Question 1 of 5

(demo test)

Product Demo for Clinical

A 72 year old male presents to his primary care physician with hematuria. He is otherwise asymptomatic and his exam is within normal limits. A CT scan of the chest, abdomen and pelvis is ordered by his primary care physician, which demonstrates no evidence of disease. He is seen by urology and a urine cytology is non-diagnostic. An exam under anesthesia, cystoscopy, and transurethral resection of bladder tumor (TURBT) is performed. The procedure demonstrates a bladder tumor involving the posterior bladder wall and left trigone and pathology reveals a papillary urothelial carcinoma, high-grade, invading the lamina propria. However, detrusor muscle was not present in the specimen, and a repeat TURBT demonstrates urothelial carcinoma involving the detrussor muscle, consistent with clinical T2 disease. His work-up, including imaging of the upper urinary tract, is completed with no evidence of metastatic disease. His past medical history includes gastroesophageal reflux, hypertension, and diabetes mellitus type 2. He is a former smoker (~25 pack year history) and quit smoking 15 years ago. He does not drink alcohol and is a retired construction worker. His vitals are within normal limits and he has a very good performance status (ECOG 1). The patient is considered a good candidate for surgery, radiation, and chemotherapy. What treatment do you recommend for this patient?

A. Chemoradiation (5-FU and Mitomycin with external beam radiation therapy)

B. Cystoprostatectomy + pelvic lymph node dissection

C. Neoadjuvant cisplatin-based combination chemotherapy followed by cystoprostatectomy + pelvic lymph node dissection

D. Neoadjuvant cisplatin-based chemotherapy followed by external beam radiation therapy

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Category:

Non-prostate Genitourinary

Topic:

Bladder

High Yield:

No

Your Answer:

U

Correct Answer:

C

Explanation:

The patient presents with muscle-invasive urothelial cacinoma of the bladder and is a good surgical candidate. Therefore, the best management recommendation for this patient is neoadjuvant cisplatin-based chemotherapy followed by radical cystoprostatectomy with pelvic lymph node dissection.

For patients with muscle-invasive bladder cancer, the NCCN Guidelines recommend the following management options:

• Neoadjuvant cisplatin-based combination chemotherapy followed by radical cystectomy (Category 1)
• Neoadjuvant cisplatin-based combination chemotherapy followed by partial cystectomy in highly selected patients
• Transurethral resection of bladder tumor (TURBT) followed by bladder preservation with chemoradiation

While bladder preservation is an option, and the preferred option for non-surgical candidates, neoadjuvant chemotherapy followed by radical cystectomy remains the preferred treatment for those who are fit for surgery.

Based on meta-analyses and randomized trials, neoadjuvant cisplatin-based chemotherapy confers a 5% overall survival benefit compared to surgery alone. Regimens used for neoadjuvant or adjuvant chemotherapy include gemcitabine/cisplatin x 4 cycles (von der Maase et al., JCO 2005), dose-dense MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) x 3-4 cycles (Sternberg et al., JCO 2001), or CMV (cisplatin, methotrexate, vinblastine) x 3 cycles. Note that all regimens are cisplatin-based.

Clinical Pearl: The preferred treatment for patients with muscle invasive bladder cancer is neoadjuvant cisplatin-based cominbation therapy followed by radical cystectomy + pelvic node dissection. For non-surgical candidates, consider maximal transurethral resection of bladder tumor followed by chemoradiation.

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