Left lateral wall large bladder growth with left HUN -50 years male

• 20 May 2020 10:33:58 AM
• |Onco Urology

50 years male patient presented with history of painless haematuria on and off since couple of months. 

Comments(14)

• 

  Utsav Shah

  20 May 2020 01:04:45 PM

  Respected Sir,

  
  

  50y Male with huge mass in left lateral wall of bladder with Hydronephrosis. This patient has one important factor on his side: his performance status due to his age and no comorbidities. 

  
  

  This cancer shud hence be treated aggressively. 

  Going by the guidelines, he should be subjected to neoadjuvant chemotherapy with GC or Dose dense MVAC for 3 cycles followed by Radical cystoprostatectomy(RC)+ Ileal conduit(IC) + Pelvic node dissection(PND) followed by adjuvant chemotherapy. 

  
  

  If Neoadjuvant not available/not preferred then go ahead with RC + IC + PND. 

  
  

  Trimodal therapy and bladder preservation therapy protocols don’t apply here as it is a large tumor with Hydronephrosis. 

  
  

  Giving radical treatment at this stage will give better chance of survival. 

• 

  Utsav Shah

  20 May 2020 01:06:19 PM

  I would like to mention that the above procedures shud be done after proving Ca bladder by TURBT. 

• 

  Tikenjit Mazumdar

  20 May 2020 02:02:30 PM

  Sir..it's looks like T3b disease.perveicular macroscopic mass..nodes status difficulty to make in Thai ct..I would definitely like to give neadjuv chemo..2 cycle MVAC... assess status...good response..thne go ahead n do radical cystectomy n ileal conduit..then complete.rest of chemo..

  Before that...I would like to do ct urogram to rule out upper tract tcc as tumour is in uteteric orific..n hydronephrotic is also present..

  N cystoscopy n turnt...if possible..if not only biopsy

  Also like to do metastatic workup...ct thorax..ct abdomen n pelvis cuts already available..

• 

  Prabir Basu

  20 May 2020 03:01:32 PM

  A recent multicentre Indian study by  Narain et al infers that the risk of immunosuppression with NAC in times of SARS Cov2 may outweigh the 6% OS benefit.

  
  

  A similar Chinese study by Liang et al advised to altogether avoid immunosuppressive cispl based chemotherapy in neoadjuvant or adjuvant settings.

  We know from literature that delay> 12 wks from diagnosis to curative surgery is associated with worst outcomes.

  
  

  So, my plan will be an immediate clinical staging with TUR biopsy + endoscopic fulguration following which patient is counselled for open radical cystectomy + ileal conduit with attendant morbidity and mortality risk in this covid era.

  
  

  If pathological staging suggests advanced urothelial cancer which has a very high probability in this case, I would like to take opinion of tumor board whether immune checkpoint inhibitors can be given in first line adjuvant setting.

• 

  Tikenjit Mazumdar

  20 May 2020 04:24:21 PM

  Respected prabir Basu sir...if u see the ct cuts...mass is already in the pervesical space..still u will consider upfront rc?

• 

  Dr. Anil Takvani

  20 May 2020 05:06:45 PM

  @ all,

  Thank you very much for very useful inputs.

  How will you take exactly TUR Biopsy in this case? Growth is very big and he has active gross haematuia...

  Thanks

• 

  Prabir Basu

  20 May 2020 05:26:04 PM

  Dr Mazumder, what you have described is an ideal textbook teaching, and I have tried to  modify my plan according to present covid scenario.

  Dr Anil Takvani sir , I guess in actively bleeding tumor I may not be able to take deep muscle biopsy in such a large necrotic tumor, that's why I mentioned cystofulguration of bleeding points after a bladder wash. Must aim for tissue diagnosis . CT evidence of extravesical spread and bimanual examination will confer muscle invasion. Even then if in nowhere land , will do a video capture and keep as proof.

• 

  Dr. Anil Takvani

  20 May 2020 06:16:38 PM

  Can only positive urine cytology in this particular case obviate need of risky cystoscopy and futile attempts at fulguration?

  Can cytology only relied in circumstance of gross haematuria in this case?

  Thanks

• 

  Nitesh Jain

  20 May 2020 07:35:21 PM

  Issues -

  Large mass possible t3

  Left Gross HUN - small contracted kidney 

  NxMx(not evaluated)

  
  

  Needs TURBx to know the histology and grade of tumor 

  
  

  Needs a DMSA to assess the renal function of left side 

  
  

  If kidney is functioning 

  Ideally needs Neoadjuvant Chemo followed by RC + diversion 

  
  

  If kidney non functioning needs a Left a Nephroureterectomy with RC + diversion 

  
  

  Even in COVID time given the nature of disease and stage T3 will prefer neoadjuvant 

  
  

• 

  SHIVAM PRIYADARSHI

  20 May 2020 11:30:23 PM

  we must know the findings of metastatic workup and the lymph node status . On the left side there is gross perivesical extension with the the possibility of a lymph node mass is not ruled out.

  I think if urine cytology is positive or even if we can prove by a cold cup biopsy , we can go ahead with the definitive management  which in this case is definitely chemotherapy first followed by reasssessment to decide for surgery or radiation next.

• 

  SHIVAM PRIYADARSHI

  20 May 2020 11:34:15 PM

  Scan is not required as there is good enhancement of the cortical tissue on left side suggestive of reasonable function to rule out any ablative surgery of Lt. kidney.

• 

  Dr. Anil Takvani

  21 May 2020 06:08:46 AM

  @ Shivam, I concur with you no need of DMSA scan. Left kidney is smaller and there is HUN but well enhancing.

  @ I have provided available images, many be images are not great but with encashment of left ureter with invasion of growth in perivesical area, does clarity on lymphnodes make much difference in further management in this case?

  X ray chest is done-normal, CT not done.

  Relevant lab. investigations normal.

  @ Prabir, if we go ahead with cystectomy straight chances of leaving residual growth is very high. In that circumstance I have not seen much of the benefits of post cystectomy chemotherapy and/or radiotherapy. They develop local recurrence with or without distal metastasis in couple of months.

  Thanks

• 

  Nitesh Jain

  21 May 2020 08:25:23 AM

  Sharing two edited images of same patient , I am still skeptical of size and enhancement... still will go ahead with DMSA ... fup of a poorly functioning kidney small  is difficult post radical Cystectomy as there may not be any excretion .... @anil sir you are the best judge as you have all the sequences 

  

• 

  Dr. Anil Takvani

  21 May 2020 09:16:04 AM

  @ Nitesh,  let me try pulling out best possible images... Thanks