LWBK1006-21 LWW-Govindan-Review December 12, 2011 19:6
Chapter 21•Genitourinary Cancer 291those observed in cystectomy series. The therapy is, however, an aggressive
and potentially toxic approach in which approximately 30% of patients
will require cystectomy for incomplete response. It is thus not more tol-
erable than cystectomy. The patient’s cardiac history does not preclude
major surgery, and in fact willingness to accept a cystectomy has been an
inclusion criterion for most organ preservation trials.Answer 21.15. The answer is A.
Randomized studies have demonstrated that cisplatin-based combination
chemotherapy provides a survival advantage. The largest phase III stud-
ies used methotrexate, vinblastine, doxorubicin, and cisplatin or a similar
regimen in which the doxorubicin was eliminated (MVC). The strongest
data supporting neoadjuvant chemotherapy are in the surgical setting,
with no survival advantage demonstrated in modest-sized trials using
combined chemotherapy and radiation for primary tumor treatment. The
randomized data further demonstrate that there is no increase in surgical
morbidity or complications after neoadjuvant chemotherapy. There are
no data on the neoadjuvant use of carboplatin-based regimens, and data
in the metastatic setting strongly suggest that carboplatin is an inferior
agent in comparison with cisplatin for this disease.Answer 21.16. The answer is D.
Chromosome 9 deletions are the most common alteration in urothelial
carcinoma of the bladder, appear to be critical for the initiation of blad-
der cancer, and occur on both the long and short arms. Alterations of
both p53 and pRb are most common in invasive disease and are mark-
ers of poor prognosis. Activating mutations of FGFR3 are common in
papillary noninvasive cancers but are actually unusual in more invasive
lesions.Answer 21.17. The answer is A.
The standard definitive treatment for renal pelvis urothelial cancers is rad-
ical nephroureterectomy with resection of the bladder cuff at the ureteral
insertion site. Radical nephrectomy without ureter resection is inappro-
priate because of the high incidence of undiagnosed or recurrent disease
in the ureter. Definitive radiotherapy would also be inappropriate because
this would be expected to lead to kidney necrosis.Answer 21.18. The answer is B.
The Prostate Cancer Prevention Trial randomized patients with normal
rectal examination and PSA less than 3.0 ng/dL to finasteride or placebo,
and required an end-of-treatment biopsy because of the decrease in PSA
observed with 5-reductase inhibitor therapy. It demonstrated an overall
decrease in the incidence of prostate cancer but an increase in the number
of high-risk prostate cancers. Single nucleotide polymorphisms on 8q24
have been identified as risk alleles for prostate cancer in multiple inde-
pendent studies. Although dietary studies have suggested that vitamin E
correlates with a decreased incidence of prostate cancer, early data from