Rafee Talukder

@rafee_talukder

May 10, 2023 • 20 tweets • 184 min read • Read on X

@TumorBoardTues @PGrivasMDPhD 1/17 #TumorBoardTuesday #UrothelialCancer #OncTwitter @PGrivasMDPhD

73yo 👴🏼
PMH: HTN, CKD stage 3 (GFR 40), hearing loss
2 month hx flank pain, urinary hesitancy, & hematuria
🩻CT chest abd/pelvis: focal mass-like thickening of anterior bladder wall; no LN-pathy or other mets

@TumorBoardTues @PGrivasMDPhD 2/17 #TumorBoardTuesday #UrothelialCancer #BladderCancer @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter

👴🏼 underwent TURBT
🔬biopsy: high grade urothelial carcinoma, micropapillary variant (100%) with involvement of muscularis propria

🧐 What would you do for this pt?

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK 3/17 #TumorBoardTuesday
👨🏽‍🏫Mini tweetorial 1👨🏻‍🏫

📌Variant histology in #BladderCancer
📍10-20% present as pure or predominant variant histologies

From @fredhutch/@LDiamantMD:
📚sarcom: pubmed.ncbi.nlm.nih.gov/35101380/
📚plasm: pubmed.ncbi.nlm.nih.gov/34109262/
📚micropap: pubmed.ncbi.nlm.nih.gov/33160889/

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @LDiamantMD 4/17 #TumorBoardTuesday
👨🏽‍🏫Mini tweetorial 2👨🏻‍🏫

⚖️Comparing conventional urothelial carcinoma (CUC) to variant histology

🔬VH can be associated with
🔹more advanced dz at dx (higher rates of pT3/T4 / N+)
🔹higher positive margin %
🔹lower path response to neoadjuvant chemotherapy

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @LDiamantMD 5/17 #TumorBoardTuesday #BladderCancer
👨🏽‍🏫Mini tweetorial 3👨🏻‍🏫

📌neoadjuvant treatment options for VH BC?

@RishiSekarMD @PGrivasMDPhD
📚ascopubs.org/doi/10.1200/JC…
📚ascopubs.org/doi/abs/10.120…
📚pubmed.ncbi.nlm.nih.gov/29154041/

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @spsutkaMD @ReneeSaliby

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa 6/17 #TumorBoardTuesday
👨🏽‍🏫Mini tweetorial 4👨🏻‍🏫

🕵🏽‍♂️Currently 2 open neoadjuvant variant histology trials @fredhutch @UWMedicine

✨aMVAC + pembro ➡️ RC (cisplatin eligible):
🔗 clinicaltrials.gov/ct2/show/NCT04…

✨SG ➡️ RC (cisplatin ineligible)
🔗 clinicaltrials.gov/ct2/show/NCT05…

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @UWMedicine 7/17 #TumorBoardTuesday #BladderCancer
Back to our patient 🔎

👴🏼 Patient underwent upfront radical cystectomy ✂️

🔬Path: micropapillary variant urothelial carcinoma (100%) - pT3N0M0

👴🏼 Patient elected not to proceed with adjuvant treatment after discussion #SharedDecision

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @UWMedicine 8/17 #TumorBoardTuesday #UrothelialCancer

🗓️Restaging CT CAP 1 year later
🩻Multiple enlarged RP lymph nodes and lung nodule

🔬Biopsy of RP lymph node: metastatic urothelial carcinoma, micropapillary variant

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @UWMedicine 9/17 #TumorBoardTuesday #BladderCancer

Noting 👴🏼 patient has underlying hearing loss and CKD3 (GFR 40 cc/min)

🤨 What would you pick as 1L treatment for mUC in this patient?

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa 10/17 #TumorBoardTuesday
👨🏽‍🏫Mini tweetorial 5👨🏻‍🏫
Platinum & cisplatin eligibility in #BladderCancer

📍Cis @MattGalsky
ECOG P ≥2
CrCl <60ml/min
Hearing G ≥2
Neuropathy G ≥2
CHF NYHA Class III/IV

📍Plat @shilpaonc
ECOG PS ≥3
CrCl <30ml/min
Neuropathy G ≥2
CHF NYHA Class III/IV

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @MattGalsky 11/17 #TumorBoardTuesday
👨🏽‍🏫Mini tweetorial 6👨🏻‍🏫

👍🏽FDA grants accelerated approval for combo 1L EV + Pembrolizumab for cisplatin-ineligible aUC
📰fda.gov/drugs/resource…

📚✨PURPOSE EV-103, cohorts A & K ascopubs.org/doi/10.1200/JC…
📚✨LBA73 EV-103 oncologypro.esmo.org/meeting-resour…

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @MattGalsky 12/17 #TumorBoardTuesday
👨🏽‍🏫Mini tweetorial 7👨🏻‍🏫

📌Common side effects with combination EV + Pembro

🖐️🦶🏽Neuropathy
👹Skin rash
🥱Fatigue
🍽️Anorexia
😝Dysgeusia
🚽Diarrhea
🤢Nausea
👀Ocular (e.g. dry eyes, blurred vision)
🍭Hyperglycemia
🧑🏼‍🦲Alopecia

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @MattGalsky 13/17 #TumorBoardTuesday #UrothelialCancer
👨🏽‍🏫Mini tweetorial 8👨🏻‍🏫

📌Carbo+ gem ➡️ avelumab maintenance

✨JAVELIN Bladder 100
📚nejm.org/doi/full/10.10…
📚pubmed.ncbi.nlm.nih.gov/37121850/
📚JAVELIN results ≥2yrs follow-up pubmed.ncbi.nlm.nih.gov/37071838/

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @MattGalsky 14/17 #TumorBoardTuesday #BladderCancer
👨🏽‍🏫Mini tweetorial 9👨🏻‍🏫

📌 cis/carbo + gem ➡️ avelumab maintenance

✨READY: Real-world data
📚ascopubs.org/doi/abs/10.120…
📚ascopubs.org/doi/abs/10.120…
📚ascopubs.org/doi/abs/10.120…
📚pubmed.ncbi.nlm.nih.gov/36484294/

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @MattGalsky 15/17 #TumorBoardTuesday #UrothelialCancer

🤨 How to choose: 1L carbo + gem ➡️ avelumab vs EV + pembro in cis-ineligible mUC?

❌No head to head…yet…

Tx decision based on:
📍ECOG PS, age, comorbs
📍cancer burden, met site
📍trial data
📍🧑🏻‍⚕️ exp
📍👴🏼 pref
📍#SharedDecision

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @MattGalsky 16/17 #TumorBoardTuesday

✍🏼Need
🔹data on regimens
🔹better molecular/genomics of VH #BladderCancer ➡️ identify ‘actionable’ targets & biomarkers

📚ERBB2 amp in micropap VH BC: pubmed.ncbi.nlm.nih.gov/24192927/

📚Anti-HER2 ADC in mUC: ascopubs.org/doi/abs/10.120…
clinicaltrials.gov/ct2/show/NCT04…

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa @MattGalsky 17/17 #TumorBoardTuesday

👴🏼Patient decides to start EV + Pembro (used EV-103 trial data for prior auth) 🙏🏼
👀 Close monitoring for AEs, working with PCP, Nutrition, Palliative Care
🩻Plan for repeat scans after 2 cycles
🧪Tumor NGS testing sent to check for “targets”

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD @OncoAlert @BCMCancerCenter @Daniel_J_George @BlkBoiScientist @SimaPorten @dawood_findakly @mtsiatas @TomJayram @arnabguonc @KidneyCancerDoc @HHammersMD @arihakimi @AmandaNizamMD @montypal @brian_rini @shilpaonc @DrYukselUrun @TiansterZhang @fuatbcr @UROncDoc @KNJobanputra @minaseconomides @DrRosenbergMSK @fredhutch @neerajaiims @YuWeiChenMD @MarkTysonMD @IBCG_BladderCA @AmerUrological @uromc @UrogerliMD @JVentoMD @kauymartinez @MariaJRibal @mario_sofer @DRBakaloudiMD @betsykoehne @sginzbu @VigneshPackiam @wandering_gu @UroTouzani @urotoday @Tach164n @T_AlonsoGordoa #PostTest Q1️⃣ #TumorBoardTuesday
👉🏽#CME Eval integrityce.com/TBTeval23

🤔@PGrivasMDPhD @rafee_talukder taught us cis-ineligible mUC, test your 🧠 with a Q

🧐What 1L to NOT pick for 73yo👴🏽
mUC (predom UC hx with micropap)
RP LN-pathy
HTN
CKD (GFR 40 cc/min)
G3 hearing loss

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More from @rafee_talukder

Rafee Talukder

@rafee_talukder

Jan 11, 2023

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD 1/19 #TumorBoardTuesday #BladderCancer #OncTwitter

74 yo🧓🏼
HTN
DM2
2020: localized Rt upper tract urothelial carcinoma
2020: ✂️ radical nephroureterectomy
🧪Germline testing negative
Complicated by CKD stage 4 after ✂️ (creatinine clearance 25 ml/min)
🩻Restaging CT CAP 1 year

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD 🩻 NEW metastatic disease to spine, 🫁 and retroperitoneal lymph nodes
ECOG PS 2
🔬Biopsy of RP lymph node: Metastatic #UrothelialCarcinoma
🧪Molecular: FGFR3-TACC3 fusion, MTAP loss, CDKN2A loss

🤨 What 1L treatment would you pick for this patient?

@TumorBoardTues @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD 3/19 #TumorBoardTuesday @PGrivasMDPhD @MPishvaian @JohnEbbenMDPhD #UrothelialCancer

🤔 Is the above 74yo 🧓🏼 patient a good candidate for platinum-based chemotherapy?

🤨 Poll: Which of these criteria would make this patient platinum-ineligible?

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