Update of the International Consultation on Urological Diseases on bladder cancer 2018: non-urothelial cancers of the urinary bladder

Clinical characteristics and molecular mechanisms underlying bladder cancer in individuals with spinal cord injury: a systematic review

BACKGROUND

Patients with spinal cord injury have a relatively high risk for bladder cancer and often complicated with bladder cancer in advanced stages, and the degree of aggressiveness of malignancy is high. Most of the literature is based on disease clinical features while, our study reviews the clinical characteristics and molecular mechanisms of spinal cord injury patients with bladder cancer, so that it might help clinicians better recognize and manage these patients.

METHOD

We searched PubMed, Web of Science and Embase, using retrieval type like ("Neurogenic Lower Urinary Tract Dysfunction" OR "Spinal cord injury" OR "Spinal Cord Trauma") AND ("bladder cancer" OR "bladder neoplasm" OR "bladder carcinoma" OR "Urinary Bladder Neoplasms" OR "Bladder Tumor"). In Web of Science, the retrieval type was searched as "Topic", and in PubMed and Embase, as "All Field". The methodological quality of eligible studies and their risk of bias were assessed using the Newcastle-Ottawa scale. This article is registered in PROSPERO with the CBD number: CRD42024508514.

RESULT

In WOS, we searched 219 related papers, in PubMed, 122 and in Embase, 363. Thus, a total of 254 articles were included after passing the screening, within a time range between 1960 and 2023. A comprehensive analysis of the data showed that the mortality and incidence rates of bladder cancer in spinal cord injury patients were higher than that of the general population, and the most frequent pathological type was squamous cell carcinoma. In parallel to long-term urinary tract infection and indwelling catheterization, the role of molecules such as NO, MiR 1949 and Rb 1. was found to be crucial pathogenetically.

CONCLUSION

This review highlights the risk of bladder cancer in SCI patients, comprehensively addressing the clinical characteristics and related molecular mechanisms. However, given that there are few studies on the molecular mechanisms of bladder cancer in spinal cord injury, further research is needed to expand the understanding of the disease.

POU2F3-positive small cell carcinoma of the bladder: A clinicopathologic analysis of 4 cases and literature review

POU class 2 homeobox 3 (POU2F3)-positive small cell bladder carcinoma (SCBC) is an extremely rare entity, and its clinicopathologic features have not been fully described. Here, we investigated the clinicopathologic features of 4 cases of POU2F3-positive small cell bladder carcinoma (SCBC) and reviewed the literature. We collected 12 cases of SCBC from our departmental archives and detected the expression of POU2F3 by immunohistochemical (IHC) staining. Selected cases with or without POU2F3 expression were subjected to gene expression analysis between two different groups using DESeq2 software. We identified 4 POU2F3-positive SCBC patients, 2 males and 2 females, with a mean age of 77 years. Three patients had hematuria, and 1 patient had dysuria. Radiologic findings showed a bladder mass. Pathologic diagnosis showed that 3 cases were pure SCBC and 1 was mixed urothelial cancer (UC). Histopathologically, four POU2F3-positive SCBC tumors were composed of small round cells with sparse cytoplasm, the nuclei were salt-and-pepper-like or finely granular. Tumor cells showed characteristic cytoplasmic staining with punctate positive signals for cytokeratin. Syn and CD56 were diffusely positive in all the 4 patients. CgA was positive in only one patient. POU2F3-positive SCBC showed higher expression levels of POU2F3, HMGA2 and PLCG2 genes by RNA-Seq. Our data showed the specific clinicopathologic features of 4 rare POU2F3-positive SCBC cases, and the distinct molecular feature was observed between POU2F3-positive and negative SCBC in the limited number of cases.

Establishment and validation of nomograms to predict the overall survival and cancer-specific survival for non-metastatic bladder cancer patients: A large population-based cohort study and external validation

This study aimed to develop nomograms to accurately predict the overall survival (OS) and cancer-specific survival (CSS) of non-metastatic bladder cancer (BC) patients. Clinicopathological information of 260,412 non-metastatic BC patients was downloaded from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2020. LASSO method and Cox proportional hazard regression analysis were utilized to discover the independent risk factors, which were used to develop nomograms. The accuracy and discrimination of models were tested by the consistency index (C-index), the area under the subject operating characteristic curve (AUC) and the calibration curve. Decision curve analysis (DCA) was used to test the clinical value of nomograms compared with the TNM staging system. Nomograms predicting OS and CSS were constructed after identifying independent prognostic factors. The C-index of the training, internal validation and external validation cohort for OS was 0.722 (95%CI: 0.720-0.724), 0.723 (95%CI: 0.721-0.725) and 0.744 (95%CI: 0.677-0.811). The C-index of the training, internal validation and external validation cohort for CSS was 0.794 (95%CI: 0.792-0.796), 0.793 (95%CI: 0.789-0.797) and 0.879 (95%CI: 0.814-0.944). The AUC and the calibration curves showed good accuracy and discriminability. The DCA showed favorable clinical potential value of nomograms. Kaplan-Meier curve and log-rank test uncovered statistically significance survival difference between high- and low-risk groups. We developed nomograms to predict OS and CSS for non-metastatic BC patients. The models have been internally and externally validated with accuracy and discrimination and can assist clinicians to make better clinical decisions.

Primary Small-Cell Carcinoma of the Urinary Bladder: A Case Report and Literature Review

Small-cell carcinoma of the bladder (SCCB) is an uncommon and aggressive malignancy of the urinary tract. Its clinical presentation often mimics that of other bladder neoplasms, posing a diagnostic challenge. This case report presents a rare instance of SCCB in a 65-year-old female, shedding light on the diagnostic journey and emphasizing the need for heightened and prompt clinical suspicion due to its aggressive nature. The patient presented to the urological department with hematuria, dysuria, and hypogastric pain. Initial investigations revealed a bladder mass, prompting biopsies with inconclusive results. A comprehensive histopathological examination, including immunohistochemistry, confirmed a SCCB. A computed tomography (CT) scan was used to evaluate local and distal extention. Following the initial evaluation, a referral to an oncological service was needed. Diagnoses encompassed SCCB, with interventions that comprise chemotherapy without radical cystectomy. Despite the rarity of SCCB, timely and accurate diagnosis facilitated a tailored multidisciplinary approach, leading to prompt clinical oncology management. This case demonstrates the importance of meticulous diagnostic evaluation in rare malignancies, guiding individualized therapeutic strategies for optimal patient outcomes.

Development and preliminary validation of a PROS scale for Chinese bladder cancer patients with abdominal stoma

Bladder cancer is a common malignant tumor, and patients who have undergone radical cystectomy and urinary diversion require a lifelong abdominal stoma. This greatly affects their physiological, psychological, and social well-being. However, there is currently a lack of a self-assessment outcome scale specifically designed for bladder cancer patients with abdominal stomas. Therefore, we developed and validated a self-assessment outcome scale (PROS-BCAS) for Chinese bladder cancer patients with abdominal stomas. The scale was initially developed through literature research and expert consultation, and it comprised four dimensions: physiological, psychological, social, and treatment, with a total of 66 items. After item analysis, 44 items were retained. We collected scale data from 382 patients to examine its validity and reliability. The results showed that the PROS-BCAS scale had good content validity (S-CVI/Ave = 0.992), construct validity (KMO > 0.6), and discriminant validity (correlation coefficient 0.404-0.870). The Cronbach's alpha coefficients (0.801-0.954), test-retest reliability (0.778-0.956), and split-half reliability (0.896-0.977) all demonstrated good internal consistency for each dimension and the overall scale. The study demonstrated that the PROS-BCAS scale is a reliable and valid tool for accurately assessing the health-related quality of life of bladder cancer patients with abdominal stomas, providing reference for developing individualized clinical care plans.

Continuity of care in suicide prevention: current status and future directions

Introduction

Continuity of Care (CoC) is central to suicide prevention. The present study aims to review contemporary definitions, operationalization in research, and key components of CoC in the prevention of suicide.

Methods

The present study is a narrative review. A thorough search of available literature on CoC and suicidality was conducted. Studies published between 1995 and 2021 were reviewed and selected based on relevance to CoC and suicidality. Selected research was subsequently summarized to outline definitions of CoC, its operationalization in research, and key components for suicide prevention.

Results

The definition, measurement, and operationalization of CoC in suicide prevention varies tremendously, derailing clinical practice. Key elements of CoC identified across the literature include (1) CoC across multiple levels of care, (2) the role of primary care providers and case managers in CoC of suicidal patients, (3) the importance of follow up contact with suicidal patients post-treatment, and (4) the role of national and institutional guidelines for CoC of suicidal patients. Limitations: There is a dearth of randomized controlled trials and insufficient evidence on specific populations.

Conclusion

CoC refers to a wide, complex concept that must be broken down into specific categories that can provide more nuanced guidance of research and clinical implications.

The role of maintenance therapy in the treatment of advanced urothelial cancer: a comprehensive systematic review and network meta-analysis

Concerns increase with maintenance therapy for advanced urothelial cancer (aUC). We perform a comprehensive network meta-analysis (NMA) to investigate the efficacy and toxicities of maintenance therapy in aUC patients. Trials assessing maintenance treatment with either a continuous or a switch strategy for aUC were identified. The primary outcome was overall survival (OS), and secondary outcome was progression-free survival (PFS) and toxicities. Nine articles reporting eight trials were included. The pooled hazard ratio demonstrated that maintenance therapy significantly improved OS giving HR 0.83 (95%CI: 0.74-0.93, P = 0.0013) and PFS with HR of 0.78 (95%CI: 0.62-0.99, P = 0.05), but increased the risk of developing severe adverse events and treated-related discontinues (P < 0.05). Sub-group analysis indicated that 'switch' ICI (immune checkpoint inhibitor) maintenance therapy significantly improved OS and PFS when compared to best support care (BSC) (P < 0.05). NMA showed that chemotherapy followed by 'switch' maintenance with ICI significantly improved OS (HR 0.70, 95%CI: 0.57-0.87) when compared to BSC. 'Continuous' maintenance with ICI alone had a tendency to improve OS (HR 0.85, 95%CI: 0.71-1.01), and TA (HR0.93, 95%CI: 0.58-1.50) and vinflunine (HR 0.74, 95%CI: 0.44-1.24) was no significantly associated with a lower likelihood of disease death. Based on the analysis of the treatment ranking, 'switch' maintenance with ICI appeared as the best treatment approach. Our pooled results confirm that maintenance therapy yields a significant survival advantage for aUC patients. NMA indicates that switch maintenance with ICI is the optimum maintenance treatment for aUC and reduces mortality by about a third.

Partial cystectomy for bladder squamous cell carcinoma with a 10-year follow-up: a case report

Squamous cell carcinoma (SCC) of the bladder is a rare malignancy of the urinary system. It is prone to invasion and metastasis in the early stage and has a poor prognosis. This case reports a 65-year-old female patient with SCC of the bladder who was free of disease recurrence and metastasis 10 years after partial cystectomy (PC) combined with left ureteral reimplantation. The treatment plan and admission of this patient were retrospectively analyzed in order to provide some reference significance for the treatment plan for the SCC of the bladder.

Global trends in the epidemiology of bladder cancer: challenges for public health and clinical practice

Bladder cancer is among the ten most common cancers globally, causes considerable morbidity and mortality and is, therefore, a substantial burden for health-care systems. The incidence of bladder cancer is affected by demographic trends, most notably population growth and ageing, as well as exposure to risk factors, especially tobacco smoking. Consequently, the incidence has not been stable throughout the world over time, nor will it be in the near future. Further primary prevention efforts are of the utmost importance to reduce the medical and financial burden of bladder cancer on populations and health-care systems. Simultaneously, less-invasive and lower-cost approaches for the diagnosis of both primary and recurrent bladder cancers are required to address challenges posed by the increasing shortage of health-care professionals and limited financial resources worldwide. In this regard, urinary biomarkers have demonstrated promising diagnostic accuracy and efficiency. Awareness of the risk factors and symptoms of bladder cancer should also be increased in society, particularly among health-care professionals and high-risk groups. Studies investigating the associations between lifestyle factors and bladder cancer outcomes are scarce and should be a research priority. In this Review, we outline global trends in bladder cancer incidence and mortality, and discuss the main risk factors influencing bladder cancer occurrence and outcomes. We then discuss the implications, challenges and opportunities of these epidemiological trends for public health and clinical practice.

Conditional survival after radical cystectomy for non-metastatic muscle-invasive squamous cell carcinoma of the urinary bladder: A population-based analysis

PURPOSE

To assess the effect of event-free survival duration on cancer-specific mortality (CSM) after radical cystectomy (RC) in nonmetastatic muscle-invasive squamous cell carcinoma of the urinary bladder.

METHODS

RC patients treated for non-metastatic muscle-invasive squamous cell carcinoma of the urinary bladder were identified within the Surveillance, Epidemiology, and End Results database (2000-2018). Independent predictor status for CSM of T and N stage groupings (i.e., T2N0, T3N0, T4N0, and TanyN1-3) was tested in multivariable Cox-regression models. Conditional 5-year CSM-free estimates were assessed at baseline and at 4 specific event-free survival times (i.e. 6, 12, 18 and 24 months), within each of the 4 examined stage groups.

RESULTS

Of 981 RC patients, 206 (21%), 416 (42%), 152 (16%), and 207 (21%) were T2N0, T3N0, T4N0, and TanyN1-3, respectively. In multivariable Cox-regression models T3N0 (HR 1.94), T4N0 (HR 5.22), and TanyN1-3 (HR 6.62) were independent predictors of CSM, relative to T2N0. In conditional survival analyses based on 24 months event-free status, survival estimates were: 89% for T2N0 vs. 76% at baseline (Δ = 13%), 84% for T3N0 vs. 58% at baseline (Δ = 26%), 69% for T4N0 vs. 25% at baseline (Δ = 44%), 69% for TanyN1-3 vs. 22% at baseline (Δ = 47%).

CONCLUSIONS

Event-free status at 24 months of follow-up is associated with substantially higher CSM-free survival than when CSM-free survival is predicted at baseline. The magnitude of this effect is most pronounced in TanyN1-3 and T4N0 patients, intermediate in T3N0 and more modest, nonetheless important, in T2N0.

Recent Progress in Nanomaterial-Based Biosensors and Theranostic Nanomedicine for Bladder Cancer

Bladder cancer (BCa) is one of the most expensive and common malignancies in the urinary system due to its high progression and recurrence rate. Although there are various methods, including cystoscopy, biopsy, and cytology, that have become the standard diagnosis methods for BCa, their intrinsic invasive and inaccurate properties need to be overcome. The novel urine cancer biomarkers are assisted by nanomaterials-based biosensors, such as field-effect transistors (FETs) with high sensitivity and specificity, which may provide solutions to these problems. In addition, nanomaterials can be applied for the advancement of next-generation optical imaging techniques and the contrast agents of conventional techniques; for example, magnetic resonance imaging (MRI) for the diagnosis of BCa. Regarding BCa therapy, nanocarriers, including mucoadhesive nanoparticles and other polymeric nanoparticles, successfully overcome the disadvantages of conventional intravesical instillation and improve the efficacy and safety of intravesical chemotherapy for BCa. Aside from chemotherapy, nanomedicine-based novel therapies, including photodynamic therapy (PDT), photothermal therapy (PTT), chemodynamic therapy (CDT), sonodynamic therapy (SDT), and combination therapy, have afforded us new ways to provide BC therapy and hope, which can be translated into the clinic. In addition, nanomotors and the nanomaterials-based solid tumor disassociation strategy provide new ideas for future research. Here, the advances in BCa diagnosis and therapy mentioned above are reviewed in this paper.

Differences in Cancer-Specific Mortality after Trimodal Therapy for T2N0M0 Bladder Cancer according to Histological Subtype

We aimed at assessing the impact of non-urothelial variant histology (VH), relative to urothelial carcinoma of the urinary bladder (UCUB), on cancer-specific mortality (CSM) in T2N0M0 bladder cancer patients treated with trimodal therapy (TMT). TMT patients treated for T2N0M0 bladder cancer were identified within the Surveillance, Epidemiology, and End Results database (2000−2018). Patients who underwent TMT received trans-urethral resection of the bladder tumor, chemotherapy, and radiotherapy. CSM-FS rates were tested using Kaplan−Meier plots and multivariable Cox-regression (MCR) models according to histological subtype: UCUB vs. neuroendocrine carcinoma vs. squamous cell carcinoma vs. adenocarcinoma. A total of 3846 T2N0MO bladder cancer patients treated with TMT were identified. Of these, 3627 (94.3%) harbored UCUB, while 105 (2.7%), 85 (2.2%), and 29 (0.8%) harbored neuroendocrine carcinoma, squamous cell carcinoma, and adenocarcinoma, respectively. In Kaplan−Meier analyses, 3-yr CSM-FS rates were 57% for UCUB, 51% for neuroendocrine carcinoma, 35% for squamous cell carcinoma, and 60% for adenocarcinoma (p-value < 0.0001). In MCR models, only squamous cell carcinoma exhibited higher CSM than UCUB (HR 1.98, 95%CI 1.5−2.61, p-value < 0.001). Despite the small number of observations, squamous cell carcinoma distinguished itself from UCUB based on worse survival in T2N0M0 patients after TMT.

Expression and Prognostic Implication of PD-L1 in Patients with Urothelial Carcinoma with Variant Histology (Squamous Differentiation or Micropapillary) Undergoing Radical Cystectomy

The expression and prognostic role of programmed death ligand-1 (PD-L1) on tumor-infiltrating immune cells (TICs) has not been determined in urothelial carcinoma (UC) with variant histology. We retrospectively reviewed 90 patients (44 with micropapillary variant of UC (MPUC) and 46 with UC with squamous differentiation (UCSD)) who underwent radical cystectomy between January 2013 and December 2019. The expression of PD-L1 in TICs was measured using the VENTANA (SP-142) immunohistochemistry assay and dichotomized using a 5% cutoff value (positive ≥ 5%). Kaplan–Meier survival analysis was used to estimate recurrence-free survival (RFS), and multivariable Cox proportional hazard models were used to identify factors predicting tumor recurrence. Overall, positive PD-L1 expression in TICs was confirmed in 50 of 90 (55.6%) patients (40.1% (18/44) of MPUC and 69.9% (32/46) of UCSD). RFS was significantly shorter in patients with positive PD-L1 expression in TICs than in those with negative PD-L1 expression both in MPUC (p = 0.005) and UCSD (p = 0.046). Positive PD-L1 expression in TICs was significantly associated with an increased risk of tumor recurrence in both MPUC (HR = 1.85; 95% CI: 1.323–2.672; p = 0.017) and UCSD (HR = 1.58; 95% CI: 1.162–2.780; p = 0.032). In conclusion, positive PD-L1 expression in TICs was significantly associated with poorer RFS in both MPUC and UCSD patients. Our results support the use of adjuvant immunotherapy in these patients if they test positive for PD-L1 in their TICs.

Bladder Cancer Sample Handling and Reporting: Pathologist's Point of View

The aim of this narrative review is to provide adequate information on handling and reporting of the bladder cancer samples to improve the closely collaboration between pathologists and urologists. The main (but not exclusive) research tool used was PubMed and 87 references were selected and quoted in the text. We have considered handling of biopsies, transurethral resection (TUR), and cystectomy specimens to summarize the different methods of sampling and the related issues. Moreover, we considered and discussed the main prognostic factors, such as histological tumor type, grade, and stage of bladder cancer, that should be described in the pathological report. In addition, critical issues encountered in the interpretation of histological samples were discussed.

Insulinoma-associated Protein 1 (INSM1) Expression in Small Cell Neuroendocrine Carcinoma of the Urinary Tract

Clinical guidelines state that neoadjuvant chemotherapy should be administered before surgery in muscle invasive urinary bladder small cell neuroendocrine carcinoma. Recently described marker insulinoma-associated protein 1 (INSM1) has been reported to be sensitive and specific for neuroendocrine differentiation, however, its efficacy in urinary tract small cell carcinoma is not well established. This study examines immunohistochemical expression of INSM1 on whole tissue sections of urinary tract small cell neuroendocrine carcinoma and compares INSM1 expression with established neuroendocrine markers. Immunohistochemical stains for CD56, INSM1, synaptophysin, and chromogranin were performed on 32 cases of small cell neuroendocrine carcinoma of the bladder. Staining was scored for intensity (0: no staining; 1: weak; 2: moderate; 3: strong) and proportion of cells stained (0: 0%; 1: >0% to ≤25%; 2: >25% to ≤50%; 3: >50% to ≤75%; 4: >75% to 100%). INSM1 was positive (intensity 1 to 3 or proportion 1 to 4) in 87% (28/32) of cases (20 with intensity 2 to 3, 17 with proportion 3 to 4). CD56, synaptophysin, and chromogranin were positive in 75% (24/32), 60% (19/32), and 44% (14/32) of cases, respectively. INSM1 was negative (n=4) or only showed weak intensity staining (n=7) in 34% (11/32) of cases. INSM1 is a sensitive marker of small cell neuroendocrine differentiation of the urinary tract. However, this study suggests that optimal utilization of INSM1 would be inclusion in a limited panel of stains rather than as a stand-alone screening marker given that it is negative or only shows weak intensity staining in a significant proportion of cases.

Nanotechnology in Bladder Cancer: Diagnosis and Treatment

Bladder cancer (BC) is the second most common cancer of the urinary tract in men and the fourth most common cancer in women, and its incidence rises with age. There are many conventional methods for diagnosis and treatment of BC. There are some current biomarkers and clinical tests for the diagnosis and treatment of BC. For example, radiotherapy combined with chemotherapy and surgical, but residual tumor cells mostly cause tumor recurrence. In addition, chemotherapy after transurethral resection causes high side effects, and lack of selectivity, and low sensitivity in sensing. Therefore, it is essential to improve new procedures for the diagnosis and treatment of BC. Nanotechnology has recently sparked an interest in a variety of areas, including medicine, chemistry, physics, and biology. Nanoparticles (NP) have been used in tumor therapies as appropriate tools for enhancing drug delivery efficacy and enabling therapeutic performance. It is noteworthy, nanomaterial could be reduced the limitation of conventional cancer diagnosis and treatments. Since, the major disadvantages of therapeutic drugs are their insolubility in an aqueous solvent, for instance, paclitaxel (PTX) is one of the important therapeutic agents utilized to treating BC, due to its ability to prevent cancer cell growth. However, its major problem is the poor solubility, which has confirmed to be a challenge when improving stable formulations for BC treatment. In order to reduce this challenge, anti-cancer drugs can be loaded into NPs that can improve water solubility. In our review, we state several nanosystem, which can effective and useful for the diagnosis, treatment of BC. We investigate the function of metal NPs, polymeric NPs, liposomes, and exosomes accompanied therapeutic agents for BC Therapy, and then focused on the potential of nanotechnology to improve conventional approaches in sensing.

EHHADH contributes to cisplatin resistance through regulation by tumor-suppressive microRNAs in bladder cancer

Background

Cisplatin-based chemotherapy is recommended as the primary treatment for advanced bladder cancer (BC) with unresectable or metastatic disease. However, the benefits are limited due to the acquisition of drug resistance. The mechanisms of resistance remain unclear. Although there are some reports that some molecules are associated with cisplatin resistance in advanced BC, those reports have not been fully investigated. Therefore, we undertook a new search for cisplatin resistance-related genes targeted by tumor suppressive microRNAs as well as genes that were downregulated in cisplatin-resistant BC cells and clinical BC tissues.

Methods

First, we established cisplatin-resistant BOY and T24 BC cell lines (CDDP-R-BOY, CDDP-R-T24). Then, Next Generation Sequence analysis was performed with parental and cisplatin-resistant cell lines to search for the microRNAs responsible for cisplatin resistance. We conducted gain-of-function analysis of microRNAs and their effects on cisplatin resistance, and we searched target genes comprehensively using Next Generation mRNA sequences.

Results

A total of 28 microRNAs were significantly downregulated in both CDDP-R-BOY and CDDP-R-T24. Among them, miR-486-5p, a tumor suppressor miRNA, was negatively correlated with the TNM classification of clinical BC samples in The Cancer Genome Atlas (TCGA) database. Transfection of miRNA-486-5p significantly inhibited cancer cell proliferation, migration, and invasion, and also improved the cells’ resistance to cisplatin. Among the genes targeted by miRNA-486-5p, we focused on enoyl-CoA, hydratase/3-hydroxyacyl CoA dehydrogenase (EHHADH), which is involved in the degradation of fatty acids. EHHADH was directly regulated by miRNA-486-5p as determined by a dual-luciferase reporter assay. Loss-of-function study using EHHADH si-RNA showed significant inhibitions of cell proliferation, migration, invasion and the recovery of cisplatin sensitivity.

Conclusion

Identification of EHHADH as a target of miRNA-486-5p provides novel insights into the potential mechanisms of cisplatin resistance in BC.

Bladder preserving chemoradiotherapy compared to surgery for variants of urothelial carcinoma and other tumors types involving the bladder: An analysis of the National Cancer Database

PURPOSE

For muscle-invasive bladder cancer, bladder preserving chemoradiotherapy (BPCRT) has shown to be a viable alternative for patients with urothelial carcinoma (UCa). Traditionally bladder cancer with variant histology UCa or other tumors types involving the bladder have worse outcomes and BPCRT has been contraindicated. However, there is limited high level evidence for this recommendation.

MATERIALS/METHODS

The National Cancer Database (NCDB) was queried for all patients with Bladder cancer treated from 2004 to 2015 restricted to clinical stage T2-4, N0, M0 who had variants of UCa or other tumors types involving the bladder (e.g. adenocarcinoma and squamous cell carcinoma). Only patients treated with definitive intent with either radical cystectomy or BPCRT after maximal transurethral tumor resection were analyzed. Propensity-score matching was used.

RESULTS

356 patients had BPCRT and 2093 patients had definitive surgery for muscle-invasive bladder cancer limited to variants of UCa and other tumors types involving the bladder. On multivariable analysis worse prognosis was associated with age >65 years old (HR 1.24, p = 0.004) and T4 disease (HR 1.90, p < 0.001). In propensity score weighted sample, there was no statistical significant difference in OS for patients with BPCRT as compared to cystectomy (p = 0.387) and for neuroendocrine, micropapillary or not otherwise specified histology subgroups there was no significant difference. Patients with adenocarcinoma (HR 1.75) or squamous cell carcinoma (HR 1.49) had worse OS associated with BPCRT compared to surgery.

CONCLUSION

From 2004 to 2015, BPCRT in muscle-invasive bladder cancer was associated with similar overall survival compared to cystectomy in patients with selected variant histology but with worse OS for adenocarcinoma or squamous cell carcinoma specifically. As our study has inherent limitations, these hypotheses require validation in a prospective setting and/or with a larger sample size.

Urological malignancies in neurogenic patients

PURPOSE OF REVIEW

To review recent literature related to urologic malignancies in patients with neurogenic lower urinary tract dysfunction (NLUTD). We performed a literature search of electronic databases (PubMed, ScienceDirect, Scopus, and CIANHL), with a focus on articles published between January 2015 and December 2019.

RECENT FINDINGS

Recent reports demonstrate a lower incidence of bladder cancer in the NLUTD population than previously found, although still significantly higher than the general population. Bladder cancer in patients with NLUTD is usually diagnosed at a younger age, and is associated with higher rates of squamous cell cancer, a higher stage at presentation, and increased mortality. Evidence for screening for bladder cancer in NLUTD is conflicting, with no formal protocols proven for general use. NLUTD has been shown to have a lower rate of prostate cancer, and may be associated with an earlier diagnosis of renal cancer.

SUMMARY

Genitourinary malignancies, although still rare, are an important source of morbidity and mortality in patients with NLUTD. Physicians should recognize that bladder cancer in NLUTD is often a lethal disease. Further research is needed to assist physicians with early recognition of these malignancies to improve patient outcomes.

Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada

BACKGROUND: Despite recent advances in the management of muscle-invasive bladder cancer (MIBC), treatment outcomes remain suboptimal, and variability exists across current practice patterns. OBJECTIVE: To promote standardization of care for MIBC in Canada by developing a consensus guidelines using a multidisciplinary, evidence-based, patient-centered approach who specialize in bladder cancer. METHODS: A comprehensive literature search of PubMed, Medline, and Embase was performed; and most recent guidelines from national and international organizations were reviewed. Recommendations were made based on best available evidence, and strength of recommendations were graded based on quality of the evidence. RESULTS: Overall, 17 recommendations were made covering a broad range of topics including pathology review, staging investigations, systemic therapy, local definitive therapy and surveillance. Of these, 10 (59% ) were level 1 or 2, 7 (41% ) were level 3 or 4 recommendations. There were 2 recommendations which did not reach full consensus, and were based on majority opinion. This guideline also provides guidance for the management of cisplatin-ineligible patients, variant histologies, and bladder-sparing trimodality therapy. Potential biomarkers, ongoing clinical trials, and future directions are highlighted. CONCLUSIONS: This guideline embodies the collaborative expertise from all disciplines involved, and provides guidance to further optimize and standardize the management of MIBC.

Role of microRNA/Epithelial-to-Mesenchymal Transition Axis in the Metastasis of Bladder Cancer

Bladder cancer (BC) is the 11th most common diagnosed cancer, and a number of factors including environmental and genetic ones participate in BC development. Metastasis of BC cells into neighboring and distant tissues significantly reduces overall survival of patients with this life-threatening disorder. Recently, studies have focused on revealing molecular pathways involved in metastasis of BC cells, and in this review, we focus on microRNAs (miRNAs) and their regulatory effect on epithelial-to-mesenchymal transition (EMT) mechanisms that can regulate metastasis. EMT is a vital process for migration of BC cells, and inhibition of this mechanism restricts invasion of BC cells. MiRNAs are endogenous non-coding RNAs with 19-24 nucleotides capable of regulating different cellular events, and EMT is one of them. In BC cells, miRNAs are able to both induce and/or inhibit EMT. For regulation of EMT, miRNAs affect different molecular pathways such as transforming growth factor-beta (TGF-β), Snail, Slug, ZEB1/2, CD44, NSBP1, which are, discussed in detail this review. Besides, miRNA/EMT axis can also be regulated by upstream mediators such as lncRNAs, circRNAs and targeted by diverse anti-tumor agents. These topics are also discussed here to reveal diverse molecular pathways involved in migration of BC cells and strategies to target them to develop effective therapeutics.

Clinical Characteristics, Treatment Strategy, and Outcomes of Primary Large Cell Neuroendocrine Carcinoma of the Bladder: A Case Report and Systematic Review of the Literature

Purpose: The aim of this study was to review the clinicopathologic characteristics, treatments, and outcomes of patients with primary large cell neuroendocrine carcinoma of the bladder (LCNEC).

Patients and Methods: We report one patient diagnosed with primary pure LCNEC of the bladder in Sun Yat-sen Memorial Hospital. In addition, we performed a systematic literature review, in April 2020, on case report and case series of LCNEC of the bladder. The clinicopathologic characteristics, treatments and outcomes of this rare disease were analyzed.

Results: A total of 39 patients were included in our analysis (1 case from our institution and 38 cases from the literature). Most patients (79.5%) were male. The average age at the surgery for the patients is 61.5 years (range 19–85 years). The most common symptom was hematuria (n = 20, 76.9%). Almost all patients (38, 97.4%) underwent surgery, with 26 (66.7%) receiving multimodality therapy. Out of 24 patients with available data, regional or distant recurrences developed in 14 patients (58.3%). The median overall survival of the patients was 11.5 months, with 1- and 3-year survival rates of 54.0 and 21.4%, respectively. In the survival analysis, theT1–2 tumors (P = 0.025), no distant metastases at diagnosis (P = 0.001), and multimodality therapy (P = 0.017) were associated with better overall survival (OS).

Conclusions: LCNEC of the bladder is an extremely rare neoplasm. The available data suggest that the disease has an aggressive natural history with poor prognosis. Early pathologic stage and multimodality treatment may be important factors in determining prognosis.

Atezolizumab in patients with renal insufficiency and mixed variant histology: analyses from an expanded access program in platinum-treated locally advanced or metastatic urothelial carcinoma

Background

Atezolizumab is a treatment for locally advanced/metastatic urothelial carcinoma (mUC). However, its use in patients with renal insufficiency or UC with mixed variant histology (MVH) is not well characterized.

Objective

To report efficacy and safety of atezolizumab in these special subpopulations from an expanded access program (EAP).

Design, setting, and participants

A total of 218 patients were enrolled at 36 US study sites (November 2015–August 2016), and the trial ended following the approval of atezolizumab by the US Food and Drug Administration. This post hoc analysis investigated outcomes in specific study subgroups.

Intervention

Atezolizumab 1200 mg was administered intravenously every 3 weeks until loss of clinical benefit, unacceptable toxicity, death, consent withdrawal, decision to discontinue, commercial availability, or study closure.

Outcome measurements and statistical analysis

Response Evaluation Criteria in Solid Tumors V.1.1 responses and safety were evaluated by baseline renal function and histology.

Results and limitations

Objective responses occurred in 0/6 (0%), 4/19 (21%), 1/27 (3.7%), and 12/62 (19%) of evaluable patients with creatinine clearance (CrCl) <30, 30–45, 45–60, and ≥60 mL/min, respectively, and stable disease was seen in three patients with CrCl <30 mL/min. Objective responses were seen in 13/102 patients (13%) with urothelial carcinoma (UC) histology only and in 4/12 patients (33%) with UC with MVH. Treatment-related adverse event frequencies ranged from 35% to 54% across the earlier indicated CrCl subgroups and they were also similar in patients with pure UC or UC with MVH (46%).

Conclusions

In this EAP mUC subgroup analysis, clinical benefit of atezolizumab occurred in patients with compromised renal function or MVH UC tumors. Safety was comparable across subgroups.

Patient summary

We examined the efficacy and safety of atezolizumab for UC in certain patients participating in an EAP. We found that responses to atezolizumab occurred, and safety was similar, in most patient subgroups with varying levels of kidney functioning or less common types of tumor tissue histology.

U-shaped relationship of age at diagnosis and cancer-specific mortality in primary urachal adenocarcinoma: a cohort study

BACKGROUND

To examine the association between age at diagnosis and cancer-specific mortality (CSM) in primary urachal adenocarcinoma.

METHODS

The data was obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results program (SEER). A total of 393 patients were included in the study. Smooth curve fitting and two-piecewise Cox proportional hazards models were used to identify the nonlinearity between the age at initial diagnosis and cancer-specific survival rate. Survival time between different groups was compared using Kaplan-Meier survival curves and the log-rank test.

RESULTS

Using smooth curve fitting we found that the relationship between age at diagnosis and cancer-specific survival takes on a U-shaped curve. The inflection point that we identified for the age at initial diagnosis was 60 years. The log-likelihood ratio test (P<0.05) indicated that the two-piecewise Cox regression model was more appropriate for fitting the correlation of age at diagnosis and CSM. The two-piecewise Cox regression model showed that when the age was <60 years, reduced risk of CSM was significantly associated with increased age (HR: 0.95, P=0.0002). Conversely, when age was >60 years, increased risk of CSM was significantly associated with increased age (HR: 1.05, P=0.0499).

CONCLUSIONS

In summary, our study suggested that the relationship between age at diagnosis and cancer-specific survival is nonlinear, and takes on a U-shaped curve. Both younger and older age at initial diagnosis age were associated with increased CSM.

Radical cystectomy plus chemotherapy in patients with pure squamous cell bladder carcinoma: a population-based study

PURPOSE

To test the effect of perioperative chemotherapy (CHT) on overall mortality (OM) and cancer-specific mortality (CSM) in patients with locally advanced or metastatic squamous cell carcinoma of the urinary bladder (SCC UB).

METHODS

Within the Surveillance, Epidemiology and End Results database (1988-2016), we identified 1,018 SCC UB patients (664 T_3-4aN₀M₀, 197 TanyN_1-3M₀ and 156 T_4bN_0-3 or M₁), who underwent radical cystectomy with or without perioperative chemotherapy administration. Inverse probability of treatment-weighting (IPTW), Kaplan-Meier plots and Cox-regression models (CRMs) were used.

RESULTS

CHT was administrated in 116 (17.5%) T_3-4aN₀M₀, 77 (39.1%) TanyN_1-3M₀ and 47 (30.1%) T_4bN_0-3 or M₁ patients. IPTW-adjusted 2-year cancer-specific survival (CSS) was 66.5 vs. 71.5% (p = 0.19), 60.9 vs. 29.5% (p < 0.001) and IPTW-adjusted 1-year CSS was 46.2 vs. 31.1% (p = 0.03) for CHT vs. no CHT administration in T_3-4aN₀M₀, TanyN_1-3M₀ and T_4bN_0-3 or M₁, respectively. In multivariable IPTW-adjusted CRMs, chemotherapy was an independent predictor of lower CSM in TanyN_1-3M₀ (HR 0.44) and in T_4bN_0-3 or M₁ (HR 0.60), but not in T_3-4aN₀M₀ (p = 0.6) patients. Virtually the same results were obtained on OM, as well as without IPTW-adjustment and after stratification according to age and gender.

CONCLUSIONS

The use of perioperative CHT in patients with SCC UB confers survival benefit in the presence of T4b disease, lymph node or distant metastases. Conversely, patients with locally advanced disease but negative lymph node invasion do not benefit from its use. Pending higher quality data from prospective trials, these data should encourage the use of perioperative CHT in those high-risk patient groups.

Bladder Preservation for Patients With Bladder Paragangliomas: Case Series and Review of the Literature

Bladder paragangliomas are rare tumors, with no prospective studies or guidelines on the management of this disease. We present a case series of 6 patients managed with bladder preservation over a median follow-up period of 124 months. We also present a review of the recent literature on bladder paragangliomas. We aim to provide a timely synthesis of the recent evidence on bladder paragangliomas as changing paradigms necessitate individualized treatment.

Condyloma Acuminatum of Urinary Bladder: Relation to Squamous Cell Carcinoma

Condyloma acuminatum rarely occurs in the urinary bladder and is considered to be a risk factor for squamous cell carcinoma, although there are only a few publications with limited cases. We studied 51 cases of condyloma acuminatum of the urinary bladder from transurethral resections of the urinary bladder of 38 patients from the consult files of one of the authors. Transurethral resections of the urinary bladder were obtained from 25 males with a median age of 73 years (range: 41 to 87 y) and 13 females with a median age of 68 years (range: 30 to 86 y). The follow-up period ranged from 15 months to 20 years (median: 6 y). Bladder lesions were accompanied by urethral lesions in 4 men. Eight patients (8/38; 21.0%) had a history of immunosuppression. Seven patients (7/8; 87.5%) from this group had multiple and/or recurrent condylomas. One patient (1/38; 2.6%) with renal transplantation had 10 separate bladder condylomas over time. One patient (1/38; 2.6%) had extensive anogenital condylomas and anal intraepithelial neoplasia grade 3. One patient (1/8; 12.5%) with renal transplantation presented with a solitary condyloma with synchronous squamous cell carcinoma in situ. Three female patients (3/38; 7.9%) had a history of premalignant vagina/cervix lesions. In total, 17 patients (17/38; 44.7%) had squamous cell carcinoma of the bladder, either invasive or in situ. In all cases, the squamous cell carcinoma (either in situ or invasive) was diagnosed either concurrent with the diagnosis of bladder condyloma or within 1 year of the condyloma diagnosis). In total, 9 of 38 (23.7%) patients had invasive squamous cell carcinoma with or without in situ squamous cell carcinoma. Eight of 38 (21.0%) patients had squamous cell carcinoma in situ only (without a definitive invasive component-in 3 cases invasive squamous cell carcinoma could not be excluded with certainty). In total, 19 patients (19/38; 50%) were positive for either low-risk human papillomavirus (LR-HPV) or high-risk human papillomavirus (HR-HPV) or both (3 were positive for both LR-HPV and HR-HPV, 12 patients for only LR-HPV, and 4 for only HR-HPV). Of the 19 patients that were negative for both LR-HPV and HR-HPV, 9 of 19 (47.4%) patients had associated squamous cell carcinoma. Of the 12 patients with only LR-HPV, 4 (33.3%) had associated squamous cell carcinoma (either invasive or in situ). Of the 7 patients with HR-HPV (with or without LR-HPV), 4 (57.1%) has associated squamous cell carcinoma. In summary, condyloma acuminatum of the urinary bladder shows a strong association with squamous cell carcinoma of the bladder, regardless of the condyloma's HPV in situ hybridization results. Immunosuppression is associated with condylomas of the bladder. It is important to distinguish bladder condylomas from papillary urothelial carcinoma, given their different risks for panurothelial disease and risk of squamous cell carcinoma. Recognition of bladder condylomas histologically is often challenging given their rarity, and that they can be negative for both LR-HPV and HR-HPV. The lack of a history of other anogenital human papillomavirus-related lesions further increases the difficulty in establishing the correct diagnosis.

Adherence to guideline recommendations for multimodality treatment of patients with pT2-3 M0 non-urothelial carcinoma of the urinary bladder: Temporal trends and survival outcomes

OBJECTIVES

To analyze contemporary multimodality treatment rates, defined as radical cystectomy plus chemotherapy and/or radiotherapy, for pT2-3 any N-stage M0 non-urothelial carcinoma of urinary bladder patients. Additionally, we tested for the effect of multimodality treatment versus radical cystectomy alone on cancer-specific mortality.

METHODS

Within the Surveillance, Epidemiology and End Results database (2004-2015), 887 pT2-3 any N-stage M0 non-urothelial carcinoma of urinary bladder patients treated with radical cystectomy were identified. Kaplan-Meier plots, and univariable and multivariable Cox regression analyses focused on cancer-specific mortality rates.

RESULTS

Squamous cell carcinoma was recorded in 499 (56.3%) patients, neuroendocrine carcinoma in 246 (27.7%) and adenocarcinoma in 142 (16.0%). The highest proportion of multimodality treatment patients was recorded in neuroendocrine carcinoma (69.1%), relative to adenocarcinoma (34.5%) and squamous cell carcinoma (26.4%). A statistically significant annual increase was recorded in multimodality treatment rates in neuroendocrine carcinoma patients (46.7-74.2%, P < 0.01), but not in adenocarcinoma or squamous cell carcinoma patients. The 5-year cancer-specific mortality rate in neuroendocrine carcinoma patients was significantly lower after multimodality treatment versus radical cystectomy alone (37.0% vs 51.5%; P < 0.01), but no statistically significant differences were recorded in both adenocarcinoma (46.1% vs 35.5%; P = 0.8) and squamous cell carcinoma (41.4% vs 31.1%; P = 0.8) patients. In multivariable analyses, for neuroendocrine carcinoma patients, multimodality treatment was an independent predictor of a lower cancer-specific mortality rate (hazard ratio 0.58, P = 0.03).

CONCLUSIONS

Multimodality treatment has been increasingly used during the study period in neuroendocrine carcinoma patients, and it has translated into a cancer-specific mortality benefit. This is not the case for other non-urothelial carcinoma of urinary bladder patients, such as adenocarcinoma or squamous cell carcinoma.

Comprehensive Assessment of Immuno-oncology Biomarkers in Adenocarcinoma, Urothelial Carcinoma, and Squamous-cell Carcinoma of the Bladder

BACKGROUND

In patients with rare histologies of bladder cancer, including adenocarcinoma of the bladder (ACB) and squamous-cell carcinoma (SCC), there are limited standard therapy options, defining an unmet medical need.

OBJECTIVE

In this comparative comprehensive genomic profiling (CGP) study, genomic alterations (GAs), and immuno-oncology (IO) biomarkers have been analyzed.

DESIGN, SETTING, AND PARTICIPANTS

Within the Foundation Medicine database, 143 cases with centrally reviewed pure ACB, 2142 with pure urothelial carcinoma (UC), and 83 with pure SCC were subjected to CGP. All patients developed advanced disease following a primary diagnosis of bladder cancer.

INTERVENTION

CGP using a hybrid capture-based assay and immunohistochemistry (IHC).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Tumor mutational burden (TMB) was determined on 1.1 Mbp of sequenced DNA, and microsatellite instability (MSI) was determined on 114 loci. Programmed cell-death ligand-1 (PD-L1) expression was determined by IHC (Ventana SP-142 assay), with >1% tumor cells (TCs) or tumor-infiltrating lymphocytes (TILs) scoring positive.

RESULTS AND LIMITATIONS

Pure ACB patients were younger and more often female than pure UC and pure SCC patients. UC and SCC had a significantly higher median TMB than ACB (p < 0.001). Rare CD274 (PD-L1) amplification cases were more frequently seen in SCC than in UC (5% vs 1%), and were not seen in ACB. MSI high status was very uncommon in all tumor types (0-1%). The frequencies of PD-L1 expression in both TCs and TILs was higher in UC and SCC (both 30%) than in ACB (18%). The results are limited by their retrospective nature and lack of clinical data annotation.

CONCLUSIONS

Deep sequencing revealed significant differences in IO biomarkers among the three major subtypes of bladder carcinomas. UC and SCC revealed higher frequencies of PD-L1 expression and higher TMB than ACB, and SCC has the highest frequency of CD274 amplification. The presence of pure SCC features should not disqualify patients for inclusion in IO trials.

PATIENT SUMMARY

Tumor samples from patients diagnosed with advanced pure adenocarcinoma of the bladder (ACB) or pure squamous-cell carcinoma (SCC) have been analyzed in terms of frequency of putative immunotherapy biomarkers. The results indicated that pure SCC of the bladder was characterized by genomic features that portend similar response possibilities to immunotherapy compared with the classical pure urothelial carcinoma. Conversely, for pure ACB there might be different therapeutic opportunities, such as targeted therapies against peculiar genomic alterations in selected patients.

Dataset for the reporting of carcinoma of the bladder-cystectomy, cystoprostatectomy and diverticulectomy specimens: recommendations from the International Collaboration on Cancer Reporting (ICCR)

The International Collaboration on Cancer Reporting (ICCR) is a not for profit organisation whose goal is to produce standardised internationally agreed and evidence-based datasets for pathology reporting. With input from pathologists worldwide, the datasets are intended to be uniform and structured. They include all items necessary for an objective and accurate pathology report which enables clinicians to apply the best treatment for the patient. This dataset has had input from a multidisciplinary ICCR expert panel. The rationale for some items being required and others recommended is explained, based on the latest literature. The dataset incorporates data from the World Health Organization (WHO) 2016, and also from the latest (8th edition) TNM staging system of the American Joint Committee on Cancer (AJCC). Fifteen required elements and eight recommended items are described. This dataset provides all the details for a precise and valuable pathology report required for patient management and prognostication. This dataset is intended for worldwide use, and should facilitate the collection of standardised comparable data on bladder carcinoma at an international level.

Updated Results of PURE-01 with Preliminary Activity of Neoadjuvant Pembrolizumab in Patients with Muscle-invasive Bladder Carcinoma with Variant Histologies

BACKGROUND

Patients with predominant variant histology (VH) of bladder tumors, defined as involving >50 % of the tumor specimens, are typically excluded from clinical trials, and for these patients, the efficacy of standard chemotherapy is limited.

OBJECTIVE

To evaluate the activity of preoperative pembrolizumab in patients with muscle-invasive bladder carcinoma (MIBC) and VH, enrolled in PURE-01 study (NCT02736266).

DESIGN, SETTING, AND PARTICIPANTS

In the open-label, single-arm, phase 2 PURE-01 study, three courses of 200 mg pembrolizumab preceding radical cystectomy (RC) were administered in T2-4aN0M0 MIBC patients. The amended study design included patients with predominant VH.

INTERVENTION

Neoadjuvant pembrolizumab and RC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Pathological complete response (pT0) in intention-to-treat population was the primary endpoint. Biomarker analyses included programmed cell-death ligand-1 (PD-L1) expression using the combined positive score (CPS; Dako 22C3 antibody) and comprehensive genomic profiling (FoundationOne assay). Multivariable logistic regression analyses (MVAs) evaluated the histological category (predominant VH vs nonpredominant VH vs pure urothelial carcinoma), tumor mutational burden (TMB) and CPS in association with the pathological response.

RESULTS AND LIMITATIONS

From February 2017 to June 2019, 114 patients were enrolled; 34 (30%) of them presented with VH, including 19 (17%) with predominant VH. In total, the pT0 rate was 37% (95% confidence interval [CI]: 28-46) and the pT ≤ 1 rate was 55% (95% CI: 46-65). The majority of predominant VH patients presented with squamous-cell carcinoma (SCC; N = 7), and six of seven (86%) had downstaging to pT ≤ 1, with one pT0; two of three lymphoepithelioma-like (LEL) variants had a pT0 response. None of the remaining nine predominant VHs had a response. On MVA, TMB and CPS were associated with both the pT0 and the pT ≤ 1 response, regardless of tumor histology.

CONCLUSIONS

The updated PURE-01 results confirm the activity of neoadjuvant pembrolizumab in MIBC. Patients with SCC and LEL features may be suitable for neoadjuvant immunotherapy trials. CPS and TMB are the key response predictors irrespective of the histological subtypes.

PATIENT SUMMARY

In the PURE-01 study, we have preliminarily evaluated the activity of neoadjuvant pembrolizumab in patients with predominant variant histology (VH). Of these patients, those harboring squamous-cell carcinoma or a lymphoepithelioma-like variant feature had major, although preliminary, pathological responses compared with those with other predominant VHs. Expression of programmed cell-death ligand-1 and tumor mutational burden may predict the pathological response to pembrolizumab, and provide a rationale for selecting patients according to these features instead of the histological bladder cancer subtypes.

Molecular and histopathology directed therapy for advanced bladder cancer

Bladder cancer is a heterogeneous group of tumours with at least 40 histological subgroups. Patients with localized disease can be cured with surgical resection or radiotherapy, but such curative options are limited in the setting of recurrent disease or distant spread, in which case systemic therapy is used to control disease and palliate symptoms. Cytotoxic chemotherapy has been the mainstay of treatment for advanced bladder cancer, but high-quality evidence is lacking to inform the management of rare subgroups that are often excluded from studies. Advances in molecular pathology, the development of targeted therapies and the resurgence of immunotherapy have led to the reclassification of bladder cancer subgroups and rigorous efforts to define predictive biomarkers for cancer therapies. In this Review, we present the current evidence for the management of conventional, variant and divergent urothelial cancer subtypes, as well as non-urothelial bladder cancers, and discuss how the integration of genomic, transcriptomic and proteomic characterization of bladder cancer could guide future therapies.

Urothelial carcinoma with villoglandular differentiation (UCVGD) with small cell neuroendocrine carcinoma of urinary bladder

Urothelial carcinoma with villoglandular differentiation (UCVGD) is a rare aggressive variant of urothelial carcinoma. It is usually associated with high-grade urothelial carcinoma or rarely adenocarcinoma. There is only one other previous report of UCVGD associated with small cell neuroendocrine carcinoma of urinary bladder. We report the second case of UCVGD with small cell neuroendocrine carcinoma of urinary bladder in a 74-year-old non-smoker male patient. The mass was muscle invasive and also invaded the prostate. This entity needs to be confidently diagnosed due to its prognostic and therapeutic implications.

The continuing role of chemotherapy in the management of advanced urothelial cancer

Despite intense drug development in the last decade in metastatic urothelial carcinoma and the incorporation of novel compounds to the treatment armamentarium, chemotherapy remains a key treatment strategy for this disease. Platinum-based combinations are still the backbone of first-line therapy in most cases. The role of chemotherapy in the second line has been more ill-defined due to the complexity of this setting, where patient selection remains critical. Nevertheless, two regimens, one in monotherapy (i.e. vinflunine) and one in combination with antiangiogenics (i.e. docetaxel + ramucirumab) have shown efficacy. Immunotherapy through checkpoint inhibition has revealed remarkably durable benefit in a small proportion of patients in the first and second line and is currently the preferred partner for combinations with chemotherapy. Difficult populations such as patients with liver metastases or those progressing to checkpoint inhibition represent a medical challenge and selective ways of delivering cytotoxics, like the antibody-drug conjugates, might represent a valid alternative. This article reviews the current role of chemotherapy in the management of advanced urothelial carcinoma and the ongoing and coming studies involving this treatment strategy.