Editing CUA: Muscle-invasive Bladder Cancer (2019) (section)

== Answers ==

# Based on the control arms of trials evaluating NAC in MIBC, what is the approximate pT0 rate in patients undergoing RC without NAC?
#* 15%
# What are the recommended chemotherapy regimen options for NAC?
#* 3 recommended chemotherapy options for NAC in MIBC:
### Gemcitabine-cisplatin
### MVAC
### ddMVAC (dose-dense MVAC)
# BONUS: describe SWOG 8710
#* SWOG 8710 randomized approximately 300 patients to MVAC vs. RC alone and found a 14% benefit in OS at 5-years, but did not reach statistical significance (p=0.06)
# What are the components of MVAC?
#* Methotrexate, vinblastine, Adriamycin, cisplatin
# What is the mechanism of action of gemcitabine? Cisplatin?
#* Gemcitabine: pyrimidine antagonist
#* Cisplatin: alkylating agent
# What toxicities are associated with cisplatin?
#* The main 4 toxicities (related to contraindications) associated with cisplatin and include:
### Nephrotoxicity
### Ototoxiciy
### Neurotoxicity
### Diminished cardiac
# What is the OS benefit of NAC?
#* 5% at 5 years
# What are the absolute contraindications to NAC? Relative?
#* 6 absolute contraindications to NAC in MIBC:
### eGFR < 50
### Heart failure (NYHA III or IV)
### ≥grade 2 neuropathy
### ≥grade 2 hearing impairment
### Untreated infection
### ECOG ≥2
#* 2 relative contraindications to NAC in MIBC:
### eGFR 50-60
### history of recurrent infection or concomitant immunosuppresion
# What is the preferred management of patients with contraindications to NAC?
#* Radical local therapy, carboplatin-based neoadjuvant chemotherapy should not be prescribe for clinically resectable stage cT2-T4aN0 bladder cancer
# A patient agrees to undergo NAC with GC. When will you see them next in follow-up?
#* After 2 of the 4 cycles with a CT scan to evaluate response to treatment
# When should a patient undergo radical cystectomy after receiving NAC?
#* CUA says within 4-6 weeks and before 10 weeks after completing NAC
#* AUA says within 6-8 weeks and before 4 months of completing NAC
# If a patient does not receive NAC, who should be referred for adjuvant chemotherapy?
#* pT3+ or N+ disease
# If a patient does not receive NAC, when should the cystectomy be done in relation to timing of the TURBT?
#* Within 6 weeks of TURBT
# What are the indications for a urethrectomy as per the CUA MIBC guidelines?
#* 4 indications for urethrectomy:
### Positive urethral margin
### Men with HG or invasive urothelial carcinoma distal to prostatic urethra
### Men with suspected prostatic urethral stromal involvement
### Women with bladder neck tumours
# As per the CUA MIBC guidelines, what patients are ideal for TMT?
#* Ideal patients for TMT have 5 characteristics:
### Small (<5cm) tumour
### No CIS
### No hydronephrosis
### Good baseline bladder function
### Patient motivated for bladder preservation
# What are the ideal characteristics to consider partial cystectomy in MIBC?
#* There are 6 characteristics considered ideal for partial cystectomy:
### Solitary tumour
### Small (<2cm) tumour
### Dome location
### No CIS
### No hydronephrosis
### Good bladder capacity
# As per the AUA MIBC guidelines, what are the absolute contraindications to a continent diversion?
## Insufficient bowel segment length
## Inadequate motor function or psychological issues that limit the ability to perform self-catheterization
## Inadequate renal or hepatic function that increases the risk metabolic abnormalities as a consequence of reabsorption of urine from continent diversions (e.g. an eGFR < 45)
## Cancer at the urethral margin (specifically for orthotopic neobladder)
## Significant urethral stricture disease that is not correctable
# What are the most common sites of metastasis?
#* Bone, liver, lungs
# As per the AUA MIBC guidelines, which laboratory investigations should be ordered during the follow-up of a patient treated for MIBC?
#* Electrolytes, Cr, and vitamin B12