NCCN Bladder 6.2020 Flashcards Preview

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Flashcards in NCCN Bladder 6.2020 Deck (103)
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1

INITIAL EVALUATION
Suspicious bladder mass

H and PE
Office cystoscopy
Consider cytology
Abdominal and pelvic imaging with upper tract collecting system BEFORE TURBT
Smoking screening


BL-1

2

PRIMARY EVALUATION and SURGICAL TREATMENT
Bladder mass

EUA/bimanual exam
TURBT
Single-dose intravesical chemotherapy within 24 hours of TURBT: Gemcitabine (preferred, cat 1) or mitomycin (cat 1)
Sessile or suspicious for high grade or Tis: selected mapping biopsies
Upper tract imaging if not yet done


BL-1

3

Initial workup for muscle-invasive bladder CA

CBC
Chemistry profile, with ALK PHOS
Chest imaging
Bone imaging, if suspicious/symptomatic


BL-1

4

Thanos FAQ!

"Sige, immediate intravesical chemotherapy reduces the ________ by ________ %."

Immediate intravesical chemotherapy reduces 5-year RECURRENCE (rekerens) rate by 35 %, and has a NNT to prevent recurrence of 7.

Does NOT reduce risk of progression or mortality.


BL-1 footnote, BL-F

5

SECONDARY SURGICAL TREATMENT/ADJUVANT INTRAVESICAL TREATMENT
cTa, low grade

Observation
OR
Intravesical therapy


BL-2

6

SECONDARY SURGICAL TREATMENT/ADJUVANT INTRAVESICAL TREATMENT
cTa, high grade

Repeat TURBT if:
1. Incomplete resection
2. No muscle in specimen

Then:
BCG (preferred)
OR
Intravesical chemotherapy
OR
Observation


If BCG given --> give maintenance BCG (preferred)


BL-2

7

SECONDARY SURGICAL TREATMENT
cT1

Strongly advise repeat TURBT
OR
Consider cystectomy if high-grade


BL-2

8

ADJUVANT INTRAVESICAL TREATMENT
cT1
Repeat TURBT: (+) residual disease

BCG (cat 1)
OR
Cystectomy


If BCG given --> give maintenance BCG (preferred)


BL-2

9

ADJUVANT INTRAVESICAL TREATMENT
cT1
Repeat TURBT: (-) residual disease

BCG (cat 1)
OR
Intravesical chemotherapy
OR
Observation in highly selected cases: low grade, limited lamina propria invasion, no CIS


If BCG given --> give maintenance BCG (preferred)


BL-2

10

ADJUVANT INTRAVESICAL TREATMENT
Tis

BCG


BL-2

11

Evaluation and Treatment
Posttreatment cTa, T1, Tis recurrent or persistent
Cystoscopy: positive

TURBT
Single-dose intravesical chemotherapy within 24 hours of TURBT: gemcitabine (cat 1) or mitomycin (preferred, cat 1)

Based on tumor grade and stage:
Adjuvant intravesical therapy
OR
Cystectomy
OR
Pembrolizumab


BL-3

12

Pembrolizumab is indicated for ________.

Pembrolizumab is indicated for treatment of patients with:
BCG-unresponsive high-risk, NMIBC with Tis or without papillary tumors


BL-3, footnote

13

Valrubicin is approved for ________.

Valrubicin is approved for BCG-refractory carcinoma in situ.


BL-3, footnote

14

Evaluation and Treatment
Posttreatment cTa, T1, Tis recurrent or persistent
Cystoscopy: suspicious for recurrence post-intravesical therapy (no more than 2 cycles)

TURBT
Single-dose intravesical chemotherapy within 24 hours of TURBT: gemcitabine (cat 1) or mitomycin (preferred, cat 1)

TURBT result:
- No residual disease: maintenance BCG (preferred)
- cTa, cT1, Tis: cystectomy (preferred for cT1 OR pembrolizumab (select patients) or change intravesical agent (consider)
- T2 or higher: RESTAGE and manage accordingly


BL-3

15

Evaluation and Treatment

Cytology: positive
Imaging: negative
Cytoscopy: negative

Selected mapping biopsies including transurethral prostate biopsy
AND
Upper tract cytology
AND
Consider URS
AND
Enhanced cystoscopy (if available)


BL-4

16

Treatment

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: bladder, prostate, upper tract negative

Follow-up at 3 mo, then at longer intervals
OR
If prior BCG, maintenance BCG (optional)


BL-4

17

Treatment

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: bladder positive

BCG, then:
If no evidence of disease (NED): maintenance BCG (preferred)
If persistent r recurrent disease:
Cystectomy OR pembrolizumab (select pxs) OR change intravesical agent (if incomplete response, cystectomy OR pembrolizumab)

If BCG-unresponsive:
Cystectomy OR pembrolizumab (in select patients)


BL-4

18

WORKUP

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: prostate positive

Urothelial CA of the Prostate!


DRE
Cystoscopy (with bladder biopsy)
TUR biopsy of prostate to include stroma
PSA
Needle biopsy if DRE is abnormal (in selecte patients)
Imaging of upper tract collecting system

19

PRIMARY TREATMENT

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: prostate positive: MUCOSAL prostatic urethra

TURP and BCG

If on ffup imaging: local recurrence, then cystoprostatectomy + urethrectomy



UCP-1

20

PRIMARY TREATMENT

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: prostate positive: ductal + acini

CXR + abdominal/pelvic CT

Cystoprostatectomy + urethrectomy
OR
TURP and BCG, then if on ffup imaging: local recurrence, then cystoprostatectomy + urethrectomy


UCP-1

21

PRIMARY TREATMENT

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: prostate positive: stromal invasion

CXR + abdominal/pelvic CT

Cystoprostatectomy + urethrectomy + neoadjuvant chemotherapy

then consider adjuvant chemotherapy (if neoadjuvant not given)


UCP-1

22

PRIMARY TREATMENT

Cytology: positive
Imaging: negative
Cytoscopy: negative

After workup: prostate positive: metastatic

Systemic therapy



UCP-1

23

PRIMARY TREATMENT and ADJUVANT TREATMENT
Stage II, cystectomy candidates

Neoadjuvant cisplatin-based combination chemotherapy followed by radical cystectomy (cat 1)
OR
Neoadjuvant cisplatin-based combination chemotherapy followed by partial cystectomy (highly selected patients with solitary lesion in a suitable location, no Tis)
OR
Cystectomy alone for those not eligible to receive cisplatin-based chemotherapy
OR
Concurrent chemoradiotherapy (cat 1) then reassess after 2-3 mos --> no tumor: observe;
--> tumor: Tis Ta T1: intravesical BCG OR surgical consolidation OR treat as metastatic


BL-5

24

PRIMARY TREATMENT and ADJUVANT TREATMENT
Stage II, NON-cystectomy candidates

Concurrent chemoradiotherapy (cat 1, preferred)
OR
RT
OR TURBT

Then reassess after 2-3 mos --> no tumor: observe;
--> tumor: Systemic therapy OR concurrent chemoRT or RT alone if no prior RT or TURBT and best supportive care


BL-6

25

PRIMARY TREATMENT ADJUVANT TREATMENT
Stage IIIA, cystectomy candidates

Neoadjuvant cisplatin-based combination chemotherapy followed by radical cystectomy (cat 1)
OR
Cystectomy alone for those not eligible to receive cisplatin-based chemotherapy
OR
Concurrent chemoradiotherapy (cat 1) then reassess after 2-3 mos --> no tumor: observe;
--> tumor: Tis Ta T1: intravesical BCG OR surgical consolidation OR treat as metastatic


BL-7

26

PRIMARY TREATMENT and ADJUVANT TREATMENT
Stage IIIA, NON-cystectomy candidates

Concurrent chemoradiotherapy (cat 1) then reassess after 2-3 mos;
- no tumor: observe;
- tumor: systemic therapy OR TURBT OR best supportive care
OR
RT


BL-7

27

Optimal candidates for bladder preservation with chemoRT:

Patients with tumors WITHOUT hydronephrosis
NO concurrent or extensive Tis
< 6 cm

Tumors should allow visually complete or maximally debulking TURBT


BL-7

28

ADJUVANT TREATMENT
Stage IIIA, cystectomy candidates

Based on pathologic risk (pT3-T4 or positive nodes or positive margins:
Consider adjuvant cisplatin-based chemotherapy or adjuvant RT (cat 2B) if no neoadjuvant given


BL-7

29

PRIMARY TREATMENT
Stage IIIB, downstaging systemic therapy option

Downstaging systemic therapy, then reassess tumor status 2-3 mo after treatment

Complete response: Consolidation cystectomy OR consolidation chemoRT OR observation

Partial response: Cystectomy OR chemoRT OR treat as metastatic

Progression: treat as metastatic


BL-8

30

PRIMARY TREATMENT
Stage IIIB, concurrent chemoradiotherapy

Reassess tumor status 2-3 mo after treatment

Complete response: ffup algorithm

Partial response: Tis, Ta, T1 consider intravesical BCG OR surgical consolidation OR treat as metastatic

Progression: treat as metastatic disease


BL-8