Bladder Cancer Treatment Overview

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Questions and Answers

What is the peak age for bladder cancer incidence?

6th decade

5th decade

4th decade

7th decade (correct)

Which environmental factor is known to increase the risk of bladder cancer?

Living in a high-altitude area

Exposure to carbon monoxide

Occupational exposure to aniline dyes (correct)

Exposure to ultraviolet light

What is the most prevalent symptom of bladder cancer experienced by 75% to 80% of patients?

Gross painless hematuria (correct)

Frequent urination

Burning sensation during urination

Lower back pain

Which prognostic indicator suggests a favorable prognosis for bladder cancer?

Well-differentiated tumors Signup and view all the answers

In terms of incidence, which demographic is more likely to develop bladder cancer?

Men Signup and view all the answers

What can be a clinical presentation of bladder cancer indicating carcinoma in situ?

Frequency and dysuria Signup and view all the answers

What has been identified as a significant risk factor for bladder cancer compared to non-smokers?

Smoking habits Signup and view all the answers

Which type of tumor morphology in bladder cancer has a worse prognosis?

Infiltrating tumors Signup and view all the answers

What is the recommended treatment for carcinoma in situ?

Radical cystectomy Signup and view all the answers

Which factors influence the choice of bladder cancer treatment?

Size and multiplicity of tumors Signup and view all the answers

For T1, grade 2/3 lesions, what is the suggested treatment?

Intravesical immunotherapy chemotherapy Signup and view all the answers

Which of the following is NOT an indication for partial cystectomy?

Tumors involving the prostatic urethra Signup and view all the answers

What is the typical recurrence rate after partial cystectomy?

50% to 70% Signup and view all the answers

Which treatment is most appropriate for diffuse grade 3, T1 disease?

Radical cystectomy Signup and view all the answers

In cases of muscle-invasive disease, which treatment approach is usually not applicable?

Transurethral resection Signup and view all the answers

Which of the following options describes a characteristic of lesions suitable for electrofulguration?

Well delineated lesions Signup and view all the answers

What is the purpose of a urostomy?

To collect urine through a bag outside the body Signup and view all the answers

Which type of surgery is involved in bladder cancer treatment?

Transurethral surgery Signup and view all the answers

What is the primary function of a neobladder surgical procedure?

To use a bowel section for storing urine Signup and view all the answers

What distinguishes intravesical chemotherapy from systemic chemotherapy?

Intravesical chemotherapy is delivered directly into the bladder Signup and view all the answers

Which statement is true about photodynamic therapy (PDT) for bladder cancer?

It combines light energy with a medicine to destroy cancer cells Signup and view all the answers

What challenge was faced by photodynamic therapy in clinical use?

Morbidity affecting muscle layers leading to incontinence Signup and view all the answers

What is the role of a photosensitizer in photodynamic therapy?

To convert light into cytotoxic radical oxygen species Signup and view all the answers

Which surgical procedure involves the complete removal of the bladder?

Cystectomy Signup and view all the answers

What is the inferior border for the 4-fields pelvic technique?

1 cm inferiorly to the caudal border of the obturator foramen Signup and view all the answers

What is a common indication for radical cystectomy?

Recurrences after transurethral resection increase in frequency Signup and view all the answers

Which lymph nodes should be included in the pelvic field for treatment planning?

Perivesical, obturator, external iliac, and internal iliac lymph nodes Signup and view all the answers

What is the primary reason for administering full-dose external beam radiation?

To ensure patients have a tumor-free bladder after treatment Signup and view all the answers

What is the boost volume dose when using radiation alone?

65 Gy or 70 Gy Signup and view all the answers

What is the purpose of concurrent chemotherapy when paired with irradiation?

To sensitize the local tumor and minimize metastasis Signup and view all the answers

What is the prescribed dose range for the larger pelvic field?

45 to 50 Gy at 180 cGy/day Signup and view all the answers

Which treatment approach is used for T2 to T3 muscle-invasive tumors?

Bladder sparing with chemotherapy and irradiation Signup and view all the answers

What is the recommended position for simulation during the boost target volume treatment?

Supine position Signup and view all the answers

What is a contraindication for bladder sparing with chemotherapy plus irradiation?

Poor renal function Signup and view all the answers

What acute reaction can occur due to radiation treatment of the bladder?

Frequency and urgency from radiation cystitis Signup and view all the answers

What is the recommended cystoscopy schedule after radiation treatment?

Every 3 months for 2 years, then every 6 months Signup and view all the answers

What technique is recommended for inserting a Foley catheter during simulation?

Sterile technique Signup and view all the answers

What total radiation dose is typically used for bladder sparing therapy with a boost to the bladder?

40 to 45 Gy, with a boost to a total of 65 Gy Signup and view all the answers

What is the purpose of the iodinated contrast material used during simulation?

To outline the posterior portion of the bladder Signup and view all the answers

Which anatomical areas are targeted in the initial radiation therapy volume?

The bladder, prostate, prostatic urethra, and pelvic lymph nodes Signup and view all the answers

Study Notes

Bladder: Treatment

Treatment of bladder cancer depends on the stage, histology, size, and multiplicity of tumors, age, and general medical condition of the patient.
For carcinoma in situ, radical cystectomy is curative.
For lesions less than 5 cm, well-defined, and without involvement of the bladder neck, prostatic urethra, or ureters, electrofulguration followed by intravesical chemotherapy or Bacillus Calmette-Guérin (BCG) is a standard treatment.
Transurethral resection and fulguration are performed for Ta and T1 lesions.
Cystectomy is selected for diffuse grade 3, T1 disease, or involvement of the prostatic urethra/ducts.
For T1, grade 2/3 lesions, intravesical immunotherapy chemotherapy is administered after transurethral resection.
Most physicians withhold intravesical treatment for patients with T1, grade 1 tumors.
For muscle-invasive disease, definitive treatment with transurethral resection is not applicable in most cases.
Failure to eradicate high-grade disease, progression to muscle invasion, or involvement of the prostatic urethra or prostatic periurethral ducts usually indicates the need for radical cystectomy.
Partial cystectomy is indicated for small, solitary, well-defined lesions with muscle invasion or superficial disease, lesions unsuitable for transurethral resection, and lesions located in the bladder dome, right or left bladder wall, well removed from the ureteral orifices and trigone area.
Recurrence rates after partial cystectomy can range from 50–70%.

Bladder: Radical Cystectomy

Radical cystectomy is indicated when conservative management fails, there are recurrences after transurethral resection and/or intravesical chemotherapy, the tumor progresses to muscle invasion, local tumor persists after 3 months of resection, recurrent tumors substantially decrease bladder capacity after repeated transurethral resections and intravesical chemotherapy, and for stage T2, T3, and resectable T4a disease.
Preoperative radiation may be used for stage T3 and T4a disease when resectability is questionable.

Bladder: Full-Dose External Beam Radiation With Surgery Reserved for Salvage

Radical radiation is indicated for adequate bladder capacity without substantial voiding symptoms or incontinence.
Approximately 40% of patients have a tumor-free bladder after radiation alone with doses of 65 to 70 Gy.
Following radiation, cystoscopy is recommended every 3 months for 2 years and every 6 months afterward.
Persistent or recurrent lesions, especially low-grade tumors, can be downstaged with endoscopic resection after radiation therapy.

Bladder: Bladder Sparing With Chemotherapy Plus Irradiation

Radiation alone has high rates of local recurrence and distant metastasis.
Concomitant chemotherapy sensitizes the local tumor and metastases.
A tri-modality approach includes maximal transurethral resection, chemotherapy, and radiation for T2 to T3 muscle-invasive tumors.
Contraindications to bladder-sparing treatment include poor renal function and irritable bladder.
Doses of 40 to 45 Gy are used for the larger pelvic field, which includes pelvic lymph nodes.
A boost is used for the involved area of the bladder, resulting in a total dose of 65 Gy.
Cystoscopy with biopsy and cytology are performed after 40 to 45 Gy.
Cystectomy is performed if residual tumor is documented.

Bladder: Radiation Therapy: Initial Target Volume

The target volume includes the entire bladder, prostatic urethra, prostate, and pelvic lymph nodes.
A 4-field technique (AP/PA, laterals) is commonly utilized for the pelvis.
The inferior border is 1 cm inferior to the caudal border of the obturator foramen.
The superior border is below the sacral promontory or below the S1-L5 disc interspace on the AP projection.
The perivesical, obturator, external iliac, and internal iliac lymph nodes are included.
The field width extends 1.5 cm laterally to the bony margin of the pelvis at its widest point.
The field size is typically 12 x 12 cm, encompassing an empty bladder.

Bladder: Radiation Therapy: Lateral Fields Borders

The anterior border is 1 cm anterior to the most anterior portion of the bladder mucosa seen on an air contrast cystogram/CT scan or 1 cm anterior to the anterior tip of the symphysis, whichever is more anterior.
The posterior border is 2 cm posterior to the most posterior portion of the bladder or 2 cm posterior to the tumor mass if visible on a pelvic CT scan.
Lateral fields are shaped using multi-leaf collimators (MLCs) inferiorly to shield tissues outside the symphysis anteriorly and block the entire anal canal and as much of the posterior rectal wall as possible.
CT scan planning is essential.
The energy used for radiation therapy is typically 10 to 20 MV.

Bladder: Radiation Therapy: Boost Target Volume

The patient is positioned supine for simulation.
A Foley catheter is inserted using sterile technique.
150 to 250 ml of iodinated contrast material (20% concentration) is instilled to outline the posterior portion of the bladder.
100 to 150 ml of air is instilled for visualization of the anterior wall of the bladder on lateral (cross-table) radiographs.
CT scan planning is critical.

Bladder: Radiation Therapy: Doses

The larger pelvic field (bladder and pelvic lymph nodes) receives 45 to 50 Gy at 180 cGy/day for 5 to 5½ weeks.
The nodal dose with chemotherapy is 45 Gy.
The boost volume receives 65 Gy, or 70 Gy, if radiation alone is used.

Bladder: Radiation Therapy: Acute Reactions

Frequency and urgency, resulting from radiation cystitis, are common during and after the treatment course.
These symptoms are usually not serious unless bacterial infection occurs.
Painful spasms may require antispasmodic drugs.
Patients are strongly encouraged to maintain adequate fluid intake.
Patients should be informed that they may pass fragments in the urine, such as blood clots and tumor, along with some fresh blood.

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Description

This quiz covers various treatment options for bladder cancer, including the significance of tumor stage, size, and histology. Learn about different therapy methods like radical cystectomy, electrofulguration, and intravesical chemotherapy. Review the standard practices and recommendations for managing bladder cancer effectively.