Case Overview: A 75-Year-Old Woman with High-Risk Muscle Invasive Bladder Cancer

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Karim Chamie, MD: My name is Karim Chamie. I am an associate professor of urology here at UCLA [University of California, Los Angeles]. I am the director of our Society of Urologic Oncology Fellowship Program. Today, we will be talking about a case of a 75-year-old woman with high-risk muscle-invasive bladder cancer. This patient had gross painless hematuria back in August of 2020. She has diabetes and hypertension, which are both managed medically. She has a 10-year pack smoke history. Her performance status is 0 and she has no family history of bladder cancer in the family. Her GFR [Glomerular filtration rate] is 56 mL/minute. She has undergone a prior TURBT [Trans urethral resection of bladder tumor] which found muscle-invasive bladder cancer. The patient underwent imaging of the chest, abdomen, and pelvis, and she was found to have an external iliac lymph node that was 1cm in diameter. Additionally, she underwent an MRI of the bladder, and she was found to have an area that was concerning for extravesical fat involvement. Her clinical stage is T3N1M0. The patient then chose to undergo neoadjuvant chemotherapy. She received 4 cycles of gemcitabine and cisplatin, and then was referred for a radical cystectomy. The patient underwent a radical cystectomy and an ileal conduit urinary diversion. She undergoes postoperative imaging and evaluations with CT scans of the chest, abdomen, and pelvis, laboratory workup including a CBC [Complete blood count test], chem-20, urine cytology, and occasional vitamin B12 levels.

Patients with bladder cancer most often present with non-muscle-invasive disease. In fact, 70% of patients with bladder cancer present with non-muscle-invasive. Only about 25%-30% of patients have had disease that often makes them a candidate for either systemic chemotherapy, systemic immunotherapy, radiation therapy, or a cystectomy.

Follow-up of patients with muscle-invasive bladder cancer is often disease-stage-dependent. Patients with more advanced disease at the time of cystectomy require more frequent monitoring. Those who have complete response require less monitoring. Nevertheless, patients will still require imaging of the thorax, the abdomen/pelvis, laboratory workup, urine cytology as patients still have either urethra or ureter that's still intact and may harbor urothelial carcinoma in the future, as well as vitamin B12 levels that are checked annually.

Transcript edited for clarity.

Case: A 75-Year-Old Woman with High-Risk Muscle Invasive Bladder Cancer

Initial presentation

• A 75-year-old woman with gross painless hematuria in August 2020

Patient history

• Diabetes and hypertension, both of which are managed with medications
• Current smoker 10 pack/year
• ECOG PS 0
• No family history of bladder cancer

Clinical workup and imaging

• eGFR 56 mL/min
• Patient undergoes TURBT and is found to have muscle invasive bladder cancer (MIBC)
• Patient undergoes chest, abdominal and pelvic imaging and a 1 cm external iliac lymph node is identified
• Clinical stage T3N1M0 urothelial carcinoma

Treatment

• Patient undergoes neoadjuvant treatment with gemcitabine + cisplatin for 4 cycles, followed by radical cystectomy in Jan. 2021.
• Patient undergoes imaging and lab work to monitor for disease progression.