Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Bladder tumors > TCC Treatment > Flashcards

TCC Treatment Flashcards

1
Q

What determines low risk bladder cancer (50% of TCC)

A

Low grade, solitary, primary Ta tumor

Progression rate < 5% at 5 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Tx for low risk bladder cancer?

A

Single dose mitomycin C after TURBT

After restaging TURBT, wait 3 months for cystoscopy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What determines intermediate risk bladder cancer (35%)

A

Recurrent or multifocal low grade Ta/T1

Progression < 10% at 5 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Tx for intermediate risk?

A

Single dose mitomycin C after TURBT

BCG for 6 weeks +/- maintenance BCG

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What determines high risk bladder cancer? (15%)

A

Any high grade tumor or CIS

Progression rate 25-50% at 5 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Tx for high risk bladder cancer?

A

Single dose mitomycin C after TURBT

BCG for 6 weeks with maintenance

Consider early cystectomy (< 3 months)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the benefit of mitomycin C?

A

Reduces recurrence absolutely 12-15% (25-50% relative reduction)

**does not change progression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

SE’s of mitomycin C?

A

Chemical cystitis
Gential/palmer rash (urine irritating)

*Rarely causes retroperitoneal fibrosis if given and bladder perforates

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the indication for using intravesical Valrubicin (Valstar)?

A

CIS refractory to BCG and not an adequate surgical candidate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Benefits of valrubicin?

A

18% disease free at 6 months with durable response > 1 year

  • if failure, reconsider cystectomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

MOA of BCG?

A

immunotherapy; recruiting T1-helper immune response (IL-2, IFN-gamma), neutrophils, T-cells, NK cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

When is BCG started?

A

Start 2-6 weeks after TURBT for intermediate and high risk patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is the BCG schedule?

A

Weekly treatments for 6 weeks

Maintenance is 3 weeks every 3 months for 3 years, but need at least 1 year of maintenance (high risk recommended 3 years)

If unable to tolerate, reduce dose to 10%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Benefits of BCG?

A

~25% reduction in risk of NMIBC (Ta, T1, CIS) progression (10% BCG vs 14% controls)

45% reduction in risk of CIS progression

*Superior to intravesical chemotherapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are some contraindications of BCG?

A 
traumatic catheter
hematuria
UTI
immunosuppression
active autoimmune disease
known allergy to BCG

***reflux, positive PPD, h/o treated TB, prosthetic devices are no CI’s

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

SE’s of BCG therapy?

A

irritative symptoms (cystitis)
- persistent symptoms > 48 hours, get UCx
malaise
hematuria

  • BCG reaction (25%; flu-like symptoms)
  • tx with steroids and tylenol
    • Serious BCG reaction (5%; recurring high fever after 24 hours)
  • Tx with 3-6 months isoniazid, possibly add rifampin and ethambutol
17
Q

Does isoniazid affect efficacy of BCG?

A

No

However, fluoroquinolones can decrease efficacy (watch for ? with patient taking something for pneumonia)

18
Q

If concerned about BCG sepsis (0.5% patients, continued severe pyrexia), what should you do?

A

R/o most common etiology–bacterial UTI

Tx 3-6 months isoniazid, rifampin, ethambutol, and steroids

19
Q

If a patient tried and failed intravesical chemotherapy (i.e. mitomycin C, thiotepa), can they still get BCG?

A

Yes.

However, intravesical chemotherapy likely won’t help if BCG failure

20
Q

If patient fails BCG treatment, what next?

A

Consider salvage BCG (30-50% response)

Consider radical cystectomy

Consider radiation, salvage chemo (MVAC or gemcitabine + cisplatin) if not surgical candidate

21
Q

When should you consider neoadjuvant chemotherapy?

A

To ALL patients prior to cystectomy for MIBC, unless contraindicated

22
Q

What is the survival benefit/difference between MVAC chemo (methotrexate, vinblastine, doxorubicin, and cisplatin) vs. Gemcitabine + cisplatin

A

They’re equivalent in survival benefit

MVAC however, has greater toxicity

23
Q

If patient has renal insufficiency, what must you change regarding the chemotherapy?

A

Change cisplatin to carboplatin

24
Q

Indications for cystectomy with pelvic LND?

Contraindications?

A

Stage T2-T4 MIBC

high grade NMIBC (micropapillary variants, T1 with lymphovascular invasion, sarcomatoid variant, nested variant)

Prostatic stromal invasion

BCG failure (at least 2 rounds)

Multifocal high grade T1 disease

Bladder cripple with recurrent disease

Lymph node involvement

Contraindications: metastatic disease

25
Q

In men, when do you perform a urethrectomy?

What about women?

A

If prostatic stromal TCC invasion (men)

In women, urethrectomy if NOT constructing an orthotopic neobladder or if tumor at bladder neck

26
Q

What all constitutes cystectomy in a woman?

A

Radical cystectomy, hysterectomy, and resection of anterior vaginal wall

27
Q

What is the overall recurrence-free survival in cystectomys?

A

~65 % at 5 and 10 years

Up to 85-90% for pTa and pTis with negative lymph nodes

28
Q

What lymph nodes are targeted during PLND, and how many nodes, at minimum, are required?

A 
External/internal iliacs
Obturator nodes
Presacral nodes
Perivesical nodes
Infererior para-aortic

**> or = to 9 nodes are required for adequate lymph node analysis

29
Q

What is the STANDARD bladder cancer PLND dissection template? (Proximal, Medial, Lateral, Distal, Inferior)

A

Proximal: Midportion of common iliac artery or aortic bifurcation

Medial: bladder wall

Lateral: genitofemoral nerve

Distal: Inguinal ligament

Inferior: Pelvic floor

30
Q

What is the EXTENDED bladder cancer PLND dissection template? (Proximal, Medial, Lateral, Distal, Inferior)

A

Proximal: Inferior mesenteric arter

Medial: bladder wall

Lateral: genitofemoral nerve

Distal: Inguinal ligament

Inferior: Pelvic floor

31
Q

Difference in standard vs. extended PLND dissection template?

A

Extended PLND has increased survival in both node positive and negative disease

32
Q

What are the indications for early/immediate cystectomy (< 3 months)

A

High risk disease (high grade Ta, T1, CIS), especially in younger patients

BCG failures

Multifocal, high grade T1 disease

Unfavorable histology (micropapillary)

Lymphovascular invasion in T1 disease

Prostatic stromal TCC invasion (technically this is T4a)

Bladder cripple with recurrent disease

High grade T1 in a diverticulum (consider partial cystectomy)

33
Q

What is the risk of progression in high risk NMIBC?

A

~85% progression to MIBC in 48 months

34
Q

Why do early/immediate cystectomy??

A

B/c in high risk NMIBC, there is 10% and 25% increased cancer specific survival for immediate cystectomy vs. delayed cystectomy

Bladder tumors (7 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions