Enfortumab vedotin合併Pembrolizumab作為肌肉侵犯型膀胱癌接受部分膀胱切除術前之輔助性治療: 個案報告

梁柏崧  陳柏華  裘坤元  石宏仁

彰化基督教醫院外科部泌尿科

Enfortumab vedotin plus Pembrolizumab as Neoadjuvant Therapy Before Parital Cystectomy in Muscle-Invasive Bladder Cancer: A Case Report

Po-Sung Liang, Pao-Hwa Chen, Kun-Yuan Chiu, Hung-Jen Shih

Division of Urology, Department of Surgery, Changhua Christian Hospital

Introduction:

The combination of enfortumab vedotin and pembrolizumab has been found to result in considerably prolonged progression-free survival and overall survival in advanced urothelial carcinoma (UC). About 67.7 percent response rate of primary tumor was noted from the trial. This report presents the clinical efficacy of enfortumab vedotin combined with pembrolizumab as neoadjuvant therapy for a patient with muscle-invasive bladder cancer (MIBC).

Case presentation:

A 77-year-old man with a history of hypertension, abdominal aortic aneurysm, coronary artery disease, left internal carotid artery stenosis post stenting, and chronic renal disease presented with a weak urine stream with gross hematuria for several months. An abdominal ultrasound identified a heterogeneous echogenic density mass in the bladder. An ensuing intravenous pyelography (IVP) revealed a filling abnormality in the urinary bladder. During cystoscopy, a substantial mass was seen, with necrotic surface tissue and erythematous blood seeping. It was located above the dome, extending to the anterior wall. A biopsy was performed, and the pathology results indicated high-grade papillary urothelial carcinoma. A contrast-enhanced magnetic resonance imaging (MRI) scan verified the existence of a large increased polypoid mass lesion on the left lateral wall of the urinary bladder, measuring up to 9 cm, consistent with UC of the urinary bladder. Perivesical fatty stranding was observed, indicating invasion of the perivesical tissue. The clinical staging was cT3N0M0, indicating stage IIIA. Cisplatin-based chemotherapy was deemed unsuitable for the patient due to chronic renal impairment. Following comprehensive discussion with the patient, neoadjuvant therapy utilizing the combination of enfortumab vedotin and pembrolizumab was administered for 3 cycles. The subsequent MRI revealed a dramatic reduction in the primary tumor diameter from 9 cm to 2 cm. The patient was advised of the necessity for definitive surgery following neoadjuvant therapy and requested bladder preservation. The tumor initially occupied the urinary bladder and diminished in size after neoadjuvant therapy, enabling a partial cystectomy. During the procedure, cystoscopy was conducted first. The primary tumor was located on the left lateral wall near the dome, and an additional minor papillary lesion was observed on the right posterior wall. A transurethral resection of the bladder tumor (TURBT) was performed on the lesions excluding the primary tumor. The bladder tumor's location was detected under laparoscopic examination with cystoscopy guidance. A robotic partial cystectomy with left pelvic lymph node dissection was executed smoothly. The tumor was completely excised en bloc with adequate margins, then a two-layer cystography was conducted. The postoperative recovery was uneventful. To our surprise, the pathology confirmed the absence of residual invasive carcinoma. He achieves a complete response on imaging and cystoscopy after 4 months of follow-up. Currently, he is participating in follow-up appointments at our outpatient department.

Conclusions:

In patients with muscle-invasive bladder cancer (MIBC), neoadjuvant enfortumab vedotin combined with pembrolizumab, followed by partial cystectomy, proved to be a viable approach for achieving bladder preservation without compromising oncological outcomes. The long-term outcome requires further evaluation.