FULCRUM CDS
Urothelial carcinoma — bladder
DEMOJames MorrisonAisha PatelRobert ChenMaria Santos|Enter Real Patient
RC

Robert Chen

70 y/o MaleMRN: 0762410Urothelial carcinoma — bladderCisplatin eligiblePD-L1 15%
Stage III (MIBC)Window open — early intervention

Treatment Window

S1 Attend
The immune system is intact and surveilling. The treatment window is wide open. Intervention at this stage has the highest probability of durable response.
Critical question: Can the immune system detect this tumour?
If detection is strong, proceed with confidence. If weak, consider strategies that enhance antigen presentation or innate activation.
○ LOW — wide treatment window

Immune Advantagei

Borderline
0.6×
Tumour advantage (adjusted: 0.49×)
Tumour proliferation exceeds immune output. Single-agent checkpoint blockade unlikely to be sufficient.
Can the immune system detect this tumour?
If detection is strong, proceed with confidence. If weak, consider strategies that enhance antigen presentation or innate activation.
Primary drain
Innate signal
Secondary drain

Step Coverage

2/4 Steps
⚠
Detection
Open
✓
Priming
Tremelimumab
✓
Encounter
Durvalumab
⚠
Maintenance
Open
AgentStepMechanism
Durvalumab—Anti-PD-L1 — releases T cell brake
Tremelimumab—Anti-CTLA-4 — enables new T cell generation
Open Escape Routes
Detection, Maintenance steps uncovered. Adding a TIGIT inhibitor would NOT help — same Encounter step.

Structural Recommendations

?

Consider LAG-3 inhibitor if available

LAG-3 addresses antigen presentation (Detection step) — genuinely different from PD-1.

FULCRUM CDS is a structural analysis tool. It does not replace clinical judgement. Not FDA approved.

Tumour Immune Profile

GZMB
4.9 log₂
PRF1
4.3 log₂
IFNG
3.6 log₂
GZMA
4.7 log₂
MKI67
7.2 log₂
Immune Adv.
0.6×
Host Drain
IL1B
4.1 log₂
CXCL8
3.8 log₂
SPP1
4.5 log₂
MARCO
2.9 log₂

Host Capacity

Albumin
3.5 g/dL
NLR
5.8
TMB
8.1 mut/Mb
PD-L1 TPS
15 %

Timeline

Jun 2025
Diagnosis — MIBC, cT3N0
Jul 2025
Molecular — TMB 8.1, PD-L1 15%
Aug 2025
RNA-seq — immune profiling completed
Mar 2026
Perioperative decision — FULCRUM CDS consulted
—
Perioperative durvalumab + tremelimumab (VOLGA regimen)
New Patient
SMART on FHIR · FULCRUM v0.2.0 · generativegeometry.science