Campbell Management of Muscle-Invasive and Metastatic Bladder CA Flashcards
_____ 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.
Twenty percent to 30%
A smaller subset (approximately 20%)
85% of cases
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 ____
urothelial carcinomas
90%
5% SCCA
Middle East and Africa
Schistosomal parasites
_____ 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) _____
Pure neuroendocrine
NAC + RC
PNS: ectopic adrenocorticotropic hormone production, hypercalcemia, and hypophosphatemia.
Variant histologies of UC (4):
Micropapillary: aggressive, resemble papillary serous CA of the ovary
Sarcomatoid
Squamous
Glandular differentiation
** subtypes are considered aggressive - early definitive therapy
_____ is the gold standard method for establishing the diagnosis of muscle-invasive bladder cancer
TUR
Prostatic urethra biopsy
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
Bimanual Examination under Anesthesia
- 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
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).
BEFORE TUR
7 days delay
Baladder CA T staging
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
Bladder CA N staging
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
Bladder CA M staging
M0 No distant metastasis
M1 Distant metastasis
Anatomic Stage/Prognostic Groups
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
For patients with clinical T2–T4a, N0, M0 disease, _____ remains the gold standard therapy.
radical cystectomy and bilateral pelvic lymph node dissection
Risks of Delaying RC
Higher proportion of extravesical tumors, nodal metastasis, and poorer survival in patients in which cystectomy was DELAYED more
than _____.
12 weeks
RC in Men: _____
RC in Women: _____
RC in Men: bladder, perivesical soft tissue, prostate, and seminal vesicles
RC in Women: bladder, ovaries, uterus with cervix, and anterior vagina.
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 _____.
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.
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.
Approximately 25%
Long-term recurrence-free and OS
The primary lymphatic drainage site for bladder cancer includes: (4)
Secondary drainage sites: (4)
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
Standard PLND during RC: _____
Extended PLND: _____
Superextended PLND: _____
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
PLND: Threshold number of LNs associated with risk for pelvic failure
10 lymph nodes
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 _____.
cisplatin-based systemic chemotherapy
cystectomy
overwhelming majority of patients who initially respond to chemotherapy but do not have
surgery are destined to recur:
THEREFORE: _____
consolidative cystectomy should be strongly considered in appropriate surgical candidates who respond to systemic therapy.
INTRAOP: Cystectomy is NOT performed (aborted) when: (4)
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.
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
Prostatic stromal invasion
URETHRECTOMY should be considered in men with _____.
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.
_____ has demonstrated high correlation with final urethral margin and should be performed in all women in which orthotopic bladder substitution is being considered.
Frozen-section analysis of the distal urethra
____% of patients with muscle-invasive bladder cancer treated with cystectomy ALONE will progress to metastatic disease.
Nearly 50%
- Surgery alone is not sufficient therapy in a large number of patients with invasive bladder cancer
Arguments for/advantages of NAC (cisplatin-based) for MIBC: (4)
- Systemic chemo better tolerated before surgery (post-op debilitation/complications)
- Micrometastatic disease will receive therapy when burden of disease is potentially low
- NAC has potential to downstage bulky and locally advanced tumors - higher likelihood of negative surgical margins
- NAC allows clinician to assess individual’s response to therapy
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.
pT3–T4 or node-positive
Adjuvant chemotherapy
A major limitation of ADJUVANT chemotherapy is ____.
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.
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: _____
pT3–4 or node-positive
EAU: adjuvant chemotherapy within clinical trials but not as a routine
therapeutic option
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.
postoperative small bowel obstruction
positive soft-tissue surgical margins
Bladder PRESERVATION is a curative intent
paradigm that should be considered in two (2) distinct populations: _____
(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
The most rigorously studied approach to bladder preservation is: _____
Trimodality therapy: a maximal safe and ideally visibly complete TUR, chemotherapy, and radiation
