Bladder Cancer - Episode 17

Case 4: MUC With Non-Muscle Invasive Recurrence

November 27, 2019


Arlene O. Siefker-Radtke, MD:For our last case I’m pleased to have Betsy Plimack present a patient with metastatic urothelial cancer that unfortunately has recurred.

Elizabeth R. Plimack, MD:This is a case of a 78-year-old man with some comorbidities. He had CHF [congestive heart failure] and chronic kidney disease, and he presented with a left upper tract urothelial carcinoma of the renal pelvis. This was resected surgically and he was set on a surveillance protocol. He had imaging per guidelines, but unfortunately 3 years later, now age 81, he developed metastatic disease to the lung, and this was biopsy-proven. At the same time, he had a concurrent non-muscle invasive recurrence in the bladder. His creatinine was 2.7 mg/dL and his Eastern Cooperative Oncology Group performance status was 1. He was felt to be cisplatin ineligible, and this was before the FDA label restriction, he was initiated on pembrolizumab.

He had an initial response to pembrolizumab that was durable, but after 2-1/2 years, he had progression with new lung lesions. At this time, he was initiated on enfortumab vedotin, also on a clinical trial. And we noticed an initial immediate response in his target lesions in the lung. However, in the 6th to 7th month he started mentioning neuropathy, and by the 8th month it was clear to us in the clinic that this neuropathy had become debilitating, and so we held the drug.

His neuropathy unfortunately did not improve, and he was then on a treatment break. And after 6 months of treatment breaks, his imaging did show progression in the lung.

So the question is what to do at this juncture. I will add that a fresh biopsy forFGFRstatus was felt to be too high-risk due to the location and small size of his lung metastases. He did have non-muscle disease in the bladder, which was potentially accessible, but his primary upper tract tumor was quite remote at this point, now 4 years.

Transcript edited for clarity.