A metachronous bilateral upper urinary tract urothelial carcinoma achieved partial remission by multiple treatment modalities: A case report and literature review

Abstract

Abstract Background: Upper tract urothelial carcinoma (UTUC) is less common but more aggressive than bladder urothelial carcinoma in China. Bilateral UTUC is even rarer. Managing bilateral UTUC is a great challenge, especially when patients request kidney sparing and refuse hemodialysis. Besides robot-assisted laparoscopic radical nephroureterectomy (RNU) and chemotherapy, immune checkpoint inhibitor therapy is a promising strategy. We present a case of metachronous bilateral UTUC that benefited from multiple treatment modalities. Case Description: We report a special case of a 68-year-old woman with metachronous bilateral UTUC. She underwent robot-assisted laparoscopic radical nephroureterectomy (RNU) due to an occupied lesion in the middle segment of the right ureter. Pathological findings indicated muscle-invasive high-grade urothelial carcinoma (on the right), clinical stage T3N1M0, high-risk. Adjuvant gemcitabine/cisplatin chemotherapy for three cycles every 21 days was administered. To prevent tumor recurrence in bladder, sapylin (OK-432) was used for intravesical instillation, made from a low-virulence strain (Su) of Streptococcus pyogenes (group A) incubated with penicillin. Twenty-nine months later, a left renal pelvis-occupied lesion was found. Pathological examination by ureteroscopy suggested that the tumor was non-invasive high-grade papillary urothelial carcinoma. The patient requested kidney sparing and declined radical surgery. The tumor was too large for complete endoscopic resection. The patient underwent neoadjuvant chemoimmunotherapy followed by retrograde intrarenal surgery (RIRS). After surgery, adjuvant immunotherapy was continued as before. The patient finally achieved partial remission. Conclusions: We present a rare case of metachronous bilateral UTUC. The patient had radical surgery for the right UTUC and requested kidney sparing for the subsequent left UTUC. The patient received neoadjuvant chemoimmunotherapy followed by RIRS and adjuvant immunotherapy for the left UTUC. The patient achieved a stable state with no disease progression and partial remission of the left UTUC. Our report suggests a new approach for the treatment of bilateral UTUC.