Gemcitabine and carboplatin in the treatment of transitional cell carcinoma of the urothelium: a single centre experience and review of the literature

Anti-tumor effect of trametinib in bladder cancer organoid and the underlying mechanism

Bladder cancer (BC), a main neoplasm of urinary tract, is usually inoperable and unresponsive to chemotherapy. As a novel experimental model for muscle-invasive BC, we previously established a culture method of dog BC organoids. In the present study, the detailed in vitro and in vivo anti-tumor effects of trametinib were investigated by using this model. In each BC organoid strain, epidermal growth factor receptor (EGFR)/ERK signaling was upregulated compared with normal bladder cells. Trametinib even at a low concentration inhibited the cell viability of BC organoids and the activation of ERK through decreasing expression of c-Myc, ELK1, SIK1, and PLA2G4A. Trametinib arrested cell cycle of BC with few apoptosis. Dual treatment of BC organoids with trametinib and YAP inhibitor, verteporfin extremely inhibited the cell viability with apoptosis induction. Moreover, trametinib induced basal to luminal differentiation of BC organoids by upregulating luminal markers and downregulating basal ones. In vivo, trametinib decreased the tumor growth of BC organoids in mice and the xenograft-derived organoids from trametinib-administered mice showed enhanced sensitivity to carboplatin due to MSH2 upregulation. Our data suggested a new strategy of trametinib-YAP inhibitor or trametinib-carboplatin combination as a promising treatment of BC.

Usefulness of neoadjuvant chemotherapy in non-metastatic muscle-invasive bladder cancer

OBJECTIVE

We analyzed the profile of patients who were candidates for neoadjuvant chemotherapy (NACT) in stage pT2-4aN0M0, the tolerability and adherence of our cisplatin-based protocol and oncological outcomes.

MATERIAL AND METHODS

Retrospective observational cohort study including patients diagnosed with muscle-invasive bladder carcinoma treated with NACT. Clinical, histopathological, therapeutic and evolutionary characteristics of the patients were analyzed. The use of NACT was evaluated by the complete response in the surgical specimen (pT0). This and other pathological factors were related to overall survival and progression-free survival.

RESULTS

We included 90 patients with muscle-invasive bladder carcinoma (clinical stage T2a-T4aN0M0) who received a cisplatin-based NACT regimen between January 2011 and December 2018, prior to radical surgery. Forty percent of patients presented an adverse reaction, with a compliance with the NACT regimen of 92.2%. There were no deaths related to systemic treatment and no adverse reaction to treatment made radical cystectomy impracticable. After performing radical cystectomy, the presence of complete response (pT0) was observed in 20 patients (21%), lower stage in the surgical specimen (<pT2) in 36 patients (40%), positive surgical margins in 7 patients (8%), lymph node involvement (N1) in 16 patients (17.8%). A shorter time to progression was observed in the group of patients who did not achieve a complete pathological response (53 months vs. 83.1 in pT0 patients, P=0.012), in patients with lymph node involvement compared to pN0 (65.4 vs. 28, 2 months, P=0.014) and in those with positive surgical margins compared to those with tumor-free margins (63.5 vs. 8.5 months, P=0.021).

CONCLUSION

The adequate selection of patients with muscle-invasive bladder carcinoma has shown a good tolerance to NACT, with a high compliance rate prior to RC. The improvement in the complete response rate implies a greater survival in this group of patients, with lymph node involvement and positive surgical margins being important prognostic factors.

Molecular targets in urothelial cancer: detection, treatment, and animal models of bladder cancer

Bladder cancer remains one of the most expensive cancers to treat in the United States due to the length of required treatment and degree of recurrence. In order to treat bladder cancer more effectively, targeted therapies are being investigated. In order to use targeted therapy in a patient, it is important to provide a genetic background of the patient. Recent advances in genome sequencing, as well as transcriptome analysis, have identified major pathway components altered in bladder cancer. The purpose of this review is to provide a broad background on bladder cancer, including its causes, diagnosis, stages, treatments, animal models, as well as signaling pathways in bladder cancer. The major focus is given to the PI3K/AKT pathway, p53/pRb signaling pathways, and the histone modification machinery. Because several promising immunological therapies are also emerging in the treatment of bladder cancer, focus is also given on general activation of the immune system for the treatment of bladder cancer.

Efficacy and Safety of Gemcitabine Plus Either Taxane or Carboplatin in the First-Line Setting of Metastatic Urothelial Carcinoma: A Systematic Review and Meta-Analysis

Although gemcitabine plus carboplatin (GCa) is the conventional first-line chemotherapy for cisplatin-ineligible metastatic urothelial carcinoma, its results are suboptimal. A meta-analysis evaluated the results of gemcitabine with either carboplatin or a taxane (GT). Literature was searched for studies including GT (paclitaxel or docetaxel) and GCa. We pooled trial level data including response-rate, progression-free survival, overall survival (OS), and Grade 3 to 4 side effects. Trial characteristics and outcomes were univariably compared between GT and GCa. Those factors, which were recorded in > 12 trials, were analyzed. Multivariable regression models were used adjusting for Eastern Cooperative Oncology Group performance status 2 and the presence of visceral metastases. Each trial was weighted by its sample size. Twenty-seven arms of trials totaling 1032 patients were selected, of which 13 contained GT (n = 484) and 14 GCa (n = 548). The percentage of patients with Eastern Cooperative Oncology Group performance status 2 was statistically significantly different between the 2 groups (median, 8.7% vs. 23.9%; P = .003). No efficacy outcome was statistically significantly different. Median OS was 13.2 months (range, 10-15.8 months) for GT and 10 months (range, 3.3-20 months) for GCa (P = .12). However, statistically significant increases in the frequency of Grade 3 to 4 anemia (P = .010) and thrombocytopenia (P = .010) for GCa, and neuropathy (P = .040) for GT were observed. No difference in OS according to treatment was found multivariably (P = .79). In this analysis, a similar response rate and survival and worse neurotoxicity were observed with GT compared with GCa, for which hematologic toxicity was more frequent. GT is an alternative to GCa for advanced cisplatin-ineligible urothelial cancer.

The Impact of Adding Taxanes to Gemcitabine and Platinum Chemotherapy for the First-Line Therapy of Advanced or Metastatic Urothelial Cancer: A Systematic Review and Meta-analysis

CONTEXT

Gemcitabine/platinum chemotherapy is the most widely used first-line regimen for metastatic urothelial carcinoma, and the potential improvement of adding taxanes needs to be clarified.

OBJECTIVE

To study the survival impact of taxane plus gemcitabine/platinum compared with gemcitabine/platinum alone as upfront therapy.

EVIDENCE ACQUISITION

Literature was searched for studies including gemcitabine/platinum ± taxanes (paclitaxel or docetaxel only). We pooled trial level data including the median, proportions, and confidence intervals on response-rate, progression-free survival, overall survival (OS), and side effects. Univariable and multivariable regression models evaluated the prognostic role of addition of taxanes after adjusting for platinum type, performance status 2, and the presence of visceral metastases. Data were weighted by the logarithm of the trial sample size.

EVIDENCE SYNTHESIS

Thirty-five arms of trials including 2,365 patients were selected (seven with taxanes [n=617], and 28 arms without taxanes [n=1,748]). Median OS was univariably significantly different (p=0.019) between trials with and without taxanes. Across trials, the median 'median OS' amongst trials containing taxanes was 15.5 mo, compared with 12.5 mo in trials which did not. Multivariably, visceral disease and performance status were significantly associated with OS, and the addition of taxanes trended toward significantly better OS (p=0.056) and increase in grade ≥ 3 neurotoxicity (p=0.051), regardless of specific platinum agent used.

CONCLUSIONS

In this meta-analysis, adding taxanes to gemcitabine and platinum showed a trend for improved OS and higher grade ≥ 3 neurotoxicity. Improvements in patient selection and the evaluation of a more potent and tolerable tubulin inhibitor in combination with gemcitabine/platinum in a well-powered trial are the critical next steps.

PATIENT SUMMARY

In this report, a trend for improved overall survival and worse neurotoxicity was observed for adding a taxane to first-line gemcitabine/platinum chemotherapy for metastatic urothelial carcinoma. More effective taxanes should be investigated further in urothelial carcinoma in combination with gemcitabine/platinum.

Combination of gemcitabine and carboplatin as first line treatment in elderly patients or those unfit for cisplatin-based chemotherapy with advanced transitional cell carcinoma of the urinary tract

PURPOSE

Although cisplatin-based chemotherapy is the standard of care for advanced transitional cell carcinoma, tolerability is a challenging issue in unfit patients. This study was conducted to evaluate the efficacy, toxicity, and tolerability of the combination of gemcitabine and carboplatin in unfit patients with advanced transitional cell carcinoma.

METHODS

Thirty-one patients who had advanced transitional cell carcinoma and one of the following clinical features were evaluated: Eastern Cooperative Oncology Group performance status equal or greater than 2, age older the 75 years or estimated glomerular filtration rate less than 60 ml/min. The patients were treated with carboplatin and gemcitabine delivered every 4 weeks.

RESULTS

Of the 31 patients, 71 % had an estimated glomerular filtration rate of less than 60 ml/min, and the remaining patients were treated by this protocol due to poor performance status or age older than 75. The median age of the patients was 74 years old. A total of 162 cycles of treatment were delivered to the patients. The overall response rate was 45.1 %. After the median follow-up of 15 months, the median progression-free survival time was 9.4 months (95 % CI 7.3-11.4) and overall survival time was 20 months (95 % CI 14.9-25.0). Grades 3 and 4 anemia, thrombocytopenia, and neutropenia were observed in 22.6, 6.45, and 6.45 % of patients, respectively. There was no treatment-related mortality in our patient series.

CONCLUSION

The combination of gemcitabine and carboplatin is effective in elderly patients with advanced transitional cell carcinoma or those unfit for cisplatin-based chemotherapy, with manageable toxicity.

Gemcitabine-associated "pseudocellulitis" and "pseudosepsis": a case report and review of the literature

Chemotherapeutic agents have been associated with sepsis and a variety of opportunistic and nonopportunistic infections. This was attributed to their immunosuppressive effects. Like all other chemotherapeutic agents, the use of gemcitabine has been associated with different infectious processes, yet many conditions that mimic infections have also been linked to its use. Pseudosepsis is a condition that should be added to these previously described conditions, such as gemcitabine-induced pseudocellulitis. We describe a patient who suffered from 2 different gemcitabine-induced adverse events including pseudocellulitis that was not related to prior lymphedema or radiation recall phenomenon and pseudosepsis wherein antibiotics have no role in the treatment, and the discontinuation of the offending agent resulted in the resolution of the patient's symptoms.