Nomogram-based Prediction of Overall Survival in Patients with Metastatic Urothelial Carcinoma Receiving First-line Platinum-based Chemotherapy: Retrospective International Study of Invasive/Advanced Cancer of the Urothelium (RISC)

The Vanishing Clinical Value of PD-L1 Status as a Predictive Biomarker in the First-Line Treatment of Urothelial Carcinoma of the Bladder

BACKGROUND

Our study endeavors to elucidate the clinical implications of PD-L1 positivity in individuals afflicted with advanced urothelial carcinoma of the bladder (UCB).

METHODS

Patients with advanced UCB were prospectively enrolled following a radical cystectomy (RC) performed within January 2017 to December 2022 at our tertiary referral center. The clinical outcome, defined as the progression-free survival (PFS) and overall survival (OS) on systemic treatment, was analyzed using an χ2-test, Mann-Whitney U-test, the Kaplan-Meier method, and a log-rank test.

RESULTS

A total of 648 patients were included following an RC performed within January 2017 to December 2022. Their PD-L1 status was analyzed with the primary PD-L1-specific antibody (clone SP263, Ventana) and defined both by the CPS and IC-score in 282 patients (43.5%) with a high risk (pT3-pT4 and/or lymph node involvement) or metastatic UCB. While the median PFS was significantly prolonged 5-fold in PD-L1+ patients, we found no difference in OS, regardless of PD-L1 status, or treatment regimen.

CONCLUSIONS

While PD-L1 positivity indicates prolonged PFS, the presence of PD-L1 does not influence OS rates, suggesting its limited usefulness as a prognostic biomarker in bladder cancer. However, the positive correlation between an PD-L1 status and a sustained response to ICI treatments indicates its potential role as a predictive biomarker. Further research is required to understand how the predictive value of PD-L1 positivity may extend to the use of ICIs in combination with antibody-drug conjugates.

Clinical variables associated with immune checkpoint inhibitor outcomes in patients with metastatic urothelial carcinoma: a multicentre retrospective cohort study

OBJECTIVES

Immune checkpoint inhibitors (ICIs) are indicated for metastatic urothelial cancer (mUC), but predictive and prognostic factors are lacking. We investigated clinical variables associated with ICI outcomes.

METHODS

We performed a multicentre retrospective cohort study of 135 patients who received ICI for mUC, 2016-2021, at three Canadian centres. Clinical characteristics, body mass index (BMI), metastatic sites, neutrophil-to-lymphocyte ratio (NLR), response and survival were abstracted from chart review.

RESULTS

We identified 135 patients and 62% had received ICI as a second-line or later treatment for mUC. A BMI ≥25 was significantly correlated to a higher overall response rate (ORR) (45.4% vs 16.3%, p value=0.020). Patients with BMI ≥30 experienced longer median overall survival (OS) of 24.8 vs 14.4 for 25≤BMI<30 and 8.5 months for BMI <25 (p value=0.012). The ORR was lower in the presence of bone metastases (16% vs 41%, p value=0.006) and liver metastases (16% vs 39%, p value=0.013). Metastatic lymph nodes were correlated with higher ORR (40% vs 20%, p value=0.032). The median OS for bone metastases was 7.3 versus 18 months (p value <0.001). Patients with liver metastases had a median OS of 8.6 versus 15 months (p value=0.006). No difference for lymph nodes metastases (13.5 vs 12.7 months, p value=0.175) was found. NLR ≥4 had worse OS (8.2 vs 17.7 months, p value=0.0001). In multivariate analysis, BMI ≥30, bone metastases, NLR ≥4, performance status ≥2 and line of ICI ≥2 were independent factors for OS.

CONCLUSIONS

Our data identified BMI and bone metastases as novel clinical biomarkers that were independently associated with ICI outcomes in mUC. External and prospective validation are warranted.

Nationwide Study of Real-World Treatment Patterns and Clinical Outcomes in Patients with Metastatic Urothelial Carcinoma in Hungary

INTRODUCTION

Data describing real-world treatment patterns in patients with metastatic urothelial carcinoma (mUC) in Central-Eastern Europe are scarce, and data from Hungary have not been published. This retrospective, nationwide, real-world study investigated patient characteristics, treatment patterns, comorbidities, and clinical outcomes in patients with mUC in Hungary.

METHODS

Adults diagnosed with mUC from January 2016 through June 2021 were identified using the National Health Insurance Fund Administration database. Overall survival (OS) was estimated using the Kaplan-Meier method.

RESULTS

In total, 2523 patients with mUC were identified. Median follow-up was 7.1 months. Overall, 50% of patients received an identified systemic anticancer treatment; within this subgroup, first-line treatment was platinum-based chemotherapy (PBC) in 86%, non-PBC in 8%, and immune checkpoint inhibitor (ICI) in 6%. The proportion of patients receiving treatment increased from 41% in 2016 to 59% in 2020, driven by increased use of first-line PBC or first-line ICI treatment. Comorbidities were more common in patients receiving first-line ICI treatment vs PBC or non-PBC and in patients receiving carboplatin + gemcitabine vs cisplatin + gemcitabine. Overall, only 24% received a second-line treatment. Unadjusted median OS from the start of first-line treatment in the PBC, non-PBC, and ICI subgroups was 12.8, 7.5, and 6.3 months, respectively. Median OS from date of diagnosis in untreated patients was 7.8 months. OS comparisons adjusted for differences in baseline characteristics between subgroups could not be performed.

CONCLUSION

To our knowledge, this is the first study to assess treatment patterns in patients with mUC in clinical practice in Hungary, using the national health insurance database. Rates of first- and second-line treatment were consistent with those observed in other countries. Avelumab first-line maintenance treatment became available for reimbursement in Hungary in late 2022, after the study period. Given the evolving landscape of reimbursed treatments in Hungary, further analyses are warranted.

Regional differences in metastatic urothelial carcinoma of the urinary bladder patients across the United States SEER registries

INTRODUCTION

Despite advances in treatment, metastatic urothelial carcinoma of the urinary bladder (mUCUB) is associated with high mortality and treatment risk. We tested for regional differences in mUCUB within a large-scale, population-based database.

METHODS

Using the Surveillance, Epidemiology and End Results (SEER) database (2010-2018), patient (age, sex, race/ethnicity), tumor (T-stage, N-stage, number of metastatic sites), and treatment (systemic therapy, radical cystectomy) characteristics were tabulated for mUCUB patients according to 11 SEER registries. Multinomial regression models and multivariable Cox regression models tested overall mortality (OM), adjusting for patient, tumor and treatment characteristics.

RESULTS

In 4817 mUCUB patients, registry-specific patient counts ranged from 1855 (38.5%) to 105 (2.2%). Important inter-regional differences existed for race/ethnicity (3-36% for others than non-Hispanic Whites), N-stage (28-39% for N1-3, 44-58% in N0, 8-22% for unknown N-stage), systemic therapy (38-54%) and radical cystectomy (3-11%). In multivariable analyses adjusting for these patient, tumor, and treatment characteristics, one registry exhibited significantly lower OM (SEER registry 10: hazard ratio [HR] 0.83) and two other registries exhibited significantly higher OM (SEER registries 9: HR 1.13; SEER registry 8: HR 1.24) relative to the largest reference registry (n=1855).

CONCLUSIONS

We identified important regional differences that included patient, tumor, and treatment characteristics. Even after adjustment for these characteristics, important OM differences persisted, which may warrant more detailed investigation.

Prognostic nomograms for gastric carcinoma after D2 + total gastrectomy to assist decision-making for postoperative treatment: based on Lasso regression

OBJECTIVE

This study aimed to establish novel nomograms that could be used to predict the prognosis of gastric carcinoma patients who underwent D2 + total gastrectomy on overall survival (OS) and progression-free survival (PFS).

METHODS

Lasso regression was employed to construct the nomograms. The internal validation process included bootstrapping, which was used to test the accuracy of the predictions. The calibration curve was then used to demonstrate the accuracy and consistency of the predictions. In addition, the Harrell's Concordance index (C-index) and time-dependent receiver operating characteristic (t-ROC) curves were used to evaluate the discriminative abilities of the new nomograms and to compare its performance with the 8th edition of AJCC-TNM staging. Furthermore, decision curve analysis (DCA) was performed to assess the clinical application of our model. Finally, the prognostic risk stratification of gastric cancer was conducted with X-tile software, and the nomograms were converted into a risk-stratifying prognosis model.

RESULTS

LASSO regression analysis identified pT stage, the number of positive lymph nodes, vascular invasion, neural invasion, the maximum diameter of tumor, the Clavien-Dindo classification for complication, and Ki67 as independent risk factors for OS and pT stage, the number of positive lymph nodes, neural invasion, and the maximum diameter of tumor for PFS. The C-index of OS nomogram was 0.719 (95% CI: 0.690-0.748), which was superior to the 8th edition of AJCC-TNM staging (0.704, 95%CI: 0.623-0.783). The C-index of PFS nomogram was 0.694 (95% CI: 0.654-0.713), which was also better than that of the 8th edition of AJCC-TNM staging (0.685, 95% CI: 0.635-0.751). The calibration curves, t-ROC curves, and DCA of the two nomogram models showed that the prediction ability of the two nomogram models was outstanding. The statistical difference in the prognosis between the low- and high-risk groups further suggested that our model had an excellent risk stratification performance.

CONCLUSION

We reported the first risk stratification and nomogram for gastric carcinoma patients with total gastrectomy in Chinese population. Our model could potentially be used to guide treatment selections for the low- and high-risk patients to avoid delayed treatment or unnecessary overtreatment.

The utility of clinical registries for guiding clinical practice in upper tract urothelial cancer: a narrative review

Background and Objective

Upper tract urothelial cancer (UTUC) lacks high-quality evidence to appraise current patterns of presentation, diagnosis, treatment and outcomes as a result of disease rarity and patient heterogeneity. Registries may overcome many of the challenges making clinical trials challenging in UTUC and provide answers to many of the clinical questions that afflict UTUC management. In this narrative review we aim to summarise the design of registries that have contributed to the UTUC literature, discuss their strengths and limitations and the future directions of registries in UTUC.

Methods

Two independent reviewers conducted a search of the OVID MEDLINE database from July 2002-July 2022. Included articles were required to be published in peer reviewed journals and use registry-based methodology to report on UTUC. Search was limited by MeSH and key words and was limited to the English language.

Key Content and Findings

One hundred and forty-four articles were identified and included as reporting on UTUC from a registry-based methodology. Articles utilising registry-based data have substantially increased over the study period with the majority of articles arising from large generalised cancer databases in North America. There has been an increase in UTUC-specific registries in the previous five years that have offered the most granular, complete analysis and these will continue to report in the coming years. The majority of published data assessed epidemiological factors and compared outcomes of treatment modalities with a small proportion of articles focusing on prognostic nomograms and quality of life. Larger cancer registries that contribute the majority of the published analysis are likely subject to significant selection bias when comparing cohorts for treatment analysis and the need for prospective UTUC specific registries is apparent. Future directions include the potential for registry-based randomised controlled trials (RCTs) and clinical quality registries (CQR) that have the ability to change practice and improve care.

Conclusions

The utilisation of registry-based methodology for analysis in UTUC has increased substantially over the last 20 years. In addition to the utilisation of large cancer registries, the creation of UTUC specific registries is likely to contribute the most granular, translatable data in diagnosis and management.

Prognostic nomograms for gastric carcinoma after surgery to assist decision-making for postoperative treatment with chemotherapy cycles <9 or chemotherapy cycles ≥9

Objective

We sought to develop novel nomograms to accurately predict overall survival (OS) of chemotherapy cycles &lt;9 and chemotherapy cycles ≥9 and construct risk stratification to differentiate low-risk and high-risk of two cohorts.

Methods

Patients who underwent curative-intent resection for gastric cancer between January 2002 and May 2020 at a single China institution were identified. Variables associated with OS were recorded and analyzed according to multivariable Cox models. Nomograms predicting 3- and 5-year OS were built according to variables resulting from multivariable Cox models. Discrimination ability was calculated using the Harrell's Concordance Index. The constructed nomogram was subjected to 1,000 resamples bootstrap for internal validation. Calibration curves for the new nomograms were used to test the consistency between the predicted and actual 3- and 5-year OS. Decision curve analysis (DCA) was performed to assess the clinical net benefit. The Concordance index (C-index) and time-dependent receiver operating characteristic (t-ROC) curves were used to evaluate and compare the discriminative abilities of the new nomograms. Finally, prognostic risk stratification of gastric cancer was conducted with X-tile software and nomograms converted into a risk-stratified prognosis model.

Results

For the nomogram predict OS of chemotherapy cycles &lt;9, C-index was 0.711 (95% CI, 0.663–0.760) in internal validation and 0.722 (95% CI, 0.662–0.783) in external validation, which was better than AJCC 8th edition TNM staging (internal validation: 0.627, 95% CI, 0.585–0.670) and (external validation: 0.595,95% CI, 0.543–0.648). The C-index of the nomogram for chemotherapy cycles ≥9 in internal validation was 0.755 (95% CI, 0.728–0.782) and 0.785 (95% CI, 0.747–0.823) in external validation, which was superior to the AJCC 8th edition TNM staging (internal validation: 0.712 95% CI, 0.688–0.737) and (external validation 0.734, 95% CI, 0.699–0.770).The calibration curves, t-ROC curves and DCA of the two nomogram models show that the recognition performance of the two nomogram models was outstanding. The statistical differences in the prognosis among the two risk stratification groups further showed that our model had an excellent risk stratification performance.

Conclusion

This is first reported risk stratification for chemotherapy cycles of gastric carcinoma. Our proposed nomograms can effectively evaluate postoperative prognosis of patients with different chemotherapy cycles of gastric carcinoma. Chemotherapy cycles ≥9 is therefore recommended for high-risk patients with chemotherapy cycles &lt;9, but not for low-risk patients. Meanwhile, combination with multiple therapies are essential to high-risk patients with chemotherapy cycles ≥9 and unnecessary for low-risk patients.

Clinico-Genomic Characterization of Patients with Metastatic Urothelial Carcinoma in Real-World Practice Identifies a Novel Bladder Immune Performance Index (BIPI)

PURPOSE

This retrospective analysis of the largest available clinico-genomic database used de-identified patient-level electronic health record-derived real-world data (RWD) combined with FoundationOne® comprehensive genomic profiling (CGP) to characterize patients with metastatic urothelial carcinoma (mUC) treated in the real-world setting, detect potential biomarkers, and develop a bladder immune performance index (BIPI).

EXPERIMENTAL DESIGN

Patients with mUC who started front-line single-agent immune checkpoint inhibitors (ICIs) and an unmatched group treated with front-line platinum-based chemotherapy between January 1, 2011 and September 30, 2019 were selected. Clinical and genomic data were correlated with overall survival (OS). A novel BIPI predicting outcome with ICIs was developed using machine learning methods and validated using data from a phase II trial (NCT02951767).

RESULTS

In ICI-treated patients (n=118), high tumor mutational burden (≥10 mutations/megabase) was associated with improved OS (HR 0.58 [95% CI, 0.35-0.95]; P=0.03). In chemotherapy-treated patients (n=268), those with high APOBEC mutational signature had worse OS (HR 1.43 [95% CI, 1.06-1.94]; P=0.02). Neither FGFR3 mutations nor DNA damage-repair pathway alterations were associated with OS. A novel BIPI combining clinical and genomic variables (non-metastatic at initial diagnosis, normal or above normal albumin level at baseline, prior surgery for organ-confined disease, high TMB) identified ICI-treated patients with longest OS and was validated in an independent dataset.

CONCLUSIONS

Contemporary RWD including FoundationOne® CGP can be used to characterize outcomes in real-world patients according to biomarkers beyond PD-L1. A validated, novel clinico-genomic BIPI demonstrated satisfactory prognostic performance for OS in patients with mUC receiving front-line ICI therapy.

A Predictive Nomogram of Early Recurrence for Patients with AFP-Negative Hepatocellular Carcinoma Underwent Curative Resection

Background: Alpha-fetoprotein-negative (<20 ng/mL) hepatocellular carcinoma (AFP-NHCC) cannot be easily diagnosed in clinical practice, which may affect early treatment and prognosis. Furthermore, there are no reliable tools for the prediction of AFP-NHCC early recurrence that have been developed currently. The objective of this study was to identify the independent risk factors for AFP-NHCC and construct an individual prediction nomogram of early recurrence of these patients who underwent curative resection. Methods: A retrospective study of 199 patients with AFP-NHCC who had undergone curative resection and another 231 patients with AFP-positive HCC were included in case-controlled analyses. All AFP-NHCC patients were randomly divided into training and validation datasets at a ratio of 7:3. The univariate and multivariate Cox proportional hazards regression analyses were applied to identify the risk factors, based on which the predictive nomogram of early recurrence was constructed in the training dataset. The area under the curve (AUC), calibration curve, and decision curve was used to evaluate the predictive performance and discriminative ability of the nomogram, and the results were validated in the validation dataset. Results: Compared to AFP-positive patients, the AFP-negative group with lower values of laboratory parameters, lower tumor aggressiveness, and less malignant magnetic resonance (MR) imaging features. AST (HR = 2.200, p = 0.009), tumor capsule (HR = 0.392, p = 0.017), rim enhancement (HR = 2.825, p = 0.002) and TTPVI (HR = 5.511, p < 0.001) were independent predictors for early recurrence of AFP-NHCC patients. The nomogram integrated these independent predictors and achieved better predictive performance with AUCs of 0.89 and 0.85 in the training and validation datasets, respectively. The calibration curve and decision curve analysis both demonstrated better predictive efficacy and discriminative ability of the nomogram. Conclusions: The nomogram based on the multivariable Cox proportional hazards regression analysis presented accurate individual prediction for early recurrence of AFP-NHCC patients after surgery. This nomogram could assist physicians in personalized treatment decision-making for patients with AFP-NHCC.

Clinical evidence and insights supporting the use of avelumab first-line maintenance treatment in patients with advanced urothelial carcinoma in the Asia-Pacific region

Until recently, international and Asia-specific guidelines for advanced urothelial carcinoma (UC) recommended first-line (1L) platinum-based chemotherapy, followed by second-line (2L) anti-PD-1 or anti-PD-L1 immune checkpoint inhibitor (ICI) therapy where possible, or 1L ICI therapy in cisplatin-ineligible patients with PD-L1+ tumors. However, long-term outcomes remain poor and only a minority of patients receive 2L therapy. The JAVELIN Bladder 100 trial-which assessed avelumab (anti-PD-L1 antibody) as 1L maintenance therapy plus best supportive care (BSC) versus BSC alone in patients with advanced UC that had not progressed with 1L platinum-based chemotherapy-is the only phase 3 trial of ICI-based treatment in the 1L setting to show significantly improved overall survival, and this treatment approach is now recommended in updated treatment guidelines. Available data from the trial suggest that efficacy and safety in patients enrolled in the Asia-Pacific region were similar to findings in the overall population. In this review, we discuss the treatment of advanced UC, with a specific focus on studies in the Asia-Pacific region, and summarize key findings supporting the use of avelumab 1L maintenance as a standard of care in this setting both in cisplatin-eligible and cisplatin-ineligible patients and irrespective of PD-L1 status.

Second Primary Malignancy in Patients with Hypopharyngeal Carcinoma: A SEER-Based Study

Background

A population-based analysis of the risk of secondary primary malignancy (SPM) in patients with hypopharyngeal carcinoma (HPC) has been lacking in the literature. Therefore, we conducted this study to determine the risk factors and assess the effects of SPM on the overall survival (OS) and cancer-specific survival (CSS) of patients with HPC.

Methods

Data on selected patients diagnosed with HPC from the Surveillance, Epidemiology and End Results (SEER) database between 1973 and 2015 were examined through logistic regression, Cox regression and nomogram methods.

Results

The overall risk of SPM in patients with HPC was higher than that in the general population (SIR: 2.77; P < 0.05). The specific-site, including the oral cavity, pharynx, digestive system, respiratory system and endocrine system, had a relatively higher risk of SPM. The overall risks of the subgroup of people 55–75 years of age and all subgroups of sex, race and latency were significantly elevated. In addition, patients with HPC were more likely to have been diagnosed in 2010–2015 (vs 2004–2009; P = 0.002), to be unmarried (vs married; P = 0.008), to have distant metastasis (vs no metastasis; P = 0.016) and to have had no surgery for the first tumor (vs surgery for the first tumor; P = 0.021), and these aspects were associated with a significantly elevated risk of developing SPM. SPM was independently associated with better OS and CSS. The OS and CSS in patients with HPC with SPM were better than those in patients without SPM (log rank P < 0.0001). The C indexes of the nomogram constructed with ten influencing factors including SPM were 0.681:0.699 for OS and 0.705:0.724 for CSS (training cohort:validation cohort).

Conclusion

Although the overall risk of SPM in patients with HPC was elevated, SPM did not decrease the OS and CSS in patients with HPC. This finding is inconsistent with clinical observations and thus requires further research and exploration. It possibly because HPC might have a shorter survival time, or the follow-up time was not long enough.

PD-L1 expression in bladder cancer: Which scoring algorithm in what tissue?

INTRODUCTION

For cisplatin-ineligible patients, approval of first-line immune-checkpoint inhibitor therapy relies on the programmed death ligand 1 (PD-L1) expression assay employed, namely, the combined positive score (CPS) or immune cell (IC) score. This study compares PD-L1 diagnostic scores and positivity in primary and matched metastatic bladder cancer tissue.

METHODS

A total of 108 patients undergoing radical cystectomy for urothelial bladder cancer and lymphatic spread (pN+) were included. PD-L1 expression was compared by immunohistochemistry (IHC) between the primary bladder tumor and associated lymph node metastases using Ventana SP263 anti-PD-L1 antibody. In a subset of cases further IHC was performed with Ventana SP142 and Dako 22C3 antibodies. Second, the PD-L1 scoring algorithms for the CPS and IC score were compared. Correlation of PD-L1 positivity with clinical parameters and tumor stage was assessed. Intra- and intertissue analyses were performed with Pearson's chi square test, McNemar test and Spearman correlation employing IBM SPSS 25.

RESULTS

PD-L1 expression did not correlate with clinicopathological parameters. The CPS (43.5% vs. 35.6%; P=0.006) and the IC score (28.7% vs. 21.2%; P=0.002) yielded PD-L1 positivity significantly more often in primary BC than in matched lymph node metastasis. Both the CPS (r=0.775; P<0.001) and the IC score (r=0.711; P<0.001) correlated between primary and metastatic bladder cancer tissue. Employing CPS vs. IC led to significantly more PD-L1-positive classified cases in primary BC (CPS vs. IC; 43.5% vs. 28.7%; P<0.001) and lymph node metastasis (CPS vs. IC; 35.6% vs. 21.2%, P<0.001).

CONCLUSION

Compared to lymph node analysis, bladder tissue yields more PD-L1 positivity assessed with the CPS and IC scores. This is particularly evident when employing the CPS. The findings highlight that employing both PD-L1 assays may maximize eligibility for first-line checkpoint-inhibitors to treat bladder cancer patients unfit for cisplatin-based chemotherapy.

A New Prognostic Model in Patients with Advanced Urothelial Carcinoma Treated with First-line Immune Checkpoint Inhibitors

BACKGROUND

While immune checkpoint inhibitors (ICIs) are approved in the first-line (1L) setting for cisplatin-unfit patients with programmed death-ligand 1 (PD-L1)-high tumors or for platinum (cisplatin/carboplatin)-unfit patients, response rates remain modest and outcomes vary with no clinically useful biomarkers (except for PD-L1).

OBJECTIVE

We aimed to develop a prognostic model for overall survival (OS) in patients receiving 1L ICIs for advanced urothelial cancer (aUC) in a multicenter cohort study.

DESIGN, SETTING, AND PARTICIPANTS

Patients treated with 1L ICIs for aUC across 24 institutions and five countries (in the USA and Europe) outside clinical trials were included in this study.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We used a stepwise, hypothesis-driven approach using clinician-selected covariates to develop a new risk score for patients receiving ICIs in the 1L setting. Demographics, clinicopathologic data, treatment patterns, and OS were collected uniformly. Univariate Cox regression was performed on 18 covariates hypothesized to be associated with OS based on published data. Variables were retained for multivariate analysis (MVA) if they correlated with OS (p < 0.2) and were included in the final model if p < 0.05 on MVA. Retained covariates were assigned points based on the beta coefficient to create a risk score. Stratified median OS and C-statistic were calculated.

RESULTS AND LIMITATIONS

Among 984 patients, 357 with a mean age of 71 yr were included in the analysis, 27% were female, 68% had pure UC, and 13% had upper tract UC. Eastern Cooperative Oncology Group performance status ≥2, albumin <3.5 g/dl, neutrophil:lymphocyte ratio >5, and liver metastases were significant prognostic factors on MVA and were included in the risk score. C index for new 1L risk score was 0.68 (95% confidence interval 0.65-0.71). Limitations include retrospective nature and lack of external validation.

CONCLUSIONS

We developed a new 1L ICI risk score for OS based on data from patients with aUC treated with ICIs in the USA and Europe outside of clinical trials. The score components highlight readily available factors related to tumor biology and treatment response. External validation is being pursued.

PATIENT SUMMARY

With multiple new treatments under development and approved for advanced urothelial carcinoma, it can be difficult to identify the best treatment sequence for each patient. The risk score may help inform treatment discussions and estimate outcomes in patients treated with first-line immune checkpoint inhibitors, while it can also impact clinical trial design and endpoints. TAKE  HOME MESSAGE: A new risk score was developed for advanced urothelial carcinoma treated with first-line immune checkpoint inhibitors. The score assigned Eastern Cooperative Oncology Group performance status ≥2, albumin <3.5 g/dl, neutrophil:lymphocyte ratio >5, and liver metastases each one point, with a higher score being associated with worse overall survival.

Early Bone Metastases are Associated with Worse Outcomes in Metastatic Urothelial Carcinoma

BACKGROUND: Outcomes of patients with metastatic urothelial carcinoma (mUC) with early bone metastases (eBM) vs no early bone metastases (nBM) have not thoroughly been described in the age of immuno-oncology. OBJECTIVE: To compare survival and other clinical outcomes in patients with eBM and nBM. METHODS: We used a multi-institutional database of patients with mUC treated with systemic therapy. Demographic, metastatic site, treatment patterns, and clinical outcomes were recorded. Wilcoxon rank-sum, chi-square tests were performed. Survival was estimated by Kaplan-Meier method; multivariable Cox analysis was performed. RESULTS: We identified 270 pts, 67% men, mean age 69±11 years. At metastatic diagnosis, 27% had≥1 eBM and were more likely to have de novo vs. recurrent metastases (42% vs 19%, p < 0.001). Patients with eBM had shorter overall survival (OS) vs. those with nBM, (6.1 vs 13.7 months, p < 0.0001). On multivariable analysis, eBM independently associated with higher risk of death, HR = 2.52 (95% CI: 1.75–3.63, p < 0.0001). OS was shorter for patients with eBM who received initial immune checkpoint inhibitor vs platinum-based chemotherapy, (1.6 vs 9.1 months, p = 0.02). Patients with eBM received higher opioid analgesic doses compared to patients with nBM and received quantitatively more palliative radiation. CONCLUSIONS: Patients with mUC and eBM have poorer outcomes, may benefit less from anti-PD-1/PD-L1 therapy and represent an unmet need for novel therapeutic interventions. Dedicated clinical trials, biomarker validation to assist in patient selection, as well as consensus on reporting of non-measurable disease are required.

Diabetes Mellitus and Obesity as Risk Factors for Bladder Cancer Prognosis: A Systematic Review and Meta-Analysis

BACKGROUND

Urinary bladder carcinoma is common in developed settings, and prognosis may be impacted by lifestyle factors such as excess body weight and diabetes mellitus. The present meta-analysis aimed to systematically collate and analyze evidence on the impact of diabetes and excess BMI on bladder cancer outcomes.

METHODS

PubMed, Scopus, and Google Scholar databases were screened for relevant studies that examined the association between bladder cancer outcomes and diabetes and/or excess body weight. The primary outcomes for this study were mortality (both all-cause and cancer-specific), risk of cancer progression, and recurrence. Strength of association was presented in the form of pooled adjusted hazard ratios (HR). Statistical analysis was performed using STATA version 16.0.

RESULTS

Twenty-five articles met inclusion criteria. Nine of these examined diabetes mellitus while 16 studied body mass index. All studies were retrospective. Diabetic patients had significantly higher risk for all-cause mortality (HR 1.24, 95% CI: 1.07, 1.44, n=3), cancer specific mortality (HR 1.67, 95% CI: 1.29, 2.16, n=7), disease progression (HR 1.54, 95% CI: 1.15, 2.06, n=8), and recurrence (HR 1.40, 95% CI: 1.32, 1.48, n=8) compared to non-diabetics. No statistically significant risk change for all-cause mortality, cancer specific mortality, disease progression, and recurrence was found for overweight patients. However, obese individuals were at higher risk for disease progression (HR 1.88, 95% CI: 1.41, 2.50, n=3) and recurrence (HR 1.60, 95% CI: 1.06, 2.40, n=7) compared to normal BMI patients.

CONCLUSIONS

These findings suggest that diabetes and excess body weight negatively influences bladder cancer prognosis and outcome. The increased risk of mortality due to diabetes was similar to that in the general population. Since retrospective studies are potentially susceptible to bias, future prospective studies on this subject are required.

Marital Status and Prognostic Nomogram for Bladder Cancer With Distant Metastasis: A SEER-Based Study

Background

To investigate the impact of marital status on overall survival (OS) and create a prognostic nomogram predicting OS in distant-metastatic bladder cancer (DMBC) patients.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was explored to recruit DMBC patients from 2010 to 2015. Kaplan–Meier survival analysis was used to compare survival differences among different marital status. Univariate and multivariate analyses were used to screen for prognostic factors and then constructed the nomogram based on Cox proportional hazard regression models. Calibration plot diagrams and concordance index (C-index) were used to verify the prognostic nomogram.

Results

Kaplan–Meier curves suggested the significant differences of OS among different marital status existed in total (P < 0.001), female (P = 0.011) and male (P = 0.001) DMBC patients, respectively. Multivariate analysis indicated marital status was an independent prognostic factor for OS of DMBC patients. Nomogram showed the contribution of marital status to predicting OS was small. Other independent prognostic factors included age, grade, histology type, surgery of primary site, chemotherapy, and metastasis pattern. By combining seven factors, we constructed a prognostic nomogram for DMBC patients. The C-index of this nomogram for OS prediction was 0.722 (95% CI 0.712–0.732). The calibration curves showed perfect consistency between observed and predictive survival.

Conclusions

Marital status was an independent prognostic factor for OS of DMBC patients, but its contribution to predicting OS was small. The prognostic nomogram will provide an individualized evaluation of OS and guidance for suitable treatments in DMBC patients.

Prognostic Value of a Nomogram Based on the Dynamic Albumin-to-Alkaline Phosphatase Ratio for Patients with Extensive-Stage Small-Cell Lung Cancer

Purpose

Small-cell lung cancer (SCLC) is known as the characteristics of high invasion, rapid progression, and poor prognosis. Therefore, identification of patients with high risk of progression and death is critical to improve the survival of patients with extensive-stage SCLC (ES-SCLC). This study was designed to determine the prognostic importance of the albumin-to-alkaline phosphatase ratio (AAPR) in the survival of patients with ES-SCLC and to develop a nomogram based on AAPR dynamics for ES-SCLC prognosis.

Patients and Methods

Characteristics were reviewed from 300 patients with ES-SCLC. Training and validation cohorts included 200 and 100 patients, respectively. We applied univariate and multivariate Cox models to assess the prognostic value of AAPR for ES-SCLC. The nomogram for progression-free survival (PFS) and overall survival (OS) of ES-SCLC patients was developed based on the multivariate survival analysis of the training cohort. External validation of the established nomogram was performed using the validation cohort.

Results

N3 stage, thoracic radiotherapy, and post-AAPR were the independent factors identified for PFS. T stage, thoracic radiotherapy, and high post-AAPR were the independent risk factors identified for death. The prognostic nomogram was established by integrating the independent significant factors for PFS and OS in the training cohort with the c-indices of 0.675 and 0.662, respectively, and validated in the validation cohort. The nomogram had superior prognosis prediction ability than did TNM stage. Decision curve analysis (DCA) also indicated clinical net benefits from the nomogram.

Conclusion

AAPR was valuable for prognosis prediction in patients with ES-SCLC and was recommended to be dynamically evaluated to guide patient treatment. Additionally, the nomogram covering post-AAPR accurately predicted individual survival probability.

Development and Validation of Prognostic Nomograms to Predict Overall and Cancer-Specific Survival for Patients with Adenocarcinoma of the Urinary Bladder: A Population-Based Study

BACKGROUNDS

Adenocarcinoma of the bladder (ACB) rarely occurs but is associated with poor outcome. We aim to establish reliable nomograms for estimating cancer-specific survival (CSS) and overall survival (OS) of ACB patients.

METHODS

ACB patients were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database (2004-2015). A total of 1,149 patients were randomly divided into training cohort (n = 692) and validation cohort (n = 457). Multivariate Cox proportional hazards regression models were employed to identify independent prognostic factors. Nomograms predicting OS and CSS were constructed utilizing screened factors. The performance of nomograms was internally and externally validated by calibration curves, the receiver operating characteristic (ROC) curves, concordance index (C-index), and decision curve analysis (DCA).

RESULTS

OS nomogram incorporated age, race, histologic grade, American Joint Committee of Cancer (AJCC) stage, metastasis, surgery, chemotherapy, and tumor size. The C-indices were 0.754 (95% CI: 0.732-0.775) for training set and 0.743 (95% CI: 0.712-0.767) for validation set. Meanwhile, the calibration plots for 3- and 5-year OS displayed fine concordance between actual and predicted outcomes. In addition, higher areas under the curve (AUCs) were seen in training cohort (3-year: 0.799 vs. 0.630; 5-year: 0.797 vs. 0.648) and validation cohort (3-year: 0.802 vs. 0.662; 5-year: 0.752 vs. 0.660). Finally, DCA curves of the nomograms exhibited larger net benefits than AJCC stage. CSS nomogram showed similar results.

CONCLUSION

Our study constructed and validated nomograms with improved discriminative abilities and clinical benefits to predict the survival outcomes of ACB patients. The models might assist clinicians in optimizing therapeutic management on individual levels.

Development and validation of a nomogram prognostic model for esophageal cancer patients with oligometastases

Platinum-based chemotherapy is recommended as the standard treatment for metastatic esophageal cancer (EC) patients; however, the outcome is poor. Oligometastasis is less aggressive and has limited growth potential. However, the prognostic factors for EC patients with oligometastases was largely unknown. Thus, we intend to determine the prognostic factors, and develop and validate nomograms for prediction of survival for EC patients with oligometastases. In this study, characteristics of 273 oligometastatic EC patients were analyzed using univariate and multivariate Cox models to determine the independent prognostic factors for progression-free survival (PFS) and overall survival (OS). The result showed that history of alcohol consumption, longer tumor, no local radiotherapy for EC, and no local treatment for metastases were independent factors for PFS. Sex, esophageal fistula, number of metastatic organs, and local radiotherapy for EC were independent prognostic factors for OS. On the basis of Cox models, the respective nomogram for prediction of PFS and OS was established with the corrected concordance index of 0.739 and 0.696 after internal cross-validation. In conclusion, local treatment for metastases and local radiotherapy for EC were demonstrated to be beneficial for oligometastatic EC patients, and the validated nomograms are valuable in prognosis prediction and could guide individualized management for these patients.

Safety, efficacy and prognostic impact of immune checkpoint inhibitors in older patients with genitourinary cancers

INTRODUCTION

Immunosenescence might impact immunotherapy (IT) in patients with advanced age. However, pivotal studies were not powered for this clinical question. Our aim is to explore toxicity (primary objective) and activity (secondary objective) of immune checkpoint inhibitors (ICIs) in patients with renal cell (RCC) and urothelial carcinoma (UC) older than 75 years compared to the younger population.

PATIENTS AND METHODS

Patients treated at our tertiary care Uro-oncology Department with atezolizumab, pembrolizumab, nivolumab or ipilimumab were retrospectively analyzed. Immune-related adverse events (irAEs) were determined and graded using the Common Terminology Criteria for Adverse Events (CTCAE v.4.0). Disease Control rate (DCR) was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST v1.1). IrAEs and DCR were compared between patients ≥75 vs. <75 years, chi-squared test. Impact of age and other key clinical parameters on irAEs and DCR were tested in a binary logistic regression employing a backward selection. Impact of irAEs on oncological prognosis was assessed in log-rank and Cox regression analyses.

RESULTS

We included 99 patients treated between 11/2015 and 01/2019. Frequency of irAEs (36.4% vs. 39.4%) and DCR (59.4% vs. 41.0%) was comparable between patients ≥75 vs. <75 years. Advanced age was not associated with irAEs or worse DCR. IrAEs occurrence correlated with better disease-specific survival in the univariate and multivariate analyses. IrAEs could be successfully treated with corticosteroids in 78.9% of cases.

CONCLUSIONS

ICIs seem to be both safe and efficacious in an aging population with metastatic RCC or UC. Occurrence of irAEs predicted better prognosis.

Predicting the occurrence of multidrug-resistant organism colonization or infection in ICU patients: development and validation of a novel multivariate prediction model

Background

Multidrug-resistant organisms (MDROs) have emerged as an important cause of poor prognoses of patients in the intensive care unit (ICU). This study aimed to establish an easy-to-use nomogram for predicting the occurrence of MDRO colonization or infection in ICU patients.

Methods

In this study, we developed a nomogram based on predictors in patients admitted to the ICU in the First Affiliated Hospital of Xiamen University from 2016 to 2018 using univariate and multivariate logistic regression analysis. We externally validated this nomogram in patients from another hospital over a similar period, and assessed its performance by calculating the area under the receiver operating characteristic (ROC) curve (AUC) and performing a decision curve analysis.

Results

331 patients in the primary cohort and 181 patients in the validation cohort were included in the statistical analysis. Independent factors derived from the primary cohort to predict MDRO colonization or infection were male sex, higher C-reactive protein (CRP) levels and higher Pitt bacteremia scores (Pitt scores), which were all assembled in the nomogram. The nomogram yielded good discrimination with an AUC of 0.77 (95% CI 0.70–0.84), and the range of threshold probabilities of decision curves was approximately 30–95%.

Conclusion

This easy-to-use nomogram is potentially useful for predicting the occurrence of MDRO colonization or infection in ICU patients.

Nomogram for predicting overall survival of patients with bladder cancer: A population-based study

OBJECTIVE

The aim of this study was to develop and validate a reliable nomogram to estimate overall survival in bladder cancer.

METHOD

Patients diagnosed with bladder cancer identified in the Surveillance, Epidemiology, and End Results database were randomly divided into training and validation cohorts. The powerful prognostic variables were examined using Cox regression analyses. A nomogram was developed on the prognostic factors.

RESULTS

The results suggested that age, sex, race, grade, histologic type, primary site, pathological stage, surgical treatment, and number of primary tumors, were the powerful prognostic factors. All these factors were integrated to construct the nomogram. The nomogram for predicting overall survival showed better discrimination power than the tumor-node-metastasis (TNM) stage system 8th edition.

CONCLUSION

The nomogram has the potential to provide an individualized prediction of overall survival in patients with bladder cancer.

Dynamic prediction of cancer-specific survival for primary hypopharyngeal squamous cell carcinoma

OBJECTIVES

This study investigated a large cohort of patients to construct a predictive nomogram and a web-based survival rate calculator for dynamically predicting the cancer-specific survival of patients with primary hypopharyngeal squamous cell carcinoma (HSCC).

METHODS

Patients (n = 2007) initially diagnosed with primary HSCC from 2004 to 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. All patients were randomly divided into the training and validation cohorts (1:1). The Lasso Cox regression model was applied to identify independent risk factors of cancer-specific survival for a predictive nomogram and a web-based calculator. The model was evaluated by concordance index, calibration, and decision curve analysis.

RESULTS

Cancer-specific survival rates decreased with time, while 3-year conditional survival increased. Cancer-specific deaths evolved from relatively high within the first 3 years to low thereafter. Age, race, T stage, N stage, M stage, surgery, radiotherapy, chemotherapy, and marital status were identified as independent risk factors. We constructed a predictive nomogram for survival and a web-based calculator ( https://linzhongyang.shinyapps.io/Hypopharyngeal/ ). Additionally, a prognostic risk stratification was developed according to nomogram total points.

CONCLUSIONS

Patients with primary HSCC were found at a high risk of cancer-specific death during the first 3 years, indicating that additional effective follow-up strategies should be implemented over the period. This is the first study to construct a predictive nomogram and a web-based calculator for all patients with HSCC.

Prognostic Predicting Role of Contrast-Enhanced Computed Tomography for Locally Advanced Pancreatic Adenocarcinoma

INTRODUCTION

Contrast-enhanced computed tomography (CECT) imaging is commonly used to assess pancreatic adenocarcinoma (PAC). However, the value of semiquantitative and quantitative assessments of CECT parameters used to predict survival in PAC remains unknown. This study aims to investigate the prognostic role of pretreatment CECT imaging in patients with locally advanced pancreatic adenocarcinoma (LAPAC).

MATERIALS AND METHODS

From June 2013 to May 2017, eighty-six newly diagnosed patients with pathologically and radiologically confirmed LAPAC were retrospectively recruited. All patients were evaluated by CECT and experienced gemcitabine-based chemotherapy. The relationship between overall survival (OS) and clinical factors including age, sex, serum carbohydrate antigen 19-9 value, and CECT findings (including tumour location, tumour volume, peripancreatic involvement, blood vessel involvement, tumour enhanced rate, and distance liver metastasis) was determined using Cox proportional hazard regression models, and a nomogram was constructed for the prediction of 1- and 1.5-year survival rates of patients with LAPAC.

RESULTS

On univariate analysis, patients who had a tumour enhanced rate (TER) less than 80.465% and those who had a TER ≥ 80.465% are with a 3.587-fold increase in OS (p < 0.001). After multivariate Cox regression, a nomogram was established based on a new model containing the predictive variables of high Ca19-9 level, higher clinical stages, larger tumour volume, the presence of peripancreatic involvement, and liver metastases. The model displayed good accuracy in predicting OS with a C-index of 0.614. The calibration plots also showed a good discrimination and calibration of the nomogram between the predicted and observed survival probabilities.

CONCLUSION

Our results showed that TER can be used to predict survival in LAPAC, and we developed a nomogram for determining the prognosis of patients with LAPAC. However, the purposed nomogram still requires external data verification in future applications.

Factors Influencing the Efficacy of Anti-PD-1 Therapy in Chinese Patients with Advanced Melanoma

Purpose

Anti-PD-1 antibody improves the survival of patients with advanced melanoma. However, the efficacy and safety of anti-programmed death protein 1 (PD-1) antibody have not been fully elucidated in Chinese melanoma patients, who show high frequency of mucosal and acral melanoma subtypes; besides, the factors influencing the efficacy of anti-PD-1 antibody have not been evaluated broadly.

Patients and Methods

Patients with advanced melanoma treated with regimens containing anti-PD-1 antibody from June 2016 to January 2019 were evaluated. Baseline characteristics and blood parameters were assessed, and outcome and adverse events were evaluated according to different regimens. The Cox proportional hazards regression model was used for univariate and multivariate analyses.

Results

A total of 51 patients with advanced melanoma were included in this study. The overall objective response rate (ORR) was 17.6%, the disease control rate was 58.5%, and the median time to progression was 5.2 months. The ORR of patients with PD-1 blockade-based combination therapy, without liver metastases and higher level of C-reactive protein (CRP) before PD-1 blockade, is higher than that of those not. Univariate analysis based on clinical features showed that ECOG scores, liver metastasis, elevated lactate dehydrogenase (LDH), and CRP levels were the factors affecting time to progression (TTP). Multivariate analysis showed that elevated CRP before PD-1 blockade was an independent predictive factor for ORR of PD-1 blockade therapy (P=0.009), while only Eastern Cooperative Oncology Group (ECOG) score was an independent predictor for TTP (P=0.032). The treatment was well tolerated in these cohort patients, and there was no treatment-related death.

Conclusion

Anti-PD-1 antibody-containing regimen was safe and effective in Chinese patients with advanced melanoma, and elevated CRP and ECOG score were independent factors predicting the efficacy of anti-PD-1 therapy.

Inflammatory Biomarkers as Predictors of Response to Immunotherapy in Urological Tumors

Immunotherapy represents the new era of cancer treatment because of its promising results in various cancer types. In urological tumors, the use of the immune-checkpoint inhibitors (ICIs) is increasingly spreading. Although not all patients and not all diseases respond equally well to immunotherapy, there is an increasing need to find predictive markers of response to ICIs. Patient- and tumor-related factors may be involved in primary and secondary resistance to immunotherapy: tumor-derived protein and cytokines, tumor mutational burden, and patient performance status and comorbidities can condition tumor response to ICIs. Recently, some of these factors have been evaluated as potential biomarkers of response, with conflicting results. To date, the expression of programmed death-ligand 1 (PD-L1) and the presence of deficient mismatch repair (dMMR) in tumor tissue are the only biomarkers capable of guiding the clinician's decision in urothelial cancer and prostate cancer, respectively. In this review, we performed a comprehensive search of the main publications on biomarkers that are predictive of response to ICIs in urological cancers. Our aim was to understand whether existing data have the potential to drive clinical decision-making in the near future.

Survival Benefit for Patients With Metastatic Urothelial Carcinoma Receiving Continuous Maintenance Chemotherapy

BACKGROUND/AIM

Urothelial carcinoma is a chemo-sensitive cancer. We investigated the contributory factors to survival benefit of metastatic urothelial carcinoma (MUC) patients receiving continuous maintenance chemotherapy.

PATIENTS AND METHODS

Inclusion criteria were: i) pathology-confirmed urothelial carcinoma, ii) metastatic lesions identified mainly on pre-therapy computed tomography (CT) scans, and iii) inpatient-administered chemotherapy of at least three cycles. Chemotherapy regimens included 5-fluorouracil, leucovorin, cisplatin, and gemcitabine.

RESULTS

A total of 139 cases were enrolled in this study. The overall objective response rate was 60% and the median survival time was 17 months. Eight-two (59%) patients had inflammation-related symptoms following the course of chemotherapy. Fifty-five (41%) patients survived more than two years. All patients exhibited various fibrosis formations. No patient experienced unfavorable metastatic conditions. Inflammation-related symptoms remained in 28 (51%) patients. We found that surgery, invasive procedures, and infection likely led to a rapid tumor progression.

CONCLUSION

Continuous maintenance chemotherapy targeting chemo-sensitive tumors, administered at metronomic intervals and focus on tumor microenvironment, can increase MUC survival benefits.

Multicentric analytical comparability study of programmed death-ligand 1 expression on tumor-infiltrating immune cells and tumor cells in urothelial bladder cancer using four clinically developed immunohistochemistry assays

Programmed death-ligand 1 (PD-L1) expression on tumor cells (TC) or tumor-infiltrating immune cells (IC) correlated in several studies with PD-L1/programmed death-1 (PD-1) checkpoint inhibitor efficacy. Since June 2018, a positive PD-L1 status is required for atezolizumab or pembrolizumab treatment of patients with advanced or metastasized urothelial bladder cancer, who are ineligible for cisplatin-containing therapy. We examined technical comparability and inter-reader agreement of four clinically developed PD-L1 assays in locally advanced disease. Archived, formalin-fixed, paraffin-embedded sections from 30 patients (73.3% cystectomies, 26.7% transurethral resections) were stained by PD-L1 immunohistochemistry using VENTANA SP142, VENTANA SP263, DAKO 22C3, and DAKO 28-8 at two sites per manufacturers’ protocols and scored blinded at five sites for PD-L1 expression on IC (% per tumor area) and TC (%). Small, non-significant inter-assay differences were observed for IC. For TC, SP142 showed significantly lower staining percentages. Pairwise comparisons revealed − 0.3 to 1.6% differences in adjusted means between assays for IC, and for TC, − 10.5 to − 7.8% (SP142 versus others) and − 1.9 to 2.7% (other comparisons). Inter-reader and inter-assay agreement was moderate to high for both IC and TC. Allocation to binary cutoffs (1%, 5%, 10%) showed substantial to high Kappa agreement scores (0.440–0.923) for IC and TC between assays for each reader. This first multicenter study, with five independent readers blinded with respect to the assay used, suggests that all four currently clinically relevant assays are analytically similar for evaluation of PD-L1-stained IC and three (SP263, 22C3, and 28-8) for PD-L1-stained TC. Inter-observer agreement for trained readers in scoring of both IC and TC positivity was generally high.

Impact of fluorodeoxyglucose uptake on positron emission tomography/computed tomography on chemosensitivity and survival in patients with metastatic urothelial carcinoma

OBJECTIVES

To evaluate the impact of fluorodeoxyglucose uptake on positron emission tomography/computed tomography on chemosensitivity and survival in patients with metastatic urothelial carcinoma.

METHODS

The present study assessed 51 metastatic urothelial carcinoma patients undergoing fluorodeoxyglucose positron emission tomography/computed tomography before first-line systemic chemotherapy. Fluorodeoxyglucose uptake in metastases was evaluated using the maximum standardized uptake value, which was measured for all eligible lesions, and the highest value among the maximum standardized uptake value measurements in each case was defined as the highest maximum standardized uptake value. The associations between the highest maximum standardized uptake value and objective response rate to chemotherapy, progression-free survival or cancer-specific survival were analyzed. For cancer-specific survival, the C-index was compared between multivariate models that incorporated predictors in the Bajorin model including the Karnofsky performance status and the presence of visceral metastasis, and the Apolo model additionally including hemoglobin and albumin levels, with/without the highest maximum standardized uptake value.

RESULTS

The median age was 69 years. The Karnofsky performance status was ≥80% for all patients. Visceral metastasis was observed in 12 patients (24%). The objective response rate, median progression-free survival and median cancer-specific survival were 61%, 9 and 26 months in the entire cohort, respectively. The higher highest maximum standardized uptake value was significantly associated with a lower objective response rate, shorter progression-free survival and shorter cancer-specific survival (P = 0.01, <0.001 and 0.004, respectively). On multivariate analyses, the highest maximum standardized uptake value was an independent predictor for all end-points. In the multivariate models for cancer-specific survival, the C-index improved from 0.559 to 0.601 and from 0.604 to 0.652 by adding the highest maximum standardized uptake value to the parameter set of the Bajorin model and Apolo model, respectively.

CONCLUSIONS

Higher fluorodeoxyglucose uptake in metastases was significantly and independently associated with poor chemosensitivity and worse survival outcomes. Fluorodeoxyglucose positron emission tomography/computed tomography might aid in patient counseling and treatment decisions for metastatic urothelial carcinoma patients.

The Impact of Cisplatin- or Non-Cisplatin-Containing Chemotherapy on Long-Term and Conditional Survival of Patients with Advanced Urinary Tract Cancer

BACKGROUND

The impact of cisplatin use on long-term survival of unselected patients with advanced urinary tract cancer (aUTC) has not been adequately investigated. We used a multinational database to study long-term survival and the impact of treatment type in unselected patients with aUTC.

MATERIALS AND METHODS

A total of 1,333 patients with aUTC (cT4bN0M0, cTanyN+M0, cTanyNanyM+), transitional-cell, squamous, or adenocarcinoma histology who received systemic chemotherapy and had available survival data were selected. Long-term survival was defined as alive at 3 years following initiation of first-line chemotherapy. Conditional overall survival (COS) analysis was employed to study change in prognosis given time survived from initiation of first-line chemotherapy.

RESULTS

Median follow-up was 31.7 months. The combination of cisplatin use and cisplatin eligibility accurately predicted long-term survival. Eligible patients treated with cisplatin conferred a 31.6% probability of 3-year survival (95% confidence interval [CI]: 25.1-38.3), and 2-year COS for patients surviving 3 years after initiation of cisplatin-based chemotherapy was 83% (95% CI: 59.7-93.5). The respective probabilities for patients who were ineligible for cisplatin or not treated with cisplatin despite eligibility were 14% (95% CI: 10.8-17.6) and 49.3% (95% CI: 28.2-67.4). Two-year COS remained significantly different between these two groups up to 3 years after chemotherapy initiation.

CONCLUSION

Cisplatin-based therapy was associated with the highest likelihood of long-term survival in patients with aUTC and should be used in patients who fulfill the established eligibility criteria. Novel therapies are necessary to increase long-term survival in cisplatin-ineligible patients.

IMPLICATIONS FOR PRACTICE

Long-term, disease-free survival is possible in one in four eligible-for-cisplatin patients with advanced urinary tract cancer (aUTC) treated with cisplatin-based combination chemotherapy. Therefore, deviations from eligibility criteria should be avoided. Consolidation surgery should be considered in responders. These data provide benchmarks for the study of novel therapies in aUTC.

Impact of contemporary patterns of chemotherapy utilization on survival in patients with advanced cancer of the urinary tract: a Retrospective International Study of Invasive/Advanced Cancer of the Urothelium (RISC)

Background

Cisplatin-based combination chemotherapy is the standard treatment of advanced urinary tract cancer (aUTC), but 50% of patients are ineligible for cisplatin according to recently published criteria. We used a multinational database to study patterns of chemotherapy utilization in patients with aUTC and determine their impact on survival.

Patients and methods

This was a retrospective study of patients with: UTC (bladder, renal pelvis, ureter or urethra); advanced disease (stages T4b and/or N+ and/or M+); urothelial, squamous or adenocarcinoma histology. Primary objective was overall survival (OS). Eligibility-for-cisplatin was defined by Eastern Cooperative Oncology Group performance status ≤ 1, creatinine clearance ≥ 60 ml/min, no hearing loss, no neuropathy and no heart failure. Cox regression multivariate analyses were used to establish independent associations of cisplatin versus noncisplatin-based chemotherapy on OS.

Results

1794 patients treated between 2000 and 2013 at 29 centers were analyzed. Median follow-up was 29.1 months. About 1333 patients (74%) received first-line chemotherapy: the use of first-line chemotherapy was associated with longer OS: [hazard ratio (HR): 1.91, 95% confidence interval (CI): 1.67-2.20]. Type of first-line chemotherapy received was: cisplatin-based 669 (50%), carboplatin-based 399 (30%) and other 265 (20%). Cisplatin use was an independent favorable prognostic factor (HR: 1.54, 95% CI: 1.35-1.77). This benefit was independent of baseline characteristics or comorbidities but was associated with eligibility-for-cisplatin: eligible patients treated with cisplatin lived longer than those who were not (HR: 1.74, 95% CI: 1.36-2.21), while such benefit was not observed among ineligible patients. About 26% of patients who did not receive cisplatin were eligible for this agent. Median OS of ineligible patients was poor irrespective of the chemotherapy used.

Conclusions

The importance of applying published criteria of eligibility-for-cisplatin was confirmed in a multinational, real-world setting in aUTC. The reasons for deviations from these criteria set targets to improve adherence. Effective therapies for cisplatin-ineligible patients are needed.

Primary Results from SAUL, a Multinational Single-arm Safety Study of Atezolizumab Therapy for Locally Advanced or Metastatic Urothelial or Nonurothelial Carcinoma of the Urinary Tract

BACKGROUND

Atezolizumab, a humanised monoclonal antibody targeting PD-L1, is approved for locally advanced/metastatic urothelial carcinoma. SAUL evaluated atezolizumab in a broader, pretreated population, including patients ineligible for the pivotal IMvigor211 phase 3 trial of atezolizumab.

OBJECTIVE

To determine the safety and efficacy of atezolizumab in an international real-world setting.

DESIGN, SETTING, AND PARTICIPANTS

Between November 2016 and March 2018 (median follow-up 12.7mo), 1004 patients with locally advanced or metastatic urothelial or nonurothelial urinary tract carcinoma who experienced progression during or after one to three prior therapies for inoperable, locally advanced, or metastatic disease were enrolled. Patients with renal impairment, treated central nervous system metastases, or stable controlled autoimmune disease were eligible; 10% had Eastern Cooperative Oncology Group performance status (ECOG PS) 2 and 98% were platinum pretreated (Clinicaltrials.gov: NCT02928406).

INTERVENTION

Atezolizumab 1200mg every 3wk until progression or unacceptable toxicity.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was safety. Secondary efficacy endpoints included overall survival (OS), progression-free survival (PFS), and overall response rate (ORR).

RESULTS AND LIMITATIONS

The median treatment duration was 2.8mo (range 0-19); 22% remained on treatment and 8% discontinued because of toxicity. Grade ≥3 adverse events occurred in 45% of patients. The most common grade ≥3 treatment-related adverse events were fatigue, asthenia, colitis, and hypertension (each in 1%). Median OS was 8.7mo (95% confidence interval [CI] 7.8-9.9). The 6-mo OS rate was 60% (95% CI 57-63%), median PFS was 2.2mo (95% CI 2.1-2.4), and the ORR was 13% (95% CI 11-16%; 3% complete responses). Among IMvigor211-like patients (excluding ECOG PS 2 and other IMvigor211 exclusion criteria), median OS was 10.0mo (95% CI 8.8-11.9) and 6-mo OS was 65% (95% CI 61-69%).

CONCLUSIONS

SAUL confirms the tolerability of atezolizumab in a real-world pretreated population with urinary tract carcinoma. Efficacy overall and in the IMvigor211-like subgroup is consistent with previous pivotal anti-PD-L1/PD-1 urothelial carcinoma trials. These results support the use of atezolizumab in urinary tract carcinoma, including patients with limited treatment options.

PATIENT SUMMARY

In this international study we investigated the efficacy and safety of atezolizumab treatment for advanced urinary tract cancer in a large population of pretreated patients, including those who would not normally be candidates for clinical trials. Patients tolerated the treatment well, even if they had autoimmune disease, were being treated with corticosteroids, or had disease that had spread to their brain. Life expectancy in this study for patients typical of everyday clinical practice was similar to that seen in trials that enrolled only selected fitter patients.

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.

Integrative analysis of differential genes and identification of a "2-gene score" associated with survival in esophageal squamous cell carcinoma

Background

Developments in high‐throughput genomic technologies have led to improved understanding of the molecular underpinnings of esophageal squamous cell carcinoma (ESCC). However, there is currently no model that combines the clinical features and gene expression signatures to predict outcomes.

Methods

We obtained data from the GSE53625 database of Chinese ESCC patients who had undergone surgical treatment. The R packages, Limma and WGCNA, were used to identify and construct a co‐expression network of differentially expressed genes, respectively. The Cox regression model was used, and a nomogram prediction model was constructed.

Results

A total of 3654 differentially expressed genes were identified. Bioinformatics enrichment analysis was conducted. Multivariate analysis of the clinical cohort revealed that age and adjuvant therapy were independent factors for survival, and these were entered into the clinical nomogram. After integrating the gene expression profiles, we identified a “2‐gene score” associated with overall survival. The combinational model is composed of clinical data and gene expression profiles. The C‐index of the combined nomogram for predicting survival was statistically higher than the clinical nomogram. The calibration curve revealed that the combined nomogram and actual observation showed better prediction accuracy than the clinical nomogram alone.

Conclusions

The integration of gene expression signatures and clinical variables produced a predictive model for ESCC that performed better than those based exclusively on clinical variables. This approach may provide a novel prediction model for ESCC patients after surgery.

Prognostic impact of lactic dehydrogenase to albumin ratio in hepatocellular carcinoma patients with Child-Pugh I who underwent curative resection: a prognostic nomogram study

Background

Radical resection is the treatment of choice for hepatocellular carcinoma (HCC). However, even with this treatment, HCC prognosis and the efficacy of current predictive models for such patients remain unsatisfactory. Here, we describe an accurate and easy-to-use prognostic index for patients with HCC who have undergone curative resection.

Methods

The study population comprised of 1,041 patients with HCC who underwent curative resection at Zhongshan Hospital. This population was reduced to 768 patients who were treated in 2012 analyzed as the training cohort and 273 patients treated in 2007 who were used as a validation cohort.

Results

The lactic dehydrogenase to albumin ratio (LAR) was identified as a significant prognostic index for both overall survival and recurrence-free survival in two independent cohorts. The optimal cutoff value for LAR was determined to be 5.5. The C-index of LAR was superior to other inflammatory scores and serum parameters. This biomarker was also shown to be a stable predictive index in the validation cohort. The new nomogram combining LAR with the Barcelona Clinic Liver Cancer staging system had an improved ability to discriminate overall survival and recurrence-free survival. Nomogram predictions were consistent with observations based on calibration and decisive curve analysis in both independent cohorts.

Conclusion

LAR is a novel, convenient, reliable, and accurate prognostic predictor in patients with HCC undergoing curative resection. Our results suggest the recommendation of LAR to be used in routine clinical practice.

Impact of the Number of Cycles of Platinum Based First Line Chemotherapy for Advanced Urothelial Carcinoma

PURPOSE

We evaluated the impact of the number of cycles of platinum based, first line chemotherapy (fewer than 6 cycles vs the conventional 6 cycles or more) on the survival of patients with metastatic urothelial carcinoma.

MATERIALS AND METHODS

We used the RISC (Retrospective International Study of Invasive/Advanced Cancer of the Urothelium) database. The association of the number of cycles of chemotherapy with overall survival was investigated by Cox multiple regression analysis after controlling for recognized prognostic factors. We excluded patients who received fewer than 3 or more than 9 platinum chemotherapy cycles to reduce confounding factors. The primary analysis was a comparison of overall survival for 3 to 5 vs 6 to 9 cycles using 6-month landmark analysis when 281 death events were observed.

RESULTS

Of the 1,020 patients in the RISC 472 received cisplatin or carboplatin, of whom 338 and 134, respectively, were evaluable. A total of 157 patients received 3 to 5 cycles (median 4) and 315 received 6 to 9 cycles (median 6). There was no significant difference in overall survival between 3 to 5 and 6 to 9 cycles (HR 1.02, 95% CI 0.78-1.33, p = 0.91). No significant interactions were observed for the type of platinum (p = 0.09) and completed planned chemotherapy (p = 0.56). The limitations of a hypothesis generating, retrospective analysis applied.

CONCLUSIONS

Four cycles of platinum based, first line chemotherapy appeared adequate and did not significantly compromise the survival of patients with advanced urothelial carcinoma. The omission of excessive cycles may avoid unnecessary cumulative toxicity and facilitate a better transition to second line therapy and investigational switch maintenance therapy strategies. These results require prospective validation but they may impact practice in select patients.

Nomogram to Assess the Survival Benefit of New Salvage Agents for Metastatic Urothelial Carcinoma in the Era of Immunotherapy

INTRODUCTION

Optimal end points in phase 2 trials evaluating salvage therapy for metastatic urothelial carcinoma are necessary to identify promising drugs, particularly immunotherapeutics, where response and progression-free survival may be unreliable. We developed a nomogram using data from phase 2 trials of historical agents to estimate the 12-month overall survival (OS) for patients to which observed survival of nonrandomized data sets receiving immunotherapies could be compared.

PATIENTS AND METHODS

Survival and data for major prognostic factors were obtained from phase 2 trials: hemoglobin, performance status, liver metastasis, treatment-free interval, and albumin. A nomogram was developed to estimate 12-month OS. Patients were randomly allotted to discovery:validation data sets in a 2:1 ratio. Calibration plots were constructed in the validation data set and data bootstrapped to assess performance. The nomogram was tested on external nonrandomized cohorts of patients receiving pemetrexed and atezolizumab.

RESULTS

Data were available from 340 patients receiving sunitinib, everolimus, docetaxel + vandetanib, docetaxel + placebo, pazopanib, paclitaxel, or docetaxel. Calibration and prognostic ability were acceptable (c index = 0.634; 95% confidence interval [CI], 0.596-0.652). Observed 12-month survival for patients receiving pemetrexed (n = 127, 23.5%; 95% CI, 16.2-31.7) was similar to nomogram-predicted survival (19%; 95% CI, 16.5-21.5; P > .05), while observed results with atezolizumab (n = 403, 39.0%; 95% CI, 34.1-43.9) exceeded predicted results (24.6%; 95% CI, 23.4-25.8; P < .001).

CONCLUSION

This nomogram may be a useful tool to interpret results of nonrandomized phase 2 trials of salvage therapy for metastatic urothelial carcinoma by assessing the OS contributions of drug intervention independent of prognostic variables.

Anti-Programmed Cell Death 1/Ligand 1 (PD-1/PD-L1) Antibodies for the Treatment of Urothelial Carcinoma: State of the Art and Future Development

Immunotherapy with programmed cell death 1/ligand 1 (PD-1/PD-L1) checkpoint inhibitors has expanded a previously limited pool of effective treatment options for patients with metastatic urothelial carcinoma, particularly those with recurring or refractory disease and those who are ineligible for cisplatin. This review reports key findings from completed and ongoing clinical trials that highlight the potential of PD-1/PD-L1 blockade in urothelial carcinoma. A literature search was performed of PubMed, Embase, ClinicalTrials.gov, and selected annual congress abstracts. Prospective studies, reviews, editorials, and descriptions of ongoing anti-PD-1/PD-L1 studies in bladder cancer were included. Anti-PD-1/PD-L1 monoclonal antibodies have shown efficacy and safety across patient subgroups with urothelial carcinoma, including those with poor prognostic factors. Efficacy was similar across different anti-PD-1/PD-L1 agents. Although these antibodies have demonstrated durable responses in a subset of patients with urothelial carcinoma, clinicians are currently unable to predict which patients may derive benefit from immune checkpoint blockade. Anti-PD-1/PD-L1 antibodies have shown favorable clinical activity and tolerability in patients with metastatic urothelial carcinoma refractory to platinum-based therapy or who are ineligible for cisplatin. The activity of PD-1/PD-L1 inhibitors is now also being studied as first-line monotherapy in cisplatin-eligible patients in combination with chemotherapy as maintenance therapy after first-line chemotherapy, and in earlier disease states, such as muscle-invasive and non-muscle-invasive bladder cancer. Better predictive tools to define target patient populations are needed, as are further investigations to define optimal combinations or sequencing of treatments.

New nomogram predicts the recurrence of hepatocellular carcinoma in patients with negative preoperative serum AFP subjected to curative resection

BACKGROUND

There is currently no established model for predicting the recurrence of hepatocellular carcinoma (HCC) in patients with negative alpha-fetoprotein (AFP) after curative resection. Therefore, the objective of this study was to establish a nomogram to identify the risk of recurrence in AFP-negative (<or = 20 ng/mL) patients with HCC.

METHODS

A retrospective study was conducted to establish the recurrence-free survival (RFS) nomogram in a training cohort of 326 AFP-negative HCC patients. The results were validated on a well-matched validation cohort in the literature.

RESULTS

Macrovascular tumour invasion (P = 0.018, HR = 1.642), macronodular cirrhosis (P < 0.001, HR = 2.128), tumor size (P = 0.004, HR = 1.691), and γ-glutamyl transferase (P = 0.039, HR = 1.496) were found to be independent risk factors for RFS in the training cohort, and all these factors were included in the nomogram. The C-index for RFS in the nomogram was 0.661, which was higher than that of the BCLC system (0.551), the CLIP score (0.537), and the prediction model of Ju (0.618). The high consistency between the nomogram prediction and actual observation was further demonstrated by the calibration curve. In the subsequent study, the better net benefit and higher threshold probability of the nomogram were determined by decision curve analysis, and these advantages were confirmed in the validation cohort.

CONCLUSIONS

The present RFS nomogram for AFP-negative HCC patients after curative resection provides an accurate and reliable prognostic model to facilitate recurrence surveillance. Once AFP-negative patients are predicted to have a high recurrence score, additional high-end imaging examinations, such as MRI or CT exams, should be considered, and the interval time of regular folow-up should be reduced.

Prognostic Effect of FGFR Mutations or Gene Fusions in Patients with Metastatic Urothelial Carcinoma Receiving First-line Platinum-based Chemotherapy: Results from a Large, Single-institution Cohort

FGFR gene alterations represent a target for treatment in clinical trials of urothelial carcinoma (UC). Little is known about their prognostic effect in patients with metastatic UC. We analyzed data for 112 patients treated with platinum-based first-line chemotherapy at our center between October 2011 and March 2017 and who were screened for the presence of FGFR mutations or gene fusions within multiple clinical trials with pan-FGFR inhibitors. Centralized targeted exome sequencing analyses were performed to detect multiple FGFR mutations and fusions. Cox regression analyses were performed, adjusting for recognized prognostic factors. Thirty-seven patients (33%) had upper tract UC (UTUC). A total of 22 patients (19.6%) had FGFR alterations and ten (8.9%) received salvage pan-FGFR inhibitor therapy. Thirty-two patients (45.4%) received salvage treatment with an immune checkpoint inhibitor. FGFR alterations were more frequently observed in UTUC versus bladder UC (p=0.017). On multivariable analyses, FGFR alterations were not significantly associated with OS (p=0.860) or PFS (p=0.147) after first-line chemotherapy. PATIENT SUMMARY: In an original single-center study, FGFR gene alterations were not prognostic for either progression-free survival or overall survival in patients receiving first-line chemotherapy for metastatic urothelial carcinoma. These results will be useful in interpreting findings from future clinical trials.

The New Age of -omics in Urothelial Cancer - Re-wording Its Diagnosis and Treatment

Unmet needs in urothelial cancer management represent an important challenge in our effort to improve long-term overall and disease-free survival rates with no significant compromise in quality of life. Radical cystectomy with pelvic lymph node dissection is the standard for the management of muscle-invasive, non-metastatic cancers. In spite of a 90% local disease control, up to 50% of patients ultimately die of distant metastasis. Bladder preservation using chemo-radiation is an acceptable alternative, but optimal patient selection remains elusive. Recent research is focused on the employment of tailored-made strategies in urothelial cancer exploiting the potential of theranostics in patient selection for specific therapies. Herein, we review the current knowledge on molecular theranostics in urothelial cancer and we suggest that this is the time to move toward imaging theranostics, if tailored-made disease management and patient stratification is envisaged.

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Urothelial cancer management represents an important challenge.

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Optimum patient stratification and tailored-made theranostics remain elusive.

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Imaging theranostics is envisaged as a cancer roadmap.

Body Mass Index, Diet-Related Factors, and Bladder Cancer Prognosis: A Systematic Review and Meta-Analysis

Background

Urologists are frequently confronted with questions of urinary bladder cancer (UBC) patients about what they can do to improve their prognosis. Unfortunately, it is largely unknown which lifestyle factors can influence prognosis.

Objective

To systematically review the available evidence on the association between body mass index (BMI), diet, dietary supplements, and physical activity and UBC prognosis.

Methods

We searched PubMed and Embase up to May 2017. We included thirty-one articles reporting on observational and randomized controlled trials investigating BMI, diet and dietary supplements in relation to recurrence, progression, cancer-specific or all-cause mortality in UBC patients.

Results

In non-muscle invasive bladder cancer (NMIBC) patients, both overweight (3 studies, pooled hazard ratio (HR) 1.29, 95% CI 1.05-1.58, I² = 0%) as well as obesity (3 studies, pooled HR 1.82, 95% CI 1.12-2.95, I² = 79%) were associated with increased risk of recurrence when compared to normal weight. No association of BMI with risk of progression was found. Results for BMI and prognosis in muscle-invasive or in all stages series were inconsistent. Observational studies on diet and randomized controlled trials with dietary supplements showed inconsistent results. No studies on physical activity and UBC prognosis have been published to date.

Conclusions

Evidence for an association of lifestyle factors with UBC prognosis is limited, with some evidence for an association of BMI with risk of recurrence in NMIBC. Well-designed, prospective studies are needed to develop evidence-based guidelines on this topic.