Epidemiology of Bladder Cancer: A Systematic Review and Contemporary Update of Risk Factors in 2018

Interaction between opium use and cigarette smoking on bladder cancer: An inverse probability weighting approach based on a multicenter case-control study in Iran

Introduction

Opium and cigarette smoking have been identified as significant cancer risk factors. Recently, the International Agency for Research on Cancer (IARC) classified opium as a Group 1 carcinogen in 2020.

Method

Using data from a multicenter case-control study in Iran called IROPICAN, involving 717 cases of bladder cancer and 3477 controls, we assessed the interactions on the causal additive scale between opium use and cigarette smoking and their attributing effects to evaluate public health relevance and test for different mechanistic interaction forms to provide new insights for developing of bladder cancer. A minimally sufficient set of confounders was identified using a causal directed acyclic graph, and the data were analysed employing multiple logistic regression and the inverse probability-of-treatment weighting estimator of the marginal structural linear odds model.

Results

Our findings indicated a significant increase in the risk of bladder cancer associated with concurrent opium use and cigarette smoking (adjusted OR = 6.34, 95 % CI 5.02-7.99; p < 0.001), demonstrating a super-additive interaction between these exposures (Weighted RERIOR = 2.02, 95 % CI 0.47-3.58; p = 0.005). The presence of a super-additive interaction suggests that interventions targeting opium users who smoke cigarettes would yield greater benefits compared to non-opium users. Furthermore, there was a mechanistic interaction between two exposures (P-value = 0.005) if we assumed two of the exposures have positive monotonic effects, i.e., there must be a sufficient-component cause for developing bladder cancer, which has both opium use and cigarette smoking as components.

Conclusion

There is a causal additive interaction between opium use and cigarette smoking. We observed a super-additive interaction, suggesting the need to focus interventions on specific subgroups. Furthermore, the presence of mechanistic interactions offers profound insights into the mechanisms of cancer induction.

The Association between Tea Consumption and Bladder Cancer Risk Based on the Bladder Cancer Epidemiology and Nutritional Determinants (BLEND) International Consortium

OBJECTIVES

Evidence regarding the association between tea consumption and bladder cancer (BC) risk is inconsistent. This study aimed to increase our knowledge of the association by using international data from the Bladder Cancer Epidemiology and Nutritional Determinants Consortium.

METHODS

Individual data on 2,347 cases and 6,871 controls from 15 case-control studies with information on black, green, herbal, or general tea was pooled. The association was estimated using multilevel multivariable logistic regression analysis adjusted for multiple (non-)dietary factors.

RESULTS

Association between tea consumption and BC risk was observed (odds ratio, OR = 0.72, 95% confidence interval, 95% CI = 0.65-0.80) compared to non-tea drinkers. Stratified analyses based on gender and smoking status yielded similar results. Stratified analysis showed no significant association between black or green tea consumption and BC risk across models, while herbal tea consumption was linked to a reduced BC risk (OR = 0.59, 95% CI = 0.36-0.96). As daily tea consumption increased within a suitable range (<5.67 cups/day), BC risk decreased.

CONCLUSIONS

Camellia sinensis tea showed no association with BC risk, while herbal tea was inversely linked to BC incidence. Despite some significant findings in the selected strata, further studies are required to clarify the underlying mechanisms.

Development and validation of interpretable machine learning models to predict distant metastasis and prognosis of muscle-invasive bladder cancer patients

Muscle-Invasive Bladder Cancer (MIBC) is a more aggressive disease than non-muscle-invasive bladder cancer (NMIBC), with greater chances of metastasis. We sought to develop machine learning (ML) models to predict metastasis and prognosis in MIBC patients. Clinical data of MIBC cases from 2000 to 2020 were sourced from the Surveillance, Epidemiology, and End Results (SEER) database. Clinical variables used to predict DM were identified through univariate and multivariate logistic regression, and Recursive Feature Elimination (RFE). Thirteen ML models predicting DM were evaluated based on AUC, PRAUC, accuracy, sensitivity, specificity, precision, cross-entropy, Brier score, balanced accuracy, and F-beta score. SHapley Additive exPlanations (SHAP) framework helped interpret the best model. Additionally, we utilized ML algorithm combinations to predict prognosis in MIBC patients with metastasis. A total of 43,951 T2-T4 MIBC patients aged over 18 years old from the SEER database were enrolled consecutively. Nine clinical variables were selected to predict DM. The CatBoost model was identified as the optimal predictor, with AUC values of 0.956 [0.933, 0.969] for the training set, 0.882 [0.857, 0.919] for the internal test set, and 0.839 [0.723, 0.936] for the external test set. The model achieved an accuracy of 0.875 [0.854, 0.896], sensitivity of 0.869 [0.851, 0.889], specificity of 0.883 [0.823, 0.912], and precision of 0.917 [0.885, 0.944]. SHAP analysis revealed that tumor size was the most influential factor in predicting distant metastasis. For prognosis, the "RSF + Enet[alpha = 0.8]" model emerged as the top performer, with C-index values of 0.683 in training, 0.688 in the internal test, and 0.666 in the external test sets. Our ML models provide high accuracy and dependability, delivering refined, individualized predictions for metastasis risk and prognosis in MIBC patients.

Lines of Therapy for Locally Advanced/Metastatic Urothelial Carcinoma: The New Paradigm

Urothelial carcinoma (UC) is the most common malignancy of the urinary tract, with urothelial bladder cancer accounting for approximately 90% of cases. Metastatic UC (mUC) is a particularly aggressive subset that presents significant treatment challenges, especially in patients who are often older than 70 years and have multiple comorbidities. For several decades, cisplatin-based chemotherapy has been the standard first-line treatment for locally advanced (LA) mUC. However, its utility has been limited as many patients are ineligible owing to their health status, and overall survival rates remain suboptimal. Recent advancements, including antibody-drug conjugates and immunotherapies, have begun to reshape the treatment landscape for LA/mUC. The combination of enfortumab vedotin and pembrolizumab has shown promising clinical outcomes. The approval of multiple novel drugs and combination therapies not only provides new opportunities for patient care but also creates the need for physicians to adapt to this evolving therapeutic paradigm. This review explores the latest clinical data on the management of LA/mUC and offers insights into sequencing therapies for patients with LA/mUC.

Home Urine Dipstick Screening for Bladder and Kidney Cancer in High-Risk Populations in England: A Microsimulation Study of Long-Term Impact and Cost-Effectiveness

BACKGROUND

Testing high-risk populations for non-visible haematuria may enable earlier detection of bladder cancer, potentially decreasing mortality. This research aimed to assess the cost-effectiveness of urine dipstick screening for bladder cancer in high-risk populations in England.

METHODS

 A microsimulation model developed in R software was calibrated to national incidence data by age, sex and stage, and validated against mortality data. Individual risk factors included age, sex, smoking status and factory employment. We evaluated three one-time screening scenarios: (1) current and former smokers of different ages within the 55-70 years range, (2) a mixed-age cohort of smokers aged 55-80 years and (3) individuals aged 65-79 years from high-risk regions. Probabilistic and scenario analyses evaluated uncertainty. The incremental cost-effectiveness ratio (ICER) was calculated and compared with the standard £20,000/quality-adjusted life year (QALY) threshold using payer's perspective and 2022 year of evaluation with 3.5% discounting for both costs and effects.

RESULTS

 Screening all current and former smokers (scenario 1) and both mixed-age cohorts (scenarios 2 and 3) was not cost-effective at the threshold of £20,000/QALY. Screening at age 58 years had a 33% probability of being cost-effective at £20,000/QALY threshold and a 64% probability at £30,000/QALY threshold. Screening current and former smoking men aged 58 and 60 years was cost-effective, with ICERs of £18,181 and £18,425 per QALY, respectively. Scenario results demonstrated the high impact of assumptions on lead time, diagnostic pathway, and screening efficacy on predictions.

CONCLUSIONS

 Screening smoking men aged 58 or 60 years for bladder cancer using urine dipstick tests may be cost-effective.

A machine learning-based prognostic signature utilizing MSC proteomics for predicting bladder cancer prognosis and treatment response

BACKGROUND

Mesenchymal stem cells (MSCs), due to their tumor-targeting homing properties, are present in the tumor microenvironment (TME) and influence the biological behaviors of tumors. The purpose of this paper is to establish a signature based on the MSC secretome to predict the prognosis and treatment of bladder cancer (BLCA).

METHODS

The presence of MSCs in BLCA was validated through flow cytometry and multiplex fluorescence immunohistochemistry (mFIHC), and the relationships between MSCs and clinical characteristics were explored. Unsupervised clustering analysis was performed on BLCA according to the differential proteins detected in MSC-conditioned medium (MSCCM) using a cytokine array. Using the TCGA-BLCA, GSE32548, and GSE32894 datasets as background data, a risk signature was constructed according to the differential proteins in MSCCM through machine learning. For the risk groups with high and low prognoses, we calculated Kaplan-Meier (K-M) curves. Additionally, we explored the relationships between the signature and the tumor immune landscape, response to immunotherapy, and chemotherapy drugs.

RESULTS

Both flow cytometry and mFIHC confirmed the presence of MSCs in bladder tumors, and clinical samples revealed correlations between MSCs and the pathological grade, T stage, and Ki67 in BLCA. Based on differential proteins and unsupervised clustering analysis, BLCA patients were divided into two groups, and significant differences were found between these groups in terms of TME, immune response, and clinical treatments. Using machine learning, a signature was constructed with the combination algorithm Stepcox (both) + plsRcox, revealing significant survival differences between the high- and low-risk MSC groups. Regression analyses, along with ROC curves, further demonstrated that risk score independently predict the prognosis of patients with high predictive performance. Moreover, there were notable differences between the high- and low-risk groups in terms of the TME scores, immune infiltration, and immune checkpoints. For BLCA immunotherapy, the low-risk group suggested better efficacy, while conventional chemotherapy drugs such as gemcitabine and cisplatin might be less effective in the low-risk group.

CONCLUSION

The signature based on MSC secreted protein profiles could effectively predict the prognosis of BLCA and provided valuable guidance for treatment and drug resistance.

Urology on a changing planet: links between climate change and urological disease

Urological diseases and their varied forms of management warrant special attention in the setting of climate change. Regarding urological cancers, climate change will probably increase the incidence and severity of cancer diagnoses through exposures to certain environmental risk factors, while simultaneously disrupting cancer care delivery and downstream outcomes. Regarding benign urological diseases, a burgeoning body of work exists on climate-related heat waves, dehydration, urolithiasis, renal injury and infectious and vector-borne diseases. Adding to the potential effect on disease pathogenesis, many patients with urological diseases undergo high-tech, resource-intensive interventions, such as robotic surgery, and entail intensive longitudinal assessments over many years. These features incur a considerable carbon footprint, generate substantial waste, and can introduce vulnerabilities to climate-related weather events. Links exist between planetary health (the health of humans and the natural systems that support our health), climate change and urological disease and urological care providers face many challenges in the era of anthropogenic climate change. The next steps and priorities for research, management, and health care delivery include identification and prioritization of health care delivery strategies to minimize waste and carbon emissions, while supporting climate resilience. Examples include supporting telemedicine, limiting low-value care, and building resilience to minimize impacts of climate-related disasters to prepare for the challenges ahead.

[Microhematuria: literature review and evidence-based guidelines]

Hematuria is one of the most common diagnoses in urology and is a common cause of referral to urologist from Primary Care consultations. Its importance derives from the potential risk of clinically significant pathology, including malignant pathology, urinary lithiasis or medical diseases. Although the study of gross hematuria is accepted by the various medical societies, the need to investigate microscopic hematuria is a topic of debate. The indiscriminate study of microscopic hematuria carries associated clinical and economic risks and benefits. It is necessary to update the recommendations of the main scientific societies that can help us in decision making in our patients with microhematuria.

Cancer incidence and cause-specific mortality in 2663 male submariners with service in the Royal Norwegian Navy between 1942 and 2005: a registry-based cohort study

OBJECTIVES

A previous cohort study of male Norwegian Navy submariners showed higher overall cancer incidence and lower all-cause mortality than the general Norwegian population. We have extended the follow-up and show more precise estimates through seven decades.

DESIGN

Historical cohort study using outcome data from Norwegian cancer incidence and cause-of-death registries.

SETTING

Linkage with the outcome registries was performed by means of unique national identification numbers given to all Norwegian citizens.

PARTICIPANTS

2663 military men who ever served aboard a Navy submarine between 1942 and 2005.

OUTCOME MEASURES

Standardised incidence ratios for cancer and mortality ratios were calculated from national period-specific, gender-specific and age-specific rates. Poisson regression was used to compare cancer incidence in groups with different length of submarine service (>2 years vs ≤2 years).

RESULTS

The overall cancer incidence was 15% higher than expected from the national rates, with colon, lung, skin (melanoma and non-melanoma) and urinary tract contributing 90% of the excess number of cases. Most of the excess was confined to those with shorter-time service, who also showed elevated risk of alcohol-related cancers. Excess non-melanoma skin cancer was most clearly seen among submariners with >2 years of service. Mortality from all causes combined was lower among submariners than in the general population, due to a markedly low mortality from non-neoplastic diseases and external causes.

CONCLUSIONS

Increased risk of non-melanoma skin cancer was found among submariners with long-term service, and skin exposure to carcinogens in petroleum products was hypothesised as an explanation. Less support for occupational risks was found for other cancers, although the lack of specific exposure data and limited statistical power reduced the possibility of identifying such associations. A 'healthy soldier effect' appeared in the mortality data, mainly restricted to low mortality from non-neoplastic diseases and external causes.

A histopathological snapshot of bladder cancer: a Johannesburg experience of 1480 histopathology reports

PURPOSE

To evaluate the histopathological characteristics of bladder cancer in patients presenting to Johannesburg hospitals over a 13-year period (2010-2023).

METHODS

Following ethical clearance, a retrospective observational, descriptive review of histopathological reports over 13 years was conducted in Johannesburg. Inclusion criteria was bladder biopsies, TURBT specimens, and radical cystectomy (RC) specimens positive for bladder cancer. Exclusion criteria was non-primary bladder cancers (prostate, cervical, colon) and urothelial carcinoma of upper tract origin (N = 970). Of the initial specimens (N = 2450), 1480 met the inclusion criteria, representing 858 patients, owing to multiple transurethral resections of bladder tumours (TURBT). Categorical variables were summarised as counts and percentages, while numerical variables were reported as means with standard deviations or medians with interquartile ranges, depending on data distribution and tested via the Shapiro‒Wilk test. Statistical comparisons were performed using Fisher's exact test (sex), one-way ANOVA, or the Kruskal‒Wallis test (age). Statistical significance was set at p < 0.05.

RESULTS

Urothelial carcinoma accounted for 88.8% of bladder cancer, squamous cell carcinoma (7.7%), adenocarcinoma (1.5%), and other malignancies (2%). High-grade urothelial carcinoma was predominant at 75%. Non-muscle invasive disease accounted for 72% of these cases, while 28% were muscle invasive. Data from radical cystectomies showed a high proportion of aggressive and advanced disease.

CONCLUSIONS

The study highlights the predominance of high-grade non-muscle invasive bladder cancer in Johannesburg, consistent with global trends. The findings suggest a shift in bladder cancer trends in Johannesburg away from assumed squamous cell carcinoma towards urothelial carcinoma.

Development of a Technique for Diagnosis and Screening of Superficial Bladder Cancer by Cell-Pellet DNA From Urine Sample

Bladder cancer (BCa) is the most common malignancy of the urinary system with high incidence and recurrence rates. There are several ways to detect BCa. However, different approaches have different accuracy, which essentially depends on the sensitivity and specificity of the technique. Alternative noninvasive diagnostic tools for BCa are needed. We isolated and compared urinary cell-pellet DNA (cpDNA), cell-free DNA, and exosomal DNA from patients with localized BCa. Consequently, we analyzed 12 tissues and cpDNA samples by next-generation sequencing and then used bioinformatic tools to analyze genomic and transcriptomic alterations in coding and noncoding sequences. Then, cpDNA and tissue DNA from 12 patients were analyzed using next-generation sequencing to verify that the genomic characteristics of cpDNA are concordant with those of tissue. We also detected somatic mutation patterns between tissues and their corresponding cpDNA samples. An overlapping variant analysis was performed based on somatic mutation data and a high similarity was observed. Moreover, we identified frequently mutated signaling pathways. In these results, several point mutations were analyzed in FGFR3, TTN, and LEPROTL1 from the cpDNA of patients with BCa. Tumor mutational burden analysis showed that cpDNA had no significant difference in tumor mutational burden compared with tumor tissue. These results provide that cpDNA is a potential diagnostic source for detecting and managing BCa using alternative noninvasive methods from patient urine. Our findings may serve as a clinical tool for early detection or recurrence screening of nonmuscle invasive BCa using urinary cpDNA.

Isoflavones: Promising Natural Agent for Cancer Prevention and Treatment

Isoflavones are currently being investigated by researchers in order to demonstrate their ability to prevent the proliferation of cancer cells. The current review aimed to demonstrate the potential of isoflavones to eliminate cancerous cells in the stomach, liver, lung, breast, and prostate, as their anticancer properties are due to the ability to block the signaling pathways of the extracellular signal-controlled kinase (MAPK/ERK) and proteasome (PI3K/AKT/mTOR). Isoflavones can inhibit the cell division of various cancer cells. Isoflavones can block the androgen receptor (AR), a protein that is required for the growth and dissemination of prostate cancer. It initiates the caspase cascade and obstructs the production of new proteins to eliminate lung cancer cells. These inhibit colon cancer cells by entering their G2/M cell cycle phase and inducing apoptosis. These are also known to inhibit the production of cyclin-dependent kinase 2 and cyclin B1, two proteins that are related to an enhanced risk of colon cancer. These suppress the breakdown of cyclin B1 and CDK2 to stop the development of cancer. Preclinical evidence consistently supports the efficacy of isoflavones in suppressing tumor growth; however, human clinical trials show variability due to differences in bioavailability, metabolism, and dosage. Despite their promise as alternative or adjunctive cancer therapies, limitations such as low solubility, interindividual metabolic variations, and inconsistent clinical outcomes necessitate further large-scale, controlled trials. Future research should focus on improving bioavailability and exploring synergistic effects with conventional therapies.

Inverted U-shape association between urine equol levels and cancer: a national population-based cross-sectional study

Equol, a naturally occurring phytoestrogen derived from the fermentation of soy and soy-based products by gut bacteria, is recognized for its diverse health benefits. While there is speculation about its association with cancer prevention, the scientific community has yet to reach a consensus due to the variability in research findings. Our study aims to shed light on this topic by examining the correlation between urine equol concentrations and the cancer risk among the American population. The National Health and Nutrition Examination Survey (NHANES) is a national survey of U.S. civilians in which cancer participants are enrolled in a database by a sample questionnaire. This study included 2797 Americans aged 40 years and older in the NHANES database (2005-2010). The relationship between urine equol concentration and cancer was analysed using weighted logistic regression models, stratified analysis, smoothed curve fitting and threshold effect analysis were also performed. Among the 2797 participants in our study, 390 individuals received a cancer diagnosis. Our findings indicate a positive correlation between urine equol levels and the risk of cancer. Notably, individuals in the highest quartile of equol excretion exhibited a significantly elevated risk of cancer, with a 25.4% increase compared to those in the lowest quartile (POR = 1.254, 95% CI: 1.252, 1.256), after fully adjusting for confounders. Similar results were observed in other adjusted models. A non-linear relationship in the shape of an inverted U-shape can be observed by smoothed curve fitting, and the inflection point is 25.5. Urinary equol concentrations below 25.5 ng/ml were positively associated with cancer risk, while equol concentrations above 25.5 ng/ml showed a slight negative trend in cancer risk. However, further prospective studies are needed to provide more robust evidence and confirmed in large clinical trials.

Analysis the diagnostic performance of H4C6/SOX1-OT gene methylation in bladder cancer based on urine sample

Bladder cancer (BCa) is the second most common urological malignancy, but the techniques used today to detect and monitor BCa are frequently invasive and/or have inadequate sensitivity and specificity. Therefore, it is imperative to create a noninvasive test that is both sensitive and accurate for diagnosing BCa. This research introduces and validates the diagnostic performance of H4C6/SOX1-OT gene methylation in the diagnosis of BCa based on urine samples by designing two parts of studies: the case-control study and the prospective validation study. In the case-control study, the methylation test of H4C6/SOX1-OT achieved a sensitivity/specificity/positive predictive value (PPV)/negative predictive value (NPV) of 87.9%(95%CI, 79.4%-93.3%)/90.4%(95%CI, 80.7%-95.7%)/92.6%(95%CI, 84.8%-96.7%)/ 84.6%(95%CI, 74.3%-91.5%) (kappa value 77.6%). The sensitivities for low grade, high grade, Ta-T1, and T2-T4 were 85% (17/20), 88.6% (70/79), 85.4% (41/48) and 92.6% (25/27). Statistical analysis showed the diagnostic sensitivity of test was not affected by sex, age, tumor grade or tumor stage (P > 0.05). In the prospective validation study, the H4C6/SOX1-OT methylation test yielded an overall sensitivity/specificity/PPV/NPV of 84.8%(95%CI, 67.3%-94.3%)/90.0%(95%CI, 75.4%-96.7%)/87.5% (95%CI, 70.1%-95.9%)/84.6% (95%CI, 73.0%-95.4%) (kappa value 75.0%), indicating 38.4% of spared cystoscopy. These findings highlight the potential of the H4C6/SOX1-OT methylation in urine DNA as a promising molecular diagnostic tool for detecting BCa, especially for early-stage tumors, which may reduce the need for cystoscopy.

The significant impact of opium use on various types of cancer: an updated - systematic review and meta-analysis

OBJECTIVE

The existing literature on the direct effects of opioid use on cancer is limited. The goal of our systematic review and meta-analysis is to consolidate the findings of previous studies and provide a pooled effect size regarding the association between opioid usage and cancer.

METHODS

The PRISMA guidelines were employed to construct a framework for conducting this systematic review and meta-analysis. A systematic search was conducted in international and national databases. A search of PubMed, Web of Science, Scopus, and national electronic databases was conducted up to May 2024. The random effects model was employed for the presentation of results with a 95% confidence interval. The statistical analysis was conducted using Stata 11.

RESULTS

Out of 1674 articles were retrieved 38 studies remained in the final analysis (six cohort study and 32 case-control studies). The pooled adjusted odds ratio of opium on esophageal cancer was 1.68 (95% CI: 1.36, 2.08), for bladder cancer was 5.00(95% CI: 3.76, 6.66), for head and neck cancer was 4.93 (95% CI: 2.41, 10.06) for pancreatic cancer was 2.4 (95% CI: 1.62, 2.56) for lung cancer was 2.89(95% CI: 2.14, 3.30) for laryngeal cancer was 6.76 (95% CI: 3.77, 11.80) for gastric cancer was 3.13 (95% CI: 1.92, 5.11) and for colorectal cancer was 2.51 (95% CI: 1.04, 6.07).All association were statistically significant.

CONCLUSION

The findings underscore the potential carcinogenic effects of opium on cancers. Public health organizations should work collaboratively to mitigate opioid exposure while promoting alternative pain management strategies to protect community health and reduce the burden of cancer.

Ailanthone inhibits bladder cancer tumor and cell proliferation, epithelial-mesenchymal transition, and activation of the Janus kinase/signal transducer and activator of transcription 3 signaling pathway

Objective

Ailanthone (AIL), a medicinal component with antitumor properties, was distilled from Ailanthus altissima. The aim of this work was to probe the cancer-fighting effect of AIL on bladder cancer (BC) cells and the molecular basis of this effect.

Material and Methods

We developed a subcutaneous BC mouse model and then administered AIL treatment. The effects of AIL on tumor tissue integrity and apoptosis were analyzed using hematoxylin and eosin (H&E) staining and terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) staining methods. Furthermore, we investigated the effect of AIL on the Janus kinase/signal transducer and activator of transcription 3 (JAK/STAT3) pathway and associated proteins through quantitative reverse transcription polymerase chain reaction and Western blot analysis. Various concentrations of AIL were applied to BC cells, and its effects on cell survival, motility, and apoptosis were detected through cell counting kit-8 assay, Transwell assay, and flow cytometry. In addition, we examined the influence of AIL on apoptosis-related proteins and epithelialmesenchymal transition (EMT)-related proteins in BC cells through Western blot analysis.

Results

AIL significantly suppressed the growth and migration of 5637 and T24 cells while promoting apoptosis (P < 0.05, P < 0.01, and P < 0.001). In addition, AIL increased the levels of cell death-associated proteins (P < 0.05, P < 0.01, and P < 0.001) and reversed EMT in BC cells. In vivo, AIL treatment reduced tumor growth and lowered the transcriptional levels of interleukin (IL)-6, IL-10, and IL-23, which are activation factors in the JAK/STAT3 signaling pathway. It also decreased the phosphorylation levels of JAK1, JAK2, and STAT3 in tumor tissues (P < 0.05 and P < 0.01).

Conclusion

AIL exhibits multiple anticancer effects, such as BC cell growth suppression, apoptosis enhancement, reversion of EMT reversion, tumor growth, and JAK/STAT3 pathway activation suppression.

Epigenetic modifications in bladder cancer: crosstalk between DNA methylation and miRNAs

Bladder cancer (BC) is a malignant tumor characterized by a high incidence of urinary system diseases. The complex pathogenesis of BC has long been a focal point in medical research. With the robust development of epigenetics, the crucial role of epigenetic modifications in the occurrence and progression of BC has been elucidated. These modifications not only affect gene expression but also impact critical biological behaviors of tumor cells, including proliferation, differentiation, apoptosis, invasion, and metastasis. Notably, DNA methylation, an important epigenetic regulatory mechanism, often manifests as global hypomethylation or hypermethylation of specific gene promoter regions in BC. Alterations in this methylation pattern can lead to increased genomic instability, which profoundly influences the expression of proto-oncogenes and tumor suppressor genes. MiRNAs, as noncoding small RNAs, participate in various biological processes of BC by regulating target genes. Consequently, this work aims to explore the interaction mechanisms between DNA methylation and miRNAs in the occurrence and development of BC. Research has demonstrated that DNA methylation not only directly influences the expression of miRNA genes but also indirectly affects the maturation and functionality of miRNAs by modulating the methylation status of miRNA promoter regions. Simultaneously, miRNAs can regulate DNA methylation levels by targeting key enzymes such as DNA methyltransferases (DNMTs), thereby establishing a complex feedback regulatory network. A deeper understanding of the crosstalk mechanisms between DNA methylation and miRNAs in BC will contribute to elucidating the complexity and dynamics of epigenetic modifications in this disease, and may provide new molecular targets and strategies for the early diagnosis, treatment, and prognostic evaluation of BC.

An Unusual Presentation of Bladder Carcinoma in a Visceral Hernia: A Case Report and Literature Review

INTRODUCTION

Bladder carcinoma (BC) is the most prevalent malignancy of the urinary system. These cancers are primarily seen in adults > 60 years old and mostly present with microscopic or frank hematuria or obstruction of the urinary system. However, these rare cancers can be found in hernias.

CASE PRESENTATION

This report discusses a rare, localized bladder urothelial carcinoma (UC) manifestation. The patient had presented with lower abdominal pain several times. However, no accurate diagnosis was made due to the unspecified pain features. After being referred to a radiologic evaluation with ultrasonography, a bladder hernia was detected entering the abdominal wall, and it contained an unusual mass. Further evaluations revealed the malignant feature of the tumor. The abdominal wall hernia was replaced, and a TURP procedure was performed. The resulting sample showed UC without the involvement of the muscle layer.

CONCLUSION

One of the most common malignancies of the urogenital and reproductive systems in male patients is BCs. They are most commonly seen in men older than 60 years old with a history of smoking. The prevalent manifestations of cancer are microscopic or macroscopic hematuria, urinary obstruction, and abdominal pain. A rare but previously reported bladder cancer location is within inguinal or abdominal hernias. The diagnosis of this cancer is not always straightforward, and delays can result in the spread of malignancy and the transition of the patient's clinical condition to a poorer prognosis.

CLINICAL KEY MESSAGE

The presentation of bladder cancer is not always accompanied by typical symptoms such as hematuria or urinary obstruction. Patients with persistent lower abdominal pain should be evaluated to rule out bladder malignancy. These tumors might be hidden within abdominal or inguinal hernias, and more radiologic accuracy is demanded for their diagnosis.

Prevalence and Clinical Outcomes of Human Epidermal Growth Factor Receptor 2 Expression in Patients With Advanced Urothelial Carcinoma

Background

The prognosis for urothelial carcinoma remains poor, with limited therapeutic options, emphasizing the need for further research into targeted therapies. The prognostic and predictive significance of human epidermal growth factor receptor 2 (HER2) expression in urothelial carcinoma remains unclear, with previous studies reporting conflicting results.

Methods

We conducted a retrospective analysis of advanced urothelial carcinoma cases diagnosed between January 2017 and December 2022. HER2 status was prospectively determined using the Leica CB11 antibody on available biopsy specimens. Patient data, tumor characteristics, and survival outcomes were retrieved from hospital records for analysis.

Results

Of the 84 patients initially identified with muscle-invasive disease, HER2 immunohistochemistry (IHC) was performed on 50 samples. Among these, 54% exhibited HER2 scores ≥ 1+, with 22% classified as HER2-positive (3+ score by IHC), 10% as equivocal (2+ score by IHC), and 22% as HER2-low (1+ score by IHC). The distribution of HER2 score ≥ 1+ tumors included 25.7% in the bladder, 20.0% in the renal pelvis, and none in the ureter. HER2-positive (3+ score by IHC) tumors were all histological grade 3. Among these patients, 13.4% presented with localized disease, 20% with locally advanced disease, and 50% with metastatic disease at the time of diagnosis. Notably, 42.8% of recurrent tumors originating from the renal pelvis and 62.5% of those from the bladder exhibited HER2 scores ≥ 1+. Among patients diagnosed with non-metastatic disease, 100% with renal pelvis tumors and 75% with bladder tumors experienced metastatic recurrence if they were HER2-positive (3+ score by IHC). The overall survival for HER2-negative patients was 31.0 months (95% confidence interval (CI): 15.29 - 66.70) compared to 13.0 months (95% CI: 7.32 - 18.68) in the HER2 score ≥ 1+ population (P = 0.0029).

Conclusions

In this cohort of Mexican patients with urothelial carcinoma, HER2 expression was observed in 54.4% of cases. HER2-positive (+3 by IHC) tumors were associated with higher histological grade and worse prognostic outcomes, including increased recurrence, progression, and mortality.

Clinical value of combining epirubicin with mindfulness intervention in patients with urinary system tumors and depression

BACKGROUND

Urinary system tumors often cause negative psychological symptoms, such as depression and dysphoria which significantly impact immune function and indirectly affect cancer prognosis. While epirubicin (EPI) is recommended by the European Association of Urology and can improve prognosis, its long-term use can cause toxic side effects, reduce treatment compliance, and increase psychological burden. Therefore, an appropriate intervention mode is necessary.

AIM

To explore the clinical value of EPI combined with mindfulness intervention in patients with urinary system tumors and depression.

METHODS

This was a retrospective study including 110 patients with urinary system tumors and depression admitted to Zhumadian Central Hospital between March 2021 and July 2023. Patients were divided into conventional (n = 55) and joint intervention (n = 55) groups. The conventional group received mitomycin and routine nursing, while the joint intervention group received EPI and mindfulness intervention. Both groups underwent three cycles of chemotherapy. Immune function (CD4+ cells, CD8+ cells, CD4+/CD8+ ratio), tumor marker levels [urinary bladder cancer antigen (UBC), bladder tumor antigen (BTA) and nuclear matrix protein 22 (NMP22)], quality of life questionnaire-core 30 (QLQ-C30), 17-item Hamilton depression scale (HAMD-17), and cancer-related fatigue [cancer fatigue scale (CFS)] were assessed. Adverse reactions and nursing satisfaction were recorded and evaluated.

RESULTS

Post-intervention, CD4+, CD8+, and CD4+/CD8+ levels increased in both groups, with the joint intervention group showing more significant improvement (P < 0.05). Tumor marker levels (NMP22, BTA, and UBC) were lower in the joint intervention group compared to the conventional group (P < 0.05). The joint intervention group also showed a greater reduction in HAMD-17 scores (9.38 ± 3.12 vs 15.45 ± 4.86, P < 0.05), higher QLQ-C30 scores, and lower CFS scores (both P < 0.05). Additionally, the joint intervention group had a lower incidence of adverse reactions and higher nursing satisfaction (P < 0.05).

CONCLUSION

EPI combined with mindfulness intervention significantly improved clinical outcomes in patients with urinary system tumors and depression and is worthy of clinical application.

Matrix Metalloproteinase-9 is associated with tumor microenvironment remodeling of bladder cancer

Tumor microenvironment (TME) takes an essential part in the bladder cancer progression, which is associated with intercellular cross-talk between stroma cells and cancer. We aimed use bioinformatics tools to analyze tumor microenvironment remodeling in bladder cancer. CIBERSORT and ESTIMATE are bioinformatics tools based on deconvolution for calculating proportions of tumor-infiltrating immune cells and stromal components in TME. We utilized these two algorithms to analyze the immune components of 433 bladder cancer cases from The Cancer Genome Atlas database, aiming to compensate for the current lack of large-sample single-cell information. Then we used Cox regression to analyze the prognostic value of differentially expressed genes, and the protein-protein interaction network was constructed. Matrix Metalloproteinase-9 (MMP9) was identified as a predictive biomarker related to immune microenvironment. Using Gene Set Enrichment Analysis, the genes from the group with high MMP9 expression gathered in items related to immune diseases, and genes in the group with low MMP9 expression were negatively associated with valine, leucine and isoleucine degradation and glycosylphosphatidylinositol anchor biosynthesis. MMP9 expression and presence of macrophages M0 were positively correlated, while naïve B cells, activated dendritic cells, monocytes and plasma cells were negatively correlated. The results were confirmed by brightfield and multiplex fluorescence immunohistochemistry using stained bladder cancer and normal tissue.

Gefitinib Reverses PD-L1-Mediated Immunosuppression Induced by Long-term Glutamine Blockade in Bladder Cancer

Glutamine is a major energy source for tumor cells, and blocking glutamine metabolism is being investigated as a promising strategy for cancer therapy. However, the antitumor effect of glutamine blockade in bladder cancer remains unclear, necessitating further investigation. In this study, we demonstrated that glutamine metabolism was involved in the malignant progression of bladder cancer. Treatment with the glutamine antagonist 6-diazo-5-oxo-L-norleucine (DON) inhibited the growth of bladder cancer cells in vitro in several ways. In addition, we observed inhibition of tumor growth in bladder cancer-bearing mice by using JHU083, a prodrug that was designed to prevent DON-induced toxicity. However, the antitumor immune effect of T cells changed from activation to inhibition as the administrated time extended. We found that both in vitro treatment with DON and in vivo prolonged administration of JHU083 led to the upregulation of PD-L1 in bladder cancer cells. Mechanistically, glutamine blockade upregulated PD-L1 expression in bladder cancer cells by accumulating reactive oxygen species, subsequently activating the EGFR/ERK/C-Jun signaling pathway. Combination treatment of JHU083 and gefitinib reversed the upregulation of PD-L1 in bladder cancer cells induced by prolonged glutamine blockade, resulting in the alleviation of T-cell immunosuppression and a significant improvement in therapeutic outcome. These preclinical findings show promise for glutamine metabolism targeting as a viable therapeutic strategy for bladder cancer, with the potential for further enhancement through combined treatment with gefitinib.

AI predicting recurrence in non-muscle-invasive bladder cancer: systematic review with study strengths and weaknesses

Background

Non-muscle-invasive Bladder Cancer (NMIBC) is notorious for its high recurrence rate of 70-80%, imposing a significant human burden and making it one of the costliest cancers to manage. Current prediction tools for NMIBC recurrence rely on scoring systems that often overestimate risk and lack accuracy. Machine learning (ML) and artificial intelligence (AI) are transforming oncological urology by leveraging molecular and clinical data to enhance predictive precision.

Methods

This comprehensive review critically examines ML-based frameworks for predicting NMIBC recurrence. A systematic literature search was conducted, focusing on the statistical robustness and algorithmic efficacy of studies. These were categorised by data modalities (e.g., radiomics, clinical, histopathological, genomic) and types of ML models, such as neural networks, deep learning, and random forests. Each study was analysed for strengths, weaknesses, performance metrics, and limitations, with emphasis on generalisability, interpretability, and cost-effectiveness.

Results

ML algorithms demonstrate significant potential, with neural networks achieving accuracies of 65-97.5%, particularly with multi-modal datasets, and support vector machines averaging around 75%. Models combining multiple data types consistently outperformed single-modality approaches. However, challenges include limited generalisability due to small datasets and the "black-box" nature of advanced models. Efforts to enhance explainability, such as SHapley Additive ExPlanations (SHAP), show promise but require refinement for clinical use.

Conclusion

This review illuminates the nuances, complexities and contexts that influence the real-world advancement and adoption of these AI-driven techniques in precision oncology. It equips researchers with a deeper understanding of the intricacies of the ML algorithms employed. Actionable insights are provided for refining algorithms, optimising multimodal data utilisation, and bridging the gap between predictive accuracy and clinical utility. This rigorous analysis serves as a roadmap to advance real-world AI applications in oncological care, highlighting the collaborative efforts and robust datasets necessary to translate these advancements into tangible benefits for patient management.

Are androgen receptor agonists a treatment option in bladder cancer?

Sex-related differences in bladder cancer incidence and progression infer a role for sex hormones and their cognate receptors in this disease. In part due to the oncogenic role of androgen receptor signaling in prostate cancer, the focus of most preclinical and clinical research to-date has been on the potential pro-tumorigenic action of androgens in urothelial cancers. However, clinical studies of androgen receptor antagonism have yielded minimal success. In this review, we explore the tumor suppressor role of androgen receptor in bladder cancer and discuss how it might be harnessed therapeutically.

Heterogeneous treatment effects of BCG vaccine on Alzheimer's disease risk

Background

This project has investigated the role of the Bacillus Calmette-Guérin (BCG) vaccine as a potential treatment against Alzheimer's disease (AD) and related dementias (ADRD).

Objective

To further establish that BCG treatment results in lower risk of ADRD through novel machine learning methods and to analyze the heterogeneity of treatment effects.

Methods

This retrospective cohort study was conducted from May 28, 1987 to May 6, 2021, in patients who were 50 years or older and were diagnosed with non-muscle-invasive bladder cancer (NMIBC). Follow-up duration was 15-years. Machine learning algorithms using survival analysis and the random forest algorithm were the primary methods of data analysis.

Results

The research has found that on average, NMIBC patients who received BCG treatment had a 6.9% (95% CI: 0.43%, 13.4%) lower risk of developing ADRD compared to those who did not. Heterogeneous treatment effects were also detected for those with a history of mental health disorders and also for those with a history of respiratory diseases. Those with mental health disorders were at a 14.7% (95% CI: 0.6%, 28.9%) reduced risk of ADRD if they received BCG treatment compared to no BCG treatment. Additionally, those taking BCG with respiratory diseases increased risk of ADRD by 13.6% (95% CI: 1.1%, 26.1%) compared to those with no BCG treatment.

Conclusions

BCG is associated with a lower risk of ADRD through novel analysis methods and has detected heterogeneity of treatment effects. This presents BCG as a potential low-cost method, with few side-effects, to prevent ADRD.

Risk of postoperative bleeding and thromboembolic events in anticoagulated patients undergoing transurethral resection of bladder tumors

Background

Transurethral resection of the bladder (TURB) harbors a high-risk for postoperative bleeding, especially in patients requiring anticoagulation. Recently, direct oral anticoagulants (DOACs) have become a popular alternative to vitamin K antagonists (VKAs), though their impact on TURB complications remains unclear.

Objectives

To assess the postoperative complications of TURB from patients taking DOACs and VKAs.

Design

Retrospective cohort study.

Materials and methods

We retrospectively identified anticoagulated patients undergoing a TURB at our institution between 2012 and 2022 and divided them into two groups: whether they received VKA or DOAC. Follow-up of each patient was performed for 3 months. Occurrence and time to event of postoperative bleeding and thromboembolic events were recorded. A multivariable regression analysis was performed to assess risk differences.

Results

A total of 167 patients (11.7%) fulfilled the inclusion criteria, of which 102 patients (61.1%) received a DOAC and 65 patients (38.9%) a VKA. Postoperative bleeding led to re-catheterization in 13 (12.8%) DOAC and 6 (9.2%) VKA patients (p = 0.49) and re-intervention in 7 (6.9%) DOAC and 4 (6.2%) VKA patients (p = 0.86). Blood transfusions were administered to 3 DOAC patients (2.9%), none in the VKA group. No thromboembolic events were reported.

Conclusion

TURB carries low morbidity in anticoagulated patients. Thromboembolic events and the need for blood transfusion are infrequent. No substantial difference between the postoperative bleeding risk of patients receiving DOAC or VKA was found. All bleeding complications occurred within 2 weeks, marking it a potentially safe point in time to restart the OAC thereafter.

Proteomic analysis of non-muscle invasive and muscle invasive bladder cancer highlights distinct subgroups with metabolic, matrisomal, and immune hallmarks and emphasizes importance of the stromal compartment

We present the proteomic profiling of 79 bladder cancers, including treatment-naïve non-muscle-invasive bladder cancer (NMIBC, n = 17), muscle-invasive bladder cancer (MIBC, n = 51), and neoadjuvant-treated MIBC (n = 11). Proteins were extracted from formalin-fixed, paraffin-embedded samples and analyzed using data-independent acquisition, yielding >8,000 quantified proteins. MIBC, compared to NMIBC, shows an extracellular matrix (ECM) and immune response signature as well as alteration of the metabolic proteome together with concomitant depletion of proteins involved in cell-cell adhesion and lipid metabolism. Neoadjuvant treatment did not consistently impact the proteome of the residual tumor mass. NMIBC presents two proteomic subgroups that correlate with histological grade and feature signatures of cell adhesion or lipid/DNA metabolism. Treatment-naïve MIBC presents three proteomic subgroups with resemblance to the basal-squamous, stroma-rich, or luminal subtypes and signatures of metabolism, immune functionality, or ECM. The metabolic subgroup presents an immune-depleted microenvironment, whereas the ECM and immune subgroups are enriched for markers of M2-like tumor-associated macrophages and dendritic cells. Markers for natural killer cells are exclusive for the ECM subgroup, and markers for cytotoxic T cells are a hallmark of the immune subgroup. Endogenous proteolysis is increased in MIBC alongside upregulation of matrix metalloproteases, including MMP-14. Genomic panel sequencing yielded the prototypical profile of prevalent FGRF3 alterations in NMIBC and TP53 alterations in MIBC. Tumor-stroma interactions of MIBC were investigated by proteomic analysis of patient-derived xenografts, highlighting specific tumor and stroma contributions to the matrisome and tumor-induced stromal proteome phenotypes. © 2024 The Author(s). The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Integrating gene therapy into the treatment paradigm for non-muscle invasive bladder cancer

INTRODUCTION

Approximately 75% of bladder cancer cases are non-muscle invasive at diagnosis. Drug development for non-muscle invasive bladder cancer (NMIBC) has historically lagged behind that of other malignancies. No treatment has demonstrated the ability to overcome drug resistance that ultimately leads to recurrence and progression. Gene therapy is emerging as a promising option for patients with NMIBC.

AREAS COVERED

This review summarizes the clinical application of gene therapy in NMIBC management and discusses recent clinical trials involving the adenoviral vector-based treatment nadofaragene firadenovec, and the oncolytic serotype 5 adenovirus, cretostimogene grenadenorepvec. Nadofaragene received approval by the Food and Drug Administration in December 2022, and cretostimogene has been granted Fast Track Designation and Breakthrough Therapy Designation. Ongoing trials are investigating strategies to augment efficacy and durability of these therapies.

EXPERT OPINION

Gene therapy may overcome resistance mechanisms of other NMIBC treatments, and data suggest a role for combination therapy with additive or synergistic agents. Significant differences in trial design limit comparability of agents across trials, highlighting the need for critical assessment of published findings. While initial investigations were in high-risk patients who recur despite frontline therapy with Bacillus Calmette-Guerin (BCG), there is growing interest in BCG-naïve and intermediate-risk populations.

Bladder Cancer in Lebanon: An Updated Epidemiological Comparison with Global Regions and a Comprehensive Review of Risk Factors

ObjectivesThis study aims to analyze urinary bladder cancer (UBC) incidence rates in Lebanon over a 12-year period (2005-2016) and compare them with rates in other countries. It also discusses UBC risk factors in Lebanon.IntroductionLebanon has one of the highest estimated age-standardized incidence rates (ASIRw) of UBC worldwide.MethodsData on UBC were obtained from the Lebanese national cancer registry for the years 2005-2016. The study calculated age-standardized incidence rates (ASIRw) and age-specific rates per 100 000 population. It also estimated the population attributable fractions of smoking, water pollution, and air pollution for UBC incidence in Lebanon in 2016. However, limited data precluded sensitivity analyses, potentially affecting the robustness of the estimates.ResultsDuring this period, UBC ranked as the third most common cancer in males (12.9% of all new cancer cases) and the eighth most common in females (2.8% of all new cancer cases), excluding non-melanoma skin cancer. The average ASIRw was 28.8 in men and 6.6 in women, placing Lebanon among the countries with the highest UBC incidence rates globally. UBC incidence rates increased with age. Estimates indicated that 46.4% of UBC cases in the Lebanese population were attributed to current smoking, 8.6% to water pollution with disinfection byproducts, and 6.0% to air pollution with PM2.5.ConclusionThis study underscores the urgent need to mitigate UBC risk in Lebanon through tobacco control and by reducing exposure to preventable environmental and occupational risk factors, including tobacco smoking, water pollution, and air pollution.

Risk of bladder cancer in patients with type 2 diabetes mellitus: a retrospective population-based cohort study in Lithuania

PURPOSE

The objective of our study was to evaluate bladder cancer risk among Lithuanian type 2 diabetes mellitus (T2DM) patients and the effect of antihyperglycemic therapy on bladder cancer risk.

METHODS

We analyzed bladder cancer risk in a cohort of patients who were diagnosed with T2DM between 2001 and 2012 in Lithuania. Bladder cancer risk in four groups of antihyperglycemic medication users (insulin-only, metformin-only, sulfonylurea-only, and pioglitazone ± any other drug) was also assessed. Standardized incidence ratios for bladder cancer were calculated.

RESULTS

A total of 76,818 patients (28,762 males and 48,056 females) with T2DM were included in the final cohort. In the whole cohort of diabetic patients, 277 bladder cancer cases were observed, compared to 232.75 expected cases, according to bladder cancer rates in the general population (Standardized Incidence Ratio 1.19; 95% Confidence Interval: 1.06-1.34). Higher risk of bladder cancer was found in both men and women; however, in women the risk increase was not statistically significant. We found higher risk of bladder cancer in patients of both sexes diagnosed with T2DM at the age of 50-79 years and also in all groups of different antihyperglycemic medication users.

CONCLUSION

T2DM was associated with increased risk of bladder cancer.

Prognostic feature based on androgen-responsive genes in bladder cancer and screening for potential targeted drugs

OBJECTIVES

Bladder cancer (BLCA) is a tumor that affects men more than women. The biological function and prognostic value of androgen-responsive genes (ARGs) in BLCA are currently unknown. To address this, we established an androgen signature to determine the prognosis of BLCA.

METHODS

Sequencing data for BLCA from the TCGA and GEO datasets were used for research. The tumor microenvironment (TME) was measured using Cibersort and ssGSEA. Prognosis-related genes were identified and a risk score model was constructed using univariate Cox regression, LASSO regression, and multivariate Cox regression. Drug sensitivity analysis was performed using Genomics of drug sensitivity in cancer (GDSC). Real-time quantitative PCR was performed to assess the expression of representative genes in clinical samples.

RESULTS

ARGs (especially the CDK6, FADS1, PGM3, SCD, PTK2B, and TPD52) might regulate the progression of BLCA. The different expression patterns of ARGs may lead to different immune cell infiltration. The risk model indicates that patients with higher risk scores have a poorer prognosis, more stromal infiltration, and an enrichment of biological functions. Single-cell RNA analysis, bulk RNA data, and PCR analysis support the reliability of this risk model, and a nomogram was also established for clinical use. Drug prediction analysis showed that high-risk patients had a better response to fludarabine, AZD8186, and carmustine.

CONCLUSION

ARGs played an important role in the progression, immune infiltration, and prognosis of BLCA. The ARGs model has high accuracy in predicting the prognosis of BLCA patients and provides more effective medication guidelines.

Comparisons of Intravesical Treatments with Mitomycin C, Gemcitabine, and Docetaxel for Recurrence and Progression of Non-Muscle Invasive Bladder Cancer: Updated Systematic Review and Meta-Analysis

Background: Non-muscle-invasive bladder cancer (NMIBC) comprises about 75% of all bladder cancers. Although NMIBC is treatable, it poses significant costs and burdens to patients due to high recurrence rates. We conducted an updated meta-analysis of studies that evaluated the efficacy of and outcomes after treatment with mitomycin C (MMC), gemcitabine (GEM), and docetaxel (DOCE) for NMIBC recurrence and progression. Methods: We searched the PubMed and Cochrane databases for observational cohort studies and randomized clinical trials (RCT) conducted between 2009 and 2022 that assessed the efficacy of GEM, DOCE, or MMC, alone or in combination, regarding NMIBC outcomes. A total of 49 studies that met the inclusion criteria were reviewed for their quality, sample size, outcomes, and potential for bias, and relevant data were extracted for the meta-analysis. Separate meta-analyses were performed to assess the risks of recurrence or progression when comparing GEM/DOCE or MMC vs. other treatments. Study heterogeneity was assessed by I2 statistics. Results: Among 31 studies comparing GEM or MMC to other treatments for NMIBC recurrence, there were statistically significant risk reductions of 24% for GEM (pooled relative risk (RR) of 0.76; 95% confidence interval (CI) 0.64-0.87) and 37% for MMC (pooled RR = 0.63; 95% CI 0.58-0.68). Recurrence-free survival (RFS) for GEM or MMC alone was 69.5% (95% CI 66.6-72.3%) and 67.2% (95% CI 66.2-68.2%), respectively. Studies assessing the combination of treatments had a pooled RFS of 44.6% (95% CI 40.4-48.7%). Fewer studies examined the risk of NMIBC progression, with large variability and inconclusive results across them. Conclusions: Our findings corroborate recent guidelines indicating that both GEM and MMC are effective treatments that reduce tumor recurrence and improve survival of NMIBC, although with large variability across the studies. Fewer studies evaluated DOCE treatment, with inconclusive results. Women and minorities were generally underrepresented, raising concerns about the generalizability of the findings and highlighting the importance of including a broader patient population in future RCTs.

Tumor immune microenvironment dynamics and outcomes of prognosis in non-muscle-invasive bladder cancer

Agents that target PD-1 and PD-L1 have been developed in the treatment of bladder cancer (BC). However, the diversity of immune cell infiltration in non-muscle-invasive BC (NMIBC) and the dynamics of the microenvironment as it progresses to muscle-invasive/metastatic disease remains unknown. To assess tumor immune activity, hierarchical clustering was applied to 159 BC samples based on cellular positivity for the defined immune cellular markers (CD3/CD4/CD8/FOXP3/CD20/PD-1/PD-L1/LAG3/TIGIT), divided into two clusters. There was a "hot cluster" (25%) consisting of patients with a high expression of these markers and a "cold cluster" (75%) comprising those without. The expression of CD39, CD44, CD68, CD163, IDO1, and Ki67 was significantly higher in tumors in the hot cluster. Immunologically, high-grade T1 tumors were significantly hotter, whereas tumors that had progressed to muscle invasion turned cold. However, a certain number of high-grade NMIBC patients were in the cold cluster, and these patients had a significantly higher risk of disease progression. Using an externally available TCGA dataset, RB1 and TP53 alterations were more frequently observed in TCGA hot cluster; rather FGFR3, KDM6A, and KMT2A alterations were common in TCGA cold/intermediate cluster. Analyses of recurrent tumors after BCG therapy revealed that tumor immune activity was widely maintained before and after treatment, and high FGFR3 expression was detected after recurrence in tumors initially classified into the cold cluster. Collectively, we revealed the dynamics of the tumor microenvironment in BC as a whole and identified candidate molecules as therapeutic targets for recurrent NMIBC, e.g., after BCG therapy.

Gastric Outlet Obstruction as a First Symptom of a Non-Muscle Invasive Bladder Cancer (NMIBC) Progression-A Case Report

BACKGROUND

Metastatic disease of a urinary bladder cancer localized in the upper abdomen is very rare. This case report describes the first patient with a urinary bladder cancer progression, initially presenting as a gastric outlet obstruction due to peritoneal carcinomatosis.

CASE

We present the case of a 78-years-old male patient who was admitted to Hospital St. Josef Braunau in Austria with persistent vomiting. In the medical history, the most prominent finding was a diagnosed high-risk NMIBC. At the time, patient was between 2. and 3. BCG maintenance instillation cycle, following two transurethral resections. Routine follow-up cystoscopy 1 month before admission to our department showed no evidence of disease recurrence. Due to the therapy resistant vomiting, gastroscopy was performed, revealing duodenal stenosis without mucosal changes. Subsequently performed abdominal CT-scan showed homogenous swelling of the mesenteric fat tissue around duodenum, spreading retroperitoneal to both kidneys. In the absence of the typical peritoneal carcinomatosis features, the finding was firstly described as an inflammation of mesenteric fat or panniculitis mesenterialis. Further deterioration of patient's condition and later occurred bilateral hydronephrosis raised a suspicion of peritoneal carcinomatosis. Consequently, conducted laparoscopic exploration confirmed the suspicion describing the tissue conglomerate typical for peritoneal carcinomatosis surrounding the duodenum. Pathohistological analysis of taken samples proved urothelial cancer cells, confirming the diagnosis of metastatic bladder cancer disease.

CONCLUSION

This case report presents a very unusual presentation of metastatic urinary bladder cancer that could help clinicians to consider this diagnosis when encountering similar clinical features.

Oncological and Survival Outcomes of Pelvic Lymph Node Dissection in Patients with Nonmuscle Invasive Bladder Cancer Undergoing Radical Cystectomy Using the National Cancer Database

OBJECTIVE

To evaluate the role of pelvic lymph node dissection (PLND) in patients diagnosed with high-risk nonmuscle-invasive bladder cancer (NMIBC) undergoing radical cystectomy (RC) using a national cohort of NMIBC patients.

METHODS

A cohort of patients diagnosed with NMIBC cancer with urothelial carcinoma from the National Cancer Database (NCDB) between 2004 and 2019 was utilized. The cohort consists of patients who have not received BCG and underwent upfront radical cystectomy or pelvic exenteration. Kaplan-Meier analysis was utilized to assess overall survival (OS) outcomes. Cox regression was also utilized to identify independent predictors of OS.

RESULTS

The cohort of 9399 patients was stratified by clinical T stage and then subdivided by pathological outcome. For patients with cTa, a majority received a lymph node dissection 97.74% (941/1019), amongst the entire cohort, a minority had node positive disease 3.3% (34/1019). For cTis, most patients received a lymph node dissection 94.08% (482/507), and a minority had node positive disease 5.1% (26/507). For cT1, most patients had a lymph node dissection 95.62% (6,060/6,337), and a 13.1% (832/6337) of patients had a positive lymph node. Amongst patients with cT1 disease who underwent PLND, KMA demonstrated better OS compared to patients who did not undergo PLND (P < .001).

CONCLUSION

The data suggests an OS benefit in patients with later stage (cT1) NMIBC. Thus, our findings support the existing clinical guidelines of pelvic lymph node dissection in patients with high-risk nonmuscle invasive bladder cancer.

Role of anoikis-related gene RAC3 in prognosis, immune microenvironment, and contribution to malignant behavior in vitro and in vivo of bladder urothelial carcinoma

Background

Anoikis disrupts the normal apoptotic process in cells, leading to abnormal proliferation and migration, thereby promoting tumor formation and development. However, the role of anoikis in bladder urothelial carcinoma (BLCA) still requires further exploration.

Methods

Anoikis-related genes (ARGs) were retrieved from the GeneCards and Harmonizome databases to distinguish various subtypes of BLCA and develop a predictive model for BLCA. The immune microenvironment and enrichment pathways between various subtypes were also analyzed using consensus clustering. Potential medications were screened by utilizing drug sensitivity analysis. In vitro and vivo, the character of the independent prognostic gene in BLCA was confirmed through cell studies and mouse xenograft models.

Results

One hundred thirty differentially expressed genes (DEGs) were identified, and nine of them were chosen to construct predictive models that can accurately forecast the prognosis of BLCA patients. K = 2 was correctly identified as the optimal clustering type for BLCA, showing prominent differences in survival rates between the two subgroups. The immune-related functional studies manifested that the two subtypes' immune cell expressions differed. It was verified that RAC3 is an independent prognostic gene for BLCA. RAC3 shows high expression levels in BLCA, as indicated by its consistent mRNA and protein levels across different gene expressions. The functional verification results of RAC3 in BLCA showed that silencing RAC3 can significantly inhibit BLCA cell proliferation, colony formation, and migration. RAC3 knockdown inhibited the growth and migration of BLCA in vivo. SB505124 exhibited a significant inhibitory effect on the proliferation of BLCA cells.

Conclusion

Based on the predictive model developed in this study, BLCA patients' prognoses can be accurately predicted. SB505124 could become an important drug in the treatment of BLCA patients. RAC3 is essential in prognosis, immune microenvironment, and malignant behavior of BLCA in vitro and in vivo. It will also offer the potential for personalized treatment for BLCA patients and generate new research avenues for clinical investigators.

Association of HLA-G Expression, Its Genetic Variants and Related Neuro-Immunomodulation with Characteristics of Bladder Carcinoma

BACKGROUND

Human leukocyte antigen G (HLA-G) is an immune checkpoint molecule with immunosuppressive and anti-inflammatory activities. It belongs to class I non-classical major histocompatibility complex molecules and has been upregulated in various cancer types. In bladder cancer (BC) tumors, the association of HLA-G with cancer progression has to be explained.

METHODS

A total of 89 BC patients and 74 control subjects were genotyped for the HLA-G 14 bp ins/del polymorphism. In urine cell samples, HLA-G mRNA expression was analyzed using real-time PCR. Soluble HLA-G (sHLA-G) serum levels were measured by ELISA. The associations between the HLA-G 14 bp ins/del polymorphism, HLA-G mRNA expression, and/or sHLA-G levels and selected variables including tumor grade, disease stage, body mass index, and heart rate variability (HRV) parameters were evaluated.

RESULTS

The protective HLA-G 14 bp ins/ins genotype under the recessive genetic model was associated with lower HLA-G mRNA expression in the BC group (p = 0.049). Significantly higher HLA-G mRNA expression was detected in patients with pT2 + pT3 as compared to those with pTa + pT1 stages (p = 0.0436). Furthermore, higher HLA-G mRNA expression was observed in high-grade muscle-infiltrating BC (MIBC) than in the low-grade non-MIBC group (p = 0.0365). Patients with a level of sHLA-G above 29 U/mL had shorter disease-free survival than patients with lower sHLA-G levels. Furthermore, the opposite HRV correlations with sHLA-G levels in BC patients as compared to controls probably reflect the different roles of HLA-G in health and cancer.

CONCLUSIONS

Our results suggest the impact of the HLA-G 14 bp ins/del variant, HLA-G expression, and autonomic nervous system imbalance on advanced stages of BC.

Metastasis development in non-muscle-invasive bladder cancer

Non-muscle-invasive bladder cancer (NMIBC) is the most common type of bladder cancer presentation and is characterized by a varying probability of recurrence and progression. Sporadically, patients with NMIBC might also develop tumour metastases without any pathological evidence of muscle-invasive disease within the bladder, a condition known as metastatic NMIBC. In the published literature, this phenomenon is limited to several case reports and small reviews, with few data regarding the possible aetiologies. Several possible factors can be potentially associated with metastatic NMIBC, including tumour understaging, the number of transurethral resection procedures received by the patient, the presence of circulating tumour cells, the modality used for diagnostic cystoscopy and possible gender-associated differences. In this Perspective, our aim was to integrate and report currently available data on this relatively rare entity and provide some potential aetiological explanations.

Non-coding RNAs in bladder cancer, a bridge between gut microbiota and host?

In recent years, the role of gut microbiota (GM) in bladder cancer has attracted significant attention. Research indicates that GM not only contributes to bladder carcinogenesis but also influences the efficacy of adjuvant therapies for bladder cancer. Despite this, interventions targeting GM have not been widely employed in the prevention and treatment of bladder cancer, mainly due to the incomplete understanding of the complex interactions between the host and gut flora. Simultaneously, aberrantly expressed non-coding RNAs (ncRNAs) have been frequently associated with bladder cancer, playing crucial roles in processes such as cell proliferation, invasion, and drug resistance. It is widely known that the regulation of GM-mediated host pathophysiological processes is partly regulated through epigenetic pathways. At the same time, ncRNAs are increasingly regarded as GM signaling molecules involved in GM-mediated epigenetic regulation. Accordingly, this review analyzes the ncRNAs that are closely related to the GM in the context of bladder cancer occurrence and treatment, and summarizes the role of their interaction with the GM in bladder cancer-related phenotypes. The aim is to delineate a regulatory network between GM and ncRNAs and provide a new perspective for the study and prevention of bladder cancer.

Bladder cancer: a retrospective audit at a single radiation oncology unit of an academic hospital in Johannesburg, South Africa

BACKGROUND

Bladder cancer (BCa) is one of the most common urological cancers and remains a leading cause of cancer-related mortality worldwide. Bladder cancer is associated with a range of risk factors, with smoking being one of the most significant contributors. In addition to smoking, exposure to certain chemicals, particularly aromatic amines found in industries such as dye, rubber, leather, and textiles, also increases the risk of bladder cancer. In low-and-middle countries with lower Human Development Index (HDI), data on the underlying causes, incident rate, modes of presentation, treatment, and prognosis of bladder cancer remains unclear and often appear to be inadequate. This study aimed to assess the prevalence, mode of presentation, treatment, and risk factors associated with bladder cancer in Johannesburg, South Africa. By examining these factors, the study seeks to identify possible patterns or predisposing factors that contribute to the development and progression of bladder cancer, which could generate insights that could help to reduce the significant morbidity and mortality associated with this cancer.

METHODS

This retrospective study analyzed secondary data from 115 patients who were treated in the radiation oncology unit of an academic hospital between January 2010 and December 2020. By reviewing the medical records of these patients, the study aimed to gather comprehensive information on the prevalence of bladder cancer, modes of presentation, treatment approaches, and associated risk factors. Bladder cancer in this study was assessed using a comprehensive analysis of patient data on demographics, risk factors, clinicopathological aspects, and the specific therapies received. A comparison of patients with squamous cell carcinoma (SCC) and transitional cell carcinoma (TCC) of the bladder was conducted as part of this study. This comparison aimed to explore differences in demographic profiles, risk factors, clinicopathological characteristics, and treatment outcomes between these two histological subtypes.

RESULTS

A total of 115 patients presenting with bladder cancer symptoms were referred to the academic hospital for evaluation and treatment. The incidence rate of bladder cancer was highest among patients with a mean age of 60.7 ± 14.9. Males constituted 60.9% of the cases, resulting in a male-to-female ratio of 1.6:1. The most common risk factors associated with bladder cancer complications included smoking, being male, black ethnicity and increasing age. Transitional cell carcinoma remained the most prevalent histological subtype at the academic hospital, compared to squamous cell carcinoma (SCC). Patients with transitional cell carcinoma (TCC) were more likely to be older (odds ratio (OR): 1.03, 95% Confidence Interval (CI): 1.01-1.06, p = 0.029), male (OR: 2.60, 95% CI:1.10-6.04, p = 0.030). The study also found that most of the TCC cases were among black patients, though white patients were four times more likely to present with TCC compared to SCC (OR:4.22, 95% CI: 1.43-12.48, p = 0.009).

CONCLUSION

Bladder cancer is still widespread in LMICs, with lower HDI, with elderly males being at risk. To aggressively prevent mortality and morbidity from bladder cancer, bladder cancer health awareness must be maintained to improving prevention, as well as early detection, management and comprehensive patient care and health services for bladder cancer patients. These findings highlight the importance of targeted screening and prevention strategies for high-risk groups, particularly older males with a history of smoking.

Oncological outcomes of organ-sparing cystectomy versus standard radical cystectomy in male patients diagnosed with bladder cancer

PURPOSE

To compare the oncological outcomes between standard radical cystectomy (SRC) and organ-sparing cystectomy (OSC) in male patients diagnosed with bladder cancer.

METHODS

Patients with stage Ta-T3 bladder cancer who underwent OSC or SRC were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015. The association between preoperative factors and the implementation of OSC was analyzed using logistic regression. Propensity score matching (PSM) was employed to balance baseline characteristics between the two groups. Patients' overall survival (OS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Subgroup analyses based on the T stage were also conducted.

RESULTS

A total of 7264 patients were included, with 96.8% (7033 patients) receiving SRC and 3.2% (231 patients) receiving OSC. Patients with higher T stages and high-grade tumors were less likely to undergo OSC. After PSM, OSC was associated with significantly worse OS and CSS than SRC. Subgroup analysis revealed that OSC did not lead to worse OS and CSS in non-muscle invasive bladder cancer and T2 stage patients, but it resulted in significantly worse outcomes in T3 stage patients.

CONCLUSION

Our study indicates that OSC is associated with poorer oncological outcomes compared to SRC, particularly in patients with advanced-stage tumors. These findings suggest the need for stringent selection criteria for OSC in bladder cancer patients. Given the negative impact on prognosis, stage T3 should potentially be considered a contraindication for OSC. Further evidence is required to confirm these assertions.

Incidence rates of bladder and kidney cancers among US military servicemen: comparison with the rates in the general US population

OBJECTIVE

The military population may differ from the general population in factors related to bladder and kidney cancers. However, incidence rates of these cancers have not been systematically compared between the two populations. This study compared incidence rates of bladder and kidney cancers between active-duty servicemen and men in the general US population.

METHODS

Data were obtained from the Department of Defense's Automated Central Tumor Registry (ACTUR) and the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) database. Included were 18-59-year-old active-duty servicemen in ACTUR and men in SEER who were diagnosed with malignant bladder and kidney cancers from 1990 to 2013. Age-adjusted rates, incidence rate ratios (IRR) and their 95% confidence intervals (95% CI) were compared between the two populations by age, race, and cancer stage.

RESULTS

Incidence rates were lower in ACTUR than SEER for bladder cancer overall (IRR = 0.55, 95% CI, 0.48-0.62) and by age (except ages 50-59), race, and tumor stage. For ages 50-59, rates did not differ between the populations. Kidney cancer incidence rates were lower in the military for younger groups and Black men, but higher for ages 50-59.

CONCLUSION

Lower bladder and kidney cancer incidence in ACTUR, notably in younger men, may be primarily associated with better health and healthcare access. The lack of differences in bladder or kidney cancer incidence among 50-59-year-old men between the populations might result from multifactorial effects, such as the possible effects of cumulative military-related exposures offset by healthier status and better medical care.

Enhancing PDT efficacy in NMIBC: Efflux inhibitor mediated improvement of PpIX levels and efficacy of the combination of PpIX-PDT and SO-cleavable prodrugs

Protoporphyrin IX (PpIX)-based photodynamic therapy (PDT) has shown limited efficacy in nonmuscle-invasive bladder cancer (NMIBC). To improve PDT efficacy, we developed singlet oxygen-cleavable prodrugs. These prodrugs, when combined with PpIX-PDT, induce cancer cell death through both PDT and drug release mechanisms. Inhibition of PpIX efflux was reported to be an effective strategy to improve PpIX-PDT in certain cancer cells. Our main goal was to investigate whether adding an efflux inhibitor to the combination of PpIX and prodrugs can improve the PpIX levels in bladder cancer cells and the release of active drugs, thus improving the overall efficacy of the treatment. We treated bladder cancer cell lines with lapatinib and evaluated intracellular PpIX fluorescence, finding significantly increased accumulation. Combining lapatinib with prodrugs led to significantly reduced cell viability compared to prodrugs or PpIX-PDT alone. The effect of lapatinib depended on the expression level of the efflux pump in bladder cancer cells. Interestingly, lapatinib increased paclitaxel (PTX) prodrug uptake by threefold compared to prodrug alone. Adding an efflux inhibitor (e.g., lapatinib) into bladder instillation solutions could be a straightforward and effective strategy for NMIBC treatment, particularly in tumors expressing efflux pumps, with the potential for clinical translation.

Comparison of the overall survival of different treatment methods in patients with Muscle-invasive bladder cancer: A retrospective study

OBJECTIVES

Bladder-Sparing Approach was presented in patients who are not willing or not suitable for Radical Cystectomy (RC). There have been inconsistencies in the literature regarding the comparison of survival rates of these two methods. Our objective is to evaluate the survival rate of patients with muscle-invasive bladder cancer (MIBC) undergoing different treatment methods.

DESIGN

Retrospective cross-sectional study.

SETTING

A secondary care, multicenter study in Kerman, Iran 2008 to 2016.

PARTICIPANTS

All 200 patients who were diagnosed with Muscle Invasive Bladder Cancer and were admitted to our hospitals. Patients with inaccessible medical files and patients with pathologies other than TCC were excluded.

MAIN OUTCOME MEASURES

Radical cystectomy and different methods of bladder preservation were compared based on their survival rate.

INTERVENTIONS

Radical cystectomy or bladder preservation.

RESULTS

Overall survival of the patients was 2 years [95% CI: 1.37-2.63]. The overall 5-year survival rate of patients with MIBC was 32%. Having a 6.4 years overall survival, the RC group showed the highest survival compared with others (p = 0.01); the overall survival of patients undergoing TMT, TURT, chemotherapy, or radiotherapy monotherapy was 3.15 years [95% CI: 2.242-4.061], 4.06 [95% CI: 3.207-4.931], 2.58 [95% CI: 1.767-3.399], and 3.14 [95% CI: 1.614-4.672] years, respectively. Patients younger than 65 undergoing RC had an overall survival of 7 years, compared with 2 years for the TMT group. (p = 0.0001).

CONCLUSIONS

The Bladder-Preservation method, as a replacement for RC, showed a lower overall survival rate in our study. A prospective randomized clinical trial may declare the best treatment.

A novel smartphone application for bladder cancer management (BCM App): Design, development, and usability evaluation

BACKGROUND

Providing clinical guidelines to clinicians using innovative technologies seems practical and useful. This study aimed to design, develop, and evaluate a smartphone application to assist urologists in managing bladder cancer (BCM App).

MATERIALS AND METHODS

The study was conducted in three phases, following the user-centered design model, at the urology clinic of Khorshid Hospital (Isfahan, Iran) in 2021. Components and functionalities for BCM App were specified in three focus group sessions with urologists and urology residents using clinical guidelines. Adopting the Delphi technique, the participants completed a questionnaire addressing issues including educating and informing clinicians, performing clinical calculations, representing graphical information, and recording patient information. A conceptual model for the app was designed, and the final product was developed. The usability of the BCM App was evaluated using the think-aloud technique by usability experts and end-users.

RESULTS

The app's components were categorized into three groups: Patient evaluation, disease staging and management, and patient follow-up. The app's main components included "bladder cancer classification," "disease grading and staging," "management based on the disease stages," "principles of intravesical treatment," and "classifying follow-ups by disease stages." Moreover, the most prominent app's functionalities were "using staging and grading table," "using American Urological Association risk stratification," "calculating disease stages," "calculating patient's follow-up," and "recording patient information." The usability evaluation results revealed that the BCM App was at a "highly acceptable" level.

CONCLUSION

To design and develop a smartphone app for managing bladder cancer, the involvement of urologists is crucial. Apart from assisting urologists in effectively managing bladder cancer, the proposed app has the potential to enhance residents' knowledge and streamline their access to evidence.

Differential Urinary Microbiome and Its Metabolic Footprint in Bladder Cancer Patients Following BCG Treatment

Recent studies have identified a urinary microbiome, dispelling the myth of urine sterility. Intravesical bacillus Calmette-Guérin (BCG) therapy is the preferred treatment for intermediate to high-risk non-muscle-invasive bladder cancer (BCa), although resistance occurs in 30-50% of cases. Progression to muscle-invasive cancer necessitates radical cystectomy. Our research uses 16S rRNA gene sequencing to investigate how the urinary microbiome influences BCa and its response to BCG therapy. Urine samples were collected via urethral catheterization from patients with benign conditions and non-muscle-invasive BCa, all of whom underwent BCG therapy. We utilized 16S rRNA gene sequencing to analyze the bacterial profiles and metabolic pathways in these samples. These pathways were validated using a real metabolite dataset, and we developed predictive models for malignancy and BCG response. In this study, 87 patients participated, including 29 with benign diseases and 58 with BCa. We noted distinct bacterial compositions between benign and malignant samples, indicating the potential role of the toluene degradation pathway in mitigating BCa development. Responders to BCG had differing microbial compositions and higher quinolone synthesis than non-responders, with two Bifidobacterium species being prevalent among responders, associated with prolonged recurrence-free survival. Additionally, we developed highly accurate predictive models for malignancy and BCG response. Our study delved into the mechanisms behind malignancy and BCG responses by focusing on the urinary microbiome and metabolic pathways. We pinpointed specific beneficial microbes and developed clinical models to predict malignancy and BCG therapy outcomes. These models can track recurrence and facilitate early predictions of treatment responses.

Reclassification of Urinary Cytology according to the Paris System for Reporting Urinary Cytology Correlation with Histological Diagnosis

INTRODUCTION

The Paris System for Reporting Urinary Cytology (TPS) was designed to provide precise diagnostic criteria when evaluating urine cytology and standardize the terminology used in reporting. In our study, we have aimed to determine the effect of TPS on the diagnostic performance of urine cytology, its impact on establishing appropriate risk stratification, and its effectiveness in the diagnosis and follow-up of the patients.

METHODS

We reevaluated 200 liquid-based urine cytologies with available histological diagnoses reported between 2015 and 2021 according to TPS criteria and compared them with the original cytological diagnoses. Area under the curve, sensitivity, specificity, and diagnostic accuracy of both methods were calculated and statistically analyzed to determine the diagnostic performance of the original reporting and TPS.

RESULTS

The sensitivity, specificity, positive predictive, negative predictive, and diagnostic accuracy rates of TPS were 60%, 99.3%, 97.2%, 97.2%, 85.7%, and 87.2%, respectively. In TPS, the risk of malignancy for negative for high-grade urothelial carcinoma, atypical urothelial cells, suspicious for high-grade urothelial carcinoma, and high-grade urothelial carcinoma (HGUC) is 3.5%, 20.9%, 60.8%, 97.2%, respectively. In the original reporting, the corresponding risks were 13.4%, 15%, 52%, 100%, respectively. A statistically significant difference was observed between diagnostic criteria of original cytology and TPS (p = 0.001). When the original reporting was compared with the TPS, the discriminative power of TPS in the diagnosis of HGUC was significantly higher (p < 0.001).

CONCLUSIONS

The use of TPS provided a more accurate risk stratification of patients. The diagnostic performance of urine cytology was improved, especially for HGUC.

Incidence trends, histological subtypes, and topographical distribution of bladder cancer in Iran: a study based on the Iranian National Cancer Registry during 2006-2015

Background

Bladder cancer (BCa) is a significant public health concern. This study aimed to analyze the incidence trends, histological subtypes, and topographical distribution of BCa in Iran over a decade.

Methods

This retrospective registry-based study analyzed data on BCa patients diagnosed between March 20, 2006, and March 20, 2015. Following data quality control, age-standardized incidence rates (ASIRs) were calculated for BCa overall, by sex and histological subtype using the new World Health Organization (WHO) standard population.

Results

We identified 51,379 BCa cases (81.97% male) with a mean age of 65.10 ± 14.89 years. The overall ASIR was 8.92 per 100,000 (95% CI: 8.84-9.00). While a modest increase in ASIR was observed overall (8.77 in 2006 to 9.64 in 2015) and among males (14.13 in 2006 to 15.95 in 2015) during the study period, males consistently had a significantly higher ASIR compared to females (approximately 4.5:1 ratio). BCa incidence showed a progressive increase across older age groups, particularly those aged 40-44 to 80-84 years. Urothelial cell carcinoma (UCC) was the most prevalent histological type (ASIR: 8.19 to 7.93), followed by adenocarcinoma (AC; ASIR: 0.13 to 0.11). Squamous cell carcinoma (SCC) displayed a decreasing trend (ASIR: 0.11 to 0.06). Both UCC and AC were more frequent in males (approximately 5 and 3 times higher than females, respectively). Malignant neoplasm of the bladder, unspecified, constituted over 95% of BCa topography classifications.

Conclusion

This study identified a modest rise in BCa incidence, with male predominance and a higher burden in older adults. Further investigation into potential risk factors contributing to this increase is warranted.

An efficient improved parrot optimizer for bladder cancer classification

Bladder Cancer (BC) is a common disease that comes with a high risk of morbidity, death, and expense. Primary risk factors for BC include exposure to carcinogens in the workplace or the environment, particularly tobacco. There are several difficulties, such as the requirement for a qualified expert in BC classification. The Parrot Optimizer (PO), is an optimization method inspired by key behaviors observed in trained Pyrrhura Molinae parrots, but the PO algorithm becomes stuck in sub-regions, has less accuracy, and a high error rate. So, an Improved variant of the PO (IPO) algorithm was developed using a combination of two strategies: (1) Mirror Reflection Learning (MRL) and (2) Bernoulli Maps (BMs). Both strategies improve optimization performance by avoiding local optimums and striking a compromise between convergence speed and solution diversity. The performance of the proposed IPO is evaluated against eight other competitor algorithms in terms of statistical convergence and other metrics according to Friedman's test and Bonferroni-Dunn test on the IEEE Congress on Evolutionary Computation conducted in 2022 (CEC 2022) test suite functions and nine BC datasets from official repositories. The IPO algorithm ranked number one in best fitness and is more optimal than the other eight MH algorithms for CEC 2022 functions. The proposed IPO algorithm was integrated with the Support Vector Machine (SVM) classifier termed (IPO-SVM) approach for bladder cancer classification purposes. Nine BC datasets were then used to confirm the effectiveness of the proposed IPO algorithm. The experiments show that the IPO-SVM approach outperforms eight recently proposed MH algorithms. Using the nine BC datasets, IPO-SVM achieved an Accuracy (ACC) of 84.11%, Sensitivity (SE) of 98.10%, Precision (PPV) of 95.59%, Specificity (SP) of 95.98%, and F-score (F1) of 94.15%. This demonstrates how the proposed IPO approach can help to classify BCs effectively. The open-source codes are available at https://www.mathworks.com/matlabcentral/fileexchange/169846-an-efficient-improved-parrot-optimizer.

Phase 3 THOR Japanese subgroup analysis: erdafitinib in advanced or metastatic urothelial cancer and fibroblast growth factor receptor alterations

BACKGROUND

In the THOR trial (NCT03390504) Cohort 1, erdafitinib demonstrated significantly prolonged overall survival (OS) (median 12.1 versus 7.8 months) and reduced risk of death by 36% (hazard ratio 0.64, P = 0.005) compared with chemotherapy in metastatic urothelial carcinoma (mUC) patients with FGFR alterations who progressed after ≥ 1 prior treatments, including anti-PD-(L)1. There have been no reports of the Japanese subgroup results yet.

METHODS

THOR Cohort 1 randomized patients to erdafitinib once daily or docetaxel/vinflunine once every 3 weeks. Primary endpoint was OS. Secondary endpoints included progression-free survival (PFS) and objective response rate (ORR). No specific statistical power was set for this Japanese subgroup analysis.

RESULTS

Of 266 patients randomized, 27 (14 erdafitinib; 13 chemotherapy) were Japanese. Baseline characteristics were generally similar between treatments and to the overall population, except for more males, lower body weight, and more upper tract primary tumors among Japanese patients. Compared with chemotherapy, erdafitinib showed improved OS (median 25.4 versus 12.4 months), PFS (median 8.4 versus 2.9 months) and ORR (57.1% versus 15.4%). Any grade treatment-related adverse events (AEs) occurred in all patients from both arms but Grade 3/4 AEs and AEs leading to discontinuation were lower in the erdafitinib arm. No new safety signals were observed in the Japanese subgroup.

CONCLUSION

In the Japanese subgroup, erdafitinib showed improved survival and response compared to chemotherapy, with no new safety concerns. These results support erdafitinib as a treatment option for Japanese mUC patients with FGFR alterations, and early FGFR testing after diagnosis of mUC should be considered.