Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Would you give adjuvant immunotherapy after nephrectomy?
The KN-564 will certainly change the landscape of adjuvant RCC. Prior studies had either been negative, or have been positive (sunitinib in S-TRAC) but with toxicity that has precluded widespread use. The OS data from KN-564 is too immature to interpret, in my opinion, so the debate of whether to tr...
Do you use the highest or most recent PSA for risk stratification for newly diagnosed prostate cancer?
This happens on occasion and can be a dilemma. First, I would repeat the PSA and see if it is <20 or >20, and take that into account. I would also take into account the genomic score. This may help further clarify the patient's risk category. If the patient had a reason for the first elevated PSA li...
Will you offer adjuvant BEP after orchiectomy to a patient with embryonal carcinoma, solely based on the size at presentation, such as a 6 cm testicular mass?
I would not consider adjuvant BEP in this setting. While the risk of relapse is likely higher than smaller non ECC predominant tumor, it likely does not exceed a 50% chance of recurrence. Our general stance is active surveillance for all CS 1 seminoma and non seminoma patients. Adjuvant anything imm...
How would you approach a pT2 nonseminomatous testicular cancer, embryonal caricnoma with +LVI with persistent b-hcg < 20 post-operatively?
If a patient has had an inguinal orchiectomy and has a persisting b-HCG in a reliable lab (remember that alpha-HCG can cross-react with the alpha chain of LH, so a "good" beta-HCG assay is important, especially as hypogonadal males often have an elevated LH), it suggests clearly that there is residu...
How would you treat a patient with newly diagnosed prostate cancer with low volume bone metastases and extensive lung metastases with a very low PSA (< 5) and no neuroendocrine differentiation on pathology?
Generally, I would treat such a patient with ADT plus abiraterone (or enzalutamide). A recent paper from our group suggested that patients who present with pulmonary mets, without concurrent liver mets, usually have a great prognosis with hormonal therapies. Another interesting phenomenon is that pa...
Would diagnosis of a low grade, non-invasive papillary bladder cancer alter your recommendations for salvage prostate radiotherapy after rising PSA?
I would treat with salvage RT as that’s definitive treatment for recurrent prostate cancer and treat non invasive bladder cancer with TURBT and cystoscopic surveillance.
How would you treat high risk prostate adenocarcinoma who relapsed after RT and ADT with a very low PSA, widespread mets to bone and soft tissue who is progressing on ADT, docetaxel and carboplatin?
Difficult situation, this patient likely has neuroendocrine differentiation. I would check for markers like NSE, chromogranin if positive, then can make the case of treating as small cell ca progressed on platinum based chemotherapy and treat with lurbinectedin (Trigo et al., PMID 32224306).PSMA bas...
How and when are you using sipuleucel-T in metastatic prostate cancer given the increase in available treatment options?
At the present time, they do not. The options of treatment in the mHSPC setting include ADT, NHT, and docetaxel only. There are some ongoing clinical trials evaluating the combination of immune therapy with PD-1/PD-L1 checkpoint inhibitors and docetaxel or NHTs currently. Some phase II clinical tria...
What is the preferred adjuvant therapy for high-risk non-clear cell RCC?
Unfortunately, non-clear cell RCC (nccRCC) has not been included in past or current adjuvant trials. Sunitinib, which has limited effect in the adjuvant setting, would be expected to have even less in nccRCC given relative activity in the metastatic setting. A similar scenario exists for IO adjuvant...
How do you approach a tumor bed recurrence after previous neoadjuvant chemo and cystectomy for bladder cancer?
I would opt for concurrent chemoRT in most instances. Here is my explanation as to why: First, I think it's important to establish that recurrence of bladder cancer after radical cystectomy (RC) usually portends a very poor prognosis; these patients have a median survival of 5.6 months after diagnos...