癌症免疫療法用於轉移膀胱癌且自體免疫疾病的案例報告

鄭偉權、康智雄

高雄長庚紀念醫院泌尿科

Case report: Pembrolizumab treatment in metastatic urothelial carcinoma with underlying disease of autoimmune disease

Wei Quen Tee, Chih-Hsiung Kang

Department of Urology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan.

Introduction:

Pembrolizumab is one of the immunotherapies for urothelial carcinoma. The efficacy and safety of pembrolizumab in urothelial carcinoma with autoimmune disease is still unclear. We present a case of metastatic bladder cancer woman who had systemic lupus erythematous (SLE) and end stage renal disease (ESRD) treated with pembrolizumab and had a remarkable response without obvious adverse effects.

Case report:

A 35 years old woman admitted due to grossly hematuria for months. She has underlying disease of systemic lupus erythematous (SLE) with lupus nephritis and end stage renal disease (ESRD). She had been diagnosed with SLE for 20 years and controlled with hydroxychloroquine and prednisolone. She received regular hemodialysis once a week. Initially, she was diagnosed with bladder cancer at other hospital and transferred to our hospital. Abdominal CT showed bladder cancer (T2N2M2) with pelvic lymph nodes and multiple lung metastases with tissue proofed by wedge resection of lung. We performed transurethral resection of bladder tumor. The pathology report showed high-grade infiltrating papillary urothelial carcinoma with muscle, lymph-vascular invasion.  

She received Pembrolizumab as first line systemic therapy every 3 weeks. There was total 6 cycles of Pembrolizumab. The bladder tumor was disappeared and all lymph nodes and metastatic nodules were regression during 1 year after the final cycle of pembrolizumab. Daily administration of hydroxychloroquine (200mg) was continued throughout pembrolizumab therapy. Grade 1 diarrhea was noted and probiotics was administrated. She had been followed up with serological parameters (C3, C4, DSDNS) during treatments, there were no significantly changes and no acute lupus flare up was noted. Her cancer free survival duration was 2 years after pembrolizumab therapy and still regularly followed up.

Discussion:

Pembrolizumab is one of the PD-1 blockage immunotherapies for urothelial carcinoma. It has revolutionized the cancer treatment for several years and the various adverse effects is remained unclear especially between autoimmune disease and immunotherapies. This case reported pembrolizumab can treat in patients with well control SLE.

Corticosteroid is commonly prescribed to treat and control autoimmune disease for immunosuppressive effect. Theoretically, this immunosuppressive effect could reduce the effective of PD-1 inhibitor. Previous study showed that high dose of corticosteroid was correlated with worse clinical outcome in patients with non-small cell lung cancer treated with PL-1/PD-L1. In our case, due to patient had well control of SLE with daily hydroxychloroquine 200mg, no prednisolone was prescribed.

Further study was required for efficacy and safety of PL-1/PD-L1 inhibitor in metastatic urothelial carcinoma with autoimmune disease patients and the using/dosage of immunosuppressants.

Conclusion:

Pembrolizumab could be beneficial to a patient with metastatic urothelial carcinoma combined with SLE and ESRD.