Campbell Management Strategies for NMIBC Flashcards
Low-grade Ta lesions recurrence rate ____ and progression rate ____.
Ta Recurrence rate 50-70% and Progression rate less than 5% of cases
High-grade T1 lesions recurrence rate ____ and progression rate ____ .
High-grade T1 recurrence rate 80%
Progression rate 50% in 3 years
Prognosis correlates with: (5)
Tumor size Multiplicity Papillary vs sessile configuration Presence or absence of LVI Status of remaining epithelium
High grade and low grade CAs may essentially be considered ___.
Different diseases
Chromosomal alterations –> oxidative DNA damage –> 2 separate genetic pathways in UC development
____ tumors could almost be considered benign in contrast to ___ tumors.
Papillary Ta tumors = almost considered benign compared to high-grade tumors.
____ of Ta tumors are high grade.
Most important risk factor for progression is ___, NOT ____
2.9% to 18% are high grade.
Most important risk factor for progression is GRADE, NOT stage.
CIS is regarded as a precursor to the development of ____.
Invasive high-grade cancer
Lesions interpreted as ____ are regarded as being the same entity as CIS.
Severe/high-grade dysplasia
____ % of patients with CIS develop muscle invasion if untreated, especially if associated with papillary tumors.
40-83% of CIS develop MIBC, esp. if associated with papillary tumors.
T1 tumors = usually papillary with a narrow stalk.
A ___ appearance suggests deeper invasion.
Nodular or sessile appearance
Deep penetration into the ____ increases the risk of ___ and ___.
Lamina propria, muscularis mucosae
Increases risk of recurrence and progression
These also increase risk of progression and recurrence in T1 tumors: (3)
LVI
Pyuria
Bladder neck involvement
____ often indicated muscle invasion.
Hydronephrosis
CT urography is commonly performed BEFORE TUR to: (2)
Identify other sources of hematuria
Assess extravesical urothelium (field change nature of UC)
Resection is performed using ____ irrigation and resectoscope, with bladder filled _____.
This minimizes: (3)
Continuous flow
Only enough to visualize bladder contents
(3)
Bladder wall movement
Lessens thinning of detrusor due to overdistention
Reduces risk of perforation
____ tumors can be removed without the use of electrical energy.
___ lessens the chance of perforation.
Friable, low-grade tumors
Lifting the tumor edge away from detrusor
** minimizes chances of bladder perforation and unnecessary cautery damage
After visible tumor is resected, an additional pass of the cutting loop or cold-cup biopsy can be obtained to ____.
…determine the presence of muscle invasion.
Non-muscle invasive bladder CA is the term for malignant urothelial tumors that ___.
… have NOT invaded the detrusor muscle of the bladder.
** Encompasses the relatively benign course of low-grade papillary tumors, the more aggressive clinical course of high-grade tumors including urothelial carcinoma in situ (CIS), and high-grade Ta and T1 tumors
Approximately ____ of bladder tumors are non–muscle invasive at presentation with:
____ as stage Ta
____ as T1, and approximately
____ as CIS
Approximately 70% to 80% of bladder tumors are non–muscle invasive at presentation with 60% to 70% as stage Ta, 20% to 30% as T1, and approximately 10% as CIS
____ is the most common presenting symptom of NMIBC.
The presence of ____ in the absence of ____ is also associated with CIS with some studies reporting rates of up to ___ %.
Painless hematuria (either visible or non-visible).
** Patients with visible hematuria have reported rates of bladder cancer much higher than that observed in patients with non-visible (>3 RBC/hpf on microscopic urinalysis) hematuria.
The presence of irritative voiding symptoms in the absence of UTI; up to 80%
____ and ____ are indicated in patients with hematuria and/or unexplained irritative symptoms.
Cystoscopy and upper tract imaging are indicated in patients with hematuria and/or unexplained irritative symptoms.
** In a review of 600 patients diagnosed with interstitial cystitis, 1% of the patients had a missed diagnosis of urothelial carcinoma, although the majority of these patients did not have hematuria.
Resection of diverticular tumors presents significant risk for ___.
Accurate staging is difficult because of ____.
Therefore: low grade diverticular tumors are best treated with ____ + ____ , followed by ____ if high-grade.
Bladder wall perforation
The absence of underlying detrusor.
**Invasion beyond the diverticular lamina propria immediately involves perivesical fat (stage T3a by definition)
Combined resection + fulguration of the base
Followed by repeat resection if high-grade
** High-grade requires adequeate sampling of tumor base despite near certainty of perforation –> leave IFC for several days to allow for urothelial healing.
Partial or radical cystectomy should be strongly considered for high-grade diverticular lesions because _____.
…tumors can penetrate extravesically with relative ease given the lack of a muscularis layer in the diverticula
Tumor near the ureteral orifice:
____ causes minimal scarring and may be safely performed, including resection of the orifice if necessary.
Pure cutting current
*** Resection of the intramural ureter may lead to complete eradication of some tumors but risks reflux of malignant cells. The clinical implications of this are unclear
** As long as resection of the ureteral orifice is performed with pure cutting current, scarring is minimal and obstruction unlikely.
____ resection of bladder tumors represents another alternative, relatively novel resection technique that can be performed with the traditional loop electrode, Hybrid-Knife, holmium laser, Thulium laser, or KTP lase.
En bloc
***This technique involves excision of the entire tumor with underlying segment of muscle with the specimen being resected and extracted intact, rather than piecemeal. The benefit of this derives from less cautery artifact, thereby allowing more accurate assessment of muscle invasion by pathology.
If a tumor appears to be muscle invasive, may be performed in lieu of complete resection, given the likelihood of subsequent cystectomy.
Biopsies of the borders and base to establish invasion
TURBT: Perforations tend to occur in ___ with ___, particularly in cases involving previous treatment with multiple courses of intravesical therapy
Perforations tend to occur in elderly patients with large posterior wall tumors, particularly in cases involving previous treatment with multiple courses of intravesical therapy.
The incidence of perforation can be reduced by attention to technical details (3):
- Avoiding overdistention of the bladder
- Anesthetic paralysis during the resection of significant lateral wall lesions to lessen an obturator reflex response
- Large, bulky tumors and those that appear to be muscle invasive are often best resected in a staged manner
TURBT: Majority of perforations are ____, but ____ is possible when tumors are resected at the dome.
Majority = extraperitoneal Dome = intraperitoneal
- The risk of tumor seeding from perforation appears to be low
- ** Bladder perforation during TUR does appears to be associated with greater risk of recurrence and worse disease-free survival in a series published by Comploj et al. (2014)
TURBT: Extraperitoneal bladder perforation during TURBT can typically be managed ____. Intraperitoneal perforation is less likely to close spontaneously and usually requires ____.
Extraperitoneal = prolonged urethral catheter drainage.
Intraperitoneal = open or laparoscopic surgical repair.
In the setting of high-grade T1 tumors, ____ is recommended within ____ of initial TURBT based on the well- established risk of identifying worse prognostic findings or upstaging to muscle-invasive disease in up to ____% of repeat TURBT specimens.
Repeat TURBT
6 weeks
25-30% of repeat TURBT specimens
- This is especially important if no muscle is identified on initial pathology, where repeat resection of patients with T1 disease can identify upstaging to muscle-invasive disease in up to 49% of cases
The efficacy of BCG in preventing recurrence and progression appears to be higher in patients with high-grade papillary tumors and CIS if ____.
a restaging TURBT was performed before instillation of BCG.
