Bladder Cancer FRCR CO2A Flashcards
(163 cards)
1
Q
What are the types of primary malignant bladder cancer?
A
Transitional Cell Carcinoma 90%
Sq Cell Carc 5%
Adenocarcinoma 1-2 %
Small cell carcinoma
others
2
Q
what is the male to female ratio for incidence of BC ?
A
5:2
3
Q
What are the RFs for BC?
A
Smoking (2 naphthylamine, polycyclic aromatase hydrocarbons)
Passive smoking
Occupation: petroleum, rubber, dye and paint (chlorinated hydrocarbons)
4
Q
what are the genetic syndromes a/w BC?
A
RB1 and Lynch syndrome
5
Q
How does family history of BC affect its risK?
A
1st degree relative doubles an individual’s risk
6
Q
is any screening recommended for BC detection
A
No
7
Q
which site of bladder is MC affected ?
A
The base of bladder and multiple tumors are frequent
8
Q
which NMIBC should be considered as high grade?
A
CIS, High grade G3 T1 lesions, 20% of NMIBC will become muscles invasive and recc risk is 50%
9
Q
what investigations for hematuria of unknown case
A
Urinanalysis for cytology and culture
Flexible white light cystoscopy,
In NMIBC, blue light cystoscopy, dissease appears red and normal tissue as blue
10
Q
Whats the mc clinical presentation for BC
A
Painless hematuria
11
Q
What investigations should be done after confirmation of BC diagnosis?
A
TURBT
Pelvic MRI or CT
CT chest abdomen pelvis
12
Q
is bone scan routinely done
A
no, only if symptoms or raised Ca or ALP
13
Q
is there any role of PET
A
limited use bcoz of interference from urinary excretion of contrast
14
Q
what should be included in histology report ?
A
- location and grade
- Depth of invasion
- CIS present/absent
- LVSI
- aberrant histology
15
Q
what is important in specimen
A
presence of detrusor muscle, its absence means incomplete resection
16
Q
what are the chances of LN spread
A
- 20 % for lamina propria involvment
- 30% for superficial muscle involvement
- 60% for full thickness muscle involvment
17
Q
what is the treament of NMIBC
A
TURBT followed by single dose of perioperative intravesical chemotherapy, reduces rist by 11.7% compared to TURBT alone
18
Q
which intravesical agent is superior to ChT
A
BCG
18
Q
what are other chemo intravesical options?
A
Doxorubicin and epirubicin
19
Q
which agent is commonly given in UK as intravesical chemo?
A
Mitomycin C 20 mg
20
Q
what are C/I for intravesical therapy
A
suspected or confirmed cases of perforation following TURBT
21
Q
what is recommeded duration of Rx with BCG
A
1 year for intermediate risk, 1-3 years for high risk
22
Q
what are absolute C/I for BCG
A
difficult catherisation or during 14 days of TURBT
23
Q
What are relative C/I for BCG
A
immunosuppression or asymptomatic bacteriuria
24
what follow up timing is recommened for NMIBC post treatment?
Cystoscopy and urine cytology initially 3 months post TURBT, should be followed up for 5 years after low risk disease and life long for intermediate and high risk disease
25
what is the treament for MIBC T2-T4a N0/Nx M0
Radical Cystectomy (RC)
25
what things should be looked at before RC
patient PS, comorbidities and their wish
25
When is RC Treatment of choice
high risk pts, defined as cT4, CIS, multifocal, incomplete TURBT, HDUN and fit for surgery
25
when is definitive CRT recommended
not fit for surgery and wish for bladder preservation
25
whats the advantage of extended b/l pelvic lymphadenectomy
better 5 years survial than stand LND
25
which pts should be given option of bladder preservation?
medically fit and intermediate RFs cT2-T3, no CIS, unifocal, complete TURBT and no HDUN
26
What does RC involve
cystoprostatectomy for mend and anterior exenteration for women with urinary diversion using a bowel segment
27
what is poor prognostic feature
positive nodal status
28
what are complications of RC
bleeding infection TE lymphocele formation anastomotic leakage bowel obstruction and sexual dysfunction
29
for how long surveillance is mandatory for MIBC post treatment
life long
30
which organs are common sites of metastasis for BC
lungs, liver bones
31
what is the rationale for NACT
addressing micrometastases and downstaging the primary tumor
32
who are the candidates for NACT
all fit surgical candidates with adequaate renal function
33
what are recommended chemo regimens for NACT
MVAC and Gem Cis
34
when is response evaluation done with NACT
after 2 cycles, if good response, chemo for 3 to 4 cycles
35
what gap should be given between chemo completion and surgery
atleast 4 weeks
36
whats the role of adjuvant chemo?
survival benefit with cisplatin based regimens
NACT remains SOC however adjuvant for someone who missed NACT or high volume nodal disease or extravesical spread at RC
37
what is trimodality bladder preseving strategy
TURBT followed by CRT (with early salvage cystectomy for recurrent disease)
38
how is trimodality strategy compared to RC
similar survival rates
39
what are important prognostic factors post trimodality therapy
pts age
tumor size
response to RT
HDUN and
completeness of TURBT
40
what is split course regimen
Maximal TURBT and CRT to 40 Gy with cis and 5 FU given before repeat cystoscopy and biopsy: complete ressponse in 72% of pts who proceed to condolidation CRT to total dose of 64 Gy
41
what has BCON study shown
survival benefit with hypoxic modification in addition to standard RT
42
how long surveillance is required post cystectomy
3 monthly for first year, six monthly for 2nd year then annually
CT at 6 and 12 months and then annually
43
how should NMIBC recurrence be managed
for 1st prsentation with TURBT and Intravesical therapy, if recurrent cystectomy
44
What things should be kept in mind while planning RT for BC
empty rectum and empty bladder, unless partial bladder irradiation is planned
44
How is RT simulation for BC done
supine, flat couch arms folded across the chest
45
where should skin tatoos be placed
anteriorly over the pubic symphisis and laterally over the iliac crests to prevent lateral rotation
46
what should be planning CT field
3 mm slice bottom of the ischial tuberosities to 3 cm above the dome of bladder or bottom of L5, whichever is higher
47
What CTV includes
visible known tumor and normal bladder,
48
what is margin from CTV for PTV
15 mm around normal bladder and 20 mm around tumor
49
IS nodal irradiation frequently done in UK even in high risk of nodal disease
no, because the benefits are unclear
50
what direction beams are given
one anterior and two posterior oblique wedged fields
51
What RT dose is frequently used for radical Rx
64 Gy/32# over 6.5 weeks or 55 Gy/20# over 4 weeks
52
how is T4b or N+ disease treated?
Many consider it systemic disease and treat with 4 to 6 cycles of systemic therapy, if good response consolidation RT to the bladder and possibly pelvic nodes
53
if nodal irradiation is planned, what bladder protocol should be followed and why
full bladder to avoid high doses to bowel
53
what is EORTC defined fitness for cisplatin
GFR > 60 ml/min and PS 0-1, uretric shunt should be placed first before systemic Rx is planned for obstruction
53
what treatment for PS >2
BSC
53
can carboplatin replace cisplatin for cisplatin fit pts
no, OS is inferior with Carboplatin
53
what is 1st Line Treatment for Cisplatin ineligible pts in recurrent/metastatic setting ?
Pembrolizumab and enfortumab vedotin
53
what is 1st Line Treatment for Cisplatin eligible pts in recurrent/metastatic setting ?
Pembrolizumab and enfortumab vedotin-ejfv1
54
what are other 1st Line Treatment for Cisplatin eligible/ineligible pts in recurrent/metastatic setting ? except pembro and enfortumab vedotin?
Gemcitabine and cisplatin (category 1) followed by avelumab maintenance therapy (category 1)
Nivolumab, gemcitabine, and cisplatin (category 1) followed by nivolumab maintenance therapy14
55
what are Palliative RT doses for BC
21 Gy/3# or 36 Gy/10# or 30 Gy/10#
56
if Rx to the whole pelvis with parallel fields is required, what dose should be used
30 Gy/ 10#
57
if low volume bladder only is being treated, what dose should be used
21 Gy/ 3#
58
is Single Fraction of 8 Gy effective
yes for hematuria and for PS > 2
59
what palliative RT dose should be considered for Rx with CT planning
35 Gy/10# or 36 Gy/ 6#
60
Very High Risk Features
NMIBC, AUA
Lymphovascular invasion,
prostatic urethral involvement of tumor
subtype histology (eg, micropapillary,
plasmacytoid, sarcomatoid
61
62
What percentage of all malignancies does bladder cancer account for?
4%
## Footnote
Bladder cancer accounts for a significant portion of malignancies in the UK.
63
How many new diagnoses of bladder cancer occur each year in the UK?
Over 10,000
## Footnote
This statistic highlights the prevalence of bladder cancer in the UK.
64
What is the worldwide male to female ratio for bladder cancer?
10:3
## Footnote
This ratio indicates a higher prevalence in males.
65
At what age group is bladder cancer most common?
Over 70 years old
## Footnote
Bladder cancer is rare in individuals under 50.
66
List three risk factors for bladder tumors.
* Smoking
* Infections (especially schistosomiasis)
* Occupational/chemical exposures
## Footnote
Other factors include bladder calculi, chronic indwelling catheters, and previous radiotherapy.
67
What is the most common histological type of bladder tumor in Western countries?
Transitional cell carcinoma (TCC)
## Footnote
Over 90% of bladder tumors are TCC.
68
What percentage of bladder tumors are papillary versus flat in appearance?
80% papillary, 20% flat
## Footnote
Flat tumors are typically of higher grade.
69
What is the prognosis for carcinoma-in-situ?
Poor prognosis with invasive components
## Footnote
At least 30% of grade III carcinoma-in-situ will become invasive.
70
What is the most common initial presentation of bladder cancer?
Painless haematuria
## Footnote
Macroscopic haematuria has a 25% chance of indicating a bladder tumor.
71
What is the likelihood of lymph node involvement in grade 1 versus grade 3 tumors?
Less than 10% for grade 1, 80% for grade 3
## Footnote
Tumor grade significantly affects lymph node involvement.
72
What are the initial investigations for suspected bladder cancer?
* Urine cytology
* Intravenous urogram (IVU)
* Cystoscopy
## Footnote
Cystoscopy includes bimanual examination and biopsies of suspicious areas.
73
True or False: MRI is better for showing early invasion of adjacent organs than CT scans.
True
## Footnote
MRI is preferred for detecting early invasion.
74
Fill in the blank: Bladder cancer is the ______ most common cancer worldwide.
9th
## Footnote
This statistic emphasizes the global prevalence of bladder cancer.
75
What are common symptoms associated with bladder cancer aside from haematuria?
* Frequency
* Urgency
* Dysuria
* Loin pain
## Footnote
Symptoms may also include issues caused by metastases.
76
What is the main site for metastatic spread of bladder cancer?
Lungs and bones
## Footnote
Understanding metastatic patterns is crucial for treatment planning.
77
What is the role of a bone scan in bladder cancer investigations?
Only necessary if indicated by symptoms or a raised alkaline phosphatase
## Footnote
Bone scans are not routine and depend on specific clinical findings.
78
What is an indication for radical cystectomy related to carcinoma-in-situ?
Severe/persistent carcinoma-in-situ
## Footnote
Carcinoma-in-situ refers to a group of abnormal cells that remain in the place where they first formed.
79
What type of cancer invasion is an indication for radical cystectomy?
Muscle invasion
## Footnote
Muscle invasion indicates that cancer has spread into the muscle layer of the bladder.
80
What is indicated by multiple recurrences of T1 disease despite treatment?
Radical cystectomy
## Footnote
T1 disease refers to a stage of bladder cancer that has invaded the subepithelial connective tissue.
81
What Gleason grade is an indication for radical cystectomy?
T1 G3
## Footnote
G3 indicates a higher grade of tumor with a more aggressive behavior.
82
Which types of carcinoma are indications for radical cystectomy?
Squamous cell carcinoma and adenocarcinoma
## Footnote
These are types of bladder cancer that may require more aggressive treatment approaches.
83
What patient condition may lead to an indication for radical cystectomy?
Unreliable patient (surveillance is not realistic)
## Footnote
An unreliable patient may not adhere to follow-up or treatment protocols, necessitating surgical intervention.
84
What does the management of bladder tumours depend on?
The degree of invasion into the bladder wall and the histological grade of the cancer
85
How are superficial, non-muscle invasive tumours generally treated?
Transurethral resection, with intravesical chemotherapy or immunotherapy for multiple or recurrent tumours
86
What are the treatment options for localized muscle invasive disease?
Primary cystectomy or radiotherapy to the bladder and perivesical tissues
87
What does intravesical therapy reduce?
Short-term recurrence rates following transurethral resection
88
What are the options for intravesical therapy?
* Chemotherapy with agents such as mitomycin
* Immunotherapy with BCG
89
What is the incidence of chemical cystitis with chemotherapy?
Approximately 40%
90
What is the incidence of chemical cystitis with BCG?
Approximately 90%
91
What is the effect of mitomycin on recurrence rates following the first cystoscopy?
Reduces recurrence rate from 25% to 12%
92
How should mitomycin be administered?
As a single dose within 6 hours of transurethral resection or weekly for 6–8 weeks
93
How long should mitomycin be left in contact with the bladder?
1–2 hours
94
What are the reported response rates for mitomycin?
65%, with a 35% complete response
95
What are the side effects of mitomycin?
* Cystitis
* Reduced bladder capacity
* Palmer desquamation
* Rash
96
What is the response rate for intravesical BCG?
75%
97
What is the mean time to recurrence for intravesical BCG?
2 years
98
How does BCG treatment affect cystectomy rates in CIS patients?
It has been shown to reduce cystectomy rate
99
What are the side effects of intravesical BCG?
* Cystitis
* Fever
* Haematuria
* Prostatitis
100
How long should BCG treatment be withheld after resection?
For a month to allow the mucosa to heal
101
What is the initial BCG treatment schedule?
A 6-week induction course (81 mg of BCG in 50 ml of normal saline) of weekly treatments
102
What happens if there is a response after the initial BCG treatment?
A second 6-week course is initiated
103
What should be considered if there is progression after BCG treatment?
Cystectomy should be considered
104
What have trials of maintenance therapy shown?
Variable benefits using a schedule following the initial 6-week course with three consecutive weekly treatments every 6 months for 3 years
105
What is the aim of treatment for localized muscle invasive disease?
Cure with bladder preservation if possible
## Footnote
Treatment aims to eliminate the disease while maintaining bladder function.
106
What is the reported curative rate of radical cystectomy for disease confined to the bladder?
60–70%
## Footnote
Radical cystectomy is a surgical procedure aimed at removing the bladder to treat cancer.
107
What is the reported cure rate for radical external beam radiotherapy?
50%
## Footnote
This treatment option may allow for bladder function preservation but has lower cure rates compared to radical cystectomy.
108
What percentage of patients with T3 disease can expect radical treatment to be curative?
<30%
## Footnote
T3 disease indicates that cancer has spread beyond the bladder.
109
What is the likelihood of patients developing distant metastases within 1–2 years after treatment for T3 disease?
Half of patients
## Footnote
The prognosis is poor once cancer has spread beyond the bladder.
110
What does radical cystectomy involve?
Excision of the bladder, perivesical fat, and attached peritoneum
## Footnote
This procedure includes the removal of surrounding tissues and may involve additional structures depending on the patient's sex.
111
What additional organs are removed in men during a radical cystectomy?
Prostate and seminal vesicles
## Footnote
The extent of the surgery varies by sex due to anatomical differences.
112
What additional organs are removed in women during a radical cystectomy?
Uterus, urethra, adnexa, ovaries, and a cuff of vagina
## Footnote
The surgery is more complex for women due to the number of organs involved.
113
What is the risk of urethral recurrence if the urethra is left in-situ during radical cystectomy?
5–10%
## Footnote
Leaving the urethra intact can lead to potential recurrence of cancer.
114
What is the role of lymphadenectomy in radical cystectomy?
Controversial but now generally accepted as standard
## Footnote
Lymphadenectomy involves the removal of lymph nodes and has evolved in its acceptance as part of the surgical procedure.
115
What is an ileal conduit?
A type of urinary diversion that involves creating a stoma using a segment of the ileum
116
What are the two main types of continent diversions?
Mainz II and Mitrofanoff diversion
117
What is the Mainz II diversion?
Insertion of ureters into the rectum if no urethra is present, with increased risk of bowel cancer and lifelong diarrhea
118
Describe the Mitrofanoff diversion.
Ureters implanted into a small bowel reservoir connected to the skin via a native tube; requires self-catheterization
119
What happens if the urethra is preserved during urinary diversion?
Ureters can be diverted into a small bowel reservoir that empties via the urethra, requiring bladder training due to lack of voiding sensation
120
What is the mortality rate associated with radical cystectomy?
Up to 3%
121
What percentage of men may experience impotence after radical cystectomy?
70–100%
122
List some side effects of radical cystectomy.
* Impotence in men
* Dyspareunia in women
* Uterocutaneous fistulas
* Infection
* Small bowel fistulas (30%)
123
What is the aim of radical radiotherapy?
Cure with bladder preservation
124
What factors should be considered when deciding between radical cystectomy and radiotherapy?
Multidisciplinary meeting and patient involvement
125
What are the outcomes of randomized studies comparing radiotherapy and cystectomy?
Radiotherapy has higher local recurrence rates but similar overall survival with close follow-up and salvage cystectomy
126
What are poor prognostic factors for radiotherapy?
* Ureteric obstruction
* Incomplete transurethral resection
* Sessile tumors
* Persistence/recurrence at first cystoscopy
127
When is radical radiotherapy contraindicated?
* Previous pelvic radiotherapy
* Inflammatory bowel disease
* Small bowel adhesions
* Extensive CIS
* Poor bladder function
* Multiple transurethral resections or intravesical chemotherapy installations
128
What is the typical planning method for radical radiotherapy?
CT-planned with a target volume including a 1.5–2 cm margin around the bladder, prostatic urethra, and tumor extension
129
What are common complications of radiotherapy?
* Radiation cystitis (<5%)
* Radiation proctitis (<5%)
* Bowel obstruction (<3%)
* Erectile dysfunction (60%)
130
What is the purpose of palliative radiotherapy?
Beneficial for patients with node-positive or locally advanced disease, especially for symptoms like haematuria or pelvic pain
131
What are typical dose schedules for palliative radiotherapy?
* 30 Gy in 10 fractions over 2 weeks
* 21 Gy in three fractions over 1 week
* Single fraction of 8–10 Gy for frail patients
132
What is the response rate of chemotherapy in metastatic bladder cancer?
40–70%
133
What are common chemotherapy combinations used for bladder cancer?
* CMV (cisplatin, methotrexate, vinblastine)
* MVAC (methotrexate, vinblastine, adriamycin, cisplatin)
* Gemcitabine and cisplatin
134
What is the absolute benefit in overall survival from neoadjuvant chemotherapy in muscle invasive bladder cancer?
5%
135
What is the role of adjuvant chemotherapy after cystectomy?
Conflicting evidence on benefit; not routinely recommended
136
Is there evidence that concurrent cisplatin with radiotherapy is better than radiotherapy alone?
No definitive evidence
137
Fill in the blank: The chemotherapy regime _______ consists of Gemcitabine and Cisplatin.
Gem/Cis
138
What is the recommended dose for Cisplatin in the CMV regimen?
100 mg/m2 on Day 2 only (70 mg/m2 if palliative)
139
What is the recommended dose for Methotrexate in the MVAC regimen?
30 mg/m2 on Days 2, 15, and 22
140
In patients with poor renal function, what is considered as a substitute for Cisplatin?
Carboplatin (AUC 4–5)
141
What is the treatment for renal pelvic and upper urothelial transitional carcinomas?
Radical resection of the kidney and ureter
## Footnote
Nephron-sparing procedures may be considered for small, localized tumors.
142
What is the role of adjuvant radiotherapy after complete resection of renal pelvic and ureter carcinomas?
Confers no survival advantage but may be considered for patients with positive margins or residual local disease
## Footnote
Typically delivers 45–50.4 Gy in 25–28 fractions.
143
What chemotherapy regimen is suggested to improve survival in T3/4 and/or node-positive disease following surgical resection?
Concurrent cisplatin chemotherapy added to radiotherapy
## Footnote
Evidence suggests improvement in overall and disease-free survival.
144
What is the current evidence for adjuvant chemotherapy in renal pelvic and ureter cancers?
Stronger for node positive disease than for locally advanced but node negative disease
## Footnote
Limited published data on benefits of systemic adjuvant therapy.
145
What is the treatment approach for metastatic disease in renal pelvic and ureter carcinomas?
Platinum-based chemotherapy regimes similar to those used in metastatic bladder cancer
## Footnote
Treatment aims to manage distant relapses.
146
What percentage of bladder cancers does small cell bladder cancer account for?
Less than 1%
## Footnote
Commonly presents at an advanced stage.
147
What is the recommended treatment for localized small cell bladder cancer?
Neoadjuvant platinum-based chemotherapy prior to surgery or radiotherapy
## Footnote
Responses to chemotherapy are also seen in metastatic disease.
148
What is the median survival rate for patients with metastatic small cell bladder cancer?
Less than 12 months
## Footnote
Most published data relates to neuroendocrine regimens like carboplatin/cisplatin with etoposide.
149
What are the 5-year survival rates for bladder cancer at stage T2?
50–80%
## Footnote
Survival rates vary significantly by stage.
150
What is the 5-year survival rate for bladder cancer at stage T4?
10%
## Footnote
Indicates poor prognosis at advanced stages.
151
What is the survival rate with metastatic bladder cancer despite reasonable response rates to chemotherapy?
<10% 2-year survival
## Footnote
Highlights the challenges in treating metastatic disease.
