bladder palliative case

[Ray D. Ayshun]

Wondering how aggressive to be. IOW, how much RT and where. 67 otherwise healthy with M1a urothelial cancer dx'd in Jan of 21 and treated with carbo/gem now on immunotherapy. Initially positive para-aortic nodes, now with progression in the external iliac chain into the groin. No local therapy beyond initial intracystic stuff when it was NMIBC. He was referred to me for palliative RT to the enlarging groin nodes, which are causing pain and edema in just the left side, though adenopathy is bilateral. Otherwise, there's nothing enlarged/progressing elsewhere. Wondering about just treating unilateral groin and pelvis, bilateral groin and pelvis (oligoprogression), or also including the bladder and treating to like 50/55 Gy in 20 fx. As he's otherwise doing well, my concern is another symptomatic pelvic progression (obstruction/pain, hematuria, etc) and more danger with retreatment then just treating everything aggressively now. Thoughts?

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[jondunn]

Interesting case. my take, with major caveat that we don't have the patient in front of us - he is progressing on systemic therapy and also has groin nodes, both not good signs at all in terms of prognosis. this is not going to go well. would treat the symptomatic groin nodes, and call it. if he needs palliation to the bladder later, that should be easy to do.

 

[communitydoc13]

he is progressing on systemic therapy and also has groin nodes

Agree with this take. Things could be different with response to chemo. I'm guessing there was a good reason that he did not get MVAC or similar up front?

I have had patients with pelvic and/or limited RP nodes up front who have very good response to up front chemo. I believe these patients benefit from pretty definitive pelvic/ rp RT and have had good clinical experience doing this now followed by Avelumab. I think waiting for pelvic progression on Avelumab with these patients is probably a mistake, but I suspect is also likely SOC from medonc perspective.

 

[Ray D. Ayshun]

Agree with this take. Things could be different with response to chemo. I'm guessing there was a good reason that he did not get MVAC or similar up front?

I have had patients with pelvic and/or limited RP nodes up front who have very good response to up front chemo. I believe these patients benefit from pretty definitive pelvic/ rp RT and have had good clinical experience doing this now followed by Avelumab. I think waiting for pelvic progression on Avelumab with these patients is probably a mistake, but I suspect is also likely SOC from medonc perspective.

Yes. My first time seeing him. He did have a good response to gem/carbo. Hypothetically, if he were switched to MVAC now and had a good response, would you then treat aggressively in a few months?

 

[TheWallnerus]

If you want a negative take:
Four weeks of RT sounds like a stretch for palliative RT given essentially 100% chance of progression beyond the areas that are now palliatable (sp?). 50/20 won’t be a guaranteed walk in the park with the largeness of the volumes. Concurrent chemoRT has seemingly been more of a LC achieving thing in bladder cancer versus pure RT dose considerations; that is to say, pure radiation even to 50/20 will control maybe 2 out of 3 (maybe less?) localized bladder cancers long term.

If you want a positive take:
I’m sure you can make a nice looking 50/20 plan.

 

[communitydoc13]

Yes. My first time seeing him. He did have a good response to gem/carbo. Hypothetically, if he were switched to MVAC now and had a good response, would you then treat aggressively in a few months?

This is very unlikely to happen at this point. I think resistant clones likely selected out (ancient way of thinking, I know, but I don't think it is always wrong).

Sure, if remarkable response on MVAC, reasonable to radiate more comprehensively. I would be shocked if this occurs, and with symptomatic groin nodes at this point, I agree with @jondunn take.

My last similar patient was an interesting case. T1N3BMx with nodes up to top of L3 and questionable tiny pulm nodules. Excellent initial response to MVAC and standard fractionation IMRT plan with concurrent chemo to 63+ gy given because of large volume. Good tolerance to therapy and pt. Placed on avelumab 4 months later.

Pt died suddenly 18 months after completion of XRT with no evidence of systemic or regional progression except some atypical cytology.

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[Ray D. Ayshun]

If you want a negative take:
Four weeks of RT sounds like a stretch for palliative RT given essentially 100% chance of progression beyond the areas that are now palliatable (sp?). 50/20 won’t be a guaranteed walk in the park with the largeness of the volumes. Concurrent chemoRT has seemingly been more of a LC achieving thing in bladder cancer versus pure RT dose considerations; that is to say, pure radiation even to 50/20 will control maybe 2 out of 3 (maybe less?) localized bladder cancers long term.

If you want a positive take:
I’m sure you can make a nice looking 50/20 plan.

No doubt about the positive take. Here's an axial slice, and why the conundrum in my mind:

These are some of the nodes that are enlarged. Obviously, he's only having problems on one side, and I was, of course, taught to palliate symptoms, not imaging, and not myself. At the same time, it's easy enough to grab a little bit more, and a little bit more, and so on, as the only areas with gross disease essentially abut the bladder.

 

[communitydoc13]

No doubt about the positive take. Here's an axial slice, and why the conundrum in my mind:
View attachment 348972
These are some of the nodes that are enlarged. Obviously, he's only having problems on one side, and I was, of course, taught to palliate symptoms, not imaging, and not myself. At the same time, it's easy enough to grab a little bit more, and a little bit more, and so on, as the only areas with gross disease essentially abut the bladder.

While I would forego definitive type treatment here because of the reasons given above, it is always appropriate to extend your palliative field to prevent symptomatic progression where it is likely to occur. Easy enough to radiate bilaterally here with minimal toxicity.

 

[DoctwoB]

If toxicity is minimal I'd definitely treat what you can see. If he has any known disease in bladder not unreasonable to palliate that as well, but if NED locally would then defer.

He's not in a great situation. If he progressed through GC don't expect a response to MVAC (its the C doing the heavy lifting in both regimens). Now that he's progressing on immunotherapy we're looking et conjugates like enfortumab vedotin, which is a lot better then nothing but still not looking great).

 

[Lamount]

I like 3 Gy x 13 for aggressive palliation.

 

[deleted1111261]

36/6 weekly is pretty effective, but that is usually for bladder disease itself. With nodes, 39/13 (@Lamount ’s Aggression) sounds solid.

 

[jondunn]

39/13 more of an option for me when it's not an area I'm worried about acute toxicity.

 

[evilbooyaa]

39/13 more of an option for me when it's not an area I'm worried about acute toxicity.

Nodes only, even if doing bilateral nodes, even with some partial RT dose to bladder, shouldn't be too toxic if using IMRT planning. I like 45/15 a lot with IMRT with underdosing to 37.5 near critical structures as necessary. Similar EQD2 to 55/25 at a/b3 which makes figuring out dose constraints for small bowel and duodenum not too much of a problem.

 

[medgator]

Nodes only, even if doing bilateral nodes, even with some partial RT dose to bladder, shouldn't be too toxic if using IMRT planning. I like 45/15 a lot with IMRT with underdosing to 37.5 near critical structures as necessary. Similar EQD2 to 55/25 at a/b3 which makes figuring out dose constraints for small bowel and duodenum not too much of a problem.

That's what i would do.... 40-45/15 imrt to all symptomatic gross disease

 

[seper]

Palliation = do no harm and waste no time

 

[jondunn]

Palliation = do no harm and waste no time

my take as well.

 

[deleted1111261]

You have to treat 10 patients with 10 fractions to save one from coming back for a retreatment (even though there is no evidence there is a pain relief benefit with extended fractionation).

Talk about so much time wasted !!

 

[Ray D. Ayshun]

When I start making treatment decisions based on platitudes I'll know it's really time to start making furniture.

 

[jondunn]

Nodes only, even if doing bilateral nodes, even with some partial RT dose to bladder, shouldn't be too toxic if using IMRT planning. I like 45/15 a lot with IMRT with underdosing to 37.5 near critical structures as necessary. Similar EQD2 to 55/25 at a/b3 which makes figuring out dose constraints for small bowel and duodenum not too much of a problem.

sure, and I do this a lot, especially in a consolidation setting.

this is not that.

 

[Ray D. Ayshun]

sure, and I do this a lot, especially in a consolidation setting.

this is not that.

It's progressive disease, sure. But 100% of the gross disease on ct in his body can be encompassed by a reasonable and contiguous ptv.

 

[Reaganite]

Are there other nodes involved or just the ones you highlighted? Also are these enlarged relative to previous imaging? I don't know any of the specifics of your case but i have seen many patients with big nodes in that area that were mostly pet negative and, there's an interesting write up in the newer gyn pelvis contouring guidelines on how these nodes are frequently enlarged in people without cancer.

 

[Ray D. Ayshun]

Are there other nodes involved or just the ones you highlighted? Also are these enlarged relative to previous imaging? I don't know any of the specifics of your case but i have seen many patients with big nodes in that area that were mostly pet negative and, there's an interesting write up in the newer gyn pelvis contouring guidelines on how these nodes are frequently enlarged in people without cancer.

More involved in the same distribution, just picked that slice to emphasize proximity to bladder when considering volumes. Biopsy proven. Initially biopsy proven in a para aortic node at level of kidneys one year ago. No progression there at present.