CUA GL management of NMIBC- 2015

Question 1

what are risk factors for bladder cancer?

Answer 1

smoking, chronic inflammatory changes( due to infection, stones, indwelling catheter, shisto), chemotherapeutic exposure( cyclophosphamide) , pelvic radiation, occupational exposure to aromatic amines, chronic phenacetin use. lynch syndrome

Question 2

what percentage of bladder cancer is NMIBC?

Answer 2

75-80%, Ta>T1>CIS, bladder cancer is the most expensive human cancer to treat

Question 3

what are prognostic factors for recurrence and progression of bladder cancer

Answer 3

grade(very important) , stage, multifocality, presence of LVI, presence of CIS, size, recurrence, number of tumors, Others: variant histology

Question 4

WHAT IS THE OVERALL recurrence rate of NMIBC?

Answer 4

60-70%

Question 5

Based on the EORTC what is low risk and high risk NMIBC?

Answer 5

low risk: Ta low grade, solitary, <3cm high risk: T1, high grade or CIS– also treat Ta and >3cm and multifocal and multi recurrent like high risk

Question 6

what is intermediate risk NMIBC per EORTC?

Answer 6

multifocal, or multi-recurrent TaLG, >3cm

Question 7

algorithm for manamgent of NMIBC

Answer 7

Question 8

What are key elements of TURBT to keep in mind?

Answer 8

Complete resection of all visible tumor (including CIS) with adequate depth to include muscularis propia

bimanual examination should be performed under GA at the begining and at the end

Question 9

How do HAL Photodynamic diagnosis and NBI help with NMIBC ?

Answer 9

improve tumor detection and early recurrences. not known if this benefit keeps with post-op instilation of mitomycin C.

the impact on long term is not known( per 2015 GL)

Question 10

what is the fluoroscent diet used for fluroscent cysto?

Answer 10

Hexyl-aminolevulunate (HAL) - given in bladder an hour before - which is a derivative of 5-ALA( given in bladder 2-4 hours before). works for patients who have had BCG too.

When patients were given a single dose of post op mitomycin C there was no difference in recurrence rate

Question 11

what can cause false positive findings for fluoroscent cystoscopy?

Answer 11

inflammation, recent TUR, recent intravesical therapy

Question 12

what are the wavelength for NBI?

Answer 12

415nm(Blue) to 540(green)

this light is strongly absorbed by hgb making it easier to see the tumor. Tumor tissue is usually more vascular

Question 13

when is prostatic urethral biopsy recommended in the context of NMIBC?

Answer 13

tumor of the trigone or bladder neck, visible abnormality of the prostate, extensive CIS, positive cytology wihtout a source,

Question 14

how should prostate urethra biopsies be performed?

Answer 14

suspicious areas + 5 and 6 oclock(precollicular area) esp at the level of veromonatnum. why? bc this has the most prostatic ducts. make sure to take a good bite to have stroma in it too

Question 15

how do you treat CIS of prostatic urethra?

Answer 15

TURP and then BCG as usual. rebiopsy after induction to reassess

if prostatic ducts are involved it is controversial( bc of high risk of invasion)

Question 16

what are indicaitons for cystectomy and urethrectomy?

Answer 16

high grade recurrence POST BCG, prostatic stromal involvment

Question 17

when should a restaging TUR be performed?

Answer 17

for any T1 or high grade disease or when there is no muscle in the specimen, or if the resection is incomplete

Question 18

in patients with T1HG what percentage were upstaged on Re-TUR?

Answer 18

50% if no muscle on initial specimen, 14% if the initial specimen had muscle

Question 19

is restaging TUR associated with decreased recurrence and improved PFS?

Answer 19

yes it is at 5 years

Question 20

when should a restaging TUR be perfomred per CUA?

Answer 20

2-6 weeks after initial resection

Question 21

how should low risk bladder ca patients be followed up?

Answer 21

Cysto at 3 months and 12 months and annually thereafter, CAn consider stopping at 10 years and switching to US and or urine cytology

Question 22

how should high risk patients be followed?

Answer 22

cysto at 3 months then Q 3-4 months for 2 years, Q6 months for 2 years and annually htereafter. cytology should be done with cystos.

Upper tract imaging Q 1-2 years

Question 23

Who should get immediate post op chemotherapy (mitomycin)?

when should it be given?

Answer 23

all patients post TURBT(unless contraindicated )

best within 6 hours, efficacy decreases if given beyond 24 hours

Question 24

Is there a benefit to given MMC if BCG is planned?

Answer 24

maybe, it is not clear

Question 25

who should not get chemo(MMC) post TURBT?

Answer 25

extensive resection, bladder perforation,

Question 26

name three agents that can be given in the immediate post-op period?

Answer 26

Doxorubicin, epirubicin, MMC

improves recurrence rates

Question 27

can you describe Au et all protocol for MMC that was associated with prolonged time to recurrence?

Answer 27

pre-treatment dehydration(no fluids for 8 hours before treatment), urinary alkalinzation, completely drain bladder prior to instilation, high MMC concentration( 40mg in 20mL)

Question 28

How would you give intravesical chemotherapy to intermediate risk NMIBC?

Answer 28

for 1 year( MMC, epirubicin, doxurubicin). induction and maintenance. often given in monthly fashion but optimal schedule has not been determined.

Question 30

what are the intravesical treatment options for intermediate risk NMIBC?

Answer 30

intravesical chemo( induction + maintenance for 1 year)

Intravescial BCG( induction+ maintenance for 1 year)

if one doesnt work you can do other.

Question 31

what is the standard of care intravesicla treatment option for high risk NMIBC?

Answer 31

intravesical BCG( induction + maintenance for 3 years)

Question 32

what are the benefits of intravesical BCG?

Answer 32

Reduced tumor recurrences( better than chemo), delays( maybe even decreased only in patients who recieved maintenance) disease progression

Question 33

Is there any role to adding interferon to BCG for BCG naieve patients?

Answer 33

controversial. one RCT says no, One RCT says yes. so dont do it until there is good evidence

Question 34

What is grade 1 BCG toxicity and how do you treat it?

Answer 34

mild to moderate symptoms< 48 hours( non bacterial cystitis) , (including fever<38.5)

Treat with NSAIDs, pyridium( phenozypyridine) , anticholinergics

Question 35

What is grade 2 bcg toxicity and how is it treated?

Answer 35

Moderate to severe symptoms >48 hours, (non-bacterial cystitis or prolonged cystitis)

symptomatic treatment with pyridium, NSAIDs, anticholinergics

Quinolone or culture directed Abx

Question 36

What is grade 3 BCG toxicity and how is it treated?

Answer 36

grade 3 is regional or systemic disease

1) Allergic reaction: treat with antihistamines, NSAIDs, consider suspending BCG. if severe symptoms stop BCG and give corticosteroids + INH and Rifampin for 3 months
2) Fever>38.5

Stop BCG, Consult ID, CXR, septic work up, Start treatment with (INH+rifampin+/- quinolones) pending cultures. Tx for 3-6 months

3) epididymo-orchitis, symptomatic granulamatos prostatitis: high dose quinolone( for gram -ves)+ INH+Rifampin for 3-6 months
4) caseous abscesses, granulmatous masses of the kidney, hepatitis, pneumonitis and osteomyelitis.

INH+Rifapin+Ethambutol for 6 months

Question 37

What is grade 4 BCG toxicity?

Answer 37

Multiorgan failure and spetic shock

Tx with admission to hospital, dc BCG, INH, rifampin,ethambutol, for 6 months, high dose quinolone, high dose steroids, and additional gram negative coverage

Question 38

What are the different forms of BCG failure?

Answer 38

Question 39

What is a treatment option for patients with BCG failure who cant or dont want cystectomy?

Answer 39

depends on the kind of failure but

gemcitabine has shown promise in this space

Question 40

Is there any diffference in terms of what BCG strain to use?

Answer 40

Nope

Question 41

What are indications for early/timely cystectomy?

Answer 41

BCG refractory disease(T1 Hg recurrence at 3 month or 6 months for other high grade recurrence), high volume high grade NMIBC, T1 disease with variant features, T1HG with LVI, T1 HGwith concomitant CIS bladder or prostate, Persistent T1 on repeat TUR, invasive tumor involving diverticula.