切换至 "中华医学电子期刊资源库"

中华腔镜泌尿外科杂志(电子版) ›› 2024, Vol. 18 ›› Issue (06) : 648 -652. doi: 10.3877/cma.j.issn.1674-3253.2024.06.019

所属专题: 经典病例

MDT精选病例

广东省医学会泌尿外科疑难病例多学科会诊(第15期)——转移性膀胱癌的综合治疗
林逸1, 钟文龙1, 李锴文1, 何旺1, 林天歆1,()   
  1. 1.510000 广州,中山大学孙逸仙纪念医院泌尿外科
  • 收稿日期:2024-08-19 出版日期:2024-12-01
  • 通信作者: 林天歆
  • 基金资助:
    国家自然科学基金(82373254、81961128027)广东省自然科学基金(2023A1515010258)广东省科技计划项目(2023B1212060013)

Multidisciplinary consultation on difficult cases in Guangdong Urological Association (Phase 15): comprehensive treatment of metastatic bladder cancer

Yi Lin1, Wenlong Zhong1, Kaiwen Li1, Wang He1, Tianxin Lin1,()   

  1. 1.Department of Urology,Sun Yat-sen Memorial Hospital,Sun Yat-sen University,Guangzhou 510000,China
  • Received:2024-08-19 Published:2024-12-01
  • Corresponding author: Tianxin Lin
引用本文:

林逸, 钟文龙, 李锴文, 何旺, 林天歆. 广东省医学会泌尿外科疑难病例多学科会诊(第15期)——转移性膀胱癌的综合治疗[J]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(06): 648-652.

Yi Lin, Wenlong Zhong, Kaiwen Li, Wang He, Tianxin Lin. Multidisciplinary consultation on difficult cases in Guangdong Urological Association (Phase 15): comprehensive treatment of metastatic bladder cancer[J]. Chinese Journal of Endourology(Electronic Edition), 2024, 18(06): 648-652.

本文报道一例膀胱高级别浸润性尿路上皮癌(MIBC)的患者。患者2年前诊断为膀胱癌伴多发淋巴结转移及阴茎转移,2022年6月22日行诊断性经尿道膀胱肿瘤电切术(TURBT)后予吉西他滨+顺铂(GC)联合替雷利珠单抗治疗6个疗程。2022年11月23日复查,提示膀胱多发病灶并累及肌层,继续予以免疫维持治疗,并盆腔放疗。2023年6月因甲减暂停免疫治疗,后恢复。2023年12月4日复查仍发现多发淋巴结转移。经广东省医学会泌尿外科疑难病例多学科会诊,建议予以患者维迪西妥单抗联合特瑞普利单抗 q2w治疗6周期。经治疗后,患者经尿道电切镜检+活检均未见癌灶,淋巴结较前明显缩小或消失。因此,对于孤立转移病灶的晚期尿路上皮癌,基于循证医学证据选择含免疫的一线治疗方案,联用放疗可进一步获益;一线治疗进展后,免疫“再挑战”仍旧可获益,免疫联合抗体偶联药物是可选方案。

This article reports a case with high-grade invasive urothelial carcinoma of the bladder. The patient was diagnosed as bladder cancer with multiple lymph node metastasis and penis metastasis two years ago. On June 22,2022,he was treated with Gemcitabine+Cisplatin (GC) combined with Lirilumab after diagnostic transurethral resection of bladder tumor(TURBT). On November 23,2022,a follow-up examination revealed multiple lesions in the bladder involving the muscular layer. Immune maintenance therapy was continued,along with pelvic radiotherapy. In June 2023,immunotherapy was temporarily suspended due to hypothyroidism and later resumed. On December 4,2023,multiple lymph node metastases were still found during the follow-up examination. After a multidisciplinary consultation on difficult cases in Guangdong Urological Association,it is recommended that the patient be treated with Disitamab Vedotin combined with Toripalimab q2w for 6 cycles. After treatment,the patient's transurethral resection and biopsy did not show any cancer lesions,and the lymph nodes were significantly reduced or disappeared compared to before.Therefore,for advanced urothelial carcinoma with isolated metastatic lesions,based on evidence-based medicine,selecting first-line treatment options that include immunotherapy in combination with radiotherapy can further benefit.After the progress of first-line treatment,the immune "re-challenge" can still benefit,and the combination of immune and antibody conjugated drugs is an optional solution.

图1 转移性膀胱癌患者基线及治疗后复查MR情况 注:a为患者治疗前的MR结果,箭头示膀胱内多发病灶;b为化疗联合免疫治疗前、第2周期后、第4周期后、第6周期后的MR结果,箭头分别指向膀胱内病灶、盆腔淋巴结及阴茎结节
图2 转移性膀胱癌患者治疗前后全身PET-CT显像+血糖监测 注:2023年PET-CT结果示左侧锁骨上、腹主动脉旁、双侧髂血管旁多发淋巴结转移
图3 转移性膀胱癌患者首次TURBT病理结果
图4 转移性膀胱癌患者二次TURBT病理结果 注:3a示膀胱肿物为高级别浸润性尿路上皮癌,侵犯肌层,未见明确脉管内癌栓;免疫组化示Her-2(2+)、CK20(+)、GATA-3(+)、P53约80%强(+)、Ki67约75%(+)、PD-L1(22C3)综合阳性评分(CPS)为5(3b~3g);图4a示膀胱肿物为高级别乳头状尿路上皮癌,伴坏死及钙化,灶性基底膜欠清,考虑浸润固有层,平滑肌组织未见癌;免疫组化示CK20(+)、GATA-3(+)、P53(约90%强+,突变型)、Ki67约60%(+)、Her-2(呈异质性表达,约60%癌细胞3+,约40%癌细胞2+)、CK5/6(-) (4b~4g)
图5 转移性膀胱癌患者随访PET-CT结果 注:2024年8月复查膀胱未见肿瘤复发病灶,左侧锁骨上、双侧膈肌脚旁、腹主动脉旁、髂血管旁肿大淋巴结减少、消失
[1]
Compérat E,Amin MB,Cathomas R,et al. Current best practice for bladder cancer: a narrative review of diagnostics and treatments[J].Lancet,2022,400(10364): 1712-1721.
[2]
Bellmunt J,de Wit R,Vaughn DJ,et al. Pembrolizumab as secondline therapy for advanced urothelial carcinoma[J]. N Engl J Med,2017,376(11): 1015-1026.
[3]
Balar AV,Castellano D,O'Donnell PH,et al. First-line pembrolizumab in cisplatin-ineligible patients with locally advanced and unresectable or metastatic urothelial cancer (KEYNOTE-052):a multicentre,single-arm,phase 2 study[J]. Lancet Oncol,2017,18(11): 1483-1492.
[4]
Wang Z,Wang Y,Wang S,et al. Tislelizumab with gemcitabine and cisplatin as a neoadjuvant regimen for muscle-invasive bladder cancer: case series[J]. Ann Med Surg,2024,86(1): 245-251.
[5]
Zhang M,Zuo Y,Chen S,et al. Antibody-drug conjugates in urothelial carcinoma: scientometric analysis and clinical trials analysis[J]. Front Oncol,2024,14: 1323366.
[6]
Lattanzi M,Rosenberg JE. The emerging role of antibody-drug conjugates in urothelial carcinoma[J]. Expert Rev Anticancer Ther,2020,20(7): 551-561.
[7]
Wei Y,Zhang R,Yu C,et al. Disitamab vedotin in combination with immune checkpoint inhibitors for locally and locally advanced bladder urothelial carcinoma: a two-center’s real-world study[J].Front Pharmacol,2023,14: 1230395.
[8]
Wang A,Chen M,Li D,et al. Disitamab vedotin alone or in combination with immune checkpoint inhibitors in bladder-sparing treatment of muscle-invasive bladder cancer: a real-world study[J].Clin Genitourin Cancer,2024,22(3): 102085.
[9]
Yu P,Zhu C,You X,et al. The combination of immune checkpoint inhibitors and antibody-drug conjugates in the treatment of urogenital tumors: a review insights from phase 2 and 3 studies[J]. Cell Death Dis,2024,15(6): 433.
[10]
Bilim V,Kuroki H,Shirono Y,et al. Advanced bladder cancer:changing the treatment landscape[J]. J Pers Med,2022,12(10): 1745.
[11]
Ashley S,Choudhury A,Hoskin P,et al. Radiotherapy in metastatic bladder cancer[J]. World J Urol,2024,42(1): 47.
[12]
Anderson B. Bladder cancer: overview and management. Part 2:muscle-invasive and metastatic bladder cancer[J]. Br J Nurs,2018,27(18): S8-S20.
[13]
Stenzl A,Cowan NC,de Santis M,et al. Treatment of muscleinvasive and metastatic bladder cancer: update of the EAU guidelines[J]. Eur Urol,2011,59(6): 1009-1018.
[14]
Szabados B,Kockx M,Assaf ZJ,et al. Final results of neoadjuvant atezolizumab in cisplatin-ineligible patients with muscle-invasive urothelial cancer of the bladder[J]. Eur Urol,2022,82(2): 212-222.
[15]
Zargar H,Espiritu PN,Fairey AS,et al. Multicenter assessment of neoadjuvant chemotherapy for muscle-invasive bladder cancer[J].Eur Urol,2015,67(2): 241-249.
[16]
Milowsky MI,Rumble RB,Booth CM,et al. Guideline on muscleinvasive and metastatic bladder cancer (European Association of Urology Guideline): American society of clinical oncology clinical practice guideline endorsement[J]. J Clin Oncol,2016,34(16): 1945-1952.
[17]
Patel VG,Oh WK,Galsky MD. Treatment of muscle-invasive and advanced bladder cancer in 2020[J]. CA Cancer J Clin,2020,70(5):404-423.
[18]
Witjes JA,Bruins HM,Cathomas R,et al. European Association of Urology Guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2020 guidelines[J]. Eur Urol,2021,79(1):82-104.
[19]
Mollica V,Rizzo A,Montironi R,et al. Current strategies and novel therapeutic approaches for metastatic urothelial carcinoma[J].Cancers,2020,12(6): 1449.
[20]
Powles T,Bellmunt J,Comperat E,et al. Bladder cancer: ESMO Clinical Practice Guideline for diagnosis,treatment and follow-up[J].Ann Oncol,2022,33(3): 244-258.
[21]
Wen F,Lin T,Zhang P,et al. RC48-ADC combined with tislelizumab as neoadjuvant treatment in patients with HER2-positive locally advanced muscle-invasive urothelial bladder cancer: a multi-center phase Ib/II study (HOPE-03)[J]. Front Oncol,2023,13: 1233196.
[1] 刘哲魁, 马文星, 聂灵芝, 吴云桦, 单良, 王泽正. HALP评分联合术前检查预测老年胃癌淋巴结转移的价值[J]. 中华普通外科学文献(电子版), 2024, 18(03): 209-215.
[2] 梁孟杰, 朱欢欢, 王行舟, 江航, 艾世超, 孙锋, 宋鹏, 王萌, 刘颂, 夏雪峰, 杜峻峰, 傅双, 陆晓峰, 沈晓菲, 管文贤. 联合免疫治疗的胃癌转化治疗患者预后及术后并发症分析[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 619-623.
[3] 贺斌, 马晋峰. 胃癌脾门淋巴结转移危险因素[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 694-699.
[4] 达热拜·热达提, 刘林, 赵为民, 孟涛, 雷程, 金博, 毕建军, 李新宇, 王海江. 中低位直肠癌新辅助放化疗后侧方淋巴结清扫术的临床观察[J]. 中华普外科手术学杂志(电子版), 2024, 18(04): 415-418.
[5] 庞名扬, 魏勇, 沈露明, 朱清毅. 运用国产单孔机器人完成经膀胱入路膀胱部分切除术治疗膀胱癌一例报道[J]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(06): 638-643.
[6] 吴伟宙, 王琼仁, 詹雄宇, 郑明星, 李亚县. 广东省医学会泌尿外科疑难病例多学科会诊(第16期)——左肾肉瘤样癌[J]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(05): 525-529.
[7] 李勇, 彭天明, 王倩倩, 陈育纯, 蒲小勇, 刘久敏. 基于失巢凋亡相关基因的膀胱癌预后模型构建及分析[J]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(04): 331-339.
[8] 刘中文, 刘畅, 高洋, 刘东, 林世庆, 杨建华, 赵福义. 尿液microRNA-326与腹腔镜根治性膀胱切除术治疗膀胱癌患者预后的相关性研究[J]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(04): 386-391.
[9] 李飞, 郑灶松, 吴芃, 谭万龙. 广东省医学会泌尿外科疑难病例多学科会诊(第16期)——延胡索酸水合酶缺陷型晚期肾细胞癌[J]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(04): 410-414.
[10] 邓楠, 刘平. 广东省医学会泌尿外科疑难病例多学科会诊(第14期)——左肾盂恶性肿瘤并左肾巨大积液[J]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(03): 296-299.
[11] 陈伟杰, 何小东. 胆囊癌免疫靶向治疗进展[J]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 763-768.
[12] 魏妙艳, 徐近. 合并远处转移胰腺癌系统性治疗的梳理和展望[J]. 中华肝脏外科手术学电子杂志, 2024, 13(05): 644-650.
[13] 张英信, 林婷, 张剑文. 构建靶向HLA-A2且表达PD-L1的CAR-Treg细胞及验证其对CD4+T细胞抑制作用[J]. 中华肝脏外科手术学电子杂志, 2024, 13(05): 719-728.
[14] 张燕, 许丁伟, 胡满琴, 李新成, 李翱, 黄洁. 胆囊癌免疫治疗的知识图谱可视化分析[J]. 中华肝脏外科手术学电子杂志, 2024, 13(03): 319-327.
[15] 王昌前, 林婷婷, 宁雨露, 王颖杰, 谭文勇. 光免疫治疗在肿瘤领域的临床应用新进展[J]. 中华临床医师杂志(电子版), 2024, 18(06): 575-583.
阅读次数
全文


摘要