A 61 year old previously healthy man had gross hematuria and was found to have a muscle invasive urothelial cancer of the bladder. The clinical stage was T2 and there was lymphovascular invasion.
A metastatic work up consisting of lab work and imaging with a CT scan of the chest, abdomen, and pelvis was negative. He did have left upper tract obstruction with resultant hydronephrosis. A stent was placed to preserve as much renal function as possible. His creatinine was 1.6 after the stent.
After a thorough discussion, the patient agreed to neoadjuvant chemotherapy to be followed by a radical cystoprostatectomy and an orthotopic neobladder.
He received 4 cycles of cisplatin and gemcitabine which he tolerated quite well. An office flexible cystoscopy after two cycles indicated an excellent response with no obvious tumor in the bladder. The patient received two additional cycles of chemotherapy.
Three months after the diagnosis he underwent a radical cystoprostatectomy with bilateral standard PLND, and an orthotopic neobladder was constructed. The postoperative course was benign.
The pathology revealed a small area of residual urothelial carcinoma of the bladder. One of 14 removed lymph nodes contained metastatic urothelial carcinoma.
It is now 6 weeks from surgery. The patient looks and feels well. He is continent during the day and usually continent at night.
A CT scan shows one enlarged paraaortic lymph node, 1.5 cm.
A rectal exam indicates an empty fossa with no apparent local recurrence.
In light of the pathology after four cycles of systemic induction chemotherapy and the current imaging results what is the optimal approach?
1) PET/CT to further characterize para-aortic node and identify other potential metastatic sites.
2) CT guided biopsy of para-aortic node.
3) Salvage systemic chemotherapy.
4) Adjuvant/Salvage immunotherapy with checkpoint inhibitor.
5) Retroperitoneal lymphadenectomy.
6) Other ____________________________.
Please indicate recommendation and provide a short description of justification.