Bladder cancer Flashcards
(121 cards)
1
Q
presentation - musc vs non musc inv, vs metastatic
A
75% non musc, 20% musc, 5% metastatic
2
Q
cigaretter smoking dose threshold
A
dose dependent but 40 pk yrs is esp important. no risk plateau
3
Q
4 things assd w bilateral upper tract ca
A
arsenic, balken nephropathy, bracken fern, aristolochia fangchi
4
Q
2 polymorphisms confering higher suceptibility to environmental carcinogens
A
- slow acetylators, 2. glutathione s transferase M1 null
5
Q
congential condition w higher risk of adnenoca
A
extrophy
6
Q
iatrogenic condition w higher risk of adnenoca
A
ureterosigmoidostomy
7
Q
signet cell adenoca significance
A
very bad
8
Q
small cell/neuroendocrine markers - 3
A
synaptophysin, chromogranin, neuron speciic enolase
9
Q
tx for small cell
A
VP-16 then cystectomy for ANY stage
10
Q
3 premalignant lesions
A
- leikoplakia (20% risk of SCC), 2. cystitis glandularis (adenoca), 3. inverted papilloma (assd w TCC elsewhere)
11
Q
benign lesions - 5
A
squamous metaplasia (50% females), nephrogenic adenoma (turbt), cystis cystica / follicularis, pseudosarcoma (spindle cell tumor), malacoplakia (rxn to chronic UTI)
12
Q
significance of 9q loss
A
low grade tcc
13
Q
significance of high p53, KI 67, matril metaloprotease
A
high grade
14
Q
what is KI 67
A
marker of proliferation
15
Q
tetraploidy significance
A
normal - found in umbrella cells
16
Q
sig of low RB, e-cadgerin, p27
A
high grade
17
Q
what is RB
A
“cell cycle brake” - loss promotes cancer proliferation
18
Q
sig of high urokinase type pasminogen activator
A
high grade
19
Q
nephrogenic adenoma sx
A
hematuria, dysuria, frequency
20
Q
clinical stage for fixed vs palpable mass after turbt
A
fixed - T4, palpable - ct3
21
Q
rate of understaging if no muscle in T1 specimen
A
50%
22
Q
chance understaging in T1 with muscle in specimen or chance of leaving tumor behind
A
10-20% understaging, 30-50% residual tumor behind
23
Q
retur?
A
all high grade T1 reduces understaging to < 10%
24
Q
tumor in diverticulum - Ta vs T1
A
Ta - can be safely removed, T1 - may need partial cystectomy
25
2 situations where intraperitoneal perf can be managed conservatively
1. small and late in TUR - switch to glycine, 2. large/ assd w bleeding or early in TUR - stop and retuen another time
26
absolute indication to e-lap in intraperitoneal bladder injury
bowel injury
27
LVI in T1 - prognostic sig - 3
88% chanc of understaging, increased occult LN mets, decreased survival
28
LVI mgmt in T1 - 2
early cystectomy with neoadjuvant chemo
29
risk of recurrence at 2 yrs vs 4 yrs for HG TCC
80% vs 20%
30
things primarily affecting recurrence - 4
prior recurrence > 1x/yr, multifocality, tumor > 3 cm, recurrence at 3 mo cysto
31
things affecting progression
CIS, stage (T1/CIS)
32
low risk bca - 3
low grade, solitary, Ta
33
progression risk for low risk
<5% @5 yrs
34
intermediate risk - 2
recurrent OR multifocal Ta/T1 low grade
35
progression risk for intermediate risk
10% at 5 yrs
36
high risk
any high grade (CIS, Ta, T1)
37
highest risk
multifocal T1G3+CIS
38
progression risk for high risk
25-50% @ 5 yrs
39
post TUR agents - 3
mitomicin, thiotepa, doxorubicin
40
when to give post TUR chemo
within 6 hrs
41
dwell time for post tur agents
30-60 minutes
42
what agent does not cause severe local tissue reaction/peritonitis with perforation
thiotepa
43
thiotepa risk with perf
myelosupression (lowest molecular weight)
44
benefit of post chemo agent
25-50% relative risk of recurrence, 15% absolute risk reduction
45
techniques for optimization of intravesical chemo (delayed) - 4
1. relative dehydration, 2. empty bladder prior to instillation, 3. increase concentration (40 mg in 20 cc water), 4. alkalinize urine with po bicarb (reduces mitomicin degradation)
46
mitomycin toxicity
hypersensitivity, palmar rash, bladder contracture
47
thiotepa toxicity
myelpsupression- have to check weekly CBC
48
who is intravesical chemo best for
intermediate risk papillary, or if BCG is contraindicated
49
effect of intravesical chemo
recurrence only, no effect on progression
50
limitations of multidose chemo -3
1. reduces recurrence only, 2. ineffective if prior bcg failure, 3. failure of 1 chemo agent increases failure likelyhood of another chemo agent
51
contraindications to BCG dose - 4
1. traumatic cath, 2. recent gross hematuria, 3. unresolved UTI, 4. significant immunosupression or autoimmune disease
52
what are not contraindications to BCG - 4
1. reflux, 2. hx treated TB, 3. positive PPD, 4. prosthetic devices
53
benefit to BCG
30% reduction in recurrence and progression
54
BCG MOA - 2
1. T-helper type 1 immune response (inc IL2 and interferon gamma), 2. opposed by T helper type 2 response (increased IL-4 and IL-10)
55
1st steps to improve BCG tolerance
sx relieving drugs - antichol, pyridium
56
alternate methods of improving BCG toelrance - 3
1. BCG dose reduction, 2. space tx out to 2 wks apart, 3. decrease dwell time to 30 mins
57
BCG sepsis meds - 2 steps
3-6 months with INH, or triple therapy (INH, ethambutol, rifampin) if severe case + steroids(!) in acute phase
58
supplementation with INH
B6, pyridoxine
59
mgmt of BCG prostatitis
anti tb meds
60
most common cause of BCG sepsis
traumatic catheterization
61
low, intermediate, high risk and chemo/BCG
low - postop chemo only, intermediate/high - postop chemo + 6 wk chemo or BCG + maintenance
62
indications for upfront cystectomy in nonmuscle invasive disease - 7
unfavorabel histology, LVI, bulky/incompletely resectable T1 HG, BCG failure x 2 in T1HG, prostatic stromal invasion, HGT1 in bladder diverticulum, bladder cripple with recurrent disease
63
unfavorable histology qualifying for upfront cystectomy
SCC, small cell, adenoca, nested or plasmacytoid, micropapillary
64
relative indications for RC
T1HG after repeat TUR, T1HG after BCG x 1, multifocal T1HG + CIS at presentation
65
upper tract studies - low risk, multifocal low risk, high risk
low risk - initial study only, multifocal low risk, every 2 yrs, high risk - q 1-2 yrs
66
delay in tx of small Ta with hx low/intermediate risk disesae
safe - 2 mm growth per mo
67
when is selective positive upper tract cytology unreliable
visible bladder tumor or bx + CIS - contamination
68
in female, if bladder workup negative for positive cytology
check gyn source
69
outcome if initial workup of positive cytology is negative
bladder source eventually in 80%
70
bcg failure vs chemo failure
bcg failure responds to 2nd line bcg (30-50% response) but not to chemo, chemo failure responds to bcg like untreated patient
71
most common cause of death in bladder ca
distant mets at the time of locoregional tx
72
what timeframe does progression of cancer happen after locoregional tx
within 2 yrs
73
small cell associated paraneoplastic syndromes - 3
ectopic ACTH, hypercalcemia, hypophosphatemia
74
T2a/b
Ta2 - inner muscle, b - outer muscle
75
T4a
t4b - prostate stroma (via SV, urethra, or bladder neck), vag, uterus, rectum. mobile. T4b - pelvic side wall, fixed
76
CIS of prostatic urethra or ducts and stage?
does not upstage as outcome is determined by primary bladder ca
77
most significant pathologic risk for progression
LN status
78
% upstaging from T1 at TUR to T2 at RC
40%
79
hydro on preop workup and cT stage
cT3
80
prostate prior to RC
always do prostate biopsies at 5/7 oclock. if neg, dont need to send urethral margin at RC
81
when to absolutely get CT chest other than abn cxr
T4, N+ on c stage
82
when to preserve uterus/vagina in F
better support when considering neobladder
83
when can a female not have orthotopic diversion
anterior vaginal wall invovlement b/c have to remove urethra
84
when not to preserve urethra in F and mgmt
poster based invasice ca. have to include a small strip of anterior vag for margin.
85
prostate/SV sparing RC
investigational as prostate is involved 40% of the time
86
extended LN dissection and survival
no current evicence extended LN dissection (to IMA) improves survival.
87
extended LN dissection and tumor involvement
involved in upto 50% of T3/4
88
4 situations to abort cystectomy
1. LN disease unresectable, 2. extensive periureteral disease, 3. fixation to pelvic side wall, 4. invading rectum
89
when can you keep the urethra if there is tumor involvement
small, papillary tumors that have been resected
90
recurrent urethral TCC risk and diversion type
lower with orthotopic vs cutaneous diversion
91
how to preserve urethral innervation in female
limit dissection to above endopelvic fascia
92
nerve sparin cystectomy?
only if no evidence of local extension intraoperatively. 40% achieve erections. age dependent
93
CIS of ureter or prostate and outcome
not associated with poor outcome
94
noncontiguous vs contiguous involvement of prostate and outcome
contiguous = very bad, T4 disease
95
all of the following surgical LN characteristics impact survival: 5
LN, # LN positive, % LN positive, path stage of tumor, extranodal extension
96
death and women
upto 50% higher risk of death
97
timeframe to recurrence
most within 1st 3 yrs
98
who needs annual upper tract monitoring post cystectomy - 3
urethral margin, + ureteral margin, CIS
99
tumor location for partial cystectomy
dome of the bladder, away fro ureteral orifaces
100
partial cystectomy outcome
poorer outcome.
101
poor pronostic features in EBRT of bladder - 4
anemia, T3a> or T4, hydronephrosis, CIS (radioresistant)
102
benefit of neoadjuvant chemo
5% overall survival benefit
103
who benefits most from adjuvant
residual micromets
104
FGFR3 mutation and tcc type
Ta papillary
105
P53 chromosome location
short arm of 17
106
P53 pathway
DNA damage --> inc P53 --> P21 --> cell cycle arrest (G1-S)
107
RB gene location
chr 13q
108
where are mets most likely after chemo and why
cns - privelaged site
109
positive prognostic factors for chemo in mets - 2
LN only mets, asymptomatic
110
mgmt of solitary mets post chemo
resect
111
(absolute) criteria for neobladde - 5
live expectancy > 1 yr, manual dexterity (need for CIC), cr cl > 50 or cr < 2, normal bowel function, urethra not involved by cancer
112
study to do before using colon in reservoir
colonoscopy
113
who is not excluded from orthotopic neobladder - 3
> 80 yo, locally advanced disease, prior pelvic rsadiation
114
absolute contraindication for neobladder in F
ca at bladder neck or posterior bladder. must retain distal 2/3 urethra for nl urinary function
115
signifance of urinary retention in men post nb
likely suggests recurrence
116
bowel segment to use for cutaneous diversion if prior pelvic radiation
transverse colon
117
use fo turnbull stoma
eliminates risk of stomal stenosis
118
what is hematuria/dysuria syndrome
reduced HCL secretion = loss of feedback on gastrin secretion --> peptic ulcers, hematuria
119
cause of diarrhea after urinary diversion and mgmt
fat malabsorbtion and bile salt irritation of colon.
120
mgmt of persistent diarrhea after colon conduit
metamucil --> antimotility drugs --> cholestyramine
121
pathophys of increased renal calculi in diversion
decreased bile acids --> fat malabsorbtion and ca binding --> increased oxalate
