Thread by @BartsECMC

@TumorBoardTues 1/15 #TumorBoardTuesday #BladderCancer #OncTwitter
75yo👴🏽
HTN: Amlodipine
T2DM: Metformin, Insulin
6 mo: haematuria & weight loss
CTCAP: thickened bladder wall with L side hydronephrosis & borderline paraaortic LNS. No distant mets
TURBT: G3 PT2N1M0 bladder TCC
CrCl: 75ml/min

@TumorBoardTues 2/15 #TumorBoardTuesday #BladderCancer @tompowles1 @MPishvaian @JohnEbbenMDPhD

👴🏽 Patient opts for cystectomy.

🤔 Should we do a PET scan prior to surgery? Why or why not?

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD 3/15 #TumorBoardTuesday #BladderCancer

❌PET scan prior to✂️
🩻PET lacks sensitivity in MIBC (70% in prior study n=43)
📚@adamkibel_uro pubmed.ncbi.nlm.nih.gov/19652070/
clinically negative CT + bone scan, PET/CT had SNS of 70% in MIBC
🧑🏻‍⚕️🤝👴🏽 #SharedDecision 4 cycles neoadju gem+cis

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro 4/15 #TumorBoardTuesday #BladderCancer

🩻 CTCAP shows small reduction in lymph nodes and bladder tumour after 4 cycles NA chemotherapy

👴🏽Patient proceeded to surgery.
pT3N0 disease

🧐 Should we measure ctDNA?

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD 5/15 #TumorBoardTuesday

✨CheckMate-274: Adjuvant nivolumab 👍🏽Improves DFS
🚫OS data yet
📚@MattGalsky Dean Bajorin
✨Imvigor010: Adju atezolizumab
👌🏽OS improves not significant
📚@OncoBellmunt
🤨With above info, should we give adju tx? If yes, which? If no,

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt 6/15 #TumorBoardTuesday

📆 Surveillance with 3 mo CTCAP scans
3,6,9 months: stable disease 🙌🏽

📆12 mos: PD in lungs
🫁48mm RLL mass
Crcl: ⬇️to 45ml/min

🤔 Hypothetically, if Px was PD-L1 positive and FGFR negative, what therapy would you give?

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @NikiTripathi27 @JessicaHawleyMD @pbandmurthy @JLWrightMD @Uromigos @AJangMD @BenMironMD @DRBakaloudiMDi @DMakrakisMD @djmcconkey @maxkates @tbivala1 @drphil_urology

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt 7/15 #TumorBoardTuesday #UrothelialCancer
Answer: B) Gem/carbo + maintenance avelumab

Due to low creatinine clearance: Gemcitabine/carboplatin + maintenance avelumab

🤔Assuming 👴🏽 tolerates treatment ok, how many cycles of chemotherapy should we give this patient?

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt 8/15 #TumorBoardTuesday #UrothelialCancer

✨DISCUS✨

📌Optimising duration of 1L chemotherapy in advanced/mUC
📍3 vs 6 cycles chemo for advanced/metastatic UC followed by maintenance avelumab

📚Eudra enrolling: clinicaltrialsregister.eu/ctr-search/tri… @drenriquegrande @tompowles1 @y_loriot

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @y_loriot @AmandaNizamMD @DRBakaloudiMD @kylerosemd @QingZhangLab @rafee_talukder @shilpaonc @DrYukselUrun @morr316 @faltaslab @MSKCC @JVentoMD @blkboiscientist @kyrillus2 @dawood_findakly @mtsiatas @heer_lab @AarmstrongDuke @MariaChiaraMCS @ReisLO @JoshMeeks @williamyshi @Prof_Nick_James

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @y_loriot 9/15 #TumorBoardTuesday #UrothelialCancer
🙏🏽Overall tolerates chemo well
Some G1 Fatigue
G1 hair loss
G1 skin rash

CTCAP: partial response
🫁Lung mass 18mm (was 48mm) RECIST -62.5%.
Bladder thickening & pelvic LNs stable

What should the next step be?

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @y_loriot 10/15 #TumorBoardTuesday

➡️ Maintenance Avelumab following 1L chemotherapy is SOC
📚Javelin Bladder 100 @tompowles1 @PGrivasMDPhD nejm.org/doi/10.1056/NE…

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @y_loriot @PGrivasMDPhD 11/15 #TumorBoardTuesday

Unfortunately after 6 cycles of gem/carbo chemotherapy + 3 cycles maintenance avelumab, CTCAP shows good response in lungs but progression in the lymph nodes and new bone metastases in the spine.

DNA testing shows alterations to FGFR3.

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @y_loriot @PGrivasMDPhD 12/15 #TumorBoardTuesday #BladderCancer

Considering all of the above information and criteria.

🤨 What would you do next?

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @y_loriot @PGrivasMDPhD 13/15 #TumorBoardTuesday #BladderCancer

In this case, the answer is Enfortumab Vedotin (✨EV301)

📚@tompowles1 @DrRosenbergMSK clinicaltrials.gov/ct2/show/NCT03…
📚 nejm.org/doi/full/10.10…

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @y_loriot @PGrivasMDPhD @DrRosenbergMSK 14/15 #TumorBoardTuesday #BladderCancer

Following Cycle 3, Day 1 treatment with EV, 👴🏽 patient develops some mild G2 skin toxicity.

🤨How do you proceed to treat this patient?

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @y_loriot @PGrivasMDPhD @DrRosenbergMSK 15/15 #TumorBoardTuesday #BladderCancer

👴🏽Patient is now in remission🎉
> 60% reduction in target lesions

🔮We are planning to continue EV until possible progression
🤔 Do you agree with this approach?

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @y_loriot @PGrivasMDPhD @DrRosenbergMSK #PostTest Q1️⃣ #TumorBoardTuesday
👉🏽#CME Eval 🔗integrityce.com/tbtEval
👉🏽ALL CME🔗 integrityce.com/tbt

🤔@tompowles1 @drfrankiejs taught us 1L tx, & maintenance of #BladderCancer, test your 🧠

🧐Which neoadju tx would you pick for
75yo👨🏼‍🦳
pT2N1M0 MIBC
HTN
T2DM
75 mL/min crcl

@TumorBoardTues @tompowles1 @MPishvaian @JohnEbbenMDPhD @adamkibel_uro @DrChoueiri @cdanicas @drenriquegrande @SCUColombia @wroclawski_uro @raymanneh @T_AlonsoGordoa @hannahdzmd @sandysrimd @sumitshahMD @MattGalsky @OncoBellmunt @y_loriot @PGrivasMDPhD @DrRosenbergMSK @drfrankiejs #PostTest Q2️⃣ #TumorBoardTuesday
👉🏽 Free CME (AMA & MOC)
🔗 integrityce.com/tbt

🧐What 2L would you pick for 👆🏽 patient
now CrCl 45 mL/min
lymph node progression
new spine bone metastases
newly identified FGFR3 alteration post 1L gem/carbo & maintenance avelumab?