Bladder Cancer Update & Renal Cell Cancer Update, 2017 (Video Program)Case discussion: A 52-year-old man who initially receives treatment for nonmuscle-invasive UBC presents 4 years later with metastatic disease
6:09 minutes.
TRANSCRIPTION:
DR GALSKY: This is a 52-year-old man who initially presented with nonmuscle-invasive bladder cancer. And, like nonmuscle-invasive bladder cancer is commonly treated, he received treatment with BCG. And after receiving treatment with BCG, he was monitored and ultimately developed abdominal pain a couple of years after his initial diagnosis and on imaging was found to have diffuse adenopathy. And he underwent a biopsy of those enlarged lymph nodes, ultimately revealing metastatic disease, metastatic urothelial cancer, not the most common scenario to present with, nonmuscle-invasive disease and really go directly to metastatic disease, but something that we do see from time to time. DR LOVE: And then did they go back in to look in his bladder? DR GALSKY: They did, and he did have evidence of disease in the bladder at that time. DR LOVE: Interesting. I was going to ask you before, what fraction of patients — I mean, I guess you couldn’t really — maybe you could say this, but present for the first time, at first diagnosis, with metastatic disease? And how do you manage them? DR GALSKY: So it’s about 5%, if you look at SEER data. And those patients are probably — have a little bit more aggressive disease in terms of its behavior. They’re probably overrepresented on clinical trials for a number of reasons. But when you look at the breakdown of patients who’ve had prior definitive treatment of their primary tumor on clinical trials, it’s usually not this 95% that you would expect based on SEER data. In fact, we see that probably about 20% to 30% of patients, depending on the trial, have not had definitive treatment to their primary tumor in the past. Those patients we really don’t treat differently in terms of the regimens that we use, but anecdotally it does seem to be a little bit more of an aggressive course. DR LOVE: How do you deal with the primary in that situation if it’s asymptomatic? Do you use systemic therapy? What do you do if they are having local symptoms? DR GALSKY: So if they’re not having local symptoms, certainly we tend not to do a whole lot about the tumor in the bladder. If they’re having local symptoms, primarily bleeding, then it depends how bothersome the bleeding is. Oftentimes a good transurethral resection of bladder tumor, TURBT, is sufficient to control bleeding without having to resort to something like radiation, which might interfere with or delay the initiation of systemic treatment. DR LOVE: Now, when you do use systemic therapy, whether it’s chemotherapy or immunotherapy, do you see responses in the primary? DR GALSKY: We do. We do. And if there are symptoms related to the primary, such as pain, but not something like intractable bleeding, then usually there’s a sufficient likelihood of response with these treatments that patients will experience some alleviation of those symptoms. DR LOVE: So before we go on to his management, maybe just to backtrack to when he got the BCG, anything new in terms of management of superficial bladder cancer? And I’m also curious about what your thought process is about the mechanism of action of BCG. DR GALSKY: So the mechanism of action is still a little bit unclear, although it almost certainly involves some nonspecific immune response related to the urothelium actually taking up the BCG itself. There is ongoing work in this area and a really nice paper from a group in France a couple of years ago now, which showed that a preexisting immune response to BCG enhanced the likelihood of responding to treatment. And so, of course, in other countries, patients are vaccinated. And looking at a cohort of patients who had received vaccination compared to those who didn’t — and subsequently all patients had developed nonmuscle-invasive disease and received BCG — the outcomes appeared to be better in patients who had a history of a tuberculin vaccine in the past. And so that’s really led to the design of an ongoing SWOG trial. And this trial randomizes patients to receive a subcutaneous BCG and then go on to receive intravesical treatment versus placebo. DR LOVE: Wow! That’s really fascinating. And how effective is BCG? DR GALSKY: BCG is actually a quite effective treatment for carcinoma in situ, with a likelihood of clearing the disease in the majority of patients and even demonstrating a survival benefit in some older studies. So it’s quite an effective treatment. Carcinoma in situ can be an aggressive disease and has the propensity to both recur and progress — that is, not only come back as carcinoma in situ, but come back and more deeply invade the bladder. And so these patients do require really lifelong surveillance, almost more intense surveillance in the initial BCG treatment period and years thereafter. But BCG does eliminate the disease in a large proportion of these patients. DR LOVE: So this patient was one of those who did develop progressive disease. Incidentally, being age 52, what’s the age distribution of invasive, muscle-invasive bladder cancer? DR GALSKY: So the median age of diagnosis is around 73 in the United States. And so certainly he is on the young side of that age distribution. DR LOVE: And what was his renal function? He had this extensive adenopathy, retroperitoneal adenopathy. Any renal obstruction or renal dysfunction? DR GALSKY: He didn’t have any renal dysfunction and really had intact kidney function. DR LOVE: And his disease was confined to the nodes? DR GALSKY: That’s right. And subsequently he was found to have an adrenal mass as well. |