TCC Treatment Flashcards
What determines low risk bladder cancer (50% of TCC)
Low grade, solitary, primary Ta tumor
Progression rate < 5% at 5 years
Tx for low risk bladder cancer?
Single dose mitomycin C after TURBT
After restaging TURBT, wait 3 months for cystoscopy
What determines intermediate risk bladder cancer (35%)
Recurrent or multifocal low grade Ta/T1
Progression < 10% at 5 years
Tx for intermediate risk?
Single dose mitomycin C after TURBT
BCG for 6 weeks +/- maintenance BCG
What determines high risk bladder cancer? (15%)
Any high grade tumor or CIS
Progression rate 25-50% at 5 years
Tx for high risk bladder cancer?
Single dose mitomycin C after TURBT
BCG for 6 weeks with maintenance
Consider early cystectomy (< 3 months)
What is the benefit of mitomycin C?
Reduces recurrence absolutely 12-15% (25-50% relative reduction)
**does not change progression
SE’s of mitomycin C?
Chemical cystitis
Gential/palmer rash (urine irritating)
*Rarely causes retroperitoneal fibrosis if given and bladder perforates
What is the indication for using intravesical Valrubicin (Valstar)?
CIS refractory to BCG and not an adequate surgical candidate
Benefits of valrubicin?
18% disease free at 6 months with durable response > 1 year
- if failure, reconsider cystectomy
MOA of BCG?
immunotherapy; recruiting T1-helper immune response (IL-2, IFN-gamma), neutrophils, T-cells, NK cells
When is BCG started?
Start 2-6 weeks after TURBT for intermediate and high risk patients
What is the BCG schedule?
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%
Benefits of BCG?
~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
What are some contraindications of BCG?
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
SE’s of BCG therapy?
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
Does isoniazid affect efficacy of BCG?
No
However, fluoroquinolones can decrease efficacy (watch for ? with patient taking something for pneumonia)
If concerned about BCG sepsis (0.5% patients, continued severe pyrexia), what should you do?
R/o most common etiology–bacterial UTI
Tx 3-6 months isoniazid, rifampin, ethambutol, and steroids
If a patient tried and failed intravesical chemotherapy (i.e. mitomycin C, thiotepa), can they still get BCG?
Yes.
However, intravesical chemotherapy likely won’t help if BCG failure
If patient fails BCG treatment, what next?
Consider salvage BCG (30-50% response)
Consider radical cystectomy
Consider radiation, salvage chemo (MVAC or gemcitabine + cisplatin) if not surgical candidate
When should you consider neoadjuvant chemotherapy?
To ALL patients prior to cystectomy for MIBC, unless contraindicated
What is the survival benefit/difference between MVAC chemo (methotrexate, vinblastine, doxorubicin, and cisplatin) vs. Gemcitabine + cisplatin
They’re equivalent in survival benefit
MVAC however, has greater toxicity
If patient has renal insufficiency, what must you change regarding the chemotherapy?
Change cisplatin to carboplatin
Indications for cystectomy with pelvic LND?
Contraindications?
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
