pre-sacral lymph nodes for bladder cancer

[lazers]

Would you cover these for T3 disease? What about T4 disease?

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[deleted4401]

Eh ... RTOG protocols don't specifically mention it (block edge 2.5cm posterior to bladder), and I haven't been doing it (had a few cases recently). But, if it was T4 because of involvement of the rectum, I'm sure you could make the argument to do it. But, for post-op, recent article in Red Journal (http://www.redjournal.org/article/S0360-3016(12)00458-0/abstract) says for T3 or T4 for positive margin, you should consider it in the adjuvant setting. If in the adjuvant setting, I wonder why not in the definitive setting.

I was surprised at the few cases I had - very limited toxicity with carbo/taxol. Another one coming up soon.

 

[seper]

with weekly carbo/taxol, I'd worry about efficacy MedOncs use to for freaking everything.

 

[medgator]

I was surprised at the few cases I had - very limited toxicity with carbo/taxol. Another one coming up soon.

Because that's an easy regimen to give. There isn't a ton of data for concurrent regimens to use in bladder from what I've seen but I'd wager that 5-FU or cis has more data than carbo/taxol (and probably more toxicity too)

with weekly carbo/taxol, I'd worry about efficacy MedOncs use to for freaking everything.

yep. It's amazing how much carbo has supplanted cis in multiple sites, despite the evidence for doing so.

 

[deleted4401]

Good point! It is easier to tolerate than 5FU/Mitomycin or Cis.

Thing is, here, we don't necessarily get the medically operable people wanting bladder preservation a la Harvard with the cystoscopy/cytology/bx at 4 weeks with cystectomy salvage if positive. It's mostly people in not-so-hot medical condition who can't get surgery, and less often, people that outright refuse cystectomy. So, that's why I think our medoncs don't give cis. I don't know. Carbo/Taxol although considered chemo light, seems to be fine. It's a SOC for lung and esophagus, and used as an alternative for head and neck and cervical in cisplatin-shortage areas. No one seems to be wanting to do the comparative effectiveness trials for it.

 

[Palex80]

Good point! It is easier to tolerate than 5FU/Mitomycin or Cis.

Thing is, here, we don't necessarily get the medically operable people wanting bladder preservation a la Harvard with the cystoscopy/cytology/bx at 4 weeks with cystectomy salvage if positive. It's mostly people in not-so-hot medical condition who can't get surgery, and less often, people that outright refuse cystectomy. So, that's why I think our medoncs don't give cis. I don't know. Carbo/Taxol although considered chemo light, seems to be fine. It's a SOC for lung and esophagus, and used as an alternative for head and neck and cervical in cisplatin-shortage areas. No one seems to be wanting to do the comparative effectiveness trials for it.

Carbo/Taxol should be abolished as SOC for RCT in NSCLC in my opinion. It's been shown, that this combination is an independent risk factor for pneumonitis.
http://www.ncbi.nlm.nih.gov/pubmed/22682812

 

[seper]

carbo/taxol is not SOC for neither lung nor esophagus

 

[medgator]

carbo/taxol is not SOC for neither lung nor esophagus

Wouldn't go that far. It's "a" SOC. Probably not the most efficacious one though. Carbo/taxol was good enough for RTOG 0617 as well as the recently published CROSS study on esophageal/GE junction cancer. NCCN also recognizes it as a SOC for both disease sites (Cat 1 for esophagus).

 

[Gfunk6]

Wouldn't go that far. It's "a" SOC. Probably not the most efficacious one though. Carbo/taxol was good enough for RTOG 0617 as well as the recently published CROSS study on esophageal/GE junction cancer. NCCN also recognizes it as a SOC for both disease sites (Cat 1 for esophagus).

Per NCCN, CDDP/Etoposide or CDDP/Vinblastine are preferred. Carbo/Taxol is only a category 2B recommendation.

For esophagus, NCCN has a bunch of chemo regimens listed but only CDDP/5FU is category 1. Once again, Carbo/Taxol is 2B.

 

[medgator]

Per NCCN, CDDP/Etoposide or CDDP/Vinblastine are preferred. Carbo/Taxol is only a category 2B recommendation.

For esophagus, NCCN has a bunch of chemo regimens listed but only CDDP/5FU is category 1. Once again, Carbo/Taxol is 2B.

Depends on if we are talking about neoadjuvant (pre-op) vs Definitive.

If you check the "Principles of systemic therapy" section of GE/esophagus, you'll see that carbo/taxol is a cat 1 recommendation under preoperative regimens but 2B in the definitive setting. My guess is they are using the recently reported CROSS group study to support the pre-op rec (even though carbo/taxol wasn't the study question there. Going to 41.4 with carbo/taxol yielded a pCR rate of 29% in that study. Contrast this to lung where the RTOG/Intergroup study used cis/etoposide pre-op to get their results.

Bottom line, I personally think cis is the way to go in fit patients whether it's lung or esophagus but carbo/taxol is a generally accepted SOC in the US. But this is an exercise in SDN forum posting as we all know none of us typically make these decisions

 

[Pewl]

ng where the RTOG/Intergroup study used cis/etoposide pre-op to get their results.

Bottom line, I personally think cis is the way to go in fit patients whether it's lung or esophagus but carbo/taxol is a generally accepted SOC in the US. But this is an exercise in SDN forum posting as we all know none of us typically make these decisions

I think for head and neck right now cisplatin is still the way to go, if the patient can tolerate it. Nancy Lee is publishing a paper soon with cetuximab, which will be interesting since she traditionally dislikes that agent haha.

 

[deleted4401]

Category 2B is a standard of care, i.e. an acceptable variation.
I love these blanket statements. I was careful not to say "the" standard of care.