bladder Flashcards by Sam O'Boy

What proportion of non-muscle invasive bladder cancer will become muscle invasive
and what proportion of non-muscle invasive bladder cancer becomes recurrent

20%, and 50% recurrent

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What are the 2WW criteria for bladder cancer

> 45 years old - Visible haematuria that persists or recurs after successful treatment / exclusion of UTI
60 with unexplained non-visible haematuria and either dysuria/raised WCC on bloods

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What are the investigations for a new bladder cancer diagnosis

CTCAP / KUB & thorax - to exclude synchronous upper urinary tract cancer
MRI abdomen / pelvis
Flexible cystoscopy
TURBT - to assess depth of invasion - aiming for complete removal of all visible lesions
EDTA / NM-GFR for renal function

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How is non-muscle invasive bladder cancer defined by T stage

Ta or T1
Muscle invasive from T2 onward

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How is a stage 1 bladder cancer defined
How is a stage 2 bladder cancer defined

1 = T1N0
2 = T2N0 (muscle invasive)

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How is a stage 3 bladder cancer defined

3 = either T3 or T4a, or node positive

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How is a stage 4 bladder cancer defined

4 = T4b or distant mets

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How is the management of non-muscle invasive cancer categorised

Low risk
Intermediate risk
High risk
Very high risk

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What is the management of low risk non-muscle invasive bladder cancer
How is low risk defined

Ta & Gr1
TURBT and single dose of intravesical MMC
Cystoscopic surveillance

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What is the management of intermediate risk non-muscle invasive bladder cancer

Neither low nor high risk
Intravesical MMC for 1yr or 1yr full dose BCG (6x weekly instillations, then 3-weekly instillations at 3, 6 & 12mths)

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What is the management of high risk non-muscle invasive bladder cancer
How is it defined

Any of T1, grade 3, CIS, multiple, recurrent and large
Intravesical BCG for 1-3 years or radical cystectomy

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What is the management of very high risk non-muscle invasive bladder cancer
How is it defined

T1 G3 or high grade associated with concurrent CIS
multiple / large T1 / recurrent with CIS in the prostatic urethra

Radical cystectomy or 3yrs of intravesical BCG

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What are the side effects of intravesical MMC
What is the contraindication

Bladder irritation, myelosuppression, rash, risk of fibrosis
CI for MMC: Suspected/confirmed bladder perforation

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When is a radical cystectomy indicated for non-muscle invasive bladder cancer

High risk - Multiple high risk G3 pT1 tumours or Widespread CIS
Recurrence following BCG treatment
Progression to muscle invasive BC
Side-effects preventing completion of BCG treatment

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What are the side effects of intravesical BCG
Contraindications

Side effects
Cystitis (70%), Fever (50%), Haematuria (25%)
Joint pain, lethargy, nausea & vomiting, anorexia, diarrhoea, allergic  reactions, granulomatous prostatitis/epididymitis, TB

Absolute CI
<2 weeks since TURBT
Following difficult catheterisation
Symptomatic UTI or haematuria (both due to risk of systemic absorption)

Relative CI:
Immunosuppression, asymptomatic infection

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What are the treatment options for muscle invasive bladder cancer

neo-adjuvant chemotherapy followed by radical cystectomy or RT
Radical cystectomy/RT followed by adjuvant chemotherapy

What is the benefit of neoadjuvant chemotherapy in MIBC
And according to what
What does this bring the 5yr OS to

According to the ABC met-analysis, NACT has a 5% OS benefit

5yr OS 45 -> 50%

Surgery within 4-6wks of completing chemotherapy

What are the exceptions where NACT would not be given

Hydronephrosis (pre-chemo) – straight to surgery

Pure squamous histology or adenocarcinoma - proceed to radical cystectomy without NACT

What NACT regimen is given

Either 3-4 cycles of gem/cis, with MRI before cycle 4 (6 cycles if T4 disease)
Or MVAC if <70yrs and fit
Methotrexate, vinblastine, doxorubicin, cisplatin
With folinic acid and GCSF

What are the indications for radical cystectomy

T2 -T4a disease (Muscle invasive)
Multiple lesions - Extensive CIS or Multifocal tumour
Histology: Sarcomatous, Adenocarcinoma, Squamous carcinoma

When is adjuvant chemotherapy indicated for MIBC

Following surgery, in those who did not receive NACT, but found to have node positive disease or extravesical spread (T3)

What is the dose and chemo regimens for radical CRT for MIBC

What is the 5yr survival

55Gy/20# with concurrent MMC & 5FU
-MMC given on day 1, 5FU pump runs over day 1-5

Or with BCON - carbogen and nicotinamide as radiosensitiser
SE - nausea and headache

5-yr OS: 48% for RT with MMC/5FU, according to BC2001 trial

What are the RT options for someone not fit enough for radical CRT

RT alone - 55Gy/20#
21Gy/3# alternate days
36Gy/6#/6wks
8Gy single fraction or 20Gy/5# for symptoms

What are the contraindications to radical chemoRT for MIBC

Irretrievable loss of bladder function after RT therefore organ preservation pointless - opt for cystectomy
Patient will not comply with regular check cystoscopy post CRT
IBD

When should urethral volume be included in MIBC CTV What volume of urethra should be included

Bladder base tumour or distant CIS present Include 1.5cm of prostatic urethra in males and 1cm of urethra in females

What is the CTV-PTV margin for MIBC

1.5cm, with 2cm if dome of bladder tumour

What is the follow up after radical RT for MIBC

Most recurrences occur in first 2 years Life-long surveillance is mandatory Cystoscopy & urine cytology 3/12 -> year 1 6/12 -> year 2 Annually thereafter CTCAP - Distant disease most common in lung, liver and bones 6, 12 & 24 months after CRT Annually thereafter for 5 years

What is the treatment for recurrence post radical RT

salvage cystectomy, but associated with poorer survival outcomes

What is the prognosis of MIBC locally advanced and metastatic

5-year survival: T2: 60% with chemo T3: 40% with chemo T4: 20% with chemo N+ (stage IV): 10% with chemo Metastatic disease: mOS 14 months with chemo

What is the first line management of metastatic bladder cancer What is the second line management

Pt eligible: Gem/cis 4-6 cycles - if no progression -> maintenance avelumab If cisplatin contraindicated: Gem/carbo If PDL1>5%, single agent atezolizumab If PDL1>1%, single agent pembrolizumab Second line: Pembrolizumab or Atezolizumab (independent of PDL1 status) Must have had platinum before & not had any PD-L1 directed treatment

How are upper urinary tract tumours categorised according to risk

Low & High Low - unifocal, <1cm, low grade & no invasive features on imaging High - >2cm, possible hydronephrosis, high grade disease, variant histology or previous radical cystectomy for bladder cancer

What is the management of a low risk upper urinary tract tumour

Kidney sparing - endoscopic laser ablation

What is the management of a high risk upper urinary tract tumour

Nephrectomy +/- single dose of MMC Adjuvant carbo/cis + gem for 4 cycles POUT trial demonstrated improved DFS Or adjvuant nivolumab if Pt-chemotherapy ineligible & PDL1 >1%

When is nivolumab indicated in bladder cancer or upper urinary tract urothelial cancer

Adjuvant monotherapy after complete tumour resection in high risk muscle invasive urothelial cancer with PD-L1 expression of ≥1% and in whom adjuvant treatment with platinum-based treatment is unsuitable, or have received neoadjuvant chemotherapy, for a maximum of 1 year

What surveillance is required after upper urinary tract tumour treatment

Pts with upper tract cancer have 40% chance developing bladder tumour -> LIFE LONG cystoscopies

What is the prognosis after upper urinary tract tumour treatment

5yr survival <50% for pT2-3 and <10% for pT4

How should a small cell cancer of the bladder be treated

very chemo sensitive give neoadjuvant cis/etopo followed by radical RT/cystectomy