Bladder CA

Question 1

Low-grade; high-risk of recurrence
○ Rarely progress to more lethal invasive type

Answer 1

Papillary Lesions

Question 2

High-grade tumor
○ Precursor of the more lethal muscle-invasive disease

Answer 2

Carcinoma in situ (CIS)

Question 3

solitary tumor, low grade,
size <1 cm, and no invasive component on
imaging.

Answer 3

Tumors
possessing all of the following are consid-
ered low risk:

Question 4

Low-risk tumors can successfully
be treated by

Answer 4

laser ureteroscopic ablation
or surgical resection and reanastomosis
of the remaining ureter ends

Question 5

NMIBC

Answer 5

75% of bladder cancer

involve
only the immediate epithelial layer of cells (carcinoma in situ [CIS] and
Ta) or that only penetrate into the connective tissue below the urothe-
lium (T1) but not into the muscular layer known as the muscularis
propria.

Question 6

involve
only the immediate epithelial layer of cells

Answer 6

carcinoma in situ [CIS] and
Ta

Question 7

only penetrate into the connective tissue below the urothe-
lium

Answer 7

T1

Question 8

tumors
that invade into the muscularis propria, through the muscularis
propria to involve the surrounding serosa, or into immediately
adjacent pelvic organs such as the rectum, prostate, vagina, or cervix.

Answer 8

Muscle-invasive bladder cancer (MIBC)

Question 9

immediately
adjacent pelvic organs such as the rectum, prostate, vagina, or cervix

Answer 9

T4

Question 10

through the muscularis
propria to involve the surrounding serosa

Answer 10

T3

Question 11

considered the mainstay of
surgical treatment.

Answer 11

removal of all visible tumors
by TURBT in the operating room

Question 12

Treatment For patients with intermediate- or
high-risk tumors

Answer 12

weekly intravesical instillations for 6 con-
secutive weeks of the attenuated mycobacterium strain known as
Bacille Calmette-Guérin (BCG)

Question 13

For patients with low-risk disease, meta-analyses
have demonstrated a 12% reduction in early relapses when a single
chemotherapy treatment of

Answer 13

mitomycin C, epirubicin, or gemcitabine
was instilled directly into the bladder (intravesical therapy) within
24 hours of the TURBT.

Question 14

For patients who are not fit enough for
or who refuse cystectomy,

Answer 14

non-BCG alternative intravesical agents
(mitomycin C, gemcitabine, docetaxel, valrubicin)

Or

agents that inhibit the PD-1/
PD-L1 immune checkpoint pathway (pem-
brolizumab)

Question 15

In patients with NMIBC that
recurs long after initial BCG treatment,

Answer 15

repeat course of BCG

Question 16

For patients with recurrence after a second adequate
course of BCG or with relapsed NMIBC within 6 months of initial
BCG exposure,

Answer 16

surgical removal of the entire bladder by cystectomy
is recommended due to the high risk of progression to MIBC and
potentially metastatic disease.

Question 17

In carefully selected patients
with no evidence of CIS or hydronephrosis,

Answer 17

bladder-sparing combined-modality ther-
apy with concurrent chemotherapy and
radiation can achieve cure in ~65% of
patients.

Question 18

Various chemotherapy regimens
have been utilized in combination with
radiation including

Answer 18

cisplatin, carboplatin,
5-fluorouracil, mitomycin C, paclitaxel,
and gemcitabine.

Question 19

In patients who achieve a complete response to combined-
modality therapy,

Answer 19

regular cystoscopic monitoring of the bladder is
required with salvage cystectomy offered to patients who develop
MIBC in follow-up.

Question 20

For patients with high-risk urothelial carcinoma of the upper urinary tract

Answer 20

resection of the kidney and ureter (including the ureter
bladder cuff) by nephroureterectomy is preferred.

Question 21

In patients with decreased renal function

Answer 21

Segmental ureter-
ectomy may be appropriate in patients with decreased renal function
in which nephron-sparing outcomes are critical to prevent the need
for dialysis.