Non-muscle invasive bladder cancer

Question 1

What are the demographics of NMIBC?

Answer 1

Caucasian american men (3:1) older than 65 years of age

Question 2

What are the risk factors for bladder cancer?

Answer 2

Tobacco smoking
Aromatic amines
polycyclic hydrocarbons
Arsenic
Cyclophosphamide

Lynch syndrome

Schistosoma hematobium (sqaumous cell)
Aristocholic acid (upper tracts)

Question 3

What are some common mutations of tumor suppressor genes found in NMIBC?

Answer 3

GSTM-1
NAT-2
P16
CDKN2A
PTEN
RB1
TP53

Question 4

What are some oncogene mutations seen in NMIBC?

Answer 4

FGFR3
PIK3CA
RAS

Question 5

What is the rate of urinary tract malignancy in patient with asymptomatic microscopic hematuria?

Answer 5

2.6%

Question 6

What are the common presenting symptoms of NMIBC?

Answer 6

Hematuria

irritative voiding symptoms

Question 7

What is Ta bladder cancer?

Answer 7

Non invasive papillary carcinoma

Question 8

What is Tis bladder cancer?

Answer 8

Carcinoma in situ

Question 9

What is T1 bladder cancer?

Answer 9

Tumor invades the lamina propria

Question 10

What is T2a bladder cancer?

Answer 10

Tumor invades the muscularis propria inner half

Question 11

What is T2b bladder cancer?

Answer 11

Tumor invades deep muscularis propria (outer half)

Question 12

What is T3a bladder cancer?

Answer 12

Tumor invades perivesical fat microscopically

Question 13

What is T3b bladder cancer?

Answer 13

Tumor invades perivesical fat macroscopically

Question 14

What is T4a bladder cancer?

Answer 14

Tumor invades adjacent organs

Question 15

What is T4b bladder cancer?

Answer 15

Tumor invades pelvic side wall.

Question 16

What is the 10 year survival prognosis for high grade NMIBC?

Answer 16

70-85%

Question 17

What are the recurrence and progression rates for Ta NMIBC?

Answer 17

Recurrence: 55%
Progression: 6%

Question 18

What are the recurrence and progression rates for T1 high grade NMIBC?

Answer 18

Recurrence: 45%
Progression: 17%

Question 19

What defines low risk NMIBC?

Answer 19

Low grade
Solitary lesion
Ta < 3cm
Papillary urothelial neoplasm of low malignant potential

Question 20

What defines intermediate risk NMIBC?

Answer 20

Recurrent low grade Ta within 1 year
Solitary LG Ta > 3cm
Multifocal LG Ta
HG Ta < 3cm 
LG T1

Question 21

What defines high risk NMIBC?

Answer 21

HG T1
Recurrent HG Ta
HG Ta > 3cm or multifocal

CIS
BCG failure in HG patient
Any variant histology

LVI
HG prostatic urethral involvement

Question 22

How should NMIBC be diagnosed?

Answer 22

By thorough cystoscopy.

Question 23

What should be the initial treatment of NMIBC?

Answer 23

At initial diagnosis of a patient with bladder cancer, a clinician should perform complete visual resection of the bladder tumor(s), when technically feasible

Question 24

What should be included in addition to cystoscopy for evaluation of hematuria or a suspected bladder tumor?

Answer 24

Upper tract imaging.

Question 25

What should be done if a patient has a normal cystoscopy but positive cytology?

Answer 25

``` Prostatic urethral biopsies Upper tract imaging Ureteroscopy Blue light cystoscopy Random bladder biopsies ```

Question 26

What should be done if NMIBC shows variant histology?

Answer 26

Repeat TURBT in 4-6 weeks.

Question 27

What is the rate of muscle invasion with variant histology?

Answer 27

86%

Question 28

What is the preferred tx option for NMIBC with variant histology?

Answer 28

Due to the high rate of upstaging associated with variant histology, a clinician should consider offering initial radical cystectomy

Question 29

What are the 5 FDA approved tumor markers?

Answer 29

``` NMP22 BTA Urovysion FISH Immunocyt Cxbladder ```

Question 30

What is the role of urinary biomarkers in NMIBC?

Answer 30

In surveillance of NMIBC, a clinician should not use urinary biomarkers in place of cystoscopic evaluation.

Question 31

What is the role of urinary biomarkers during surveillance for low risk NMIBC?

Answer 31

In a patient with a history of low-risk cancer and a normal cystoscopy, a clinician should not routinely use a urinary biomarker or cytology during surveillance.

Question 32

What is the indication for urinary biomarkers in NMIBC?

Answer 32

In a patient with NMIBC, a clinician may use biomarkers to assess response to intravesical BCG (UroVysion® FISH) and adjudicate equivocal cytology (UroVysion® FISH and ImmunoCyt™). (Expert Opinion)

Question 33

What should be done for a patient with NMIBC who underwent an incomplete initial resection?

Answer 33

Repeat TURBT if feasible.

Question 34

What is the next step for high risk, high grade, Ta tumors after resection?

Answer 34

Repeat TURBT in 6 weeks.

Question 35

What percentage of T1 tumors get upstaged?

Answer 35

30%

Question 36

What is the next step after resection of a T1 NMIBC?

Answer 36

Repeat TURBT in 6 weeks.

Question 37

What percentage of high grade Ta NMIBC get upstaged?

Answer 37

15%

Question 38

What percentage of high grade Ta NMIBC have residual tumor?

Answer 38

50%