CUA GL Muscle invasive bladder Ca 2019 Flashcards
what is the overall mortality rate of patients diagnosed with MIBC? at 5 years?
40-50%
How should MIBC be diagnosed? can you do MRI to diagnose?
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
Is review by a secondary pathologist recommended for all cases of muscle invasive bladder cancer?
No, just for variant cases
What should be reported on TURBT pathology?
Histological type, depth of invasion, grade, prescense of CIS, LVI,
what are poor pathological indicators?
high grade, CIS, LVI, variant histology.
particularly CIS is bad in T2 patients and worse survival after RC
How should bladder cancer be staged?
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
What are the main options for NAC?
Gem-Cis, MVAC, ddMVAC( methotrexate, vinblastine, doxurubicin, cisplatin)
who should get NAC?
all eligible patients with cT2-T4a N0 M0 disease
what are absolute contraindications to NAC?
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
what should happen if someone is not a candidate for standard NAC>
proceed with radical local therapy
How should you drain someone who has malignant ureteral obstruction prior to NAC?
NT
do you need to reimage patients during NAC?
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
When should RC be performed after NAC
4-6 weeks after, certainly not more than 10 weeks after. otherwise would compromise survival
what is the role of NAC in pure non-urothelial bladder ca?
Particularly for SCC not define and should not be used.
What should be offered to patients who have RC but dont get NAC
adjuvant GC, MVAc or ddMVAC if they got T3/T4 or N+ disease
what if someone has nonmetastatic clinically unresectable disease? what systemic treatment if any
cT4b or cN+ ==> try induction chemo GC, MVAc, ddMVac or if not carboplatin/gem, clinical trial, if they respond then RC
what is the absolute survival benefit of NAc at 5 years
5%
NAC is part of the mainstay of treatment for small cell carcinoma of the bladder
yes, this is the only variant that it is shown to work well
What is the standard surgical treatment for MIBC
RC
What is the optimal timing of RC if NAC is not given?
4-6 weeks after TURBT
Should RC patietns get ERAS?
yeah
What does RC entail in males?
Bladder, prostate, SV en bloc, Nerve sparing can be offered in those interested in preservation of sexual function
What does RC entail in females?
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
who should be offered orthoptic urinary diversion
all eligible patients, send a urethral margin frozen section intraop before making the diversion
who should have urethrectomy
men with high grade or invasive urethral tumors distal to prostate, positive urethral margin, suspected prostatic stromal involvement. bladder neck tumors in women
who can have a partial cystectomy?(MIBC)
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
what does the standard PLND for cystectomy should include?
external iliac, obturator, internal iliac,
What should the final RC pathology report include?
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
who should get trimodal therapy?
unfit for RC, want to preserve bladder, refuses RC
what is an ideal patient for TMT?
small<5cm, unifocal, no cis, no hydronephrosis, good bladder function, motivated for bladder preservation
Complete TURBT (radical TURBT) is needed prior to chemo RT in TMT
Correct
can RT be given alone?
yes, sub-par but can be give to those who cant have rc or chemo
what kind of chemo will be given with RT
5FU/MMC, gem, cis,
is there any tole for neo-adjuvant RT or adjuvant RT in MIBC
Nope
should you resect mets in oligometastatic bladder ca or if there is a recurrence?
No
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.
Kinda, yes
but must be on a case-by-case
basis after multidisciplinary tumor board discussion
what would FU of RC MIBC entail to?
depends on TNM
but generally imaging to RO upper tract reccurence or local reccurence, hydro,
Bw to look for metabolic complications of diversion
who should have FU cytologies?
patients at high risk for urethral or upper tract recurrence ( if urethral remnant then urethral washings+ cysto)
how do you manage recurrence after bladder preservation
like a primary bladder tumor, consider RC
for high risk recurrences/
consider biopsy after TMT to assess response
What should be done for patients with MIBC unfit for TMT or RC
radical TURBT for local control
what should be offered for intractable hematuria or pellvic pain secondary to bladder tumor? advanced disease
Palliative cystectomy, (non-curable)
Palliative RT, can also give for bone pain other mets
Palliative chemotherapy (….) may be
offered to patients with unresectable or metastatic
disease who are ineligible for or have failed platinum-
based combination chemotherapy
e.g., gemcitabine/ RCT
ALWAYS consider early palliative care referral.
