Campbell Bladder Cancer + NCCN Bladder 3.2021 Flashcards
Bladder CA
Risk Factors
Tobacco smoking (MAIN)
Aromatic amines (2-naphthylamine, 4-aminobiphenyl, benzidine)
NAT2 and GSTM1 gene deletions
Lynch syndrome, HNPCC
MSH2 mutations
Increased BMI
Occupational exposure to aromatic amines: tobacco, dye, and rubber workers, hairdressers, painters, and leather workers
Bladder calculi, urinary outflow obstruction, recurrent UTIs, and inflammation from direct catheter trauma
Schistosomiasis (S. hematobium)
Cyclophosphamide
Arsenic in drinking water
The gold-standard test for the diagnosis of bladder cancer is: ___
Cystoscopy and biopsy
Blue-light cystoscopy (BLC)
360-450 nm
Porphyrin-induced fluorescence cystoscopy uses photoactive porphyrins, such as hexaminolevulinate (HAL), that accumulate preferentially in neoplastic tissue and emit red fluorescence under blue-wavelength light
5-ALA and HAL
Narrow-band imaging (NBI)
enhances contrast between mucosal surfaces and microvascular surfaces without the use of dyes.
lluminates the mucosal surface with light of a narrow bandwidth in the blue (415 nm) and green (540 nm) light spectrum, which are strongly absorbed by hemoglobin
Inverted papilloma
benign proliferative lesion that is associated with chronic inflammation or bladder outlet obstruction and can be located throughout the bladder but most commonly on the trigone, accounting for less than 1% of all bladder tumors
Painless gross hematuria
Benign behavior, 1% chance of recurrence
Nephrogenic adenoma
rare tumor caused by chronic irritation of the urothelium and can arise from trauma, prior surgery, renal transplantation, intravesical chemotherapy, stones, catheters, and infection
Cystoscopy: appear like a papillary neoplasm and may be hard to distinguish from more aggressive bladder neoplasms
Recurrence is uncommon, manageed with repeat resection
Leukoplakia
White, flaky plaques floating in the bladder
NO evidence to suggest that this condition was premalignant; therefore cystoscopy, biopsy, and further treatment were unnecessary.
Cystitis Cystica and Glandularis
Benign lesions represent cystic nests that are lines by columnar or cuboidal cells and are generally associated with prolifera- tion of Von Brunn nests
Treatment is transurethral resection and relief of the obstruction or inflammatory condition.
Most common malignancy of the urinary tract
Urothelial carcinoma
** Second most common cause of death among all GU tumors
Micropapillary variant
- ny amount of micropapillary urothelial carcinoma may be present for it to be defined as micropapillary
TX: surgical resection, must be completely resected for TURBT + BCG to be effective;
Early cystectomy for NMIBC
Sarcomatoid variant
large infiltrative masses
5-year cancer-specific survival as low as 28.4% across all stages
worse outcomes than pure urothelial tumors
TX: Immediate radical cystectomy when feasible
Plasmacytoid variant
rare, comprising less than 1% of all urothelial tumors
includes the signet ring variant: presence of cytoplasmic vacuoles with or without intracellular mucin
metastatic median survival: only 17.7 months
TX: chemosensitive, NAC whenever possible;
Nested variant
Rare, aggressive
Male:female ratio 6:1
Can be confused with benign lesions such as Von Brunn nests that are located in the lamina propria, cystitis cystica, and inverted papillomas
Small Cell
rare, poorly differentiated neuroendocrine neoplasm
paraneoplastic syndromes associated with small cell carcinoma including hypercalcemia, Cushing syndrome, and sensory neuropathy.
TX: chemosensitive, platinum-based chemotherapy at initial presentation;
Cisplatin + etoposide regimen of choice
Squamous cell cancer
S. haematobium or other bacteria, chronic infection
Spinal cord injury + chronic catheterization
Lower incidence of nodal/mets disease, but seen initially at more advanced stages vs urothelial
TX: Adjuvant and intraop radiation = no clear consensus
Adenocarcinoma
RFs: bladder exstrophy, schistosomiasis, and chronic irritation or obstruction
Recommended: colonoscopy
No evidence for use of chemo or RT in NAdj or Adj setting
MVAC or GC: little benefit
Other regimen: 5-FU + cisplatin
Urachal adenocarcinoma
1/3 of all bladder adenocarcinomas
Allantoic remnant connecting bladder to umbilical cord
Urachal = almost always adenoCA
Criteria:
- Located in the bladder dome or ant. abdominal wall, epicenter at bladder dome
- Could not have widespread cystitis cystica
- Investigae secondary source of adenoCA
Nearly all are muscle invasive
St. I: urachal mucosa
St. II: confined to urachus
St. IIIA: extend locally into bladder IIIB abd. wall IIIC peritoneum
St. IV metastatic
TX: en bloc resection of dome, urachal ligament and umbilicus
Initial evaluation of bladder cancer
• H&P
• Office cystoscopy,
enhanced if available
• Consider cytology • Abdominal/pelvic
• Examination under anesthesia (EUA) (bimanual)
Suspicion of bladder cancer
imagingb that includes imaging of upper urinary tract collecting system before transurethral resection of bladder tumor (TURBT)
• Screen for smoking
Primary evaluation + surgical treatment:
- EUA
- TURBT
- Single dose intravesical chemo within 24 hrs of TURBT: Gemcitabine (pref. cat 1) or mitomycin (cat 1)
- Upper tract imaging if not previously done
AUA RIsk Stratification for NMIBC
LOW RISK
• Papillary urothelial neoplasm of low malignant potential
• Low grade urothelial carcinoma Ta and
≤3 cm and
Solitary
AUA RIsk Stratification for NMIBC
INTERMEDIATE RISK
• Low grade urothelial carcinoma T1 or >3 cm or Multifocal or Recurrence within 1 year • High grade urothelial carcinoma Ta and ≤3 cm and Solitary
AUA RIsk Stratification for NMIBC
HIGH RISK
• High grade urothelial carcinoma CIS or T1 or >3 cm or Multifocal • Very high risk features (any): BCG unresponsivek Variant histologiesl Lymphovascular invasion Prostatic urethral invasion
Management NMIBC
LOW RISK
Surveillance
If prior BCG, maintenance BCG (preferred)
Management NMIBC
INTERMEDIATE RISK
Intravesical therapyo,p (preferred)
or
Surveillance
If prior BCG, maintenance BCG (preferred)
