Challenging Cases in Urothelial Cancer

A 67 year old woman with congestive heart failure underwent an extensive medical evaluation prior to consideration for a heart transplant. She has a 20 year history of cardiomyopathy. In 2015 she developed recurrent ventricular tachycardia and had an implantable cardioverter/defibrillator (ICD) placed and underwent cardiac ablation.

This is an 83 year old man with a several month history of gross hematuria. He smoked cigarettes and cigars for approximately 50 years. His past medical history is pertinent for a coronary artery stent placed in 2009 and a stroke in 2019 from which he recovered without neurologic impairment. He has been taking the anticoagulant apixaban (Eliquis) since.

This is a 69 year old healthy woman who has a long history of urothelial cancer of the bladder. She was a cigarette smoker from age 20 to 35 when she stopped. She smoked one pack per day. She has had an appendectomy and a total abdominal hysterectomy.

This is a 65-year-old current and longtime cigarette smoker who presented to me with an 8 month history of intermittent gross hematuria and a diagnosis of muscle invasive urothelial cancer of the bladder. He has type 2 diabetes mellitus. He had symptomatic coronary artery disease and coronary artery stents were placed in 2015. He currently has a good performance status.

RS is an 81 year old man with a history of low and high grade Ta bladder cancer in 2010. He was free of any bladder cancer until 2020. He had routine office cystoscopy and cytology through 2016 with urinalysis only from 2016 to 2020.

This is a healthy appearing 76 year old man who presented with mild gross hematuria that lasted for two days.

I performed a radical prostatectomy on him twelve years ago. His PSA has been 0 since. He is continent. A CT urogram was normal with the exception of a possible small filling defect on the left side of the bladder.

He is a former cigarette smoker with a 20 pack year history.

V.L. is a 76 year old man in good health. He had a 20 pack year history of cigarette smoking. He stopped smoking at age 45. In 2003 he had an episode of gross hematuria and a work up revealed a papillary low grade Ta bladder tumor which was resected endoscopically.

M.L. is a very healthy 60 year old woman who presented with an episode of gross hematuria in November 2018. A CT scan indicated a bladder tumor on the left wall. The upper urinary tract was normal. Her past medical history was entirely negative. An outpatient flexible cystoscopy identified a papillary exophytic solitary tumor on the left lateral wall of the bladder. The remainder of the bladder was normal.

L.R. is a healthy appearing 83 year old woman that presented to a urologist upon referral from her primary care physician with a 6 month history of recurrent urinary tract infections and more recently some right flank discomfort. A CT scan of the abdomen and pelvis revealed moderate right hydronephrosis with a point of obstruction near or at the bladder. The left upper tract was normal. Images of the bladder indicated masses consistent with bladder cancer.

MG is a 75 year old man who presented with a single episode of gross hematuria in October 2017. He is overweight and has insulin dependent diabetes mellitus. He has some lower urinary tract voiding symptoms. These consist of nocturia twice and some daytime frequency. His urinary stream is slow.

Approximately 80 per cent of patients who have a urothelial tumor of the bladder have a low or high grade papillary tumor which is non invasive (Ta) or is high grade papillary or sessile and invades the lamina propria (T1). The initial presentation is most commonly gross hematuria, which promptly leads to outpatient endoscopy and a subsequent transurethral resection (TUR BT).

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.