Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
When would you consider active surveillance for a patient with metastatic RCC?
How do you evaluate PSA decline after EBRT for low-and intermediate risk prostate cancer not treated with ADT?
This is not an answer that comes with any hard data, although both NCCN and AUA offer guidelines on PSA monitoring after therapy. First, I check a PSA at treatment completion. This is not so important when ADT is used, as PSA pretty much universally will decline (at least initially) on ADT. However,...
If a patient with low metastatic burden has bulky retroperitoneal adenopathy without osseous metastasis, would you recommend prostatic radiation?
We could debate whether "bulky" retroperitoneal adenopathy is a truly low volume metastatic disease, but technically it would fit the definition used in the STAMPEDE Trial. In addition, patients presenting with nodal metastatic disease may have a more indolent course than those presenting de novo wi...
In a patient with pN1 penile squamous cell carcinoma s/p inguinal lymph node dissection, would you offer adjuvant TIP vs adjuvant chemoRT vs surveillance?
With no high risk features (i.e. pN1 disease is <= 2 unilateral inguinal lymph nodes involved with no extracapsular extension), the best evidence for any treatment would be for adjuvant chemoradiotherapy which would come from an extrapolation of a GOG study on vulvar cancer. As reference, NCCN Guide...
Do you consider adjuvant chemotherapy in a patient who has received ddMVAC preoperatively and had pT3pN2 disease at time of surgery?
No. There is no high level evidence of doing that. I would strongly favor clinical trial, e.g. AMBASSADOR is accruing (or active surveillance if no trial available).
In a patient with M0CRPC with PSA doubling time < 6 months, will you wait until the absolute PSA value is >2, or is PSADT alone sufficient to start an AR targeted agent?
The SPARTAN trial required patients to have evidence of PSA progression per Prostate Cancer Working Group 2 (PCWG2) criteria at the time of enrollment. Per PCWG2 criteria, the PSA must be ≥25% and ≥2 ng/ml above the nadir, and it must be confirmed to be rising ≥3 weeks later. Similar eligibility cri...
What is the protocol for stopping TKI used in RCC prior to a surgery?
It depends on the half life of the TKI, but generally I stop 4-5 half lives prior to any invasive procedure from dental work to a major surgery. The bigger issue is when to restart afterwards, and I usually wait until surgical wounds are 90% or more healed. This might depend on the disease status of...
How would you manage a patient with intact prostate cancer with metastases to a para-aortic node and single bone?
I would consider treating the primary site per STAMPEDE as well as possible SABR the other lesions, so long as he understands this is an evolving area and the benefit has not been conclusively demonstrated. Would recommend confirming the bone lesion by biopsy as well.
How do you treat metastatic testicular cancer with the primary orchiectomy pathology showing non-seminoma with components of teratoma and primitive neuroectodermal tumor?
If such a patient had evidence of widespread metastases with normal tumor markers, I would have the pathology on the orch specimen reviewed at an experienced center. Assuming that review confirms PNET component, I would consider systemic chemotherapy with alternating VIP/CAV. It is very unlikely to ...
What would be the best treatment approach for bladder cancer patients s/p neoadjuvant therapy and surgical resection who develop oligometastatic recurrence within 1 year that is amenable to resection?
I agree with @Dr. First Last that this is a systemic disease and a "harbinger" for other micrometastasis. Data on metastasectomy is retrospective and of low level of evidence due to selection and confounding factors. I personally would not recommend local therapy with surgery or radiation, but rathe...