TROPHY-U-01: A Phase II Open-Label Study of Sacituzumab Govitecan in Patients With Metastatic Urothelial Carcinoma Progressing After Platinum-Based Chemotherapy and Checkpoint Inhibitors

Emerging Paradigms in Genitourinary Cancers: Integrating Molecular Imaging, Hypoxia-Inducible Factor-Targeted Therapies, and Antibody-Drug Conjugates in Renal Cell and Urothelial Carcinomas

Novel approaches in molecular imaging and targeted therapeutics are transforming the management of renal cell carcinoma (RCC) and urothelial carcinoma (UC). This review focuses on three key areas of innovation: molecular imaging, hypoxia-inducible factor-2α (HIF-2α) inhibition, and antibody-drug conjugates (ADCs). In molecular imaging, prostate-specific membrane antigen positron emission tomography/computed tomography has shown promise in RCC, while novel tracers targeting carbonic anhydrase IX and nectin-4 are emerging for RCC and UC, respectively. These approaches may enable better characterization of disease and treatment response monitoring. HIF-2α inhibition represents a breakthrough in targeting the fundamental pathobiology of clear cell RCC, with belzutifan demonstrating significant clinical benefit in both von Hippel-Lindau disease and sporadic RCC. Next-generation HIF-2α inhibitors, including casdatifan, show promising early clinical results with distinct pharmacologic properties. ADCs have become a cornerstone of UC treatment, with enfortumab vedotin plus pembrolizumab now approved as first-line therapy. Multiple human epidermal growth factor receptor 2 (HER2)-directed ADCs have shown efficacy in HER2-expressing UC, including trastuzumab deruxtecan, which recently received tumor-agnostic approval. While ADC development in RCC faces unique challenges, novel approaches including immunostimulatory payloads and bispecific antibodies are being explored. The integration of these advances in molecular imaging and therapeutics offers opportunities for more personalized treatment approaches in RCC and UC.

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.

RC48-ADC monotherapy or in combination with immunotherapy for locally advanced or metastatic urothelial carcinoma with HER2 low and null expression: a multicenter, real-world, retrospective study

BACKGROUND

Approximately half of urothelial carcinoma (UC) patients exhibit low or null HER2 expression. Limited data are available on the efficacy of anti-HER2 RC48-ADC (Disitamab Vedotin) in HER2 low and null advanced UC.

METHODS

Patients with locally advanced or metastatic UC (la/mUC) with HER2 low (IHC 1+) and null (IHC 0) expression who received RC48-ADC monotherapy or in combination with programmed cell death protein 1 (PD-1) inhibitors were enrolled in this multi-center, retrospective study. The primary endpoint was objective response rate (ORR). Secondary endpoints included disease control rate (DCR), progression-free survival (PFS), overall survival (OS), and adverse events (AEs).

RESULTS

A total of 27 patients were included, with a median age of 64 years, and 17 (63%) were male. Seven (26.0%) patients received RC48-ADC alone, and 20 (74.1%) received RC48-ADC combined with a PD-1 inhibitor. Eight (30.8%) patients achieved partial response (PR), and twelve (46.2%) exhibited stable disease (SD). The ORR was 30.8%, and DCR was 76.9%. The median PFS and OS were 7.4 months and 13.8 months, one-year PFS and OS rates were 29.1% and 57.2%, respectively. Both RC48 monotherapy and combination were well-tolerated. Grade 3 AEs occurred in 4 (14.8%) patients received combination treatment, including 2 cases of anemia, 1 case of increased serum creatinine, and 1 case of autoimmune encephalitis. No grade 3 or higher AEs were observed in RC48-ADC monotherapy.

CONCLUSION

RC48-ADC demonstrated favorable efficacy and manageable safety in la/mUC patients with HER2 low and null expression in real-world settings. Prospective studies with large sample size are warranted to validate this finding.

Novel Molecular Biomarkers to Guide Treatment Decision-making in Metastatic Urothelial Cancer-A Patient Cohort Analysis

The current options and recent developments in the field of systemic therapy for advanced urothelial cancer (UC) patients urge the need for selection criteria to identify the most optimal therapeutic option for individual patients. The molecular makeup of tumors, including molecular subtype, tumor microenvironment composition, and gene mutations, fusions, and amplifications, has previously been correlated with a response to immune checkpoint inhibitors, erdafitinib, or enfortumab vedotin (EV) monotherapy, and may withhold potential candidate biomarkers. In this study, we aimed to stratify metastatic UC (mUC) patients based on molecular biomarkers that might be associated with a response to EV, a fibroblast growth factor receptor inhibitor, or anti-PD-(L)1, by using whole-genome DNA-sequencing and paired RNA-sequencing data of fresh-frozen metastatic tumor biopsies of 155 mUC patients. We observed that NECTIN4 amplification, FGFR2/3 mutations, and the RNA expression-based T-cell-to-stroma enrichment (TSE) score were mutually exclusive, and may therefore reflect biologically distinct tumors and sensitivity to treatments. This finding was validated in two independent bladder cohorts: the IMvigor210 study and The Cancer Genome Atlas. Stratification of patients into subgroups based on these molecular features is possible. Our data challenge the concept of a one-treatment-fits-all paradigm and support the rationale for prospective clinical trials with biomarker-guided treatment selection of mUC patients.

Clinical Outcomes, Genomic Heterogeneity, and Therapeutic Considerations Across Histologic Subtypes of Urothelial Carcinoma

BACKGROUND AND OBJECTIVE

Divergent differentiation and histologic subtypes are common findings in urothelial carcinoma (UC). Clinically relevant genomic alterations and oncogenic drivers of individual subtypes remain poorly defined. We characterized surgical outcomes and the genomic landscape of UC with aberrant histology (UCAH), with a focus on biomarkers and targetable alterations.

METHODS

The clinical cohort comprised 3052 patients who underwent radical cystectomy (RC) with or without neoadjuvant chemotherapy. Targeted exon sequencing was performed for a genomic cohort of 1060 bladder tumors from RC or transurethral resection specimens. We characterized the frequency of oncogenic mutations and targetable alterations, and the tumor mutational burden (TMB) of each subtype. We defined the clonal relatedness of morphologically distinct regions of tumors with mixed histology.

KEY FINDINGS AND LIMITATIONS

Patients with plasmacytoid, micropapillary, sarcomatoid, or mixed-histology tumors had worse cancer-specific survival than patients with pure urothelial histology. ERBB2, FGFR3, and PTEN alterations were most frequent in micropapillary, nested/squamous, and sarcomatoid UC, respectively. TMB was highest in plasmacytoid, neuroendocrine, and micropapillary tumors. Regions of mixed histology had shared clonal origins, but exceptions were observed. The retrospective design and potential for selection bias are limitations of our study.

CONCLUSIONS AND CLINICAL IMPLICATIONS

UCAH tumors have distinct patterns of genomic alterations, which may be targetable via novel therapies and have implications for clinical trial inclusion. Biomarker-driven systemic therapy should be explored in patients with histologic subtypes that are associated with worse clinical outcomes.

Trop-2 and Ephrin B2 expression in urothelial carcinoma with divergent differentiation and aggressive urothelial carcinoma subtypes

OBJECTIVES

Urothelial carcinomas (UCs) encompass a heterogeneous group of tumors. Several histopathologic features are associated with poor clinical outcomes and limited treatment options. With new rising therapeutic modalities, we aimed to determine the pattern of expression of Trop-2 and ephrin B2 in UC with aggressive subtype histology and/or divergent differentiation (SH/DD).

METHODS

We performed a retrospective analysis of 113 UC samples with SH/DD at our institution from 2011 to 2021. Immunohistochemical staining for Trop-2 and ephrin B2 expression was performed on all cases. Expression was determined by the percentage of samples with a moderate or strong H-score.

RESULTS

Our results show Trop-2 expression was the highest in squamous cell carcinoma and UC with squamous differentiation, adenocarcinoma and UC with glandular differentiation, and plasmacytoid subtype, while ephrin B2 expression was highest in adenocarcinoma, UC with glandular differentiation, and small cell carcinoma.

CONCLUSIONS

Expression of Trop-2 and ephrin B2 may demonstrate therapeutic possibilities for patients with SH/DD, who usually have limited treatment options, particularly in small cell carcinoma, in which few targets have been identified. Clinical trials to investigate the efficacy of these novel treatments are warranted.

Evaluation of Nectin-4 and Trop-2: implications for patient outcomes and therapy in penile cancer

BACKGROUND

Metastatic penile cancer (PC) continues to have a poor prognosis due to inadequate treatment options. Enfortumab vedotin (EV) and sacituzumab govitecan (SG) are antibody-drug conjugates (ADCs) that have significantly improved the prognosis of several other tumor types and are, therefore, promising candidates for the successful treatment of metastatic PC.

OBJECTIVE

We examined the expression of the ADC targets Nectin-4 and Trop-2 in an international multicenter cohort of 203 PC patients, both in the primary tumor and in metastases. Additionally we evaluated their prognostic values.

RESULTS

Either intermediate or high Nectin-4 membrane expression was found in 28.0% of primary tumors and in 18.8% of metastases. The expression in the primary tumor decreased significantly with increasing T-stage (p = <0.001). It did not correlate with HPV status (p = 0.307) and was not associated with metastasis-free survival (MFS), cancer-specific survival (CSS) or overall survival (OS). Nectin-4 expression levels at the tumor front and in metastases were significantly associated with each other (p = 0.005). Trop-2 was detected on the membrane of almost all samples with an intermediate or high expression (primary tumor: 98.1%, metastasis: 100%). It was not associated with MFS, CSS or OS. The expression at the tumor front was significantly increased in HPV-positive tumors (p = 0.005).

CONCLUSIONS

Neither Nectin-4 nor Trop-2 was found to be of prognostic value in PC. EV therapy seems promising for selected patients with high Nectin-4 expression, which should be confirmed in PC metastases before treatment is considered. As Trop-2 is highly expressed in almost all PCs, it is a very interesting potential target for SG therapy. Both ADCs warrant investigation in clinical trials focusing on PC.

Current update on pharmacological strategies of penile cancer

INTRODUCTION

Penile cancer considered an orphan malignancy - due to its low incidence - makes research and clinical development challenging. The limited understanding of molecular biology and genetic landscape adds to the complexity of developing effective therapies.

AREAS COVERED

This review takes a closer look at how penile cancer treatment has evolved - from traditional modes like surgery and radiation to now vaccines - over the period of time. Breakthroughs in immunotherapy offer a ray of hope alongside treatments like adoptive T-cell therapies (ATCT), anti-angiogenic agents, Antibody-Drug Conjugates (ADCs), and Bispecific Antibodies (BsAbs).

EXPERT OPINION

The integration of immunotherapy and targeted therapy has demonstrated promising results, particularly in patients with advanced or metastatic disease. While these advancements bring hope, more research is needed to refine treatment strategies to benefit patients from these novel approaches.

Spatially precise chemo-radio-immunotherapy by antibody drug conjugate directed tumor radiosensitization to potentiate immunotherapies

Concurrent chemo-radiotherapy is standard of care for locally advanced cancer patients. While radiotherapy and immuno-oncology have advanced precision oncology, chemotherapies in the chemo-radiotherapy paradigm remain non-targeted cytotoxins. Antibody drug conjugates offer an opportunity for targeted radiosensitization that stimulates immune responses while protecting normal tissues. Here, we discuss the rationale for combining antibody drug conjugates, radiotherapy and immunotherapies and opportunities for clinical translation to advance towards targeted chemo-radio-immunotherapy precision cancer care.

Lines of Therapy for Locally Advanced/Metastatic Urothelial Carcinoma: The New Paradigm

Urothelial carcinoma (UC) is the most common malignancy of the urinary tract, with urothelial bladder cancer accounting for approximately 90% of cases. Metastatic UC (mUC) is a particularly aggressive subset that presents significant treatment challenges, especially in patients who are often older than 70 years and have multiple comorbidities. For several decades, cisplatin-based chemotherapy has been the standard first-line treatment for locally advanced (LA) mUC. However, its utility has been limited as many patients are ineligible owing to their health status, and overall survival rates remain suboptimal. Recent advancements, including antibody-drug conjugates and immunotherapies, have begun to reshape the treatment landscape for LA/mUC. The combination of enfortumab vedotin and pembrolizumab has shown promising clinical outcomes. The approval of multiple novel drugs and combination therapies not only provides new opportunities for patient care but also creates the need for physicians to adapt to this evolving therapeutic paradigm. This review explores the latest clinical data on the management of LA/mUC and offers insights into sequencing therapies for patients with LA/mUC.

Nausea and vomiting in an evolving anticancer treatment landscape: long-delayed and emetogenic antibody-drug conjugates

Nausea and vomiting are common, distressing side effects associated with chemotherapeutic regimens, resulting in reduced quality of life and treatment adherence. Appropriate antiemetic prophylaxis strategies may reduce/prevent chemotherapy-induced nausea and vomiting (CINV). Historically, investigators assessed antiemetics up to 120 hours after chemotherapy. However, CINV can extend beyond this time. Thus, the effect of antiemetics during the long-delayed period (>120 hours) requires investigation. Emerging treatment options, including certain antibody-drug conjugates (ADCs), are associated with high rates of acute and late-onset nausea and vomiting that can last for extended duration. With the increasing number of ADCs approved and in development, there is urgency to control nausea and vomiting in patients receiving these new therapies. In this narrative review, we present the emetogenic potential of ADCs and CINV in the long-delayed period along with antiemetic prophylaxis strategies used to date. We also discuss the promising role of the fixed-combination antiemetic NEPA ([fos]netupitant plus palonosetron) in controlling long-delayed nausea and vomiting, addressing characteristics that may contribute to its longer efficacy duration compared to other antiemetics. Finally, we highlight encouraging results with NEPA in patients receiving the ADCs trastuzumab deruxtecan or sacituzumab govitecan, which suggest NEPA may be an effective antiemetic prophylaxis in these settings.

Targeting the tumour cell surface in advanced prostate cancer

Prostate cancer remains a substantial health challenge, with >375,000 annual deaths amongst men worldwide. Most prostate cancer-related deaths are attributable to the development of resistance to standard-of-care treatments. Characterization of the diverse and complex surfaceome of treatment-resistant prostate cancer, combined with advances in drug development that leverage cell-surface proteins to enhance drug delivery or activate the immune system, have provided novel therapeutic opportunities to target advanced prostate cancer. The prostate cancer surfaceome, including proteins such as prostate-specific membrane antigen (PSMA), B7-H3, six transmembrane epithelial antigen of the prostate 1 (STEAP1), delta-like ligand 3 (DLL3), trophoblastic cell-surface antigen 2 (TROP2), prostate stem cell antigen (PSCA), HER3, CD46 and CD36, can be exploited as therapeutic targets, as regulatory mechanisms might contribute to the heterogeneity of expression of these proteins and subsequently affect treatment response and resistance. Specific treatment strategies targeting the surfaceome are in clinical development, including radionuclides, antibody-drug conjugates, T cell engagers and chimeric antigen receptor (CAR) T cells. Ultimately, biomarker development and clinical implementation of these agents will be informed and refined by further understanding of the biology of various targets; the target specificity and sensitivity of different agents; and off-target and toxic effects associated with these agents. Understanding the dynamic nature of cell-surface targets and non-overlapping expression patterns might also lead to future combinational strategies.

A novel anti-HER2/EGFR bispecific antibody-drug conjugate demonstrates promising antitumor efficacy and overcomes resistance to HER2- or EGFR-targeted ADCs

HER2 and EGFR are frequently co-expressed in various tumors. While antibody-drug conjugates (ADCs) targeting HER2, such as T-DM1 and T-Dxd, have shown remarkable antitumor effects in clinical responses, their effectiveness is constrained by drug resistance. EGFR amplification or high expression is one of the factors that lead to resistance against HER2-targeted ADCs. Likewise, the amplification of HER2 may lead to the development of resistance to EGFR-targeted therapies. To overcome these challenges, we, therefore, developed a bispecific antibody (B2C4) that targets HER2 and EGFR. B2C4 exhibited strong binding affinity and internalization activity in tumor cells with high expression of HER2 and EGFR, as well as in those with high expression of either target. B2C4 was then conjugated with vc-MMAE to create a bispecific ADC (B2C4-MMAE) with an average DAR of 4.05. By effectively engaging both arms of the bispecific ADC, B2C4-MMAE demonstrated significant antitumor activity in tumor cells and animal models that were unresponsive HER2- or EGFR-targeted ADCs. B2C4-MMAE could serve as an alternative therapeutic option for tumors that are resistant to single-target treatments. Additionally, B2C4-MMAE exhibited potential in treating tumors resistant to T-Dxd, underscoring its promise as a treatment for challenging cases.

Comparative Genomic Characterization of Small Cell Carcinoma of the Bladder Compared With Urothelial Carcinoma and Small Cell Lung Carcinoma

PURPOSE

Small cell bladder cancer (SCBC) is a rare histologic variant of bladder cancer with an aggressive disease course and poor outcomes. Given its uncommon nature, there is a paucity of high-quality data characterizing genomic drivers of this disease, and most patients are treated with approaches mirroring small cell lung cancer (SCLC). Leveraging the Tempus Lens deidentified clinically annotated genomic data set, we sought to evaluate the mutational landscape of SCBC relative to urothelial carcinoma (UC) and SCLC.

METHODS

Somatic pathogenic genomic alterations in patients with SCBC, UC, and SCLC of any stage who underwent blood- or tissue-based genomic profiling through the Tempus assay were cataloged. Baseline clinical and demographic features were compared across histologic groups. Alterations were collated and summarized using descriptive statistics. Pairwise comparisons were performed to assess differences in mutation frequency across pathologic cohorts.

RESULTS

In total, 149 SCBC, 4,350 UC, and 1,697 SCLC patients were included in the study. The most common genomic alterations in SCBC were in TP53 (87%), TERT (75%), and RB1 (70%). Among SCBC patients with TP53 mutations, RB1 comutations were observed in 77% of patients. Compared with UC, SCBC patients were significantly enriched for TP53, RB1, KMT2D, and KDM6A mutations. Compared with SCLC, SCBC patients were enriched for TERT, ARID1A, and CREBBP mutations, among others (P < .05). Multiple clinically targetable mutations were observed in SCBC, including PIK3CA (19%), ERBB2/3 (13%), and ALK (10%). Limitations of this study include its retrospective nature.

CONCLUSION

This study represents one of the most extensive efforts to characterize SCBC to date, providing a novel understanding of the genomic alterations underlying the disease and revealing actionable mutations that could serve as potential targets for improved clinical outcomes.

Implications and Lessons from the Withdrawal of Sacituzumab Govitecan for Treating Advanced Urothelial Carcinoma

The recent withdrawal of sacituzumab govitecan for advanced urothelial carcinoma has revealed several implications, including concerns over a lack of remaining effective treatment options, reimbursement, supportive care measures (such as granulocyte-colony stimulating factor), dose reductions, and inconsistencies with related historical regulatory decisions.

Key immune cells and their crosstalk in the tumor microenvironment of bladder cancer: insights for innovative therapies

Bladder cancer (BC) is a heterogeneous disease associated with high mortality if not diagnosed early. BC is classified into non-muscle-invasive BC (NMIBC) and muscle-invasive BC (MIBC), with MIBC linked to poor systemic therapy response and high recurrence rates. Current treatments include transurethral resection with Bacillus Calmette-Guérin (BCG) therapy for NMIBC and radical cystectomy with chemotherapy and/or immunotherapy for MIBC. The tumor microenvironment (TME) plays a critical role in cancer progression, metastasis, and therapeutic efficacy. A comprehensive understanding of the TME's complex interactions holds substantial translational significance for developing innovative treatments. The TME can contribute to therapeutic resistance, particularly in immune checkpoint inhibitor (ICI) therapies, where resistance arises from tumor-intrinsic changes or extrinsic TME factors. Recent advancements in immunotherapy highlight the importance of translational research to address these challenges. Strategies to overcome resistance focus on remodeling the TME to transform immunologically "cold" tumors, which lack immune cell infiltration, into "hot" tumors that respond better to immunotherapy. These strategies involve disrupting cancer-microenvironment interactions, inhibiting angiogenesis, and modulating immune components to enhance anti-tumor responses. Key mechanisms include cytokine involvement [e.g., interleukin-6 (IL-6)], phenotypic alterations in macrophages and natural killer (NK) cells, and the plasticity of cancer-associated fibroblasts (CAFs). Identifying potential therapeutic targets within the TME can improve outcomes for MIBC patients. This review emphasizes the TME's complexity and its impact on guiding novel therapeutic approaches, offering hope for better survival in MIBC.

Influence of the UGT1A1 gene polymorphism on treatment with sacituzumab govitecan. Narrative review

OBJECTIVE

Sacituzumab govitecan is an antineoplastic therapy composed of a monoclonal antibody directed to the Trop2 antigen, conjugated to SN-38, an active metabolite of irinotecan that inhibits topoisomerase I. It is indicated for the treatment of metastatic triple-negative breast cancer in patients who have received at least two prior lines of treatment, with at least one in the metastatic context. SN-38 is eliminated by glucuronidation mediated by uridine diphosphate-glucuronosyltransferase-1A1 (UGT1A1) enzymes, present in the liver. Mutations in the UGT1A1 gene decrease the expression of these enzymes, which increases the concentration of SN-38 and, consequently, increases the toxicity of the drug, especially in the form of neutropenia and diarrhea. This study aims to analyze the relationship between UGT1A1 gene polymorphisms and toxicity associated with treatment with sacituzumab govitecan, in addition to reviewing the usefulness of genetic screening prior to starting therapy.

METHODS

A non-systematic literature review was conducted on the impact of UGT1A1 gene polymorphisms on the safety of sacituzumab govitecan treatment in patients with triple-negative breast cancer. The search included primary and secondary literature sources and communications from oncology conferences.

RESULTS

Patients treated with sacituzumab govitecan with the UGT1A1*28/*28 mutated genotype are more likely to experience grade more than 3 hematologic adverse events: neutropenia (approximate incidence of 60% compared to 40% for 1/*1 and 1/*28 genotypes), febrile neutropenia (18% homozygotes vs. 5% heterozygotes and 3% wild-type), grade more than 3 anemia (15% vs. 6% and 4%, respectively); as well as grade more than 3 diarrhea (24% vs. 13% and 6%, respectively). Additionally, treatment discontinuation rates are higher in *28/*28 individuals (6% compared to 1% heterozygotes and 2% wild-type).

CONCLUSIONS

Patients homozygous for the UGT1A1*28 allele are at significantly increased risk of developing serious adverse events. Despite the clear relationship between UGT1A1 polymorphisms and sacituzumab-govitecan toxicity, the review suggests that there is insufficient consensus on the need for systematic genetic screening. However, the findings indicate that such screening could be useful for identifying patients at risk and personalizing sacituzumab govitecan therapy.

Real-World Clinical Outcomes with First-Line Systemic Treatment and Avelumab Maintenance in US Patients with Locally Advanced or Metastatic Urothelial Carcinoma: The SPEAR Bladder-II Study

Avelumab first-line maintenance (1LM) is approved for patients with locally advanced or metastatic urothelial carcinoma (la/mUC) who do not have disease progression after platinum-based chemotherapy (PBC). This retrospective study describes real-world treatment patterns and clinical outcomes in patients with la/mUC who initiated first-line (1L) systemic treatments, including avelumab 1LM, within iKnowMed, the US community oncology electronic health records database, between 1 December 2019 and 30 November 2023 and followed through 28 February 2024. In total, 1658 patients with la/mUC initiated 1L treatment: immuno-oncology (IO) monotherapy (41.2%), PBC only (32.4%), PBC followed by avelumab 1LM (11.2%), and other treatments (15.1%). The median OS (95% CI) from the start of 1L treatment was 20.4 (13.8, 30.0), 11.0 (8.5, 14.5), and 14.6 (12.6, 17.3) months for cisplatin-based only, carboplatin-based only, and IO monotherapy, respectively. Among the overall population, 36.1% and 11.8% of patients received second-line (2L) and third-line treatment, respectively. The median (95% CI) OS from the start of avelumab 1LM was 18.5 (13.8, 23.8) months. After discontinuation of avelumab 1LM, 43.5% received 2L treatment, and 59.3% of those received enfortumab vedotin (EV); the median (95% CI) OS from start of 2L EV was 12.7 (7.2, 16.5) months. Survival outcomes among patients treated with avelumab 1LM and 2L EV are consistent with respective clinical trials and other real-world studies.

Efficacy and safety of DV in HER2-negative and HER2-low locally advanced or metastatic urothelial carcinoma: Results of a phase 2 study

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) has emerged as a new target for metastatic urothelial carcinomas (mUCs). Disitamab vedotin (DV), an anti-HER2 antibody-drug conjugate (ADC), demonstrates a promising efficacy in patients with HER2-positive mUC. However, the role of DV in HER2-negative and HER2-low mUCs remains unknown.

METHODS

Patients with HER2-negative and HER2-low (immunohistochemistry [IHC] 0 or 1+) mUCs who received ≥1 line of systemic chemotherapy were included. Patients received 2 mg/kg DV intravenously once every 2 weeks. The primary endpoint was the objective response rate (ORR). Secondary endpoints included progression-free survival (PFS), overall survival (OS), and safety.

FINDINGS

Nineteen patients with UC were enrolled from September 2019 to December 2021. The median age was 64.0 years. 15 patients (79%) had visceral metastases. HER2 IHC 0 and 1+ were detected in 6 and 13 patients, respectively. As of September 30, 2022, the confirmed ORR was 31.6% (95% confidence interval [CI]: 12.6, 56.6), and the disease control rate was 94.7% (18/19). The median PFS and OS were 5.5 (95% CI: 3.9, 5.7) and 16.4 (6.8, 26.8) months, respectively. Common treatment related adverse events were mostly grade 1 or 2, including leukopenia (52.6%) and hypoesthesia (47.4%).

CONCLUSIONS

This is the first exploratory trial demonstrating substantial anti-tumor activity and a manageable safety profile using a HER2-targeting agent in patients with HER2-low mUC. This study was registered at ClinicalTrials.gov (ClinicalTrials.gov: NCT04073602).

FUNDING

The study was funded by the Natural Science Foundation of China, the Natural Science Foundation of Tibet Autonomous Region, the Beijing Xisike Clinical Oncology Research Foundation, and RemeGen, Ltd.

Molecular Classification of Urothelial Carcinoma

Urothelial carcinoma exhibits a wide spectrum of morphologic and molecular heterogeneity. Advances in molecular testing have improved our understanding of the molecular biology of urothelial carcinoma, including recurrent genomic alterations and transcriptomic features, leading to the development of molecular classification schemes with potential therapeutic implications. This review summarizes the molecular characteristics of urothelial carcinoma, focusing on genomic and transcriptomic features, updates on variant histology, and novel biomarkers that may guide contemporary and future clinical management.

Tissue-Based Biomarkers Important for Prognostication and Management of Genitourinary Tumors, Including Surrogate Markers of Genomic Alterations

A better understanding of the molecular alterations that underlie urologic malignancies and advances in targeted therapies has impacted classification, prognostication, and treatment. In bladder tumors, these advances include the development of antibody-drug conjugates targeting nectin-4 and Trop-2, as well as human epidermal growth factor receptor 2 and immunotherapy. In prostate cancer, assessment of the percentage of Gleason pattern 4, presence of cribriform glands, and molecular alterations, including PTEN and mismatch repair protein loss, have become standard for clinical care. In renal malignancies, alterations in TSC1/2, mammalian target of rapamycin, anaplastic lymphoma kinase, and other genes impact classification and therapeutic decisions.

Practical clinical management of ocular adverse events related to Antibody-Drug Conjugates in gynaecological malignancies

BACKGROUND

The advent of Antibody-Drug Conjugates (ADC) represents a significant advancement in targeted therapy for gynaecological malignancies. However, the ocular toxicities associated with ADCs, particularly Tisotumab Vedotin (TV) and Mirvetuximab Soravtansine (MIRV) necessitate effective mitigation in order to optimise patient care.

METHODS

This review synthesises findings from clinical trials to delineate the spectrum of ocular adverse events induced by ADCs. The analysis focuses on the incidence, onset, severity and reversibility of adverse events. It examines the underlying mechanisms of toxicity and provides management strategies based on study protocols.

RESULTS

Adverse events mainly impact the anterior ocular segment, resulting in conjunctivitis and keratopathy. They affect up to 56 % of patients treated with MIRV and 50 to 60 % of those receiving TV. Symptoms like blurred vision, dryness and pain hinder the patient's quality of life. Events are CTCAE grade 3 or higher in less than 10 % of cases. The median time to onset is 1.3 months. However, ocular toxicity may appear up to 10 months after treatment initiation, indicating a need for prolonged vigilance. Primary prophylaxis calls for local corticotherapy, lubricants and in some cases, vasoconstrictors. Despite the potential for severity, most cases are reversible with local treatment and transient dose reduction and/or delay. Close monitoring is crucial for early detection and subsequent management.

CONCLUSIONS

Clinicians ought to be cognizant of the potential ocular toxicity of ADCs. Proactive prophylaxis, patient education and a multidisciplinary approach involving ophthalmologists are paramount to minimising the impact of these AEs. Further research is essential to measure the real outcome of preventive strategies and balance their benefits with potential short and long-term risks.

Antibody-Drug Conjugates: The Toxicities and Adverse Effects That Emergency Physicians Must Know

Antibody-drug conjugates are novel antineoplastic agents whose use is expanding, both in terms of the number of drugs and the number of patients being treated. This article reviews the known toxicities and complications of antibody-drug conjugates that are currently approved for the treatment of cancer in the United States, with a focus on their emergency presentation and management. Similar to many other cancer therapies, most antibody-drug conjugates can cause diarrhea, nausea/vomiting, rash, peripheral neuropathy, and cytopenia, which are generally treated following standard-of-care. Interstitial lung disease, which may mimic pneumonia and cause respiratory failure and death, has been seen with trastuzumab deruxtecan and mirvetuximab soravtansine; emergency treatment of this condition includes oxygenation, ventilatory support, and corticosteroids. Inotuzumab ozogamicin and gemtuzumab ozogamicin are both associated with sinusoidal obstruction syndrome, a potentially fatal liver dysfunction that presents with weight gain, fluid overload, and jaundice. Abnormal liver function tests in patients who have been recently treated with these agents should be cautiously evaluated. Cardiac adverse events with antibody-drug conjugates are rare, but trastuzumab emtansine and trastuzumab deruxtecan may cause a decrease in cardiac contractility, and heart rate corrected QT interval prolongation is a rare effect of trastuzumab deruxtecan. Ocular adverse events, especially blurred vision, and keratopathy, are common with mirvetuximab soravtansine and tisotumab vedotin. Progressive multifocal leukoencephalopathy has been reported with brentuximab vedotin and polatuzumab vedotin. Tumor lysis syndrome may occur after treatment with gemtuzumab ozogamicin, polatuzumab vedotin, and brentuximab vedotin. Patients receiving enfortumab vedotin or brentuximab vedotin may develop hyperglycemia, sometimes presenting as diabetic ketoacidosis. Tisotumab vedotin and trastuzumab emtansine are associated with bleeding; although it is minor in most cases, severe bleeding and intracranial hemorrhage have occurred. Several antibody-drug conjugates can cause an anaphylactoid infusion-related reaction, which occurs most commonly during or soon after infusion but may be delayed up to 24 hours. Further research is needed to establish the real-world incidence of rare complications and how often patients with these complications present to the emergency department.

Management of nausea and vomiting induced by antibody-drug conjugates

Antibody-drug conjugates (ADCs) are an emerging class of anticancer therapy that combines the specificity and long circulation half-life of monoclonal antibodies with the cytotoxic potency of the payload connected through a chemical linker. The optimal management of toxicities is crucial for improving quality of life in patients undergoing ADCs and for avoiding improper dose reductions or discontinuations. This article focuses on the characteristics and management of nausea and vomiting (NV) induced by three ADCs: trastuzumab deruxtecan (T-DXd), sacituzumab govitecan (SG), and datopotamab deruxtecan (Dato-DXd). We summarize the proposed mechanism of NV, clinical study data on NV, and recommendations from clinical guidelines. We also discuss three prospective studies evaluating prophylactic antiemetic therapy in patients receiving T-DXd, along with future perspectives.

A Comprehensive Review of Current Approaches in Bladder Cancer Treatment

Bladder cancer is one of the most common malignant tumors of the urinary system globally. It is also one of the most expensive cancers to manage, due to the need for extensive treatment and follow-ups that often involve invasive and costly procedures. Although there have been some improvements in treatment options, the quality of life they offer has not improved at the same rate as other cancers. Therefore, there is an urgent need to find new alternatives to ease the burden of bladder cancer on patients. Recent discoveries have opened new avenues for the diagnosis and management of bladder cancer even though the clinical approach has largely remained the same for years. The decline in bladder cancer-specific mortality in regions that promote social awareness of risk factors and reduction of carcinogenic exposure demonstrates the effectiveness of such measures. New agents have been approved for patients who have undergone radical cystectomy after Bacillus Calmette-Guérin failure. Current best practices for diagnosing and treating bladder cancer are presented in this review. The review discusses radiation therapy, photodynamic therapy, gene therapy, chemotherapy, and nanomedicine in relation to non muscle-invasive cancers and muscle-invasive bladder cancers, as well as systemic treatments.

Real-Life Impact of Enfortumab Vedotin or Chemotherapy in the Sequential Treatment of Advanced Urothelial Carcinoma: The ARON-2 Retrospective Experience

BACKGROUND

Recently, a plethora of novel systemic agents have been incorporated into the therapeutic armamentarium of advanced urothelial carcinoma (aUC). The antibody-drug conjugate (ADC), enfortumab vedotin (EV), has demonstrated relevant clinical benefit in patients with aUC refractory to platinum and immune-checkpoint inhibitor (ICI) therapy. Our study provides a retrospective, international, real-world analysis comparing the effectiveness of EV to chemotherapy in this setting.

METHODS

The data were extracted from the medical records of patients treated with EV or chemotherapy following pembrolizumab for recurrent or progressive aUC after platinum-based chemotherapy. Patients were assessed for overall survival (OS), progression-free survival (PFS), overall response rate (ORR) and duration of response (DoR).

RESULTS

Our analysis included 247 patients treated with EV (88, 36%) or chemotherapy (159, 64%). Median OS was 9.1 months (95%CI 7.2-10.7) in the overall study population, 13.6 months (95%CI 10.0-31.0) in patients receiving EV and 6.8 months (95%CI 6.0-8.9) in patients receiving chemotherapy (p < 0.001). The OS benefit of EV was not affected by primary tumour site and histology, metastatic sites, type of first platinum-based chemotherapy or response to pembrolizumab. In the EV cohort, the median PFS was significantly longer (8.8 months [95%CI 6.5-17.0] vs. 3.0 months [95%CI 2.6-3.7]) and the ORR was significantly higher (56% vs. 23%) than in the chemotherapy cohort.

CONCLUSIONS

The results of our international analysis of real-world data confirm the effectiveness of EV in the sequential strategy of aUC patients who have received prior platinum-based chemotherapy and anti-PD-1 pembrolizumab, regardless of commonly considered prognostic factors.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05290038.

Resistance to antibody-drug conjugates: A review

Antibody-drug conjugates (ADCs) are antitumor drugs composed of monoclonal antibodies and cytotoxic payload covalently coupled by a linker. Currently, 15 ADCs have been clinically approved worldwide. More than 100 clinical trials at different phases are underway to investigate the newly developed ADCs. ADCs represent one of the fastest growing classes of targeted antitumor drugs in oncology drug development. It takes advantage of the specific targeting of tumor-specific antigen by antibodies to deliver cytotoxic chemotherapeutic drugs precisely to tumor cells, thereby producing promising antitumor efficacy and favorable adverse effect profiles. However, emergence of drug resistance has severely hindered the clinical efficacy of ADCs. In this review, we introduce the structure and mechanism of ADCs, describe the development of ADCs, summarized the latest research about the mechanisms of ADC resistance, discussed the strategies to overcome ADCs resistance, and predicted biomarkers for treatment response to ADC, aiming to contribute to the development of ADCs in the future.

Impact of Membranous Nectin-4 on Outcomes of Platinum-Based Chemotherapy in Metastatic Urothelial Carcinoma

Metastatic urothelial carcinoma (mUC) is a highly aggressive malignancy [...].

Exploring the Prognostic Role of Trop-2, CD47, and CD163 Expression Levels on Survival Outcomes in Patients with Triple-Negative Breast Cancer

Background: This study evaluated the prognostic impact of Trop-2, CD47, and CD163 expression on clinical outcomes in triple-negative breast cancer (TNBC) and investigated their interactions with tumor progression. Methods: A retrospective cohort of 92 patients with TNBC was analyzed. The expression scores for Trop-2, CD47, and CD163 were categorized as negative/low (0-3 points) or high (4-6 points). The primary endpoint was overall survival (OS). Results: The median age of the cohort was 50 years old. High Trop-2 expression was observed in 55.4% of the patients and was significantly associated with advanced disease stage (p < 0.001). High CD47 expression (44.6%) was correlated with advanced stage (p = 0.044), whereas high CD163 expression (45.7%) was associated with advanced stage (p = 0.021), absence of comorbidities (p = 0.022), and lower pT stage (p = 0.023). Moderate positive correlations were found between Trop-2 and CD47 (p = 0.022), Trop-2 and CD163 (p = 0.037), and CD47 and CD163 (p < 0.001), respectively. Kaplan-Meier survival analysis revealed that patients with low Trop-2 expression exhibited significantly prolonged OS (p = 0.021) and progression-free survival (PFS) (p = 0.026) compared to those with high Trop-2 expression. Univariate and multivariate analyses revealed significant associations between OS and PFS for Trop-2, lymphovascular invasion, and BRCA status. Conclusions: Trop-2 expression is a significant prognostic factor for TNBC and is correlated with worse outcomes. Although CD47 and CD163 showed trends for poorer prognosis, their significance was not confirmed. These findings offer promising prospects for future studies on combined antibody-drug conjugates (ADCs), as they may present opportunities to address multiple resistance mechanisms in the management of TNBC and enhance clinical outcomes.

Nanoparticle innovations in targeted cancer therapy: advancements in antibody-drug conjugates

Antibody-drug conjugates (ADCs) have emerged as a promising strategy in targeted cancer therapy, enabling the precise delivery of cytotoxic agents to tumor sites while minimizing systemic toxicity. However, traditional ADCs face significant limitations, including restricted drug loading capacity, where an optimal drug-to-antibody ratio (DAR) is crucial; low DARs may lead to insufficient potency, while high DARs can cause rapid clearance and increased toxicity. Additionally, ADCs often suffer from instability in circulation due to the potential for premature release of cytotoxic agents, resulting in off-target effects and reduced therapeutic efficacy. Furthermore, their large size can impede adequate penetration into solid tumors, particularly in heterogeneous environments with varying antigen expressions. This review explores the innovative use of nanoparticles as carriers for ADCs, which offers a multifaceted approach to enhance therapeutic efficacy. By leveraging the unique properties of nanoparticles, such as their small size and ability to exploit the enhanced permeability and retention (EPR) effect, researchers can improve drug stability, prolong circulation time, and achieve more effective tumor targeting. Recent studies demonstrate that nanoparticle-encapsulated ADCs can significantly enhance treatment outcomes while reducing off-target effects, as evidenced by improved targeting capabilities and reduced toxicity in preclinical models. Despite the promising advancements, challenges remain, including potential nanoparticle toxicity and manufacturing complexities. This review aims to provide a comprehensive overview of the current research on nanoparticle-encapsulated ADCs. It highlights their potential to transform cancer treatment and offers insights into future directions for optimizing these advanced therapeutic strategies.

The combination treatment of RC48 and STAT3 inhibitor acts as a promising therapeutic strategy for basal bladder cancer

As an antibody-drug conjugate (ADC), disitamab vedotin (RC48) is a promising treatment targeting ERBB2 for locally advanced and metastatic bladder cancer (BLCA). However, the subtype heterogeneity of muscle-invasive bladder cancer (MIBC) often leads to different therapeutic outcomes. In our study, we aim to explore sensitivity differences and mechanisms of different molecular subtypes of MIBC to RC48 treatment and develop a strategy for combination therapy against cancer. Using large-scale mRNA expression profile datasets, Western blotting, and immunohistochemistry, we first found that ERBB2 is upregulated in the luminal type but downregulated in basal bladder cancer. In addition, luminal cells showed higher sensitivity to RC48 than basal cells. Basal cells with ERBB2 overexpression demonstrated increased sensitivity to RC48 in vitro and in vivo, indicating that ERBB2 expression mediates RC48's therapeutic efficacy against cancer. In basal or RC48-exposed luminal cells, the JAK/STAT3 pathway was highly enriched, suggesting that downregulation or pharmacological inhibition of ERBB2 leads to compensatory activation of this pathway. Silencing STAT3 increased the inhibitory efficacy of RC48. In addition, artesunate (ART, a STAT3 inhibitor) showed a synergistic effect with RC48 against basal bladder cancer both in vitro and in vivo. In summary, these findings provide a theoretical foundation for subsequent clinical trials combining RC48 and ART in MIBC based on molecular subtypes.

Phase 2 Open-Label Study of Sacituzumab Govitecan as Second-Line Therapy in Patients With Extensive-Stage SCLC: Results From TROPiCS-03

INTRODUCTION

The phase 2 TROPiCS-03 study evaluated the efficacy/safety of sacituzumab govitecan (SG) as second-line treatment in patients with previously treated extensive-stage SCLC (ES-SCLC).

METHODS

TROPiCS-03 (NCT03964727) is a multicohort, open-label, phase 2 basket study of solid tumors, including ES-SCLC. Adults with ES-SCLC that progressed after one previous line of platinum-based chemotherapy and anti-programmed death-(ligand) 1 (PD-[L]1) therapy received SG 10 mg/kg on days 1 and 8 of a 21-day cycle. The primary end point was the investigator-assessed objective response rate (ORR) according to Response Evaluation Criteria in Solid Tumors version 1.1. Key secondary end points included investigator-assessed duration of response (DOR) and progression-free survival (PFS); blinded independent central review-assessed ORR, DOR, and PFS; overall survival (OS); and safety. Efficacy was evaluated in patients with platinum-resistant and platinum-sensitive disease.

RESULTS

Among 43 patients (median follow-up, 12.3 [range, 8.1-20.1] mo), investigator-assessed ORR was 41.9% (95% confidence interval [CI]: 27.0%-57.9%), with 18 confirmed partial responses; median (95% CI) DOR, PFS, and OS were 4.73 (3.52-6.70), 4.40 (3.81-6.11), and 13.60 (6.57-14.78) months, respectively. The efficacy results of the blinded independent central review assessments were similar. The investigator-assessed ORR (95% CI) was 35.0% (15.4%-59.2%) in patients with platinum-resistant disease (n = 20) and 47.8% (26.8%-69.4%) in patients with platinum-sensitive disease (n = 23). Furthermore, 32 patients (74.4%) had grade greater than or equal to 3 treatment-emergent adverse events (TEAEs). No TEAE led to SG discontinuation; one treatment-related TEAE (neutropenic sepsis) led to death.

CONCLUSIONS

SG has promising efficacy as second-line treatment of ES-SCLC, irrespective of platinum sensitivity. Safety was manageable and consistent with that observed in other SG studies.

Impact of DNA repair deficiency on sensitivity to antibody-drug conjugate (ADC) payloads in bladder cancer

Background

Enfortumab vedotin (EV) and Sacituzumab govitecan (SG) are antibody-drug conjugates (ADCs) with demonstrated activity in advanced bladder cancer. A subset of bladder tumors harbors a DNA repair deficiency in either the homologous recombination (HR) or nucleotide excision repair (NER) pathway that has the potential to impact sensitivity to specific classes of therapeutics.

Objective

Define the impact of HR or NER deficiency on sensitivity to ADC payloads alone or in combination with DNA repair targeted agents in bladder cancer.

Methods

Isogenic cell pairs with versus without HR or NER deficiency were profiled using DNA repair and drug sensitivity assays. Sensitivity to the ADC payloads monomethyl auristatin E (MMAE) and SN-38 alone or in combination with small molecule inhibitors of poly(ADP-ribose) polymerase (PARP), ATR, or USP1 were measured using cell viability assays.

Results

BRCA2 loss was sufficient to confer an HR deficient phenotype and increase sensitivity to cisplatin and PARP inhibition in bladder cancer cell lines. HR deficiency, but not NER deficiency, increased sensitivity to MMAE and SN-38 in bladder cancer cells. The combination of SN-38 and PARP inhibition displayed synergistic cell killing independent of HR or NER status.

Conclusion

HR and NER deficiency have distinct impacts on sensitivity to cisplatin and ADC payloads in bladder cancer preclinical models.

Treatment Patterns for Metastatic Urothelial Carcinoma Across Eight Mexican Centers: The ALEBRIJE Study

PURPOSE

Metastatic urothelial carcinoma (mUC) poses a challenge to health care systems, given its treatment complexity and mortality. We aimed to describe the characteristics, treatment patterns, and survival outcomes of Mexican patients with mUC.

METHODS

A retrospective study was conducted across eight centers for adults with mUC from January /2001 to December 2021. We recorded medical history, eligibility for first-line platinum therapy, treatment lines received, and access to novel drugs. Descriptive statistics were used and survival analysis, including Kaplan-Meier curves and Cox proportional hazards model, was performed.

RESULTS

We identified 379 patients with mUC; 37 were excluded, and 76% was male, with a median age of 67 years. The median follow-up was 8.4 months. Among those who received a first-line treatment (65%), cisplatin-based chemotherapy (45%) was the most common followed by carboplatin (39%). Causes of cisplatin ineligibility were Eastern Cooperative Oncology Group ≥2 (41%) and glomerular filtration rate <60 mL/min (33%). The overall response rate to up-front platinum therapy was 33%, with a median progression-free survival of 6.1 months (95% CI, 4.9 to 6.9). Second-, third-, and fourth-line treatment was given to 24.6%, 8.8%, and 3.5%, respectively. Chemotherapy was the most common regimen prescribed. Access to novel drugs was limited, 14 patients received avelumab, and 25% received immunotherapy as second-line treatment. The median overall survival was 11.8 months (95% CI, 10.2 to 15.2). Multivariate analysis showed that first-line treatment was independently associated with better survival, whereas poor performance status and visceral disease were associated with worse survival.

CONCLUSION

To our knowledge, these data represent the first effort to delineate treatment trends of mUC in Mexico. First-line treatment prescription and rates of progression to platinum therapy were higher than those described worldwide. Factors affecting survival included performance status, first-line treatment, and visceral disease. Our study highlights unequal access to novel treatments, underscoring the need for equitable care.

The biologic landscape and therapeutic implications of upper tract urothelial cancer

PURPOSE OF REVIEW

Management of upper tract urothelial cancer (UTUC) has been largely extrapolated from bladder cancer due to its rarity; however, unique biological and clinical differences between UTUC and bladder cancer have been uncovered. The purpose of this review is to present the current therapeutic landscape of UTUC with an emphasis on biologically driven rationale.

RECENT FINDINGS

Prospective trials for patients with high-risk localized UTUC have shown improved outcomes with adjuvant and neoadjuvant platinum-based chemotherapy. However, the timing of therapy relative to nephroureterectomy may impact platinum eligibility due to renal functional decline following surgery. In recent years, emerging therapeutic classes including immune checkpoint inhibition, antibody drug conjugates, and targeted therapies have emerged as tolerable alternatives to platinum-based chemotherapy in treating metastatic disease. Biomarker-selected therapies, including those targeting HER2 and FGFR3, have shown encouraging results and are relevant to UTUC based on increased expressions of these targets; however, no prospective study to date has been powered to assess the effect of these modern treatments on patients with UTUC specifically.

SUMMARY

Unique biological insights into UTUC pathogenesis and risk factors have expanded the therapeutic landscape for these patients beyond conventional platinum-based chemotherapeutic approaches. Novel therapeutic classes have emerged to guide more precise approaches in treating patients with urothelial cancer, with a need for further trials powered specifically to the UTUC population.

Unmet Potential of Antibody-Drug Conjugates: An Evaluation of the Past, Present, and Future of Antibody-Drug Conjugate Development in Advanced Urothelial Carcinoma

Antibody-drug conjugates (ADCs) represent an emerging class of therapeutics across solid tumor oncology and are already positioned as a cornerstone therapy for patients with urothelial carcinoma (UC). In recent years, there has been a paradigm shift in the therapeutic landscape as frontline treatment of UC formerly relied on the use of platinum-based agents and has now evolved to include combination strategies with ADCs. These dramatic changes are due in part to our improved understanding of the molecular features of bladder tumors and the identification of tumor-associated antigens specific to UC, which may serve as druggable targets. Despite notable advances and the clinical success of ADCs in other malignancies, their full potential in UC remains largely unmet. Early clinical success of enfortumab vedotin and sacituzumab govitecan demonstrated antitumor activity; however, there are multiple challenges with these ADCs, including on-target, off-tumor toxicity and difficulty in maintaining sustained responses. Newer-generation ADC constructs, either alone or as part of combination approaches, are currently under investigation. This review examines the historical development, current landscape, and emerging trends in ADC therapy for UC, highlighting both the progress made and obstacles that continue to hinder optimal therapeutic outcomes.

Vaccine approaches to treat urothelial cancer

Bladder cancer (BC) accounts for about 4% of all malignancies. Non-muscle-invasive BC, 75% of cases, is treated with transurethral resection and adjuvant intravesical instillation, while muscle-invasive BC warrants cisplatin-based perioperative chemotherapy. Although immune-checkpoint inhibitors, antibody drug conjugates and targeted agents have provided dramatic advances, metastatic BC remains a generally incurable disease and clinical trials continue to vigorously evaluate novel molecules. Cancer vaccines aim at activating the patient's immune system against tumor cells. Several means of delivering neoantigens have been developed, including peptides, antigen-presenting cells, virus, or nucleic acids. Various improvements are constantly being explored, such as adjuvants use and combination strategies. Nucleic acids-based vaccines are increasingly gaining attention in recent years, with promising results in other malignancies. However, despite the recent advantages, numerous obstacles persist. This review is aimed at describing the different types of cancer vaccines, their evaluations in UC patients and the more recent innovations in this field.

Targeting Refractory Triple-Negative Breast Cancer with Sacituzumab Govitecan: A New Era in Precision Medicine

Advanced triple-negative breast cancer (TNBC) has poorer outcomes due to its aggressive behavior and restricted therapeutic options. While therapies like checkpoint inhibitors and PARP inhibitors offer some benefits, chemotherapy remains ineffective beyond the first line of treatment. Antibody-drug conjugates (ADCs) like sacituzumab govitecan-hziy (SG) represent a significant advancement. SG combines SN-38, an irinotecan derivative, with a Trop-2-targeting antibody via a pH-sensitive linking moiety, achieving a good drug:antibody ratio. In a phase I-II study involving metastatic TNBC (mTNBC) individuals, SG achieved an overall response rate of 33.3% and a median response period of 7.7 months. The phase III ASCENT trial demonstrated SG's efficacy in relapsed or refractory TNBC, improving median progression-free survival and median overall survival compared to chemotherapy. Common side effects include neutropenia, nausea, and fatigue. This article highlights the clinical potential, pharmacokinetics, safety profile, and resistance mechanisms of SG along with key ongoing clinical trials, emphasizing its role in managing refractory mTNBC, especially in third-line therapy. The review also discusses current strategies for managing adverse reactions and sequencing ADC treatments in clinical practice, along with the predicted basis of resistance. The optimal sequencing of SG relative to other ADCs, such as trastuzumab deruxtecan or T-DXd, remains an evolving question, especially as newer agents with distinct mechanisms of action and safety profiles enter the field. Further research is essential to establish evidence-based strategies for sequencing SG and addressing disease progression post-ADC therapy.

Distinct effects of sacituzumab govitecan and berzosertib on DNA damage response in ovarian cancer

Antibody-drug conjugates (ADCs) have become an important class of anticancer drugs in solid tumors including drug-resistant gynecologic malignancies. TROP2 is a cell surface antigen that is highly expressed in ovarian carcinoma (OC) but minimally expressed in normal ovarian tissues. In this study, we aimed to identify how TROP2-specific ADC, sacituzumab govitecan (SG), modulates DNA damage response pathways in drug-resistant OC. We found that SG induces G2/M arrest, increases RPA1 foci, and decreases replication fork speed, resulting in replication stress in TROP2-positive cells while these were less evident in TROP2-negative cells. In OC in vitro and in vivo models, SN-38 sensitivity and TROP2 expression play key roles in response to either ATR inhibitor or SG alone, or in combination. Additionally, inhibition of translesion DNA synthesis enhances SG and PARP inhibitor (PARPi) sensitivity in PARPi-resistant OC cells. These findings provide mechanistic insights for clinical development of SG in drug-resistant OC.

Influence of antibody-drug conjugate cleavability, drug-to-antibody ratio, and free payload concentration on systemic toxicities: A systematic review and meta-analysis

While in theory antibody drug conjugates (ADCs) deliver high-dose chemotherapy directly to target cells, numerous side effects are observed in clinical practice. We sought to determine the effect of linker design (cleavable versus non-cleavable), drug-to-antibody ratio (DAR), and free payload concentration on systemic toxicity. Two systematic reviews were performed via PubMed search of clinical trials published between January 1998-July 2022. Eligible studies: (1) clinical trial for cancer therapy in adults, (2) ≥ 1 study arm included a single-agent ADC, (3) ADC used was commercially available/FDA-approved. Data was extracted and pooled using generalized linear mixed effects logistic models. 40 clinical trials involving 7,879 patients from 11 ADCs, including 9 ADCs with cleavable linkers (N = 2,985) and 2 with non-cleavable linkers (N = 4,894), were included. Significantly more composite adverse events (AEs) ≥ grade 3 occurred in patients in the cleavable linkers arm (47%) compared with the non-cleavable arm (34%). When adjusted for DAR, for grade ≥ 3 toxicities, non-cleavable linkers remained independently associated with lower toxicity for any AE (p = 0.002). Higher DAR was significantly associated with higher probability of grade ≥ 3 toxicity for any AE. There was also a significant interaction between cleavability status and DAR for any AE (p = 0.002). Finally, higher measured systemic free payload concentrations were significantly associated with higher DARs (p = 0.043). Our results support the hypothesis that ADCs with cleavable linkers result in premature payload release, leading to increased systemic free payload concentrations and associated toxicities. This may help to inform future ADC design and rational clinical application.

The Role of Antibody-Drug Conjugates in Urothelial Cancer: A Review of Recent Advances in the Treatment of Locally Advanced and Metastatic Urothelial Cancer

Locally advanced and metastatic urothelial cancer (la/mUC) is an aggressive disease with poor prognosis. Platinum-based chemotherapy has remained the first-line treatment for decades and until recently no other treatment options existed. Today, novel agents called antibody drug conjugates (ADCs), including enfortumab vedotin (EV) and sacituzumab govitecan (SG), have been approved for la/mUC offering patients treatment options following or instead of traditional chemotherapy. The EV consists of the chemotherapy monomethyl auristatin E linked to anti-nectin-4 antibody. Single-agent response rates for EV are 40% to 52% including activity in patients with liver metastases, a phenotype associated with worse outcomes. In 2023, EV in combination with pembrolizumab almost doubled progression-free and overall survival versus platinum-based chemotherapy, which led to accelerated FDA approval as first-line treatment for all patients with la/mUC. Safety profile of EV monotherapy and combination with pembrolizumab is generally manageable with peripheral neuropathy and cutaneous toxicity among the most common treatment-related adverse events (TRAEs). The SG is another ADC targeting TROP-2 with SN-38 as payload. It is approved as late-line treatment for la/mUC with ORR 27% and most common TRAEs include gastrointestinal symptoms and neutropenia. Finally, a recent cancer agnostic accelerated approval for trastuzumab deruxtecan (T-DXd) in HER2-positive (IHC3+) solid tumors provides another active ADC option for biomarker-selected patients with treatment refractory la/mUC. Several new ADCs are being investigated in urothelial cancer (UC) clinical trials. This review summarizes the clinical studies and real-world data regarding the use of ADCs in UC.

Reevaluating the role of platinum-based chemotherapy in the evolving treatment landscape for patients with advanced urothelial carcinoma

Platinum-based chemotherapy has been the standard first-line (1L) treatment for advanced urothelial carcinoma (UC) for decades, based on the proven efficacy and established safety profiles of cisplatin- and carboplatin-based regimens. With the emergence of novel regimens, it is important to reevaluate and contextualize the role of 1L platinum-based chemotherapy. Platinum-based chemotherapy followed by avelumab 1L maintenance in patients without disease progression following platinum-based chemotherapy was established as a standard 1L regimen based on the JAVELIN Bladder 100 phase III trial. More recently, the EV-302 phase III trial showed the superiority of 1L enfortumab vedotin (EV) + pembrolizumab versus platinum-based chemotherapy, and the Checkmate 901 phase III trial showed the superiority of 1L nivolumab + cisplatin/gemcitabine versus cisplatin/gemcitabine alone. These 2 regimens have now been included as standard 1L options in treatment guidelines for advanced UC. EV + pembrolizumab is now the preferred 1L treatment, and in locations where EV + pembrolizumab is not available or individual patients are not considered suitable, recommended options are platinum-based chemotherapy followed by avelumab maintenance or nivolumab + cisplatin-based chemotherapy. In this review, we discuss current treatment options for advanced UC recommended in guidelines, practical considerations with platinum-based chemotherapy, the role of avelumab 1L maintenance, recent phase III trials of EV + pembrolizumab and nivolumab + cisplatin/gemcitabine, safety profiles of recommended 1L treatments, and second-line treatment options.

Integrating single cell and bulk RNA sequencing data identifies RBM17 as a novel response biomarker for immunotherapy in bladder cancer

Checkpoint inhibitors (CPIs) have been widely applied in the treatment of patients with bladder cancer (BLCA). However, there is still unmet need to dissect response predict biomarkers. To uncover CPI response-related marker genes in cancer cells, we utilized SCISSOR, integrating single-cell RNA and bulk RNA sequencing data. Transcriptomic and clinical data from IMvigor210, UNC-108, and BCAN/HCRN datasets were collected to evaluate and validate the identified biomarkers and signatures. Additionally, we analyzed TCGA-BLCA and local-BLCA RNA-seq data to investigate alternative splicing events (ASEs). Cell viability was assessed in T24 and UMUC3 cells with RBM17 upregulation or downregulation. Through SCISSOR analysis, we discovered that the expression levels of RBM17, TAP1, and PSMB8 were significantly associated with CPI response. Since PSMB8 displayed a highly positive correlation with TAP1, we developed a CPI response score (CRS) signature based on the expression profiles of RBM17 and TAP1. The CRS demonstrated robust predictive capacity in IMvigor210, UNC-108, and BCAN/HCRN datasets and was associated with higher tumor mutational burden (TMB), PD-L1 expression, and unique genomic features. Notably, RBM17 was not linked to the clinical outcomes of BLCA patients but positively correlated with BLCA cell proliferation in vitro. In the meantime, RBM17 was correlated with higher activity in core biological pathways, including antigen processing machinery, CD8 + T effector cells, cell cycle, DNA damage repair, epithelial-mesenchymal transition, histone regulation, and immune checkpoints. Moreover, the high-RBM17 group showed enrichment of LumU/Ba/sq subtypes but fewer FGFR3 alterations. Lastly, RBM17 significantly upregulated ASEs in BLCA samples, leading to higher neoantigen levels, a more inflamed tumor microenvironment, and improved CPI response. RBM17 is associated with higher ASEs and neoantigen levels, thereby potentiating the efficacy of CPI in BLCA. The established predictive signature, utilizing only two genes, has the potential to streamline clinical applications, providing a cost-effective alternative to expensive genomic, transcriptomic, and biological feature tests.

Precision medicine for urothelial carcinoma: An international perspective

The treatment landscape of urothelial cancers has evolved in the last decade with the approval of chemotherapy, immune checkpoint inhibitors, targeted therapies, and antibody drug conjugates. Although improvements in response and survival have been achieved with these strategies, in some scenarios their benefit is still questionable. Current efforts to identify prognostic and predictive biomarkers are crucial for better patient selection and treatment outcomes. In this paper we will review the most promising biomarkers under investigation, such as molecular classifiers, genomic alterations, programmed cell death ligand 1 expression, tumor mutational burden, circulating tumor DNA, urinary biomarkers among others, for muscle invasive bladder cancer and metastatic urothelial cancers. Deeper understanding of these biomarkers will aid clinical decision-making and help tailor treatment strategies.

Prognostic Impact of Bone Metastasis in Patients With Metastatic Urothelial Carcinoma Treated With Durvalumab With or Without Tremelimumab in the DANUBE Study

INTRODUCTION

Bone metastases (BM) in metastatic urothelial carcinoma (mUC) may impact patient outcomes, but their independent effect with immune checkpoint inhibitors (ICIs) is uncertain. We aimed to assess the impact of BM and PD-L1 status on outcomes in mUC patients treated with ICIs.

PATIENTS AND METHODS

This post hoc analysis of the DANUBE study included 1032 mUC patients treated with durvalumab (D), D + tremelimumab (T), or standard chemotherapy (SoC). Patients were categorized by BM status and assessed for median overall survival (mOS) and median progression-free survival (mPFS) stratified by PD-L1 expression and treatment arm.  RESULTS: Among all patients enrolled in the study, those with BM had a lower mOS than those with no BM (8.7 vs. 15.8 months; P < .0001). Patients with BM and high PD-L1 expression, treated with D or D + T, had numerically longer mOS than patients with BM and low PD-L1 expression. In contrast, in the chemotherapy arm, there was no difference in mOS for BM or no BM, based on PD-L1 expression. Patients with BM had shorter mPFS compared to no BM (2.6 vs. 5.4 months; P < .0001). The study is limited by its post hoc nature.

CONCLUSION

Presence of BM was associated with worse outcomes across treatment arms. Patients with BM and high PD-L1 expression treated with D or D + T had longer mOS, suggesting potential benefits of ICIs in this subgroup. Consideration of BM and PD-L1 status in treatment decisions for mUC patients receiving ICIs may improve clinical outcomes.

Dermatologic toxicities of antibody-drug conjugates

Antibody-drug conjugates (ADCs) are a new and emerging category of oncologic treatments that combine the target specificity of a monoclonal antibody with a cytotoxic payload. These drugs are associated with unique cutaneous toxicities that vary across agents. Currently, there are eleven ADCs with regulatory approval for solid and liquid tumors and over 80 ADCs currently in clinical development, it is critical for dermatologists to recognize and appropriately mitigate the cutaneous toxicities associated with these therapies. This clinical review will summarize the novel mechanisms and indications of approved ADCs, discuss dermatologic toxicities demonstrated in clinical trials and postmarketing studies, and impart recognition and management guidance when encountering these reactions to help maintain patients safely and comfortably on their medications.

Safety and efficacy of antibody-drug conjugates plus immunotherapy in solid tumours: A systematic review and meta-analysis

BACKGROUND

Combining antibody-drug conjugate (ADCs) with immune checkpoint inhibitors (ICIs) is emerging as a promising treatment option to increase efficacy outcomes. However, concerns arise regarding the safety of these combinations, as some toxicities may overlap. Currently, there is still limited information about the safety profiles of this strategy.

METHODS

A systematic review and meta-analysis was conducted to identify clinical trials investigating FDA-approved ADCs in combination with ICI drugs in the metastatic setting across all solid tumors. The primary endpoint of this study was the percentage of adverse events (AEs) of any grade and grade ≥ 3. Secondary endpoints include the percentage of patients with AEs leading to death, treatment discontinuation, proportion of complete responses (CR) and overall response rate (ORR). A parallel search was conducted to quantify the safety profile of ADCs and ICIs in monotherapy. Random effects models were used to estimate pooled outcomes.

RESULTS

Sixteen trials involving 1,133 patients treated with ADC plus ICI met the inclusion criteria with six different ADCs evaluated. Overall, 55.3 % of patients developed grade ≥ 3 AEs, 30.0 % of patients had treatment discontinuation, and 3.0 % experienced AEs leading to death. When compared to trials evaluating ADC or ICI as monotherapy, the combination results in similar rates of the most common AEs. However, it increases the risk of specific toxicities, such as ILD/pneumonitis (15.0 % with T-DXd plus ICI vs. 11.5 % with T-DXd alone). The pooled ORR was 48.8 % (95 %CI 39.4 % - 58.4 %) and the CR rate was 9.0 % (95 %CI 5.5 - 14.5). PD-L1-positive tumors showed numerically better efficacy outcomes.

CONCLUSIONS

This meta-analysis shows that the safety profile of the ADC plus ICI is comparable to that of ADC monotherapy. However, it increases the risk of certain toxicities of special interest, such as ILD/pneumonitis, highlighting the need for careful monitoring.