HYU Onc - Bladder and Upper Tract Flashcards
Microhematuria definition
> or = 3 RBCs/hpf on microscopic evaluation of a single, properly collected urine specimen
Evaluation should not change based on presence or absence of AC/anti-plt meds
Microhematuria: Low-Risk
Must meet ALL of the following criteria:
Women < 50yo
Men < 40yo
<10 pack-years
3-10 RBCs/hpf
No prior episodes of MF
No other risk factors
Microhematuria: Intermediate Risk
If you meet ANY of the following criteria:
Women 50-59 yo
Men 40-59 yo
11-30 pack years
11-25 RBCs/ hpf
Presence of additional risk factors
Previously low-risk without prior evaluation and 3-25 RBCs/hpf
Microhematuria: Intermediate Risk
If you meet ANY of the following criteria:
Women 50-59 yo
Men 40-59 yo
11-30 pack years
11-25 RBCs/ hpf
Presence of additional risk factors
Microhematuria: High Risk
If you meet ANY of the following criteria:
Man or woman >60yo
>30 pack years
>25 RBCs/hpf
History of gross hematuria
Previously low-risk without prior evaluation and >25 RBCs/hpf
Management of low-risk microhematuria
Shared decision making
Can repeat UA within 6 months or
Cysto + US
Management of intermediate-risk microhematuria
Cysto + RUS
Management of high-risk microhematuria/gross hematuria
Cysto (for all)
CTU > MRU > retrograde pyelograms and noncon axial imaging or RUS
Additional risk factors for urothelial carcinoma
Irritative LUT voiding symptoms
History of cyclophosphamide of ifosfamide chemotherapy
Family history of US or lynch syndrome
Occupational exposure to benzene chemicals or aromatic amines
History of chronic indwelling foreign body in the urinary tract
Imaging when microhematuria in a patient with family history of RCC or known genetic renal tumor syndrome
Perform upper tract imaging regardless of risk stratification
When use urine cytology and markers in MH patients?
Do not use in initial MH evaluation
Can use cytology for patients with persistent MH + irritative LUTS or RFs for CIS after a negative initial MH workup
MH follow-up after negative evaluation
Repeat UA in 12 months
If UA negative, discontinue further evaluation
If UA persistent MH, shared decision making regarding need for initial evaluation
After negative evaluation, initiate further evaluation if new gross hematuria, increasing degree of MH, or new urologic symptoms
Bladder Cancer Staging
Tis = mucosa
T1 = lamina propria
T2 = Muscularis propria
- a = inner
- b = outer
T3 = Perivesical tissue/fat
- a = microscopic
- b = macroscopic
T4 = Extravesical
- a = adjacent organs
- b = body wall
Ta: This refers to noninvasive papillary carcinoma. This type of growth often is found on a small section of tissue that easily can be removed with TURBT.
Low risk bladder cancer
LG solitary Ta less than or = to 3 cm
PUMLUMP
Intermediate Risk Bladder Cancer
Recurrence of LG Ta within 1 year
Solitary LG Ta >3cm
Multifocal LG Ta
HG Ta < or = to 3 cm
Any LG T1
High Risk Bladder Cancer
HG T1
Any Recurrent HG Ta
HG Ta > 3 cm or multifocal
Any CIS
Any BCG failure in HG patient
Any variant histology (micropapillary, sarcomatoid, plasmacytoid)
Any LVI
Any HG prostatic urethral involvement
Positive cytology with normal cysto in a patient with a history of NMIBC
Consider upper tract imaging, prostatic urethral biopsies, blue light cysto, ureteroscopy, random bladder biopsies
Variant histology, extensive squamous or glandular differentiation, + LVI
Obtain GU pathologist review
Offer restaging TURBT 4-6 weeks after diagnostic TURBT (if attempting to spare bladder)
Or, offer up front radical cystectomy
When is the use of urine markers appropriate?
For NMIBC, can use biomarkers to assess response to BCG and to adjudicate equivocal cytology
- Should NOT use in lieu of cytology
- Should NOT use for surveillance of low risk patients with with normal cytology
- SHOULD use cytology with surveillance cystoscopy for IR and HR disease
When do you perform a restaging TURBT?
Within 6 weeks of initial TURBT
If incomplete resection
If pathology is high-risk HG Ta OR HG T1
Must get muscle in specimen
Single dose intravesical MMC or gemcitabine use?
Postop
Consider in suspected/known LG disease within 24 hours of TURBT, except in cases of suspected perforation or extensive resection
When do you use BCG?
Don’t use in LR
Consider in IR
Use in HR
If it works, maintenance BCG (3 weekly doses starting 3 months after induction) for 1 year in IR and 3 years in HR
What is maintenance BCG dosing/timing?
If it works, maintenance BCG (3 weekly doses starting 3 months after induction) for 1 year in IR and 3 years in HR
What do you do for persistent/recurrent NMIBC s/p 1 induction course of BCG?
- Ta?
- CIS?
- HG T1?
Ta - Second induction course of BCG
CIS - Second induction course of BCG
RC w/o NAC also an option for both of these
HG T1 - RC