From the Guidelines
The next steps for bilateral urothelial masses with small liver lesions and mediastinal and bilateral axillary adenopathy seen on CT should include a comprehensive diagnostic workup to confirm malignancy and determine its extent, as recommended by the most recent guidelines from the European Society of Urology and the American College of Radiology 1.
Diagnostic Approach
The diagnostic approach should include:
- Urologic consultation for cystoscopy with biopsy of the urothelial masses to establish a tissue diagnosis
- CT-guided or ultrasound-guided biopsy of the liver lesions or accessible lymph nodes to determine if these represent metastatic disease
- Complete laboratory studies including complete blood count, comprehensive metabolic panel, and urinalysis with cytology
- Additional imaging with PET-CT to evaluate the full extent of disease and identify potential metastases not seen on conventional CT
- Tumor markers relevant to urothelial carcinoma should be checked
Rationale
This approach is necessary because the imaging findings suggest a potentially advanced urothelial malignancy with metastatic spread to the liver and lymphatic system, as supported by recent studies on the use of CT urography for diagnosing and staging urothelial malignancies 1. The diagnostic confirmation will guide treatment planning, which may involve a multidisciplinary approach including urology, medical oncology, and radiation oncology depending on the stage and grade of disease identified.
Considerations
It is essential to consider the patient's overall health and potential comorbidities when determining the best course of action, as some patients may not be suitable for certain treatments, such as radical cystectomy 1. The use of neo-adjuvant chemotherapy before cystectomy for T2 and T3 disease has been shown to have a survival benefit, and should be considered in the treatment plan 1.
From the Research
Next Steps for Bilateral Urothelial Masses with Small Liver Lesions and Mediastinal and Bilateral Axillary Adenopathy
- The patient's condition suggests metastatic urothelial carcinoma, which requires a comprehensive treatment approach 2, 3, 4.
- The first-line therapy for metastatic bladder cancer (urothelial carcinoma, UC) depends on whether a patient is cisplatin-fit or not 2.
- For cisplatin-fit patients, the standard chemotherapy protocol is GC (gemcitabine/cisplatin) or alternatively MVAC (methotrexate/vinblastine/doxorubicin/cisplatin) 2.
- The optimal first-line therapy for cisplatin-unfit patients remains unclear, but one criterion for selecting therapy can be the PD-L1 (programmed cell death ligand 1) status of the tumor 2.
- PD-L1-negative patients may benefit from combination chemotherapy GCa (carboplatin/gemcitabine), while PD-L1-positive patients may benefit from immune checkpoint inhibitors such as atezolizumab and pembrolizumab 2, 5.
- The patient's performance status, access to treatment, and outcomes should be analyzed, and treatment decisions should be made based on individual patient characteristics 6.
- Emerging strategies for treating urothelial carcinoma include the use of immune checkpoint inhibitors, targeted agents, and combination therapies 3, 4, 5.