Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How would you approach adjuvant therapy for a finding of carcinosarcoma in a prostatectomy specimen?
Pure "carcinosarcoma" a biphasic neoplasm with both epithelial adenocarcinoma with second component which is a clearly recognizable type of sarcoma is of course extremely rare, thus my comments must be considered in the data free zone from which they eminate. Both local recurrence and systemic failu...
What is your preferred second-line agent for treatment of metastatic urothelial carcinoma?
Great question, currently only atezolizumab and nivolumab are FDA-approved in this setting. Overall, there are several parameters to take into account (by the way, I suggest a recent review on ASCO "value-based care", which is creating a framework and parameters for the evaluation of cancer drugs ut...
How do you approach non-metastatic castration-resistant prostate cancer?
The two recent placebo controlled trials comparing apalutamide and enzalutamide in M0CRPC (SPARTAN and PROSPER) have shown sizeable and consistent effects on various outcome measures, clearly met the primary study endpoints and hence satisfied FDA regulatory criteria for drug approval in this space....
How do you approach isolated recurrence in a para-aortic lymph node following definitive radiation for localized prostate cancer?
This is a challenging situation with no data to guide therapy; it is not unreasonable to pursue novel PET imaging (PSMA on trial, fluciclovine) to ensure there is no evidence of other sites of metastatic disease. The treatment of oligometastatic disease continues to evolve. In this situation, I woul...
Is a fluciclovine (Axumin) PET scan an adequate imaging modality for prostate cancer re-staging after a biochemical failure?
Fluciclovine (Axumin) [FACBC] PET scan was FDA approved in May 2016 for recurrent prostate cancer – FDA approval was based on high accuracy of PET uptake when correlating with biopsy. As with any diagnostic imaging test, Axumin has higher diagnostic yield with increasing PSA. While Axumin can assist...
Would you consider a trial of anti-PD-1 therapy following disease progression through anti-PD-L1 therapy for advanced urothelial carcinoma?
This is a great question and should be answered in a clinical trial setting. We need trials in patients with progression on anti-PDL1 or anti-PD1 agent; currently we don't have data to answer this question of cross-resistance
What surveillance strategy do you use for patients after resection of localized renal cell cancer?
Surveillance depends on the pathological stage of the patient. For T1a disease I follow annually. For T1b disease and higher I follow q 6 mos with MRI imaging if abdimen and low dose Ct of chest. I do not perform imaging of bones or brain without a clinical indication. For LN positive disease i star...
When do you consider for first-line atezolizumab for metastatic bladder cancer?
I see these patients in 2 groups, "cisplatin-ineligible" or "chemotherapy-ineligible”. In the “cisplatin- ineligible” group one may consider a carboplatin-based regimen (carboplatin plus gemcitabine or carboplatin plus taxol) or atezolizumab. In “chemotherapy-ineligible”, I consider both performanc...
Does a transitional zone vs. peripheral zone location of low risk prostate cancer affect your recommendation for active surveillance?
All other things being equal, the location of the cancer would not impact my recommendation for active surveillance. Transitional zone tumors tend to have a better prognosis than peripheral zone cancers. They are typically found in men who have had an elevated PSA and a prior negative biopsy, which ...
How do you manage a patient with a history of non-seminomatous germ cell tumor who has a rising AFP after primary chemotherapy without any imaging evidence of recurrence?
It would depend on the timing of the rise of AFP after chemotherapy, how elevated it is, whether they were good or poor risk patients at the time of chemotherapy, whether they had liver disease and whether the AFP was definitively elevated prior to chemo In most cases, we sort of ignore AFP < 25 or ...