Thread by @glovedoc

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 1/15 #TumorBoardTuesday #BladderCancer #OncTwitter

71 y/o 👨🏽‍🦳
Former 🚬
👨‍🏭Worked in various factories in 80s-00s
Recently diagnosed metastatic #UrothelialCancer (lymph nodes/lung)

🤨 What would you pick for your first line of therapy?

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 2/15 #TumorBoardTuesday
1L treatment for UC

📍cis eligible: SOC is gem/cis
📚pubmed.ncbi.nlm.nih.gov/11001674/
📍Frontline EV+P promising early phase results in cis-ineligible
📚ascopubs.org/doi/abs/10.120…
📍Ongoing ph3 trial: EV+pembro vs gem/cis (or carbo) clinicaltrials.gov/ct2/show/NCT04…

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman 3/15 #TumorBoardTuesday
Checkpoint☑️

✅Pembrolizumab: approved as single agent for those NOT eligible for platinum chemotherapy
📚thelancet.com/journals/lanon…

BUT

✨KEYNOTE-361: adding pembro to platinum based chemo did NOT result in PFS/OS improvement
📚thelancet.com/journals/lanon…

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc 4/15 #TumorBoardTuesday #BladderCancer

👨🏽‍🦳Patient started on gemcitabine and cisplatin
🧷🪡 some mild paresthesias after C3

After 4 cycles
🩻 CT scan 📷 shows
👎🏽 Growth of multiple lymph nodes
👎🏽 pulmonary 🫁 nodules, previously 2 cm now 3cm
🙁

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc 5/15 #TumorBoardTuesday
👨🏽‍🏫Mini tweetorial 1
🧐How do we think about platinum resistance?

🤨How many cycles did they get?
4 cycles seems adequate
📚ncbi.nlm.nih.gov/pmc/articles/P…
🤔How quickly did they progress?
platinum refractory = best response is PD
🧐How does it affect outcomes?

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc 6/15 #TumorBoardTuesday
👨🏽‍🏫Mini tweetorial 2 👨🏻‍🏫

🕵🏽@rafee_talukder @arkhaki
Looked into it!
📚pubmed.ncbi.nlm.nih.gov/36155169/
Early progress on plat-based chemo associated with shorter overall survival & progression🆓survival than pts with progression after >6mos

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki 👨🏽‍🏫Mini tweetorial 3 👨🏻‍🏫

219 Pts divided into cohorts based on time from 1L chemo to ICI
🔸< 3m
🔸3-6m
🔸> 6m

🕵🏽Then analyzed response to ICI between cohorts
🔹PFS: < 3 m shorter than > 6m (3m vs 5m, p < 0.05)
🔸OS: < 3m shorter than > 6m (4m vs 14m p < 0.05)

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki 8/15 #TumorBoardTuesday
👨🏽‍🏫Mini tweetorial 4👨🏻‍🏫

To summarize:

📌Patients who progress quickly on first line platinum chemo also have faster progression and shorter OS with 2L IO

‼️More research is needed in this population‼️

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki 9/15 #TumorBoardTuesday
Back to case🔎
Options for subsequent therapies

Pembro L1 evidence📚nejm.org/doi/full/10.10…
Nivo📚thelancet.com/journals/lanon…
Enfortumab vedotin could be considered if ineligible for immune checkpoint inhibitor📚
FGFR2/3 mut? nejm.org/doi/full/10.10…

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki 👨🏽‍🦳+🥼 Decided to start on Pembro q3w

After 6 cycles of pembro
Develops orthopnea, PND
🩻CXR 🫁 shows this (see attached)

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki @DrChoueiri @TiansterZhang @neerajaiims @sophia_kamran @RCCadvocate @DarcyBurbage @TripNish @PBarataMD @ReneeBultijnck 👨🏽‍🦳Admitted to the hospital

Vitals:
HR ♥️ 104
🌡️BP 90/70
😮‍💨SpO2 🫁88% on 2L
T 37
Troponin (hs) 45
nt-BNP 20,000
🧲 Cardiac MRI (see attached)
📚 ahajournals.org/doi/10.1161/CI…

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki @DrChoueiri @TiansterZhang @neerajaiims @sophia_kamran @RCCadvocate @DarcyBurbage @TripNish @PBarataMD @ReneeBultijnck @HanZhuMD @helitropen @Ron_Witteles @anguyen4194 @SWaliany @RohanGarjeMD 12/15 #TumorBoardTuesday

🫀Myocarditis after immune checkpoint inhibitor - rare but serious🚨

📍Incidence from ~0.06% for monotherapy or 0.27% for doublet IO
📍Case fatality up to≤ 50%
📍Recommended w/u - ECG, TTE, troponin, nt-BNP

‼️Get your friendly ♥️🥼 involved early‼️

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki @DrChoueiri @TiansterZhang @neerajaiims @sophia_kamran @RCCadvocate @DarcyBurbage @TripNish @PBarataMD @ReneeBultijnck @HanZhuMD @helitropen @Ron_Witteles @anguyen4194 @SWaliany @RohanGarjeMD 13/15 #TumorBoardTuesday
ICI ♥️ treatment

📖guides rec high dose👺steroids with long taper
📖series of pts treated with abatacept, MMF, infliximab, but usually reserved for 👺non-responders
📚ahajournals.org/doi/10.1161/JA…

👨🏽‍🦳started👺methylpred 1g/qd
4 days👍🏽hypoxia, BP, perfusion

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki @DrChoueiri @TiansterZhang @neerajaiims @sophia_kamran @RCCadvocate @DarcyBurbage @TripNish @PBarataMD @ReneeBultijnck @HanZhuMD @helitropen @Ron_Witteles @anguyen4194 @SWaliany @RohanGarjeMD 14/15 #TumorBoardTuesday
💫Recap💫

📍Platinum based doublet chemotherapy is SOC 1L UC
📍Response to 1L chemo may predict response to subsequent tx, including IO
📍Subsequent line opts include IO, ADCs, & 🎯agents
📍Always be suspicious for iRAEs & ☎️local multi-d specialists

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki @DrChoueiri @TiansterZhang @neerajaiims @sophia_kamran @RCCadvocate @DarcyBurbage @TripNish @PBarataMD @ReneeBultijnck @HanZhuMD @helitropen @Ron_Witteles @anguyen4194 @SWaliany @RohanGarjeMD 15/15 #TumorBoardTuesday

Happy Valentine’s day!!
Take care of all those ♥️s

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki @DrChoueiri @TiansterZhang @neerajaiims @sophia_kamran @RCCadvocate @DarcyBurbage @TripNish @PBarataMD @ReneeBultijnck @HanZhuMD @helitropen @Ron_Witteles @anguyen4194 @SWaliany #PostTest Q1️⃣ #TumorBoardTuesday
👉🏽#CME Eval 🔗 integrityce.com/tbtEval
👉🏽ALL CME🔗 integrityce.com/tbt

🤔@arkhaki @glovedoc taught us progression of #UrothelialCancer test your 🧠 with quick❓

🧐56y with met urothelial carcinoma plat ineligible. Which 1L would you pick?

@TumorBoardTues @TomJayram @arnabguonc @UroCancerMD @vinay_onc @simon_p_kim @AlexAlvaro_PSC @AlyaShamsan @MichaelStaehler @DrOmarMian @kaydaustin @josiegarcia1 @LeeJonesMBA @mcricardoa @UroDocAsh @Uromigos @AJangMD @BenMironMD @ChrisSweens1 @Tanjin097 @NikiTripathi27 @PGrivasMDPhD @PauloBergerot @spsutkaMD @shilpaonc @montypal @tompowles1 @NazliDizman @DrKarineTawagi @ShuchiGulati @wandering_gu @KidneyCancerDoc @rafee_talukder @arkhaki @DrChoueiri @TiansterZhang @neerajaiims @sophia_kamran @RCCadvocate @DarcyBurbage @TripNish @PBarataMD @ReneeBultijnck @HanZhuMD @helitropen @Ron_Witteles @anguyen4194 @SWaliany 👉🏽 Free CME (AMA & MOC)
🔗 integrityce.com/tbt

🧐 Which of the following criteria would prevent a patient from receiving platinum based chemotherapy?