Bladder Cancer Flashcards
Bladder Cancer
BONUS:
What is the epithelial lining of the bladder?
transitional epithelium
Bladder Cancer
What is the most common risk factor for the development of bladder cancer?
smoking
Others, (for the sake of learning from this card) are enviromental/industrial/medical exposures to aromatic amines, polycyclic aromatic and chlorinated hydrocarbons,
arsenic-laced drinking water, aristolochic acid, cyclophosphamide exposure
Bladder Cancer
What parasite, the causative agent of bilharzia is implicated in the development of bladder cancer?
Schistosoma heamatobium
Bladder Cancer
What is the metabolite of arylamines responsible for the carcinogenesis in patients exposed to arylamines?
o-aminophenol
Bladder Cancer
What is this theory/hypothesis in bladder cancer pathogenesis?
The whole urothelium is exposed to the same
urinary carcinogens, leading to the transformation of many independent separate
urothelial cells and resulting in multiple tumors developing independently in
multiple sites.
Such tumors are thus genetically unrelated.
field cancerization
Bladder Cancer
What is this theory/hypothesis in bladder cancer pathogenesis?
The multifocality of TCC arises as a result of a single
carcinogenic insult to a single cell or group of cells. The progeny or clones of
these cells spread throughout the bladder, either through intraepithelial migration
or through cell shedding and reimplantation, leading to multiple synchronous
and metachronous tumors.
These tumors are thus topographically distinct but
are genetically related.
hypothesis of clonality
Bladder Cancer
Deletions on chromosome 9p occur most frequently and early in transitional cell carcinogenesis with 17p13 losses (p53 gene mutations) occurring in more advanced TCCs, shedding some light on the molecular pathology of bladder TCC.
TRUE or FALSE?
True.
copy paste lang yan. tinamad ako magmodify haha
Bladder Cancer
Most common presenting symptoms?
painless, visible hematuria
infection
storage symptoms
PIS! (Phis)
Bladder Cancer
What is the most approppriate next step for patients referred for evaluation of hematuria with suspicion of bladder cancer?
TURBT
Bladder Cancer
Upon pathologic review of TURBT specimen, the findings was either NMIBC or CIS.
What is the next step?
Do you request for cross-sectional imaging?
do not require further cross-sectional imaging,
except in “extensive CIS” or grade 3 lesions.
intravesical treatment and surveillance.
Bladder Cancer
TNM staging
Identify the T stage:
flat tumor
Tis
Bladder Cancer
TNM staging
Identify the T stage:
non-invasive papillary carcinoma
Ta
Bladder Cancer
TNM staging
Identify the T stage:
extravesical mass
T3b
Bladder Cancer
TNM staging
Identify the T stage:
macroscopically invades perivesical tissues
T3b
Bladder Cancer
TNM staging
Identify the T stage:
microscopically invades perivesical tissues
T3a
Bladder Cancer
TNM staging
Identify the T stage:
invades outer half of muscle
T2b (outer is the deep muscle)
Bladder Cancer
TNM staging
Identify the T stage:
invades inner half of muscle
T2a (inner is the superficial)
Bladder Cancer
TNM staging
Identify the T stage:
invades subepithelial connective tissues
T1
Bladder Cancer
TNM staging
Identify the N stage:
single lymph node in the true pelvis
N1
Bladder Cancer
TNM staging
Identify the N stage:
single lymph node in the true pelvis (contralateral side)
N1 pa rin.
not affected by laterality
Bladder Cancer
TNM staging
Identify the N stage:
single lymph node in the common iliac nodes
single or multiple, common iliac nodes is/are N3
Bladder Cancer
TNM staging
Identify the N stage:
multiple lymph nodes in the true pelvis
N2
Bladder Cancer
TNM staging
Identify the stage group.
N1, 2, 3, M0
Stage IV
Bladder Cancer
Which is more common? NMIBC? or MIBC?
NMIBC 80%
Bladder Cancer
NMIBC
Recurrences after TURBT are found in up to ___% of
patients undergoing surveillance, and more importantly, up to ___ of patients on
surveillance will progress to muscle-invasive bladder cancer.
70%
15%
Bladder Cancer
NMIBC
What is administered into the bladder as a single dose for 1 hr within 24 hours of surgery to reduce the relative risk of recurrence by about 24.2%?
Mitomycin C
Bladder Cancer
NMIBC
Define low-risk.
<3 cm in diameter
G1
Ta
no evidence of CIS
Bladder Cancer
NMIBC
Low-risk tumors have a
15% probability of recurrence and a 0.2% risk of progression at 1 year.
What is the treatment/surveillance schedule after initial resection?
flexible cystoscopy 3 months after.
If (–), repeat 9 months later (1 year after resection)
and then annually
Bladder Cancer
NMIBC
High-risk tumors have a 61% probability of recurrence and a 17%
risk of progression at 1 year.
What is the treatment/surveillance schedule after initial resection?
3 monthly flexible cystoscopy for 2 years,
6 monthly for further 5 years (total 7 years)
and then annually thereafter
Bladder Cancer
NMIBC
Patients with high-risk tumors or CIS should be offered intravesical immunotherapy using ____?
What is the schedule?
BCG
bacille Calmette-Guérin
once a week x 6 weeks
followed by subsequent 3 weeks as an induction treatment.
Bladder Cancer
NMIBC
What is the maintenance treatment following intravesical immunotherapy in patients with no cystoscopic evidence of recurrence?
6-week courses of BCG every 3 to 6 months.
Bladder Cancer
What structures are removed by a radical cystectomy procedure?
Radical cystectomy by definition implies the en bloc removal of the pelvic–iliac lymph nodes along with the pelvic organs anterior to the rectum: the bladder, urachus, prostate, seminal vesicles, and visceral peritoneum in men and the bladder, urachus, ovaries, fallopian tubes, uterus, cervix, vaginal cuff, and the anterior pelvic peritoneum in women.
Bladder Cancer
How many lymph nodes is considered adequate for a radical systectomy?
15
Bladder Cancer
Trivial question for radonc ☻
What are the boundaries for lymphadenectomy/dissection in a radical cystectomy?
Although the exact limits of the lymphadenectomy for patients with bladder cancer undergoing cystectomy are currently debated, the boundaries include initiation at the level of the inferior mesenteric artery (superior limits of dissection), extending laterally over the inferior vena cava or aorta to the genitofemoral nerve (lateral limits of dissection), and distally to the lymph node of Cloquet medially (on Cooper ligament) and the circumflex iliac vein laterally.
Bladder Cancer
Molecular biomarkers
High levels of _____ on TURBT had better response to radical RT.
Also, studying other
protein expression within the biopsy material, it was found that ___ was
associated with poor prognosis after either RT or cystectomy
meiotic recombination homolog (MRE11)
and
p16
respectively
Bladder Cancer
There is mounting substantial evidence for PD-1–
and PD-L1–directed therapies, and a vigorous debate surrounds the use of PDL1
immunohistochemical assessment to identify appropriate patients for therapy.
What drug has been employed in this setting?
atezolizumab
Bladder Cancer
What are the three types of recurrence based on location?
local (pelvic)
distant
uretheral
Bladder Cancer
What is the median time to any recurrence?
(based on the USC series)
and
majority of recurrences (from the series) and in general recur within ___ years of treatment.
12 months
and
3 years
Bladder Cancer
What are the parameters significantly associated with local recurrence after radical cystectomy?
T and N stage
Three strata of risk were
defined, including low-risk patients with pT3N0 disease, intermediate-risk
patients with pT3N1 or pT4N0 disease, and high-risk patients with pT4N1
disease, who had a 2-year incidence of LRF of 12%, 33%, and 72%,
respectively
-Reddy et al.
Bladder Cancer
What are the most common sites of local recurrence after radical cystectomy?
external iliac, internal iliac and obturator nodes.
Bladder Cancer
What is the most important risk factor for urethral tumor involvement in women?
Tumor involving the bladder neck is the most important risk factor for urethral tumor involvement in women.
hence they are excluded from orthotopic reconstruction
Bladder Cancer
What are the two important variables that significantly increase the risk of a urethral tumor recurrence following cystectomy in men?
any prostate involvement
the form of urinary diversion
cutaneous > orthotopic
Bladder Cancer
What is/are the role/s of RT in this setting?
CIS, Ta, T1 N0M0
None
Bladder Cancer
What is/are the role/s of RT in this setting?
CT2-T4a N0M0
bladder preservation
Potential role for radiation therapy, combined with synchronous chemotherapy if
patient sufficiently fit (bladder preservation)
Bladder Cancer
What is/are the role/s of RT in this setting?
Any-T, N1-3M0, or
Any-T, Any-N, M1
No role for radical radiation therapy as sole treatment for stage IV disease.
It may
be worth considering, as part of “radical” palliation in combination with systemic
chemotherapy.
No randomized data on the use of radiation therapy in this
setting beyond studies of fractionation
Bladder Cancer
What is the optimal RT dose for bladder preservation?
63-66 Gy
64 Gy/32 fx
Bladder Cancer
RT volumes : dose?
66 Gy (gross residual) 60 Gy (whole bladder) 50 Gy (pelvic)
no consensus yet
Bladder Cancer
What is the optimal hypofractioneted RT dose?
55/2.5/20 fractions
Bladder Cancer
What is the CTV is treating whole-bladder?
uninvolved bladder wall + 1.5 cm
extravesical extent + 2 cm margin
Bladder Cancer
(from in-service bank)
1. What is the complete response rate after chemoradiation for patients undergoing selective bladder preservation regimen? A. 20-40% B. 40-60% C. 60-80% D. 80-95%
C
Bladder Cancer
(from in-service bank)
2. What is the 5-yr OS for patients who have completed selective bladder preservation? A. 20-40% B. 40-60% C. 60-80% D. 80-95%
B
Bladder Cancer
(from in-service bank)
- The 5-yr OS for completed selective bladder preservation treatment compares favorably with the 5-yr OS of patients undergoing upfront radical cystectomy.
This was shown in a recently randomized control trial comparing the two regimens known as ____:
A. BC2001
B. RTOG 8903
C. SWOG 9312
D. No randomized control trial was ever mounted comparing selective bladder preservation therapy vs. radical cystectomy.
D
Bladder Cancer
(from in-service bank)
4. most common risk factor implicated in the carcinogenesis of urinary bladder cancer is: A. chronic intake of phenacetins B. exposure to aromatic amines C. Schistosomiasis hematobium infection D. smoking
D
Bladder Cancer
(from in-service bank)
- The main therapeutic options for muscle-invading bladder cancer (MIBC) are ______.
A. combined radiation and chemotherapy
B. radical cystectomy or selective bladder preservation
C. TURBT and intravesical therapy
D. TURBT only or radical systectomy
B
Bladder Cancer
(from in-service bank)
- The following flowchart best describes the sequence of interventions in Selective Bladder Preservation therapy as introduced by Massachusetts General Hospital Group:
A. TURBT – induction chemotherapy and radiation to full dose – response evaluation (cystoscopy, biopsy, cytology)
B. TURBT – intravesical therapy x 2 – induction chemotherapy and radiation to full dose – response evaluation – radical cystectomy for incomplete response
C. TURBT – induction chemotherapy and radiation – response evaluation (cystoscopy, biopsy, cytology): 1. For complete response – continue with chemo and boost radiation to tumor; or 2. For incomplete response – radical cystectomy
C
