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review course > 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

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
51
Q

contraindications to BCG dose - 4

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

what are not contraindications to BCG - 4

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

benefit to BCG

A

30% reduction in recurrence and progression

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)
55
Q

1st steps to improve BCG tolerance

A

sx relieving drugs - antichol, pyridium

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
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

58
Q

supplementation with INH

A

B6, pyridoxine

59
Q

mgmt of BCG prostatitis

A

anti tb meds

60
Q

most common cause of BCG sepsis

A

traumatic catheterization

61
Q

low, intermediate, high risk and chemo/BCG

A

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

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

63
Q

unfavorable histology qualifying for upfront cystectomy

A

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

64
Q

relative indications for RC

A

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

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

66
Q

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

A

safe - 2 mm growth per mo

67
Q

when is selective positive upper tract cytology unreliable

A

visible bladder tumor or bx + CIS - contamination

68
Q

in female, if bladder workup negative for positive cytology

A

check gyn source

69
Q

outcome if initial workup of positive cytology is negative

A

bladder source eventually in 80%

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

71
Q

most common cause of death in bladder ca

A

distant mets at the time of locoregional tx

72
Q

what timeframe does progression of cancer happen after locoregional tx

A

within 2 yrs

73
Q

small cell associated paraneoplastic syndromes - 3

A

ectopic ACTH, hypercalcemia, hypophosphatemia

74
Q

T2a/b

A

Ta2 - inner muscle, b - outer muscle

75
Q

T4a

A

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

76
Q

CIS of prostatic urethra or ducts and stage?

A

does not upstage as outcome is determined by primary bladder ca

77
Q

most significant pathologic risk for progression

A

LN status

78
Q

% upstaging from T1 at TUR to T2 at RC

A

40%

79
Q

hydro on preop workup and cT stage

A

cT3

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

81
Q

when to absolutely get CT chest other than abn cxr

A

T4, N+ on c stage

82
Q

when to preserve uterus/vagina in F

A

better support when considering neobladder

83
Q

when can a female not have orthotopic diversion

A

anterior vaginal wall invovlement b/c have to remove urethra

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.

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

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