Bladder cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up

The role of cisplatin in modulating the tumor immune microenvironment and its combination therapy strategies: a new approach to enhance anti-tumor efficacy

Cisplatin is a platinum-based drug that is frequently used to treat multiple tumors. The anti-tumor effect of cisplatin is closely related to the tumor immune microenvironment (TIME), which includes several immune cell types, such as the tumor-associated macrophages (TAMs), cytotoxic T-lymphocytes (CTLs), dendritic cells (DCs), myeloid-derived suppressor cells (MDSCs), regulatory T cells (Tregs), and natural killer (NK) cells. The interaction between these immune cells can promote tumor survival and chemoresistance, and decrease the efficacy of cisplatin monotherapy. Therefore, various combination treatment strategies have been devised to enhance patient responsiveness to cisplatin therapy. Cisplatin can augment anti-tumor immune responses in combination with immune checkpoint blockers (such as PD-1/PD-L1 or CTLA4 inhibitors), lipid metabolism disruptors (like FASN inhibitors and SCD inhibitors) and nanoparticles (NPs), resulting in better outcomes. Exploring the interaction between cisplatin and the TIME will help identify potential therapeutic targets for improving the treatment outcomes in cancer patients.

Differential response of low- and high-grade intermediate-risk non-muscle-invasive bladder cancer to bacillus Calmette-Guérin and gemcitabine-docetaxel therapy

BACKGROUND AND OBJECTIVE

Sequential intravesical gemcitabine/docetaxel (Gem/Doce) is a potential alternative to bacillus Calmette-Guérin (BCG) for treating non-muscle-invasive bladder cancer (NMIBC). Intermediate-risk NMIBC group (IR-NMIBC) includes both low-grade (LG) and high-grade tumors (HG). This study investigates the response of HG and LG IR-NMIBC to Gem/Doce compared to BCG therapy.

METHODS

We included patients with IR-NMIBC who received either BCG or Gem/Doce between 2013 and 2023. Maintenance regimens were administered to patients without recurrence after induction for 1 year. Follow-up cystoscopies were performed per American Urological Association (AUA) guidelines. Kaplan-Meier and Cox regression analyses were performed to evaluate recurrence-free survival (RFS) and progression-free survival (PFS).

RESULTS

Among 505 NMIBC patients, 150 were IR-NMIBC: 115 with HG tumors (69 received BCG, 46 received Gem/Doce) and 35 with LG tumors (14 received BCG, 21 received Gem/Doce).With a median follow-up time of 31 months (Interquartile Range [IQR] 13-54), The overall 2-year any-grade RFS was 55%. For HG and LG groups, the 2-year any-grade RFS was 58% and 35% (P = 0.009), respectively. High-grade RFS at 2 years was 75% for HG and 94% for LG (P = 0.065). The 2-year PFS was similar between groups, at 96% for both HG and LG (P = 0.39). In HG patients, 2-year high-grade RFS was higher with BCG than Gem/Doce (81% vs. 59%, P = 0.008). In LG patients, 2-year any-grade and high-grade RFS were comparable between BCG and Gem/Doce (P = 0.067 and P = 0.37, respectively).

CONCLUSIONS

Our findings suggest that BCG may offer a superior benefit in terms of high-grade RFS for HG IR-NMIBC compared to Gem/Doce, while LG tumors respond similarly to both treatments. This emphasizes the role of risk stratification in treatment selection. Prospective studies are needed to validate these findings and refine treatment strategies.

Enfortumab vedotin plus pembrolizumab versus chemotherapy in patients with previously untreated locally advanced or metastatic urothelial cancer (EV-302): patient-reported outcomes from an open-label, randomised, controlled, phase 3 study

BACKGROUND

In the ongoing EV-302 trial, first-line enfortumab vedotin plus pembrolizumab improved progression-free survival and overall survival versus platinum-based chemotherapy in patients with locally advanced or metastatic urothelial cancer. Patient-reported outcomes (PROs) from EV-302 are reported here.

METHODS

EV-302 was a phase 3, open-label, two-group, randomised global study to evaluate the combination of enfortumab vedotin plus pembrolizumab versus standard-of-care platinum-based chemotherapy (gemcitabine with cisplatin or carboplatin) in patients with previously untreated locally advanced or metastatic urothelial cancer. The study was done at 185 clinical sites in 25 countries. Eligible patients were aged 18 years and older with unresectable untreated locally advanced or metastatic urothelial cancer, were eligible for platinum-based chemotherapy, and had an Eastern Cooperative Oncology Group performance status of 2 or less. Patients were randomly assigned (1:1) to receive either enfortumab vedotin (1·25 mg/kg, intravenously) on days 1 and 8 of 3-week cycles plus pembrolizumab (200 mg, intravenously) on day 1 of each cycle; or platinum-based chemotherapy consisting of gemcitabine (1000 mg/m2, intravenously) on days 1 and 8 of each cycle plus either cisplatin (70 mg/m2) or carboplatin (area under the curve [AUC] 4·5 or 5·0 according to local guidelines) on day 1 of each 3-week cycle for up to six cycles using interactive response technology. Randomisation was stratified by cisplatin eligibility, PD-L1 expression status, and presence or absence of liver metastases. The dual primary endpoints of progression-free survival and overall survival in patients with locally advanced or metastatic urothelial cancer have been reported previously. Here, we report additional, protocol-prespecified secondary endpoint data, and statistical analysis plan-prespecified descriptive endpoints assessing patient quality of life (QOL). These endpoints related to patient functioning and symptoms and were assessed using two PRO questionnaires: the Brief Pain Inventory-Short Form (BPI-SF) and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). The PRO full analysis set comprised patients who received study treatment and completed at least one baseline PRO questionnaire. The BPI-SF and the EORTC QLQ-C30 were completed at baseline, weekly for 12 weeks, at week 14, then every 3 weeks during follow-up. Time to pain progression and mean change from baseline in BPI-SF worst pain at week 26 were protocol-prespecified secondary endpoints tested by the hierarchical gatekeeping strategy. Mean change from baseline to week 26 in EORTC QLQ-C30 and BPI-SF scale scores were analysed descriptively. The trial is registered with ClinicalTrials.gov, NCT04223856.

FINDINGS

At data cutoff on Aug 8, 2023, 886 patients were enrolled in the study, with a median duration of follow-up for survival of 17·2 months (IQR 12·5-21·7). 731 (83%) of 886 patients completed at least one PRO questionnaire at baseline and were included in the PRO full analysis set, with 376 patients treated with enfortumab vedotin plus pembrolizumab and 355 with platinum-based chemotherapy. 570 (78%) of 731 patients were male, 161 (22%) were female, and 479 (66%) patients were White. There was no significant difference in time to pain progression between treatments; hence differences in least squares mean change in BPI-SF worst pain score from baseline to week 26 with enfortumab vedotin plus pembrolizumab versus platinum-based chemotherapy were not formally tested. However, a numerical improvement from baseline up to week 26 was observed (least squares mean -0·74, SE 0·12 vs -0·36, 0·12; least squares mean difference -0·38, SE 0·13; 95% CI -0·64 to -0·12; nominal two-sided p value 0·0037). Overall least squares mean change in EORTC QLQ-C30 Global Health Status (GHS)/QOL from baseline up to week 26 favoured enfortumab vedotin plus pembrolizumab (least squares mean difference 2·54, 95% CI 0·41-4·67). In patients with moderate to severe baseline pain (worst pain score ≥5) receiving enfortumab vedotin plus pembrolizumab, there were clinically meaningful improvements from baseline up to week 26 in worst pain (least squares mean change: enfortumab vedotin plus pembrolizumab -2·96 [SE 0·22], platinum-based chemotherapy -2·43 [0·21]; least squares mean difference -0·53, 95% CI -1·03 to -0·02; nominal p=0·041) and in EORTC QLQ-C30 GHS/QOL (least squares mean change: enfortumab vedotin plus pembrolizumab 8·88 [1·53], platinum-based chemotherapy 4·11 [1·45]; least squares mean difference 4·77, 95% CI 1·24-8·29; nominal p=0·0083).

INTERPRETATION

Enfortumab vedotin plus pembrolizumab significantly improved survival outcomes versus platinum-based chemotherapy without detriment to GHS/QOL, pain, or functioning. Patients with moderate to severe baseline pain had clinically meaningful improvements in worst pain and GHS/QOL with enfortumab vedotin plus pembrolizumab. These data provide further evidence to support the use of enfortumab vedotin plus pembrolizumab as a preferred treatment option for patients with previously untreated locally advanced or metastatic urothelial cancer.

FUNDING

Seagen (acquired by Pfizer in December, 2023), Astellas Pharma, and Merck Sharp & Dohme.

Real-World Treatment Patterns and Outcomes in Patients With Bacillus Calmette-Guérin-Unresponsive High-Risk Non-Muscle-Invasive Bladder Cancer: A Multicountry Medical Chart Review

INTRODUCTION

Treatment patterns for patients with bacillus Calmette-Guérin (BCG)-unresponsive high-risk non-muscle-invasive bladder cancer (NMIBC) who are ineligible for or decline radical cystectomy (RC) are inconsistently reported. We retrospectively described demographic, clinical, and treatment characteristics for these patients and assessed their clinical outcomes.

PATIENTS AND METHODS

Medical charts of patients with BCG-unresponsive high-risk NMIBC (carcinoma in situ [cohort A] or T1/high-grade Ta [cohort B]) who were ineligible for or declined RC documented between January 1, 2011, and December 31, 2018, at 15 academic centers were reviewed. Primary objectives were to characterize demographic, clinical, and nonsurgical treatment characteristics. Secondary objectives included assessing real-world progression-free survival (rw-PFS) from muscle-invasive/metastatic disease, rw-PFS from worsening grade or stage, real-world complete response rate (rw-CRR) in cohort A, real-world event-free survival (rw-EFS) from high-risk NMIBC in cohort B, and overall survival.

RESULTS

The study included 129 patients (cohort A, n = 57; cohort B, n = 72). Median age was 72.0 years (interquartile range, 64.0-80.0). Most patients were male (72.1%) and current/former smokers (69.8%). Median follow-up was 32.1 months (interquartile range, 20.7-47.6). BCG rechallenge with or without interferon-α (63.6%) was the most commonly utilized first nonsurgical therapy, followed by intravesical mitomycin C with or without electromotive drug administration or thermochemotherapy (15.5%), and intravesical valrubicin (10.9%); among those who received BCG rechallenge alone, 54.8% later received a non-BCG therapy in ≥ 2 subsequent treatments. 36-month rate for rw-PFS from muscle-invasive/metastatic disease was 73.5%, 66.8% for rw-PFS from worsening grade/stage, and 82.5% for overall survival. In cohort A, 6-month rw-CRR was 22.2%. In cohort B, 36-month rw-EFS rate from high-risk NMIBC was 50.2%.

CONCLUSION

After BCG-unresponsive disease, most patients with high-risk NMIBC received BCG rechallenge with or without other therapies, and > 25% experienced disease progression within the first 3 years. Effective bladder-sparing options for BCG-unresponsive NMIBC are needed.

CLINICAL TRIAL REGISTRATION

N/A.

PD-1 monoclonal antibody (Tislelizumab)-induced DRESS syndrome in an intrahepatic cholangiocarcinoma patient with FGFR3 mutation and elevated IgG4:A case report

BACKGROUND

Immune-related adverse events (irAEs) include a rare, idiosyncratic but potentially life-threatening drug reaction with eosinophilia and systemic symptoms (DRESS), characterized by exanthem, fever, as well as hematologic and visceral organ involvement.

CASE PRESENTATION

We describe a 54-year-old man under the novel sequential treatment including all-trans retinoic acid (ATRA) and programmed death protein 1(PD-1) antibody (Tislelizumab) for advanced intrahepatic cholangiocarcinoma (iCCA). He was found to have Tislelizumab-induced DRESS syndrome during adjuvant therapy, and also showed the evidence of IgG4-related lymphadenopathy (IgG4-RLAD) as well as Epstein-Barr virus (EBV) infection in the absence of hemophagocytic lymphohistiocytosis (HLH) and T cell lymphoma. The patient's clinical status was successfully ameliorated through the administration of corticosteroids, intravenous immunoglobulin (IVIG), and antiviral agents, demonstrating a positive response to the treatment protocol. He was the first-ever case report of Tislelizumab-induced DRESS syndrome in the context of IgG4-RLAD with an exploration of potential mechanisms. Furthermore, we found that a somatic fibroblast growth factor receptor (FGFR) 3 p.P774L mutation at the frequency of 1.96 % was detected in his iCCA tissue.

CONCLUSION

These findings indicated that this novel therapy, based on ARTA and PD-1 antibody, is more effective and could guide the clinical application of PD-1 antibody in the iCCA patients with elevated IgG4. Human leukocyte antigen (HLA) typing assay might help to screen the potential susceptible individuals to avoid immune checkpoint inhibitors (ICIs)-induced DRESS syndrome.

A Cost-Effectiveness Analysis for Avelumab as a First-Line Maintenance Treatment of Advanced Urothelial Carcinoma in the Netherlands

INTRODUCTION

Advanced or metastatic urothelial carcinoma (UC) is an incurable disease with a high disease burden and a poor prognosis. Avelumab as first-line (1L) maintenance treatment is an innovative therapy option for patients with advanced or metastatic UC that has not progressed after 4-6 cycles of 1L platinum-based chemotherapy. This study aimed to assess the cost-effectiveness of avelumab maintenance treatment plus best supportive care (BSC) versus BSC alone from a Dutch societal perspective.

METHODS

A partitioned survival model was developed incorporating JAVELIN Bladder 100 trial data to inform overall and progression-free survival, adverse events incidence, and health-state utilities. Costs for drugs, healthcare resource use, adverse events, and indirect costs were obtained from national databases, the Dutch costing manual, and published literature. Assumptions were validated by clinical experts. An incremental cost-effectiveness ratio (ICER) was determined using lifetime incremental costs and quality-adjusted life years (QALY).

RESULTS

Avelumab 1L maintenance treatment plus BSC was estimated to have €48,186 discounted incremental costs and 0.63 discounted incremental QALYs versus BSC alone, leading to a base-case ICER of €76,450, supported by consistent scenario and sensitivity analyses.

CONCLUSION

Avelumab 1L maintenance treatment is likely to be a cost-effective treatment in advanced or metastatic urothelial carcinoma in the Netherlands.

Tumour-infiltrating immune cells as a novel prognostic model for bladder cancer

Bladder cancer (BLCA) is the tenth most commonly diagnosed cancer and poses a significant challenge due to its complexity and associated high morbidity and mortality rates in the absence of optimal treatment. The tumor microenvironment (TME) is recognized as a critical factor in tumor initiation, progression and therapeutic response, and offers numerous potential targets for intervention. A comprehensive understanding of immune infiltration patterns in BLCA is essential for the development of effective prevention and treatment strategies. In this study, bioinformatics analysis was used to identify differentially expressed genes (DEGs) and tumor-infiltrating immune cells (TIICs) between BLCA tissues and adjacent normal tissues. Weighted gene co-expression network analysis (WGCNA) and protein-protein interaction (PPI) analysis were used to identify the top 10 hub genes with the most significant co-expression effects, and their potential relationship with patient prognosis was then predicted. The random survival forest (RSF) model was used to further identify six variables among the hub genes and establish a novel scoring system, defined as the tumor-infiltrating immune score (TIIS) to predict the prognosis of BLCA patients. In addition, the correlation analysis between TIIS and drug sensitivity was investigated using the Genomics of Drug Sensitivity in Cancer (GDSC) and Cancer Therapeutics Response Portal (CTRP) databases. Patients with high TIIS were found to have a poor prognosis but may be more sensitive to Cisplatin and certain novel agents. This study provided a systematic analysis of immune cell infiltration in BLCA and established TIIS to predict patient prognosis and the efficacy of specific drugs in the treatment of BLCA.

Oncological outcomes after non-surgical management versus radical cystectomy in non-organ-confined non-urothelial bladder cancer

INTRODUCTION

We hypothesized that among non-organ-confined (NOC, T3-4 and/or N1-3) non-urothelial carcinoma of urinary bladder (non-UCUB) patients, bladder-sparing non-surgical management (NSM) provides cancer-specific mortality (CSM) rates comparable to those of radical cystectomy (RC).

METHODS

Within the SEER database (2004-2021) rates of NSM vs. RC use in NOC non-UCUB patients were tabulated. Nearest-neighbor 1:1 propensity score matching (PSM) for age, sex, stage, race/ethnicity, and histological subtype was applied. Cumulative incidence plots depicted five-year CSM. Univariable and multivariable competing risks regression (CRR) models were fitted. Sensitivity analyses were performed within squamous cell carcinoma (SCC), small cell carcinoma (small-CC) and adenocarcinoma (ADK).

RESULTS

Of 775 NOC non-UCUB patients, 290 (37.4%) received NSM vs. 485 (62.6%) RC. After PSM, five-year CSM rate was 70.4% after NSM vs. 60.6% after RC and NSM was associated with 1.6-fold higher CSM relative to RC (multivariable HR [mHR]: 1.61, p < 0.001). In sensitivity analyses within 253 (32.6%) SCC, after re-applying PSM, five-year CSM rate was 85.0% after NSM vs. 53.3% after RC and NSM was associated with 2.8-fold higher CSM relative to RC (mHR: 2.80, p < 0.001). Conversely, within 216 (27.9%) small-CC and 135 (17.4%) ADK patients, CSM after NSM did not differ from CSM after RC (54.3 vs. 62.5%, mHR: 0.85; 69.8 vs. 71.7%, mHR: 1.0; all p > 0.05).

CONCLUSION

In NOC non-UCUB patients, NSM is associated with higher CSM than RC. Subgroup analyses according to histological subtypes suggest that these differences virtually exclusively originated from SCC patients but not from their small-CC and ADK counterparts.

Serum Lactate Dehydrogenase Level Prior to First-Line Chemotherapy for Metastatic Urothelial Carcinoma Is a Prognostic Factor for Avelumab Maintenance Therapy: A Multicenter Retrospective Study

OBJECTIVES

We investigate the association between serum lactate dehydrogenase and prognosis in patients with urothelial carcinoma who were treated with avelumab maintenance therapy in combination with other biomarkers.

METHODS

We identified 54 patients with advanced or metastatic urothelial carcinoma that received avelumab maintenance therapy between June 2021 and February 2024 at our institutions. We retrospectively analyzed progression-free survival and overall survival from the initiation of avelumab maintenance therapy. Best overall response was evaluated based on the RECIST guidelines v1.1. To investigate factors potentially associated with response to avelumab maintenance therapy and overall survival, we conducted an assessment of markers that have been previously reported as prognostic factors, including urothelial carcinoma and other cancers.

RESULTS

The median overall survival by best overall response of first-line chemotherapy was not reached for complete response, partial response, or 15-month stable disease (p = 0.27). As for avelumab maintenance therapy, median overall survival by best overall response was not reached for complete response, partial response, and not evaluable; it was 18 months for stable disease and 13 months for progressive disease, with significant differences (p = 0.04). In multivariable analysis, lactate dehydrogenase level below the upper limit of normal prior to first-line chemotherapy was a significant independent factor in predicting disease control rate (p < 0.01) and overall survival (p = 0.04) in avelumab maintenance therapy.

CONCLUSIONS

Normal serum lactate dehydrogenase level prior to first-line chemotherapy was a significant predictor of favorable response or prognosis for avelumab maintenance therapy in our cohort.

The nephroprotective effect of metformin with cisplatin in bladder cancer: randomized clinical trial

PURPOSE

Cisplatin-based combination chemotherapy is the mainstay treatment strategy in various forms of carcinomas and sarcomas. However, its dosage and therapeutic efficacy are significantly limited by its nephrotoxicity. Based on metformin renal benefits in different studies, the study aims to determine safety and the potential nephroprotective effect of metformin when used with cisplatin in patients with bladder cancer.

METHODS

This was a prospective, randomized, parallel, controlled, open-label study in which 78 chemotherapy naïve bladder cancer patients aged 18-65 years and would receive gemcitabine/cisplatin regimen were selected and randomly assigned to treatment or control group in 1:1 allocation. Both groups were receiving cisplatin standard-of-care regimen, whereas metformin (500 mg, twice daily) was added to the treatment group's regimen only. Patients were prospectively followed up for four cycles of gemcitabine/cisplatin with assessment of renal function tests, serum neutrophil gelatinase-associated lipocalin (NGAL), cystatin-c, and metformin's adverse effects.

RESULTS

Serum creatinine, serum NGAL, and cystatin-C significantly increased in the control group only (P < 0.001). Estimated glomerular filtration rate (eGFR) significantly declines in the control group only (P < 0.001). On the contrary, serum NGAL significantly improved in the treatment group (P = 0.02) with stable and normal mean value of serum creatinine, eGFR, and cystatin-C without a concomitant significant increase in adverse events, such as hypoglycemia, gastrointestinal symptoms, or weight loss compared to the control group.

CONCLUSION

Metformin prevented renal damage and deterioration in kidney function in cisplatin-treated patients. Therefore, it is a promising agent in reducing cisplatin-induced nephrotoxicity. The study was registered in ClinicalTrials.gov on December, 16, 2023, Identifier Number NCT06215976.

Bempegaldesleukin plus nivolumab in first-line advanced/metastatic urothelial carcinoma: Results from a phase II single-arm study (PIVOT-10)

BACKGROUND

In PIVOT-02, bempegaldesleukin (BEMPEG), a pegylated interleukin-2 cytokine prodrug, in combination with nivolumab (NIVO), a Programmed cell death protein 1 inhibitor, demonstrated the potential to provide additional benefits over immune checkpoint inhibitor monotherapy in patients with urothelial carcinoma, warranting further investigation. We evaluated BEMPEG plus NIVO in cisplatin-ineligible patients with previously untreated locally advanced or metastatic urothelial carcinoma.

METHODS

This open-label, multicenter, single-arm, phase II study enrolled patients with locally advanced/surgically unresectable or metastatic urothelial carcinoma and who were ineligible for cisplatin-based treatment. Patients received BEMPEG plus NIVO were administered intravenously every 3 weeks for ≤2 years or until progression or unacceptable toxicity. The primary endpoint was objective response rate (ORR) by blinded independent central review (BICR) in patients with low programmed death ligand-1 (PD-L1) expression. Secondary endpoints included ORR and duration of response in the overall population. Progression-free survival (PFS) and overall survival (OS) were exploratory endpoints.

RESULTS

One hundred and eighty-eight patients were enrolled; 123 patients were PD-L1 low (combined positive score [CPS] <10; 65.4%), 59 were PD-L1 high (31.4%; CPS ≥10), and 6 had PD-L1 status unknown (3.2%). ORR per blinded independent central review in patients with PD-L1-low tumors was 17.9% (95% confidence interval [CI] 11.6-25.8) while in all treated patients was 19.7% (95% CI 14.3-26.1). Median PFS and OS in the overall population were 3.0 months and 12.6 months, respectively. BEMPEG plus NIVO combination was well tolerated, with a safety profile similar to previously reported trials; no new or unexpected safety signals were reported.

CONCLUSIONS

BEMPEG plus NIVO did not meet the efficacy threshold for ORR in patients with previously untreated locally advanced or metastatic urothelial carcinoma and low PD-L1 expression.

Real-world treatment patterns, survival outcomes, and health care resource utilization for locally advanced or metastatic urothelial carcinoma in Spain

PURPOSE

Real-world evidence on locally advanced or metastatic urothelial carcinoma (la/mUC) management in Spain is limited. This study describes patient characteristics, treatment patterns, survival, and health care resource utilization (HCRU) in this population.

METHODS/PATIENTS

This retrospective observational study included all adults with a first diagnosis/record of la/mUC (index date) from January 2015 to June 2020 at nine university hospitals in Spain. Data were collected up to December 31, 2020 (end of study), death, or loss to follow-up. Patient characteristics, treatment patterns, median overall survival (OS) and progression-free survival (PFS) from index date (Kaplan-Meier estimates), and disease-specific HCRU were described.

RESULTS

Among 829 patients, median age at diagnosis was 71 years; 70.2% had ≥ 1 comorbidity, and 52.5% were eligible for cisplatin. Median follow-up was 12.7 months. Most (84.7%) patients received first-line systemic treatment; of these, 46.9% (n = 329) received second-line and 16.6% (n = 116) received third-line therapy. Chemotherapy was the most common treatment in all lines of therapy, followed by programmed cell death protein 1/ligand 1 inhibitors. Median (95% confidence interval) OS and PFS were 18.8 (17.5-21.5) and 9.9 (8.9-10.5) months, respectively. Most patients required ≥ 1 outpatient visit (71.8%), inpatient admission (56.6%), or emergency department visit (56.5%).

CONCLUSIONS

Therapeutic patterns were consistent with Spanish guideline recommendations. Chemotherapy had a role in first-line treatment of la/mUC in Spain during the study period. However, the disease burden remains high, and new first-line treatments recommended in the latest European guidelines should be made available to patients in Spain.

Effects of the Number of Neoadjuvant Cycles and Addition of Adjuvant Chemotherapy on the Prognosis of Muscle-Invasive Bladder Cancer Treated With Radical Cystectomy

OBJECTIVE

To evaluate the effects of the number of neoadjuvant chemotherapy (NAC) cycles and the addition of adjuvant chemotherapy (AC) after NAC on overall survival (OS) of patients with muscle-invasive bladder cancer (MIBC).

PATIENTS AND METHODS

We retrospectively evaluated 1687 patients with cT2-4NxM0 MIBC who received radical cystectomy (RC) alone or RC plus perioperative chemotherapy at 36 institutions within the Japanese Urological Oncology Group. We evaluated the effect of the number of NAC cycles (2 vs. ≥ 3 cycles) and the addition of AC on OS.

RESULTS

Among the 1687 patients analyzed, 946 received a median of three NAC cycles. The pathologic complete response rate did not significantly differ between those who received 2 (22.9%) and ≥ 3 cycles (27.5%, p = 0.112). Moreover, no significant difference in OS was observed between the groups (p = 0.559). Multivariable Cox regression analysis showed that pathologic high-risk (ypT2-4, pT3-4, or pN+) or cisplatin ineligibility were significantly associated with poor OS but not the number of NAC cycles (p = 0.238). We identified 942 pathologically high-risk patients after RC who were eligible for AC. Notably, no significant OS improvement was observed with the addition of AC as intensive perioperative chemotherapy after NAC. The primary limitation was selection bias from confounding by clinical indication.

CONCLUSIONS

Our findings showed that three or more NAC cycles and the addition of AC may have limited effects on OS in MIBC patients who received RC.

Spectral CT for non-invasive evaluation of bladder cancer grade

OBJECTIVE

To investigate the potential role of dual-energy spectral computer tomography (CT) quantitative parameters in the definition of bladder cancer (BCa) pathological grading.

METHODS

This retrospective study evaluated the use of spectral CT imaging features for BCa. From 2021 to 2023, 63 patients with histologically-confirmed BCa diagnosis were examined at our Institution. The patients were pathologically divided, following international guidelines, into two groups: low-grade (n = 24) and high-grade urothelial carcinoma group (n = 39). The iodine concentrations (IC), the normalized iodine concentrations (NIC), and the slope of the spectrum curve (SLOPE) were calculated along with the measure of each lesion CT value on the monochromatic image from 40 to 120 keV. The diagnostic performance was assessed by Receiver operator characteristic curve (ROC) analysis.

RESULTS

The high-grade group showed significantly higher mean values of IC, SLOPE, and HU in 40 KeV monoenergetic images (VMI40 HU). AUC values for NIC, SLOPE, IC, and VMI40 HU were 0,677, 0,745, 0,745, and 0,755 respectively. In multivariate logistic regression models with backward stepwise, including all quantitative parameters, only VMI40 HU remained statistically significant to correlate with high-grade tumors.

CONCLUSION

Preliminary data shows that quantitative parameters of dual-energy spectral CT can be helpful to characterize low-grade and high-grade urothelial bladder tumors. The prediction of high-grade BCa with non-invasive methods (e.g. dlCT) can aid in early detection of muscle-invasive and worse prognostic tumors that need more aggressive and timely treatments, personalizing the management on the risk of recurrence.

Circulating tumor DNA in muscle-invasive bladder cancer: A systematic review

OBJECTIVES

To evaluate the role of circulating tumor DNA (ctDNA) as a prognostic and predictive biomarker in the perioperative management of muscle-invasive bladder cancer (MIBC).

METHODS

We conducted a systematic literature review using PubMed, MEDLINE, and Embase, following PRISMA guidelines. Studies from January 2013 to March 2024 were included if they examined ctDNA in MIBC patients undergoing radical cystectomy (RC) and perioperative chemotherapy or immunotherapy.

RESULTS

Eight studies were included. ctDNA detected before RC was associated with poor recurrence-free survival and higher risk of nodal and locally advanced disease. Postoperative ctDNA levels correlated with shorter disease-free survival and higher recurrence rates. ctDNA clearance during neoadjuvant chemotherapy was predictive of treatment response. ctDNA status post-neoadjuvant immunotherapy correlated with pathological outcomes and recurrence rates.

CONCLUSIONS

ctDNA is a promising biomarker for predicting oncological outcomes in MIBC, with potential to guide perioperative treatment decisions. Further randomized controlled trials are needed to validate these findings.

68Ga-FAPI and 18F-FAPI PET/CT for detection of nodal metastases prior radical cystectomy in high-risk urothelial carcinoma patients

INTRODUCTION

To determine the best therapeutic strategy for muscle-invasive bladder cancer (BC), the accuracy of lymph node staging is of paramount importance. However, diagnostic performance of conventional computed tomography in BC prior to radical cystectomy (RC) remains unsatisfactory. There is an increased interest in evaluating 18F-FAPI PET/CT for hybrid imaging due to their logistical advantages compared to [68Ga]Ga-based FAPI tracers in clinical routine. Recently, the potential diagnostic value of [68Ga]Ga-FAPI- 46 PET/CT was demonstrated in BC. Thus, we aimed to examine the diagnostic performance of [18F]F-FAPI- 74 and [68Ga]Ga-FAPI- 46 PET/CT for preoperative evaluation of locoregional lymph node metastases.

METHODS

Fifty-one patients underwent FAPI PET/CT with either [68Ga]Ga-FAPI- 46 (n = 23) or [18F]F-FAPI- 74 (n = 28) prior to RC and PLND. SUVmax, SUVmean and the ratio between the SUVmax of lymph nodes and the SUVmean of the background (SUVmax_lymph node/SUVmean_background) were assessed. Additionally, short axis diameter (SAD) for a representative lymph node were documented in each lymph node region (n = 123) and compared to histopathological findings. Each scan was interpreted visually and quantitatively. ROC-analyses were performed to determine cut-off values with highest diagnostic accuracy.

RESULTS

20/123 (16.3%) lymph node regions showed UC lymph node metastases. Histopathologically positive lymph nodes were associated with a significantly higher FAPI uptake compared to negative lymph nodes regarding SUVmax, SUVmean values and SUVmax_lymph node/SUVmean_background ratios. Visual analysis based on FAPI uptake showed a sensitivity and specificity, PPV and NPV of 63.6%, 95.8%, 77.7%, and 92.0% for [68Ga]Ga-FAPI- 46 and 55.5%, 98.1%, 83.3%, and 93.1% for [18F]F-FAPI- 74, respectively. ROC analysis revealed an optimal cut-off for SUVmax, SUVmean and SUVmax_lymph node/SUVmean_background of 1.35, 1.20 and 5.95 for [68Ga]Ga-FAPI- 46 and 1.55, 1.25 and 4.15 for [18F]F-FAPI- 74 to discriminate between histopathologically proven lymph node metastases and non-malignant lymph nodes resulting for example using SUVmax in a sensitivity and specificity, PPV and NPV of 81.8%, 89.5%, 64.2%, 95.5% for [68Ga]Ga-FAPI- 46 and 100%, 81.8%, 47.3%, 100% for [18F]F-FAPI- 74, respectively. CT visual analysis of locoregional lymph nodes showed a sensitivity, specificity, PPV and NPV of 30.0%, 97.0%, 66.6% and 87.7%, respectively. ROC analysis regarding SAD revealed a cutoff at 0.8 cm with a sensitivity, specificity, PPV and NPV of 75.0%, 84.4%, 48.3%, 94.5%, respectively.

CONCLUSION

Overall, FAPI PET imaging shows a significantly higher sensitivity than CT analysis for detection of locoregional lymph node metastases in UC. [18F]F-FAPI- 74 demonstrates a comparable diagnostic performance compared to [68Ga]Ga-FAPI- 46. Of note, the quantitative analysis with a pre-defined SUVmax as well as SUVmean values, and SUVmax_lymph node/SUVmean_background ratio-based cut-offs provided a higher sensitivity compared to visual assessment.

Severe Rectal Stenosis as the First Clinical Appearance of a Metastasis Originating from the Bladder: A Case Report and Literature Review

While locally advanced rectal cancer is the first clinical suspicion for severe rectal stenosis, in extremely unusual cases a lower bowel obstruction may be related to bladder metastasis. We present the case of a 64-year-old male who was admitted for occlusive rectal tumor (4 cm from the anal verge), for which an emergency loop-colostomy was performed. After two inconclusive endoscopic biopsies, a transanal rectal tru-cut biopsy allowed for the detection of high-grade urothelial carcinoma with signet ring cells. Furthermore, primary origin was detected in a small bladder tumor. In imaging reassessment after neoadjuvant chemotherapy, regression of the lesions both from the bladder and rectum was observed. Radical surgery with total pelvic exenteration was considered in the absence of other secondary tumors, but the patient declined and continued with radiotherapy. Subsequently he developed malignant chylous ascites and unfortunately died three months later. Reviewing the literature, we found twenty-five cases of urothelial metastasis to the rectum, originating from the bladder, including this newly present case. Rectal metastasis of urothelial origin poses a two-fold challenge in terms of both diagnosis and treatment. Determining the specific features of this uncommon manifestation of a common disease will improve future approaches.

Standard Versus Extended Pelvic Lymphadenectomy in Patients With Bladder Cancer: A Systematic Review and Meta-analysis

OBJECTIVES

For decades, pelvic lymph node dissection (PLND) has been a critical component of radical cystectomy in patients with bladder cancer. Although its role in curative surgery for high-risk non-muscle-invasive and muscle-invasive cases is well-established, the therapeutic advantages of extended PLND remain a topic of ongoing debate.

METHODS

A comprehensive literature search of major bibliographic databases was performed from inception to November 2024. Studies comparing extended PLND (extended or super extended) with standard PLND were identified. Data for clinical outcomes was extracted and pooled estimates were calculated using a random effects model with RevMan 5.4.

RESULTS

A total of 11 studies (2 RCTs and 9 observational) were included reporting data for 4001 patients. The pooled analysis demonstrated that extended PLND was associated with significantly better recurrence-free survival (HR=0.67, 95% CI: 0.60-0.74). Standard PLND led to significantly higher 5-year recurrence rates (RR=1.44, 95% CI: 1.28-1.62) compared with the extended approach. The pooled estimates for disease-specific survival (HR=0.86, 95% CI: 0.62-1.19), overall survival (HR=0.99, 95% CI: 0.86-1.16), and complications remained comparable.

CONCLUSIONS

Extended PLND can lead to favorable recurrence-free survival and 5-year recurrence rates. However, retrospective observational studies mainly drive the evidence, and additional RCTs are required to reach a definitive conclusion.

Glycosphingolipids as emerging attack points in bladder cancer

Bladder cancer is a prevalent malignancy associated with significant morbidity and mortality worldwide. Emerging research highlights the critical role of glycosphingolipids (GSLs) in bladder cancer progression. In this review, we examine GSL expression profiles in bladder cancer and explore their contributions to key cancer hallmarks, including invasion and metastasis, immune evasion, and resistance to cell death. We further discuss the potential of GSLs as therapeutic targets and non-invasive biomarkers, with an emphasis on recent advances in GSL-targeting strategies. Additionally, we highlight our recent discovery of a novel, patented biomarker for bladder cancer diagnosis, identified using cutting-edge glyco-analytical technologies.

Complete Response after Avelumab Maintenance Therapy: Successful Management of Metastatic Urothelial Carcinoma

Urothelial carcinoma is one of the most frequently diagnosed cancer types in the world and despite progress in treatment, it remains a lethal disease in the metastatic stage. Because of its high programmed cell death ligand 1 protein expression, it is associated with an increased response to immune checkpoints inhibitors. In the past few years, the gold standard for first-line treatment of metastatic urothelial carcinoma has been platinum-based chemotherapy, and avelumab (PD-1 inhibitor) maintenance therapy for non-progressing tumours. After the remarkable benefit demonstrated in the EV-302 study, the guidelines were recently revised to include enfortumab vedotin plus pembrolizumab as the new standard of care in this setting. Despite the new recommendations, in some countries, this combination is still pending approval. Furthermore, for patients who are ineligible for enfortumab vedotin plus pembrolizumab, platinum-based chemotherapy followed by avelumab maintenance therapy continues to be a preferred treatment option. This report presents a woman diagnosed with metastatic urothelial carcinoma with histologically confirmed complete response after cisplatin and gemcitabine chemotherapy and avelumab as maintenance therapy, which has been reported in only a few cases in the literature.

LEARNING POINTS

Urothelial carcinoma is associated with high mortality despite significant progresses in treatment.In metastatic urothelial carcinoma the first-line treatment was recently changed, with enfortumab vedotin plus pembrolizumab being approved by the US Food and Drug Administration and European Medicines Agency. Until now, platinum-based chemotherapy and avelumab maintenance therapy for non-progressing tumours was the only standard of care for these patients.In the literature, few cases have been reported with complete response to avelumab maintenance therapy.

Integrating International Consensus Guidelines for Anticancer Drug Dosing in Kidney Dysfunction (ADDIKD) into everyday practice

Part 2 of the International Consensus Guideline on Anticancer Drug Dosing in Kidney Dysfunction (ADDIKD) offers drug-specific consensus recommendations based on both evidence and practical experience. These recommendations build upon the kidney function assessment and classification guidelines established in Part 1 of ADDIKD. Here we illustrate how dosing recommendations differ between ADDIKD and existing guidance for four commonly used drugs: methotrexate, cisplatin, carboplatin and nivolumab. We then describe how the recommendations can be distilled into practice points for methotrexate and cisplatin. While ADDIKD is a significant improvement from previous guidelines, adoption of this new guideline requires further endorsement from key external stakeholders, 'change championing' by clinicians locally and encouraging its integration into existing reference sources, clinical trial protocols and electronic prescribing systems.

Funding

Development of the ADDIKD guideline is funded by the NSW Government as part of the Cancer Institute NSW and received no funding from external commercial sources.

Avelumab first-line maintenance for advanced urothelial carcinoma: long-term outcomes from the JAVELIN Bladder 100 trial in older patients

BACKGROUND

In the JAVELIN Bladder 100 phase III trial, avelumab first-line (1L) maintenance plus best supportive care (BSC) significantly prolonged overall survival (OS) versus BSC alone in patients with locally advanced or metastatic urothelial carcinoma (la/mUC) without progression following platinum-based chemotherapy. Older age (≥65 years) is a known risk factor for bladder cancer with a median age at diagnosis of 73.0 years. We report exploratory analyses in subgroups based on older age (≥65 years).

MATERIALS AND METHODS

Eligible patients with la/mUC without progression after 1L platinum-based chemotherapy were randomized to receive avelumab plus BSC (n = 350) or BSC alone (n = 350). This exploratory analysis included subgroups aged ≥65 years, ≥65-<75 years, ≥75 years, and the subset aged ≥80 years. OS (primary endpoint) and progression-free survival (PFS) from randomization were analyzed using the Kaplan-Meier method.

RESULTS

Of 700 patients, 464 (66.3%) were aged ≥65 years. Median OS with avelumab plus BSC versus BSC alone was 26.1 versus 15.5 months (hazard ratio 0.70, 95% confidence interval 0.56-0.89) in all patients aged ≥65 years and 28.7 versus 17.1, 24.0 versus 13.5, and 24.9 versus 10.0 months, respectively, in patients aged ≥65-<75, ≥75, and ≥80 years. PFS analyses favored avelumab plus BSC versus BSC alone in all subgroups. No new safety concerns were identified in patients aged ≥65 years, including those treated for ≥12 months. Quality-adjusted time without symptoms or toxicity was 4.57 months longer with avelumab plus BSC versus BSC alone (a 30.35% relative improvement). Limitations include small sample size for the ≥80-year age subgroup and the exploratory design.

CONCLUSIONS

These exploratory analyses support the efficacy and tolerability of avelumab 1L maintenance in patients aged ≥65 years with la/mUC that has not progressed following chemotherapy, suggesting that older age should not solely prevent a patient from receiving avelumab 1L maintenance.

A single-center retrospective comparison of pT1 substaging methods in bladder cancer

Substaging of T1 urothelial cancer is associated with tumor progression and its reporting is recommended by international guidelines. However, it has not been integrated in risk stratification tools and there is no agreement on the best method to use for its reporting. We aimed to investigate the applicability, interobserver variability, and prognostic value of histological landmark based and micrometric (aggregate linear length of invasive carcinoma (ALLICA), microscopic vs. extensive system, Rete Oncologica Lombarda (ROL) system) substaging methods. A total of 79 patients with the primary diagnosis of T1 urothelial cancer treated with conventional transurethral resection and adjuvant BCG therapy between 2000 and 2020 at the Medical University of Vienna were included. The anatomical and metrical substaging systems were evaluated using agreement rate, Cohen's kappa, Kendall's tau, and Spearman rank correlation. Prognostic value for high-grade recurrence or T2 progression was evaluated in uni- and multivariable analysis. Applicability and reproducibility were good to moderate and varied between substaging methods. Obstacles are mainly due to fragmentation of samples. Anatomical substaging was associated with progression in univariable and multivariable analysis. In our cohort, we could only identify anatomical landmark-based substaging to be prognostic for T2 progression. A major obstacle for proper pathological assessment is fragmentation of samples due to operational procedure. Avoiding such fragmentation might improve reproducibility and significance of pathological T1 substaging of urothelial cancer.

Bibliometric analysis of photodynamic research in bladder cancer: Trends and future directions

BACKGROUND

Recent years have seen the use of photodynamic technologies concerning the detection and therapy of bladder cancer (BC) due to their rapid development and well-established therapeutic impact. However, a thorough analysis and bibliometric assessment of photodynamic technologies publishing trends in BC has not been completed yet.

METHODS

Retrieving bibliographies from the Web of Science Core Collection limited the publication date to December 31, 2023, from January 1, 2004. We used VOSviewer (Version 1.6.19) and CiteSpace (Version 6.4 R1) for both statistical and visualization analysis.

RESULTS

We selected a total of 870 documents for analysis. The yearly publication findings show notable upward patterns over the last two decades. The Kochi Medical School in Japan was the most productive school, while the USA was the most productive nation. Japanese researcher Inoue Keiji published the highest number of photodynamic -related articles in BC. The most quoted and prolific journals were the Photodynamic Therapy and Photodiagnosis. According to the keyword analysis, the terms "cystoscopy," "carcinoma in situ," "drug delivery," "follow-up," "hexaminolevulinate," and "impact" are all relatively recent and hot field.

CONCLUSIONS

Our investigation produced a bibliometric outcome for the field, potentially opening up new research opportunities. We suggest that future research concentrate on in-situ carcinoma identification, photosensitizer invention, medication delivery enhancement, and photodynamic technology follow-up in BC.

Real-world Study of Avelumab First-line Maintenance Treatment in Patients with Advanced Urothelial Carcinoma in France: Overall Results from the Noninterventional AVENANCE Study and Analysis of Outcomes by Second-line Treatment

BACKGROUND

Avelumab first-line maintenance treatment was approved for patients with advanced urothelial carcinoma (aUC) without progression following platinum-based chemotherapy (PBC), based on the results from the JAVELIN Bladder 100 phase 3 trial.

OBJECTIVE

To report the results from AVENANCE, a real-world study of avelumab first-line maintenance treatment.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective and prospective, noninterventional study (NCT04822350). Eligible patients with aUC without progression on first-line PBC were enrolled at 82 centers in France between July 2021 and May 2022. The effectiveness population included 595 patients. The median follow-up was 26.3 mo.

INTERVENTION

Previous, ongoing, or planned avelumab first-line maintenance treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Overall survival (OS) from avelumab initiation (primary endpoint) and safety were evaluated.

RESULTS AND LIMITATIONS

The median age was 73.0 yr, and performance status was 0/1 in 91% of patients and ≥2 in 9.3%. The most common prior first-line chemotherapy regimen was carboplatin plus gemcitabine (61%). At data cutoff (December 7, 2023), the median duration of avelumab treatment was 5.6 mo, 125 patients remained on avelumab, and 55% had received second-line treatment. The median OS from avelumab initiation was 21.3 mo (95% confidence interval [CI], 17.6-24.6), and the median progression-free survival was 5.7 mo (95% CI, 5.2-6.5). In exploratory analyses of this population without disease progression on PBC, the median OS from the start of first-line PBC was 26.5 mo overall, and in subgroups that received second-line enfortumab vedotin (n = 55) or PBC (n = 79), it was 41.5 and 24.5 mo, respectively.

CONCLUSIONS

Real-world data from AVENANCE confirm the effectiveness and safety of avelumab first-line maintenance treatment in a heterogeneous population, supporting its recommendation for cisplatin-eligible and cisplatin-ineligible patients with aUC who are progression free after first-line PBC. In an exploratory analysis, a small subgroup that received a treatment sequence of first-line PBC without disease progression followed by avelumab first-line maintenance and second-line enfortumab vedotin had a median OS of >3 yr.

PATIENT SUMMARY

A French real-world study, called AVENANCE, looked at avelumab maintenance treatment in people with advanced urothelial cancer whose tumor disappeared, shrank, or stopped growing with chemotherapy. Overall, results were consistent with those seen in a previous clinical trial, and on average, people treated with avelumab maintenance lived for 26.5 mo from the start of chemotherapy. Analyses of different groups of people found that survival varied, with people living for an average of 18-42 mo depending on what treatment they received after they finished avelumab treatment.

Impact of Histology on Clinical Outcomes of Pembrolizumab Monotherapy in Patients With Advanced or Metastatic Urothelial Carcinoma in the Phase 3 KEYNOTE-045 and KEYNOTE-361 Trials

INTRODUCTION

A post hoc analysis of efficacy and safety outcomes with pembrolizumab monotherapy was conducted in patients with advanced or metastatic urothelial carcinoma (UC) with pure transitional cell carcinoma (TCC) or mixed predominant TCC histology enrolled in the phase 3 KEYNOTE-045 and KEYNOTE-361 studies.

METHODS

Adults with platinum-refractory advanced or metastatic UC who received pembrolizumab monotherapy in KEYNOTE-045 and adults with advanced or metastatic UC and no prior systemic chemotherapy who received pembrolizumab monotherapy in KEYNOTE-361 were analyzed separately. Pembrolizumab 200 mg was administered intravenously every 3 weeks for ≤2 years. Histology was assessed by investigator. End points included objective response rate (ORR), progression-free survival, and duration of response per RECIST v1.1 by central radiology assessment, as well as overall survival (OS) and safety.

RESULTS

In KEYNOTE-045, 268 patients had known histology (pure TCC: 186; mixed predominant TCC: 82). At data cutoff (October 1, 2020), median follow up was 62.9 months (range, 59.0-70.9). For pure TCC, confirmed ORR was 21.0% (95% CI, 15.4-27.5); median OS was 9.7 months (95% CI, 7.5-11.8). For mixed predominant TCC, confirmed ORR was 24.4% (95% CI, 15.6-35.1); median OS was 11.6 months (95% CI, 7.4-16.4). In KEYNOTE-361, 307 patients had known histology (pure TCC: 280; mixed predominant TCC: 27). At data cutoff (April 29, 2020), median follow-up was 32.5 months (range, 22.0-42.3). For pure TCC, confirmed ORR was 29.3% (95% CI, 24.0-35.0); median OS was 14.8 months (95% CI, 11.8-17.9). For mixed predominant TCC, confirmed ORR was 40.7% (95% CI, 22.4-61.2); median OS was 16.2 months (95% CI, 5.5-NR). Grade 3-5 treatment-related adverse events occurred at similar rates for treated patients in both studies.

CONCLUSION

In this post hoc analysis, efficacy and safety outcomes with pembrolizumab monotherapy were generally consistent for patients with advanced or metastatic UC in KEYNOTE-045 and KEYNOTE-361 studies between histology subgroups.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, KEYNOTE-045 (NCT02256436) and KEYNOTE-361 (NCT02853305).

Pembrolizumab Retreatment in Patients with Advanced or Metastatic Urothelial Carcinoma Who Responded to First-course Pembrolizumab-based Therapy

Patients with metastatic solid tumors who previously had stable disease or a response with immunotherapy may derive benefit from immunotherapy retreatment. This post hoc analysis evaluated pembrolizumab retreatment in patients with advanced/metastatic urothelial carcinoma who received pembrolizumab in KEYNOTE-045, KEYNOTE-052, or KEYNOTE-361, and either stopped pembrolizumab after a complete response (CR) or completed pembrolizumab (35 cycles [∼2 yr]) with an objective response or stable disease. Upon disease progression, protocol-specified pembrolizumab retreatment (200 mg intravenously every 3 wk) was administered for ≤17 cycles. Forty-nine patients met the criteria and were included. The median follow-up was 24.4 mo (range, 1.4-53.5). The median time between first-course therapy cessation and pembrolizumab retreatment was 10.7 mo (1.0-36.3). Twenty patients (41%) had an objective response with pembrolizumab retreatment, 65% of whom had a CR to first-course treatment. The median retreatment duration was 8.3 mo (range, 0.0-13.2); the median duration of response was 14.0 mo (2.1+ to 20.5). From retreatment initiation, the median (95% confidence interval) progression-free survival and overall survival were 9.5 mo (5.6-15.0) and 25.7 mo (21.5-27.5), respectively. Treatment-related adverse events occurred in 45% (grade 3-4: 6%; grade 5: 0%). Data suggest that pembrolizumab retreatment is beneficial and tolerable for some patients with advanced/metastatic urothelial carcinoma who previously had a CR or completed 2 yr of pembrolizumab.

Integrative analysis of patient-derived tumoroids and ex vivo organoid modelling of ARID1A loss in bladder cancer reveals therapeutic molecular targets

Somatic mutations in ARID1A (AT-rich interactive domain-containing protein 1A) are present in approximately 25 % of bladder cancers (BC) and are associated with poor prognosis. With a view to discover effective treatment options for ARID1A-deficient BC patients, we set out to identify targetable effectors dysregulated consequent to ARID1A deficiency. Integrative analyses of ARID1A depletion in normal organoids and data mining in publicly available datasets revealed upregulation of DNA repair and cell cycle-associated genes consequent to loss of ARID1A and identified CHEK1 (Checkpoint kinase 1) and chromosomal passenger complex member BIRC5 (Baculoviral IAP Repeat Containing 5) as therapeutically drug-able candidate molecular effectors. Ex vivo treatment of patient-derived BC tumoroids with clinically advanced small molecule inhibitors targeting CHEK1 or BIRC5 was associated with increased DNA damage signalling and apoptosis, and selectively induced cell death in tumoroids lacking ARID1A protein expression. Thus, integrating public datasets with patient-derived organoid modelling and ex-vivo drug testing can uncover key molecular effectors and mechanisms of oncogenic transformation, potentially leading to novel therapeutic strategies. Our data point to ARID1A protein expression as a suitable candidate biomarker for the selection of BC patients responsive to therapies targeting BIRC5 and CHEK1.

Real-world avelumab first-line maintenance in advanced urothelial carcinoma: systematic review and meta-analysis

AIM

This systematic literature review summarizes the real-world effectiveness, safety, and tolerability of avelumab first-line maintenance (1LM) in locally advanced or metastatic urothelial carcinoma (la/mUC).

MATERIALS & METHODS

Database searches (MEDLINE, Embase, Cochrane) and manual gray literature searches of real-world studies published from 01/01/2020-31/01/2024 were performed. Pooled 12-month overall survival (OS) and progression-free survival (PFS) rates were synthesized by meta-analysis.

RESULTS

Across 45 unique studies including >2,600 patients, median OS and PFS were 21.3 and 7.0 months, respectively. In the meta-analysis, 12-month OS and PFS rates (95% CI) from avelumab 1LM start were 69% (65-73%) and 39% (35-44%), respectively.

CONCLUSION

This study supports the established clinical benefit of avelumab 1LM across a broad range of patients with la/mUC in routine practice.

Patients with Metastatic or Locally Advanced Bladder Cancer Not Undergoing Systemic Oncological Treatment-Characteristics and Long-Term Outcome in a Single-Center Danish Cohort

BACKGROUND

A subset of patients with locally advanced or metastatic bladder cancer (la/mBC) do not receive systemic oncological treatment. The reasons for refraining from systemic treatment are poorly investigated, as are the characteristics of patients who turn out to be long-term survivors despite lack of treatment.

METHODS

This retrospective observational cohort study included patients with registration compatible with la/mBC who did not undergo systemic treatment. They were seen at a single tertiary university hospital covering one of 5 Danish regions in the study period from 1 January 2012 until 31 December 2022. Patients were identified through a coding system, and detailed patient information was obtained in the electronic medical records.

RESULTS

The initial study population consisted of 472 patients registered with la/mBC according to codes in the patient registries but with no registration of systemic oncological treatment. Out of the total cohort, 159 patients were registered correctly, while the rest of the population were excluded due to misclassification, as 10.8% did not have la/mBC and 55.5% had received oncological treatment. Among correctly registered patients, the median overall survival was 2.6 months (95% CI 0.26; 4.94) from being diagnosed with la/mBC. The most common reasons for lack of treatment were poor general condition (74.2%), patient preference (19.5%), and poor renal function (11.9%).

CONCLUSIONS

Our study found that a significant amount of patients in a cohort of suspected la/mBC not undergoing treatment either received oncological treatment or did not have la/mBC, demonstrating a misclassification in the system. This should be taken into consideration when evaluating data about survival time for this patient group. The poorest survival of untreated la/mBC is associated with a high tumor burden and specifically liver metastasis.

Impact of glucocorticoid treatment and clinical prognostic factors for outcome in patients with advanced urothelial cancer treated with pembrolizumab

BACKGROUND

Immune checkpoint inhibitors have become a cornerstone in treatment of metastatic urothelial cancer (mUC), but reliable prognostic and treatment predictive factors remain to be defined. Glucocorticoids (GC) are used to manage immune-related adverse events (irAE), and the potential impact on treatment outcome is still unclear.

OBJECTIVES

The aim of this study was to explore the impact of GC treatment alongside clinical parameters on outcome in pembrolizumab-treated mUC patients.

MATERIALS AND METHOD

A single-center retrospective real-world study was performed including all consecutive mUC patients in first- or second-line treated with pembrolizumab. Multivariate analyses were used to explore the impact of baseline characteristics on response-rate and overall survival (OS). Landmark analysis was applied to adjust for immortal time bias in survival analyzes.

RESULTS

107 patients were included. Patients developing irAE requiring GC treatment had superior OS compared to those who did not (17.6 months vs. 8.8 months, P = 0.003). Ongoing treatment with GC prior to the initiation of pembrolizumab, ECOG PS >1 and liver metastases were independently associated with worse OS. We constructed a risk-score model where the number of zero, 1, 2 or 3 risk factors correlated to an OS of 11.7 months, 3.8 months, and 3.0 months respectively (P < 0.001).

CONCLUSION

The development of irAE requiring GC treatment was associated with favorable survial outcomes. Ongoing GC treatment before the commencement of pembrolizumab, ECOG PS >1, and presence of liver metastases were associated with worse OS. We propose a risk-score model to assist clinicians in selecting patients for treatment with pembrolizumab.

Review of BCG immunotherapy for bladder cancer

SUMMARYFor several decades, intravesical Bacillus Calmette-Guérin (iBCG) immunotherapy has been the gold standard adjuvant treatment for high-risk and selected intermediate-risk patients with non-muscle-invasive bladder cancer (NMIBC). In this review, the mechanisms of iBCG immune-mediated anti-cancer activity and resistance are presented. Furthermore, a literature review of short-term and systemic iBCG-related side effects was performed. A high incidence (75.5%) of iBCG-related short-term, self-limiting adverse events was observed, while more severe iBCG-related local/systemic complications (iBCG-rL/SCs) that required medical treatment or hospitalization occurred at a lower rate (2.35%). Disseminated was the most common form of iBCG-rSCs, while two-thirds of the cases were classified as infectious. The implementation of molecular-based techniques resulted in significantly higher diagnostic rates. Anti-tuberculous treatment (ATT) is the mainstay of treatment, while in patients with any iBCG-rL/SC form involving the vasculature, ATT should be combined with surgery. Local and osteoarticular forms have the lowest mortality, but their management necessitates severe and debilitating surgical procedures. The overall iBCG-attributed mortality in patients with iBCG-rL/SC was 7.4%, with disseminated, vascular, and lung involvements exhibiting the highest rates. Given the global shortage of BCG for the last two decades, as well as the paucity of effective options for iBCG-refractory or relapsing NMIBC patients, new therapeutic strategies are being tested with promising early results.

Disulfidptosis related immune genes drive prognostic model development and tumor microenvironment characterization in bladder urothelial carcinoma

The intricate nature and varied forms of bladder urothelial carcinoma (BLCA) highlight the need for new indicators to define tumor prognosis. Disulfidptosis, a novel form of cell death, is closely linked to BLCA progression, prognosis, and treatment outcomes. Our current goal is to develop a novel disulfidptosis-related immune prognostic model to enhance BLCA treatment strategies. Utilizing RNA-seq data from The Cancer Genome Atlas (TCGA) , which included 419 patients (19 normal, 400 tumor), we performed weighted gene co-expression network analysis (WGCNA) to identify disulfidptosis-associated immune genes. Through multivariate Cox regression, and the least absolute shrinkage and selection operator (LASSO) regularization, we established a disulfidptosis-related immune risk scoring system. A nomogram combining risk score and clinical features predicted prognosis. Model performance was validated through survival curve analysis and independent validation cohort. Immune checkpoints, cell infiltration, and tumor mutation load were assessed. Differential gene enrichment analysis was conducted. Prognostic genes were validated via in vitro experiments. Eight immune genes related to disulfidptosis were identified and verified in BLCA prognosis. A prognostic model outperformed previous ones in predicting overall survival (OS) for high- and low-risk groups. Patients with low-risk scores had higher OS rates and tumor mutation burden (TMB) compared to high-risk score patients. CD4 memory T cells, CD8 T cells, M1 macrophages, and resting NK cells were found to be higher in the low-risk group. Immune checkpoint inhibitor (ICI) treatment may be more effective for the low-risk score group. High-risk score group exhibited stronger correlation with cancer malignant pathways. Knocking out tumor necrosis factor receptor superfamily member 12 A (TNFRSF12A) inhibits BLCA cell proliferation and invasion while overexpressing it has the opposite effect. We constructed a novel risk score model that combines disulfidptosis and immune genes, demonstrating good prognostic prediction performance. We discovered and verified that the TNFRSF12A gene is an oncogene in BLCA, which may help provide personalized guidance for individualized treatment and immunotherapy selection for BLCA patients to a certain extent.

Survival Outcomes and Temporal Trends of Non-Surgical Management Vs Radical Cystectomy in Non-Organ-Confined Urothelial Bladder Cancer

OBJECTIVE

To investigate whether bimodal therapy (BMT) or trimodal therapy (TMT) differ from radical cystectomy (RC) + perioperative chemotherapy (CT) in cancer control outcomes among patients with non-organ-confined (NOC; T3-4 and/or N1-3) urothelial carcinoma of the urinary bladder (UCUB).

METHODS

Within the Surveillance, Epidemiology, and End Results database (2005-2021), rates of BMT vs TMT vs RC + CT use in NOC UCUB patients were tabulated. Nearest-neighbor 1:1 propensity score matching (PSM) for age, sex, stage, and race/ethnicity was applied. Cumulative incidence plots depicted 5-year cancer-specific (CSM) and other-cause mortality (OCM) rates. Univariable and multivariable competing risks regression (CRR) models were fitted. Sensitivity analyses focused within T3-4,N0 patients.

RESULTS

Of 7401 NOC UCUB patients, 1645 (22.2%) received BMT vs 884 (11.9%) TMT vs 4872 (65.8%) RC+CT. Over the study period, BMT and TMT rates have not significantly changed. After PSM, the five-year CSM rate was 66.2% after BMT vs 44.9% after RC + CT and BMT was associated with 2.1-fold higher CSM relative to RC + CT (multivariable HR [mHR]: 2.12, P <.001). After PSM, 5-year CSM rates was 61.1% after TMT vs 46.6% after RC and TMT was associated with 1.6-fold higher CSM relative to RC (mHR: 1.63, P <.001). Virtually the same findings were found within T3-4,N0 patients.

CONCLUSION

Approximately three out of ten NOC UCUB patients were treated with either BMT or TMT. However, such practice was invariably associated with higher CSM relative to RC + CT. These observations should be discussed at clinical decision-making and prior to informed consent.

Real-world treatment patterns and clinical outcomes in patients with locally advanced or metastatic urothelial carcinoma in Germany: retrospective CONVINCE study

PURPOSE

CONVINCE is a retrospective medical chart review study that examined demographics, treatment patterns, and outcomes in patients who received first-line (1L) treatment for locally advanced or metastatic urothelial carcinoma (la/mUC) in Germany.

METHODS

Eligible patients were adults with confirmed la/mUC who received any systemic 1L anticancer treatment between January 1, 2019, and September 30, 2021, outside of a clinical trial. Patients were grouped by type of 1L treatment: platinum-based chemotherapy (PBC), immune checkpoint inhibitor (ICI), or other treatments. Follow-up was ≥ 6 months after end of PBC or start of ICI or other treatments. The primary objective was measurement of real-world progression-free survival (rwPFS).

RESULTS

Data were collected from 188 patients treated at 27 sites (hospitals or office-based practices). First-line treatment was PBC in 76.1% of patients, ICI in 19.1%, and other treatments in 4.8%. The most common PBC regimen was cisplatin + gemcitabine (72.7%), and the most common ICI was atezolizumab (44.4%); 4.2% of PBC-treated patients received avelumab 1L maintenance. In patients who received 1L PBC, ICI treatment, or other treatments, median (95% CI) rwPFS was 10.5 months (9.2-11.6), 12.6 months (8.9-22.9), and not evaluable; median (95% CI) real-world overall survival was 18.1 months (16.5-19.0), 15.9 months (11.1-24.5), and not evaluable; and objective response rates were 56.6%, 60.0%, and 83.3%, including complete response in 14.0%, 20.0%, and 0%, respectively.

CONCLUSION

PBC was the most common 1L treatment in patients with la/mUC in Germany, consistent with treatment guidelines. Future studies are needed to assess outcomes with newer treatments.

The role of MRI in muscle-invasive bladder cancer: an update from the last two years

PURPOSE OF REVIEW

Muscle invasive bladder cancer (MIBC) is aggressive and requires radical cystectomy and neoadjuvant therapy, yet over 40% of patients face recurrence. The loss of the bladder also significantly reduces quality of life. Accurate staging, crucial for treatment decisions, is typically done through transurethral resection (TURBT), but inconsistencies in pathology affect diagnosis in 25% of cases. MRI is the most precise imaging method for evaluating local tumor invasiveness. This review discusses recent advances in MRI for staging MIBC and predicting responses to neoadjuvant therapy.

RECENT FINDINGS

Vesical imaging - reporting and data system (VI-RADS) accuracy may improve if combined with ADC maps and tumor contact length, while a bi-parametric MRI approach without contrast could reduce side effects without losing diagnostic precision, though evidence is mixed. VI-RADS shows promise in predicting neoadjuvant therapy responses, and the new nacVI-RADS score is in development. Non-Gaussian diffusion-weighted imaging techniques and machine learning could enhance accuracy but need more integration with mpMRI. VI-RADS may assist in evaluating responses in bladder-sparing regimens. Urodrill, an MRI-guided biopsy, aims to replace diagnostic TURBT but needs more accuracy data.

SUMMARY

MRI in MIBC is evolving, offering potential for accurate local staging and reduced side effects by avoiding TURBT. Predicting neoadjuvant treatment response could guide personalized treatment and bladder preservation. Larger trials are needed to validate these findings.

Individualizing first-line treatment for advanced urothelial carcinoma: A favorable dilemma for patients and physicians

The treatment landscape for patients with advanced urothelial carcinoma (UC) has evolved rapidly in recent years. In current guidelines, combination treatment with enfortumab vedotin plus pembrolizumab is the first-line (1L) standard of care, and other recommended 1L treatment options are platinum-based chemotherapy followed by avelumab as switch-maintenance treatment in patients without progression, or combination treatment with nivolumab, cisplatin, and gemcitabine for cisplatin-eligible patients only. Individual patients differ in terms of their health status, disease characteristics, expected toxicities, and treatment preferences; thus, a "one-size-fits-all" approach to treatment is unlikely to be optimal. The availability of several treatment options creates the potential for individualized treatment. In this review, we discuss factors that may be considered when selecting 1L treatment for patients with advanced UC, including efficacy and safety data from phase 3 trials and real-world studies, quality of life, patient priorities for treatment, patient and disease characteristics, treatment sequencing, biomarkers, and treatment access and cost. Patients and physicians should discuss the benefit-risk balance of all available 1L options to enable shared decision-making. Longer follow-up from clinical trials and additional real-world studies are needed to further inform treatment selection.

Oncological outcomes of patients with node positive disease following neoadjuvant chemotherapy and radical cystectomy for muscle-invasive bladder cancer: A multicenter observational study of the EAU Young Academic Urologists (YAU) urothelial carcinoma working group

INTRODUCTION

Until recently there was no recommended adjuvant therapy for patients with lymph nodes metastasis (ypN+) following neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). The aim of the study was to describe the oncological outcomes of ypN+ patients following NAC and RC for MIBC.

METHODS

This collaborative retrospective study included 195 patients with ypN+ disease after NAC followed by RC and bilateral pelvic lymph node dissection for MIBC between 2000 and 2019 in seven centers. Patients' demographics, clinical and pathological features were collected. Survival analyses were carried out with Kaplan-Meier estimates and a Cox model was generated.

RESULTS

A total of 120 patients (62%) were pN1, 51 pN2 (26%) and 24 pN3 (12%). Adjuvant radiation therapy was performed in 18 (9%), adjuvant chemotherapy in 40 (21%) and the remaining 137 (70%) patients were observed. The median follow-up time was 51 months (95%CI 44-62). Median times for recurrence-free survival, cancer-specific survival and overall survival (OS) were 18 months (95%CI 16-21), 47 months (95%CI 31-70) and 28 months (95%CI 22-34) respectively. On multivariable analysis, female gender (HR = 1.5, 95%CI 1.002-2.21, p = 0.049) and positive surgical margins (HR = 1.6, 95%CI 1.06-2.38, p = 0.026) were the only independent predictor of OS. The type of adjuvant therapy did not impact OS (adjuvant chemotherapy, p = 0.44; adjuvant radiotherapy p = 0.40).

CONCLUSION

MIBC patients with residual node positive disease following NAC and RC have poor survival outcomes. Females and patients with positive margin status at RC carry a poorer prognosis. These results may be beneficial for clinical trial design.

Concomitant antihistamine administration is associated with improved survival outcomes in patients with locally advanced or metastatic urothelial carcinoma treated with atezolizumab. Analysis of individual participant data from IMvigor210 and IMvigor211

OBJECTIVES

Survival outcomes of patients with metastatic urothelial carcinoma (mUC) are still suboptimal and strategies to enhance response to immune-oncology (IO) compounds are under scrutiny. In preclinical studies, it has been demonstrated that antihistamines may reverse macrophage immunosuppression, reactivate T cell cytotoxicity, and enhance the immunotherapy response. We aimed to evaluate the role of concomitant antihistamines administration on oncological outcomes among patients with mUC.

MATERIALS AND METHODS

We relied on individual patient data from IMvigor210 (phase II single-arm trial on second line atezolizumab for mUC) and IMvigor211 trials (phase III randomized trial on second line atezolizumab vs chemotherapy for mUC). Among individuals treated with IO we identified patients who did and did not receive antihistamines. Multivariable Cox or competing-risks regression models were used to predict progression-free survival (PFS), overall survival (OS), and cancer-specific survival (CSS). The impact of antihistamines on the outcomes was assessed after adjusting for potential confounders.

RESULTS

Among 896 patients with locally advanced or metastatic urothelial cancer who had progressed after first-line chemotherapy, 155 (17 %) received antihistamines during the delivery of IO. Patients receiving antihistamines had longer OS (Hazard Ratio [HR]:0.59; 95 % Confidence interval [CI]: 0.47-0.74; P < 0.001), PFS (HR:0.70; 95 %CI: 0.57-0.87; P = 0.001) and CSS [sHR:0.58; 95 %CI:0.45-0.75; P < 0.001)] relative to those who had not used antihistamine drugs. A sensitivity analysis, after the exclusion of patients who experienced adverse events and received antihistamines, yielded similar findings of prolonged CSS (sHR 0.78; 95 %CI: 0.59-0.98, P = 0.031) and OS (HR 0.71; 95 %CI: 0.52-0.94, P = 0.021).

CONCLUSIONS

Concomitant antihistamines administration was associated with improved OS, CSS, and PFS in patients receiving atezolizumab as second line treatment for mUC. Further mechanistic and clinical investigation is warranted to elucidate the role of antihistamines in IO.

Epidemiology, resource use, and treatment patterns of locally advanced or metastatic urothelial carcinoma in France

AIM

Describe real-world epidemiology, treatment patterns, health care resource utilization, and costs of locally advanced or metastatic urothelial carcinoma (la/mUC) in France.

PATIENTS & METHODS

Retrospective study including all adults with la/mUC diagnosis during January 2017 to December 2020 in the PMSI database.

RESULTS

Annual prevalence and incidence ranged from 36.4 to 38.9 and 16.4 to 18.5 cases per 100,000 people, respectively. Of the 25,314 patients with incident la/mUC, 37.6% did not receive first-line systemic treatment. Of the 14,656 patients who started first-line systemic treatment, 66.6%, 22.5%, and 10.9% received 1, 2, and 3 lines of therapy, respectively. Annual per-patient costs in second-/third-line setting ranged from €8803 to €16,012.

CONCLUSION

The substantial disease burden of la/mUC in France highlights the unmet need for new therapies.

Cell-free Tumor DNA: a Promising Technology for Diagnosis, Surveillance and Therapeutic Decision in Urothelial Carcinoma of the Bladder

PURPOSE OF REVIEW

This narrative review aims to discuss the latest evidence for cell-free tumor DNA (ctDNA) use in bladder cancer, future perspectives and challenges in implementing this technology in clinical practice.

RECENT FINDINGS

Recent papers describe promising findings regarding ctDNA analysis in blood samples and in urine of bladder cancer patients. This biomarker can be used as a diagnostic tool, in prognostic evaluation and as additional data for treatment indication and surveillance.

Biomarkers for predicting bladder cancer therapy response

The advent of precision medicine has underscored the importance of biomarkers in predicting therapy response for bladder cancer, a malignancy marked by considerable heterogeneity. This review critically examines the current landscape of biomarkers to forecast treatment outcomes in bladder cancer patients. We explore a range of biomarkers, including genetic, epigenetic, proteomic, and transcriptomic indicators, from multiple sample sources, including urine, tumor tissue and blood, assessing their efficacy in predicting responses to chemotherapy, immunotherapy, and targeted therapies. Despite promising developments, the translation of these biomarkers into clinical practice faces significant challenges, such as variability in biomarker performance, the necessity for large-scale validation studies, and the integration of biomarker testing into routine clinical workflows. We also highlight the need for standardized methodologies and robust assays to ensure consistency and reliability. Future directions point towards longitudinal studies and the development of combination biomarker panels to enhance predictive accuracy. This review emphasizes the transformative potential of predictive biomarkers in improving patient outcomes and advocates for continued collaborative efforts to overcome existing barriers in this rapidly evolving field.

Model-informed development of a cost-saving dosing regimen for enfortumab vedotin

AIM

Enfortumab vedotin is an antibody-drug conjugate (ADC) that has been approved for locally advanced or metastatic urothelial cancer, as monotherapy and in combination with pembrolizumab, and has shown significant benefit in progression-free survival and overall survival for these patients. The economic burden of enfortumab vedotin hampers widespread patient access. The aim of this study was to develop a model-informed alternative dosing regimen that results in equivalent drug exposure while reducing the costs and prevent drug spillage.

METHODS

Population pharmacokinetic modelling was used to simulate a dosing regimen leading to equivalent exposure by using the published population pharmacokinetic model in the registration reports. The alternative dosing regimen was based on weight-bands derived from the established non-linear relationship between body weight and systemic exposure, and the usage of whole vials based on fixed doses to prevent spillage. Equivalent exposure compared to the approved body weight-based dosing regimen was defined as conservative equivalent boundaries of 90-111% for the calculated geometric mean ratios (GMRs) of area under the concentration-time curve and trough concentration.

RESULTS

A weight-band based dosing regimen for each dose level of enfortumab vedotin was developed. The GMRs for all pharmacokinetic outcomes were within the predefined equivalence boundaries. In addition, a more even exposure distribution was observed across the body weight quartiles. The average costs savings across all dose levels and per weight-band were approximately 15%.

CONCLUSION

The proposed alternative dosing regimen shows that drug costs and spillage of enfortumab vedotin can be reduced while maintaining an equivalent and more evenly distributed exposure in treated patients.

Prediction of muscular-invasive bladder cancer using multi-view fusion self-distillation model based on 3D T2-Weighted images

OBJECTIVES

Accurate preoperative differentiation between non-muscle-invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC) is crucial for surgical decision-making in bladder cancer (BCa) patients. MIBC diagnosis relies on the Vesical Imaging-Reporting and Data System (VI-RADS) in clinical using multi-parametric MRI (mp-MRI). Given the absence of some sequences in practice, this study aims to optimize the existing T2-weighted imaging (T2WI) sequence to assess MIBC accurately.

METHODS

We analyzed T2WI images from 615 BCa patients and developed a multi-view fusion self-distillation (MVSD) model that integrates transverse and sagittal views to classify MIBC and NMIBC. This 3D image classification method leverages z-axis information from 3D MRI volume, combining information from adjacent slices for comprehensive features extraction. Multi-view fusion enhances global information by mutually complementing and constraining information from the transverse and sagittal planes. Self-distillation allows shallow classifiers to learn valuable knowledge from deep layers, boosting feature extraction capability of the backbone and achieving better classification performance.

RESULTS

Compared to the performance of MVSD with classical deep learning methods and the state-of-the-art MRI-based BCa classification approaches, the proposed MVSD model achieves the highest area under the curve (AUC) 0.927 and accuracy (Acc) 0.880, respectively. DeLong's test shows that the AUC of the MVSD has statistically significant differences with the VGG16, Densenet, ResNet50, and 3D residual network. Furthermore, the Acc of the MVSD model is higher than that of the two urologists.

CONCLUSIONS

Our proposed MVSD model performs satisfactorily distinguishing between MIBC and NMIBC, indicating significant potential in facilitating preoperative BCa diagnosis for urologists.

Clinical advances and practice updates in genitourinary cancers: a 2024 review from the multidisciplinary Spanish 'Cambados annual meeting'

Prostate, bladder and kidney neoplasms are among the most prevalent genitourinary (GU) cancers worldwide. Significant therapeutic advancements in recent years have substantially improved patient outcomes. In response to this rapid progress, the Santiago de Compostela Health Research Institute (IDIS) has organized the annual 'Cambados Consensus Forum on Genitourinary Tumors' (Pontevedra, Spain) since 2018. This 2-day multidisciplinary meeting gathers Spanish medical oncologists, radiation oncologists, urologists, and hospital pharmacists to present and discuss the latest evidence in the field, merging from international congresses or journal publications. This review provides an overview of the most recent evidence regarding therapeutic advances in prostate cancer, renal cell carcinoma, and bladder cancer presented at the 2024 meeting (October), with a special focus on practice-changing innovations.

Effectiveness and safety of PD-1/L1 inhibitors as first-line therapy for patients with advanced or metastatic urothelial carcinoma who are ineligible for platinum-based chemotherapy: a meta-analysis

Objective

To evaluate the efficacy and safety of programmed cell death protein 1 or its ligand (PD-1/L1) inhibitors as first-line therapy in advanced or metastatic urothelial carcinoma (mUC) who are ineligible for platinum-based chemotherapy.

Method

A systematic search was conducted in four databases (Pubmed, Embase, Web of Science, and the Cochrane Library) to find articles that evaluate the effectiveness of first-line PD-1/L1 inhibitors for mUC, from the establishment of the databases to 22 November 2023. Meta-analyses were performed to evaluate the frequencies of progression-free survival (PFS), overall survival (OS), complete response (CR), partial response (PR), stable disease (SD), progressive disease (PD), objective response rate (ORR), disease control rate (DCR), and grade ≥ 3 treatment-related adverse events (trAEs).

Results

Totally six studies were included for meta-analysis. The CR, PR, SD, PD, ORR, DCR, and grade ≥ 3 trAEs rate were 0.06 [95% confidence interval (CI), 0.04 to 0.07], 0.22 (95% CI, 0.16 to 0.30), 0.27 (95% CI, 0.23 to 0.31), 0.31 (95% CI, 0.20 to 0.44), 0.28 (95% CI, 0.21 to 0.37), 0.57 (95% CI, 0.47 to 0.67) and 0.26 (95% CI, 0.14 to 0.40), respectively. The median PFS and OS were 4.5 months and 13.7 months, respectively. Subgroup analysis showed that PD-1/L1 inhibitors monotherapy had an ORR rate of 0.25 (95% CI, 0.21 to 0.29) and a DCR rate of 0.50(95% CI, 0.44 to 0.56), while PD-1/L1 dual immunotherapy had a better ORR rate of 0.33 (95% CI, 0.15 to 0.52) and a DCR rate of 0.65 (95% CI, 0.49 to 0.80). However, there was no significant difference in PFS and OS between the two groups.

Conclusion

The findings indicated that PD-1/L1 inhibitors could be used as a safe and viable first-line treatment option for patients with advanced or metastatic urothelial carcinoma who were not suitable candidates for platinum-based chemotherapy. Specifically, the combination of Enfortumab vedotin (EV) and pembrolizumab (Pembro) showed more effectiveness in treating patients compared to trials using the current standard treatment, suggesting that it could be a promising alternative treatment option.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024510152.

Phase Ib study of anti-PD-L1 monoclonal antibody socazolimab in combination with nab-paclitaxel as first-line therapy for advanced urothelial carcinoma

BACKGROUND

PD-1/PD-L1 immune checkpoint inhibitors (ICIs) have demonstrated activity in the post-platinum and platinum-ineligible settings for advanced urothelial carcinoma (aUC). As only around 50% of patients with aUC can tolerate platinum-containing treatment, treatments combining first-line ICIs with non-platinum drugs are urgently needed. Therefore, we assessed the safety and efficacy of the anti-PD-L1 monoclonal antibody Socazolimab in combination with nab-paclitaxel as first-line therapy in aUC (NCT04603846).

METHODS

This was a multi-center, single-arm, phase Ib study that enrolled patients with treatment-naive aUC. Patients received Socazolimab (5 mg/kg) and nab-paclitaxel (260 mg/m2) Q3w. The primary endpoint was safety and tolerability of the combination regimen. Second endpoints were the objective response rate (ORR) and progression-free survival.

RESULTS

Between September, 2020 and September, 2021, 20 patients with urothelial carcinoma were enrolled, arising from renal pelvis (5), bladder (8), and ureter (7). After a median follow-up of 17 months, the median number of treatment cycles was 12. No patients had dose limiting toxicity. All patients had treatment-related adverse events (TRAEs), most of which were grade 1 or 2. The common TRAEs (≥20%) were peripheral neurotoxicity, alopecia, rash, increased ALT, weight loss, weakness, pruritus, increased AST, increased γGT, increased ALP, neutropenia, emesis, and anorexia. Nine patients (45%) developed grade 3 TRAEs including peripheral neurotoxicity (30.0%), increased ALT (10.0%), and increased γGT (5.0%). Two patients (10%) discontinued treatment because of grade 3 mouth ulcer (n = 1) and grade 2 lung fibrosis (n = 1). No grade 4-5 TRAEs were observed. Among the 17 patients who had received at least one tumor assessment, ORR was 58.8% (95% CI, 32.9%-81.6%) and the median progression-free survival was 8.3 months (95% CI, 5.2-19.5). The median duration of response was 13.3 months (95% CI, 2.0-20.1), and the overall survival was 19.5 months (95% CI, 11.2-not reached).

CONCLUSION

Socazolimab combined with nab-paclitaxel has shown good safety and promising antitumor activity as first-line therapy in patients with advanced urothelial carcinoma.

Amyloids in bladder cancer hijack cancer-related proteins and are positive correlated to tumor stage

Despite the current diagnostic and therapeutic approaches to bladder cancer being widely accepted, there have been few significant advancements in this field over the past decades. This underscores the necessity for a paradigm shift in the approach to bladder cancer. The role of amyloids in cancer remains unclear despite their identification in several other pathologies. In this study, we present evidence of amyloids in bladder cancer, both in vitro and in vivo. In a murine model of bladder cancer, a positive correlation was observed between amyloids and tumor stage, indicating an association between amyloids and bladder cancer progression. Subsequently, the amyloid proteome of the RT4 non-invasive and HT1197 invasive bladder cancer cell lines was identified and included oncogenes, tumor suppressors, and highly expressed cancer-related proteins. It is proposed that amyloids function as structures that sequester key proteins. Therefore, amyloids should be considered in the study and diagnosis of bladder cancer.