First-line treatment of metastatic disease: cisplatin-ineligible patients

Consensus statements from the Hong Kong Urological Association and the Hong Kong Society of Uro-Oncology on the management of muscle-invasive and advanced urothelial carcinoma

Background

Muscle-invasive and advanced urothelial carcinoma (UC) are notorious for their high propensity for recurrence and metastasis. Recent advances in novel medications, surgical procedures, and radiotherapy techniques have substantially transformed the treatment landscape of muscle-invasive and advanced UC. It is crucial to navigate the optimal management approaches for muscle-invasive and advanced UC through the increasingly complex matrix of variables.

Methods

Two professional organisations convened a consensus panel of six urologists and six clinical oncologists with extensive experience in treating urological malignancies. They reviewed the literature on the management of i) non-metastatic, muscle-invasive, and locally advanced UC of the bladder; ii) locally advanced upper tract UC (UTUC); and iii) unresectable locally advanced or metastatic UC (mUC). The panel held multiple meetings to discuss and draft consensus statements using the modified Delphi method. Each drafted statement was anonymously voted on by every panellist. A consensus statement was accepted if ≥ 80% of the panellists chose 'accept completely' or 'accept with some reservation' from the five options, which also included 'accept with major reservation', 'reject with reservation', and 'reject completely'.

Results

The panel reached a consensus on 63 statements based on current evidence and expert insights. These statements addressed the considerations for different treatment modalities, including surgical approaches, radiotherapy, radiosensitisers, platinum-based chemotherapy, immune checkpoint inhibitors, and antibody-drug conjugates, in the management of different disease entities, including muscle-invasive UC of the bladder, cN1 disease, locally advanced UTUC, unresectable locally advanced/mUC, and oligometastatic bladder cancer.

Conclusion

These consensus statements are anticipated to serve as a practical recommendation for clinicians in Hong Kong, and possibly the Asia-Pacific region, regarding the management of muscle-invasive and advanced UC.

Combining serum inflammatory markers and clinical factors to predict survival in metastatic urothelial carcinoma patients treated with immune checkpoint inhibitors

Background

Despite the revolutionary impact of immune checkpoint inhibitors (ICIs) on the treatment of metastatic urothelial carcinoma (mUC), the clinical utility of reliable prognostic biomarkers to foresee survival outcomes remains underexplored.

Objectives

The purpose of this study was to ascertain the prognostic significance of serum inflammatory markers in mUC patients undergoing ICI therapy.

Design

This is a retrospective, multicenter study.

Methods

Data were collected from two independent medical centers in Taiwan, encompassing a validation and a training cohort (TC). Patients with histopathologically confirmed urothelial carcinoma who received at least one cycle of ICI monotherapy were included. Serum inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) were calculated prior to ICI therapy. Statistical analyses involved the use of receiver operating characteristic (ROC) curves to determine optimal biomarker cutoffs and Cox proportional hazards models to evaluate the independent predictive capability of these markers.

Results

A total of 192 patients were enrolled. In the univariate analysis, serum markers such as NLR, PLR, SII, and Hb were significantly associated with overall survival (OS) in both the training and validation cohorts (VC). White blood cells, NLR, and SII demonstrated a robust correlation with progression-free survival across both cohorts. Multivariate analysis revealed that Eastern Cooperative Oncology Group performance status ⩾2 (p < 0.001), visceral metastasis (p < 0.001), leukocytosis (p < 0.001), Hb levels ⩾10 mg/dL (p = 0.008), and NLR ⩾5 (p = 0.032) as independent predictors of OS. A prognostic nomogram integrating these independent factors yielded a C-index for a 3-year OS of 0.769 in the TC and 0.657 in the VC.

Conclusion

Serum inflammatory markers, combined with clinicopathologic factors, provide a practical prognostic tool in mUC treatment with ICIs.

Multiple functions of HuR in urinary tumors

PURPOSE

Human embryonic lethal abnormal visual-like protein, HuR, belongs to a member of the Hu family of RNA-binding protein and plays a critical role in urinary tumors. The purpose of this review is to summarize the current literature to demonstrate the importance of HuR in urinary tract tumors' biology and explore the potential role in therapeutic strategies aimed at targeting this molecule in cancer cells.

METHODS

The relevant literature from PubMed and Medline databases is reviewed in this article.

RESULTS

Increasing evidence supports that HuR plays a critical role in urinary tumors' biology because it regulates the expression of many urinary tumors-associated molecules through post-transcriptional regulatory mechanisms (including mRNA trafficking, mRNA decay and protein translation). Recent studies have demonstrated that HuR is associated with chemoresistance of urinary tumors, suggesting that HuR might be a novel therapeutic target and a marker for therapeutic response and prognosis assessment.

CONCLUSION

HuR is associated with various urinary tumors biological characteristics. Targeted therapy of HuR may become an attractive treatment strategy. What's more, more preclinical and clinical trials of this targeted strategy are necessary for the treatment of urinary tumors.

A Review of Immune Checkpoint Inhibitors for the Management of Locally Advanced or Metastatic Urothelial Carcinoma

Urothelial carcinoma (UC) is the second most common malignancy of the genitourinary system and the sixth most common cancer in the United States. The overall incidence of UC appears to be on the decline, but death rates have remained stable. Stage IV metastatic disease is associated with only a 5% survival rate at 5 years. Gemcitabine and cisplatin combinations or dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin are the preferred regimens for individuals with advance, metastatic disease and a good performance status and organ function. Second-line therapies in this setting are limited. During the course of 1 year, five immune checkpoint inhibitors were approved for treatment of cancers in the locally advanced or metastatic setting: atezolizumab, nivolumab, durvalumab, avelumab, and pembrolizumab. Immunotherapies have played a significant role in the treatment of various cancers and have continued to expand. It is of utmost importance that practitioners include checkpoint inhibitors as treatment options for UC. Based on the limited data, pembrolizumab and atezolizumab may be the drugs of choice, as they are supported by the most influential data to date; however, further research is warranted. Ongoing clinical trials will further assess the benefits of inducing cellular immunity in the treatment of UC. These therapies mark a new landscape in the treatment of UC. In this article, the available data on immune checkpoint inhibitors for the treatment of locally advanced or metastatic UC and their place in therapy are reviewed.

[50th anniversary of cisplatin]

We have just celebrated the 50th anniversary of cisplatin cytotoxic potential discovery. It is time to take stock… and it seems mainly positive. This drug, that revolutionized the treatment of many cancer types, continues to be the most widely prescribed chemotherapy. Despite significant toxicities, resistance mechanisms associated with treatment failures, and unresolved questions about its mechanism of action, the use of this cytotoxic agent remains unwavering. The interest concerning this "old" invincible drug has not yet abated. Indeed many research axes are in the news. New platinum salts agents are tested, new cisplatin formulations are developed to target tumor cells more efficiently, and new combinations are established to increase the cytotoxic potency of cisplatin or overcome the resistance mechanisms.

Inhibiting cytoplasmic accumulation of HuR synergizes genotoxic agents in urothelial carcinoma of the bladder

HuR, an RNA-binding protein, post-transcriptionally regulates nearly 4% of encoding proteins implicated in cell survival. Here we show that HuR is required for the efficacy of chemotherapies in urothelial carcinoma of the bladder. We identify pyrvinium pamoate, an FDA-approved anthelminthic drug, as a novel HuR inhibitor that dose-dependently inhibited cytoplasmic accumulation of HuR. Combining pyrvinium pamoate with chemotherapeutic agents (e.g. cisplatin, doxorubicin, vincristine and oxaliplatin) not only led to enhanced cytotoxicity in bladder cancer cells but also synergistically suppressed the growth of patient-derived bladder tumor xenografts in mice (P < 0.001). Mechanistically, pyrvinium pamoate promoted nuclear import of HuR by activating the AMP-activated kinase/importin α1 cascade and blocked HuR nucleo-cytoplasmic translocation by inhibiting the checkpoint kinase1/cyclin-dependent kinase 1 pathway. Notably, pyrvinium pamoate-additive treatment increased DNA double-strand breaks as indicated by elevated γH2AX expression, suggesting an involvement of DNA damage response. We further found that pyrvinium pamoate dramatically downregulated several key DNA repair genes in genotoxically-stressed cells, including DNA ligase IV and BRCA2, leading to unbearable genomic instability and cell death. Collectively, our findings are the first to characterize a clinical HuR inhibitor and provide a novel therapeutically tractable strategy by targeting cytoplasmic translocation of HuR for treatment of urothelial carcinoma of the bladder.

Utilization of Systemic Chemotherapy in Advanced Urothelial Cancer: A Retrospective Collaborative Study by the Hellenic Genitourinary Cancer Group (HGUCG)

BACKGROUND

Advanced urothelial cancer (AUCa) is associated with poor long-term survival. Two major concerns are related to nonexposure to cisplatin-based chemotherapy and poor outcome after relapse. Our purpose was to record patterns of practice in AUCa in Greece, focusing on first-line treatment and management of relapsed disease.

METHODS

Patients with AUCa treated from 2011 to 2013 were included in the analysis. Fitness for cisplatin was assessed by recently established criteria.

RESULTS

Of 327 patients treated with first-line chemotherapy, 179 (55%) did not receive cisplatin. Criteria for unfitness for cisplatin were: Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥ 2, 21%; creatinine clearance ≤ 60 mL/min, 55%; hearing impairment, 8%; neuropathy, 1%; and cardiac failure, 5%. Forty-six patients (27%) did not fulfill any criterion for unfitness for cisplatin. The main reasons for these deviations were comorbidities (28%) and advanced age (32%). Seventy-four (68%) of 109 patients who experienced a relapse received second-line chemotherapy. The most frequent reason for not offering second-line chemotherapy was poor PS or limited life expectancy (66%).

CONCLUSION

In line with international data, approximately 50% of Greek patients with AUCa do not receive cisplatin-based chemotherapy, although 27% of them were suitable for such treatment. In addition, about one third of patients with relapse did not receive second-line chemotherapy because of poor PS or short life expectancy. Enforcing criteria for fitness for cisplatin and earlier diagnosis of relapse represent 2 targets for improvement in current treatment practice for AUCa.