Atezolizumab使用於局部復發晚期尿路上皮癌患者的案例報告
陳韋辰、陳卷書、裘坤元、程千里
台中榮民總醫院 外科部 泌尿外科
Case report: Atezolizumab in local recurrent advanced urothelial carcinoma
Wei-Cheng Chen, Chuan-Shu Chen, Kun-Yuan Chiu, Chen-Li Cheng
Divisions of Urology, Department of Surgery, Taichung Veterans General Hospital
History:
This 81-year-old lady with past history of hysterectomy at the age of 40 due to abnormal pap smear finding with vaginal bleeding, neurogenic bladder and stress urinary incontinence. Otherwise, she denied any other systemic disease.
She was diagnosed as a victim of left ureteral urothelial carcinoma in a medical center in northern Taiwan. Robotic assisted left nephroureterectomy was performed there in January, 2017, which pathology reported pT3N0M0. She was regularly followed without adjuvanttherapy.
However, follow-up abdominal computed tomography (CT) revealed local tumor recurrence over left retroperitoneum, with invasion to psoas muscle complicated with adhesion ileus of small bowel and descending colon. Transverse-colostomy was done on November 30th of 2017. Palliative chemotherapy with hospice care was suggested but the patient and family refused. Thereafter, she was brought to our urology clinic.
The CT on 2018/01/08 revealed UC of left ureter s/p robotic nephroureterectomy at outside hospital with local recurrence at left retroperitoneum, invasion to left psoas muscle and adhesion to small bowel and descending colon.
We provided choices including chemotherapy with Carboplatin plus Gencitabine, immune checkpoint inhibitors(ICI), and clinical trial of immune checkpoint inhibitor or chemotherapy or combination of both. Due to poor renal function, she was exluded from clinical trials. After discussion, self-paid immune checkpoint inhibitor together with chemotherapy using regimen of Gencitabine and Carboplatin was arranged. Concerning intolerance, we started with ICI first(2018/2/2), then ICI with Gencitabine(2018/2/24), then ICI with Gencitabine and Carboplatin(2018/3/16, 4/7, 4/27, 5/18, 6/22).
Under 5 times of self-paid ICI and chemotherapy, regression change of local recurrent lesion at left retroperitoneum was noted on abdominal CT on 2018/05/10. After 7 times of treatment, the abdominal CT on 2018/07/20 showed further regression. Afterwards, we performed excision of left retroperitoneal tumor with descending colon resection on 2018/07/27, pathology proved recurrent urothelial carcinoma.
Discussion:
In the era of immuno-oncology (IO), immune checkpoint blockade therapy have stunning effect on certain cases. Current guideline for locally advanced bladder cancer suggest Gencitabine and carboplatin for Ciplatin ineligible patients. For whose tumor express PD-L1 or who are not eligible for any platinum-containing chemotherapy, Atezolizumab or Pembrolizumab are favored. Clinical trials including IMvigor130 and KEYNOTE-361 are still recruiting cases. However, our patient was not qualified due to poor renal function. After discussion, we carried out self-paid treatment with the same regimen as the ongoing trial.
Dramatic regression change was shown in the follow-up CT. Since the shrinkage of recurrent tumor, we arranged tumor excision. Surgery in patients receiving IO is feasible and safe, when unresectable tumor became resectable.
Conclusion:
We concluded that immune checkpoint inhibitor together with Gencitabine and Carboplatin chemotherapy may be related with favorable outcome for local recurrent advanced urothelial carcinoma in Ciplatin ineligible patients. Surgery in patient receiving immuno-oncology therapy is feasible and safe.