Initial Clinical Experience With Gemcitabine, Cisplatin, and Nivolumab for Advanced Urothelial Carcinoma: A Four-case Series

BACKGROUND/AIM: Gemcitabine, cisplatin, and nivolumab (GCNivo) has become an established first-line treatment for advanced urothelial carcinoma (UC) following the CheckMate 901 trial. However, real-world evidence is limited, particularly regarding shared decision-making in first-line treatment selection and subsequent management after induction therapy. We present four cases illustrating the selection of first-line GCNivo and subsequent therapeutic pathways in routine clinical practice. CASE REPORT: We report four patients with advanced UC who received first-line GCNivo. All patients experienced distinct clinical courses. GCNivo was selected through shared decision-making that considered expected efficacy, toxicity, clinical characteristics, and patient preference. An 83-year-old woman with locally advanced bladder cancer achieved a radiological complete response after four cycles. The patient underwent consolidative bladder radiotherapy followed by observation without nivolumab maintenance because of treatment-related toxicities, advanced age, and patient preference. A 71-year-old man with nodal recurrence after radical cystectomy achieved a sustained partial response and transitioned to nivolumab maintenance after completion of induction GCNivo. A 69-year-old man with rapidly progressive metastatic disease initially responded to GCNivo but subsequently experienced clinical deterioration with suspected disease progression, prompting a switch to second-line enfortumab vedotin. A 75-year-old man with synchronous bladder and upper tract UC completed four induction cycles before transitioning to nivolumab maintenance because of declining renal function despite maintained disease control. In all four cases, management was individualized according to treatment response and tolerability. CONCLUSION: GCNivo produced meaningful antitumor responses with generally manageable toxicities in patients with advanced UC. These cases highlight the importance of shared decision-making when selecting GCNivo among multiple first-line treatment options as well as individualized post-induction management. GCNivo may serve as a therapeutic platform for tailored multidisciplinary management.