EVIDENCE SUPPORTING PREOPERATIVE CHEMOTHERAPY FOR SMALL CELL CARCINOMA OF THE BLADDER: A RETROSPECTIVE REVIEW OF THE M. D. ANDERSON CANCER EXPERIENCE

Adjuvant Chemotherapy and Survival After Radical Cystectomy in Histologic Subtype Bladder Cancer

OBJECTIVES

Patients with histologic subtype bladder cancer (HSBC) suffer worse outcomes than those with conventional urothelial carcinoma (UC). We sought to characterize the use of adjuvant chemotherapy (AC) in HSBC after radical cystectomy (RC) using the National Cancer Database (NCDB).

MATERIALS AND METHODS

We retrospectively queried the NCDB (2006-2019) for patients with non-metastatic bladder cancer (BC) who underwent RC (N = 45,797). Patients were stratified by histologic subtype and receipt of AC. Multivariable logistic regression determined associations of demographic and clinicopathologic features with receipt of AC. Multivariable Cox regression evaluated associations between receipt of any AC and overall survival (OS).

RESULTS

We identified 4,469 patients with HSBC classified as squamous, adenocarcinoma, small cell, sarcomatoid, micropapillary, or plasmacytoid. Squamous comprised 31% of the HSBC cohort, followed by small cells and micropapillary. Black patients were presented with a higher prevalence of adenocarcinoma (119/322, 37.0%). Use of AC was highest in plasmacytoid and small cell (30% each) and lowest in squamous (11%). Neuroendocrine histology was independently associated with greater odds of receiving AC (HR 1.6, 95% CI 1.37-1.87), while squamous cell histology was associated with lower odds (HR 0.61, 95% CI 0.53-0.71). On multivariable Cox regression analysis, treatment with AC was associated with significantly longer OS (HR 0.69, 95% CI 0.59-0.81) and for squamous, sarcomatoid, and micropapillary cohorts after stratified by subtype.

CONCLUSIONS

AC was variably used among patients with HSBC and was associated with OS benefit in such patients.

Clinical Outcomes of Small Cell Carcinoma of the Genitourinary Tract and the Prognostic Significance of the Tumor Immune Microenvironment

PURPOSE

Small cell carcinoma of the genitourinary tract (GU SCC) is a rare disease with a poor prognosis. There are only limited treatment options due to insufficient understanding of the disease. In this study, we analyzed the clinical outcomes of patients with GU SCC and their association with the tumor immune phenotype.

MATERIALS AND METHODS

Patients diagnosed with GU SCC were included. Survival outcomes according to the primary location (prostate and non-prostate) and stages (limited disease [LD] and extensive disease [ED]) were analyzed. We performed multiplex immunohistochemistry (IHC) in non-prostate SCC patients and analyzed the immune cell population.

RESULTS

A total of 77 patients were included in this study. Their median age was 71 years, 67 patients (87.0%) were male, and 48 patients (62.3%) had non-prostate SCC. All patients with ED (n=31, 40.3%) received etoposide plus platinum (EP) as initial treatment and median overall survival (OS) was 9.7 months (95% confidence interval [CI], 7.1 to 18.6). Patients with LD (n=46, 59.7%) received EP followed by radiotherapy or surgery, and 24-months OS rate was 63.6% (95% CI, 49.9 to 81.0). The multiplex IHC analysis of 21 patients with non-prostate SCC showed that patients with a higher density of programmed death-ligand 1-expressing CD68+CD206+ M2-like macrophages had significantly worse OS outcomes with an adjusted hazards ratio of 4.17 (95% CI, 1.25 to 14.29; adjusted p=0.02).

CONCLUSION

Patients with GU SCC had a poor prognosis, even those with localized disease. The tumor immune phenotypes were significantly associated with survival. This finding provides new insights for treating GU SCC.

Multidisciplinary treatment for small cell carcinoma of the bladder: a case report

Small cell carcinoma (SCC) of the urinary bladder is a rare and highly aggressive subtype of bladder cancer. Most cases are diagnosed at advanced stages, and its therapeutic strategy remains unestablished. Here, we report a case of bladder SCC in which multidisciplinary treatment has resulted in relatively long-term survival. A 68-year-old man presented with gross hematuria. A cystoscopy revealed an invasive bladder tumor. A transurethral resection of bladder tumor (TURBT) was performed, and the pathological diagnosis was SCC. After systemic chemotherapy using etoposide and carboplatin and subsequent TURBT, a radical cystectomy and ileal conduit were performed. Three months postoperatively, the patient had a recurrence in the para-aortic lymph node. Systemic combination chemotherapy with carboplatin plus irinotecan (CBDCA + CPT-11) was administered, followed by amrubicin and an immune checkpoint inhibitor. In addition to this treatment, radiation therapy for the metastatic region led to the reduction of pain and shrinkage of the metastatic lesion. The patient survived for 2 years after the initial diagnosis. Our report indicates that multidisciplinary treatment can be effective for SCC of the bladder, and a therapeutic strategy including the identification of novel biomarkers should be established.

Emerging Insights in Small-Cell Carcinoma of the Genitourinary Tract: From Diagnosis to Novel Therapeutic Horizons

Small-cell carcinomas (SCCs) of the genitourinary (GU) tract are rare malignancies with high metastatic potential. The most common primary sites are the bladder and prostate, but case reports of primary SCC of the kidney, ureter, and urethra also exist. The majority of patients present with gross hematuria, irritative or obstructive urinary symptoms, and symptoms of locoregionally advanced or metastatic disease at initial presentation. SCC of the bladder presents with nodal or metastatic involvement in the majority of cases and requires the use of platinum-based chemotherapy in combination with surgery and/or radiation. SCC of the prostate is most commonly seen in the metastatic castrate-resistant setting, and aggressive variant disease presents with a greater propensity for visceral metastases, osteolytic lesions, and relatively low serum prostate-specific antigen for volume of disease burden. Multiple retrospective and prospective randomized studies support the use of a multimodal approach combining platinum-based systemic therapy regimens with radiation and/or surgery for localized disease. This evidence-based strategy is reflected in multiple consensus guidelines. Emerging data suggest that small-cell bladder and prostate cancers transdifferentiate from a common progenitor of conventional urothelial bladder carcinoma and prostatic acinar adenocarcinoma, respectively. Areas of active basic research include efforts to identify the key genetic and epigenetic drivers involved in the emergence of small cell cancers to exploit them for novel therapies. Here, we review these efforts, discuss diagnosis and currently supported management strategies, and summarize ongoing clinical trials evaluating novel therapies to treat this rare, aggressive GU cancer.

How Do Molecular Classifications Affect the Neoadjuvant Treatment of Muscle-Invasive Urothelial Carcinoma?

Despite the significant improvements in the field of oncological treatments in recent decades, and the advent of targeted therapies and immunotherapy, urothelial carcinoma of the bladder remains a highly heterogeneous and difficult-to-treat neoplasm with a poor prognosis. In this context, owing to the new methods of genomic sequencing, numerous studies have analyzed the genetic features of muscle-invasive bladder cancer, providing a consensus set of molecular classes, to identify malignancies that may respond better to specific treatments (standard chemotherapy, immunotherapy, target therapy, local-regional treatment, or combinations) and improve the survival. The aim of the current review is to provide an overview of the current status of the molecular landscape of muscle-invasive bladder cancer, focusing our attention on therapeutic and prognostic implications in order to select the most effective and tailored therapeutic regimen for the individual patient.

Comparative Effectiveness Analysis of Treatment Strategies for Surgically Resectable Neuroendocrine Carcinoma of the Urinary Tract

BACKGROUND

Neoadjuvant chemotherapy (neoCTX) has been recommended as the optimal strategy in surgically resectable neuroendocrine carcinoma (NEC) of the urinary tract (NEC-URO).

OBJECTIVE

To determine the systemic therapy regimen and timing, which are most active against NEC-URO.

DESIGN, SETTING, AND PARTICIPANTS

We used our institutional historical clinical and pathological database to study 203 patients (cT2, 74%; cT3/4a, 22%; and cTx, 4%) with surgically resectable NEC-URO between November 1985 and May 2020. A total of 141 patients received neoCTX and 62 underwent initial radical surgery, 24 of whom received adjuvant CTX (adjCTX).

INTERVENTION

Neoadjuvant CTX with etoposide/cisplatin (EP), an alternating doublet of ifosfamide/doxorubicin (IA) and EP, dose-dense methotrexate/vinblastine/doxorubicin/cisplatin (MVAC), gemcitabine/cisplatin (GC), or others.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Overall survival (OS), downstaging rate, and pathological complete response using a multivariable model adjusting for tumor- and patient-related factors.

RESULTS AND LIMITATIONS

Downstaging rate was significantly improved with neoCTX versus initial surgery (49.6% vs 14.5%, p < 0.0001), stage cT2N0 versus cT3/4N0 (44% vs 25%, p = 0.01), or presence of carcinoma in situ (47% vs 28%, p = 0.01). Downstaging was greatest with IA/EP (65%) versus EP (39%), MVAC/GC (27%), or others (36%, p = 0.04). After adjusting for age and Eastern Cooperative Oncology Group performance status, IA/EP was still associated with improved downstaging (odds ratio = 3.7 [1.3-10.2], p = 0.01). At a median follow-up of 59.7 mo, 5-yr OS rates for neoCTX followed by surgery, surgery alone, and surgery followed by adjCTX were 57%, 22%, and 30%, respectively. An NEC regimen (IA/EP or EP) versus a urothelial regimen (MVAC/GC or others) was associated with improved survival (145.4 vs 42.5 mo, hazard ratio = 0.49, 95% confidence interval: 0.25-0.94).

CONCLUSIONS

Neoadjuvant CTX remains the standard-of-care treatment for NEC-URO with an advantage for NEC regimens over traditional urothelial regimens. IA/EP improves pathological downstaging at the time of surgery compared with EP, but is reserved for younger and higher function patients.

PATIENT SUMMARY

In this report, we looked at the outcomes from invasive neuroendocrine carcinoma of the urinary tract in a large US population. We found that the outcomes varied with treatment strategy. We conclude that the best outcomes are seen in patients treated with chemotherapy prior to surgery and regimens tailored to histology and tolerance.

Unusual histomorphological spectrum of urinary bladder cancers and their treatment modalities revisited: Our experience with series of five cases

Background

Urinary bladder cancer is the eighth-most frequent carcinoma in men, commonly occurs in elderly male. Major risk factors are smoking, chronic cystitis, urinary stones. The most common histologic variant of bladder cancer is urothelial carcinoma (UC), but certain variants are unusual yet aggressive for which there is no consensus guideline of therapy. Those entities include neuroendocrine tumors both primary and metastatic, squamous cell carcinoma, and sarcomatoid carcinoma. Neuroendocrine tumors comprise carcinoid, small-cell carcinoma, and large-cell carcinoma.

Aim

The present study is undertaken to highlight certain biological features of these unusual aggressive histological forms of bladder carcinoma and their recent treatment modality to prevent recurrence, metastasis, upgrading of tumor stage, and enable surprisingly complete remission.

Methods

This piece of hospital-based perspective study was done from June 2018 to May 2020. Both transurethral resection of bladder tumor and cystectomy surgical samples of the symptomatic patients were collected from the urology department of our institute along with demographic data. Then processed, stained in both routine H and E stain and immunohistochemical stains (Immunohistochemistry [IHC]) like PanCK, NSE, synaptophysin, chromogranin, etc.

Results

Total number of bladder cancer encountered was 42 cases; of these five rare variants were observed, i.e., one case each of primary and secondary small cell neuroendocrine carcinoma, one large cell carcinoma, one squamous cell carcinoma (SCC), and one case of sarcomatoid carcinoma. Histomorphology with IHC conferred the diagnosis then multimodality therapy (neoadjuvant/radiotherapy/surgery) was installed and followed up.

Conclusion

The unconventional forms of UC can be easily diagnosed by histomorphology and can have better survival with the help of the recent multimodal treatment approach.

Comparison of clinicopathological characteristics, gene expression profiles, mutational analysis, and clinical outcomes of pure and mixed small-cell carcinoma of the bladder

AIMS

Small cell bladder carcinoma (SCBC) is a rare, divergent form of urothelial carcinoma (UC). We aimed to determine whether pure (n = 16) and mixed (SCBC and UC; n = 30) tumours differed in pathology, gene expression characteristics, genetic alterations, and clinical outcomes.

METHODS AND RESULTS

Forty (87%) patients received first-line chemotherapy. Twenty-nine patients had no metastatic disease at diagnosis and underwent radical cystectomy. There were no differences in age, sex, race distribution, tumour size, stage at presentation, therapy response with pathological downstaging to ≤ypT1N0, or overall or progression-free survival (PFS) between pure and mixed tumours. There was a longer PFS among downstaged chemotherapy-responding tumours ≤ypT2N0M0 than among unresponsive tumours ≥ypT2 ≥ yN1M1 (P = 0.001). Patients who achieved pathological downstaging with neoadjuvant chemotherapy (n = 10) were stage cT2N0M0 at the time of diagnosis and were alive at the last follow-up (median 37 months), while 46% of patients who failed to achieve pathological downstaging were alive at the last follow-up (median 38 months; P = 0.008). RNA sequencing showed that the UC of mixed SCBC had similar neural expression signatures to pure SCBC. DNA sequencing revealed alterations in TERT (83%), P53 (56%), ARID1A (28%), RB1 (22%), and BRCA2 (11%). Immunohistochemistry for RB1 showed loss of expression in 18/19 (95%) patients, suggesting frequent pathway downregulation despite a low prevalence of RB1 mutation.

CONCLUSION

Patients with pure and mixed SCBC have similar outcomes and these outcomes are determined by the pathological stage at RC and are best among patients who have pathological downstaging after NAC.

Challenges and opportunities in the management of non-urothelial bladder cancers

Urothelial carcinoma accounts for approximately 90% of all bladder cancer diagnoses. Localized, muscle-invasive disease is often managed with a multidisciplinary approach including either neoadjuvant chemotherapy (NAC) followed by radical cystectomy or concurrent chemoradiation, whereas multiple immunotherapies and novel antibody drug conjugates have recently joined platinum-based chemotherapy as standard of care therapy for metastatic disease. However, the clinical trials leading to these standards often require majority if not complete urothelial histology for eligibility. As many as one quarter of patients diagnosed with bladder cancer will have either divergent differentiation of their urothelial carcinoma or an alternate epithelial tumor such as squamous cell carcinoma, adenocarcinoma, or small cell carcinoma; even more rare are non-epithelial tumors such as sarcoma. The rarity of these diseases and their general exclusion from treatment within prospective clinical trials has created a challenging situation where treatment plans are often derived from case series or extrapolated from other disease types and outcomes are poor compared to pure urothelial carcinoma. In this review, we summarize the existing data on the diagnosis and treatment of epithelial, non-urothelial bladder cancers including adenocarcinoma, squamous cell carcinoma, and small cell carcinoma in their localized and advances stages. We will also review the current clinical trial landscape investigating novel approaches to these diseases.

Primary small cell carcinoma of the ureter with associated hyponatremia and rapid progression to bladder involvement: a case report

Background

Primary small cell carcinoma (SmCCa) of the ureter is rare. The majority of patients present with visible haematuria. Diagnosis is confirmed by histopathology. Associated hyponatraemia in GU lesion can be due SmCCa can be useful for early diagnosis aggressive ureteric tumors. The current management includes radical surgery or radiotherapy with concomitant chemotherapy to improve survival and quality of life.

Case presentation

We present a case of a 77 years female who was found to have unilateral hydronephrosis with a 5 cm filling defect in the distal ureter on CT urogram. Further staging showed organ-confined disease. Serum sodium levels were low at presentation. At the time of planned nephroureterectomy (NU), cystoscopy revealed a bladder tumor obstructing the right ureteric orifice. TURBT was performed instead. After TURBT, there was marked hyponatremia and histology was small cell carcinoma (SmCCa). Paraneoplastic SIADH was the likely cause. Neoadjuvant chemotherapy (NACT) followed by radiotherapy (RT) was chosen for definitive treatment. This resulted in an excellent response supported by radiological evidence of almost complete resolution of the tumor.

Conclusion

The presence of genitourinary lesion and hyponatremia should raise suspicion of paraneoplastic SIADH. The case suggests the emphasis of histological diagnosis of the genitourinary lesion with existing hyponatraemia to provide better outcome with NACT followed by definitive treatment. We share our experience of NACT and RT in the management of ureteric SmCCa extension to the bladder.

Survival analysis of small cell carcinomas of the genitourinary system

Due to low incidence, there are no large prospective studies or clinical trials for small cell carcinoma (SCC) of the genitourinary system (GU), and most data are extrapolated from SCC of the lung. Using the SEER database, we analyzed incidence trends, overall survival, and cancer-specific survival using the log-rank test. Analysis of variables was performed using the Cox proportional hazards regression model. The analysis showed that SCC of the bladder and prostate were the most common types of GU SCC, with 1836 and 606 cases, respectively. In 2018, the incidence of SCC of the bladder and prostate was twice that of 2010 (P < 0.001). The overall survival and cancer-specific survival of patients with SCC of the bladder were significantly longer than those of patients with SCC of the prostate (P < 0.0001). SCC bladder patients with advanced age, more extensive growth, lymph node involvement, no surgical intervention, and the presence of the metastasis had worse survival outcomes (P < 0.05). The Asian/Pacific Islander race provided some survival benefits for patients with SCC of the bladder (P < 0.05). For patients with SCC of the prostate, only advanced age was a risk factor for poor outcomes (P < 0.05).

Clinical characteristics and treatment outcomes of patients with small cell carcinoma of the urinary bladder

Background

Materials and methods

Results

Conclusions

Prognostic Factors of Survival for High-Grade Neuroendocrine Neoplasia of the Bladder: A SEER Database Analysis

Background: High-grade neuroendocrine carcinoma (NEC) is a rare and aggressive variant of bladder cancer. Considering its rarity, its therapeutic management is challenging and not standardized. Methods: We analyzed data extracted from the Surveillance, Epidemiology, and End Results (SEER) registry to evaluate prognostic factors for high-grade NEC of the bladder. Results: We extracted data on 1134 patients: 77.6% were small cell NEC, 14.6% were NEC, 5.5% were mixed neuro-endocrine non-neuroendocrine neoplasia, and 2.3% were large cell NEC. The stage at diagnosis was localized for 45% of patients, lymph nodal disease (N+M0) for 9.2% of patients, and metastatic disease for 26.1% of patients. The median overall survival (OS) was 12 months. Multivariate analysis detected that factors associated with worse OS were age being >72 years old (HR 1.94), lymph nodal involvement (HR 2.01), metastatic disease (HR 2.04), and the size of the primary tumor being >44.5 mm (HR 1.80). In the N0M0 populations, the size of the primary tumor being <44.5 mm, age being <72 years old, and major surgery were independently associated with a lower risk of death. In the N+M0 group, the size of the primary lesion was the only factor to retain an association with OS. Conclusions: Our SEER database analysis evidenced prognostic factors for high-grade NEC of the bladder that are of pivotal relevance to guide treatment and the decision-making process.

Delta-like canonical Notch ligand 3 as a potential therapeutic target in malignancies: A brief overview

Delta‐like canonical Notch ligand 3 (DLL3) is a member of the Delta/Serrate/Lag2 (DSL) Notch receptor ligand family and plays a crucial role in Notch signaling, which influences various cellular processes including differentiation, proliferation, survival, and apoptosis. DLL3 is expressed throughout the presomitic mesoderm and is localized to the rostral somatic compartments; mutations in DLL3 induce skeletal abnormalities such as spondylocostal dysostosis. Recently, DLL3 has attracted interest as a novel molecular target due to its high expression in neuroendocrine carcinoma of the lung. Moreover, a DLL3‐targeting Ab‐drug conjugate, rovalpituzumab tesirine (ROVA‐T), has been developed as a new treatment with proven antitumor activity. However, the development of ROVA‐T was suspended because of shorter overall survival compared to topotecan, the second‐line standard treatment. Thus, several studies on the mechanism and function of DLL3 in several malignancies are underway to find a new strategy for targeting DLL3. In this review, we discuss the roles of DLL3 in various malignancies and the future perspectives of DLL3‐related research, especially as a therapeutic target.

Primary Small Cell Carcinoma of the Bladder

A 64-year-old Caucasian man with a 20 to 25-pack-year cigarette smoking history presented to his primary care provider with the chief complaint of gross hematuria after experiencing three to four months of urinary frequency and urgency. His workup consisted of laboratory blood work, a renal/bladder ultrasound (US), a CT scan without contrast, cystoscopy with biopsy (with an attempted transurethral resection of bladder tumor), and a PET scan. He was diagnosed with stage T4 small cell carcinoma of the bladder (SCCB) shortly after seeking medical care with metastases to the liver, bone, and lymph nodes. There was no evidence of lung involvement. The patient's primary concerns included difficulty urinating and sustained hematuria. He underwent palliative radiotherapy and placement of bilateral nephrostomy tubes in order to preserve his quality of life. He also received a chemotherapy regimen consisting of cisplatin, etoposide, and atezolizumab. The patient underwent hospice care and died approximately six months after the presentation.

Accuracy of Transurethral Resection of the Bladder in Detecting Variant Histology of Bladder Cancer Compared with Radical Cystectomy

BACKGROUND

Correct identification of variant histologies (VHs) of bladder cancer (BCa) at transurethral resection of the bladder (TURB) could drive the subsequent treatment.

OBJECTIVE

To evaluate the concordance in detecting VHs between TURB and radical cystectomy (RC) specimens in BCa patients.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed 1881 BCa patients who underwent TURB and subsequent RC at seven tertiary care centers between 1980 and 2018. VHs were classified as sarcomatoid, lymphoepithelioma-like, neuroendocrine, squamous, micropapillary, glandular, adenocarcinoma, nested, and other variants.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Concordance between TURB and RC was defined as the ability to achieve histological subtypes at TURB confirmed at RC specimen, and was expressed according to Cohen's kappa coefficient.

RESULTS AND LIMITATIONS

Of the patients, 14.6% and 21% were diagnosed with VH at TURB and RC specimens, respectively. The most common VHs at TURB were squamous, neuroendocrine, and micropapillary carcinoma (5.2%, 1.5%, and 1.5%, respectively). At RC, the most frequent VHs were squamous, micropapillary, and sarcomatoid carcinoma (7.2%, 3.0%, and 2.7%, respectively). The overall concordance in detecting VH was defined as slight concordance (coefficient: 0.18). Moderate concordance was found for neuroendocrine, adenocarcinoma, and squamous carcinoma (coefficient: 0.49, 0.47, and 0.41, respectively). Micropapillary, glandular, and other variants showed slight concordance (coefficient: 0.05, 0.17, and 0.12, respectively), while nested and sarcomatoid carcinoma showed fair concordance (coefficient: 0.32 and 0.26, respectively). Results may be limited by the absence of centralized pathological analysis.

CONCLUSIONS

A non-negligible percentage of patients were diagnosed with VH at both TURB and RC. TURB showed relatively low accuracy, ranging from poor to moderate, in detecting VHs. Our study underlines the need of additional diagnostic tools in order to identify VHs properly at precystectomy time and to improve patient survival outcomes.

PATIENT SUMMARY

In this report, we underlined the low accuracy of transurethral resection of the bladder in detecting variant histologies and the need for additional diagnostic tools.

Real-world Treatment Patterns and Overall Survival in Locally Advanced and Metastatic Urothelial Tract Cancer Patients Treated with Chemotherapy in Denmark in the Preimmunotherapy Era: A Nationwide, Population-based Study

Background

Real-world treatment patterns and survival outcomes of locally advanced, unresectable, and metastatic urinary tract cancer (mUTC) patients have not previously been studied in a nationwide, population-based cohort.

Objective

To describe treatment patterns and survival outcomes in mUTC patients treated in the real-world clinical setting.

Design setting and participants

This nationwide, population-based study included all mUTC patients initiating first-line chemotherapy at Danish oncology departments from January 2010 to March 2016. Data were retrospectively obtained from electronic medical records.

Outcome measurements and statistical analysis

Outcome measurements were descriptive. Kaplan-Meier was used for survival analysis.

Results and limitations

Of 952 patients included in the study, 46.2% initiated standard gemcitabine/cisplatin (GC) and 21.1% gemcitabine/carboplatin (CaG); the remaining patients initiated other treatment regimens. Median follow-up was 11.6 mo. The overall response rate and disease control rate were 43.0% and 61.7% in all patients, 51.4% and 69.1% in GC-treated patients, and 34.4% and 58.8% in CaG-treated patients, respectively. Median overall survival (OS) was 11.7 (95% confidence interval [CI]: 10.8-12.5) mo in all patients, 14.0 (95% CI: 12.5-15.5) mo in GC-treated patients, and 9.8 (95% CI: 8.7-10.9) mo in CaG-treated patients. Limitations include the retrospective study design.

Conclusions

Real-world mUTC patients are older and less fit than patients enrolled in clinical trials; despite this, tumor responses and survival are comparable. Survival in our patient cohort is also comparable with that reported from other real-world studies in this patient group.

Patient summary

We studied treatment patterns and survival in urinary tract cancer patients receiving chemotherapy in the real-world clinical practice. Survival in our patient cohort was comparable with that reported from clinical trials and other real-world studies in this patient group.

Pelvic Lymph Node Dissection During Cystectomy for Patients With Bladder Carcinoma With Variant Histology: Does Histologic Type Matter?

Purpose

Adding pelvic lymph node dissection (PLND) to cystectomy offers significant survival benefit. However, it remains unclear whether this benefit persists in all histologic types. The aim of the study was to examine the impact of PLND on overall survival (OS) after cystectomy in bladder carcinoma patients with histological variants.

Methods

Within the Surveillance, Epidemiology and End Results database, we identified 16,880 bladder carcinoma patients receiving cystectomy between 2004 and 2015. Patients were stratified according to the following histologic types: transitional cell carcinoma, squamous cell carcinoma, adenocarcinoma, small cell carcinoma, neuroendocrine carcinoma, signet ring cell carcinoma, pseudosarcomatous carcinoma, and other histology. Cox regression models were used to evaluate the effect of PLND on OS stratified by histologic type.

Results

Histologic types were significantly associated with the presence of lymph node metastasis in patients with bladder carcinoma (P < 0.001). In multivariable Cox regression analyses, PLND compared with non-PLND was associated with OS benefit in patients with transitional cell carcinoma (hazard ratio [HR], 0.595; 95% confidence interval [95% CI], 0.557-0.634 [P < 0.001]), squamous cell carcinoma (HR, 0.646; 95% CI, 0.494-0.846 [P = 0.002]), and signet ring cell carcinoma (HR, 0.233; 95% CI, 0.107-0.504 [P < 0.001]), whereas no significant differences in OS were observed in other histological subsets.

Discussion

Our analyses revealed a significant OS benefit from PLND in patients with transitional cell carcinoma, squamous cell carcinoma, and signet ring cell carcinoma. However, a survival benefit of PLND in patients with other histologic types was not demonstrated.

Primary small-cell neuroendocrine carcinoma of the bladder: Case report and literature review

BACKGROUND

Neuroendocrine tumours (NET) are extremely rare and aggressive. Although they commonly affect intestine, many organs may be involved such as pancreas, lung or urinary tract. Bladder is rarely involved. Actually, two main forms of bladder NET have been described: small-cell and large-cell. The first one is considered highly agressive since it shows poor oncologic outcomes being mainly diagnosed at advanced stage: the second one is extremely rare and equally aggressive.

CASE REPORT

A 78-years-old Caucasian male presented to our facility for lower urinary tract symptoms and gross hematuria recently occurred. He was a strong smoker since many years. No familiarity for urothelial cancer was referred nor previous episodes of hematuria until that time. Citology was negative; outpatient ultrasound of the bladder revealed a 3 cm bladder thickening highly suspicious for bladder cancer; patient underwent TC scan that confirmed the bladder lesion. A transurethral resection of the bladder (TURB) was performed. After 3 months total body TC showed multiple visceral metastases also involving brain and lymph nodes. Best supportive care was offered but the patient died 6 months later.

RESULTS

Pathology revealed a mixed bladder tumor: 30% of the specimen resulted as an high-grade urothelial cancer (G3) and 70% as small-cell neuroendocrine variant.Microscopic muscle involvement was excluded.

CONCLUSIONS

Neuroendocrine tumors are uncommon entities which origin from cells of neuro-endocrine system and may potentially involve all human tissues. Neuroendocrine smallcell carcinoma of the bladder is a non-urothelial histotype: it is highly aggressive and diagnosed mainly at advanced stages. Whenever considering the high risk of metastatic spread and the poor prognosis, a multimodal approach is highly suggested. TURB alone is uneffective in disease control due to its aggressive nature. Unless metastatic, radical cystectomy and adjuvant chemotherapy represent the gold standard.

Small cell carcinoma of the bladder with coexisting prostate adenocarcinoma: two cases report and literature review

BACKGROUND

Primary small cell carcinoma of the bladder (SCCB) is a rare disease of the genitourinary tract and reported limitedly. SCCB is very aggressive and always mixed with other histologic components, but coexistence of SCCB and prostate adenocarcinoma is extremely rare.

CASES PRESENTATION

Two aged males (72 and 58 years) were included in this study. Both of them presented with gross hematuria as initial symptom. Magnetic resonance imaging (MRI) demonstrated protruding lesions in the urinary bladder. Pathological examination after radical cystectomy and prostatectomy showed the concurrence of SCCB and prostate adenocarcinoma. One patient died of liver and lung metastasis 8 months after surgery, and the other patient was still alive after 19 months of follow-up.

CONCLUSION

In this paper, we reported two unusual cases of coexistence of SCCB and prostate adenocarcinoma, and reviewed relative literatures with respect to the epidemiology, clinical features, pathologic features, diagnosis, treatment and prognosis of SCCB.

Facing treatment of non-urothelial bladder cancers in the immunotherapy era

Non-urothelial Bladder Cancer (BC) and variants of urothelial carcinoma account for up to 25 % of all BCs. Given their heterogeneity, these entities are not well represented in clinical trials and treatment remains challenging. Checkpoint inhibitor therapy has shown a role in the treatment of urothelial BC. By contrast, robust evidence regarding its use in other histological types is lacking. We aimed to provide a comprehensive update of non-urothelial and variant urothelial BC, exploring the evidence for immune checkpoint inhibitor therapy. A detailed analysis of the literature was conducted regarding epidemiology, aetiology, diagnosis, prognosis, treatment and outcomes of these patients in the immunotherapy era. A growing body of evidence suggests that immune checkpoint inhibition might have a role to play in non-urothelial BC, similarly to what happened with urothelial carcinomas.

Limited Stage Small Cell Bladder Cancer: Outcomes of a Contemporary Cohort

BACKGROUND: Limited stage small cell bladder cancer is curable with multi-modality therapy using external beam radiotherapy or radical cystectomy. The optimal management strategy for this rare disease is still debated, yet few case series have described patients treated after 2010. OBJECTIVE: To analyze outcomes from a contemporary cohort of patients undergoing definitive treatment. METHODS: Patients diagnosed with small cell bladder cancer after January 1, 2010 were identified from an institutional database. Clinical histories were collected by chart review. Survival outcomes were analyzed in patients who received curative-intent therapy consisting of bladder radiotherapy or cystectomy. RESULTS: Thirty patients with limited stage disease that received definitive therapy were identified. Seventeen patients received primary radiotherapy, and thirteen underwent cystectomy. Median age was 70 years. Median follow up was 39.6 months (range 7.2–95.8). The median overall survival of patients undergoing radiotherapy or cystectomy were 36.8 and 30.6 months, respectively (hazard ratio 0.99, 95% confidence interval 0.35–2.85). The median metastasis free survival for patients receiving radiotherapy was not reached, and 18.9 months in the cystectomy group (hazard ratio 0.94, 95% confidence interval 0.34–2.61). The most common sites of relapse were lymph node (n = 6) and bone (n = 5). Brain metastases were less common (n = 3). CONCLUSIONS: Patients receiving cystectomy or radiotherapy had similar outcomes in this contemporary series, but definitive comparisons are limited by the cohort size and high censoring rate (53%). Survival in our cohort is improved compared with older reports, though outcomes remain poor, reiterating the need for better therapeutic options.

Small cell carcinoma of the bladder: the characteristics of molecular alterations, treatment, and follow-up

Small cell carcinoma of the bladder (SCCB) is a rare disease associated with high invasiveness and mortality. Histologically, SCCB is difficult to distinguish from small cell lung cancer (SCLC); however, it shares more similar molecular alterations with urothelial carcinoma (UC). As a result, now, the widely accepted theory about the cells of origin is that SCCB and UC probably have a common clone origin. Even the former probably comes from a preexisting UC. At present, given its rarity, early diagnoses, treatments, and follow-ups are not well established, which are vital to patients with SCCB. Inspirationally, in recent years, with the development of molecular diagnostic methods, molecular alterations of SCCB have been understood partially, which are propitious to excavate new potential therapeutic strategies and establish sound follow-ups. Therefore, the future will be light for patients with SCCB.

Trends in the use of neoadjuvant chemotherapy for bladder cancer with nonurothelial variant histology: An analysis of the National Cancer Database

Introduction

The aim of this study is to evaluate the trends in the use of neoadjuvant chemotherapy (NAC) over time (2006-2014) for patients diagnosed with muscle-invasive bladder cancer (MIBC) with nonurothelial variant histology (NUVH) in the National Cancer Database.

Materials and Methods

We queried the NCDB for patients with muscle-invasive (i.e. cT2-4N0-3M0/X) urothelial carcinoma (UC) of the bladder. We examined demographic, clinical, and pathologic features associated with NAC, also substratifying into pure UC and NUVH. Tests of association were performed using Chi-square/Fisher's exact test for categorical variables and t-tests, ANOVA, or Kruskal-Wallis test for continuous variables. Outcomes were examined with Cox proportional hazards and 90-day mortality with the Kaplan-Meier method.

Results

Totally 22,320 patients met our inclusion criteria, of whom 22.6% received NAC. The proportion of NAC increased significantly over time in the neuroendocrine and urothelial cell categories with 57.1% and 34.1% of patients in 2014 receiving NAC vs. 44% and 10.6% in 2006. No other variant histology showed a significant increase across the time sampled. Patients receiving NAC were more likely to have downstaging to pT0 (13.4% vs. 2.7%), negative surgical margin (89.1% vs. 86%), and pN0 (63.2% vs. 60.5%) and were less likely to have 30-day (1.4% vs. 3%) or 90-day (5% vs. 8.3%) mortality. Rates of downstaging to pT0 after NAC were similar among histologies.

Conclusion

Neoadjuvant chemotherapy utilization continues to slowly increase in patients with MIBC. Patients with variant histology lag behind in terms of receiving NAC but appear to derive as much benefit as patients with pure urothelial cell bladder cancer.

Clinical outcomes of patients with pure small cell carcinoma of the urinary bladder

OBJECTIVES

There is not yet a standardized approach to treat patients with small cell carcinoma of the bladder (SmCCB). This study aims to investigate the clinical features, treatment, and survival outcomes of patients with pure SmCCB.

MATERIALS AND METHODS

Patients diagnosed with SmCCB between January 2006 and September 2015 were retrospectively evaluated.

RESULTS

A total of 34 patients with a median age of 63.0 years were included in the study, with a male to female ratio of 4.6:1.0. At the time of diagnosis, 22 patients (64.7%) had stage IV disease. At a median follow-up time of 12.7 months, 67.6% of patients died of bladder carcinoma, with an overall survival (OS) of 15.7 months for all patients. In the patients with stages I-III, nodal involvement, and distant metastases, the median OS was 31.8, 15.7, and 8.4 months, respectively (P = 0.005). Considering the survival rates of the patients (stages I-III) treated with surgery vs. local therapy, there was not a statistically significant difference (26.6 months and 31.8 months, P = 0.97, respectively). A multivariate analysis revealed that stage IV disease and poor ECOG performance status were associated with OS.

CONCLUSION

The optimal treatment of SmCCB has been under debate. For the patients with advanced stage of disease (T4b, N+, M+), platinum containing chemotherapeutic agents should be preferred. Stage IV disease and poor ECOG performance status were associated with shorter OS.

Molecular and histopathology directed therapy for advanced bladder cancer

Bladder cancer is a heterogeneous group of tumours with at least 40 histological subgroups. Patients with localized disease can be cured with surgical resection or radiotherapy, but such curative options are limited in the setting of recurrent disease or distant spread, in which case systemic therapy is used to control disease and palliate symptoms. Cytotoxic chemotherapy has been the mainstay of treatment for advanced bladder cancer, but high-quality evidence is lacking to inform the management of rare subgroups that are often excluded from studies. Advances in molecular pathology, the development of targeted therapies and the resurgence of immunotherapy have led to the reclassification of bladder cancer subgroups and rigorous efforts to define predictive biomarkers for cancer therapies. In this Review, we present the current evidence for the management of conventional, variant and divergent urothelial cancer subtypes, as well as non-urothelial bladder cancers, and discuss how the integration of genomic, transcriptomic and proteomic characterization of bladder cancer could guide future therapies.

Can Biomarkers Guide the Use of Neoadjuvant Chemotherapy in T2 Bladder Cancer?

Current guidelines recommend cisplatin-based neoadjuvant chemotherapy prior to radical cystectomy as the preferred treatment of muscle-invasive bladder cancer. Nevertheless, for multiple reasons compliance with this guideline recommendation is low. This is particularly evident in clinical T2 bladder cancer, where controversy exists regarding the role of proceeding with radical cystectomy alone. Novel biomarkers such as molecular phenotype and DNA damage repair and response gene alterations may be able to predict who will respond to cisplatin-based neoadjuvant chemotherapy. This clinical problem is discussed, and a recommendation is made given the current state of the art. PATIENT SUMMARY: Neoadjuvant chemotherapy improves survival for patients with muscle-invasive bladder cancer. In the future, perhaps validated biomarkers may predict who should and should not receive this treatment.

A comparison of adult rhabdomyosarcoma and high-grade neuroendocrine carcinoma of the urinary bladder reveals novel PPP1R12A fusions in rhabdomyosarcoma

Some rhabdomyosarcomas and sarcomatoid carcinomas with heterologous rhabdomyosarcomatous elements resemble high-grade neuroendocrine carcinoma, creating a diagnostic difficulty. The purpose of this study was to characterize the overlap of adult genitourinary rhabdomyosarcomas, excluding those occurring at paratesticular sites, with high-grade neuroendocrine carcinoma and identify features helpful in their separation. Seventeen cases of rhabdomyosarcoma (11 from the urinary bladder and 3 each from kidney and prostate) were compared to 10 cases of high-grade neuroendocrine carcinoma from the urinary bladder. These tumors were analyzed by immunohistochemistry for desmin, MyoD1, myogenin, chromogranin, synaptophysin, CD56, TTF1, and ASCL1, and RNA sequencing was performed on 4 cases of bladder rhabdomyosarcoma (2 rhabdomyosarcomas and 2 sarcomatoid-rhabdomyosarcoma) and 10 cases of bladder high-grade neuroendocrine carcinoma. This was compared to public data from 414 typical urothelial carcinomas from The Cancer Genome Atlas dataset. Morphologic and immunophenotypic overlap with high-grade neuroendocrine carcinoma was seen in half of the bladder tumors, which included 4 rhabdomyosarcomas and 2 sarcomatoid rhabdomyosarcomas. RNA sequencing confirmed expression of neuroendocrine markers in these cases (2 rhabdomyosarcomas and 2 sarcomatoid rhabdomyosarcomas). Differential neuroendocrine differentiation was highlighted by ASCL1 protein expression only in high-grade neuroendocrine carcinoma. Moreover, both a pure alveolar rhabdomyosarcoma and sarcomatoid rhabdomyosarcoma of the urinary bladder demonstrated a fusion involving PPP1R12A. In summary, adult rhabdomyosarcomas of the urinary bladder are molecularly distinct from high-grade neuroendocrine carcinomas based on specific patterns of expression of myogenic and epithelial to mesenchymal transition-related transcription factors as well as the presence of a novel PPP1R12A fusion which is seen in a subset of cases.

Non-urothelial carcinomas of the bladder

Non-urothelial carcinomas involving the bladder are uncommon and often diagnostically challenging. These carcinomas may show squamous, adenocarcinomatous or neuroendocrine features, with immunohistochemical stains aiding the diagnosis in only a subset of cases. The clinical history in non-urothelial bladder carcinomas is important, given that the differential diagnosis often includes secondary involvement of the bladder by direct extension or metastasis from carcinomas at other sites. This paper will review non-urothelial carcinomas in each of these three morphological categories, emphasising recent changes in diagnostic grouping and challenges in the histopathological diagnosis. Review of bladder cancers with squamous morphology will include discussion of conventional squamous cell carcinoma and verrucous carcinoma and their distinction from urothelial carcinoma with extensive squamous differentiation. Bladder carcinomas with adenocarcinomatous change will include primary bladder adenocarcinoma, urachal adenocarcinoma and tumours of Müllerian type. Finally, neuroendocrine neoplasms of the bladder, including well-differentiated neuroendocrine tumour and neuroendocrine carcinomas, will be discussed. Associated surface findings, risk factors and prognostic features will be described.

[A CASE OF SMALL CELL CARCINOMA IN A DIVERTICULUM OF THE BLADDER]

An 80-year-old man was referred to our hospital with a complaint of acute urinary retention due to hematuria. Cystoscopy revealed a broad-based tumor arising in a diverticulum on the right lateral wall of the bladder. Transurethral resection of the bladder tumor (TURBT) was performed immediately. The pathological diagnosis was small-cell carcinoma without any urothelial carcinomas, and clinical examination revealed a clinical stage of T3b, N0, M0. Thus, 3 courses of neoadjuvant chemotherapy with cisplatin and irinotecan were administered. Chemotherapy resulted in tumor shrinkage, and partial cystectomy was performed under a diagnosis of stage pT3aN0M0 bladder cancer in the diverticulum. The patient is alive without any evidence of tumor recurrence at 13 months after the operation. To our knowledge, this is the first case report in Japan of small-cell carcinoma in a diverticulum of the urinary bladder, for which partial cystectomy was performed after chemotherapy.

[FOUR CASES OF PRIMARY SMALL CELL CARCINOMA OF THE URINARY TRACT]

Primary small cell carcinoma of the urinary tract is a relatively rare disease that is associated with a poor prognosis. The median overall survival time of patients with primary bladder disease is 19.6 month to 1.7 years, and that of patients with small cell carcinoma of the upper urinary tract is 15 months. Generally, curative surgery with chemotherapy according to the type of small cell lung carcinoma is a preferred treatment. However, standard treatment has not been established yet because the number of cases is small. We herein report the clinical features and outcome of four patients with primary small cell carcinoma of the urinary tract between 2007 and 2018 at our institution and review the literature.

The oncological outcomes of small cell carcinoma of the bladder

INTRODUCTION

Small cell carcinoma of the bladder (SmCC) is a rare and aggressive genitourinary malignancy. The paucity of clinical trials and outcome data provide no standard treatment guidelines. Accordingly, patient prognosis is poor. Our goal was to present the first comprehensive in-depth analysis of SmCC in a tertiary Canadian centre.

METHODS

We retrospectively reviewed all patients diagnosed with primary SmCC at the London Regional Cancer Program between January 1990 and 2016. The primary outcome was overall survival (OS). We examined a number of secondary outcomes and baseline characteristics.

RESULTS

We identified 15 men and six women (median age 72 years) with a SmCC diagnosis (median followup 11.33 months). Median Charlson Comorbidity Index score was 7 (interquartile range [IQR] 5-10) and 15 patients had a smoking history. Most common presentation was gross hematuria (18 patients, 86%), and pT2 stage at transurethral resection of the bladder tumour (TURBT) (n= 7/21, 33%), although five patients had cT4 (24%). Pure SmCC was found in nine individuals (43%), whereas 12 had mixed differentiation (57%). From initial staging, 15 patients had extravesical disease (71%), 10 had positive pelvic lymphadenopathy (48%), and distant metastases occurred in six (29%). In our series, five individuals (24%) underwent cystectomy, 18 (86%) received radiation, and 14 (67%) received adjuvant chemotherapy. The median OS was 15 months (two-year OS was 19%).

CONCLUSIONS

SmCC is a rare and aggressive form of bladder cancer. Despite multimodal therapy, prognosis remains guarded, with little improvement seen over the study's 25-year duration. An understanding of study limitations is warranted in interpretation of results.

Rare Pelvic Malignant Tumors in Adults: Treatment Features and Clinical Outcome in Nonmetastatic Disease (Single Institution Experience)

BACKGROUND

Nearly 200 cancers repertories are rare, and more than 20% are pelvic neoplasia. Diagnosis and treatment are challenging, even in reference centers, and survival is influenced by the aggressiveness of certain histologies and absence of a standard of care.

PATIENTS AND METHODS

The authors report the results of a retrospective analysis of patients that attended the Institute of Oncology, Bucharest, between 2004 and 2015, for nonmetastatic pelvic malignant tumor treatment and follow-up. The outcomes are compared between the rare and common histology groups.

RESULTS

Of the 60 cases analyzed, 17 patients (28.33%) bore a rare tumor, 33 (55%) were women, and the median age was 59 years. The majority was concerned by bladder (41.66%, 25 patients) and cervix (23.33%, 14 patients) neoplasms. For a median follow-up of 27.5 months, relapse was registered in 27 patients (45%), of whom 9 (33.33%) were from the rare group (53% of this subpopulation). The highest relapse rates were recorded in patients with rare bladder tumors (66.7%, 4 patients) compared with 42.1% (8 patients) in the common group (p = 0.294) and in prostate localization (66.7%, 2 patients) compared with 16.7% (1 patient) (p = 0.134). Estimated median relapse-free survival (RFS) was 60, 12 months in the rare group and 67 months for common tumors.

CONCLUSIONS

In nonmetastatic rare pelvic tumor patients, the outcome was found to be poorer than in those concerned by common histologies stratified by organ. A higher rate of relapse and the lowest median RFS were observed in bladder and prostatic cancers.

Transcriptomic and Protein Analysis of Small-cell Bladder Cancer (SCBC) Identifies Prognostic Biomarkers and DLL3 as a Relevant Therapeutic Target

PURPOSE

Transcriptomic profiling can shed light on the biology of small-cell bladder cancer (SCBC), nominating biomarkers, and novel therapeutic targets.

EXPERIMENTAL DESIGN

Sixty-three patients with SCBC had small-cell histology confirmed and quantified by a genitourinary pathologist. Gene expression profiling was performed for 39 primary tumor samples, 1 metastatic sample, and 6 adjacent normal urothelium samples (46 total) from the same cohort. Protein levels of differentially expressed therapeutic targets, DLL3 and PDL1, and also CD56 and ASCL1, were confirmed by IHC. A SCBC PDX model was utilized to assess in vivo efficacy of DLL3-targeting antibody-drug conjugate (ADC).

RESULTS

Unsupervised hierarchical clustering of 46 samples produced 4 clusters that correlated with clinical phenotypes. Patients whose tumors had the most "normal-like" pattern of gene expression had longer overall survival (OS) compared with the other 3 clusters while patients with the most "metastasis-like" pattern had the shortest OS (P = 0.047). Expression of DLL3, PDL1, ASCL1, and CD56 was confirmed by IHC in 68%, 30%, 52%, and 81% of tissue samples, respectively. In a multivariate analysis, DLL3 protein expression on >10% and CD56 expression on >30% of tumor cells were both prognostic of shorter OS (P = 0.03 each). A DLL3-targeting ADC showed durable antitumor efficacy in a SCBC PDX model.

CONCLUSIONS

Gene expression patterns in SCBC are associated with distinct clinical phenotypes ranging from more indolent to aggressive disease. Overexpression of DLL3 mRNA and protein is common in SCBC and correlates with shorter OS. A DLL3-targeted ADC demonstrated in vivo efficacy superior to chemotherapy in a PDX model of SCBC.

Primary small-cell neuroendocrine carcinoma of the urinary bladder: A rare case and a review of the literature

Primary small-cell neuroendocrine carcinoma (SCNEC) of the urinary bladder is a rare tumor characterized by poor differentiation and high aggressiveness. Only ~150 cases have been reported in the literature to date. We herein present a case of an 87-year-old man who presented with hematuria and was found to have an ill-defined mass in the urinary bladder on computed tomography and cystoscopic examination. On pathological examination following tumor biopsy, the mucosa of the bladder wall was found to be extensively infiltrated by neuroendocrine carcinoma, positive for CD56 and synaptophysin and negative for epithelial membrane antigen, consistent with SCNEC of the urinary bladder. The patient refused further surgical treatment and succumbed to the disease 2 months after the diagnosis. In the present study, this rare case of primary SCNEC of the urinary bladder is presented, along with a discussion on the clinical presentation, immunohistochemical and cytomorphological characteristics, management, biological behavior and prognosis of this disease.

Argininosuccinate Synthetase-1 (ASS1) Loss in High-Grade Neuroendocrine Carcinomas of the Urinary Bladder: Implications for Targeted Therapy with ADI-PEG 20

High-grade neuroendocrine carcinomas (HGNECs) of the urinary bladder encompass small cell (SCNEC) and large cell neuroendocrine carcinomas (LCNEC). Currently, recommended initial management is with systemic chemotherapy, followed by consolidative therapy with either radical cystectomy or radiotherapy in patients with localized disease. Nevertheless, survival in this setting remains poor. We therefore evaluated the potential to modify arginine metabolism as an alternative, targeted therapy approach in these carcinomas. In humans, arginine is a semi-essential amino acid and its synthesis enzyme argininosuccinate synthetase (ASS1) represents the rate-limiting step in arginine biosynthesis. Neoplasms that show low to absent ASS1 expression require extracellular arginine for cancer cell survival, and thus can be targeted using arginine-degrading enzymes such as pegylated arginine deiminase (ADI-PEG 20). An initial study by our group of 19 patients demonstrated that a high percentage of SCNEC lack ASS1 expression. Herein, we evaluated an expanded cohort of 74 radical cystectomy patients with HGNEC, including 63 SCNEC, 5 LCNEC, and 6 mixed morphology HGNEC patients. ASS1 expression was assessed through immunohistochemistry. Fifty-eight (of 74, 78%) patients with HGNEC showed absent ASS1 expression, including all patients with LCNEC and mixed morphology (11 of 11, 100%). Ten-year survival from disease-specific death was not statistically significant between ASS1-expressing and ASS1-deficient cases (p = 0.75). Our results show that HGNEC of the bladder may be candidates for arginine deprivation therapy using drugs such as ADI-PEG 20. Further studies are needed to validate these findings and to determine the therapeutic efficacy of such agents.

Radiation Therapy as Definitive Local Treatment in Patients with Limited-Stage Small Cell Carcinoma of the Bladder: Does total dose matter?

Purpose:

To determine whether total radiation dose affects survival outcomes for patients with small cell carcinoma of the bladder (SCCB).

Methods:

We queried the National Cancer Database (NCDB) for patients with limited stage SCCB undergoing multimodality treatment and retrospectively analyzed survival outcomes according to total radiation dose received.

Results:

Patients aged 41–79 receiving a total radiation dose of 54 Gy or greater had a significant improvement in overall survival compared to those receiving less than 54 Gy, with a median overall survival of 58.9 months (95% confidence interval [CI] 37.2–80.6 months) compared to 21.5 months (95% CI 15.2 –27.8 months) (p < 0.05). There was no difference in outcomes for patients receiving between 54 and 60 Gy compared to those receiving 60 Gy or higher. There was also no difference in outcomes based on total radiation dose for patients 80 years and older.

Conclusions:

For patients aged 79 or younger with limited stage SCCB, total radiation dose of 54 Gy or greater is associated with better overall survival.

Nomograms to Predict Individual Prognosis of Patients with Primary Small Cell Carcinoma of the Bladder

Objectives: To develop reliable nomograms to estimate individualized overall survival (OS) and cancer specific survival (CSS) for patients with primary small cell carcinoma of the bladder (SCCB) and compare the predictive value with the AJCC stages.

Patients and Methods: 582 eligible SCCB patients identified in the Surveillance, Epidemiology, and End Results (SEER) dataset were randomly divided into training (n=482) and validation (n=100) cohorts. Akaike information criterion was used to select the clinically important variables in multivariate Cox models when establishing nomograms. The performance of nomograms was bootstrapped validated internally and externally using the concordance index (C-index) with 95% confidence interval (95% CI) and calibration curves and was compared with that of the AJCC stages using C-index, Kaplan-Meier curves and decision curve analysis (DCA).

Results: Two nomograms shared common indicators including age, tumor size, T stage, lymph node ratio, metastases, chemotherapy, radiation and radical cystectomy, while marriage and gender were only incorporated in the OS nomogram. The C-indices of nomograms for OS and CSS were 0.736 (95%CI 0.711-0.761) and 0.731(95%CI 0.704-0.758), respectively, indicating considerable predictive accuracy. Calibration curves showed consistency between the nomograms and the actual observation. The results remained reproducible when nomograms were applied to the validation cohort. Additionally, comparisons between C-indices, Kaplan-Meier curves and DCA proved that the nomograms obtained obvious superiority over the AJCC stages with wide practical threshold probabilities.

Conclusions: We proposed the first two nomograms for individualized prediction of OS and CSS in SCCB patients with satisfactory predictive accuracy, good robustness and wide applicability.

The prognostic value of histological subtype in patients with metastatic bladder cancer

We aim to evaluate the prognostic effect of the histological sub-type in patients with metastatic bladder cancer based on the Surveillance Epidemiology and End Results database. A total of 2634 eligible patients were included. The histological subtypes were: transitional cell carcinoma (TCC; 75.2%); adenocarcinoma (3.3%); squamous cell carcinoma (SQCC; 4.1%); and small cell carcinoma (4.3%). A significant association of adenocarcinoma with better survival outcomes (P < 0.015), and that of SQCC with worse outcomes (P < 0.001) was observed. On multivariate analysis, adenocarcinoma was significantly associated with longer and SQCC with shorter survival time as compared to TCC. Overall, 1331 (50.5%) patients had a single metastatic site and 523 (19.9%) had multiple sites involved. Single-site metastasis had a better survival outcome than multiple metastases (P < 0.001). Histological sub-type and presence of multiple metastatic sites are independent predictors of survival time. Prospective, in-depth research is needed to determine optimal therapeutic strategies for different histological subtypes of bladder cancer with different metastatic patterns.

[PRIMARY SMALL CELL NEUROENDOCRINE CARCINOMA OF THE URETER]

Primary small cell neuroendocrine carcinoma of the upper urinary tract is a rare disease that is associated with a poor prognosis. An 81-year-old man was diagnosed with carcinoma of the stomach and underwent laparoscopic distal gastrectomy. Computed tomography (CT) revealed carcinoma of the left ureter and left hydronephrosis. The patient was diagnosed with carcinoma of the left ureter (cT2N0M0) and left laparoscopic radical nephroureterectomy was performed via a retroperitoneal approach. The pathological diagnosis was left ureter carcinoma (small cell neuroendocrine carcinoma, pT3). He was treated with four courses of the CE regimen (carboplatin area under the curve: 5, intravenously [IV] on day 1 and etoposide [80 mg/m²], IV on days 1-3). There is no evidence of disease at 21 months after radical nephroureterectomy.

Clinicopathologic and Immunohistochemical Study of Combined Small Cell Carcinoma and Urothelial Carcinoma Molecular Subtype

Muscle invasive bladder cancer, an aggressive disease with heterogeneous molecular profiles, has recently been subclassified into three major molecular subtypes -basal, luminal and "p53-like" urothelial carcinomas (UCas), which bear prognostic and therapeutic implication. Similar to breast cancer, basal and luminal subtype UCas are designated by basal (CK5/14) and luminal (CK20) markers. The "p53-like" subtype presents with wild-type p53 gene with upregulated p53 pathways and is implicated in chemoresistance. Urinary bladder is one of the most common primary sites of extrapulmonary small cell carcinoma (SmCC). Bladder SmCC frequently coexists with UCa; however, the relation of SmCC with specific UCa molecular subtypes has not been studied. The aim of this study is to investigate the clinicopathology and immunophenotypes of the combined SmCC and UCa molecular subtypes. A total of 22 combined SmCC and UCa cases were studied for the clinicopathology and immunohistochemical (IHC) profiles by luminal and basal cell markers as well as Her2/Neu and p53. Our results demonstrated that all the urinary bladder SmCCs were associated with high grade UCas. They were more commonly seen in older male patients with a smoking history and had a poor prognosis. Based on the reported molecular subtyping, the UCas could be immunohistochemically subclassified into luminal, basal, dual and null types, which showed different clinicopathologic and IHC features. Compared to non-SmCC associated UCa, the subtypes of UCa in the combined SmCCs and UCas were characterized by: 1) Although overall luminal type was still relatively more common in men, basal marker-expressing subtypes were significantly increased in incidence and were more common in women. 2) Her2/Neu overexpression was more commonly observed in luminal than basal cell marker-expressing UCas. 3) IHC overexpression of p53 was common in all the subtypes, with UCas and SmCCs sharing the same p53 expression pattern. Although limited by relatively a small number of cases, the results of this study will enhance our understanding of the combined SmCC and UCa entity and potentially lead to a future therapeutic management.

NCCN Guidelines Insights: Bladder Cancer, Version 2.2016

These NCCN Guidelines Insights discuss the major recent updates to the NCCN Guidelines for Bladder Cancer based on the review of the evidence in conjunction with the expert opinion of the panel. Recent updates include (1) refining the recommendation of intravesical bacillus Calmette-Guérin, (2) strengthening the recommendations for perioperative systemic chemotherapy, and (3) incorporating immunotherapy into second-line therapy for locally advanced or metastatic disease. These NCCN Guidelines Insights further discuss factors that affect integration of these recommendations into clinical practice.