Introduction
In the UK Pembrolizumab can be given to patients with untreated PD-L1-positive locally advanced urothelial cancer who are not suitable for cisplatin chemotherapy in view of phase 2 data from KEYNOTE-052 trial showing superior life expectancy than best supportive care. We report the case of a 71-year lady who presented with inoperable bladder cancer.
Clinical Findings
The patient presented in March 2018 with several months history of bleeding per vaginum/per urethra, recurrent urinary tract infections and pelvic pain. No significant past medical history. Abdominal examination revealed a large right sided pelvic mass fixed to the pelvis.
Diagnosis
June 2018: Transurethral resection bladder tumour - necrotic tumour at bladder neck from 8 o’clock to 12 o’clock. Linear mass 6x2cm tethered to the pubis anteriorly
Histology: Invasive grade 3 urothelial carcinoma with extensive tumour necrosis, infiltrating lamina propria and detrusor muscle, possible lymphovascular channel involvement – G3 pT2.
PDLI expression: Tumour tested with Dako PD-L1 IHC 22C3 parhmDx Combined Positive Score (CPS) 100
USS: 48x47x32 mm mass in bladder, mild hydronephrosis right kidney.
GFR 35ml/min
CT: extensive right-sided bladder tumour with early invasion of perivesical fat and mildly enlarged right internal iliac lymph nodes, small peripheral lower lobe pulmonary nodules
Treatment/Outcomes
Aug 2018: Right percutaneous nephrostomy followed by right antegrade stent insertion
Patient was not suitable for cisplatin chemotherapy in view of recurrent UTIs and poor renal function. She was commenced on Pembrolizumab 200mg iv every 3 week in September 2018 and received 8 cycles to February 2019. CT scans Nov 2018 and Jan 2019 showed response to treatment within the bladder and static lung nodules. Treatment was tolerated well and the only toxicity was hypothyroidism requiring replacement therapy.
Patient had ongoing troublesome lower urinary tract symptoms and given excellent radiological response to treatment, she proceeded to robotic assisted radical cystectomy and bilateral pelvic node dissection, hysterectomy, salpingo-oophorectomy and removal of ureteric stent in March 2019.
Path report: Complete response to systemic immunotherapy, no residual dysplasia, CIS or invasive malignancy. Lymph node positive (1/7 right pelvic node) – ypT0 N1 Mx.
Immunotherapy treatment has not been restarted. The first 3-monthly CT surveillance scan since surgery has shown no evidence of disease. Patient remains well.
