Patient Profile 1: A 72-Year-Old With Metastatic Urothelial Carcinoma

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Scott T. Tagawa, MD, MS, FACP, FASCO, presents the case of 72-year-old patient with metastatic urothelial carcinoma and offers his initial impressions.

Case 1: A 72-Year-Old Man with Metastatic Urothelial Carcinoma

Initial Clinical Presentation: 

  • A 72-year-old man presented to the clinic with complaints of dizziness and hematuria.
  • PMH: Obesity (BMI) and poorly controlled type 2 diabetes (blood sugar, 200 mg/dL)
  • SH: Patient does not smoke and occasionally drinks, in social settings.

Initial Clinical Workup: 

  • CT of chest, abdomen, and pelvis revealed a 3.5-cm mass in the bladder and multiple liver metastases
  • ECOG PS 1
  • eGFR > 60 mL/min (cisplatin-eligible kidney function)
  • Biopsy/pathology confirmed stage IV metastatic urothelial carcinoma
  • Molecular testing: FGFR2/3 mutation and fusionnegative

Initial Treatment and Disease Progression:

  • Patient received platinum-based chemotherapy with cisplatin.
    • Experiences platinum-based peripheral neuropathy (paresthesia) that interrupted the patient’s quality of life.
      • Neuropathy was low grade AE (Grade 1)which improved to Grade 0 with supportive care.
    • Partial response after 4 cycles of cisplatin; ECOG PS 1
    • Imaging showed no growth of existing lesions or new lesions after 4 cycles ​
  • Followed with IO maintenance with avelumab 800 mg IV infusion over 60 minutes every two weeks.
    • Following 9 cycles, patient achieved partial response in the lung and bladder.
    • Liver function tests, CrCl, and other labs were within normal limits
    • No infusion reactions
    • 5 months later, disease progression is confirmed
  • Patient was initiated on sacituzumab govitecan 10 mg/kg on Days 1 and 28 for 21-day continuous treatment cycle.
    • Patient experiences grade 3 neutropenia at the time of schedule treatment.
    • Delay dosing by 2 weeks until recovery to less than grade 1. Managed with 25% dose reduction and administration of G-CSF.

This is a synopsis of a Case-Based Peer Perspectives series featuring Scott T. Tagawa, MD, MS, FACP, FASCO, of Weill Cornell Medicine.

Scott T. Tagawa, MD, MS, FACP, FASCO presented a case of a 72-year-old man with stage IV metastatic urothelial carcinoma involving the bladder and liver. The patient had a history of obesity and type 2 diabetes mellitus with a recent non-fasting blood glucose of 200 mg/dL. Molecular testing was negative for FGFR activating mutations or fusions.

Dr. Tagawa stated that for cisplatin-eligible patients with advanced urothelial carcinoma, cisplatin-based combination chemotherapy remains standard of care. This patient received cisplatin chemotherapy and achieved a partial response after 4 cycles with grade 1 neuropathy that resolved with supportive care. He completed a full course of cisplatin-based chemotherapy with maintained disease control. He was then switched to maintenance immunotherapy with pembrolizumab, a PD-1 inhibitor given every 2 weeks. He continued on therapy but had disease progression after 5 months.

Given the patient's baseline diabetes and history of grade 1 cisplatin-induced neuropathy, Dr. Tagawa discussed treatment options after disease progression on first-line platinum-based chemotherapy and pembrolizumab maintenance. The patient received enfortumab vedotin, an antibody-drug conjugate, at the standard dose of 10 mg/kg on days 1 and 8 of 21-day cycles. He experienced grade 3 neutropenia prior to cycle 2 day 1, leading to dose reduction and addition of granulocyte colony-stimulating factor (GCSF).

In summary, Dr. Tagawa emphasized that for eligible patients, first-line treatment remains cisplatin-based chemotherapy, most commonly gemcitabine + cisplatin, followed by maintenance pembrolizumab if disease control is achieved. After progression, options include enfortumab vedotin or pembrolizumab, depending on prior therapy. Supportive care interventions such as GCSF may be required to manage adverse events from chemotherapy. Research continues into additional therapies for advanced disease, including FGFR inhibitors and antibody-drug conjugates.

*Video synopsis is AI-generated and reviewed by Urology Times editorial staff.

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