Challenging Cases in Urothelial Cancer

Dear readers,

Urothelial cancer of the urinary tract is common and affects a large number of men and women, result- ing in a reasonably large part of the work effort of urologists who take care of adults. Most of the urothe- lial tumors arise in the bladder but the same causative factors can lead similar tumors of the upper urinary tract and prostatic urethra. Due to the heterogeneous nature of these tumors as well as their propensity for “recurring” in time and location over the patient’s life the clinician is often in the position of decid- ing among often challenging treatment choices for his/her patient. Although there are published guide- lines many cases do not readily fit into a typical scenario, thus leaving ample room for decision mak- ing for the individual patient. We invite our readers to review and comment on the case and management by using the comment section below each case.

Sincerely,

Mark S. Soloway
Chief, Urologic Oncology, Memorial Physician Group, Division of Urology, Memorial Healthcare System, Hollywood, FL, USA

Case 5 – Multifocal urothelial cancer of the kidney and bladder

JP is currently a 58 year old man with multifocal urothelial tumors of the urinary bladder despite two courses of intravesical mitomycin C and one six week course of BCG.

The patient appears well but has a significant past medical history consisting of diabetes mellitus, coronary artery disease, mild congestive heart failure, chronic renal disease, and peripheral neuropathy. He stopped cigarette smoking at age 35 after 15 years of smoking 1.5 packs/day. He has had a coronary artery stent placed.

Case 4

S.C. is a 71 year old man with a new diagnosis of prostate and bladder cancer. This man has been in excellent health and was a long time marathon runner. His only past medical history was of a left inguinal hernia repair. He was a former cigarette smoker with a 10 pack year history. He did not have any voiding complaints. He had been taking dutasteride for LUTS.

Case 3. High grade (grade 3) Ta urothelial carcinoma of the bladder with an adjacent area of CIS

72 year old woman who had one episode of gross hematuria and saw a urologist for an investigation. Her general health is good. The only prior surgery was a cholecystectomy. She smoked cigarettes for 15 years – one pack/day. She stopped 30 years ago.

Case 2. T2 muscle invasive urothelial bladder cancer

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.

Case 1. T1 high-grade urothelial bladder cancer

The patient is a 56 year old male practicing urologist. He had the acute onset of gross hematuria and a CT scan of the abdomen and pelvis was normal except for a possible small bladder tumor. An office cystoscopy indicated a solitary 3 cm papillary tumor at the right lateral wall. A TURBT was performed and the pathology revealed a high-grade focally invasive T1 urothelial carcinoma. Muscle was present and not involved. There was a focus of CIS adjacent to the tumor. The rest of the bladder and the prostatic urethra were visually normal but not biopsied.