French AFU Cancer Committee Guidelines - Update 2022-2024: Non-muscle-invasive bladder cancer (NMIBC)

Evaluation of the diagnostic potential of Fourier transform-infrared spectroscopy on urine for urothelial bladder cancer: an in-hospital field study

The increasing global incidence of bladder cancer necessitates better diagnostic methods. This study investigates the potential of mid-infrared spectroscopy on fresh urine samples as a non-invasive approach for diagnosing bladder urothelial carcinoma. In order to position our approach as close as possible to real clinical practice, urine samples were collected from patients undergoing cystoscopy in a hospital urology department. The spectral data were analysed using principal component analysis (PCA) and uniform manifold approximation and projection (UMAP). Unsupervised methods did not reveal clear differences between cancerous and non-cancerous samples, supervised models, including support vector machines (SVM) and random forest (RF), were applied to classify patients into cancer and control groups. These models achieved a diagnostic accuracy of approximately 65 %, with a sensitivity of 87 % for high-grade tumours and 100 % for pT2 tumours. Despite these promising results, the overall accuracy remains insufficient for routine clinical use. The inherent variability in urine composition, influenced by factors such as diet and medications, poses challenges in identifying reliable spectroscopic markers. Nonetheless, mid-infrared spectroscopy shows a promising, non-invasive diagnostic approach for bladder cancer. Further research is essential to enhance prediction models and meet the criteria for potential clinical deployment.

Organizational impact of systematic urine culture before Bacillus Calmette Guerin (BCG) induction instillations

PURPOSE

There are conflicting recommendations concerning the performance of a systematic urine culture (UC) prior to Bacillus Calmette Guerin (BCG) bladder instillations for non-muscle-invasive bladder tumor. The objective was to study the organizational impact of the UC performed before bladder instillations, defined as the number and proportion of BCG instillations postponed due to a positive urine culture result.

METHODS

Induction BCG records in a single academic center between 2015 and 2020 were retrospectively reviewed. All patients had a UC prior to each instillation, treated if positive. Risk factors associated with the occurrence of a positive UC, an adverse event or postponement of instillation were studied.

RESULTS

A total of 156 patients were included, among which 68.9% of patients had at least one risk factor of UTI and 33% of patients presented at least one positive UC at induction. During BCG induction, 76/909 (8.4%) urine cultures performed were positive and 33% of patients had at least one postponement of BCG instillation. There were 64 instillations postponed, caused by untreated positive urine culture for 40 (62.5%) and absence of urine culture performed for 6 (9.4%) In multivariate analysis, only the presence of lower urinary tract symptoms was significantly associated with a risk of positive UC.

CONCLUSION

Positive UC during BCG instillations is a frequent event and a source of disorganization in BCG induction, with possible oncological consequences. A strategy of performing UC only in selected patients, could facilitate proper BCG administration and avoid unreasonable use of antibiotics.

BCG MEDAC® for the treatment of non-muscle invasive bladder tumors: Adverse events and predictive factors for tolerance

INTRODUCTION

Adjuvant treatment with endovesical BCG instillations after resection of a bladder urothelial tumor remains the gold standard for intermediate- or high-risk non-muscle-invasive tumors. However, it is associated with frequent and sometimes serious adverse events (AEs).

OBJECTIVES

To comprehensively assess the frequency, intensity, and potential risk factors of BCG instillation AEs following the field experience of a single French center using only the Medac® BCG.

PATIENTS AND METHODS

A database obtained through a query to the Medical Information Department identified 127 patients who received 1,498 Medac® BCG instillations from July 2016 to July 2021. The study focused on the instillations performed in the 1st year (induction treatment and the first two maintenance cycles). Data included demographics, tumor characteristics, treatment conduct and adverse events and their characteristics. Logistic regression completed the descriptive statistics to search for associations between AEs and potential risk factors.

RESULTS AND DISCUSSION

Of the 127 patients, 81% had at least one AE. AEs concerned the genitourinary sphere in 80% of cases. The proportion of side effects classified as severe was 4%. BCG treatment was discontinued in 41 patients (32.2% of patients), the main reason being the occurence of AEs (21 out of 41 patients, i.e. 51%). Age, diabetes, active smoking, previous BCG instillations, residual tumor at 2nd look TURB, use of ofloxacin and non-negative urine culture were significantly associated to AEs. Conversely, gender, previous MMC instillation, stage, grade, 2nd look procedure and ASA score were not. Multivariate analysis showed that the presence of residual tumour at 2nd look and active smoking were independent predictive factors. However, these factors were not systematically found for all instillations. The analysis was also performed per instillation. Data on a total of 1498 BCG instillations were collected, with a median of 11 instillations per patient. Of these instillations, 29.6% resulted in AEs. In addition, 125 instillations (8%) were associated with more than one AE. A total of 569 AEs were recorded, with an average of 27.2% AEs per instillation. AEs led to the postponement of 16 instillations out of 93 (17%) in 15 patients.

CONCLUSION

In our study, most patients who received endovesical instillations of BCG experienced AEs, mainly localized to the genitourinary sphere and of low severity. Discontinuation of BCG and serious AEs requiring more than monitoring or symptomatic treatment were not frequent during the first year of treatment. We found no robust predictor of AEs. The problems of predicting the efficacy of BCG on the one hand, and its tolerability on the other, remain unresolved and warrant a future sufficiently powered prospective study.

LEVEL OF EVIDENCE: 5

High-risk non-muscle invasive bladder cancer: Outcomes of patients who cannot benefit from standard of care

INTRODUCTION

High-grade non-muscle invasive bladder cancer (HG-NMIBC) exposes to a high risk of recurrence and progression. Standard of care includes repeated trans-urethral resection of bladder tumor (reTURBT) and bacillus Calmette-Guérin (BCG) therapy. Not following Standard of care (SOC) may be associated with a worse prognosis. We aimed to compare prognosis outcomes of patients with primary HG-NMIBC according to the respect of the SOC or not.

MATERIALS AND METHODS

We conducted an eleven-year retrospective observational study including all patients undergoing initial bladder resection for de novo HG-NMIBC at our institution. Exclusion criteria were prior urothelial carcinoma histology, low grade NMIBC or ≥T2 staging. Four groups were formed according to the treatment received.

RESULTS

Among 164 patients, 44.5% received standard of care, 18.3% received only BCG-therapy, 16.5% benefited only from reTURBT and 20.7% did not receive treatment. Upstaging to T2 tumor was found in 6% of reTURBT specimens. Presence of residual tumor (RT) on re-TURBT (P<10-4) and having benefited from SOC (P=0.016) impacted recurrence-free survival. Progression-free survival was impacted by presence of RT (P=0.001) but not by SOC (P=0.284).

CONCLUSION

Performing standard of care on patients with HG-NMIBC is associated with a lower risk of recurrence. We believe SOC should be provided for all HG-NMIBC patients, especially those with poor prognostic factors such as T1 tumor, or multiplicity or largeness of the bladder tumor.

LEVEL OF EVIDENCE: 4

Preclinical and Clinical Feasibility Studies as the First Step Before Forthcoming Intravesical Instillation of [211At]At-anti-CA-IX Antibody (ATO-101™) Study in Patients with Non-Muscle-Invasive Bladder Cancer Unresponsive to Standard of Care

INTRODUCTION

Recently, alpha-emitting radionuclides like astatine-211 have offered promising results in clinical development. Non-muscle-invasive bladder cancer (NMIBC) presents a need for novel therapies. One promising approach is radioimmunotherapy targeting Carbonic Anhydrase IX (CA-IX), which is supported by preclinical and clinical evidence. The aim of our preclinical and clinical studies was to evaluate the [211At]At-anti-CA-IX antibody (ATO-101™) for future use in NMIBC patient care.

METHODS

The anti-CA-IX antibody, girentuximab (TLX250), was labeled with lutetium-177 and astatine-211 for in vitro studies. Affinity constant measurements of [211At]At-girentuximab in RT-112 cells were taken, and toxicity evaluations were conducted in vitro and in healthy mice. Additionally, a clinical proof-of-concept study, PERTINENCE, that used [89Zr]Zr-girentuximab for PET/CT imaging in bladder cancer patients was conducted.

RESULTS

The measurement of the affinity constant of [211At]At-girentuximab in RT112 cells revealed high binding affinity and significant cytotoxicity compared to [177Lu]Lu-girentuximab. Biodistribution studies in healthy mice indicated low systemic radioactivity uptake, and a bladder post-instillation examination showed no abnormalities in bladder mucosa, suggesting safety. In the PERTINENCE study, which involved patients with NMIBC tumors expressing CA-IX, [89Zr]Zr-girentuximab PET/CT showed no extravesical leakage. Wall bladder uptake spots correlated with recurrence or inflammatory reaction. A dosimetric study suggested the potential efficacy and favorable safety profile of intravesical alpha therapy with the [211At]At-anti-CA-IX antibody (ATO-101™) in NMIBC treatment.

CONCLUSIONS

Preclinical and clinical data demonstrate the promising therapeutic role of 211At-targeted alpha agents in NMIBC, and the [211At]At-anti-CA-IX antibody (ATO-101™) could fulfill this role. A phase I FIH clinical trial is in preparation, and results are expected within the next years.

Benzothiazole a privileged scaffold for Cutting-Edges anticancer agents: Exploring drug design, structure-activity relationship, and docking studies

Cancer is a major societal, public health, and economic burden in the 21st century, with 9.7 million deaths in 2022 (9.96 million in 2020) and 20 million new cancer cases (19.6 million in 2020). Considering the increasing number of cancer cases and deaths, heterocyclic compounds always paved the gold mine for the development of potential anticancer drugs as these compounds have unique flexibility and dynamic cores. Benzothiazoles and their derivatives have potential anticancer properties, making them a desirable scaffold among different heterocycles. Title structures are a class of chemicals that may bind to various receptors with high affinity, particularly those engaged in oncogenic processes. The use of these compounds allows medicinal chemists to rapidly produce anticancer treatments across a large range of targets over an extended length of time. The current study presents a thorough success story of benzothiazole derivatives as anticancer agents. It discusses the current state of cancer, the profile of benzothiazole-based derivatives synthetic pathways, and its relevance as an anticancer agent on several oncogenic pathways. The structure-activity relationship was also added to offer insight into the connection of biological data with structure and the rational design of more active drugs.

Comparing efficacy and safety of in-house gemcitabine to mitomycin for bladder instillation in intermediate-risk NMIBC

INTRODUCTION

Intermediate-risk (IR) Non-Muscle Invasive Bladder Cancer (NMIBC) is associated with a high rate of tumor recurrence. To improve patient outcomes, it is recommended to use adjuvant intravesical therapy, by mitomycin C (MMC) or Bacillus Calmette Guerin (BCG). Gemcitabine (GMC) is a known molecule used in urothelial cancer. We aimed to study the efficacy and safety profile of a gemcitabine solution, compared to mitomycin C, in the treatment of IR NMIBC.

MATERIAL

In this retrospective study, patients with IR NMIBC treated between 2016 and 2020 were selected from two participating centers using either gemcitabine (center A) as the intravesical chemotherapy regimen or mitomycin C (center B). The primary endpoint was recurrence rate and secondary end points were treatment interruption and its causes.

RESULTS

In our cohort of 102 IR NMIBC patients, 49 patients received GMC and 53 MMC with a median follow-up of 30 months. Overall recurrence rate was 42.1% with 22.4% in the GMC group and 60.3% in the MMC group (P<0.01). This difference was also found in the multifactorial analysis. Course interruption was observed in 14.7% of all patients, primarily attributed to adverse events (46.6%), without difference between groups.

CONCLUSION

Adjuvant intravesical gemcitabine in patients with IR NMIBC seems to be an interesting option associated with a lower tumor recurrence rate and a favorable tolerance profile when compared to MMC. Larger scale prospective randomized trials are needed to validate our findings.

LEVEL OF EVIDENCE

III.

[Surgical and pathological consequences of preoperative immunotherapy in onco-urology]

INTRODUCTION

Patients treated with immunotherapy might need surgical procedures in addition to the medical treatment. The main indications are cytoreductive nephrectomy, cystectomy (as part of clinical trials) and metastasis removal in some oligometastatic patients. This study aims to assess the feasibility of surgery for patients treated by immunotherapy and describes the histological modifications found in the pathological analysis.

MATERIAL AND METHODS

We conducted a retrospective, monocentric study. We included all patients operated for a urologic cancer and previously treated with systemic immunotherapy between February 2018 and June 2022. We compared this population with a control group of patients treated with surgery without having previous immunotherapy. Patients were compared according to the cancer type, age and sex. We compared perioperative complications. We performed an analysis for evaluation of the peri-tumoral inflammatory infiltration.

RESULTS

We included 50 patients in this study. The two groups were comparable in age (63.7 vs. 63.3years old, P=0.95) and sex (4 and 6 women in the first and second group). The peroperatory complication rate was comparable (20% vs. 16%, P=1). The mean bleeding volume was comparable (664 vs. 629mL; P=0.89). The postoperative complication rate (48% vs. 56%; P=0.78) and their grade (Clavien III-IV 8% vs. 24%; P=0.24) were comparable. The anatomopathological analysis described the same rate and intensity of peri-tumoral inflammatory infiltrate (96% vs. 96%; P=1).

CONCLUSIONS

Preoperative immunotherapy does not appear to be associated with increased surgical difficulty and perioperative complications. Blind histological analysis of the surgical specimens did not reveal any specific features related to pre operative immunotherapy.

LEVEL OF EVIDENCE

Grade 3 HAS.

Active Surveillance in Non-Muscle Invasive Bladder Cancer, the Potential Role of Biomarkers: A Systematic Review

Bladder cancer (BC) is the tenth most common cause of cancer worldwide and is the thirteenth leading cause of cancer mortality. The non-muscle invasive (NMI) variant represents 75% of cases and has a mortality rate of less than 1%; however, it has a high recurrence rate. The gold standard of management is transurethral resection in the case of new lesions. However, this is associated with significant morbidity and costs, so the reduction of these procedures would contribute to reducing complications, morbidity, and the burden to the health system associated with therapy. In this clinical scenario, strategies such as active surveillance have emerged that propose to manage low-risk BC with follow-up; however, due to the low evidence available, this is a strategy that is underutilized by clinicians. On the other hand, in the era of biomarkers, it is increasingly known how to use them as a tool in BC. Therefore, the aim of this review is to provide to clinical practitioners the evidence available to date on AS and the potential role of biomarkers in this therapeutic strategy in patients with low-grade/risk NMIBC. This is the first review linking use of biomarkers and active surveillance, including 29 articles.

Relationship between Preoperative Pyuria and Bacille Calmette-Guerin Treatment in Intravesical Recurrence after Transurethral Resection of High-Risk, Non-Muscle Invasive, Bladder Carcinoma: A Retrospective Study of Human Data

Some researchers have found that preoperative pyuria is a risk factor for recurrence after transurethral resection of high-risk non-muscle invasive bladder cancer. However, to our knowledge, none have clarified the risks associated with pyuria according to bacille Calmette-Guerin (BCG) treatment status. We retrospectively selected patients with high-risk non-muscle invasive bladder cancer according to Japanese Urological Association guidelines. Pyuria was defined as ≥10 white blood cells per high-powered field. We analyzed recurrence-free rates (RFS) in 424 patients who had and had not undergone BCG treatment. The median duration of follow-up was 45.2 months. According to multivariate analysis, postoperative intravesical BCG induction and preoperative pyuria were independent risk factors for intravesical recurrence in the whole study cohort. We found no significant risk factors for recurrence in the BCG-treated group (n = 179). In the non-BCG-treated group (n = 245), patients with pyuria were much more frequently female and more often had T1 disease than patients without pyuria. According to univariate and multivariate analysis, preoperative pyuria is an independent risk factor for intravesical recurrence. There was no significant difference in the severity of pyuria between the BCG and non-BCG-treated groups. Aggressive BCG treatment may need to be considered in patients with high-risk NMIBC and pyuria.

Urinary biomarkers for bladder cancer diagnosis and NMIBC follow-up: a systematic review

BACKGROUND

Bladder cancer detection and follow-up is based on cystoscopy and/or cytology, but it remains imperfect and invasive. Current research focuses on diagnostic biomarkers that could improve bladder cancer detection and follow-up by discriminating patients at risk of aggressive cancer who need confirmatory TURBT (Transurethral Resection of Bladder Tumour) from patients at no risk of aggressive cancer who could be spared from useless explorations.

OBJECTIVE

To perform a systematic review of data on the clinical validity and clinical utility of eleven urinary biomarkers (VisioCyt^®, Xpert^®Bladder, BTA stat^®, BTA TRAK™, NMP22 BC^®, NMP22^® BladderChek^® Test, ImmunoCyt™/uCyt1+™, UroVysion Bladder Cancer Kit^®, Cxbladder, ADXBLADDER, Urodiag^®) for bladder cancer diagnosis and for non-muscle invasive bladder cancer (NMIBC) follow-up.

METHODS

All available studies on the 11 biomarkers published between May 2010 and March 2021 and present in MEDLINE^® were reviewed. The main endpoints were clinical performance for bladder cancer detection, recurrence or progression during NMIBC monitoring, and additional value compared to cytology and/or cystoscopy.

RESULTS

Most studies on urinary biomarkers had a prospective design and high level of evidence. However, their results should be interpreted with caution given the heterogeneity among studies. Most of the biomarkers under study displayed higher detection sensitivity compared with cytology, but lower specificity. Some biomarkers may have clinical utility for NMIBC surveillance in patients with negative or equivocal cystoscopy or negative or atypical urinary cytology findings, and also for recurrence prediction.

CONCLUSION

Urinary biomarkers might have a complementary place in bladder cancer diagnosis and NMIBC surveillance. However, their clinical benefit remains to be confirmed.