侵犯性漿細胞樣膀胱泌尿上皮癌的手術及免疫治療 – 病例報告

蘇楷森¹、林子平^1,2、黃志賢^1,2 

¹臺北榮總泌尿部；²國立陽明交通大學書田泌尿科學研究中心

Surgical Intervention and Immunotherapy for Locally Advanced

Plasmacytoid Urothelial Carcinoma of Urinary Bladder: A Case Report

Kai-Sen Su¹, Tzu-Ping Lin ^1,2, William J. Huang^1,2

¹ Department of Urology, Taipei Veterans General Hospital;

² Department of Urology, School of Medicine and Shu-Tien Urological Science Research Center, National Yang Ming Chiao Tung University

Introduction:

Plasmacytoid urothelial carcinoma of the bladder (PUC) is a rare bladder cancer variant with aggressive disease behavior and poor prognosis. PUC diagnosis usually predicts an advanced disease stage with extravesical invasion and the propensity of peritoneal carcinomatosis and locoregional spread along fascial planes. Here we would like to present a female case of PUC treated at our institute. We offered radical surgery with anterior exenteration + ileal conduit as primary treatment, followed by six cycles of Nivolumab as adjuvant therapy.

Case report:

Thi 41-year-old female had no significant underlying disease. She presented with painless gross hematuria along with episodes of right flank pain for three months. Initial workup including computed tomographic urography (CTU) revealed suspected bladder tumor, with right kidney subcapsular hematoma and moderate hydronephrosis. cT2N0M0Transurethral resection of bladder tumor (TURBT)in 2021/1, yielded plasmacytoid urothelial carcinoma, with bladder neck and right ureteral orifice involvementat least T2.

Considering the generally low response rate to systemic treatment of PUC, straight radical surgery was offered.

Robotic-assisted anterior exenteration + ileal conduit was done on 2021/2. The pathology report disclosed infiltrating plasmacytoid urothelial carcinoma, with extravesical tumor invasion of pelvic serosa, pT4bN2. with no pathological diagnosis in uterus, cervix, vagina and bilateral ovaries, the surgical margin is negative. Follow up Nivolumab 200mg q2wk for total 6 cycles. The patient experienced 6 months of disease-free status post-operatively until 2021/9, local recurrence was noted at rectum along with diffuse pelvic floor muscle infiltration, with nearly total obstruction of rectal lumen. Emergent T-loop colostomy was done for obstruction relief, and she was taken over by medical oncologist for further systemic therapy and supportive care.

A single institutional cohort of 64 patients with PUC published in 2020 by Diamantopoulos, et al showed no benefit of neoadjuvant chemotherapy in PUC. Applying current systemic therapy paradigm to PUC is based on scarce and equivocal data to date, mainly extrapolating from conventional urothelial carcinoma.

Conclusions:

PUC is associated with poor prognosis despite the use of standard bladder cancer treatment modalities. PUC on TURBT may warrant aggressive therapy. Wide resection was often warranted due to high rates of surgical margin positivity. Despite successful local excision, the disease course seemed dismal. Further research on systemic therapy of choice and treatment modality for variant histology of urothelial carcinoma was warranted.