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case_images: (A) Enhanced CT of the chest and pelvis showed multiple round nodules in both lungs with clear boundaries. A dense mass of soft tissue is seen at the entrance of the ureter on the left side of the bladder. The size is about 25mm*22mm. (B) Renal dynamic imaging and glomerular filtration. 1. Renal blood perfusion image: After intravenous "projectile" injection of imaging agent 99m-Tc-DTPA, renal blood perfusion imaging was performed. After imaging of the abdominal aorta, the right kidney was immediately imaged, and the position, shape and the size is roughly normal, and the radioactivity distribution is roughly even; the left kidney is not seen. 2. Renal function shows: After renal blood flow perfusion, the left kidney is not visible; the shadow of the right kidney gradually increases, and the imaging of right kidney reaches a peak at 3.35 minutes. After that, the shadow of the renal cortex diminishes, the shadow of the renal medulla increases, and the renal excretion process. There was no abnormal reflex concentration in the right renal pelvis; after 5 hours of delay, the right kidney was lightened, there was no radioactive concentration in the right renal pelvis and ureter, and the left kidney was slightly developed. 3. Renal functional curve shows: the curve of the right kidney is roughly normal; the peak time of the right kidney is 3.35min; the GFR of the right kidney is: 43.39ml/min. (C) Pathological results of HE staining on cystoscopy biopsy.
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case_images: There are multiple swollen lymph nodes in the running area of the left iliac vessels ( Figure 1A ). No function in the left kidney ( Figure 1B ). There was no clear muscle infiltration in the submitted tissues( Figure 1C ). Immunohistochemistry: P63+,CK20+,CK7+, CyclinD1+, Ki-67: 80% ( Supplementary Figure 1 ).
case_images: Imaging examination after single-agent gemcitabine chemotherapy. (A) (2019.6.3) after two cycles of gemcitabine. Multiple round small nodules are seen in both lungs, with clear borders and reduced size compared to the previous ones. A dense mass of soft tissue at the entrance of the ureter on the left side of the bladder, with a size of about 25mm*22mm, and a clear boundary. (B) (2019.7.19) after 4 cycles of gemcitabine. Multiple round-shaped nodules in both lungs, with clear boundaries and slightly smaller than before. A dense mass of soft tissue at the entrance of the ureter on the left side of the bladder, with a size of about 25mm*22mm, with a clear boundary. (C) (2019.9.17) after 6 cycles of gemcitabine. Multiple round nodules in both lungs, with clear boundaries, and some were slightly larger than before. The soft tissue density mass at the entrance of the ureter on the left side of the bladder is shadowed, about 37mm*30mm in size, with a clear boundary and larger than before.
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case_images: After two cycles of gemcitabine treatment, the efficacy of chemotherapy was evaluated as SD (stable disease) ( Figure 2A ). The efficacy of chemotherapy remained as SD after four cycles of treatment ( Figure 2B ) and it became PD (progression disease) after six cycles of treatment ( Figure 2C ).
case_images: Imaging after three cycles of Sintilimab immunotherapy. There are multiple round-shaped nodules in both lungs, with clear boundaries, and some are smaller than before. The local soft tissue shadow at the entrance of the ureter on the left side of the bladder thickens, forming soft tissue nodules, the size is about 24mm*10mm, which is smaller than before.
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case_images: The treatment efficacy is evaluated as PR (Partial response) ( Figure 3 ).
case_images: Immunotherapy-related pneumonia before and after methylprednisolone therapy. (A) There are cords and patchy shadows in both lungs, with blurred boundaries and inflammatory changes, that are bigger than before. (B) Frequent strand shadows and patchy shadows are seen in both lungs, and the boundary is blurred, and the area is smaller than before.
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case_images: The results of chest CT examination on 2019.12.26 showed pneumonia in both lungs, that are more severe than earlier images ( Figure 4 ). We performed chest CT to observe the changes of pneumonia, and the results showed that pneumonia of both lungs had improved significantly ( Figure 4B ).
case_images: Imaging after discontinuation of Sintilimab for eight months. (A) The inflammation in both lungs disappeared, the metastases in both lungs disappeared, and the soft tissue shadow at the entrance of the ureter on the left side of the bladder disappeared. (B) Timeline of disease status and corresponding treatment regimens.
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case_images: To our surprised, the results showed that the patient's lung metastases disappeared, and the local soft tissue shadow at the entrance of the ureter on the left side of the bladder disappeared completely ( Figure 5A ). The patient achieved progression-free survival for more than one year ( Figure 5B ).