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130 Cards in this Set

  • Front
  • Back

most common type of bladder tumor?

urothelial CA
average age of pt with bladder cancer?
65
what cancers are metastatic to bladder?
most to least common
melanoma > colon > prostate > lung > breast

risk factors for bladder cancer?

smoking
chronic cystitis
chemical exposure- aniline dye, aromatic amines
phenacetin (analgesic abuse)
radiation
cyclophosphamide
what is usually administered with cyclophosphamide to reduce risk of hemorrhagic cystitis?
mesna
what is the metastatic workup for bladder cancer?
CT A/P
LFTs
CXR
BOne scan - bone pain, elevated serum CA or alk phos
clinical stage is based on what?
bimanual exam after TURBT
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
TURBT can stimulate what nerve?
Where is it located?
What does it do?
obturator
lateral walls at about 5,6 o'clock
leg adduction

why do you not want to use cautery to resect a tumor at the UO?
is it ok to use cutting current?

may cause distal stricture

yes. stricture is unlikely with cutting current
when do you take prostatic urethra biopsies?
multifocal UC of the bladder
CIS of bladder
visible abnormality
when are random bladder biopsies indicated?
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

Grade differentiations
1
2
3

1- well
2- moderately
3- poor or undifferentiated
Ta
noninvasive papillary tumor

Tis

carcinoma in situ
flat tumor
T1
invades subepithelial connective tissue
T2a
invades superficial muscularis propria
T2b
invades deep muscularis propria

T3a

microscopic extension

able to palpate on exam, but after TURBT can't feel it

T3b

macroscopic extension

able to palpate on exam but after TURBT can still feel it
T4a
invades prostatic stroma, uterus, vagina
T4b
invades pelvic wall, abdominal wall
N1
single regional LN in true pelvis (hypogastric,obturator, external iliac, presacral)
N2
Multiple regional LN
N3
mets to common iliac LN
Bladder cancer a/w schistosoma haematobium
squamous cell
Where is squamous cell carcinoma more common?
egypt
Where does squamous cell usually present?
trigone
average age for squamous cell CA?
45-55
treatment for squamous cell CA?
radical cystectomy
urachal tumors are usually what type of cancer?
adenocarcinomas
what must you do with patients presenting with adenocarcinoma?
evaluate for site of origin
what is the most common tumor in exstrophic bladders?
adenoCA
treatment for adenoCA?
radical cystectomy
where are urachal tumors usually located?
bladder dome
treatment for urachal tumor?
wide local excision with en bloc removal of urachus and umbilicus, PLN
sites of bladder CA mets?
most to least
PLN, liver, lung, bone
What type of symptoms does CIS usually present with?
irritative voiding symptoms
what is the first line treatment for CIS?
BCG
are external beam radiation and systemic chemo effective for CIS?
no
what protein mutation is a/w bladder CA?
on what chromosome?
p53
chromosome 17
is there a higher or lower rate of progression with p53 over expression?
higher
treatment for CIS
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
treatment for Ta
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
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
why do you perform upper tract imaging as part of the followup for Tis?
20% develop UTUC
f/u for low grade Ta
cysto q at 3 months, 12 months, then yearly
f/u for high grade Ta
cysto/urine tumor markers q 3-6 months x 2 years, then less often; upper tract imaging q 1-2 years
treatment for T1
1) TURBT
2) second TURBT to confirm stage
3) mitomycin after TURBT
4) BCG
5) second course BCG or cystectomy
6) maintenance BCG
f/u for T1
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
is intravesical therapy effective for T2-4?
NO!
these are muscle invasive stages
gold standard treatment for T2-T4a
radical cystectomy (with or without urethrectomy), urinary diversion, PLND
f/u T2-T4a
chest imaging
CTU
urine tumor markers, LFTs

q 3-6 months x 2 years then less
treatment for T4b or N1-3 or M1
systemic chemo
is systemic chemo for UC curative?
no
what is the most effective systemic chemo agent against UC?
platinum
first line chemo for TCC?
MVAC- methotrexate, vinblastine, adriamycin, cisplatin

OR

GC- gemcitabine, cisplatin
which is less toxic- MVAC or GC?
GC
side effects of GC?
thrombocytopenia, anemia
side effects of MVAC?
neutropenia, sepsis, mucositis, alopecia, fatigue
treatment for micropapillary urothelial CA?
why?
cystectomy

highly aggressive
how many cell layers are in normal urothelium?
7
What stages is intravesical therapy indicated?
Ta, T1, Tis/CIS
intravesical therapy is not effective for?
T2-4
non-urothelial tumors
Examples of intravesical chemo?
mitomycin
thiotepa
doxorubicin
examples of intravesical immunotherapy?
BCG, interferon
does BCG reduce recurrence, progression, both, or neither?
both
does mitomycin reduce recurrence, progression, both, or neither?
recurrence but NOT progression
is BCG or mitomycin superior for tx of CIS and high grade tumors?
BCG
when should you NEVER give BCG?
within 2 weeks of TURBT
BCG is reserved for treatment of...?
low grade Ta tumors that did not respond to intravesical chemo

high grade tumors

T1 tumors
when should you not administer intravesical chemo?
UTI
gross hematuria
traumatic foley
bladder perf
mitomycin is more effective with a urine pH >?
6.0
mitomycin has a high or low molecular weight?
what does this mean?
high
rare systemic absorption
what does systemic absorption of mitomycin cause?
myelosuppression
common side effects of mitomycin
contact dermatitis
irritative voiding symptoms
who is a candidate for valrubicin?
pt with CIS refractory to BCG who are not candidates for cystectomy
what is the mechanism of action of BCG?
activates immune system >> T cells attack abnormal urothelium
MOA of mitomycin?
direct cytotoxic effect
low grade symptoms a/w BCG?
cystitis
dysuria
hematuria
low grade fever
What do you do if a pt has a fever > 101.5 for > 12-14 hours without signs of sepsis after BCG?
stop BCG
UCx- bact, acid-fast bacilli
broad spectrum abx
isoniazid x 3 months
resume BCG when asx
What is BCg sepsis? How do you treat?
fever > 102 or sepsis

UCx
BCx
steroids
anti-TB drugs- INH, rifampin, ethambutol

NO MORE BCG ever
What do you administer with INH or cycloserine?
Why?
pyridoxine (vit B6)

prevent neurotoxicity
contraindications to BCG
gross hematuria
traumatic foley
immunosuppressed (steroids, HIV, lymphoma, leukemia) on remicade (SASP)
how long might a patient have positive cytology after BCG?
up to 3 months
what is removed in a radical cystectomy?
M vs F
M: bladder, PLN, prostate, SV
F: bladder, PLN, uterus, tubes,ovaries, ant vagina
A cystectomy should not be delayed longer than?
12 weeks from time of muscle invasion diagnosis
limits of PLND during radical cystectomy?
superior: common iliac vessels
inferior: inguinal ligament
medial: bladder
lateral: side wall, genitofemoral nerve
what type of ureteral anastomosis is recommended for conduits/neobladders? why?
refluxing

anti-refluxing has high rate of stricture
what type of ureteral anastomosis is recommended for catheterizable stomas?
anti-refluxing ureteral anastomosis
which poses a higher risk of renal deterioration: conduit or neobladder?
conduit
TURBT + chemoradiation should not be used in patients with?

why?
hydronephrosis caused by tumor

not effective in these patients
when would you perform a partial cystectomy?
1) neg random bx
2) no h/o bladder tumors
3) no prostate invasion
4) ability to maintain adequate bladder capacity after resection
when does recurrence after cystectomy usually occur?
within 2 years after cystectomy
CIS % recurrence after TURBT
80%
CIS % recurrence after TURBT + BCG
30%
% Ta recurrence after TURBT
50%
% T1 recurrence after TURBT
> 70%
percentage of women/ men with squamous metaplasia of the bladder?
40% W
5% M
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.
inverted papilloma
in which decade does bladder cancer peak?
7th
highest percentage of bladder cancer occurs where?
developed nations: north america, europe
high- malignant, non-muscle invasive bladder cancer is a/w deletions of?
tumor suppressor genes like TP53, RB
By definition, what grade is ALL CIS?
high grade
What are the genetic abnormalities a/w CIS?
RB, TP53, PTEN
The only chemo agent proven to cause bladder cancer?
cyclophosphamide
what percentage of urotherlial tumors are non-muscle invasive at initial presentation?
80%
initial treatment for PUNLMP (papillary urothelial neoplasia of low malignant potential)
perioperative mitomycin C
one of the first and most common chemical agents implicated in the formation of bladder cancer
B-naphthylamine
which food substance is a/w a low risk of urothelial cancer?
citrus
genetic abnormalities a/w low malignant potential Ta tumors?
fibroblast growth factor receptor-3 (FGFR-3)
urothelial cancer noninvasively involving the prostatic urethra is what stage?
trick question- not part of the TNM staging

INVASIVE is T4a (into stroma)
treatment for patients with noninvasive prostatic urethral cancer?
TURP + BCG
primary mode of therapy for small cell CA
chemoradiation
invasive urothelial CA with a very poor prognosis is a/w which genetic alterations?
RB, PTEN, TP53
how do tumor suppressor genes work?
activated by allelic deletion of one allele followed by point mutations of remaining allele

cause unregulated cellular growth
4 high risk factors in urothelial cancer formation
smoking
h/o pelvic radiation
UTIs
previous pelvic surgery
FISH (fluorescence in-situ hybridization) test for which chromosomal abnormalities?
3.7.9.17
which type of cancer is not sensitive to ciplatin chemotherapy?
micropapillary
nested variant of urothelial cancer can be confused with?
cystitis cystica
most common sarcoma involving the bladder?
leiomyosarcoma
4 risk factors for prostatic urethral cancer?
1) previous intravesical therapy
2) CIS of trigone
3) CIS of distal ureters
4) recurrent bladder tumors
the majority of low grade, low stage urothelial neoplasia (papillary urothelial neoplasia of low malignant potential) is a/w chromosome #?
9
Patient has small cell carcinoma of the bladder. Treatment is?
Neoadjuvant cisplatin/ etoposide followed by cystectomy

who gets neoadjuvant chemo?

ALL patients before cystectomy for MIBC (unles contraindicated)



small cell variant

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

mutations in muscle invasive bladder cancer

low Rb


high p53


PTEN deletion

tx small cell bladder ca

neoadjuvant chemo (VP-16 + cisplatin)


+


cystectomy

tx squamous cell bladder ca

cystectomy

risk for recurrence of low grade urothelial carcinoma

- multifocal


- > 2cm


- incomplete resection


- recurrence < 1 year