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case_images: Pathological findings before treatment revealed invasive urothelial carcinoma (UC) (luminal-type UC, papillary, G2, high grade (a) H&E stain, (b) GATA3 (+), (c) CK5/6 (-), (d) CK20 (+)) with squamous differentiation ((e) H&E stain, (f) CK5/6 (+), (g) p40 (+)).
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case_images: Pathological findings revealed invasive urothelial carcinoma with squamous differentiation, high grade, G2 > G3, pT1 (Figure 1).
case_images: Computed tomography (CT) findings: (a) CT before treatment shows a muscle-invasive tumor on the anterior wall of the bladder, (b) CT before pembrolizumab treatment reveals the tumor invading the surrounding bladder wall, (c) CT shows the disappearance of the tumor after seven courses of pembrolizumab treatment, and (d) CT reveals tumor regrowth after 15 courses of pembrolizumab treatment.
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case_images: CT in December 2017 revealed that the tumor had increased in size (Figure 2(a)). CT in March 2018 showed that the tumor had grown and invaded the surrounding bladder wall (Figure 2(b)). After seven courses of pembrolizumab treatment, CT in September 2018 showed that the tumor had disappeared (Figure 2(c)). March 2019 showed that the tumor had regrown (Figure 2(d)). MRI revealed a non-muscle-invasive tumor.
case_images: Pathological findings revealed invasive undifferentiated double-negative UC, high grade, G2 ((a) H&E stain, (b) GATA3 (+), (c) CK20 (-), and (d) CK5/6 (-)) consisting of relatively small tumor cells of the same size as lymphocytes, negative for neuroendocrine markers.
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case_images: TUR-BT in May 2019. The tumor was completely resected. The pathological findings revealed invasive undifferentiated urothelial carcinoma, high grade, G2 consisting of relatively small tumor cells of the same size as lymphocytes, negative for neuroendocrine markers, pT1 (Figure 3).
case_images: (a) PD-L1 expression on the tumor before treatment. A total of 70%-80% of the tumor tissue expressed PD-L1, with PD-L1-positive macrophages in the surrounding area and (b) PD-L1 expression on the tumor after pembrolizumab treatment. Less than 10% of tumor tissue expressed PD-L1, with PD-L1-positive macrophages in the surrounding area.
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case_images: The tumor tissues before treatment expressed PD-L1, with PD-L1-positive macrophages in the surrounding area (Figure 4(a)). The tumor tissue after pembrolizumab treatment barely expressed PD-L1, with PD-L1-positive macrophages in the surrounding area (Figure 4(b)).