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EAMC Urology 2022 > Campbell Management of Muscle-Invasive and Metastatic Bladder CA > Flashcards

Campbell Management of Muscle-Invasive and Metastatic Bladder CA Flashcards

1
Q

_____ of patients will present with muscle-invasive bladder cancer at the time of initial presentation.

_____ will progress to muscle-invasive disease after an initial diagnosis of non–muscle-invasive bladder cancer.

if left untreated, MIBC will result in mortality
within 2 years of diagnosis in _____% of cases.

A

Twenty percent to 30%

A smaller subset (approximately 20%)

85% of cases

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2
Q

The majority of primary bladder cancers are _____, representing more than ____ of all bladder tumors.

Squamous cell comprises ____% of all bladder cancers in the Western world, but more common in the ____ and ____ due to infection with ____

A

urothelial carcinomas

90%

5% SCCA
Middle East and Africa
Schistosomal parasites

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3
Q

_____ variants of bladder cancer are relatively rare but highly aggressive, and they typically present at high pathologic stages or with metastatic disease.

Standard treatment: ____
Paraneoplastic syndromes: (3) _____

A

Pure neuroendocrine
NAC + RC
PNS: ectopic adrenocorticotropic hormone production, hypercalcemia, and hypophosphatemia.

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4
Q

Variant histologies of UC (4):

A

Micropapillary: aggressive, resemble papillary serous CA of the ovary
Sarcomatoid
Squamous
Glandular differentiation

** subtypes are considered aggressive - early definitive therapy

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5
Q

_____ is the gold standard method for establishing the diagnosis of muscle-invasive bladder cancer

A

TUR

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6
Q

Prostatic urethra biopsy

A

Using a resectoscope, a full loop of tissue is taken from the midprostate (or bladder neck in shorter prostates) to the mid- to distal verumontanum and 5 and 7 o’clock adjacent to the verumontanum.

** This is the site of the highest concentration of prostatic ducts and the area where carcinoma in situ (CIS) is most likely to be found

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7
Q

Bimanual Examination under Anesthesia

A
  • Dominant hand on the suprapubic region and one or two fingers from the nondominant hand in the rectum (males) or vagina.
  • Should be done before and after
    resection
  • Performed with the bladder drained and without a Foley catheter in place to maximize palpation of the bladder
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8
Q

It is optimal to obtain cross-sectional imaging ____ TUR.

If imaging is obtained AFTER TUR, it should be delayed ____ post-procedure to minimize inflammatory artifact (can be mistaken for T3 disease).

A

BEFORE TUR

7 days delay

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9
Q

Baladder CA T staging

A

TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Ta Noninvasive papillary carcinoma
Tis Carcinoma in situ: “flat tumor”
T1 Tumor invades subepithelial connective tissue
T2 Tumor invades muscularis propria
pT2a Tumor invades superficial muscularis propria (inner
half)
pT2b Tumor invades deep muscularis propria (outer half)
T3 Tumor invades perivesical tissue
pT3a Microscopically
pT3b Macroscopically (extravesical mass)
T4 Tumor invades any of the following: prostatic
stroma, seminal vesicles, uterus, vagina, pelvic
wall, abdominal wall
T4a Tumor invades prostatic stroma, uterus, vagina
T4b Tumor invades pelvic wall, abdominal wall

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10
Q

Bladder CA N staging

A

Nx Lymph nodes cannot be assessed
N0 No lymph node metastasis
N1 Single regional lymph node metastasis in the true
pelvis (hypogastric, obturator, external iliac,
perivesical, or presacral lymph node)
N2 Multiple regional lymph node metastasis in the true
pelvic (hypogastric, obturator, external iliac, or
presacral lymph node metastasis)
N3 Lymph node metastasis to the common iliac lymph
nodes

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11
Q

Bladder CA M staging

A

M0 No distant metastasis

M1 Distant metastasis

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12
Q

Anatomic Stage/Prognostic Groups

A

Stage 0a Ta N0 M0
Stage 0is Tis N0 M0

Stage I T1 N0 M0

Stage II T2a N0 M0
T2b N0 M0

Stage III T3a N0 M0
T3b N0 M0
T4a N0 M0

Stage IV T4b N0 M0
Any T N1-3 M0
Any T Any N M1

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13
Q

For patients with clinical T2–T4a, N0, M0 disease, _____ remains the gold standard therapy.

A

radical cystectomy and bilateral pelvic lymph node dissection

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14
Q

Risks of Delaying RC

Higher proportion of extravesical tumors, nodal metastasis, and poorer survival in patients in which cystectomy was DELAYED more
than _____.

A

12 weeks

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15
Q

RC in Men: _____

RC in Women: _____

A

RC in Men: bladder, perivesical soft tissue, prostate, and seminal vesicles

RC in Women: bladder, ovaries, uterus with cervix, and anterior vagina.

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16
Q

Unless there is _____, a complete urethrectomy can be omitted at the time of cystectomy, allowing for orthotopic bladder substitution in women.

Although an anterior exenteration has classically been advocated in women at
the time of radical cystectomy, urothelial carcinoma rarely involves the gynecologic organs, with an overall incidence of approximately _____.

A

tumor involvement of the bladder neck

5% of cases

*** carefully selected patients can also forgo removal of the uterus and anterior vagina, which potentially allows for better anatomic support for a neobladder and preserves the autonomous nerves.

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17
Q

BPLND: essential component of radical cystectomy

_____ of patients will have pathologic lymph node metastases at the time of cystectomy.

Lymph node status is the most powerful surrogate for ____ and ____ following radical cystectomy.

A

Approximately 25%

Long-term recurrence-free and OS

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18
Q

The primary lymphatic drainage site for bladder cancer includes: (4)

Secondary drainage sites: (4)

A

The primary lymphatic drainage site for bladder cancer includes: internal iliac, external iliac, obturator, and presacral lymph nodes.

Secondary drainage sites: common iliac, para-aortic, interaortocaval, and paracaval lymph nodes

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19
Q

Standard PLND during RC: _____

Extended PLND: _____

Superextended PLND: _____

A

Standard PLND during RC: lymph node packets from the external iliac lymph vessels up to the level of the common iliac bifurcation cephalad and the genitofemoral nerve laterally to the ureter medially

Extended PLND: include the tissue extending
above the common iliac bifurcation to the aortic bifurcation and presacral region.

Superextended PLND: up to the level of the inferior mesenteric artery should be
included

20
Q

PLND: Threshold number of LNs associated with risk for pelvic failure

A

10 lymph nodes

21
Q

For patients with clinically positive lymph nodes, the standard of care is _____.

Patients who have a radiographic complete or partial response to are candidates for and should be evaluated for _____.

A

cisplatin-based systemic chemotherapy

cystectomy

22
Q

overwhelming majority of patients who initially respond to chemotherapy but do not have
surgery are destined to recur:

THEREFORE: _____

A

consolidative cystectomy should be strongly considered in appropriate surgical candidates who respond to systemic therapy.

23
Q

INTRAOP: Cystectomy is NOT performed (aborted) when: (4)

A

Lymph node metastases are unresectable because of bulk
Extensive periureteral disease
Bladder is fixed to the pelvic sidewall
Tumor is invading the rectosigmoid colon

** If RC is aborted, prognosis is poor.

24
Q

The extent of prostatic involvement is also predictive of urethral recurrence.

____ is associated with the highest risk (as high as 30%) compared with that of prostatic urethral CIS and ductal or acinar involvement

A

Prostatic stromal invasion

25
Q

URETHRECTOMY should be considered in men with _____.

A

Diffuse CIS of the prostatic urethra or ducts or if there is prostatic stromal invasion

**Given the modest value of preoperative urethral biopsy, some experts advocate for
urethrectomy only in the setting of a positive apical urethral margin.

26
Q

_____ has demonstrated high correlation with final urethral margin and should be performed in all women in which orthotopic bladder substitution is being considered.

A

Frozen-section analysis of the distal urethra

27
Q

____% of patients with muscle-invasive bladder cancer treated with cystectomy ALONE will progress to metastatic disease.

A

Nearly 50%

  • Surgery alone is not sufficient therapy in a large number of patients with invasive bladder cancer
28
Q

Arguments for/advantages of NAC (cisplatin-based) for MIBC: (4)

A
  1. Systemic chemo better tolerated before surgery (post-op debilitation/complications)
  2. Micrometastatic disease will receive therapy when burden of disease is potentially low
  3. NAC has potential to downstage bulky and locally advanced tumors - higher likelihood of negative surgical margins
  4. NAC allows clinician to assess individual’s response to therapy
29
Q

Patients with _____ disease are known to be at high risk for recurrence following cystectomy.

_____ has been used in this population in an attempt to treat micrometastatic
disease and to improve survival.

A

pT3–T4 or node-positive

Adjuvant chemotherapy

30
Q

A major limitation of ADJUVANT chemotherapy is ____.

A

that it is often difficult or impossible for patients to undergo systemic therapy following cystectomy secondary to surgical deconditioning, deteriorating renal function, or perioperative complications.

31
Q

Currently the NCCN guidelines favor neoadjuvant chemotherapy instead of adjuvant chemotherapy based on higher-level evidence
data;

HOWEVER, the guidelines do suggest considering adjuvant chemotherapy in the setting of _____ disease based
on the available data.

EAU: _____

A

pT3–4 or node-positive

EAU: adjuvant chemotherapy within clinical trials but not as a routine
therapeutic option

32
Q

Adjunctive radiation can increase risk for _____.

The strongest case for its use can be made for patients with _____, but there are several ongoing prospective studies specifically studying its role for patients with pT3–4 primary tumors, less than 10 nodes identified, and N+ disease.

A

postoperative small bowel obstruction

positive soft-tissue surgical margins

33
Q

Bladder PRESERVATION is a curative intent

paradigm that should be considered in two (2) distinct populations: _____

A

(1) patients who have high operative risks as a result of comorbidities
and frailty and

(2) patients who are fit for radical cystectomy but
have limited burden of disease, adequate normal bladder urothelial and function, and are motivated to retain their bladder

34
Q

The most rigorously studied approach to bladder preservation is: _____

A

Trimodality therapy: a maximal safe and ideally visibly complete TUR, chemotherapy, and radiation

35
Q

Two basic strategies for trimodal bladder preservation: (2)

A

SPLIT-COURSE: patients are administered induction chemoradiation therapy to approximately
40 Gy, which is followed by restaging with cross sectional imaging and endoscopic evaluation. If persistent invasive disease is noted, radical cystectomy is recommended; for surgically fit patients eligible for immediate salvage cystectomy

CONTINUOUS-COURSE: full course of chemoradiation therapy followed by an endoscopic restaging examination 3 to 4 months after therapy to allow time for an adequate response to therapy; for BOTH surgically fit and unfit patients

36
Q

Appropriate candidates for trimodality bladder preservation: (3)

A

Limited burden of disease: unifocal, small (<4 cm maximal dimension), without frank extravesicular extension on imaging, no hydronephrosis, can be totally resected with TUR

Adequate normal bladder urothelium and function

Motivated to retain their bladder

37
Q

Trimodality bladder preservation: _____ of patients will ultimately have salvage cystectomy in the long-term as a result of muscle-invasive recurrences

A

25% to 30%

38
Q

A major limitation of radical TUR monotherapy is the significant risk for _____.

_____ has been noted in cT2 cystectomy specimens in up to 40% and 9% of patients, respectively.

A

occult extravesical disease noted in patients with clinical T2 disease

Pathologic T3 and pT4 disease

**Therefore, TUR monotherapy in upward of 50% of patients presenting with muscle-invasive bladder cancer would be undertreatment.

39
Q

If a patient is going to elect TUR
monotherapy (RADICAL TUR), that patient should be properly informed regarding the risk for recurrent disease and should be appropriately selected based on clinical criteria including: (5)

A 
a negative restaging TUR
no hydronephrosis
no evidence of adenopathy
tumor size less than3 cm
lack of multifocal disease
40
Q

Ideal candidates for partial cystectomy include those with (3):

A

Small, solitary tumors amenable to wide resection with 2-cm margins

Ideally the tumor should be away from the ureteral orifices to avoid reimplantation.

Tumor is in a location that allows for complete resection while maintaining adequate functional bladder capacity.

41
Q

_____ is the standard of care for patients with metastatic urothelial bladder cancer.

Firstline systemic regimens include: _____

A

Systemic cisplatin-based combination chemotherapy

MVAC, HD-MVAC, and gemcitabine/
cisplatin

42
Q

NOT cisplatin candidates (5): _____

A

ANY of the following:
- a World Health Organization or
Eastern Cooperative Oncology Group performance status greater
than 2
- creatinine clearance less than 60 mL/min,
- grade 2 or above
audiometric hearing loss
- grade 2 or above peripheral neuropathy,
- a New York Heart Association Class III or higher heart failure

43
Q

When cisplatin therapy is contraindicated, ____ has been substituted with the benefit of improved tolerability, but with the cost of decreased efficacy

A

Carboplatin

44
Q

Stomach for urinary diversion:

ADVANTAGES: ____

ELECTROLYTE IMBALANCE: ____

COMPLICATIONS: ____

A

ADVANTAGES: less permeable to urinary solutes, it has a net excretion of chloride and protons rather than a net absorption of them, and it produces less mucus.

HYPOCHLOREMIC metabolic ALKALOSIS

Hematuria-dysuria syndrome
Rare: severe ulcerative complications

45
Q

Jejunum for urinary diversion

ADVANTAGES: ____

ELECTROLYTE IMBALANCE: ____

COMPLICATIONS: ____

A

The jejunum is usually not used for reconstruction of the urinary system because it may result in severe electrolyte imbalance, most concerningly HYPERKalemia

If it is the only segment available: USE DISTAL SEGMENT to minimize electrolyte abnormalities

46
Q

Ileum for urinary diversion

ADVANTAGES: ____

ELECTROLYTE IMBALANCE: ____

COMPLICATIONS: ____

A

ADV: mobile and of small diameter, has a constant blood
supply, and serves well for ureteral replacement and the formation of conduits.

ELECTROLYTE IMBALANCE:

COMPLICATIONS: Lack of B12 absorption, diarrhea (lack of bile salt absorption), and fat malabsorption; 10% chance of postop bowel obstruction

EAMC Urology 2022 (22 decks)

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