An expert on urothelial carcinoma reviews the case of a 76-year-old patient with advanced, resectable urothelial carcinoma.
Case 2: A 76-Year Old Man with Locally Advanced, Resectable Urothelial Carcinoma
Initial Clinical Presentation:
Initial Clinical Workup:
Treatment and Disease Progression:
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 76-year-old male with metastatic urothelial carcinoma involving the bladder and multiple liver metastases. His kidney function was impaired with an estimated glomerular filtration rate (eGFR) of 45 mL/min, making him ineligible for cisplatin chemotherapy. Molecular testing was negative for FGFR alterations.
With metastatic disease and good performance status but cisplatin-ineligibility, combination immunotherapy was recommended over single agent chemotherapy. Dr. Tagawa noted that the combination of enfortumab vedotin (an antibody-drug conjugate targeting Nectin-4) plus pembrolizumab is given on a 3-week cycle, with enfortumab vedotin dosed on days 1 and 8 and pembrolizumab at 200 mg flat dose every 3 weeks.
This patient developed a maculopapular rash after starting therapy that improved with topical steroids. He achieved a partial response after 6 cycles but then had persistent grade 2 neuropathy requiring enfortumab vedotin discontinuation. Pembrolizumab was continued as maintenance, but he eventually had disease progression.
Next treatment was sacituzumab govitecan on day 1 and day 8 of a 21-day cycle, typically at 10 mg/kg. Dr. Tagawa again reviewed that key adverse events with this Trop-2 antibody-drug conjugate are neutropenia and diarrhea, requiring monitoring and potential dose modifications.
In conclusion, Dr. Tagawa walked through treatment decision-making in a cisplatin-ineligible patient with advanced urothelial carcinoma. The case highlighted evolving use of immunotherapy combinations and newer antibody-drug conjugates for patients progressing after first-line immunotherapy. Molecular profiling for biomarker-driven therapy eligibility should be incorporated at diagnosis and upon progression.
*Video synopsis is AI-generated and reviewed by Urology Times editorial staff.