Prognosis at Diagnosis of Urothelial Carcinoma
Neeraj Agarwal, MD: If we look at the prognosis of patients who have renal insufficiency, are not candidates for therapy with cisplatin, and have locally advanced or metastatic urothelial carcinoma, the median survival reported from past studies on patients treated with carboplatin-based chemotherapy has been around 10 to 12 months. In fact, it is inferior for those patients who are able to receive cisplatin-based chemotherapy.
Until now, we really were waiting for these patients to have disease progression after they had completed carboplatin-gemcitabine. They were essentially taking a treatment break, and then we were hoping for the best. Invariably, we see disease coming back in the form of localized recurrence or metastatic disease in most of these patients.
A multidisciplinary approach comes into play when these patients are presenting to us for the first time. For example, in this case where local regional lymphadenopathy is present, and this patient was deemed ineligible for radiation therapy or surgery, this is really a call by a multidisciplinary team. Surgeons, radiation oncologists, medical oncologists all have to chime in.
Of course, the patient’s wishes are paramount. Many patients do not want to have a cystectomy or may not want to have radiation therapy. Of course, those things are taken into account. But in collaboration with the patient, once we have determined that patient is not a candidate for definitive surgery or radiation, the option is systemic chemotherapy. Until now, systemic chemotherapy alone was the definitive answer for these patients. For example, start with cisplatin-based chemotherapy or carboplatin-based chemotherapy and then hope for the best.
Transcript edited for clarity.
Case Overview: A 73-Year-Old Male With Urothelial Carcinoma
Initial presentation
- A 73-year-old man presents with LUTS with intermittent hematuria
- PMH: HTN, well-controlled on an ARB; mild hepatic and renal impairment
- PE: distension of bladder; slow flow on voiding
Clinical workup
- Labs: Hb 11.4 g/dl, WBC 3.5 x 109/L, AST and ALT: ~4x ULN, CrCl: 35 mL/min; others WNL
- Cystoscopy: showed a 2.6 cm mass around the neck of the bladder
- TURBT was performed; transition cell carcinoma of the urothelium, with tumor invading the perivesical tissue
- Chest/abdomen/pelvic CT scan: large bladder mass, evidence of multiple regional lymph nodes involved (perivesical and sacral), and a 2.3 cm mass in the left upper lobe
- Stage IIIB; ECOG PS 1
Treatment
- Patient received 6 cycles of carboplatin + gemcitabine; achieved partial response
- CT abdomen/pelvis showed decrease size in bladder mass, nodal findings mildly improved, no evidence of new disease
- Initiated avelumab 10 mg/kg IV q2W as maintenance therapy
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