Bladder Cancer FRCR CO2A Flashcards
What are the types of primary malignant bladder cancer?
Transitional Cell Carcinoma 90%
Sq Cell Carc 5%
Adenocarcinoma 1-2 %
Small cell carcinoma
others
what is the male to female ratio for incidence of BC ?
5:2
What are the RFs for BC?
Smoking (2 naphthylamine, polycyclic aromatase hydrocarbons)
Passive smoking
Occupation: petroleum, rubber, dye and paint (chlorinated hydrocarbons)
what are the genetic syndromes a/w BC?
RB1 and Lynch syndrome
How does family history of BC affect its risK?
1st degree relative doubles an individual’s risk
is any screening recommended for BC detection
No
which site of bladder is MC affected ?
The base of bladder and multiple tumors are frequent
which NMIBC should be considered as high grade?
CIS, High grade G3 T1 lesions, 20% of NMIBC will become muscles invasive and recc risk is 50%
what investigations for hematuria of unknown case
Urinanalysis for cytology and culture
Flexible white light cystoscopy,
In NMIBC, blue light cystoscopy, dissease appears red and normal tissue as blue
Whats the mc clinical presentation for BC
Painless hematuria
What investigations should be done after confirmation of BC diagnosis?
TURBT
Pelvic MRI or CT
CT chest abdomen pelvis
is bone scan routinely done
no, only if symptoms or raised Ca or ALP
is there any role of PET
limited use bcoz of interference from urinary excretion of contrast
what should be included in histology report ?
- location and grade
- Depth of invasion
- CIS present/absent
- LVSI
- aberrant histology
what is important in specimen
presence of detrusor muscle, its absence means incomplete resection
what are the chances of LN spread
- 20 % for lamina propria involvment
- 30% for superficial muscle involvement
- 60% for full thickness muscle involvment
what is the treament of NMIBC
TURBT followed by single dose of perioperative intravesical chemotherapy, reduces rist by 11.7% compared to TURBT alone
which intravesical agent is superior to ChT
BCG
what are other chemo intravesical options?
Doxorubicin and epirubicin
which agent is commonly given in UK as intravesical chemo?
Mitomycin C 20 mg
what are C/I for intravesical therapy
suspected or confirmed cases of perforation following TURBT
what is recommeded duration of Rx with BCG
1 year for intermediate risk, 1-3 years for high risk
what are absolute C/I for BCG
difficult catherisation or during 14 days of TURBT
What are relative C/I for BCG
immunosuppression or asymptomatic bacteriuria
what follow up timing is recommened for NMIBC post treatment?
Cystoscopy and urine cytology initially 3 months post TURBT, should be followed up for 5 years after low risk disease and life long for intermediate and high risk disease
what is the treament for MIBC T2-T4a N0/Nx M0
Radical Cystectomy (RC)
what things should be looked at before RC
patient PS, comorbidities and their wish
When is RC Treatment of choice
high risk pts, defined as cT4, CIS, multifocal, incomplete TURBT, HDUN and fit for surgery
when is definitive CRT recommended
not fit for surgery and wish for bladder preservation
whats the advantage of extended b/l pelvic lymphadenectomy
better 5 years survial than stand LND
which pts should be given option of bladder preservation?
medically fit and intermediate RFs cT2-T3, no CIS, unifocal, complete TURBT and no HDUN
What does RC involve
cystoprostatectomy for mend and anterior exenteration for women with urinary diversion using a bowel segment
what is poor prognostic feature
positive nodal status
what are complications of RC
bleeding infection TE lymphocele formation anastomotic leakage bowel obstruction and sexual dysfunction
for how long surveillance is mandatory for MIBC post treatment
life long
which organs are commonly sites of metastasis for BC
lungs, liver bones
what is the rationale for NACT
addressing micrometastases and downstaging the primary tumor
who are the candidates for NACT
all fit surgical candidates with adequaate renal function
what are recommended chemo regimens for NACT
MVAC and Gem Cis
when is response evaluation done with NACT
after 2 cycles, if good response, chemo for 3 to 4 cycles
what gap should be given between chemo completion and surgery
atleast 4 weeks
whats the role of adjuvant chemo?
survival benefit with cisplatin based regimens
NACT remains SOC however adjuvant for someone who missed NACT or high volume nodal disease or extravesical spread at RC
what is trimodality bladder preseving strategy
TURBT followed by CRT (with early salvage cystectomy for recurrent disease)
how is trimodality strategy compared to RC
similar survival rates
what are important prognostic factors post trimodality therapy
pts age
tumor size
response to RT
HDUN and
completeness of TURBT
what is split course regimen
Maximal TURBT and CRT to 40 Gy with cis and 5 FU given before repeat cystoscopy and biopsy: complete ressponse in 72% of pts who proceed to condolidation CRT to total dose of 64 Gy
what has BCON study shown
survival benefit with hypoxic modification in addition to standard RT
how long surveillance is required post cystectomy
3 monthly for first year, six monthly for 2nd year then annually
CT at 6 and 12 months and then annually
how should NMIBC recurrence be managed
for 1st prsentation with TURBT and Intravesical therapy, if recurrent cystectomy
What things should be kept in mind while planning RT for BC
empty rectum and empty bladder, unless partial bladder irradiation is planned
How is RT simulation for BC done
supine, flat couch arms folded across the chest
where should skin tatoos be placed
anteriorly over the pubic symphisis and laterally over the iliac crests to prevent lateral rotation
what should be planning CT field
3 mm slice bottom of the ischial tuberosities to 3 cm above the dome of bladder or bottom of L5, whichever is higher
What CTV includes
visible known tumor and normal bladder,
what is margin from CTV for PTV
15 mm around normal bladder and 20 mm around tumor
IS nodal irradiation frequently done in UK even in high risk of nodal disease
no, because the benefits are unclear
what direction beams are given
one anterior and two posterior oblique wedged fields
What RT dose is frequently used for radical Rx
64 Gy/32# over 6.5 weeks or 55 Gy/20# over 4 weeks
how is T4b or N+ disease treated?
Many consider it systemic disease and treat with 4 to 6 cycles of systemic therapy, if good response consolidation RT to the bladder and possibly pelvic nodes
if nodal irradiation is planned, what bladder protocol should be followed and why
full bladder to avoid high doses to bowel
what is EORTC defined fitness for cisplatin
GFR > 60 ml/min and PS 0-1, uretric shunt should be placed first before systemic Rx is planned for obstruction
what treatment for PS >2
BSC
can carboplatin replace cisplatin for cisplatin fit pts
no, OS is inferior with Carboplatin
what is 1st Line Treatment for Cisplatin ineligible pts in recurrent/metastatic setting ?
Pembrolizumab and enfortumab vedotin-ejfv1
what is 1st Line Treatment for Cisplatin eligible pts in recurrent/metastatic setting ?
Pembrolizumab and enfortumab vedotin-ejfv1
what are other 1st Line Treatment for Cisplatin eligible/ineligible pts in recurrent/metastatic setting ? except pembro and enfortumab vedotin?
Gemcitabine and cisplatin4 (category 1) followed by avelumab maintenance therapy (category 1)a,13
* Nivolumab, gemcitabine, and cisplatin (category 1) followed by nivolumab maintenance therapy14
what are Palliative RT doses for BC
21 Gy/3# or 36 Gy/10# or 30 Gy/10#
if Rx to the whole pelvis with parallel fields is required, what dose should be used
30 Gy/ 10#
if low volume bladder only is being treated, what dose should be used
21 Gy/ 3#
is Single Fraction of 8 Gy effective
yes for hematuria and for PS > 2
what palliative RT dose should be considered for Rx with CT planning
35 Gy/10# or 36 Gy/ 6#
