These are hypothetical cases
67 yo M, former smoker with a 30 pack year history of smoking, presents with 2 weeks of gross hematuria and mild abdominal pain. No weight loss or bone pain.
His labs show mild anemia with Hb 11 gm. No elevation of alkaline phosphatase or creatinine. GFR 65. PET scan is negative for distant disease. There is one suspicious lymph node near the bladder 1.2 cm in size.
He undergoes cystoscopy which showed a T2 lesion invading the muscularis propria.
1. What is the standard of care treatment in patients with T2 bladder cancer?
Ans: Neoadjuvant cisplatin-based chemo followed by surgery.
2. What is the ideal chemo regimen?
Ans: Both DDMVAC and gem-cisplatin are recommended, but data suggest that in the NACT setting DDMVAC is superior in terms of path CR and PFS.
PFS 66% versus 56% 3 yr.
My comment on this trial: They used 6 cycles DDMVAC rather than 3 cycles as in NCCN.
They were compared head to head in the following trial:
3. What if the patient has residual disease at surgery?
The current SOC is surveillance. The risk of recurrence is high. Average DFS is 11 months.
Checkmate 274 showed DFS 21 months ( all comers) and median DFS not reached ( if PDL1> 1%) instead of 11 months in those who received nivolumab. This was irrespective of PDL1, but robust if PDL1> 1%.
Data is not mature for OS.
If a patient with a T1 lesion underwent a TURBT, which of the following is NOT true:
a. Gemcitabine and mitomycin are both category 1 recommendations for post TURBT intra vesical chemo
b. Intravesical chemo should be given within 24 hr, ideally 6 hr
c. Thiotepa is just as good as the first 2 agents
d. Intravesical chemo reduces recurrence by 35% in 5 yr, NNT=7
e. Bladder perforation and allergy are contraindications to post-op intravesical chemo
f. This is not effective in patients with > 1 recurrence per year and more than 8 tumors in the bladder
Who are the patients who can undergo bladder preservation?
Solitary tumors < 3cm, no tumor related hydronephrosis, no CIS, no nodes, good renal function.
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