Bladder Cancer - Muscle Invasive & Metastatic Disease

Front 1

True or False. Over 25% of newly diagnosed high-grade lesions are muscle invasive or metastatic.

Back 1

False. Of the 40-45% of newly diagnosed bladder cancers that are high-grade, more than half are muscle-invasive or metastatic at the time of diagnosis.
This question is tricky because what we usually say is that 25% of all-comers with newly diagnosed bladder cancer have muscle invasive disease.

Front 2

You have a patient with T1 bladder cancer staged after endoscopic resection with a TURBT. The patient returns to your clinic and wants to know if you need to do any tests to check for metastasis?

Back 2

No, the risk of metastasis is so low with non‐muscle invasive tumors that you do not need to do a metastasis workup.

Front 3

How would the above clinical scenario have changed if the patient had been T1, or high-grade Ta?

Back 3

First of all the patient would need to undergo a re-TURBT whether there was muscle in the specimen or not. Some patients will be upstaged at re-resection, but for others the patient with residual disease at re-resection has a significantly higher risk of progression at 5 years than the patient with no residual disease at re-resection. The patient should also be given Mitomycin C at the time of the re-resection.
This patient would then be offered intravesical therapy with BCG. The patient would get an induction course of 1 treatment a week for 6 weeks. The patient would then follow-up with screening cystoscopy every 3 months and cytology. If there was no evidence of recurrent disease the patient would then be offered maintenance BCG treatment which is a maintenance treatment every 6 months (3 courses) for 2-3 years…regimen we use here with Pruthi.
The patient with high grade T1 disease has a 30-50% chance of progression to muscle invasive disease. That patient’s chance of recurrence is as high as 80%.

Front 4

You are evaluating a patient that has biopsy proven T2 high grade bladder cancer. As part of their evaluation in referral to your multidisciplinary clinic the patient gets a CT scan of the abdomen and pelvis to evaluate for metastatic disease. How accurate is this imaging modality in predicting node positive disease at the time of cystectomy?

Back 4

The range given for sensitivity for nodes is 50-85%. There are obviously a significant number of false negatives.

Front 5

Does a bone scan have any role to play in the pre-op evaluation of clinically organ confined bladder cancer?

Back 5

Besides confusing the issue….No. Studies looking at precystectomy bone scan findings and patients that went on to later develop metastatic disease showed no correlation.

Front 6

You are doing the pre-op on a male patient in Dr. Wallen clinic for radical cystoprostatectomy. This is a younger patient and he strongly desires to undergo an orthotopic ileal neobladder as opposed to a urinary conduit. How can you determine if this patient is a candidate for this type of diversion? Does this patient need to be marked by the ostomy nurses anyway?

Back 6

The patient that is willing to undergo an orthotopic continent diversion such as an ileal neobladder needs to be a younger, healthier more motivated patient. These patients have to understand the risks associated with this type of diversion such as leaking, especially at night, and retention requiring the need to be able to self-cath, especially women as their rate of urinary retention is higher than those in male patients. Risks that have been associated with urethral involvement include prostatic urethral involvement, prostatic stromal involvement, and CIS. For women risks would include CIS, bladder cancer location at the trigone or bladder neck, or a positive margin at surgery.
Yes. Both male and female patients that are requesting an orthotopic continent diversion such as an ileal neobladder after radical cystectomy must understand that if the frozen margins of the posterior urethra are positive intra-operatively then they will not be candidates for this type of urinary diversion and must undergo a conduit.

Front 7

You see a patient in Dr. Pruthi’s Tuesday clinic that is s/p radical cystoprostatectomy with ileal conduit about 5 years out from his surgery. He has been having over the past several months bloody discharge from his penis. What should you do?

Back 7

You set him up for cysto and biopsy and find that the patient has high grade invasive urothelial cancer at the urethral stump. You then set him up for urethrectomy.

Front 8

What is the number that we often use for cure rate after radical cystectomy for clinically locally confined disease?

Back 8

About 50% at 5 years.

Front 9

When following up a patient after radical cystectomy what two key things are you following and what are ways to assess them?

Back 9

It is important to remember that you are following the patient for evidence of disease recurrence, so for the tumor. You are also following the patient for the surgery, so evaluating for complications from that intervention
Tumor – the exact schedule varies based on the stage of disease but the jist is that you want to evaluate with some form of imaging, chest xray (or for T3 disease CT scan) as well as some form of upper imaging periodically to assess for disease recurrence in the upper tracts, which is not very common
Complications – serum chemistries to evaluate renal function & electrolyte abnormalities that can occur w/ conduits, upper tract imaging evaluating for hydronephrosis and possible stricture formation.

Front 10

What do the authors conclude about the efficacy of neoadjuvant radiation and neoadjuvant chemotherapy prior to cystectomy in patients with locally advanced disease?

Back 10

Preop radiation: does not significantly improve disease specific survival
Neoadjuvant Chemo: May increase survival in these patients by 5-6%

Front 11

What do the authors say about adjuvant chemotherapy following cystectomy?

Back 11

No usefulness in organ-confined cancer T1-T2
May provide some survival advantage to patients with locoregional disease and pelvic lymph node involvement. However, this has been difficult to prove due to difficulty accruing sufficient numbers of patients to demonstrate small survival advantages

Front 12

Are there any alternatives to cystectomy in the treatment of muscle invasive bladder cancer?

Back 12

It has been shown that excellent local and distant control of small, low-stage (T2) lesions can be accomplished with conservative surgical monotherapy (TUR or partial cystecomy).
For larger, more invasive lesions, trimodal (TUR/chemo/radiation) bladder preservation protocols have been attempted. Results have been promising in subsets of patients with small tumor sizes,

*Patients with hydro or with tumors that were not completely resectable are not candidates.

Front 13

What would be considered selection criteria for a patient to undergo partial cystectomy for muscle invasive bladder cancer? What about the addition of adjuvant chemotherapy?

Back 13

*First and foremost the textbook answer is radical cystectomy.

*Another point made by the authors as well as some of the research is that the emphasis for attempting partial cystectomy and some form of systemic therapy for muscle invasive disease is less than it used to be as patients now have the opportunity for continent diversions if so desired and amenable.

*The other reason to do partial cystectomy is the preservation of erectile function in the male patient for which some are now performed nerve sparing radical cystoprostatectomy or even prostate sparing radical cystectomy.

*Patient should have a solitary lesion that is on the posterior wall or dome of the bladder that can be reasonably resected, their criteria is a 2 cm margin, without the need for ureteral re-implantation. The patient must have a functional bladder as well, with no evidence of CIS.

*This is the criteria that the M.D. Anderson group uses in consideration of partial cystectomy. Based on literature review this comprises around 5% of patients with invasive bladder cancer.
Based on analysis done by the group at M.D. Anderson they basically state that the role for adjuvant chemo in this group of patients was not well established.

*Their case series is impressive though and constitutes roughly 50 patients with cure rate at 5 years of 51% which is the same as radical cystectomy.

Front 14

Systemic chemo is routinely used to treat patients with metastatic disease. What combinations are typically used? How frequently do they produce a complete response?

Back 14

Methotrexate, vinblastine, doxorubicin, and cisplatin = MVAC; 20% complete response (old standard of care)
Gemcitabine, cisplatin = GC; 40% complete response rate (new standard of care)
Taxol or Taxotere (taxoids) with cisplatin; 25 – 83%

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