吳芃諺、李建儀、陳卷書

台中榮民總醫院 外科部 泌尿科

Peng-Yen Wu, Jian-Ri Li, Chuan-Shu Chen

Division of Urology, Department of Surgery, Taichung Veterans General Hospital

 

Introduction: Surgical intervention presents as a curative management of localized urothelial carcinoma (UC) of bladder but over half of the patient who underwent operation experienced a recurrence of the disease. Pre-operative approaches have had a increasingly prominent role in treatment of UC. Among these approaches, immunotherapy represents an ongoing revolution of the management of advanced tumors including urothelial carcinoma. Here we presented a case with UC of bladder with perivesical tissue involvement, who underwent neoadjuvant chemo-immunotherapy with pembrolizumab with complete response.

Case and Experience: A 59-year-old man has suffered from gross hematuria since March, 2018. In May, 2018, the sonography of kidney was performed, which disclosed left side hydronephrosis. The abdominal computed tomography (CT) was done and showed a bladder tumor over left ureterovesical junction (UVJ), wide based, complicated with left side moderate hydronephrosis. The transurethral bladder tumor resection (TURBt) was carried out on June 6th, 2018. The pathology showed infiltrating urothelial carcinoma, high-graded, with muscular involvement. The follow-up cystoscopy on July 5th, 2018 showed residual tumor over left UVJ and trigone with involvement of prostatic urethera. The digital exam found firm consistency of anterior rectal wall, which was suspected advanced tumor involvement. The neoadjuvant chemotherapy with gemcitabine, cisplatin (GC) and pembrolizumab was administered on July 9th and July 21st, 2018. The CT of kidney on August 20th, 2018 showed thickened bladder wall without regional lymphadenopathy and distal metastasis. The radical cystoprostatectomy with pelvic lymph node dissection and Studer pouch reconstruction was carried out on August 23rd, 2018. The pathology revealed that the bladder, the prostate and lymph nodes being free of tumor. The pathological restaging was pT0N0. The patient was now followed at our outpatient department regularly.

Discussion: We presented a case with urothelial carcinoma of urinary bladder with perivesical tissue involvement, who received 2 courses of neoadjuvant chemo-immunotherapy with gemcitabine, cisplatin (GC) and pembrolizumab (100mg every dose, given at a interval of 3 weeks), following by radical cystoprostatectomy. The pathological restaging revealed complete response. The T-cell checkpoint inhibitors, including those targeted programmed death 1 (PD-1) and its ligand (PD-L1), have led to the exploration as a neoadjuvant therapy. In the PURE-01 study, preoperative pembrolizumab has been reported a high pathologic responsive rate among the patients with muscle-invasive urothelial carcinoma of urinary bladder. Further clinical trials are needed to establish the role of pembrolizumab and other immunotherapy agents in the treatment of bladder cancer in the non-muscle invasive, localized, and locally-advanced settings.