CUA GL Muscle invasive bladder Ca 2019

Question 1

what is the overall mortality rate of patients diagnosed with MIBC? at 5 years?

Answer 1

40-50%

Question 2

How should MIBC be diagnosed? can you do MRI to diagnose?

Answer 2

MIBC should be diagnosed with a good quality TURBT including muscularis propia that confirms muscle invasion. Clear all macroscopic disease, IF clearly invasive( as per bimanual exam) or size too big still get tissue for diangosis

Question 3

Is review by a secondary pathologist recommended for all cases of muscle invasive bladder cancer?

Answer 3

No, just for variant cases

Question 4

What should be reported on TURBT pathology?

Answer 4

Histological type, depth of invasion, grade, prescense of CIS, LVI,

Question 5

what are poor pathological indicators?

Answer 5

high grade, CIS, LVI, variant histology.

particularly CIS is bad in T2 patients and worse survival after RC

Question 6

How should bladder cancer be staged?

Answer 6

Exam under anesthesia, CT chest abdo pelvis, MRI ( can be considered for local extent of disease evaluation), Bone Scan Not mandatory( consider if ALP or Ca high or bony pains), Role of PET unknown

Question 7

What are the main options for NAC?

Answer 7

Gem-Cis, MVAC, ddMVAC( methotrexate, vinblastine, doxurubicin, cisplatin)

Question 8

who should get NAC?

Answer 8

all eligible patients with cT2-T4a N0 M0 disease

Question 9

what are absolute contraindications to NAC?

Answer 9

absolute: ECOG 2 or worse, grade 2 hearing loss or neuropathy, GFR<50, NYHA class III or IV, untreated infection
Relative: GFR50-60, history of recurrent infection, concomitant immunosuppression

Question 10

what should happen if someone is not a candidate for standard NAC>

Answer 10

proceed with radical local therapy

Question 11

How should you drain someone who has malignant ureteral obstruction prior to NAC?

Answer 11

NT

Question 12

do you need to reimage patients during NAC?

Answer 12

yes for gem-cis or MVAC half way image them and if they have non-metastatic progression go straight to RC(wait 4 to 6 weeks). ddMVAC is quick so dont worry about it

Question 13

When should RC be performed after NAC

Answer 13

4-6 weeks after, certainly not more than 10 weeks after. otherwise would compromise survival

Question 14

what is the role of NAC in pure non-urothelial bladder ca?

Answer 14

Particularly for SCC not define and should not be used.

Question 15

What should be offered to patients who have RC but dont get NAC

Answer 15

adjuvant GC, MVAc or ddMVAC if they got T3/T4 or N+ disease

Question 16

what if someone has nonmetastatic clinically unresectable disease? what systemic treatment if any

Answer 16

cT4b or cN+ ==> try induction chemo GC, MVAc, ddMVac or if not carboplatin/gem, clinical trial, if they respond then RC

Question 17

what is the absolute survival benefit of NAc at 5 years

Answer 17

5%

Question 18

NAC is part of the mainstay of treatment for small cell carcinoma of the bladder

Answer 18

yes, this is the only variant that it is shown to work well

Question 19

What is the standard surgical treatment for MIBC

Answer 19

RC

Question 20

What is the optimal timing of RC if NAC is not given?

Answer 20

4-6 weeks after TURBT

Question 21

Should RC patietns get ERAS?

Answer 21

yeah

Question 22

What does RC entail in males?

Answer 22

Bladder, prostate, SV en bloc, Nerve sparing can be offered in those interested in preservation of sexual function

Question 23

What does RC entail in females?

Answer 23

bladder, reproductive organs( uterus, ovaries), anterior vagina, if tumor is anterior a surgery that spares female reproductive organs can be offered to those interested in preserving sexual or reproductive function

Question 24

who should be offered orthoptic urinary diversion

Answer 24

all eligible patients, send a urethral margin frozen section intraop before making the diversion

Question 25

who should have urethrectomy

Answer 25

men with high grade or invasive urethral tumors distal to prostate, positive urethral margin, suspected prostatic stromal involvement. bladder neck tumors in women

Question 26

who can have a partial cystectomy?(MIBC)

Answer 26

should be discouraged in this setting but
unifocal, small<2cm, dome location, good bladder capacity, no hydronephrosis, minimal or no CIS.
prior to performing partial cystectomy do random bx to r/o occult disease, do a standard PLND

Question 27

what does the standard PLND for cystectomy should include?

Answer 27

external iliac, obturator, internal iliac,

Question 28

What should the final RC pathology report include?

Answer 28

histology(including variants), stage, grade, presence of concomitant CIS, presence of LVI, number of nodes, margin status, number of positive nodes, surgical margin status
assessment of reproductive organs for staging and assessment of occult disease

Question 29

who should get trimodal therapy?

Answer 29

unfit for RC, want to preserve bladder, refuses RC

Question 30

what is an ideal patient for TMT?

Answer 30

small<5cm, unifocal, no cis, no hydronephrosis, good bladder function, motivated for bladder preservation

Question 31

Complete TURBT (radical TURBT) is needed prior to chemo RT in TMT

Answer 31

Correct

Question 32

can RT be given alone?

Answer 32

yes, sub-par but can be give to those who cant have rc or chemo

Question 33

what kind of chemo will be given with RT

Answer 33

5FU/MMC, gem, cis,

Question 34

is there any tole for neo-adjuvant RT or adjuvant RT in MIBC

Answer 34

Nope

Question 35

should you resect mets in oligometastatic bladder ca or if there is a recurrence?

Answer 35

No

Question 36

Consideration of consolidative surgery (RC) combined
with oligometastectomy in initially unresectable
patients experiencing a significant complete response
(CR) or partial response (PR) can be given.

Answer 36

Kinda, yes
but must be on a case-by-case
basis after multidisciplinary tumor board discussion

Question 37

what would FU of RC MIBC entail to?

Answer 37

depends on TNM
but generally imaging to RO upper tract reccurence or local reccurence, hydro,
Bw to look for metabolic complications of diversion

Question 38

who should have FU cytologies?

Answer 38

patients at high risk for urethral or upper tract recurrence ( if urethral remnant then urethral washings+ cysto)

Question 39

how do you manage recurrence after bladder preservation

Answer 39

like a primary bladder tumor, consider RC
for high risk recurrences/

consider biopsy after TMT to assess response

Question 40

What should be done for patients with MIBC unfit for TMT or RC

Answer 40

radical TURBT for local control

Question 41

what should be offered for intractable hematuria or pellvic pain secondary to bladder tumor? advanced disease

Answer 41

Palliative cystectomy, (non-curable)

Palliative RT, can also give for bone pain other mets

Question 42

Palliative chemotherapy (….) may be
offered to patients with unresectable or metastatic
disease who are ineligible for or have failed platinum-
based combination chemotherapy

Answer 42

e.g., gemcitabine/ RCT

ALWAYS consider early palliative care referral.