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Challenging Cases in Urothelial Cancer


Urothelial cancer of the urinary tract is common and affects a large number of men and women, resulting in a reasonably large part of the work effort of urologists who take care of adults. Most of the urothelial tumors arise in the bladder but the same causative factors can lead to similar tumors in the kidneys, ureters, prostate, and urethra. Due to the heterogeneous nature of these tumors as well as their propensity for “recurring” in time and location over the patient’s life the clinician is often in the position of deciding among often challenging treatment choices for his/her patient. Although there are published guidelines many cases do not readily fit into a typical scenario, thus leaving ample room for decision making for the individual patient. We invite our readers to review and comment on the case and management by using the online comment section below each case:

Case 3. High grade (grade 3) Ta urothelial carcinoma of the bladder with an adjacent area of CIS

72 year old woman who had one episode of gross hematuria and saw a urologist for an investigation.

Her general health is good. The only prior surgery was a cholecystectomy.

She smoked cigarettes for 15 years – one pack/day. She stopped 30 years ago.

She had a CT scan which was negative with the exception of a possible bladder tumor.

In October 2015 she underwent a TUR BT of a 3 cm solitary exophytic appearing tumor. The pathology was high grade (grade 3) Ta urothelial carcinoma of the bladder with an adjacent area of CIS. There was some concern that all tumor was not removed but this is not clear.

A decision was made to proceed with intravesical BCG. She received six weeks and tolerated all treatments.

She sought a second opinion in 1/2016 and an office cystoscopy identified a small area of erythema and a new or previously unresected exophytic appearing tumor. A TUR BT revealed CIS and focal HG T1a urothelial cancer of the bladder.

She underwent a reTUR BT and the prior resection site was identified an resected. It was no more than 1.5 cm in size. The rest of the bladder was normal in appearance. The pathology revealed HG Ta and focal CIS.

What would you suggest?