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Case Presentation: Advanced Urothelial Carcinoma with Spinal and Liver MetastasiW Case Presentation
Patient Case:
A 50-year-old woman initially presented to her doctor with blood in her urine. She had a CT urogram which showed a 2.5 cm bladder mass and underwent transurethral resection of bladder tumor (TURBT) which showed high-grade urothelial carcinoma with deep muscle invasion. A new CT scan was done to complete staging which showed a suspicious lesion in the spine at the level of L1. The lesion was confirmed on MRI and biopsy, proven to be consistent with metastatic urothelial carcinoma.
She has an Eastern Cooperative Oncology Group (ECOG) performance status of 0. She has no past medical or surgical history. She has never smoked. Her globular filtration rate (GFR) is >60 mL/min and her PD-L1 (measured by 22C3) showed a combined positive score of 0. Of note, her tumor is microsatellite stable, with a tumor mutational burden of 12 mutations per megabase. She does not have an activating mutation in FGFR2 or FGFR3.
After a discussion of first-line treatment options she received dose-dense MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) for 5 cycles. Restaging scans showed stable disease. Given that the patient was having discomfort at the site of her L1 lesion, she was offered palliative radiation followed by switch maintenance therapy with 800 mg of avelumab every 2 weeks.
Unfortunately, a CT scan done after 6 cycles of therapy showed multiple new metastatic lesions in the liver and spine. Her ECOG performance status is now 1. She has some tinnitus from prior chemotherapy but otherwise is doing well. She was offered and started treatment with enfortumab vedotin at 1.25 mg/kg. She tolerated treatment well and prior to C3D1 underwent a restaging CT without contrast (due to a national shortage of IV contrast) which reported interval progression of bone metastasis (19 mm vs 14 mm and 10 mm vs 7 mm) and suboptimal evaluation of liver metastasis.
