladder cancer

A

Cis-gem (toxicity profile)
DDMVAC

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29
Q

management of patient who isn’t a cystectomy candidate

A

Trimodality therapy (TMT)

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30
Q

chemo regimens to be given with radiation in bladder + regimen for CKD patients

A

Cisplatin-taxol
Cisplatin alone
IF renal dysfunction, 5-Fu/mitomycin (MMC)

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31
Q

what are the high risk factors for non-invasive urothelial cancers warranting treatment

A
  • T1
  • CIS or Tis
  • high grade greater than 3 cm
  • high grade multifocal
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32
Q

what is the point of a TURBT in non muscle invasive

A

1) Diagnostic - rule out muscle invasion (must see muscle on path)
2) debulk as much of the tumor as possible

33
Q

management of patient treated with NAC with cis-gem who has cystectomy and then is found to have widely metastatic disease

A
  • pembro
    *can’t use platinum because this group has platinum-refractory disease
34
Q

Checkpoint inhibitors approved for locally advanced or metastatic bladder cancer

A

pembro + atezo

35
Q

Drug for patients with FGFR mutations

A

erdafitinib

36
Q

management of pure squamous cell bladder cancer

A

cystectomy or RT

37
Q

PS permitting cystectomy

A

0-2 (confirm)

38
Q

what does Tis mean?

A

urothelial carcinoma in situ

39
Q

Management of low-risk non-muscle invasive cancer

A
  • surveillance after TURBT
  • single perioperative dose of intravesical mitomycin C or gemcitabine at time of TURBT (CONFIRM)
40
Q

Very high risk features for cT1

A

1) LVI
2) Prostatic urethral involvement of tumor
3) Variant histology (micropapillary
Plasmacytoid, sarcomatoid
4) T1 with extensive CIS

41
Q

Management of non muscle invasive disease with very high risk features

A

Cystectomy

42
Q

First step in management of MIBC always

A

neoadjuvant chemo

43
Q

2 primary neoadjuvant regimens

A

Dose dense MVAC with GSCF OR
gem-cis

44
Q

Contraindications to bladder sparing approach

A

hydronephrosis + <6 cm in size + no concurrent extensive or multifocal Tis + bunch of others

45
Q

when is adjuvant therapy indicated for MIBC?

A

pT3, NOT pT2
Node positive

46
Q

management of ESRD patient and cisplatin

A

Give 50% of the dose
Dialysis within 3 hours after giving the dose

47
Q

GFR and cisplatin contraindication

A
  • variably defined
  • some will not give if GFR is less than 60
  • some will still give if GFR is less than 45
  • some will use split dose cisplatin
48
Q

adjuvant and Neoadjuvant management of bladder adenocarcinoma

A
  • No proven role for neoadjuvant or adjuvant therapy
49
Q

Major RFs for squamous cell cancer of the bladder

A
  • schistosomiasis in the developing world
  • prolonged indwelling catheters (particularly spinal cord-injured patients)
  • chronic irritants (bacterial infections, foreign bodies, chronic bladder outlet obstruction)
50
Q

primary treatment of non-muscle-invasive bladder cancer

51
Q

clinical features of plasmacytoid urothelial cancer + chemo sensitivity

A
  • aggressive
  • chemo resistant
  • peritoneal spread
52
Q

Gene alteration that is pathognomic of plasmacytoid + pattern of disease dissemination in plasmacytoid

A

CDH1 gene mutation (loss of E-cadherin permits enhanced cellular migration, likely explaining unique peritoneal pattern of disease dissemination)

53
Q

Management of patient who progresses on MVAC

A

pembro (there are several immune therapy options for patients who progress on platinum-chemo, but pembro is preferred)
*key concept. this is platinum-refractory disease

54
Q

Bladder Tis management

A
  • TURBT
  • intravesical chemo within 24 hours of TURBT
55
Q

Preferred FGFR inhibitor

A

Erdafitinib

56
Q

Management of recurrent Tis that is BCG unresponsive (BCG-refractory disease)

A
  • cystectomy
  • pembro if cystectomy refused
57
Q

Recurrent Tis management if ineligible for surgery or pembro

A

Valrubicin

58
Q

Second line if no EGFR mutation

A
  • enfortumab vedotin
59
Q

enfortumab vedotin mechanism + payload

A

ADC targeting Nectin-4, MMAE (microtubule inhibitor)

60
Q

Dosing for split dose cisplatin/gemcitabine dosing?

61
Q

sacituzumab govitecan mechanism + payload

A

ADC that targets Trop-2, a transmembrane glycoprotein highly expressed in most urothelial carcinomas, and is coupled with SN-38, an active metabolite of irinotecan.

62
Q

Toxicity profile of Tivozinib (tivo)

A

best tolerance of TKI (approved for frontline in Europe) + has issues with tolerance

63
Q

What are the drugable FGFR mutations?

A

2/3, 1 & 3 are also druggable

64
Q

Primary EV contraindication to know

A

Uncontrolled DM2 (hyperglycemia)

65
Q

Erdafitinib indication (based on molecular profiling)

A

FGFR3 or FGFR2/3 fusion

66
Q

Management of muscle invasive small cell bladder cancer

A

Neoadjuvant cisplatin + etoposide followed by consolidation surgery or radiation for local control

67
Q

Surgery for UTUC

68
Q

Adjuvant therapy for UTUC

A

4 cycles of gemcitabine/platinum

69
Q

What is the continuum of risk in NMIBC?

A

Non–muscle invasive bladder cancers exist on a continuum of risk in patients, with T1 high-grade (T1Hg) bladder cancer at the aggressive end of the spectrum.

70
Q

Ocular AE’s of erdafitinib

A
  • dry eyes
  • retinal pigment epithelium detachment
  • central serous retinopathy, conjunctivitis
  • increased lacrimation
71
Q

EV side effects

A

fatigue, peripheral neuropathy (nerve damage resulting in tingling or numbness), decreased appetite, rash, alopecia (hair loss), nausea, altered taste, diarrhea, dry eye, pruritus (itching) and dry skin

72
Q

EV payload

A

MMAE (monomethyl auristatin E), microtubule inhibitor

73
Q

New gene therapy approved for NMIBC + mechanism

A

Nadofaragene firadenovec (adenovirus that delivers INF alfa cDNA into bladder epithelium)

74
Q

Classification of NMIBC

A

Ta
Tis (or CIS)
T1

75
Q

management of high risk NMIBC

A

Restaging TURBT in 4-6 weeks. If no indication for cystectomy, you give intravesical BCG

76
Q

Intravesical BCG induction and maintenance

A
  • Induction
  • 3 years maintenance
  • followed by surveillance.
77
Q

What is split dose cisplatin? Dose reduction? Original dose?

A

50% dose reduciton, 35 mg/m2

78
Q

Galsky criteria for cisplatin ineligibility

A

WHO or Eastern Cooperative Oncology Group performance status ≥2, or Karnofsky performance status 60–70%
Common Terminology Criteria for Adverse Events version 4 grade ≥2 peripheral neuropathy
Grade ≥2 audiometric hearing loss
New York Heart Association class III heart failure

Hematology, oncology (218 decks)

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