We have detected that you are using an Ad Blocker. PracticeUpdate is free to end users but we rely on advertising to fund our site. Please consider supporting PracticeUpdate by whitelisting us in your ad blocker.
We have sent a message to the email address you have provided, . If this email is not correct, please update your settings with your correct address.
The email address you provided during registration, , does not appear to be valid. Please update your settings with a valid address before to continue using PracticeUpdate.
No comments yet, be the first to start the discussion!
In summary, this 70 year old patient had a pT3N0 upper tract urothelial carcinoma and underwent nephroureterectomy--> has metastatic recurrence 2 years later with a biopsy proven 1.6x1.8 cm retroperitoneal left periaortic node metastasis- and has a 2.6x1.4cm right inguinal lymph node (not biopsy proven). Overall, management would be guided by the patient's preferences given the absence of a single proven optimal approach. I would consider a 1) PET scan to assess for other sites of disease and 2) biopsy the inguinal node if this is suspicious for malignancy.
Assuming only 2-3 sites of nodal disease are seen after PET scan and given the long interval from initial diagnosis to metastasis: If the patient prefers an aggressive approach, my preference is initial cisplatin-based chemo for 4-6 cycles followed by SBRT - then followed by switch maintenance avelumab per JAVELIN Bladder-100 trial data (Powles T et al, NEJM 2020). I would consider an SBRT alone approach to target the nodes without systemic chemo if the patient is motivated to avoid systemic chemo. If there are other >3 sites of metastatic disease or a visceral organ involved, I would initiate cisplatin-based chemotherapy x 4-6 cycles followed by switch maintenance avelumab in accordance with JAVELIN-Bladder-100 data (although surveillance following cisplatin-based chemo may be reasonable if she attains a CR, since a proportion of patients with nodal disease only and CR is cured by cisplatin). Please see the following papers regarding metastasis directed therapy:
1. Sweeney P, et al. Is there a therapeutic role for post-chemotherapy retroperitoneal lymph node dissection in metastatic transitional cell carcinoma of the bladder? Urol 2003 Jun;169(6):2113-7.
2. Ogihara K, et al. Can urologists introduce the concept of "oligometastasis" for metastatic bladder cancer after total cystectomy? Oncotarget 2017 Dec 4;8(67):111819-111835.
3. Patel V, et al. Survival after Metastasectomy for Metastatic Urothelial Carcinoma: A Systematic Review and Meta-Analysis. Bladder Cancer 2017 Apr 27;3(2):121-132.
4. Faltas, B, et al. Metastasectomy in older adults with urothelial carcinoma: Population-based analysis of use and outcomes. Urol Oncol. 2018 Jan;36(1): 9.e11-9.e17.
5. Augugliaro M, et al. Recurrent oligometastatic transitional cell bladder carcinoma: is there room for radiotherapy? Neoplasma. 2019 Jan 15;66(1):160-165.
Pending Moderator approval.
Are you sure you want to delete this comment? This can't be undone.