Patient Case: A 73-Year-Old Man With Metastatic Urothelial Carcinoma
Arlene Siefker-Radtke, MD, discusses the nuanced treatment journey of a 73-year-old man with metastatic bladder cancer, highlighting the challenges and evolving strategies in his case.
Transcript:
Arlene O. Siefker-Radtke, MD: It’s a pleasure discussing with you today a case of metastatic bladder cancer and how we should approach the nuanced treatment strategies for these patients. I’m Arlene Siefker-Radtke, a professor of genitourinary medical oncology at the University of Texas MD Anderson Cancer Center, where I [treat] all bladder cancer all the time. The case we’re discussing today is one that you might see quite frequently in your own personal clinics. This is a 73-year-old man who was referred to you from his urologist after he presented with episodic gross hematuria. He was having so much bleeding, he’d sometimes feel a little bit lightheaded or dizzy with it. He has a past medical history of high blood pressure and unfortunately, also has type 2 diabetes that’s poorly controlled, making it quite challenging in this patient’s care. He’s a former smoker but quit a few years back, and he consumes alcohol socially approximately 2 to 3 times per week.
When he had his imaging with his urologist, a CT scan of the abdomen and pelvis…found…a 3.7-cm mass along the right lateral wall of the bladder in addition to lymph node involvement and, unfortunately, liver metastases. He’s already had a cystoscopy with transurethral resection and on pathology, he does have evidence of a high-grade urothelial carcinoma with a clinical situation very consistent with metastatic disease. He has an excellent performance status with an ECOG performance status of 1, and his creatinine clearance is 65 ml per minute. As a result of this excellent creatinine clearance, he embarked on chemotherapy with you with gemcitabine cisplatin, the current standard of care for cisplatin-eligible patients. And good news for him, he had a partial response to treatment at the completion of chemotherapy.
Due to his response, we’ve already had a discussion with him about maintenance avelumab, but due to the frequency of visits and the impact on his lifestyle, he declined the indicated immunotherapy in the maintenance setting. So he’s now coming to your clinic for restaging scans approximately 7 months after his initial response to chemotherapy and unfortunately has evidence of progressive disease with increasing liver metastases in addition to progressive lymph nodes, increasing mass on his bladder, and his hematuria is starting to come back as well. So at that point in time, you said, well, the…second-line treatment for urothelial cancer patients who haven’t had prior immunotherapy is pembrolizumab. And there’s level 1 evidence supporting pembrolizumab compared to single-agent taxane with objective response rates from around 20% and a median overall survival of around 10 months. He was started on the pembrolizumab.
He had a partial response, which is really good news for him since those with liver metastases often don’t respond as well to an immune checkpoint inhibitor. And he completed 6 cycles of treatment during that ensuing period. You also did mutation testing and there was no FGFR3 alteration or fusion present. So we now have a gentleman who has [metastatic] urothelial carcinoma…[had] relatively short duration of response to frontline chemotherapy, had some response to an immune checkpoint inhibitor that lasted for a period of about 6 cycles, but now isn’t quite doing as well. We have a sense there’s more hematuria starting to come back again and [he] may have progressive disease.
Transcript is AI-generated and edited for clarity and readability.
Case: A 73-Year-Old Man with Metastatic Urothelial Carcinoma
Initial Clinical Presentation:
- A 73-year-old man presented to you from their local urologist with dizziness and hematuria
- PMH: hypertension and diabetes (uncontrolled)
- SH: former smoker; consumes alcohol 2-3 times per week
- Chest x-ray and CT revealed a 3.7-cm mass on the right lateral wall of the bladder and liver metastases
- Cystoscopic biopsy/pathology confirmed stage IV urothelial carcinoma
- ECOG PS 1
- CrCl 65 mL/min
- The patient received gemcitabine + cisplatin (6 cycles)
- Partial response at completion of chemotherapy
- No maintenance therapy given, although discussed with patient
Current Clinical Presentation:
- 7 months later, disease progression was discovered on routine follow up imaging
Treatment:
- The patient received pembrolizumab and a partial response was achieved at 6 cycles
- Molecular testing showed no FGFR2 mutation or fusion
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