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130 Cards in this Set
- Front
- Back
most common type of bladder tumor? |
urothelial CA
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average age of pt with bladder cancer?
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65
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what cancers are metastatic to bladder?
most to least common |
melanoma > colon > prostate > lung > breast
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risk factors for bladder cancer? |
smoking
chronic cystitis chemical exposure- aniline dye, aromatic amines phenacetin (analgesic abuse) radiation cyclophosphamide |
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what is usually administered with cyclophosphamide to reduce risk of hemorrhagic cystitis?
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mesna
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what is the metastatic workup for bladder cancer?
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CT A/P
LFTs CXR BOne scan - bone pain, elevated serum CA or alk phos |
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clinical stage is based on what?
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bimanual exam after TURBT
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Why do you do a second TURBT in patients with T1 tumor?
When do you do it? |
residual tumor 25%
upstage 30% 1-4 weeks after initial |
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TURBT can stimulate what nerve?
Where is it located? What does it do? |
obturator
lateral walls at about 5,6 o'clock leg adduction |
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why do you not want to use cautery to resect a tumor at the UO? |
may cause distal stricture
yes. stricture is unlikely with cutting current |
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when do you take prostatic urethra biopsies?
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multifocal UC of the bladder
CIS of bladder visible abnormality |
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when are random bladder biopsies indicated?
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1) when partial cystectomy is planned
2) abnormal urine marker without visible tumor 3) high grade cells on cytology, but low grade on TURBT 4) after intravesical therapy to eval for complete response |
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Grade differentiations |
1- well
2- moderately 3- poor or undifferentiated |
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Ta
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noninvasive papillary tumor
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Tis |
carcinoma in situ
flat tumor |
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T1
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invades subepithelial connective tissue
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T2a
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invades superficial muscularis propria
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T2b
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invades deep muscularis propria
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T3a |
microscopic extension
able to palpate on exam, but after TURBT can't feel it |
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T3b |
macroscopic extension
able to palpate on exam but after TURBT can still feel it |
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T4a
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invades prostatic stroma, uterus, vagina
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T4b
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invades pelvic wall, abdominal wall
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N1
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single regional LN in true pelvis (hypogastric,obturator, external iliac, presacral)
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N2
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Multiple regional LN
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N3
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mets to common iliac LN
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Bladder cancer a/w schistosoma haematobium
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squamous cell
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Where is squamous cell carcinoma more common?
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egypt
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Where does squamous cell usually present?
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trigone
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average age for squamous cell CA?
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45-55
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treatment for squamous cell CA?
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radical cystectomy
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urachal tumors are usually what type of cancer?
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adenocarcinomas
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what must you do with patients presenting with adenocarcinoma?
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evaluate for site of origin
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what is the most common tumor in exstrophic bladders?
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adenoCA
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treatment for adenoCA?
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radical cystectomy
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where are urachal tumors usually located?
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bladder dome
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treatment for urachal tumor?
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wide local excision with en bloc removal of urachus and umbilicus, PLN
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sites of bladder CA mets?
most to least |
PLN, liver, lung, bone
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What type of symptoms does CIS usually present with?
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irritative voiding symptoms
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what is the first line treatment for CIS?
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BCG
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are external beam radiation and systemic chemo effective for CIS?
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no
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what protein mutation is a/w bladder CA?
on what chromosome? |
p53
chromosome 17 |
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is there a higher or lower rate of progression with p53 over expression?
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higher
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treatment for CIS
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1) TURBT
2) 6 week BCG course 2 weeks after TURBT 3) can repeat if not eradicated or cystectomy 4) cystectomy if fails BCG x 2 5) maintenance BCG if eradicated |
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treatment for Ta
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1) TURBT
2) restaging TURBT 1-4 weeks later 3) mitomycin within 6 hours after TURBT if no perf 4) low grade: BCG if risk for recurrence high grade: BCG x 6 weeks |
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f/u for Tis
- right after - when eradicated |
1) bladder bx abd bladder wash 6 weeks after finishing BCG
2) when eradicated: cysto, urine tumor marker q 3 months for 2 yrs, then less often; CTU q 1-2 years |
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why do you perform upper tract imaging as part of the followup for Tis?
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20% develop UTUC
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f/u for low grade Ta
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cysto q at 3 months, 12 months, then yearly
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f/u for high grade Ta
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cysto/urine tumor markers q 3-6 months x 2 years, then less often; upper tract imaging q 1-2 years
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treatment for T1
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1) TURBT
2) second TURBT to confirm stage 3) mitomycin after TURBT 4) BCG 5) second course BCG or cystectomy 6) maintenance BCG |
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f/u for T1
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bladder bx/wash for cytology/FISH at 6 weeks s/ps BCG
cysto/urine tumor marker q 3-6 months x 2 years then less upper tract imaging q 1-2 years |
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is intravesical therapy effective for T2-4?
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NO!
these are muscle invasive stages |
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gold standard treatment for T2-T4a
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radical cystectomy (with or without urethrectomy), urinary diversion, PLND
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f/u T2-T4a
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chest imaging
CTU urine tumor markers, LFTs q 3-6 months x 2 years then less |
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treatment for T4b or N1-3 or M1
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systemic chemo
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is systemic chemo for UC curative?
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no
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what is the most effective systemic chemo agent against UC?
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platinum
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first line chemo for TCC?
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MVAC- methotrexate, vinblastine, adriamycin, cisplatin
OR GC- gemcitabine, cisplatin |
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which is less toxic- MVAC or GC?
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GC
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side effects of GC?
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thrombocytopenia, anemia
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side effects of MVAC?
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neutropenia, sepsis, mucositis, alopecia, fatigue
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treatment for micropapillary urothelial CA?
why? |
cystectomy
highly aggressive |
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how many cell layers are in normal urothelium?
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7
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What stages is intravesical therapy indicated?
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Ta, T1, Tis/CIS
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intravesical therapy is not effective for?
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T2-4
non-urothelial tumors |
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Examples of intravesical chemo?
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mitomycin
thiotepa doxorubicin |
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examples of intravesical immunotherapy?
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BCG, interferon
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does BCG reduce recurrence, progression, both, or neither?
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both
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does mitomycin reduce recurrence, progression, both, or neither?
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recurrence but NOT progression
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is BCG or mitomycin superior for tx of CIS and high grade tumors?
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BCG
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when should you NEVER give BCG?
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within 2 weeks of TURBT
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BCG is reserved for treatment of...?
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low grade Ta tumors that did not respond to intravesical chemo
high grade tumors T1 tumors |
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when should you not administer intravesical chemo?
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UTI
gross hematuria traumatic foley bladder perf |
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mitomycin is more effective with a urine pH >?
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6.0
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mitomycin has a high or low molecular weight?
what does this mean? |
high
rare systemic absorption |
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what does systemic absorption of mitomycin cause?
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myelosuppression
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common side effects of mitomycin
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contact dermatitis
irritative voiding symptoms |
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who is a candidate for valrubicin?
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pt with CIS refractory to BCG who are not candidates for cystectomy
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what is the mechanism of action of BCG?
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activates immune system >> T cells attack abnormal urothelium
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MOA of mitomycin?
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direct cytotoxic effect
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low grade symptoms a/w BCG?
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cystitis
dysuria hematuria low grade fever |
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What do you do if a pt has a fever > 101.5 for > 12-14 hours without signs of sepsis after BCG?
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stop BCG
UCx- bact, acid-fast bacilli broad spectrum abx isoniazid x 3 months resume BCG when asx |
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What is BCg sepsis? How do you treat?
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fever > 102 or sepsis
UCx BCx steroids anti-TB drugs- INH, rifampin, ethambutol NO MORE BCG ever |
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What do you administer with INH or cycloserine?
Why? |
pyridoxine (vit B6)
prevent neurotoxicity |
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contraindications to BCG
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gross hematuria
traumatic foley immunosuppressed (steroids, HIV, lymphoma, leukemia) on remicade (SASP) |
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how long might a patient have positive cytology after BCG?
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up to 3 months
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what is removed in a radical cystectomy?
M vs F |
M: bladder, PLN, prostate, SV
F: bladder, PLN, uterus, tubes,ovaries, ant vagina |
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A cystectomy should not be delayed longer than?
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12 weeks from time of muscle invasion diagnosis
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limits of PLND during radical cystectomy?
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superior: common iliac vessels
inferior: inguinal ligament medial: bladder lateral: side wall, genitofemoral nerve |
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what type of ureteral anastomosis is recommended for conduits/neobladders? why?
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refluxing
anti-refluxing has high rate of stricture |
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what type of ureteral anastomosis is recommended for catheterizable stomas?
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anti-refluxing ureteral anastomosis
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which poses a higher risk of renal deterioration: conduit or neobladder?
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conduit
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TURBT + chemoradiation should not be used in patients with?
why? |
hydronephrosis caused by tumor
not effective in these patients |
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when would you perform a partial cystectomy?
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1) neg random bx
2) no h/o bladder tumors 3) no prostate invasion 4) ability to maintain adequate bladder capacity after resection |
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when does recurrence after cystectomy usually occur?
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within 2 years after cystectomy
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CIS % recurrence after TURBT
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80%
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CIS % recurrence after TURBT + BCG
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30%
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% Ta recurrence after TURBT
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50%
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% T1 recurrence after TURBT
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> 70%
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percentage of women/ men with squamous metaplasia of the bladder?
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40% W
5% M |
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This is a benign tumor of the bladder with a 1% incidence of tumor recurrence. it is a/w chronic inflammation/BOO and is commonly located at the trigone, most commonly occurs in men.
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inverted papilloma
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in which decade does bladder cancer peak?
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7th
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highest percentage of bladder cancer occurs where?
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developed nations: north america, europe
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high- malignant, non-muscle invasive bladder cancer is a/w deletions of?
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tumor suppressor genes like TP53, RB
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By definition, what grade is ALL CIS?
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high grade
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What are the genetic abnormalities a/w CIS?
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RB, TP53, PTEN
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The only chemo agent proven to cause bladder cancer?
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cyclophosphamide
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what percentage of urotherlial tumors are non-muscle invasive at initial presentation?
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80%
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initial treatment for PUNLMP (papillary urothelial neoplasia of low malignant potential)
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perioperative mitomycin C
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one of the first and most common chemical agents implicated in the formation of bladder cancer
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B-naphthylamine
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which food substance is a/w a low risk of urothelial cancer?
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citrus
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genetic abnormalities a/w low malignant potential Ta tumors?
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fibroblast growth factor receptor-3 (FGFR-3)
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urothelial cancer noninvasively involving the prostatic urethra is what stage?
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trick question- not part of the TNM staging
INVASIVE is T4a (into stroma) |
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treatment for patients with noninvasive prostatic urethral cancer?
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TURP + BCG
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primary mode of therapy for small cell CA
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chemoradiation
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invasive urothelial CA with a very poor prognosis is a/w which genetic alterations?
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RB, PTEN, TP53
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how do tumor suppressor genes work?
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activated by allelic deletion of one allele followed by point mutations of remaining allele
cause unregulated cellular growth |
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4 high risk factors in urothelial cancer formation
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smoking
h/o pelvic radiation UTIs previous pelvic surgery |
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FISH (fluorescence in-situ hybridization) test for which chromosomal abnormalities?
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3.7.9.17
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which type of cancer is not sensitive to ciplatin chemotherapy?
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micropapillary
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nested variant of urothelial cancer can be confused with?
|
cystitis cystica
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most common sarcoma involving the bladder?
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leiomyosarcoma
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4 risk factors for prostatic urethral cancer?
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1) previous intravesical therapy
2) CIS of trigone 3) CIS of distal ureters 4) recurrent bladder tumors |
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the majority of low grade, low stage urothelial neoplasia (papillary urothelial neoplasia of low malignant potential) is a/w chromosome #?
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9
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Patient has small cell carcinoma of the bladder. Treatment is?
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Neoadjuvant cisplatin/ etoposide followed by cystectomy
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who gets neoadjuvant chemo? |
ALL patients before cystectomy for MIBC (unles contraindicated)
small cell variant |
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painful agents for intravesicle tx of GH what do you have to do first? |
silver nitrate formalin
anesthesia cystogram- can't use if pt has reflux |
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mutations in muscle invasive bladder cancer |
low Rb high p53 PTEN deletion |
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tx small cell bladder ca |
neoadjuvant chemo (VP-16 + cisplatin) + cystectomy |
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tx squamous cell bladder ca |
cystectomy |
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risk for recurrence of low grade urothelial carcinoma |
- multifocal - > 2cm - incomplete resection - recurrence < 1 year |