Nivolumab in metastatic urothelial carcinoma after platinum therapy (CheckMate 275): a multicentre, single-arm, phase 2 trial

Real-world comparison of neoadjuvant chemoimmunotherapy and chemotherapy in muscle-invasive bladder cancer

Muscle-invasive bladder cancer (MIBC) continues to pose a significant health challenge, as conventional neoadjuvant chemotherapy (NAC) has shown limited improvements in efficacy outcomes. Recent clinical trials suggest that combining NAC with immune checkpoint blockade (NAC.NICB) may enhance therapeutic efficacy. This study aimed to explore the short-term therapeutic efficacy and outcomes of NAC.NICB compared to NAC in real-world settings for the treatment of MIBC. A total of 100 patients with MIBC who received either NAC or NAC.NICB were included in the study. The treatment efficacy of the NAC and NAC.NICB groups was evaluated based on pathological complete response (pCR) and the rate of pathological downstaging through post treatment pathological assessment. In the NAC.NICB group, clinical characteristics were compared between patients who achieved pCR and those who did not, using the independent samples t-test or the Mann-Whitney U test. Overall, 71 patients received NAC and 29 patients received NAC.NICB. At baseline, the NAC.NICB group exhibited higher T and N stages compared to the NAC group. However, 48.3% (14/29) of the patients in the NAC.NICB group achieved pCR, which was significantly higher than that observed in the NAC group (18/71, 25.4%; p = 0.034). In addition, the pathological downstaging rate in the NAC.NICB group was higher than that of the NAC group (75.9% vs. 47.9%; p = 0.014). The disease control rate (DCR) in the NAC.NICB group was higher than that observed in the NAC group (96.6% vs. 77.5%; p = 0.020). Higher pretreatment hemoglobin levels (p = 0.018) or lower platelet levels (p = 0.026) in patients undergoing NAC.NICB therapy may serve as a potential predictor for achieving a higher pCR rate. Neoadjuvant chemotherapy combined with immune checkpoint blockade improves pCR and pathological downstaging rates in MIBC, highlighting the benefits of neoadjuvant chemoimmunotherapy for MIBC.

Characterization of Patients with Lymph Node Only Metastatic Urothelial Carcinoma Treated with Nivolumab Plus Gemcitabine-Cisplatin Versus Gemcitabine-Cisplatin Alone from the CheckMate 901 Trial

Nivolumab (NIVO) plus gemcitabine-cisplatin (GC) demonstrated deep, durable responses in patients with untreated unresectable or metastatic urothelial carcinoma (mUC) with superior overall (OS) and progression-free (PFS) survival versus GC alone. We report post hoc exploratory analyses with 33.6 mo of median follow-up in patients with lymph node (LN) only disease from CheckMate 901. In this phase 3 randomized trial (n = 608), cisplatin-eligible patients received NIVO 360 mg plus GC every 3 wk (Q3W) for six or fewer cycles followed by NIVO 480 mg every 4 wk for ≤2 yr, or GC Q3W for six or fewer cycles. The primary endpoints were OS and PFS by a blinded independent central review (BICR). The objective response rate (ORR) as per the BICR and safety were exploratory. This post hoc analysis evaluated patients with LN only mUC (n = 110). In this subgroup, OS (hazard ratio [HR], 0.58; 95% confidence interval [CI] 0.34-1.00) and PFS (HR, 0.38; 95% CI 0.22-0.66) improved with NIVO + GC versus GC. The ORR was 81% with NIVO + GC versus 64% with GC; complete response rates were 63% versus 34%. The incidence of treatment-related adverse events was similar between arms. In conclusion, clinically meaningful improvements in OS, PFS, and ORR, including twice the rate of complete response and more patients with treatment-free intervals, were observed with NIVO + GC versus GC in patients with LN only disease, providing additional support for first-line NIVO plus cisplatin-based chemotherapy in mUC.

Comparative evaluation of PD-L1 expression and tumor immune microenvironment in molecular subtypes of muscle-invasive bladder cancer and its correlation with survival outcomes

OBJECTIVES

Immune checkpoint inhibitors have revolutionized treatment of platinum-refractory advanced bladder cancer, offering hope where options are limited. Response varies, however, influenced by factors such as the tumor's immune microenvironment and prior therapy. Muscle-invasive bladder cancer (MIBC) is stratified into molecular subtypes, with distinct clinicopathologic features affecting prognosis and treatment. This study assessed the expression of programmed cell death 1 ligand 1 (PD-L1) and other immune markers in MIBC, categorized by molecular phenotype.

METHODS

Using GATA3 and CK5/6 immunohistochemistry, 90 neoadjuvant chemotherapy-naive MIBC cases were classified into luminal and non-luminal subtypes. The immune microenvironment was characterized through immunostaining for PD-L1, CD4, and CD8. We applied PD-L1 positivity thresholds of 1% or greater for tumor cells and 5% or greater for immune cells. Tumors were examined for PD-L1 expression, histologic subtypes, and immune cell infiltration.

RESULTS

Varied expression of PD-L1 and T-cell subtype densities were observed among MIBC subtypes. The double-negative subtype displayed the highest PD-L1 immune cell expression and stromal CD4 and CD8 T-cell densities, indicating an active immune profile. The basal subtype exhibited the highest PD-L1 positivity in tumor cells. In contrast, the luminal type showed the lowest PD-L1 tumor and immune cell expression, with high intratumoral CD4 T-cell density. Although PD-L1 expression in tumor or immune cells did not independently affect survival, patients with basal and double-negative tumors had poorer overall survival.

CONCLUSIONS

This study highlighted the immune diversity of MIBC in the context of molecular subtypes. Distinct molecular and immune profiles could guide the development of predictive signatures for enhanced immunotherapy response in advanced bladder cancer.

Sex differences in bladder cancer: understanding biological and clinical implications

Bladder cancer (BC) remains a significant global health concern, with substantial sex and racial disparities in incidence, progression, and outcomes. BC is the sixth most common cancer among males and the seventeenth most common among females worldwide. Over 90% of BC cases are urothelial carcinoma (UC) with high degrees of pathological heterogeneity. Molecular subtyping of BC has also revealed distinct luminal, basal, and neuroendocrine subtypes, each with unique genetic and immune signatures. Emerging research uncovers the biasing effects of the sex hormones with androgens increasing BC risk through both tumor cell intrinsic and extrinsic mechanisms. The sex chromosomes, including both the X and Y chromosomes, also contribute to the sex differences in BC. The effect of sex chromosome is both independent from and synergistic with the effects of sex hormones. Loss of the Y chromosome is frequently observed in BC patients, while an extra copy of the X chromosome confers better protection against BC in females than in males. Advent of advanced technologies such as multiomics and artificial intelligence will likely further improve the understanding of sex differences in BC, which may ultimately lead to personalized preventative and treatment strategies depending on the biological sex of patients. This review delves into the impacts of biology of sex on BC, emphasizing the importance of further research into sex-specific biology to improve cancer prevention and care.

Concordance Between the PD-L1 Tumor Area Positivity Score and Combined Positive Score for Gastric or Esophageal Cancers Treated With Tislelizumab

Tumor Area Positivity (TAP) score is an emerging score measuring programmed death-ligand 1 (PD-L1) expression in tumors. However, the availability of concordance data between TAP score and other immunohistochemistry scoring methods is limited. We investigated concordance between TAP score and combined positive score (CPS) and the relationship between PD-L1 status and clinical outcomes using gastric/gastroesophageal junction adenocarcinoma (GC/GEJC) and esophageal squamous cell carcinoma (ESCC) samples from patients subsequently treated with tislelizumab. Baseline tissue samples from RATIONALE-305 (GC/GEJC; NCT03777657), RATIONALE-302 (ESCC; NCT03430843), and RATIONALE-306 (ESCC; NCT03783442) were assessed for PD-L1 expression using an investigational-use only version of the VENTANA PD-L1 (SP263) CDx Assay. PD-L1 status was scored per protocol by TAP score and post-hoc by TAP score and CPS depending on the cutoff used. Concordance and correlation of both scores with clinical and safety outcomes were analyzed. Across all trials, agreement between TAP score and CPS was significant at PD-L1 cutoffs of ≥1%/≥1, ≥5%/≥5, and ≥10%/≥10 (Cohen's Kappa, 0.64-0.85). Similar outcomes for overall survival (OS), progression-free survival, objective response rate, and duration of response were observed between TAP score- and CPS-defined PD-L1-positive subgroups at analogous PD-L1 cutoffs. OS hazard ratios (HRs) in the PD-L1-high subgroups were similar between protocol-defined TAP score and the same numeric CPS value (OS HR [95% confidence interval]: RATIONALE-305, 0.72 [0.59-0.88] and 0.73 [0.60-0.89]; RATIONALE-302, 0.52 [0.35-0.76] and 0.54 [0.37-0.78]; RATIONALE-306, 0.63 [0.45-0.89] and 0.58 [0.42-0.81], respectively). Safety outcomes were generally comparable between all PD-L1 subgroups. In conclusion, TAP score and CPS are clinically comparable immunohistochemistry measures of PD-L1 expression in tislelizumab-treated patients with GC/GEJC or ESCC.

Immune Checkpoint Inhibitors and Antibody-Drug Conjugates in Urothelial Carcinoma: Current Landscape and Future Directions

BACKGROUND/OBJECTIVES

Urothelial carcinoma (UC) treatment has been transformed by immunotherapy and antibody-drug conjugates (ADCs). This review evaluates the current evidence for these approaches and identifies future directions.

METHODS

We conducted a structured review of clinical trials, meta-analyses, and guidelines published until early 2025.

RESULTS

Immune checkpoint inhibitors have established benefits across multiple settings: post-platinum therapy (pembrolizumab, nivolumab), maintenance therapy (avelumab), adjuvant settings for high-risk muscle-invasive disease (nivolumab), and BCG-unresponsive non-muscle-invasive disease (pembrolizumab). Enfortumab vedotin (targeting Nectin-4) has proven effective in post-platinum/post-immunotherapy. Most significantly, enfortumab vedotin plus pembrolizumab has redefined first-line treatment with unprecedented survival benefits (median OS 31.5 months vs. 16.1 months with chemotherapy; HR 0.47), and nivolumab plus gemcitabine-cisplatin improved outcomes in cisplatin-eligible patients. Key challenges include managing unique toxicity profiles, optimizing treatment sequencing, and developing reliable biomarkers.

CONCLUSIONS

Combination approaches offer the most promising path forward, with future research needed on resistance mechanisms, biomarker development, and expanding these therapies to earlier disease stages.

European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2025 Guidelines

BACKGROUND AND OBJECTIVE

This publication represents a summary of the updated 2025 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC). The aim is to provide practical recommendations on the clinical management of MMIBC with a focus on diagnosis, treatment, and follow-up.

METHODS

For the 2025 guidelines, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences.

KEY FINDINGS AND LIMITATIONS

The key recommendations emphasise the importance of thorough diagnosis, treatment, and follow-up for patients with MMIBC. The guidelines stress the importance of a multidisciplinary approach to the treatment of MMIBC patients and the importance of shared decision-making with patients. The key changes in the 2025 muscle-invasive bladder cancer (MIBC) guidelines include the following: a new recommendation for the use of susceptible FGFR3 alterations to select patients with unresectable or metastatic urothelial carcinoma for treatment with erdafitinib; significant adaption and update of the recommendations for pre- and postoperative radiotherapy and sexual organ-preserving techniques in women; new recommendation related to radical cystectomy and extent of lymph node dissection based on the results of the SWOG trial; recommendation related to hospital volume; new recommendations for salvage cystectomy after trimodality therapy and for the management of all patients who are candidates for trimodality bladder-preserving treatment in a multidisciplinary team setting using a shared decision-making process; significant adaption and update to the recommendation for adjuvant nivolumab in selected patients with pT3/4 and/or pN+ disease not eligible for, or who declined, adjuvant cisplatin-based chemotherapy; and addition of a new recommendation for metastatic disease regarding the antibody-drug conjugate trastuzumab deruxtecan in case of HER2 overexpression; in addition, removal of the recommendations on sacituzumab govitecan as the manufacturer has withdrawn the US Food and Drug Administration approval for this product; update of the follow-up of MIBC; and full update of the management algorithms of MIBC.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This overview of the 2025 EAU guidelines offers valuable insights into risk factors, diagnosis, classification, treatment, and follow-up of MIBC patients and is designed for effective integration into clinical practice.

Cardiovascular Risk Profile of Nivolumab Anti-cancer Therapy: A Review of Current Literature

OBJECTIVES

Immune checkpoint inhibitors (ICI) upregulate host antitumor immunity, proving efficacy across diverse tumor types. Currently approved ICI treatment primarily targets the programmed cell death receptor 1 (PD-1) and its ligand PD-L1, and cytotoxic T lymphocyte-antigen 4 (CTLA-4). Nivolumab is a monoclonal antibody that targets the human PD-1 receptor and is an entirely human immunoglobulin G4 (IgG4), approved by the FDA for various cancers like advanced melanoma, metastatic renal cell carcinoma, Hodgkin lymphoma, and advanced lung carcinoma. This review will summarise and discuss the recent literature on cardiotoxicity associated with nivolumab therapy.

METHODS

We searched online databases like PubMed, Scopus, Google Scholar, and Embase for articles related to Nivolumab.

RESULTS

Cardiotoxicity with ICI use is most commonly represented as myocarditis. Patients present with complaints of shortness of breath, palpitations, edema, and fatigue. Takotsubo cardiomyopathy, or broken heart syndrome, is characterized by systolic dysfunction of the left ventricle, mimicking a myocardial infarction but without associated coronary ischemia and with minimal elevation of cardiac enzymes. In the CHECKMATE-037 trial, ventricular arrhythmias occurred in <10% of those who received nivolumab. In a retrospective analysis of patients treated with ICI (predominantly nivolumab monotherapy) for lung cancer, 11% of the patients developed major adverse cardiac events, including myocarditis, non-ST-segment elevated myocardial infarction, supraventricular tachycardia, and pericardial disorders.

CONCLUSION

Close collaboration between cardiology and oncology specialists is crucial for early detection and effective management of cardiac complications, enhancing the safety of nivolumab anticancer therapy.

Combined Molecular Subclass and Immune Phenotype Correlate to Atezolizumab Plus Radiation Therapy Response in Invasive Bladder Cancer: BPT-ART Phase 2 Study

PURPOSE

Bladder preservation therapy in combination with atezolizumab and radiation therapy trial, which was a multicenter, open-label, single-arm phase 2 study, showed a promisingly high interim clinical complete response (cCR) rate of 84.4% (38/45). In the present study, we aimed to identify potential tissue biomarkers for achieving cCR using bladder preservation therapy in combination with atezolizumab and radiation therapy.

METHODS AND MATERIALS

We used tumor tissue samples of the bladder and blood samples collected from patients at baseline to analyze the tumor immune microenvironment at baseline using an integrated approach of immunophenotyping, genomic, and tumor-infiltrating lymphocyte (TIL) profiling.

RESULTS

Immune phenotype analysis revealed that cCR rates of patients with the desert phenotype were as similarly high as patients with excluded/inflamed phenotypes (73.3% [11/15] vs 93.3% [14/15], P = .33) despite lower programmed death-ligand 1 expression levels in the desert phenotype. Genomic and TIL profiling then revealed that increased CD8+ and CD204+ TIL infiltration, high CD8:forkhead box protein P3 ratios in the stroma of the excluded/inflamed phenotypes, and gene alterations, such as CDK12, GNAS, NOTCH2, and AR1D1A, were associated with a high cCR rate (93.3%). Furthermore, the characteristics of these dual TILs, CD8-forkhead box protein P3 ratios, and gene alterations (especially FGFR3) bifurcated the desert phenotype into 2 subgroups with different cCR rates (100% [11/11] and 0% [0/4]).

CONCLUSIONS

These potential subgroups, defined by combined molecular subclass and immune phenotype, could lead to the identification of good responders to atezolizumab plus radiation therapy for invasive bladder cancer. However, given the small cohort size and limited number of tumor samples, these findings should be viewed as hypothesis-generating and require further validation in larger studies.

Clinical development of immuno-oncology therapeutics

Immuno-oncology (IO) is one of the fastest growing therapeutic areas within oncology. IO agents work indirectly via the host's adaptive and innate immune system to recognize and eradicate tumor cells. Despite checkpoint inhibitors being only introduced to the market since 2011, they have become the second most approved product category. Current Food and Drug Administration (FDA)-approved classes of IO agents include: immune checkpoint inhibitors (ICIs), chimeric antigen receptor T-cell therapy (CAR-T), bi-specific T-cell engager (BiTE) antibody therapy, T-cell receptor (TCR) engineered T cell therapy, tumor-infiltrating lymphocyte (TIL) therapy, cytokine therapy, cancer vaccine therapy, and oncolytic virus therapy. Cancer immunotherapy has made progress in multiple cancer types including melanoma, non-small cell lung cancer (NSCLC), renal cell carcinoma (RCC), and urothelial carcinoma; however, several cancers remain refractory to immunotherapy. Future directions of IO include exploration in the neoadjuvant/perioperative setting, combination strategies, and optimizing patient selection through improved biomarkers.

Efficacy and safety of PD-1/PD-L1 inhibitor monotherapy or combination therapy versus platinum-based chemotherapy as a first-line treatment of advanced urothelial cancer: A systematic review and meta-analysis

Background

Recent clinical trials have shown that inhibitors targeting programmed cell death protein 1 (PD-1) or its ligand (programmed cell death-ligand 1 [PD-L1]) provide significant efficacy and clinical benefit in the treatment of advanced or metastatic urothelial carcinoma (UC). This systematic review and meta-analysis aimed to compare the effectiveness and safety of PD-1/PD-L1 inhibitors in combination with chemotherapy or PD-1/PD-L1 inhibitor monotherapy versus platinum-based chemotherapy as a first-line treatment for advanced UC.

Materials and methods

From the beginning of the database construction to February 4, 2024, a combination of medical subject headings and free-text words was searched using the Population Intervention Comparison Outcome Study design framework. The PubMed, Cochrane Library, Embase, and Web of Science electronic databases were searched. Meta-analyses of progression-free survival, overall survival, objective response rate (ORR), complete remission rate, duration of remission, and grade ≥3 adverse events were performed.

Results

Four studies were included in the meta-analysis. The PD-1/PD-L1 inhibitors plus chemotherapy therapy is associated with significantly better ORR compared with chemotherapy. Unfortunately, there were no significant differences between PD-1/PD-L1 inhibitor monotherapy and chemotherapy in terms of ORR, duration of remission, or overall survival.

Conclusions

Our findings indicate that PD-1/PD-L1 inhibitors plus chemotherapy therapy provides more oncological advantages than standard chemotherapy and should be recommended as a first-line treatment for advanced or metastatic UC. Attention must also be paid to the adverse effects of the combination of PD-1/PD-L1 inhibitors and chemotherapy.

Immunotherapeutic strategies for invasive bladder cancer: a comprehensive review

Bladder cancer is a prevalent malignancy, with muscle-invasive bladder cancer (MIBC) presenting a significant therapeutic challenge. Standard treatments, including radical cystectomy (RC) and neoadjuvant chemotherapy, pose substantial risks and impact quality of life, leading to increasing interest in bladder-preserving therapies (BPT). Immunotherapy has revolutionized bladder cancer management, with strategies ranging from intravesical Bacillus Calmette-Guérin (BCG) to immune checkpoint inhibitors targeting programmed cell death protein 1 (PD-1) and its ligand (PD-L1). In BCG-unresponsive non-muscle-invasive bladder cancer (NMIBC), PD-1 inhibitors such as pembrolizumab offer promising response rates. In MIBC, neoadjuvant immunotherapy with agents like atezolizumab and pembrolizumab improves pathological complete response (pCR) and facilitates bladder preservation. Combination regimens integrating radiotherapy, chemotherapy, and immunotherapy not only enhance treatment efficacy but also exploit mechanisms such as immunogenic cell death and antigen release that further augment antitumor immune responses. This review provides a comprehensive analysis of current immunotherapeutic strategies for invasive bladder cancer, highlighting their clinical applications and future potential.

Bone metastases diminish extraosseous response to checkpoint blockade immunotherapy through osteopontin-producing osteoclasts

Bone metastatic lesions typically associate with suboptimal responses to immune checkpoint blockade (ICB) therapies. In this study, we observed that across multiple clinical cohorts and a variety of mouse models, the presence of osseous metastases induces ICB resistance in extraosseous tumors. Mechanistically, this long-distance communication is mediated by osseous tumor-conditioned osteoclasts producing osteopontin (OPN). Through circulation, OPN reprograms the extraosseous tumor microenvironment and impairs T cell recruitment and differentiation of CD8+TCF1+ precursor cells, an essential population for ICB efficacy. In mice, ICB responsiveness is restored by αRANKL blockade of osteoclastogenesis, neutralization of OPN in circulation, or tissue-specific depletion of OPN in osteoclasts. Both the mode of action and therapeutic benefit were validated in clinical cohorts with the αRANKL-ICB combinatory regimen. These findings establish bone as a specific immunoregulatory organ exploited by tumor metastasis and suggest osteoclastogenesis as a promising target to improve ICB prognosis in patients with bone metastasis.

Asparagine drives immune evasion in bladder cancer via RIG-I stability and type I IFN signaling

Tumor cells often employ many ways to restrain type I IFN signaling to evade immune surveillance. However, whether cellular amino acid metabolism regulates this process remains unclear, and its effects on antitumor immunity are relatively unexplored. Here, we found that asparagine inhibited IFN-I signaling and promoted immune escape in bladder cancer. Depletion of asparagine synthetase (ASNS) strongly limited in vivo tumor growth in a CD8+ T cell-dependent manner and boosted immunotherapy efficacy. Moreover, clinically approved L-asparaginase (ASNase),synergized with anti-PD-1 therapy in suppressing tumor growth. Mechanistically, asparagine can directly bind to RIG-I and facilitate CBL-mediated RIG-I degradation, thereby suppressing IFN signaling and antitumor immune responses. Clinically, tumors with higher ASNS expression show decreased responsiveness to immune checkpoint inhibitor therapy. Together, our findings uncover asparagine as a natural metabolite to modulate RIG-I-mediated IFN-I signaling, providing the basis for developing the combinatorial use of ASNase and anti-PD-1 for bladder cancer.

Modern Treatment of Skeletal Metastases: Multidisciplinarity and the Concept of Oligometastasis in the Recent Literature

Bone metastases are a major concern in cancer management since they significantly contribute to morbidity and mortality. Metastatic lesions, commonly arising from breast, prostate, lung, and kidney cancers, affect approximately 25% of cancer patients, leading to severe complications such as pain, fractures, and neurological deficits. This narrative review explores contemporary approaches to bone metastases, emphasizing a multidisciplinary strategy and the evolving concept of oligometastatic disease. Oligometastases, defined by limited metastatic spread (1-5 lesions), offer a potential window for curative treatment through aggressive interventions, including stereotactic ablative radiotherapy and resection surgery. Tumor boards, integrating systemic therapies with local interventions, are crucial to optimize treatment. Despite promising results, gaps remain in defining optimal treatment sequences and refining patient selection criteria. Future research should focus on personalized approaches, leveraging biomarkers and advanced imaging to enhance outcomes and the quality of life in patients with bone metastases.

The role of immunotherapy in targeting tumor microenvironment in genitourinary cancers

Genitourinary (GU) cancers, including renal cell carcinoma, prostate cancer, bladder cancer, and testicular cancer, represent a significant health burden and are among the leading causes of cancer-related mortality worldwide. Despite advancements in traditional treatment modalities such as chemotherapy, radiotherapy, and surgery, the complex interplay within the tumor microenvironment (TME) poses substantial hurdles to achieving durable remission and cure. The TME, characterized by its dynamic and multifaceted nature, comprises various cell types, signaling molecules, and the extracellular matrix, all of which are instrumental in cancer progression, metastasis, and therapy resistance. Recent breakthroughs in immunotherapy (IO) have opened a new era in the management of GU cancers, offering renewed hope by leveraging the body's immune system to combat cancer more selectively and effectively. This approach, distinct from conventional therapies, aims to disrupt cancer's ability to evade immune detection through mechanisms such as checkpoint inhibition, therapeutic vaccines, and adoptive cell transfer therapies. These strategies highlight the shift towards personalized medicine, emphasizing the importance of understanding the intricate dynamics within the TME for the development of targeted treatments. This article provides an in-depth overview of the current landscape of treatment strategies for GU cancers, with a focus on IO targeting the specific cell types of TME. By exploring the roles of various cell types within the TME and their impact on cancer progression, this review aims to underscore the transformative potential of IO strategies in TME targeting, offering more effective and personalized treatment options for patients with GU cancers, thereby improving outcomes and quality of life.

Different PD-L1 Assays Reveal Distinct Immunobiology and Clinical Outcomes in Urothelial Cancer

Testing for PD-L1 expression by IHC is used to predict immune checkpoint blockade (ICB) benefits but has performed inconsistently in urothelial cancer clinical trials. Different approaches are used for PD-L1 IHC. We analyzed paired PD-L1 IHC data on urothelial cancer samples using the SP142 and 22C3 assays from the phase III IMvigor130 trial and found discordant findings summarized by four phenotypes: PD-L1 positive by both assays, PD-L1 positive by the SP142 assay only, PD-L1 positive by the 22C3 assay only, and PD-L1 negative by both assays double negative. PD-L1 positive by both assays and PD-L1 positive by the SP142 assay only urothelial cancers were associated with more favorable ICB outcomes and increased dendritic cell (DC) infiltration. SP142 PD-L1 staining co-localized with DC-LAMP, a DC marker, whereas 22C3 staining was more diffuse. PD-L1 positive by the 22C3 assay only urothelial cancers, associated with worse outcomes, were enriched in tumor cell (TC)-dominant PD-L1 expression. Multiplex IHC in an independent ICB-treated cohort confirmed that TC-dominant PD-L1 expression was associated with shorter survival. Using different PD-L1 assays, we uncovered that SP142 may preferentially stain PD-L1-expressing DCs, key to orchestrating antitumor immunity, whereas TC-dominant PD-L1 expression, which underlies a subset of "PD-L1-positive" specimens, is associated with poor ICB outcomes. See related Spotlight by Karunamurthy and Davar, p. 454 .

Incidence and management of hepatic immune‑related adverse events in advanced urologic cancers treated with immune checkpoint inhibitors: A multicenter retrospective study

The present study aimed to evaluate the incidence, characteristics and management of hepatic immune-related adverse events (irAEs) in patients with advanced or metastatic urothelial carcinoma (UC) and renal cell carcinoma (RCC) receiving immune checkpoint inhibitors (ICIs). Data regarding the demographics, ICI regimens and hepatic irAEs from 213 patients with metastatic UC or metastatic RCC receiving ICIs between February 2018 and September 2023 at three tertiary medical centers (Inje University Busan Paik Hospital, Busan, South Korea; Dongnam Institute of Radiological and Medical Sciences Cancer Center, Busan, South Korea; Pusan National University Hospital, Busan, South Korea) in South Korea were collected and retrospectively analyzed. Hepatic irAEs were graded using the Common Terminology Criteria for Adverse Events version 5.0 and classified based on R value patterns. Among the 213 patients evaluated, 76 (35.6%) experienced at least one irAE, whereas 48 (22.5%) developed hepatic irAEs. The median onset time for hepatic irAEs was 6.5 weeks, with incidence rates being higher with combination therapies than with monotherapies (31.8 vs. 18.3%; P=0.014). Furthermore, 72.9 and 27.1% of the patients had grade 1-2 and 3-4 hepatic irAEs, respectively. The patterns of liver toxicity included cholestatic (35.4%), mixed (35.4%) and hepatocellular (29.2%). All patients with grade 1-2 hepatic irAE recovered with supportive treatment without ICI discontinuation or corticosteroids use. Among the 13 patients with grade ≥3 hepatic irAEs, 12 recovered with high-dose corticosteroids, while 1 died due to fulminant hepatitis. Hepatic irAEs are common in patients with advanced and metastatic urologic cancers who are treated with ICIs, particularly with combination therapies. Most cases have low-grade irAE that are manageable without ICI discontinuation; however, severe cases require prompt recognition and treatment with corticosteroids. These findings emphasize the importance of regular liver function monitoring and appropriate management strategies for hepatic irAEs in patients with urologic cancer receiving ICI therapy.

Isolated Urinary Tract Persistence or Progression in Patients Treated With Immunotherapy for Advanced Urothelial Carcinoma

PURPOSE

Emerging therapies including anti-PD-(L)1 immunotherapy have changed paradigms of treatment and improved oncological outcomes of advanced/metastatic urothelial carcinoma (mUC) patients. An emerging challenge in this setting is the management of isolated urinary tract persistence or progression (IUTP) of primary urothelial tumor despite stability or response of metastatic disease to immunotherapy.

METHODS

This retrospective monocentric study included all patients treated with single-agent anti-PD-(L)1 for mUC between August 2015 and October 2023. Patients were divided in cohorts of interest depending on primary UC site (lower or upper tract) and previous surgery at the time of immunotherapy initiation. Incidence of IUTP was analyzed in a competitive-risk fashion.

RESULTS

Overall,107 patients with mUC and no previous surgical treatment of primary tumor treated with immunotherapy were at risk of local progression. Among 65 mUC with an untreated bladder primary site, the cumulative incidence rate of IUTP in patients with nonprogressive metastatic disease on immunotherapy was 21.4% and 42.7% at 1 and 2 years, respectively. In responders, half of IUTP were nonmuscle invasive;5 patients, including all 3 with NMIBC, remained free of distant progression after a median follow-up of 12.7 (4.6-41.2) months. In mUTUC, 2 out of 18 patients (11.1%) experienced isolated primary site progression and underwent radical nephroureterectomy, with one patient remaining free of distant progression over 1 year.

CONCLUSIONS

These preliminary results show high incidence of IUTP as a progression pattern in mUC patients with clinical benefit of immunotherapy for mUC, highlighting the interest of monitoring the primary tumor and considering local treatment in selected cases, with promising oncological outcomes.

TAOK1 promotes filament formation in HR repair through phosphorylating USP7

Poly-ADP-ribose polymerase (PARP) inhibitors are vital therapeutic agents that exploit synthetic lethality, particularly effective in tumors with homologous recombination (HR) defects. However, broadening their clinical utility remains a significant challenge. In this study, we conducted a high-throughput kinase inhibitor screen to identify potential targets exhibiting synthetical lethality with PARP inhibitors. Our results show that thousand and one amino acid protein kinase 1 (TAOK1) plays a pivotal role in the DNA damage response by phosphorylating ubiquitin specific peptidase 7 (USP7), thereby promoting its enzymatic activity and preventing the ubiquitylation and subsequent degradation of RAD51, a crucial protein in the filament formation of HR repair. Notably, genetic depletion or pharmacological inhibition of TAOK1, as well as blocking peptide targeting the USP7 phosphorylation site, impaired USP7 function, leading to RAD51 degradation, disruption of HR repair, and increased tumor cell and sensitivity to PARP inhibition. This study highlights TAOK1 as a critical regulator of HR repair pathway in human cancer cells and presents a therapeutic strategy overcoming resistance to PARPi inhibitors. These findings support the potential clinical application of combining PARP inhibitors with TAOK1 inhibition or peptide treatment to improve therapeutic outcomes.

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

BACKGROUND

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

OBJECTIVES

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

MATERIALS AND METHOD

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

RESULTS

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

CONCLUSION

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

Nivolumab adjuvant to chemo-radiation in localized muscle-invasive urothelial cancer: primary analysis of a multicenter, single-arm, phase II, investigator-initiated trial (NEXT)

BACKGROUND

Muscle-invasive urothelial cancer (UC) has a high risk of recurrence after definitive treatment. Nivolumab adjuvant to radical surgery improves disease-free survival in patients with UC with a high risk of recurrence; however, its role adjuvant to chemoradiation therapy (CRT) is unknown.

METHODS

The NEXT trial is a single-arm, phase-2 study evaluating the efficacy and tolerability of nivolumab adjuvant to CRT in patients with localized or locoregional UC. The primary endpoint is failure-free survival (FFS) at 2 years. Secondary endpoints include patterns of recurrence, toxicity and quality of life (QoL). Plasma cell-free DNA (cfDNA) was subjected to shallow whole-genome sequencing to correlate with outcomes.

RESULTS

28 patients were enrolled and received 480 mg of nivolumab intravenously every 4 weeks for up to 12 cycles adjuvant to CRT. The FFS at 2 years was 33.2% (95% CI 18.5% to 59.6%). Nine (32%) patients had localized progression, and eight (29%) had distant progression. 25 (89%) had one or more high-risk features (ie, plasmacytoid differentiation, T4, N+, multiple tumors, tumors >5 cm, residual disease before CRT, carcinoma in situ, and hydronephrosis). Patients with ≤2 high-risk features had a median FFS of 45.2 months (95% CI 14.56 to not reached (NR)) compared with 8.2 months (95% CI 7.1 to NR) in those with three or more risk features (p=0.0024). Nivolumab-associated treatment-related adverse events occurred in 18 (64.3%) patients, only 3 had grade 3 TRAEs, with significant changes in QoL. Plasma cfDNA copy number instability (CNI) scores ≤25 before the first dose of adjuvant nivolumab and at cycle 4 were associated with better overall survival compared with CNI scores ≥26 (49.6 months vs 20.5 months, p=0.0024). Genome copy number changes indicated chromatin remodeling and tyrosine kinase pathways, among others, as oncogenic drivers implicated in progression.

CONCLUSION

Nivolumab adjuvant to CRT in localized or locally advanced UC is well tolerated. Stratification by risk factors and correlation with plasma cfDNA analyses generate hypotheses for potential patient selection and putative therapeutic targets for future study.

TRIAL REGISTRATION NUMBER

NCT03171025.

Opportunities for Discovery Using Neoadjuvant Immune Checkpoint Blockade in Melanoma

Treatment of resectable advanced-stage melanoma with neoadjuvant immunotherapy is rapidly becoming the new standard of care due to significant improvements in event-free survival (EFS) compared to surgery first followed by immunotherapy. The level of responsiveness seen in patients receiving immune checkpoint inhibitors (ICIs) must be mechanistically understood not only for the standardization of treatment but also to advance the novel concept of personalized cancer immunotherapy. This review aims to elucidate markers of the tumor microenvironment (TME) and blood that can predict treatment outcome. Interestingly, the canonical proteins involved in the molecular interactions that immunotherapies aim to disrupt have not been consistent indicators of treatment response, which amplifies the necessity for further research on the predictive model. Other major discussions surrounding neoadjuvant therapy involve the higher-level investigation of ICI efficacy due to the ability to examine a post-treatment tumor molecularly and pathologically, which this review will also cover. As neoadjuvant ICI becomes the standard of care in advanced melanoma treatment, further research aiming to identify more predictive biomarkers of treatment response to advance medical decision-making and patient care should continue to be sought after.

The interplay between angiogenesis-associated genes and molecular, clinical, and immune features in bladder cancer

BACKGROUND

Immunotherapy plays an important role in the treatment of bladder cancer (BLCA), with outcomes influenced by the tumor microenvironment (TME). Angiogenesis, a hallmark of cancer progression, shapes the TME and impacts immunotherapy efficacy. However, its specific role in BLCA remains underexplored.

METHODS

We analyzed 268 angiogenesis-related genes (ARGs) across ten gene sets using data from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) cohorts. Through unsupervised clustering, we identified ARG-based subtypes and developed an ARG scoring system to quantify angiogenesis activity. The ARG score was correlated with clinical outcomes, immune cell infiltration, and immunotherapy response. Functional validation was performed using in vitro assays.

RESULTS

Two distinct ARG clusters exhibited significant differences in immune profiles, clinical outcomes, and functional characteristics. Patients in the high ARG cluster had poorer survival but showed enhanced responsiveness to immune checkpoint inhibitors (ICIs). The novel ARG score demonstrated strong predictive power for immunotherapy efficacy and survival outcomes.

CONCLUSION

ARG expression patterns profoundly impact the TME, clinical outcomes, and immunotherapy response in BLCA. The ARG score is a novel biomarker for stratifying patients and optimizing treatment strategies. These findings may contribute to clarifying the characteristics of TME and enable the exploration of more potent immunotherapy strategies.

Enfortumab Vedotin With or Without Pembrolizumab in Metastatic Urothelial Carcinoma: A Systematic Review and Meta-Analysis

Importance

Metastatic urothelial carcinoma (mUC) presents a therapeutic challenge with poor outcome. Enfortumab vedotin has emerged as a promising treatment, necessitating a comprehensive evaluation of its effectiveness and safety.

Objective

To synthesize the available evidence on enfortumab vedotin, both as monotherapy and in combination with pembrolizumab, as an mUC treatment for the purpose of guiding clinical decision-making and future research.

Data Sources

Cochrane Library, MEDLINE (via PubMed), Google Scholar, and Web of Science were searched from database inception to August 31, 2024. Major conference abstracts from 2019 to 2024 were also included. Search strategy used a combination of Medical Subject Heading terms and free-text keywords related to mUC and enfortumab vedotin.

Study Selection

Randomized clinical trials and prospective studies investigating enfortumab vedotin in adult patients with mUC were included. Eleven studies met the inclusion criteria.

Data Extraction and Synthesis

Two independent reviewers extracted data and assessed study quality using the Cochrane Risk of Bias tool 2 and Risk of Bias in Non-Randomized Studies of Interventions tool. The meta-analysis used a random effects model, while a network meta-analysis was performed using a frequentist approach.

Main Outcomes and Measures

Primary outcomes were disease control rate (DCR), objective response rate (ORR), and 1-year survival rate.

Results

The 11 included studies (3 randomized clinical trials [27.3%] and 8 nonrandomized prospective studies [72.7%]) involved 2128 patients. Of these patients, 563 (26.5%) received enfortumab vedotin plus pembrolizumab, 814 (38.3%) received enfortumab vedotin without pembrolizumab, and 751 (35.3%) received chemotherapy. Enfortumab vedotin plus pembrolizumab was associated with a pooled DCR of 86% (95% CI, 83%-89%), ORR of 68% (95% CI, 64%-71%), and a 1-year survival rate of 79% (95% CI, 75%-82%). Enfortumab vedotin monotherapy had a pooled DCR of 73% (95% CI, 70%-76%), ORR of 43% (95% CI, 40%-47%), and a 1-year survival rate of 52% (95% CI, 48%-56%). Network meta-analysis revealed that enfortumab vedotin plus pembrolizumab significantly outperformed chemotherapy in ORR (odds ratio [OR], 3.47; 95% CI, 1.49-8.09; P = .004) and 1-year survival (OR, 2.32; 95% CI, 1.75-3.06; P < .001).

Conclusions and Relevance

In this systematic review and meta-analysis, enfortumab vedotin plus pembrolizumab showed high response rates in first-line settings, while enfortumab vedotin monotherapy was associated with clinical benefit in later lines of therapy. These findings underscore the importance of personalized treatment approaches, and future research is warranted to refine enfortumab vedotin-based therapies for mUC management.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Biomarkers for predicting bladder cancer therapy response

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

Immunoproteasome subunits are novel signatures for predicting efficacy of immunotherapy in muscle invasive bladder cancer

BACKGROUND

How to select muscle-invasive bladder cancer (MIBC) patients who are sensitive to immunotherapy is an unmet medical need. This study aimed to explore the role of immunoproteasome subunits as a novel signature for predicting efficacy of immunotherapy in MIBC.

METHODS

The expression profile of immunoproteasome subunits of MIBC and normal tissues was evaluated from data of The Cancer Genome Atlas (TCGA) and of the Chongqing University Cancer Hospital (CQUCH) cohort. Survival analysis and response to immunotherapy was further explored and compared between immunoproteasome subunitshigh and immunoproteasome subunitslow MIBC patients in the TCGA, the CQUCH and the IMvigor210 cohort. The association of the expression of immunoproteasome subunits with immune checkpoint molecules and the tumor immune microenvironment was explored by immunohistochemistry staining and bioinformatic analysis in MIBC of these three cohorts.

RESULTS

The expression of the immunoproteasome subunits PSMB8, PSMB9 and PSMB10 was significantly upregulated in MIBC. MIBC patients with high expression of immunoproteasome subunits, especially high expression of PSMB9, showed a trend of prolonged overall and progression free survival, which was further significantly improved in response to immunotherapy. Bioinformatics and immunohistochemistry staining revealed a positive correlation of the expression of immunoproteasome subunits with the expression of immune checkpoint molecules, with T cell activation and with T cell-mediated cytotoxicity.

CONCLUSIONS

Immunoproteasome subunits, in particular PSMB9, are immune microenvironment-related molecules of MIBC and are promising signatures for survival prediction in response to immunotherapy of MIBC.

Immune checkpoint inhibitors plus debulking surgery for patients with metastatic renal cell carcinoma: clinical outcomes and immunological correlates of a prospective pilot trial

Surgical removal of primary tumors reverses tumor-mediated immune suppression in pre-clinical models with metastatic disease. However, how cytoreductive surgery in the metastatic setting modulates the immune responses in patients, especially in the context of immune checkpoint therapy (ICT), is not understood. We report the first prospective, pilot, non-comparative clinical trial (NCT02210117) to evaluate the feasibility, clinical benefits, and immunologic changes of combining three different ICT-containing strategies with cytoreductive surgery or biopsy for patients with metastatic clear cell renal cell carcinoma. Primary safety endpoint of this trial has been met, with 43 patients completing cytoreductive surgery, 36 patients undergoing post-ICT biopsy, and 25 patients without either procedure due to progressive disease or toxicities or withdrawal of consent (total N = 104). Patients receiving ICT with cytoreductive surgery or biopsy, did not experience additional ICT- or procedure-related toxicities. The median overall survival was 54.7 months for patients who received ICT plus cytoreductive surgery. Immune-monitoring studies demonstrated that cytoreductive surgery increased antigen-presenting dendritic cell population and decreased KDM6B-expressing immune-suppressive myeloid cells in the peripheral blood. This study highlighted the feasibility of combining ICT with cytoreductive surgery in a metastatic setting and demonstrated the potential enhancement of immune responses following ICT plus cytoreductive surgery.

Biological and therapeutic implications of FGFR alterations in urothelial cancer: A systematic review from non-muscle-invasive to metastatic disease

FGFR3 mutations are among the most frequent genomic alterations in urothelial cancer (UC) being mainly associated with the luminal papillary (LumP) subtype. With the establishment of fibroblast growth factor receptor (FGFR) inhibitors, the treatment of UC is now shifting more and more towards personalized medicine. A systematic review using Medline and scientific meeting records was carried out according to the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines to assess the potential role of FGFR inhibitors in combination with additional therapies for the management of UC. Ongoing trials were identified via a systematic search on ClinicalTrials.gov. A total of eleven full-text papers, ten congress abstracts, and 5 trials on ClinicalTrials.gov were identified. Following the BLC2001 and THOR study, erdafitinib is the only approved FGFR1-4 inhibitor for metastatic UC with susceptible FGFR2/3 alterations following platinum-based chemotherapy. According to the THOR data of cohort 2, erdafitinib should not be recommended in patients who are eligible for and have not received prior immune checkpoint inhibitors (ICIs). One phase 3 trial is currently evaluating the intravesical device system (TAR210) in FGFR-altered intermediate non-muscle invasive bladder cancer (MoonRISe-1). Preclinical evidence suggests that combination-based approaches could be considered to improve the efficacy of FGFR inhibitors in patients with UC. Nine phase 1b/2 trials are focusing on the combination of FGFR inhibitors with ICIs, chemotherapy, or enfortumab vedotin. In metastatic disease, some preliminary analyses have reported promising results from these combinations (e.g. NORSE and FORT-2 trial). However, no phase 3 trial is terminated, so there is currently no level 1 evidence with long-term outcomes to support the combination of FGFR inhibitors with ICIs, chemotherapy, or targeted therapies. A better understanding of the different mechanisms of action to inhibit FGFR signaling pathways, optimal patient selection and treatment approaches is still needed.

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

Objective

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

Method

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

Results

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

Conclusion

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

Systematic review registration

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

Ophthalmologic toxicities of antineoplastic agents in genitourinary cancers: Mechanisms, management, and clinical implications

Genitourinary cancers affect over 480,000 patients in the United States annually. While promising therapeutic modalities continue to emerge, notably immune checkpoint inhibitors, molecular targeted therapies, antibody-drug conjugates, and radioligand therapies, these treatments are associated with a spectrum of adverse side-effects, including ophthalmologic toxicities. In this review, we cover the most commonly used antineoplastic agents for the kidneys, bladder, urinary tracts, prostate, testis, and penis, detailing mechanism, indication, and recent trials supporting their use. For each category of antineoplastic therapy, we describe the epidemiology, management, and clinical presentation, of common ophthalmologic toxicities stemming from these agents. This review serves to augment awareness and recognition of possible ophthalmologic manifestations resulting from the use of antineoplastic agents in genitourinary malignancy. Early identification of these side effects can hasten ophthalmology referral and ultimately improve visual outcomes in patients experiencing medication-induced ocular toxicities.

Immunotherapy rechallenge after significant toxicity - can it be done successfully?

AIM

We describe a single-center burden of admissions for irAE management and rechallenge feasibility.

METHODS

A retrospective single-center study of patients receiving immunotherapy between 2015-2018 assessing irAE and immunotherapy rechallenge outcomes.

RESULTS

69 of 307 patients (22%) required 124 hospitalizations for irAEs. 8 required ICU admission (2.6%). 6 (1.9%) died from irAEs. Corticosteroids were used in 96% of admissions. Additional immunosuppression was required in 26 admissions (21%). 47 of 69 patients were rechallenged (68%). The median duration between toxicity and rechallenge was 49 days (range 17-994 days). 19 of 47 rechallenged patients (40%) were admitted for subsequent irAE. 19 patients of the rechallenged group (40%) were alive at last follow-up.

CONCLUSION

Immunotherapy rechallenge following prior irAE hospitalization is feasible but carries significant toxicity risk.

Clinical Outcomes With Immune Checkpoint Inhibitors in Patients With FGFR2/3, MTAP or ERBB2 Genomic Alterations in Advanced Urothelial Carcinoma

BACKGROUND

FGFR2/3, MTAP and ERBB2 genomic alterations have treatment targets in advanced urothelial carcinoma (aUC). These alterations may affect tumor microenvironment and outcomes with immune checkpoint inhibitors (ICIs) in aUC.

PATIENTS AND METHODS

We identified patients with available genomic data in our multi-institution cohort of patients with aUC treated with ICI. Outcomes (observed response rate [ORR], progression-free and overall survival [PFS, OS]) with ICI were compared between patients with and without FGFR 2/3, MTAP, ERBB2 alterations. We compared ORR using logistic regression and PFS/OS using Cox proportional hazards.

RESULTS

Out of 1,514 patients, 276 (18%), 174 (11%) and 208 (14%) patients had known FGFR2/3, MTAP and ERBB2 alteration status, respectively. and were treated with ICI in 1L or 2 + L. In patients with (vs. without) FGFR2/3 alteration, ORR with ICI was 21% vs. 32% (OR 0.54; [95%CI 0.32-0.91]), PFS was significantly shorter in patients with FGFR2/3 alterations (HR = 1.36 [95%CI 1.03-1.80]; P=0.03); OS was not significantly different (HR = 1.22 [95%CI 0.86-1.47]). In patients with (vs. without) MTAP alteration, ORR with ICI was 25% versus 40% (OR 0.52 [95%CI 0.20-1.38]); PFS and OS were nonsignificantly different. In patients with (vs. without) ERBB2 alteration, ORR with ICI was similar (37% vs. 35%; OR 1.06; 95%CI 0.57-1.97); PFS and OS were significantly longer in patients with ERBB2 alteration [HR 0.63 (95%CI 0.41-0.95); P=0.03; HR 0.66, [95% CI 0.44-0.97]), respectively.

CONCLUSION

Our results support further evaluation of FGFR2/3, MTAP and ERBB2 alterations as putative biomarkers in patients with aUC treated with ICI.

Recent Advances in Immunotherapy for Bladder Cancer Treatment

Bladder cancer is one of the most common malignancies worldwide. Standard neoadjuvant or metastatic therapy used to be cisplatin-based chemotherapy, but many patients are ineligible due to age, renal impairment, or frailty. Checkpoint inhibitors (e.g., atezolizumab and pembrolizumab) enhance survival in cisplatin-ineligible patients. Originally approved as second-line therapy for patients after platinum-based chemotherapy, nivolumab was approved by the FDA for adjuvant therapy of high-risk muscle-invasive urothelial cancer following the Checkmate 274 trial. It is indicated for patients with resected disease or cisplatin ineligibility. Recent developments focused on the contribution of nivolumab to outcomes have been complemented by ongoing investigations on atezolizumab as a monotherapy or in combinations for muscle-invasive bladder cancer, providing further hope for improved control. This narrative review aims to clarify the current applications of immunotherapy in treating bladder cancer and to explore the future outlook based on ongoing clinical trials.

Identification of tumor-antigen signatures and immune subtypes for mRNA vaccine selection in muscle-invasive bladder cancer

BACKGROUND

Muscle-invasive bladder cancer continues to lack reliable diagnostic and prognostic biomarkers. Recently, tumor vaccines targeting specific molecules have emerged as a promising treatment in inhibiting tumor progression, which was rekindled under the background of coronavirus disease-2019 pandemic. However, the application of mRNA vaccine targeting muscle-invasive bladder cancer-specific antigens remains limited, and there has been a lack of comprehensive studies or validations to identify suitable patient subgroups for vaccination. This study aims to explore novel muscle-invasive bladder cancer antigen signatures to identify patients most likely to benefit from vaccination.

METHODS

Gene expression profiles of muscle-invasive bladder cancer samples, along with corresponding clinical data, were retrieved from the Cancer Genome Atlas Program. The least absolute shrinkage and selection operator model was applied to develop signatures for stratifying muscle-invasive bladder cancer patients. Prognostic accuracy of each factor was assessed using receiver operating characteristic analysis. Tumor Immune Estimation Resource was employed to visualize the relationship between the proportion of antigen-presenting cells and the expression of selected genes. The CIBERSORT and WGCNA R packages were used to identify differences in immune infiltration levels across muscle-invasive bladder cancer subgroups. Additionally, the STRING database and Cytoscape were used to construct the protein-protein interaction network. CCK-8 and colony formation assays were employed in invitro experiments.

RESULTS

A total of 49 potential tumor antigens were identified. Using least absolute shrinkage and selection operator Cox regression, 14 tumor antigens were selected to develop a risk evaluation signature. The risk score signature can serve as a valuable tool for predicting the outcomes of muscle-invasive bladder cancer patients. Based on differential clinical, molecular, and immune-related gene profiles, muscle-invasive bladder cancer patients were classified into 2 subtypes: the immune "cold" subtype (immune score 1) and the immune "hot" subtype (immune score 2). The immune score signature, developed using a logistic score model, effectively distinguishes between patients more likely to belong to immune score 1 or 2. Notably, patients with a high risk score exhibited a higher proportion of immune score 2 compared to those with a low risk score. Additionally, the prognostic accuracy was significantly enhanced when the risk score and immune score were combined. Different tumor subtypes displayed distinct immune landscapes and signaling pathways. Moreover, novel tumor antigens associated with oxidative stress were identified.

CONCLUSION

The risk score and immune score signatures based on tumor antigens have identified potential effective neo-antigens for the development of mRNA vaccines targeting muscle-invasive bladder cancer. Patients with low risk score and immune score 1 subtype are more likely to benefit from mRNA vaccination. Additionally, this study highlights the critical role of oxidative stress in modulating the efficacy of the mRNA vaccine.

Membrane palmitoylated protein MPP1 inhibits immune escape by regulating the USP12/ CCL5 axis in urothelial carcinoma

BACKGROUND

The response rate to immunotherapy in patients with urothelial carcinoma remains limited. Studies have shown that membrane palmitoylated proteins (MPPs) play key roles in tumor progression. However, the mechanisms by which MPP1 regulates immune escape in urothelial carcinoma are not well understood.

METHODS

The TCGA and BEST databases were used to analyze the associations between the expression of members of the MPP family and the prognosis or immunotherapy sensitivity of urothelial carcinoma patients. MPP1 was identified due to its significant association with survival and immunotherapy sensitivity. MPP1 expression in urothelial carcinoma tissues and cell lines was examined. An MPP1 overexpression vector was used to transfect urothelial carcinoma cells. The functional assays included proliferation, migration, urothelial carcinoma cell-CD8+ T-cell coculture, CD8+ T-cell chemotaxis, and tumorigenesis in human immune reconstitution NOG mice (HuNOG). Bioinformatics, coimmunoprecipitation (CO-IP), mass spectrometry, quantitative real-time polymerase chain reaction (RT-qPCR), and western blotting were used to validate the activity of the MPP1/USP12/CCL5 cascade.

RESULTS

Analysis of the BEST data revealed that, compared with other MPP family genes, MPP1 was more strongly associated with urothelial carcinoma prognosis and immunotherapy response. Low MPP1 expression was observed in urothelial carcinoma patients and was positively associated with better survival. MPP1 inhibited the proliferation and migration of urothelial carcinoma cells. Bioinformatics, in vitro coculture assays, and in vivo tumorigenesis experiments demonstrated that MPP1 promotes CCL5 production and CD8+ T-cell chemotaxis in the urothelial carcinoma tumor microenvironment (TME). Mechanistically, bioinformatics, mass spectrometry, co-IP, RT-qPCR, and western blot analyses indicated that MPP1 increases CCL5 expression by binding to and promoting USP12.

CONCLUSIONS

MPP1 significantly inhibits urothelial carcinoma cell proliferation and immune escape via the MPP1/USP12/CCL5 cascade. MPP1 has the potential to serve as a biomarker for guiding immunotherapy in patients with urothelial carcinoma.

FGFR-Altered Urothelial Carcinoma: Resistance Mechanisms and Therapeutic Strategies

Fibroblast growth factor receptor (FGFR) 2/3 alterations have been implicated in tumorigenesis in several malignancies, including urothelial carcinoma. Several FGFR inhibitors have been studied or are in development, and erdafitinib is the sole inhibitor to achieve regulatory approval. Given the rapidly evolving treatment landscape for advanced urothelial carcinoma, including regulatory approvals and withdrawals, determining the most appropriate treatment strategies and sequencing for FGFR-altered urothelial carcinoma is becoming increasing critical. However, the clinical efficacy of FGFR inhibitors is limited by acquired resistance similar to that seen with other tyrosine kinase inhibitors. Additional challenges to the clinical use of FGFR inhibitors include treatment-related adverse events and the financial costs associated with treatment. In this review, we describe known mechanisms of FGFR inhibitor resistance, including gatekeeper mutations, domain mutations, and the development of new mutations. In addition, we discuss management strategies, including ongoing clinical trials evaluating FGFR inhibitors, antibody-drug conjugates, and combination therapies with immune checkpoint inhibitors that may provide additional treatment options for localized and metastatic urothelial carcinoma.

Neutralizing GDF-15 can overcome anti-PD-1 and anti-PD-L1 resistance in solid tumours

Cancer immunotherapies with antibodies blocking immune checkpoint molecules are clinically active across multiple cancer entities and have markedly improved cancer treatment1. Yet, response rates are still limited, and tumour progression commonly occurs2. Soluble and cell-bound factors in the tumour microenvironment negatively affect cancer immunity. Recently, growth differentiation factor 15 (GDF-15), a cytokine that is abundantly produced by many cancer types, was shown to interfere with antitumour immune response. In preclinical cancer models, GDF-15 blockade synergistically enhanced the efficacy of anti-PD-1-mediated checkpoint inhibition3. In a first-in-human phase 1-2a study (GDFATHER-1/2a trial, NCT04725474 ), patients with advanced cancers refractory to anti-PD-1 or anti-PD-L1 therapy (termed generally as anti-PD-1/PD-L1 refractoriness) were treated with the neutralizing anti-GDF-15 antibody visugromab (CTL-002) in combination with the anti-PD-1 antibody nivolumab. Here we show that durable and deep responses were achieved in some patients with non-squamous non-small cell lung cancer and urothelial cancer, two cancer entities identified as frequently immunosuppressed by GDF-15 in an in silico screening of approximately 10,000 tumour samples in The Cancer Genome Atlas database. Increased levels of tumour infiltration, proliferation, interferon-γ-related signalling and granzyme B expression by cytotoxic T cells were observed in response to treatment. Neutralizing GDF-15 holds promise in overcoming resistance to immune checkpoint inhibition in cancer.

Efficacy and Safety of Low-Dose Nivolumab in Treatment of Advanced Solid Tumors: A Retrospective Audit from Resource-Constrained Settings

Background

Immunotherapy has improved outcomes in many advanced solid tumors. In resource-constrained settings, less than 2% of patients can afford standard dose immunotherapy. A recent phase II study showed the efficacy of low-dose immunotherapy in this setting. We used low-dose immunotherapy on a compassionate basis in patients who had progressed on available standard treatment options and standard dose immunotherapy was not feasible.

Patients and Methods

We retrospectively collected data from the medical oncology department for consecutive patients who had initially received standard lines of therapy followed by low-dose immunotherapy (nivolumab 40 mg) on a compassionate basis. The demographic details, histology, prior treatment, clinical and radiological response, date of disease progression, date of death, and toxicity data were collected.

Results

A total of 54 consecutive patients, who received low-dose immunotherapy with nivolumab from January 1, 2018 to February 14, 2020, were included in this analysis; 4 patients were not radiologically evaluable. The median age was 50.4 years (range 35-74 years), male:female ratio was 6:1. The most common comorbidities were hypertension and diabetes seen in 12 (22.2%) and 6 (11.1%) patients, respectively. The majority of the patients (70.4%) were of head and neck cancer. The median follow-up was 4.5 months (range 0.5-11.7). Clinical benefit was observed in 18 (33.3%) patients. Partial response and stable disease were achieved in 9 (16.7%) and 5 (9.3%) patients, respectively. Median survival was not reached for these patients. Six months progression-free survival and overall survival were 100 versus 8.7% (hazard ratio [HR] 0.05, 95% confidence interval [CI]: 0.01-0.36; p  = 0.003) and 100 versus 29.7% (HR 0.03, 95% CI: 0.00-0.95; p  = 0.047), respectively, for responders and nonresponders. The side effects were manageable.

Conclusion

In resource-constrained settings, low-dose immunotherapy with nivolumab seems to be an effective treatment option. Further studies are warranted to evaluate this approach.

Immunohistochemistry-based molecular subtypes of urothelial carcinoma derive different survival benefit from platinum chemotherapy

Distinct molecular subtypes of muscle-invasive bladder cancer (MIBC) may show different platinum sensitivities. Currently available data were mostly generated at transcriptome level and have limited comparability to each other. We aimed to determine the platinum sensitivity of molecular subtypes by using the protein expression-based Lund Taxonomy. In addition, we assessed the tumor heterogeneity within the primary tumor and between the primary and lymph node (LN) metastatic sites. Thirteen immunohistochemical markers were stained in a tissue microarray with an overall number of 1,508 cores. Statistical evaluation was performed in 199 patients divided into three chemo-naïve MIBC cohorts: (1) pT3/4 and/or LN+ patients who received radical cystectomy without platinum treatment, (2) patients who received adjuvant chemotherapy (AC), and (3) patients who underwent palliative platinum treatment for metastatic disease or postoperative progression. Overall survival (OS) was used as the primary endpoint. Patients with the genomically unstable (GU) subtype had significantly better OS in the AC group compared to the radical cystectomy group (HR: 0.395, 95% CI: 0.205-0.795, p = 0.005). In contrast, no such association was observed for the basal/squamous (Ba/Sq) subtype. Intratumor heterogeneity was present in 19% of cases, with the lowest level in the Ba/Sq and GU tumors (14% each) and the highest level of 43% in small-cell/neuroendocrine-like tumors. There was greater subtype heterogeneity between primary tumors and LN metastases. In conclusion, immunohistochemistry-based Lund Taxonomy subtypes remain stable within the same primary tumor, with the GU subtype deriving the greatest OS benefit from AC. However, high tumor heterogeneity between the primary tumor and metastatic sites can impact the effectiveness of therapies.

Programmed cell death 1 inhibitor alone or combined with chemotherapy for patients with locally advanced or metastatic urothelial carcinoma: a single-center experience

BACKGROUND

Immune checkpoint inhibitors (ICIs) alone or in combination with standard chemotherapy for advanced urothelial carcinoma (UC) have been tested as first-line treatment in clinical trials. This study aimed to evaluate the clinical outcomes of programmed cell death 1 (PD-1) inhibitor alone or combined with chemotherapy for patients with locally advanced or metastatic UC in a real world clinical care setting, and sought to identify prognostic factors for overall survival (OS).

METHODS

A retrospective, real-world study involving 35 locally advanced or metastatic UC patients treated with PD-1 inhibitor alone or in combination with chemotherapy was conducted. Kaplan-Meier curves were used to assess progression-free survival (PFS) and OS. A Cox regression analysis was conducted to explore the association of baseline variables with OS.

RESULTS

In our cohort of 35 patients, 7 patients were treated with PD-1 inhibitor alone and 28 with PD-1 inhibitor plus platinum-based chemotherapy. The median OS was 16.0 months (95% CI: 11.9-20.1), and median PFS was 12.0 months (95% CI: 8.6-15.4) for all patients. PD-1 inhibitor combined with chemotherapy was associated with better PFS than PD-1 inhibitor monotherapy (HR: 0.19, p = 0.018). Treatment-related adverse events (AEs) of any grade occurred in 5 (71.4%) patients who received PD-1 inhibitor and 24 (85.7%) patients who received PD-1 inhibitor plus chemotherapy. Eastern Cooperative Oncology Group (ECOG) performance status (PS) and neutrophil-lymphocyte ratio (NLR) were identified as prognostic factors.

CONCLUSION

This study suggested that patients with locally advanced or metastatic UC could benefit from PD-1 inhibitor alone or combined with chemotherapy in daily clinical practice. ECOG PS and NLR can be used for prognostication of survival.

Nanobodies as innovative immune checkpoint modulators: advancing cancer immunotherapy

The immune system relies on a delicate balance between attacking harmful pathogens and preserving the body's own tissues, a balance maintained by immune checkpoints. These checkpoints play a critical role in preventing autoimmune diseases by restraining excessive immune responses while allowing the immune system to recognize and destroy abnormal cells, such as tumors. In recent years, immune checkpoint inhibitors (ICIs) have become central to cancer therapy, enabling the immune system to target and eliminate cancer cells that evade detection. Traditional antibodies, such as IgGs, have been widely used in immune therapies but are limited by their size and complexity. Nanobodies (Nbs), derived from camelid heavy-chain-only antibodies, offer a promising alternative. These small, stable antibody fragments retain the antigen-binding specificity of traditional antibodies but have enhanced solubility and the ability to target otherwise inaccessible epitopes. This review explores the use of Nbs as ICIs, emphasizing their potential in cancer immunotherapy and other immune-related treatments. Their unique structural properties and small size make Nbs highly effective tools for modulating immune responses, representing a novel approach in the evolving landscape of checkpoint inhibitor therapies.

Clinical characteristics of patients requiring emergency hospitalization due to immune-related adverse events: a retrospective study

BACKGROUND

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, offering hope for various malignancies by enhancing the immune response against tumors. However, ICIs are associated with unique immune-related adverse events (irAEs), which differ significantly from conventional chemotherapy-induced toxicities. These irAEs, which affect more than 70% of patients and often escalate to severe grades, present substantial clinical management challenges and frequently necessitate emergency hospitalization. Therefore, this study aimed to investigate the clinical characteristics of patients requiring emergency hospitalization due to irAEs during ICI therapy to enhance understanding and improve management strategies.

METHODS

This retrospective study evaluated patients who received ICIs at Iwate Medical University Hospital between August 1, 2016, and December 31, 2022, and required emergency hospitalization due to irAEs. Clinical data were extracted from the medical records, including patient demographics, presenting complaints, time from ICI initiation to hospitalization, irAE diagnoses, and treatment outcomes. The Spearman rank correlation coefficient was used to analyze the associations between the chief complaints and irAE diagnoses.

RESULTS

Of 1009 ICI-treated patients, 96 required emergency hospitalization for irAEs. The cohort's mean age was 73 years, with 75.0% of patients being male. Among patients who required emergency hospitalization, a high proportion were undergoing treatment for lung cancer (41.7%). The median hospitalization duration was 87 days. The chief complaints included dyspnea (34.4%) and fatigue (34.4%), with gastrointestinal and respiratory disorders being the most frequent irAEs (35.4%). Significant correlations were observed between dyspnea and respiratory diseases (Rs = 0.66), skin diseases and disorders (Rs = 0.81), pain and musculoskeletal disorders (Rs = 0.59), and diarrhea and gastrointestinal disorders (Rs = 0.49). Corticosteroids were administered to 64.6% of the patients. Despite emergency interventions, 8.3% of patients succumbed to irAEs, while 33.3% resumed ICI therapy after hospitalization.

CONCLUSIONS

Emergency hospitalization due to irAEs is a considerable concern in ICI therapy, occurring in 9.5% of treated patients. The high incidence of severe irAEs within the first 3 months of treatment underscores the need for early and vigilant monitoring. This study highlights the importance of recognizing and promptly managing irAEs to improve patient outcomes. Future strategies should focus on developing comprehensive management frameworks and enhancing patient and caregiver education to recognize symptoms that warrant immediate medical attention.

Trastuzumab Deruxtecan with Nivolumab in HER2-Expressing Metastatic Breast or Urothelial Cancer: Analysis of the Phase Ib DS8201-A-U105 Study

PURPOSE

This multicenter phase Ib study investigated trastuzumab deruxtecan (T-DXd) plus nivolumab in patients with HER2-expressing metastatic breast cancer (mBC) and metastatic urothelial cancer (mUC).

PATIENTS AND METHODS

Part 1 determined the recommended dose for expansion of T-DXd plus nivolumab. Part 2 evaluated efficacy and safety; the primary endpoint was confirmed objective response rate by independent central review.

RESULTS

In part 1, seven patients with mBC were enrolled and received T-DXd 3.2 mg/kg (four patients) or 5.4 mg/kg (three patients) plus nivolumab. The recommended dose for expansion for T-DXd was 5.4 mg/kg plus nivolumab 360 mg intravenously every 3 weeks. In part 2, 32 patients with HER2-positive mBC (cohort 1; inclusive of three administered 5.4 mg/kg in part 1), 16 with HER2-low mBC (cohort 2), 30 with HER2-high mUC (cohort 3), and four with HER2-low mUC (cohort 4) were enrolled. At data cutoff (July 22, 2021), the confirmed objective response rates (95% confidence interval) for cohorts 1 to 4 were 65.6% (46.8%-81.4%), 50.0% (24.7%-75.3%), 36.7% (19.9%-56.1%), and not assessed due to small sample size, respectively. The median treatment duration (range) with T-DXd in cohorts 1 to 4 was 8.9 (1-23) months, 6.9 (1-21) months, 3.9 (1-21) months, and not assessed, respectively; the most common treatment-emergent adverse event was nausea (55.2%, 62.5%, 73.3%, and 75.0%, respectively). Adjudicated drug-related interstitial lung disease/pneumonitis rates (cohorts 1-3) were 20.7%, 0%, and 20.0%, respectively (one grade 5 each, cohorts 1 and 3).

CONCLUSIONS

T-DXd plus nivolumab demonstrated promising antitumor activity in HER2-expressing mBC or mUC and safety consistent with the known profile of T-DXd. Interstitial lung disease/pneumonitis is an important risk and requires careful monitoring and prompt intervention.

Molecular heterogeneity in urothelial carcinoma and determinants of clinical benefit to PD-L1 blockade

Checkpoint inhibitors targeting programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) have revolutionized cancer therapy across many indications including urothelial carcinoma (UC). Because many patients do not benefit, a better understanding of the molecular mechanisms underlying response and resistance is needed to improve outcomes. We profiled tumors from 2,803 UC patients from four late-stage randomized clinical trials evaluating the PD-L1 inhibitor atezolizumab by RNA sequencing (RNA-seq), a targeted DNA panel, immunohistochemistry, and digital pathology. Machine learning identifies four transcriptional subtypes, representing luminal desert, stromal, immune, and basal tumors. Overall survival benefit from atezolizumab over standard-of-care is observed in immune and basal tumors, through different response mechanisms. A self-supervised digital pathology approach can classify molecular subtypes from H&E slides with high accuracy, which could accelerate tumor molecular profiling. This study represents a large integration of UC molecular and clinical data in randomized trials, paving the way for clinical studies tailoring treatment to specific molecular subtypes in UC and other indications.

Tumor Expression of CD83 Reduces Glioma Progression and Is Associated with Reduced Immunosuppression

SIGNIFICANCE

Immunosuppression in malignant glioma remains a barrier to therapeutic development. CD83 overexpression in human and mouse glioma increases survival. CD83+ tumor cells promote signatures related to cytotoxic T cells, enhanced activation of CD8+ T cells, and increased proinflammatory cytokines. These findings suggest that tumor-expressed CD83 could mediate tumor-immune communications.

An overview of immune checkpoint inhibitor toxicities in bladder cancer

Bladder cancer is the tenth most prevalent malignancy worldwide, with a significant mortality burden. Urothelial carcinoma (UC) is the most common histological subtype, and treatment options are guided by whether the disease is muscle-invasive (MIBC) or non-muscle-invasive (NMIBC), with subsequent risk group stratification. The growing popularity of immune checkpoint inhibitors (ICIs) to treat MIBC and NMIBC as either monotherapy or combined with intravesical agents, may radically change the treatment paradigm of UC. Current treatments for NMBIC includes intravesical chemotherapy after trans-urethral resection of the bladder tumour, intravesical bacillus Calmette-Guerin (BCG) or radical cystectomy. Cisplatin-based chemotherapy is widely regarded as the first-line treatment for metastatic UC due to its beneficial response and survival rates when compared to alternative therapies. However, up to 70 % of metastatic UC patients are ineligible, and the prognosis of these patients remains poor, with a median survival of 13-16 months. For NMIBC and MIBC, ICIs provide a promising alternative for cisplatin-ineligible patients. In UC, ICIs including atezolizumab, nivolumab, avelumab, and pembrolizumab are Food and Drug Administration (FDA)-approved for monotherapy, and have demonstrated promising results, particularly in those who cannot receive cisplatin-based chemotherapy, and as a second-line treatment option for recurrent UC following platinum-based chemotherapy. It is important to consider that some patients may experience adverse events (AEs) with limited clinical benefit. Infusion-related reactions and immune-mediated AEs (imAEs) such as colitis, endocrinopathies, hepatitis, pneumonitis, interstitial lung disease, renal dysfunction, nephritis, cutaneous and neurological toxicities must be monitored for. Currently, there is no clear consensus on the role of a 'two-year stopping rule' in reducing the risk of imAEs, with further research on the optimal treatment duration of ICIs required. With increased ICI use, vigilance regarding their side effects is imperative. This review aims to provide an updated overview of ICI toxicities in bladder cancer, to assist clinicians in their therapeutic decision-making, with consideration of patient characteristics and the clinical context.

Clinical significance and expression of SLC35F6 in bladder urothelial carcinoma

BACKGROUND

SLC35F6 negatively regulates outer mitochondrial membrane permeability and positively regulates apoptotic signaling pathways and cell population proliferation. The biological function of SLC35F6 in bladder cancer (BC) remains inadequately established. This study evaluates the expression and clinical significance of SLC35F6 in BC, assesses its prognostic value and explores its relationship with key immune-related molecules in the tumor microenvironment.

METHODS

Combining bioinformatics tools and immunohistochemistry (IHC) analysis, the expression of SLC35F6 was analyzed through IHC in the tissues of 145 BC patients treated at the Affiliated Hospital of Nantong University from 2004 to 2009. The relationship between SLC35F6 expression levels and significant clinicopathological factors was examined using the chi-square test. Prognostic values were analyzed using the COX regression model and the Kaplan-Meier survival curve. Analysis of the receiver operating characteristic curve was conducted to assess the predictive performance of SLC35F6 in BC patients.

RESULTS

The expression levels of both SLC35F6 mRNA and protein were elevated in BC tissue relative to benign tissue. Kaplan-Meier analysis indicated that patients exhibiting elevated SLC35F6 protein expression had a worse prognosis. Multivariate Cox regression analysis confirmed that SLC35F6, TNM stage and grade are independent risk factors for bladder cancer. SLC35F6, when analyzed alongside clinical pathological factors, enhances the accuracy of survival predictions for Bladder Urothelial Carcinoma (BLCA) patients.

CONCLUSION

SLC35F6 is upregulated in BC patients compared to normal individuals and is linked to a worse prognosis. SLC35F6 analyzed alongside clinical pathological factors can enhance the accuracy of survival predictions for BLCA patients, suggesting its potential value as a prognostic and predictive biomarker.

Exploring the Immunoresponse in Bladder Cancer Immunotherapy

Bladder cancer (BC) represents a wide spectrum of diseases, ranging from recurrent non-invasive tumors to advanced stages that require intensive treatments. BC accounts for an estimated 500,000 new cases and 200,000 deaths worldwide every year. Understanding the biology of BC has changed how this disease is diagnosed and treated. Bladder cancer is highly immunogenic, involving innate and adaptive components of the immune system. Although little is still known of how immune cells respond to BC, immunotherapy with bacillus Calmette-Guérin (BCG) remains the gold standard in high-risk non-muscle invasive BC. For muscle-invasive BC and metastatic stages, immune checkpoint inhibitors targeting CTLA-4, PD-1, and PD-L1 have emerged as potent therapies, enhancing immune surveillance and tumor cell elimination. This review aims to unravel the immune responses involving innate and adaptive immune cells in BC that will contribute to establishing new and promising therapeutic options, while reviewing the immunotherapies currently in use in bladder cancer.