Sequential HER2-targeted antibody-drug conjugate therapy for acquired resistance in a 55-year-old male kidney transplant recipient with metastatic urothelial carcinoma: a case report

Introduction

Urothelial carcinoma (UC) is one of the most common malignancies of the urinary system, with a dramatically worse prognosis in the metastatic state (1). The management of metastatic urothelial carcinoma (mUC) in kidney transplant recipients presents a formidable clinical challenge as the incidence of UC continues to increase globally (2). These patients not only experience a higher incidence of UC with more aggressive pathological features, but their clinical management necessitates a delicate balance: administering potent anticancer therapies while simultaneously maintaining chronic immunosuppression to prevent allograft rejection (3). This therapeutic conflict is particularly pronounced with immune checkpoint inhibitors (ICIs) (4) ,which carries a significant risk of inducing allograft rejection, with early reports citing rejection rates of as high as 40–50% (5). Consequently, transplant recipients are systematically excluded from pivotal clinical trials, leaving a lack of evidence-based guidelines for multiline mUC management in this high-risk cohort.

Antibody-drug conjugates (ADCs) have fundamentally redefined the therapeutic landscape for UC by utilizing monoclonal antibodies to selectively deliver potent cytotoxic agents directly to malignant cells. Human epidermal growth factor receptor 2 (HER2) has been identified as a key therapeutic target, with gene amplification or overexpression in a substantial subset of UC patients (6). However, immunosuppressive regimen can influence drug metabolism and immune surveillance, making the application of novel targeted therapies particularly intricate. Patients on chronic immunosuppression face elevated risks of de novo malignancy or recurrence, compounded by potential drug-drug interactions and the altered toxicity profiles of anticancer agents.

Because a single case report is fundamentally descriptive and cannot establish definitive safety or efficacy, its primary role is to document novel clinical phenomena and generates therapeutic hypotheses. This report focuses on the unprecedented trajectory of a kidney transplant recipient with HER2-amplified mUC who received sequential treatment with two HER2-targeted ADCs: disitamab vedotin (DV), which delivers the microtubule inhibitor monomethyl auristatin E (MMAE) (7), and trastuzumab deruxtecan (T-DXd), which delivers a topoisomerase I inhibitor payload (8). By analyzing the patient’s clinical response, the specific toxicity profile observed (9,10), and the impact on allograft function, this report highlights a critical innovative point: transitioning between different ADC payloads may offer a viable strategy to overcome acquired resistance without compromising the allograft. Ultimately, this case aims to generate hypotheses regarding multiline targeted treatment strategies and address an unmet clinical need in navigating the delicate balance of oncology and transplant medicine. We present this article in accordance with the CARE reporting checklist (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2026-0596/rc).

Case presentation

A 55-year-old male patient with a history of a right kidney transplant for end-stage renal disease (ESRD) in 2019 was maintained on an immunosuppressive regimen of tacrolimus (FK506) and rapamycin. Following the procedure, the renal allograft maintained stable function without any documented immunologic rejection. Subsequently, in 2021, the patient experienced intermittent hemorrhage from the urethra. Clinical assessment identified acute kidney injury accompanied by allograft hydronephrosis. Antegrade nephrostography delineated a substantial filling defect at the lower pole of the renal allograft, along with an additional defect within the proximal ureter. So, he underwent a robot-assisted right radical nephroureterectomy for UC in April 2021. The pathology report indicated a high-grade UC at the ureteropelvic junction invading the lamina propria, with non-invasive high-grade UC in the distal ureter and low-grade UC at the right ureteral orifice. Prior to the initiation of frontline systemic therapy, a comprehensive clinical evaluation was performed in accordance with the CARE guidelines. Physical examination revealed a well-nourished nutritional status, with a body mass index (BMI) of 21 kg/m² and a serum albumin level within the normal reference range. The patient maintained a good performance status, characterized by an Eastern Cooperative Oncology Group (ECOG) performance status score of 1. This demonstrated a sufficient physiologic reserve to tolerate sequential multi-line systemic interventions while safely preserving his single functioning renal allograft.

In May 2022, imaging suggested tumor recurrence in the remnant distal ureter. To guide subsequent precision therapeutic strategies for this recurrent disease, a comprehensive biomarker assessment integrating both genomic and proteomic platforms was performed on the tumor tissue. Next-generation sequencing (NGS) explicitly revealed a distinct HER2 gene amplification alongside a high tumor mutational burden (TMB-H) of 63 mutations/Mb. Concurrently, to evaluate HER2 status at the protein expression level, automated immunohistochemistry (IHC) staining was conducted on the formalin-fixed paraffin-embedded (FFPE) specimens utilizing the commercial Ventana BenchMark Ultra platform (Ventana Medical Systems, Inc., Roche, Tucson, AZ, USA) with the rabbit monoclonal anti-HER2 antibody (clone 4B5). In the absence of a universally accepted, distinct validation standard for urinary tract UC, the IHC staining pattern was interpreted and scored in strict compliance with the American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) clinical guidelines for breast cancer. This dual-platform validation confirmed a positive/low HER2 expression status that highly rationalized the exploration of target-specific interventions.

It should be noted that platinum-based chemotherapy remains the standard of care for the first-line treatment of advanced UC globally. However, in this specific case, the patient explicitly declined conventional chemotherapy due to severe concerns over potential adverse events, a decision clinically contextualized by his history of ESRD and the presence of a functioning renal allograft. Given the confirmed HER2 gene amplification and in alignment with practices supported by the Chinese Society of Clinical Oncology (CSCO) guidelines emphasizing HER2 testing in advanced UC, a highly individualized, upfront combination of anti-HER2 targeted therapy (DV) and immunotherapy was recommended. The patient was extensively counseled that this biomarker-driven approach was tailored to his specific genomic profile and clinical constraints as an alternative to the conventional standard of care. Following comprehensive counseling regarding the potential risks of immune-related adverse events, written informed consent was obtained. Routine safety profiles were assessed prior to each drug administration. The patient commenced first-line systemic therapy with DV in May 2022 (120 mg administered every 2–4 weeks). After 10 cycles, a response assessment in August 2022 confirmed a partial response (PR) (Figure 1), with the patient reporting the disappearance of previous lung metastases. However, the treatment was complicated by significant adverse events, including alopecia and grade 3 peripheral neurotoxicity, which manifested as debilitating numbness in the hands and feet and difficulty walking. This neurotoxicity persisted for approximately 6 months.

Figure 1 Computed tomography scans before and after DV treatment. (A) Before treatment in May 2022. (B) After DV treatment. (C) Disease progression in June 2023. Red arrows indicate lesions. DV, disitamab vedotin.

In February 2023, the patient presented with headaches. A brain magnetic resonance imaging (MRI) revealed multiple new metastatic lesions with associated hemorrhage in the left parietal lobe and cerebellum. He received palliative radiotherapy to the brain, which led to an improvement in his symptoms.

In June 2023, a follow-up positron emission tomography (PET) scan demonstrated systemic progressive disease (PD), revealing enlarging hypermetabolic nodules in the lungs and a new suspicious necrotic lesion in the right lobe of the liver, while the previously irradiated brain metastases appeared stable.

In this patient, chronically immunocompromised by long-term post-transplant immunosuppressive therapy, the concurrent emergence of new visceral lesions posed a formidable diagnostic dilemma. To rigorously rule out opportunistic infections or post-transplant lymphoproliferative disorder (PTLD) prior to launching cytotoxic chemotherapy, extensive diagnostic screenings were initiated. Repeated serum and sputum fungal cultures, Interferon-Gamma Release Assays (T-SPOT.TB), and plasma BK virus DNA viral load quantification were all thoroughly documented as negative. Concurrently, the chest computed tomography (CT) and abdominal MRI delineated multiple, well-circumscribed, solid nodules exhibiting typical hypermetabolic features of malignant visceral metastases, lacking the specific cavitation, halo signs, or tree-in-bud patterns associated with fungal or mycobacterial infections.

Once the malignant metastatic etiology was clinically and radiologically established, the patient was transitioned to second-line systemic chemotherapy. However, designing a safe cytotoxic regimen presented a profound pharmacological challenge. Following the right radical nephroureterectomy of his single functioning renal allograft in 2021, the patient presented with absolute renal insufficiency and was entirely dependent on permanent maintenance hemodialysis.

Cisplatin was strategically selected over carboplatin based on critical pharmacokinetic considerations in anuric patients. While carboplatin dosing via the Calvert formula is highly erratic and carries an extreme risk of prolonged, fatal myelosuppression when the glomerular filtration rate (GFR) is unmeasurable, low-dose cisplatin dosing does not strictly rely on GFR calculations. Furthermore, since the patient already lacked any residual renal function, cisplatin-induced nephrotoxicity was no longer a clinical concern.

To ensure systemic safety, a highly attenuated regimen adjusted by body surface area (BSA) was administered from June to August 2023, consisting of gemcitabine (approximately 700 mg/m²; total dose 1.2 g) and cisplatin (approximately 25 mg/m²; initial total dose 45 mg, subsequently adjusted to 50 mg). Crucially, this regimen was administered strictly 1 to 2 hours prior to the scheduled hemodialysis sessions to facilitate the immediate dialytic clearance of unbound free platinum, thereby mitigating severe systemic toxicities.

The patient safely tolerated four cycles of this modified regimen. An initial response assessment on July 25, 2023, showed stable disease (SD), and a final comprehensive evaluation on September 25, 2023, confirmed a PR with significant regression of the pulmonary and hepatic metastases, which retrospectively confirmed the accuracy of our initial differential diagnosis.

At the time of this report, the patient has remained off therapy for 10 months with no clinical or radiographic evidence of disease recurrence, while preserving an excellent quality of life. Following this, he was started on pembrolizumab in October 2023 as a third-line strategy, but by December 2023, imaging confirmed liver metastasis again.

In January 2024, facing multi-line refractory disease, a strategic decision was made to re-challenge the HER2 pathway with a different agent. The patient commenced fourth-line therapy with T-DXd. After five cycles, imaging in May 2024 revealed a dramatic response (Figure 2). An abdominal MRI showed marked shrinkage of the liver metastases, and a brain MRI showed a slight reduction in some central nervous system (CNS) lesions. However, this benefit was compromised by grade 2 T-DXd-induced interstitial pneumonitis presented with chest tightness and dyspnea. In compliance with safety guidelines, T-DXd was immediately interrupted, and the symptoms successfully resolved following high-dose corticosteroid therapy. As of the last follow-up, the patient exhibited a classic divergent response profile. Systemically, the therapeutic response to T-DXd was highly durable. However, neuroimaging concurrently revealed isolated intracranial PD in specific CNS lesions. Given that T-DXd exhibits established blood-brain barrier (BBB) permeability, this localized failure is primarily attributable to spatial tumor heterogeneity or the emergence of a site-specific acquired resistance clone within the CNS microenvironment. To manage this isolated intracranial oligoprogression without prematurely discontinuing the systemically effective therapy, stereotactic radiosurgery (Gamma Knife) was successfully implemented as a targeted ablative intervention to eradicate the progressing CNS targets, supplemented by methylprednisolone for symptomatic pain relief (Figure 3).

Figure 2 Computed tomography scans before and after T-DXd treatment. (A,B) Before treatment in January 2024. (C) After T-DXd treatment, with significant reduction of lesions. Red arrows indicate lesions. T-DXd, trastuzumab deruxtecan.

Figure 3 Timeline scheme of major clinical event of the patient since diagnosis. DV, disitamab vedotin; PD, progressive disease; PR, partial response; SD, stable disease; T-DXd, trastuzumab deruxtecan.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

This case report describes the sequential successful application of two HER2-targeted ADCs, DV and T-DXd in the treatment of HER2-amplified mUC in a kidney transplant recipient. To our knowledge, this represents the inaugural case demonstrating efficacy of a sequential anti-HER2 ADC strategy in advanced UC. This pioneering sequence exemplifies the ‘payload switching’ strategy, providing a vital real-world proof-of-concept that tumors progressing on a microtubule-inhibitor (MMAE) can be effectively salvaged by transitioning to a topoisomerase I inhibitor (DXd), while leveraging the stable genomic anchor of HER2 amplification.

As a highly prevalent genitourinary malignancy, mUC has traditionally relied on platinum-containing regimens as primary therapy. However, its efficacy is often limited, with many patients experiencing disease progression (11). The therapeutic paradigm for mUC has been significantly transformed by the advent of ICIs directed against the programmed cell death protein 1 (PD-1)/programmed death ligand 1 (PD-L1) axis. Kidney transplant recipients have a 3- to 4-fold higher risk of developing UC than the general population, attributable to chronic immunosuppression impaired tumor surveillance and oncogenic viral persistence [BK/human papillomavirus (HPV)] (12). However, kidney transplant recipients are often excluded from clinical trials of new drugs due to the potential for overactivation of immune T cells leading to autoimmune diseases, and the use of these drugs may accelerate allograft rejection (4,13). Crucially, safe administration of third-line pembrolizumab without precipitating rejection demonstrates that, under strict multidisciplinary surveillance, anti-tumor efficacy of immune checkpoint blockade can be balanced against baseline immunosuppression. This aligns with emerging retrospective evidence confirming that immunotherapy does not inevitably dictate allograft failure (14,15).

ADC is a class of targeted biological drugs composed of highly targeted monoclonal antibody, a linker and cytotoxic drugs (16). They selectively deliver potent small-molecule cytotoxins to malignant cells, enhancing anti-tumor efficacy while minimizing systemic toxicity (17). While a diverse array of ADCs is currently available for systemic cancer therapy, enfortumab vedotin (EV), sacituzumab govitecan (SG), and DV represent the principal agents authorized for UC (18). Functioning as a transmembrane tyrosine kinase receptor, the HER2 protein fundamentally governs crucial cellular signaling cascades, including those dictating proliferation, differentiation, and survival. Consequently, its dysregulation has established HER2 as a critical prognostic biomarker and an actionable therapeutic target across multiple malignancies.

DV, a HER2-directed ADC, comprises the novel monoclonal antibody hertuzumab conjugated to the microtubule inhibitor MMAE via a cleavable linker. In a clinical evaluation by Joaquim et al., this agent demonstrated an objective response rate (ORR) of 50.0% among patients with HER2-overexpressing, locally advanced or metastatic UC who had progressed on prior chemotherapeutic regimens (19). In a phase II, single-arm investigation, UC patients with HER2low tumors (IHC 0 or 1+) and at least one prior systemic treatment had an ORR of 26.3%, alongside a disease control rate (DCR) of 94.7% (7).

The recent tumor-agnostic approval of T-DXd—an ADC utilizing a topoisomerase I inhibitor payload—has significantly expanded the therapeutic armamentarium for patients with biomarker-defined, HER2-positive (IHC 3+) solid malignancies (20). The phase II DESTINY-PanTumor02 trial enrolled patients across seven distinct solid tumor cohorts who had experienced disease progression following a minimum of one prior line of standard systemic therapy. Enrollment necessitated a baseline HER2 overexpression, defined as an IHC score of 2+ or 3+. Across the pan-tumor study population, the ORR was 37.1%, accompanied by a median duration of response (mDOR) of 11.3 months. Specifically, within the 41-patient UC subset administered T-DXd (5.4 mg/kg intravenously every 3 weeks), the ORR was highly dependent on the degree of target expression, reaching 35% in the HER2 IHC 2+ subgroup and 56% among those with HER2 IHC 3+ status. Within the heavily pretreated, combined bladder cancer cohort, the median progression-free survival (PFS) and median overall survival (OS) were 7.0 and 12.8 months, respectively. Grade 3 or higher adverse events—most notably the previously documented gastrointestinal toxicities and neutropenia—were observed in 41.5% of the study population. Interstitial lung disease (ILD) or pneumonitis, a widely recognized adverse effect associated with T-DXd, occurred in 10.5% of the 267-patient pan-tumor cohort, ultimately culminating in three fatal events (21). The administration of T-DXd represents a highly efficacious therapeutic modality for medically fit patients with biomarker-driven, treatment-refractory UC. Therefore, after obtaining the consent of patient, we chose sequential treatment with two ADCs and extended the survival time of patient.

Given that the clearance of monoclonal antibodies primarily occurs via intracellular catabolism and receptor-mediated endocytosis rather than hemodialysis, the use of ADCs in ESRD is theoretically feasible. However, as kidney transplant recipients are systematically excluded from pivotal ADC trials due to immunosuppression concerns, current dosing guidelines rely solely on isolated case reports. This case provides a critical real-world pharmacological reference for the safe administration of DV and T-DXd in this highly vulnerable population.

Furthermore, our findings offer a compelling molecular rationale for the “payload switching” strategy to overcome acquired ADC resistance. Disease progression after initial DV response implied the emergence of resistance specific to the microtubule-inhibiting MMAE payload. Because HER2 gene amplification generally acts as a stable genomic alteration, it provided a persistent cell-surface anchor for subsequent targeted therapy. The profound systemic response to T-DXd subsequently demonstrated that MMAE-resistant clones remained highly susceptible to the topoisomerase I inhibitor DXd.

Despite robust systemic control, managing a divergent response with isolated CNS oligoprogression remains chanllenging. Historically, the CNS was considered a pharmacological sanctuary due to the restricted BBB penetrance of macromolecular agents. However, recent landmark evidence from the global DV Cohort C (22) study demonstrated promising intracranial anti-tumor activity, confirming that anti-HER2 ADCs and their lipophilic payloads can cross the BBB. Consequently, the isolated intracranial progression observed in our patient under T-DXd—despite durable systemic visceral remission—cannot be simplistically attributed to failed drug delivery. Instead, this divergent failure is likely driven by spatial clonal evolution, target expression heterogeneity, or site-specific acquired resistance within the unique CNS microenvironment. To manage this localized oligoprogression without prematurely abandoning a highly effective systemic regimen, stereotactic radiosurgery (Gamma Knife) was utilized as a targeted consolidative intervention.

Crucially, the administration of these novel agents necessitates stringent toxicity management. T-DXd carries a life-threatening risk of ILD or pneumonitis, demanding rigorous respiratory surveillance via routine high-resolution CT. In solid organ transplant (SOT) recipients on chronic immunosuppression, differentiating drug-induced ILD from opportunistic pulmonary infections is challenging. Upon any clinical or radiographic suspicion of grade 2 or higher ILD, immediate T-DXd interruption and the prompt initiation of high-dose systemic corticosteroids are imperative to prevent fatal respiratory deterioration.

Conclusions

In conclusion, this report illustrates that the sequential administration of ADCs with distinct payloads represents a feasible and promising salvage strategy for multi-line refractory UC, even in highly complex clinical scenarios involving ESRD and chronic immunosuppression. Nevertheless, these findings must be interpreted cautiously and do not establish a standard of care. Given the inherent limitations of a single-case observation and the significant toxicity profiles of these agents, further prospective trials and larger cohort studies are warranted to validate the long-term safety, optimal sequencing, and biomolecular mechanisms underlying payload switching in this unique population.

Acknowledgments

The diagnosis and treatment of this case, as well as the preparation of this manuscript, received strong support from a multidisciplinary team. We sincerely thank our colleagues from the Transplantation Department, Urology Department, Oncology Department, Pathology Department, Radiology Department, and Radiation Therapy Department for their close collaboration and professional advice throughout the patient’s management. We are especially grateful to the Pathology Department for providing technical support in HER2 expression testing and NGS analysis, as well as to the nursing team for their meticulous care during long-term chemotherapy, targeted therapy, and dialysis management. At the same time, we extend our thanks to the patient and his family for their full trust in the treatment plan, active cooperation, and consent to publish this case report anonymously.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2026-0596/rc

Peer Review File: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-2026-0596/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-2026-0596/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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