PMC7292166_01
Imaging study of the case. (a) A T2-weighted image of MRI on day 436. (b) CT performed before pembrolizumab treatment on day 16. (c, d) CT after pembrolizumab treatment on day 49 and 201, respectively. Yellow and pink arrowheads in panels (a-d) indicate bladder tumor (clinical T2-T3) and the rectum, respectively.
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CT (#1, Table S1) and MRI (#1, Fig. 1a) revealed a bladder tumor invading perivesical tissue without apparent metastases (cT3N0M0). CT #5 which was performed 266 days after radical cystectomy, identified cancer recurrence in the pelvic wall (50 mm in length) which invaded to the rectum (Fig. 1b). Irrespective of two cycles of salvage chemotherapy using the same regimen as the neoadjuvant setting, the recurrent tumor significantly enlarged to 81.6 mm (CT #5, Fig. 1b). Interestingly, the tumor significantly shrunk to 25 mm only 49 days after the single pembrolizumab administration (CT #6, yellow arrowheads in Fig. 1c). The tumor remained small without any treatment after a single injection of pembrolizumab as of 201 days after the pembrolizumab injection (CT #8, Fig. 1d).
Clinical course of the case. Clinical course of the case after pembrolizumab treatment. Green arrowheads indicate occurrence date of irAEs and time of hospitalization. Laboratory data of CK, CK-MB, and troponin I and the dose of prednisolone.
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Laboratory examination showed significantly elevated CK (3385 U/L), its isozyme CK-MB (62.5 [<5] n/mL), and troponin I (372.1 [<26.20] pg/mL) (Fig. 2). He initiated 60 mg/day of prednisolone (1 mg/kg, Fig. 2). The dose of prednisolone was gradually reduced to as shown in Figure 2.
Changes in electrocardiographic findings. The electrocardiogram at baseline suggested undetermined axis and mild right ventricular loading (panel a, arrows). The complete right bundle branch block (QRS duration: 148 milliseconds developed, panel b, arrowheads). Although the complete right bundle branch block was performed in the remote period after steroid therapy, the QRS duration was slightly shortened to 134 milliseconds (panel c).
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Fig. 3a) were normal. From 12 to 34 days after the administration of pembrolizumab, he serially complained of Grade 3-diarrhea, Grade 3-erythema multiforme with pruritus and left ptosis with diplopia. ECG#2 findings revealed a right bundle branch block (Fig. 3b) which was not observed at ECG#1 (Fig. 3a) although echocardiographic findings were normal.