bladder cancer

Question 1

preferred first line for metastatic urothelial cancer

Answer 1

Gemcitabine + cisplatin, followed by avelumab maintenance

Question 2

Immunotherapy approved for UC? General response rates?

Answer 2

• 5 checkpoint inhibitors are approved

Question 3

What are the variant histologies?

Answer 3

Papillary
Squamous
Adenocarcinoma
Small cell

Question 4

why imaging should be performed prior to TURBT

Answer 4

TURBT can cause bladder wall thickening or perivesical stranding that can be interpreted as extravesical disease

Question 5

initial workup of bladder cancer

Answer 5

CT urogram
CT chest
IF bone pain or high ALP/calcium → bone scan

Question 6

Management of positive urine cytology if cystoscope negative

Answer 6

If positive and cystoscopy is negative, then you need ureteroscopy

Question 7

bladder cancer diagnostic process

Answer 7

CT urogram –> cystoscopy with bladder biopsy or TURBT

Question 8

Percentage of bladder cancer that is non muscle invasive

Answer 8

75% of all bladder tumors

Question 9

Management of low risk NMBIC

Answer 9

TURBT plus a single dose of intravesical mitomycin with 24 hours after TURBT

Question 10

Management of high risk NMBIC

Answer 10

Restaging TURBT in 4-6 weeks
Assess indications for cystectomy (if indicated, cystectomy, if not induction and 3 years of maintenance BCG)

Question 11

Surveillance after treatment

Answer 11

Serial cystoscopy and imaging

Question 12

Management of stage II/III muscle-invasive bladder cancer

Answer 12

IF surgical candidate –> Neoadjuvant platinum-based chemo followed by radical cystectomy + bilateral pelvic lymph node dissection
IF not surgical candidate –> TURBT + chemoradiation

Question 13

First targeted therapy approved for bladder cancer

Answer 13

Erdafitinib

Question 14

primary demographic

Answer 14

elderly – bladder cancer is a disease of the elderly

Question 15

Percentage of patients who are ineligible for platinum-based chemo

Answer 15

approximately 50% of patients with MIBC are ineligible for treatment with platinum-based chemotherapy

Question 16

FDA approved immune checkpoint inhibitors for bladder cancer

Answer 16

nivolumab
pembrolizumab
avelumab
atezolizumab
durvalumab

Question 17

UC and immunogenicity

Answer 17

UC has one of the longest track records of responsiveness to immunotherapy

Question 18

overall success of immunotherapies for UC to date

Answer 18

Durable responses are only observed in a minority of patients, and response rates are approximately 20% in the first- and second-line settings and beyond

Question 19

overall success of targeted therapies for UC

Answer 19

poor response rates and targeted therapy monotherapy has had little success in the metastatic UC model.

Question 20

What is bladder preserving therapy (BPT)?

Answer 20

Combination of TURBT + chemo + RT. Emerging concept that is gaining traction in UC

Question 21

primary tool for genetic profiling of tumors

Answer 21

next generation tumor sequencing

Question 22

Indications for adjuvant chemo in Stage II after Radical cystectomy in MIBC

Answer 22

PT3-T4 OR positive nodes OR positive margins

Question 23

Management of Stage II UC in non-cystectomy patient

Answer 23

Concurrent chemoradiotherapy

Question 24

Stage IIIA management

Answer 24

IF cystectomy candidate –> Neoadjuvant chemo then radical cystectomy/pelvic lymphadenectomy
OR
concurrent chemoradiotherapy

Question 25

Stage IIIB management

Answer 25

Downstaging systemic chemo
OR
Concurrent chemoradiotherapy

Question 26

Additional workup for Stage IV

Answer 26

Molecular testing

Question 27

Molecular testing for Stage IV UC

Answer 27

FGFR

Question 28

Management of Stage IV MO disease

Answer 28

Chemo OR concurrent chemoradiotherapy

Question 29

Difference in workup if Stage IVB

Answer 29

Chest CT needed
Consider CNS imaging

Question 30

What is a CT urogram?

Answer 30

CT of abdomen/pelvis with and without IV contrast with *excretory imaging

Question 31

M staging in UC

Answer 31

M1A = Mets to lymph nodes
M1B = Mets to 1 or more distant organs

Question 32

Preferred first line for stage IV UC if cisplatin ineligible

Answer 32

Gemcitabine and carboplatin followed by maintenance ***avelumab

Question 33

Definition of cisplatin ineligible

Answer 33

• Renal dysfunction, hearing loss, age, performance status

Question 34

Typical demographic of UC

Answer 34

Elderly (bladder cancer is a disease of the elderly). Classically white old male.

Question 35

Location of where most UC arises

Answer 35

90% in the bladder, 8% in the renal pelvis, 2% in ureter and urethra

Question 36

Biggest problems with BCG and SE’s

Answer 36

Availability (shortage currently)
- Flu like symptoms (induces cytokine release), intense local discomfort.

Question 37

Term for surgery for stage II and IIIA disease

Answer 37

Radical cystectomy with pelvic lymphadenectomy

Question 38

When partial cystectomy and NAC is an option

Answer 38

Stage II disease with a single tumor in a suitable location and no presence of Tis

Question 39

Stage II management

Answer 39

If cystectomy candidate, NAC followed by cystectomy OR concurrent chemoradiotherapy

Question 40

Staging difference between IIIa and IIIb

Answer 40

A = spread to one lymph node
B = spread to 2 or more lymph nodes

Question 41

why is muscle invasive disease high risk for metastasis

Answer 41

• Muscle is highly vascular and has a lot of lymphatics
• you have a 50% chance of involvement with T2 disease

Question 42

What is mitogel? clinical use?

Answer 42

mitomycin gel, only used for low grade disease (not that many)

Question 43

papillary urothelial is also known as

Answer 43

transitional

Question 44

URS means

Answer 44

ureteroscopy

Question 45

How is a CT urogram performed?

Answer 45

CT urography includes a non-contrast phase and contrast-enhanced nephrographic and excretory (delayed) phases. While the three phases add to the diagnostic ability of CT urography, it also adds potential patient radiation dose. Several techniques including automatic exposure control, iterative reconstruction algorithms, higher noise tolerance, and split-bolus have been successfully used to mitigate dose. The excretory phase is timed such that the excreted contrast opacifies the urinary collecting system and allows for greater detection of filling defects or other abnormalities.