Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
How would you treat a patient with newly diagnosed prostate cancer with low volume bone metastases and extensive lung metastases with a very low PSA (< 5) and no neuroendocrine differentiation on pathology?
Generally, I would treat such a patient with ADT plus abiraterone (or enzalutamide). A recent paper from our group suggested that patients who present with pulmonary mets, without concurrent liver mets, usually have a great prognosis with hormonal therapies. Another interesting phenomenon is that pa...
Would diagnosis of a low grade, non-invasive papillary bladder cancer alter your recommendations for salvage prostate radiotherapy after rising PSA?
I would treat with salvage RT as that’s definitive treatment for recurrent prostate cancer and treat non invasive bladder cancer with TURBT and cystoscopic surveillance.
How would you treat high risk prostate adenocarcinoma who relapsed after RT and ADT with a very low PSA, widespread mets to bone and soft tissue who is progressing on ADT, docetaxel and carboplatin?
Difficult situation, this patient likely has neuroendocrine differentiation. I would check for markers like NSE, chromogranin if positive, then can make the case of treating as small cell ca progressed on platinum based chemotherapy and treat with lurbinectedin (Trigo et al., PMID 32224306).PSMA bas...
How and when are you using sipuleucel-T in metastatic prostate cancer given the increase in available treatment options?
At the present time, they do not. The options of treatment in the mHSPC setting include ADT, NHT, and docetaxel only. There are some ongoing clinical trials evaluating the combination of immune therapy with PD-1/PD-L1 checkpoint inhibitors and docetaxel or NHTs currently. Some phase II clinical tria...
What is the preferred adjuvant therapy for high-risk non-clear cell RCC?
Unfortunately, non-clear cell RCC (nccRCC) has not been included in past or current adjuvant trials. Sunitinib, which has limited effect in the adjuvant setting, would be expected to have even less in nccRCC given relative activity in the metastatic setting. A similar scenario exists for IO adjuvant...
How do you approach a tumor bed recurrence after previous neoadjuvant chemo and cystectomy for bladder cancer?
I would opt for concurrent chemoRT in most instances. Here is my explanation as to why: First, I think it's important to establish that recurrence of bladder cancer after radical cystectomy (RC) usually portends a very poor prognosis; these patients have a median survival of 5.6 months after diagnos...
How would you treat a patient with urothelial cancer and 25% plasmacytoid variant who has a solitary recurrence in rectum 1 year after neoadjuvant chemotherapy and radical cystectomy?
Plasmacytoid urothelial carcinoma has a very high tendency to develop peritoneal carcinomatosis. And although on scan there could be solitary occurrence, on exploration, may be able to see more peritoneal involvement. Thus, systemic therapy would be a more appropriate strategy to treat. Diamantopoul...
Would you consider single agent TKI for patient with metastatic renal cell carcinoma who developed biopsy proven giant cell arteritis days after starting immunotherapy?
Clinicians are not infrequently in situations where we need to help guide patients along a decision pathway for which we have little data. The vasculitis in this patient obviously was a pre-existing condition. The first question I would ask is does the patient's RCC need treatment now? If favorable ...
Which patients with mCRPC on ADT + advanced anti-AR do you treat with bisphosphonates or denosumab?
Men with bone-metastatic CRPC face a relatively high rate of fractures due to bone loss as a result of potent AR inhibition and ongoing ADT but also due to lytic and sclerotic bone metastases which create focal weakening of the bone matrix despite the pathologic bone formation. The fracture rate was...
In addition to ADT, how would you treat Gleason 8, pure ductal prostate adenocarcinoma with oligometastatic disease?
Based on the available data and knowledge, it is difficult to answer this question definitively.Although prostate ductal adenocarcinoma (PDA), was first described more than 50 years ago and its behavior as an aggressive variant is increasingly being recognized, evidence-based management of PDA is no...