CARCINOMA OF THE BLADDER – A CASE STUDY
This 53 year old male had a history of hematuria with painful urination for one year, with increasing frequency in urination and normal PSA levels. The patient had been taking Flomax to manage the frequent urination. An investigative CT of the abdomen and pelvis was performed 5/2/2007. This scan revealed a “lobular mass involving the posterior wall of the urinary bladder measuring up to 4.1 cm in the largest AP dimension x 4.5 cm (T). The study concluded the findings as “concerning for a urinary bladder carcinoma invading the posterior wall of the urinary bladder with growth into the adjacent intrapelvic fat. It also appears to involve the ureterovesicular junctions bilaterally.”
A pathological diagnosis of invasive, high-grade transitional cell carcinoma was confirmed 5/10/2007. At this time, the patient was offered a cyctectomy and prostatectomy, which he refused. He sought a second opinion and once again, the same course of treatment was recommended.
The patient first presented to Dr. Ayre June 4, 2007 to discuss alternatives to the surgical procedures offered. Dr. Ayre informed the patient at this time that he would be a candidate for experimental procedures once he has followed through with the standard of care for his disease and have had those measures fail.
The patient again presented to Dr. Ayre November 27, 2007 with complaints of weight loss, weakness, lower back and abdominal pain, and frequent urination accompanied by burning. The patient had elected to follow a raw food and juice regimen under the direction of a naturopath, accompanied by a variety of supplements including pau pau, Vitamin D 3, curcumin, and a prostate supplement. The patient had ceased the raw food/juice diet in August and had been taking Aleve for considerable abdominal pain. A comparison CT scan of the abdomen and pelvis performed October 11, 2007 described interval increase in size of the urinary bladder mass from 4.1 cm (AP) x 4.5 cm (T) to 4.8 cm (AP) x 5.1 cm (T). Additional findings included “inherent involvement of the right ureterovesicular junction and dilation of the distal right ureter with milder proximal dilation and fullness to the right renal collecting system.” Also noted were bilateral small pelvic lymph nodes as well as mild retroperitoneal lymphadenopathy. Following the findings of this CT scan, the patient was then informed by his oncologist that chemotherapy was the only option due to the interval disease progression to his lymph nodes. At this time, Dr. Ayre strongly advised the patient to pursue chemotherapy, either standard dose or IPT.
After making financial arrangements, the patient presented December 18, 2007 to begin a course of fractionated chemotherapy using insulin biologic response modification with the following regiman: Cytoxan 150 mg, Adriamycin 10 mg, and Cisplatin 12 mg. Medications included Naltrexone 3.0 mg, Arimidex 0.5 mg, Progersterone 30 ml pump cream, and extra strength Tylenol. CA 19-9 levels taken 12/14/07 measured 41 U/ml. The patient received by IV 60 grams total of ascorbic acid following every IPT treatment. IPT and intravenous ascorbic acid treatments were given 12/18/07 – 5/29/08.
After six bi-weekly treatments over the course of three weeks, a comparison scan was performed. Dated 1/10/2008 the interpreting radiologist reported a “significant decease in size of right posterior bladder mass.” This mass reportedly measured 2.9 cm (AP) x 3.5 cm (TO) [previous measurements dated 10/11/07 were reported as 4.8 cm (AP) x 5.1 cm (T)]. Right ureterovesicular junction and distal right ureter involvement was reported, but was “much smaller in size.” No other abnormalities were reported. Also noted were the presence of bilateral inguinal hernias without herniation of bowel loops. An addendum to this report noted the presence of pelvic lymph nodes, though these were slightly smaller and no significant retroperitoneal lymph nodes were seen. A few paraaortic nodes were present though unchanged from previous studies. CA 19-9 levels measured 30 U/ml on 1/9/2008. Subjectively, the patient reported a significant reduction in abdominal pain from a “7 or 8 to a 2 on a scale of 10.”
A comparison CT scan dated March 18, 2008 was performed after seven weekly IPT treatments with the same regimen and dosages. Again, significant interval decrease in the size of the urinary bladder mass was noted, measuring 2.1 cm (AP) x 19.5 mm (T). Again noted was “involvement of the distal right ureterovesicular junction and of the right seminal vesicle region. However this is mildly smaller than the previous study [referencing 1/10/08].”
IPT treatments were tapered off to once every two weeks following the results of the 3/18 scan. The patient received another four IPT treatments in this interval, for a total of 17 treatments. A bone scan dated 5/5/08 reported “no scan evidence for metastatic disease.”
After the last IPT treatment, dated 5/29/08, a whole body PET/CT was performed on July 14, 2008. The report discussed, “Residual non-specific soft tissue change along the right base of the urinary bladder and adjacent seminal vesicle. ….However, portions of the thickened seminal vesicle do not appear hypermetabolic suggesting that there may be an element of residual scarring/post treatment change….There is no suspicious adenopathy or evidence of distant metastatic disease.”
At this time, the patient discontinued further treatment due to financial constraints and familial obligations. Office notes dated August 11, 2008 reported that the patient continues to do well with no apparent issues with bladder function. In a fax dated January 9, 2009 the patient’s only reported complaint was a possible sinus infection.
A PET/CT dated 12/1/09, which was compared to PET CT dated 7/14/08, reported: 1. No suspicious activity in the neck or chest soft tissues. 2. There is no suspicious uptake in the abdomen. The liver and adrenal glands appear normal. Non-enlarged retroperitoneal lymph nodes are unchanged. Mild residual soft tissue thickening in the region of the right seminal vesicle is less prominent. There are no new suspicious masses. There is no unusual hypermetabolic activity in or around this region. There is no suspicious regional adenopathy. 3. There is no suspicious osseous uptake. Overall impression: Normal PET CT without suspicious uptake.
The patient continues in good health as of February 16, 2010.