Bladder

Question 1

pathophysiology -3

Answer 1

transitional cell carcinoma TCC 90-95%

Question 2

T stage -4

Answer 2

superficial (Tis, Ta, T1) (70-80% of pts)
carcinoma in-situ (if untreated 60-70% will progress), ->NEED TO TX
papillary

muscle invasive (T2-T4) (20-30% of pts) (high-grade)

Question 3

superficial (Tis, Ta, or T1) primary tx -5

WHAT IS TOC?

Answer 3

SURGERY + ADJUVANT

TURBT (transurethral endoscopic resection)

adjuvant intravesicular BCG x 6wks
—10 yr PFS 62 vs 37%

can do observation and just one dose of BCG without surgery for Ta dz (NOT COMMON)

BCG better than doxo

Question 4

superficial (Tis, Ta, or T1) primary tx - BCG failure OR can not receive BCG -3

Answer 4

mitomycin (NCCN cat 1, first line)

BCG +interferon

valrubicin (anthracycline derivative)

Question 5

BCG ADR - important to manage sx to give entire course (3pts)

Answer 5

flu: (phenazopyridine, APAP, NSAIDs)

#cystitis and infx: 
urine and b cx to r/o infx. 
usually higher and prolonged fever than in flu-like sx

(1-34%) usually self limiting,
HOLD BCG until resolves,
usually 2nd, 3rd, or 4th dose

Question 6

muscle invasive (T2 to T4a) primary tx -4

WHAT IS TOC?

Answer 6

NEOADJ + SURGERY IS TOC

organ confined -> radical cystectomy unless contraindx, THEN CAN GIVE XRT.

can also use combined chemoXRT surgery to preserve bladder in select cases

neoadj x 3 cycles: CMV or M-VAC

adj chemo NO OS ADVANTAGE, some MD’s may give for T3 disease

Question 7

muscle invasive (T2 to T4a) primary tx -neoadj CMV

Answer 7

cisplatin, methotrexate, vinblastine x3 cycles

10 yr OS: 36 vs 30%

Question 8

muscle invasive (T2 to T4a) primary tx -neoadj M-VAC

Answer 8

MTX, vinblastine, doxorubicin, cisplatin x3 cycles

median OS 77 vs 46 mo (p=0.06)

Question 9

muscle invasive (T2 to T4a) primary tx -neoadj concepts

Answer 9

3 cycles appear beneficial

need combo tx (no benefit from single agent cis)

Question 10

muscle invasive (T2 to T4a) primary tx -adj concepts

Answer 10

NO OS advantage

for T3 or above 3 cycles may be used to delay recurrence (especially if neoadj not given)

Question 11

stage IV primary tx -5

WHAT IS SOC?

Answer 11

M-VAC used historically but toxic

cis-gem is TOC: OS pretty close (13.8 vs 14.8mo), much less tox.

carbo-gem (only other phase III trial) (give if can not have cisplatin in M-VAC or cis-gem)

pac-carbo

pac-gem (give if can not use platinum at all)

Question 12

M-VAC ADR -3

Answer 12

sepsis 12%

grade III-IV mucositis 22%

BOTH MUCH HIGHER THAN CIS-GEM

Question 13

stage IV M-VAC principle

Answer 13

if use instead of cis-gem give in dose dense manner (inc PFS with same tox) NCCN req- LOOK UP