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Self-Assessment Questions

Oncology

Bladder Cancer: Review Questions

Guilherme Rabinowits, MD, and Damian A. Laber, MD

Dr. Rabinowits is a fellow in hematology and medical oncology, University of Louisville, J.G. Brown Cancer Center, Louisville, KY. Dr. Laber is an associate professor of medicine and director of the Hematology and Medical Oncology Fellowship Program, Division of Hematology and Medical Oncology, University of Louisville, and director of the Genitourinary Cancer Clinical Research Program, J.G. Brown Cancer Center, Louisville, KY.


Choose the single best answer for each question.

1. All of the following regarding the epidemiology of bladder cancer in the United States are true EXCEPT
  1. Bladder cancer is the most common malignancy affecting the urinary tract
  2. Non-Hispanic whites are at highest risk
  3. Smoking is the most important risk factor
  4. There is no gender preference
  5. Transitional cell carcinoma (TCC) is the most common type
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2. A 60-year-old man with newly diagnosed high-grade superficial TCC of the bladder presents for a second opinion. One week ago, the patient underwent transurethral resection of the bladder tumor (TURBT) with multiple random biopsies, which revealed superficial TCC associated with several areas of carcinoma in situ, invasion into lamina propia but not into the muscle, and vascular invasion. He was told by another physician that his only option is a radical cystectomy. He would like to preserve his bladder but is worried about the possible spread of the cancer. What should be recommended to this patient?

  1. Combined chemoradiotherapy
  2. Radical cystectomy
  3. Repeat TURBT and close surveillance
  4. Repeat TURBT followed by intravesical bacillus Calmette-Guérin (bCG) therapy
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3. A 75-year-old man presents to his oncologist 2 weeks after undergoing a cystoscopy and TURBT. Pathology revealed a muscle-invasive TCC. The patient has diabetes mellitus and hypertension, which have been well controlled with diet and lisinopril, respectively. He does not take any other medications. Physical examination is unremarkable. An echocardiogram performed 6 months ago revealed an ejection fraction of 65% and no significant wall motion or valve abnormalities. Computed tomography (CT) of the chest, abdomen, and pelvis revealed no evidence of metastatic disease. What is the next step in this patient’s management?

  1. Chemotherapy with gemcitabine and cisplatin (GC) alone
  2. Neoadjuvant chemotherapy with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC), followed by radical cystoprostatectomy and lymphadenectomy
  3. Radiotherapy to the bladder and pelvic lymph nodes
  4. Radical cystoprostatectomy and lymphadenectomy
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4. A 61-year-old woman presents to the emergency department with a 3-day history of abdominal pain. The patient has no significant past medical history and takes no medications. She appears ill and is in acute distress. The patient is tachycardic with a normal temperature and blood pressure. The abdomen is mildly distended, with normal bowel sounds and a palpable mass in the suprapubic region that is tender to palpation. The remainder of the physical examination is unremarkable. CT scan of the abdomen and pelvis reveals an abnormal bladder with a large area of enhancement, wall thickening, and cystic changes; a small amount of fluid seen anterior to the bladder; and pathologically enlarged lymph nodes in the inguinal region bilaterally. The patient undergoes abdominal surgery, which reveals a 12-cm necrotic mass involving the bladder, uterus, fallopian tubes, ovaries, and vagina, which extends to the anterior pelvic wall. The surgeon describes spillage of tumor cells into the abdominal/pelvic cavity. Pathologic testing reveals a high-grade TCC with lymphovascular and perineural invasion with extension into the other organs. Two lymph nodes were resected and are found to be free of metastatic carcinoma. Four weeks later, the patient presents to discuss further therapy. Other than experiencing some abdominal discomfort, she has been doing well. CT scan of the chest, abdomen, and pelvis reveal no evidence of metastatic disease. What is the next step in the management of this patient?
  1. Adjuvant chemotherapy
  2. Close follow-up without further therapy
  3. Concurrent chemoradiotherapy
  4. Positron emission tomography (PET) scan to rule out metastatic disease
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5. A 49-year-old man presents with intermittent suprapubic pain and hematuria of 2 weeks’ duration. Past medical history includes hepatitis C, cocaine use, and gonorrhea treated 10 years ago. He takes no medications. Physical examination is unremarkable except for suprapubic tenderness to palpation. A complete blood count and comprehensive metabolic profile are normal. Urinalysis reveals 10 to 12 red blood cells and no leukocytes. Cystoscopy shows a large heterogeneous mass in the left posterior portion of the bladder. Biopsy of the mass reveals a poorly differentiated small cell carcinoma infiltrating into the muscle, and 1 random biopsy demonstrates TCC with no invasion into the lamina propria. CT of the chest, abdomen, and pelvis shows a fungating mass in the bladder with involvement into the extravesical fat and multiple pathologically enlarged lymph nodes scattered throughout the pelvis but no evidence of distant metastatic disease. What is the next step in the management of this patient?

  1. Chemotherapy with cisplatin and etoposide
  2. Chemotherapy with MVAC
  3. PET scan
  4. Radical cystoprostatectomy with lymph node dissection
  5. Radiotherapy
Click here to compare your answer.


 

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