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Ph RadOnc Residency PBRROE2-3 Review 2021 > Bladder Cancer > Flashcards

Bladder Cancer Flashcards

1
Q

Bladder Cancer

BONUS:
What is the epithelial lining of the bladder?

A

transitional epithelium

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2
Q

Bladder Cancer

What is the most common risk factor for the development of bladder cancer?

A

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

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3
Q

Bladder Cancer

What parasite, the causative agent of bilharzia is implicated in the development of bladder cancer?

A

Schistosoma heamatobium

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4
Q

Bladder Cancer

What is the metabolite of arylamines responsible for the carcinogenesis in patients exposed to arylamines?

A

o-aminophenol

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5
Q

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.

A

field cancerization

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6
Q

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.

A

hypothesis of clonality

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7
Q

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?

A

True.

copy paste lang yan. tinamad ako magmodify haha

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8
Q

Bladder Cancer

Most common presenting symptoms?

A

painless, visible hematuria
infection
storage symptoms

PIS! (Phis)

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9
Q

Bladder Cancer

What is the most approppriate next step for patients referred for evaluation of hematuria with suspicion of bladder cancer?

A

TURBT

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10
Q

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?

A

do not require further cross-sectional imaging,
except in “extensive CIS” or grade 3 lesions.

intravesical treatment and surveillance.

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11
Q

Bladder Cancer
TNM staging

Identify the T stage:
flat tumor

A

Tis

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12
Q

Bladder Cancer
TNM staging

Identify the T stage:
non-invasive papillary carcinoma

A

Ta

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13
Q

Bladder Cancer
TNM staging

Identify the T stage:
extravesical mass

A

T3b

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14
Q

Bladder Cancer
TNM staging

Identify the T stage:
macroscopically invades perivesical tissues

A

T3b

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15
Q

Bladder Cancer
TNM staging

Identify the T stage:
microscopically invades perivesical tissues

A

T3a

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16
Q

Bladder Cancer
TNM staging

Identify the T stage:
invades outer half of muscle

A

T2b (outer is the deep muscle)

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17
Q

Bladder Cancer
TNM staging

Identify the T stage:
invades inner half of muscle

A

T2a (inner is the superficial)

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18
Q

Bladder Cancer
TNM staging

Identify the T stage:
invades subepithelial connective tissues

A

T1

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19
Q

Bladder Cancer
TNM staging

Identify the N stage:
single lymph node in the true pelvis

A

N1

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20
Q

Bladder Cancer
TNM staging

Identify the N stage:
single lymph node in the true pelvis (contralateral side)

A

N1 pa rin.

not affected by laterality

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21
Q

Bladder Cancer
TNM staging

Identify the N stage:
single lymph node in the common iliac nodes

A

single or multiple, common iliac nodes is/are N3

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22
Q

Bladder Cancer
TNM staging

Identify the N stage:
multiple lymph nodes in the true pelvis

A

N2

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23
Q

Bladder Cancer
TNM staging

Identify the stage group.

N1, 2, 3, M0

A

Stage IV

24
Q

Bladder Cancer

Which is more common? NMIBC? or MIBC?

A

NMIBC 80%

25
Q

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.

A

70%

15%

26
Q

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%?

A

Mitomycin C

27
Q

Bladder Cancer
NMIBC

Define low-risk.

A

<3 cm in diameter
G1
Ta
no evidence of CIS

28
Q

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?

A

flexible cystoscopy 3 months after.

If (–), repeat 9 months later (1 year after resection)

and then annually

29
Q

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?

A

3 monthly flexible cystoscopy for 2 years,

6 monthly for further 5 years (total 7 years)

and then annually thereafter

30
Q

Bladder Cancer
NMIBC

Patients with high-risk tumors or CIS should be offered intravesical immunotherapy using ____?

What is the schedule?

A

BCG
bacille Calmette-Guérin

once a week x 6 weeks
followed by subsequent 3 weeks as an induction treatment.

31
Q

Bladder Cancer
NMIBC

What is the maintenance treatment following intravesical immunotherapy in patients with no cystoscopic evidence of recurrence?

A

6-week courses of BCG every 3 to 6 months.

32
Q

Bladder Cancer

What structures are removed by a radical cystectomy procedure?

A

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.

33
Q

Bladder Cancer

How many lymph nodes is considered adequate for a radical systectomy?

A

15

34
Q

Bladder Cancer

Trivial question for radonc ☻

What are the boundaries for lymphadenectomy/dissection in a radical cystectomy?

A

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.

35
Q

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

A

meiotic recombination homolog (MRE11)

and

p16

respectively

36
Q

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?

A

atezolizumab

37
Q

Bladder Cancer

What are the three types of recurrence based on location?

A

local (pelvic)
distant
uretheral

38
Q

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.

A

12 months

and

3 years

39
Q

Bladder Cancer

What are the parameters significantly associated with local recurrence after radical cystectomy?

A

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.

40
Q

Bladder Cancer

What are the most common sites of local recurrence after radical cystectomy?

A

external iliac, internal iliac and obturator nodes.

41
Q

Bladder Cancer

What is the most important risk factor for urethral tumor involvement in women?

A

Tumor involving the bladder neck is the most important risk factor for urethral tumor involvement in women.

hence they are excluded from orthotopic reconstruction

42
Q

Bladder Cancer

What are the two important variables that significantly increase the risk of a urethral tumor recurrence following cystectomy in men?

A

any prostate involvement

the form of urinary diversion
cutaneous > orthotopic

43
Q

Bladder Cancer

What is/are the role/s of RT in this setting?

CIS, Ta, T1 N0M0

A

None

44
Q

Bladder Cancer

What is/are the role/s of RT in this setting?

CT2-T4a N0M0

A

bladder preservation

Potential role for radiation therapy, combined with synchronous chemotherapy if
patient sufficiently fit (bladder preservation)

45
Q

Bladder Cancer

What is/are the role/s of RT in this setting?

Any-T, N1-3M0, or
Any-T, Any-N, M1

A

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

46
Q

Bladder Cancer

What is the optimal RT dose for bladder preservation?

A

63-66 Gy

64 Gy/32 fx

47
Q

Bladder Cancer

RT volumes : dose?

A 
66 Gy (gross residual)
60 Gy (whole bladder)
50 Gy (pelvic)

no consensus yet

48
Q

Bladder Cancer

What is the optimal hypofractioneted RT dose?

A

55/2.5/20 fractions

49
Q

Bladder Cancer

What is the CTV is treating whole-bladder?

A

uninvolved bladder wall + 1.5 cm

extravesical extent + 2 cm margin

50
Q

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%
A

C

51
Q

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%
A

B

52
Q

Bladder Cancer
(from in-service bank)

  1. 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.
A

D

53
Q

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
A

D

54
Q

Bladder Cancer
(from in-service bank)

  1. 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
A

B

55
Q

Bladder Cancer
(from in-service bank)

  1. 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
A

C

Ph RadOnc Residency PBRROE2-3 Review 2021 (57 decks)

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