Long-term survival results of a randomized trial comparing gemcitabine plus cisplatin, with methotrexate, vinblastine, doxorubicin, plus cisplatin in patients with bladder cancer

The role of cisplatin in modulating the tumor immune microenvironment and its combination therapy strategies: a new approach to enhance anti-tumor efficacy

Cisplatin is a platinum-based drug that is frequently used to treat multiple tumors. The anti-tumor effect of cisplatin is closely related to the tumor immune microenvironment (TIME), which includes several immune cell types, such as the tumor-associated macrophages (TAMs), cytotoxic T-lymphocytes (CTLs), dendritic cells (DCs), myeloid-derived suppressor cells (MDSCs), regulatory T cells (Tregs), and natural killer (NK) cells. The interaction between these immune cells can promote tumor survival and chemoresistance, and decrease the efficacy of cisplatin monotherapy. Therefore, various combination treatment strategies have been devised to enhance patient responsiveness to cisplatin therapy. Cisplatin can augment anti-tumor immune responses in combination with immune checkpoint blockers (such as PD-1/PD-L1 or CTLA4 inhibitors), lipid metabolism disruptors (like FASN inhibitors and SCD inhibitors) and nanoparticles (NPs), resulting in better outcomes. Exploring the interaction between cisplatin and the TIME will help identify potential therapeutic targets for improving the treatment outcomes in cancer patients.

Integrated network pharmacology and RNA sequencing analysis to reveal the mechanisms of Qici Sanling decoction in the treatment of gemcitabine resistant bladder cancer

Bladder cancer (BCa) is the most prevalent cancer of the urinary system in adults; the prognosis is dismal for BCa treated with gemcitabine (GEM) owing to intrinsic or acquired chemoresistance. This study investigated the potential of Qici Sanling decoction (QCSL), an herbal Chinese medicine, to augment the efficacy of GEM in treating GEM-resistant BCa via network pharmacology and RNA sequencing. We screened 103 active components of QCSL and their 226 targets from the TCMSP database and identified 3985 targets of GEM-resistant BCa via transcriptome sequencing. On the basis of the 69 common targets, a proteinprotein interaction (PPI) network was constructed to identify the top 7 targets. Disease Ontology (DO), Gene Ontology (GO), and Kyoto Encyclopedia of Genes and Genomes (KEGG) functional enrichment analyses were conducted to uncover key pathways. CCK-8 assays, Western blotting, flow cytometry, colony formation, and EdU assays were used to assess the apoptosis and proliferation of GEM-resistant T24 and J82 cells treated with QCSL. The BCa gene set was among the top enriched gene sets in the DO analysis; GO analysis revealed enrichment of 2020 terms linked to GEM resistance, and KEGG analysis revealed 161 enriched signalling pathways. Molecular docking indicated that PTGS2 has high affinity for targets of QCSL components. In vitro experiments demonstrated that cells treated with both QCSL and GEM had significantly reduced viability, increased levels of apoptosis, and decreased proliferative capacity. Thus, QCSL enhances the therapeutic effects of GEM in BCa by promoting cell apoptosis and inhibiting cell proliferation. These findings have significant clinical implications, highlighting a potential combined treatment strategy for GEM-resistant BCa to improve patient outcomes.

4-Methylpyrazole-mediated inhibition of cytochrome P450 2E1 protects renal epithelial cells, but not bladder cancer cells, from cisplatin toxicity

Cisplatin is an effective chemotherapeutic drug for the treatment of bladder cancer, though cisplatin-induced nephrotoxicity (CIN) occurs in ∼20% to 30% of patients, limiting its clinical use. Evidence has shown that cytochrome P450 2E1 (CYP2E1), a drug metabolism enzyme expressed in proximal tubules, mediates the production of reactive oxygen species during cisplatin-induced injury. Previously, we showed that the repurposed drug 4-methylpyrazole (4MP) blocks CYP2E1 activity. Here, we investigated the potential protective effects of 4MP against CIN. Male and female C57BL/6J mice were treated intraperitoneally (i.p.) with a single 20 mg/kg dose of cisplatin for 3 days or 9 mg/kg/wk for 4 wk with or without 50 mg/kg 4MP as a co-treatment. Our findings revealed that acute treatment with cisplatin induced severe histological tubular damage and elevated plasma BUN and creatinine levels in male but not female mice. This difference correlated with higher basal CYP2E1 expression in the kidneys of male mice compared with female mice. We also found that cisplatin increased renal CYP2E1 activity and that inhibition of CYP2E1 with 4MP significantly reduced cisplatin-induced cell death in male mice and primary normal human kidney cells. By contrast, human bladder cancer cells do not express CYP2E1, and treatment with 4MP did not interfere with cisplatin's anticancer effects in human bladder cancer HTB9 cells. This study highlights the critical role of CYP2E1 in CIN and suggests that its inhibition with 4MP in the kidney is a potential prophylactic therapeutic option to prevent CIN in bladder cancer patients without affecting its antineoplastic effect.

Optimizing enfortumab vedotin plus pembrolizumab therapy

Often associated with a poor prognosis, advanced urothelial carcinoma (aUC) has progressed to muscle-invasive or metastatic stages. Traditionally, chemotherapy has been the primary treatment for aUC, though its effectiveness in advanced stages remains limited. Recent developments have introduced promising therapies, notably the combination of enfortumab vedotin with pembrolizumab, which is now recommended as the first-line therapy following the EV-302 trial results. This combination has demonstrated significant improvements in survival rates. This review aims to explore the evolution of treatment strategies for aUC, emphasizing the shift towards immunotherapy and targeted therapies, and discusses the potential for optimized treatment algorithms to improve patient outcomes.

Enfortumab vedotin plus pembrolizumab versus chemotherapy in patients with previously untreated locally advanced or metastatic urothelial cancer (EV-302): patient-reported outcomes from an open-label, randomised, controlled, phase 3 study

BACKGROUND

In the ongoing EV-302 trial, first-line enfortumab vedotin plus pembrolizumab improved progression-free survival and overall survival versus platinum-based chemotherapy in patients with locally advanced or metastatic urothelial cancer. Patient-reported outcomes (PROs) from EV-302 are reported here.

METHODS

EV-302 was a phase 3, open-label, two-group, randomised global study to evaluate the combination of enfortumab vedotin plus pembrolizumab versus standard-of-care platinum-based chemotherapy (gemcitabine with cisplatin or carboplatin) in patients with previously untreated locally advanced or metastatic urothelial cancer. The study was done at 185 clinical sites in 25 countries. Eligible patients were aged 18 years and older with unresectable untreated locally advanced or metastatic urothelial cancer, were eligible for platinum-based chemotherapy, and had an Eastern Cooperative Oncology Group performance status of 2 or less. Patients were randomly assigned (1:1) to receive either enfortumab vedotin (1·25 mg/kg, intravenously) on days 1 and 8 of 3-week cycles plus pembrolizumab (200 mg, intravenously) on day 1 of each cycle; or platinum-based chemotherapy consisting of gemcitabine (1000 mg/m2, intravenously) on days 1 and 8 of each cycle plus either cisplatin (70 mg/m2) or carboplatin (area under the curve [AUC] 4·5 or 5·0 according to local guidelines) on day 1 of each 3-week cycle for up to six cycles using interactive response technology. Randomisation was stratified by cisplatin eligibility, PD-L1 expression status, and presence or absence of liver metastases. The dual primary endpoints of progression-free survival and overall survival in patients with locally advanced or metastatic urothelial cancer have been reported previously. Here, we report additional, protocol-prespecified secondary endpoint data, and statistical analysis plan-prespecified descriptive endpoints assessing patient quality of life (QOL). These endpoints related to patient functioning and symptoms and were assessed using two PRO questionnaires: the Brief Pain Inventory-Short Form (BPI-SF) and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). The PRO full analysis set comprised patients who received study treatment and completed at least one baseline PRO questionnaire. The BPI-SF and the EORTC QLQ-C30 were completed at baseline, weekly for 12 weeks, at week 14, then every 3 weeks during follow-up. Time to pain progression and mean change from baseline in BPI-SF worst pain at week 26 were protocol-prespecified secondary endpoints tested by the hierarchical gatekeeping strategy. Mean change from baseline to week 26 in EORTC QLQ-C30 and BPI-SF scale scores were analysed descriptively. The trial is registered with ClinicalTrials.gov, NCT04223856.

FINDINGS

At data cutoff on Aug 8, 2023, 886 patients were enrolled in the study, with a median duration of follow-up for survival of 17·2 months (IQR 12·5-21·7). 731 (83%) of 886 patients completed at least one PRO questionnaire at baseline and were included in the PRO full analysis set, with 376 patients treated with enfortumab vedotin plus pembrolizumab and 355 with platinum-based chemotherapy. 570 (78%) of 731 patients were male, 161 (22%) were female, and 479 (66%) patients were White. There was no significant difference in time to pain progression between treatments; hence differences in least squares mean change in BPI-SF worst pain score from baseline to week 26 with enfortumab vedotin plus pembrolizumab versus platinum-based chemotherapy were not formally tested. However, a numerical improvement from baseline up to week 26 was observed (least squares mean -0·74, SE 0·12 vs -0·36, 0·12; least squares mean difference -0·38, SE 0·13; 95% CI -0·64 to -0·12; nominal two-sided p value 0·0037). Overall least squares mean change in EORTC QLQ-C30 Global Health Status (GHS)/QOL from baseline up to week 26 favoured enfortumab vedotin plus pembrolizumab (least squares mean difference 2·54, 95% CI 0·41-4·67). In patients with moderate to severe baseline pain (worst pain score ≥5) receiving enfortumab vedotin plus pembrolizumab, there were clinically meaningful improvements from baseline up to week 26 in worst pain (least squares mean change: enfortumab vedotin plus pembrolizumab -2·96 [SE 0·22], platinum-based chemotherapy -2·43 [0·21]; least squares mean difference -0·53, 95% CI -1·03 to -0·02; nominal p=0·041) and in EORTC QLQ-C30 GHS/QOL (least squares mean change: enfortumab vedotin plus pembrolizumab 8·88 [1·53], platinum-based chemotherapy 4·11 [1·45]; least squares mean difference 4·77, 95% CI 1·24-8·29; nominal p=0·0083).

INTERPRETATION

Enfortumab vedotin plus pembrolizumab significantly improved survival outcomes versus platinum-based chemotherapy without detriment to GHS/QOL, pain, or functioning. Patients with moderate to severe baseline pain had clinically meaningful improvements in worst pain and GHS/QOL with enfortumab vedotin plus pembrolizumab. These data provide further evidence to support the use of enfortumab vedotin plus pembrolizumab as a preferred treatment option for patients with previously untreated locally advanced or metastatic urothelial cancer.

FUNDING

Seagen (acquired by Pfizer in December, 2023), Astellas Pharma, and Merck Sharp & Dohme.

Role of tumor mutational burden in patients with urothelial carcinoma treated with immune checkpoint inhibitors: a systematic review and meta-analysis

Background

The predictive value of tumor mutation burden (TMB) on the efficacy of immunotherapy has been confirmed in multiple cancer types in previous studies. For urothelial carcinoma (UC) patients treated with immune checkpoint inhibitors (ICIs), whether TMB is a suitable biomarker to predict the benefit of ICIs remains a matter of much debate. We conducted this meta-analysis to evaluate the role of TMB in patients with UC treated with ICIs.

Methods

Two investigators independently searched the literature, screened eligible studies, extracted valid data, and scored quality assessments. Meta-analyses of the effect size hazard ratio (HR) for overall survival (OS) and progression-free survival (PFS), and effect size odds ratio (OR) for objective response rate (ORR) were performed and visualized with forest plots using the STATA14.0 software. The statistical difference in benefit from ICIs for UC patients between the high TMB group and the low TMB group was significant when the p-value <0.05. Sensitivity analysis and publication bias further verified the stability and reliability of statistical results.

Results

A total of 2,499 patients from 14 studies were included in this meta-analysis. The results indicated that UC patients with high TMB showed significantly longer OS and PFS than those with low TMB after ICI treatment (OS: HR 0.69, 95% CI 0.62, 0.76, p < 0.05; PFS: HR 0.67, 95% CI 0.59, 0.76, p < 0.05). The high TMB group exhibited a superior response to ICIs than the low TMB group, with no significant difference (OR 1.64, 95% CI 0.94, 2.86, p = 0.08). The results were stable and reliable, with no publication bias.

Conclusions

This meta-analysis demonstrated that UC patients with high TMB exhibited significantly longer survival than those with low TMB after ICI treatment. TMB may be a favorable predictor for UC immunotherapy in future clinical practice.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42025642602.

Progress of antibody-drug conjugates in the treatment of locally advanced or metastatic urothelial carcinoma: opportunities and challenges

PURPOSE OF REVIEW

The objective of this review is to provide an overview of the clinical progress, administration methods, efficacy, safety, and treatment-related adverse events associated with antibody-drug conjugates.

RECENT FINDINGS

Locally advanced or metastatic urothelial carcinoma is an aggressive and lethal malignancy. Cisplatin-based chemotherapy has been the first-line therapy for most patients over the past two decades. However, approximately 50% of patients with locally advanced or metastatic urothelial carcinoma are ineligible for cisplatin-based chemotherapy due to inadequate renal function, poor performance status, or complications. Furthermore, patients who exhibit suboptimal responses or disease progression following platinum-based chemotherapy face therapeutic uncertainty regarding the selection of alternative agents. The emergence of antibody-drug conjugates has provided new options for patients afflicted with this disease, particularly enfortumab vedotin combined with pembrolizumab as a new first-line therapy for advanced urothelial carcinoma or for patients ineligible for platinum-based therapy. Additionally, in the TROPICS-04 trial, sacituzumab govitecan failed to demonstrate significant improvement in overall survival or progression-free survival compared with the physician's choice of treatment for patients with advanced urothelial carcinoma progressing after platinum-based chemotherapy and PD-(L)1 inhibitor therapy; the FDA withdrew its approval for this indication. ADCs are also being considered for the treatment of muscle-invasive bladder cancer, with ongoing clinical trials.

A clinical study of RC48-ADC combined with PD-1 inhibitor in bladder preservation therapy for muscle-invasive bladder cancer (MIBC)-based on real-world data analysis

OBJECTIVES

This study aimed to evaluate the efficacy and safety of RC48-ADC combined with PD-1 inhibitors in bladder preservation therapy for muscle-invasive bladder cancer (MIBC), and to explore the differences in treatment outcomes between primary and recurrent cases, as well as patients at different clinical stages.

METHODS

A retrospective analysis was conducted on 32 patients with clinically non-metastatic MIBC who received ≥ 3 cycles of RC48-ADC combined with PD-1 inhibitor therapy. Clinical efficacy was assessed through integrated imaging and histopathological evaluations.

RESULTS

Among the 32 patients, the 1-year progression-free survival (PFS) rate was 84.4%, the objective response rate (ORR) was 68.8%, and the 1-year bladder preservation rate was 68.8%. The primary group was superior to the recurrent group in PFS (94.7% vs. 69.2%), ORR (78.9% vs. 53.8%), and 1-year bladder preservation rate (78.9% vs. 53.8%). Similarly, T2-stage patients exhibited better clinical responses than T3-stage patients in PFS (85.0% vs. 75.0%), ORR (80.0% vs. 54.5%), and 1-year bladder preservation rate (80.0% vs. 54.5%). Treatment-related adverse events (AEs) were predominantly grade I-II, with no severe immune-related complications reported.

CONCLUSIONS

The combination of RC48-ADC and PD-1 inhibitors significantly improves bladder preservation rates in MIBC patients with a favorable safety profile, particularly in primary and T2-stage cases. This regimen provides a personalized therapeutic strategy for patients unsuitable for conventional treatments.

A lactate-related tSNE signature defines prognostic subtypes of bladder cancer and reveals LINC01094-mediated VIM stabilization in metastasis and drug resistance

Background

Bladder cancer (BLCA) is prone to metastasis and often shows poor responses to chemotherapy and immunotherapy. Investigating the underlying mechanisms of metastasis and drug resistance may therefore offer new therapeutic strategies for BLCA.

Methods

Publicly available datasets were analyzed using consensus clustering and t-distributed stochastic neighbor embedding (tSNE) to characterize a lactate-related gene signature in BLCA. Gene set variation analysis (GSVA) was employed to assess signaling pathway activity, while immune cell infiltration in the tumor microenvironment (TME) was evaluated using single-sample gene set enrichment analysis (ssGSEA), the Estimation of Stromal and Immune cells in Malignant Tumors using Expression data (ESTIMATE), and CIBERSORT. RNA pull-down and RNA-binding protein immunoprecipitation (RIP) assays were then performed to confirm molecular interactions.

Results

Two distinct BLCA subtypes were identified based on lactate-related gene expression, and a lactate-based tSNE score was constructed. This score demonstrated prognostic value and was integrated into a nomogram confirmed by a calibration curve. Functionally, higher tSNE scores correlated with immune- and inflammation-related pathways, as well as with immunotherapy efficacy in BLCA. Among candidate regulators identified, LINC01094 emerged as a key factor in BLCA metastasis and drug resistance. LINC01094 was predominantly localized in the cytoplasm and was upregulated in tumor tissues compared with adjacent normal tissues, acting as an unfavorable prognostic factor. In vitro, LINC01094 promoted metastasis and chemotherapy resistance, potentially by stabilizing VIM protein levels and inhibiting its ubiquitination.

Conclusions

This comprehensive analysis of lactate-related genes reveals how this gene signature may shape the tumor microenvironment and affect BLCA patient prognosis. Additionally, our data suggest that targeting LINC01094 with antisense oligonucleotides (ASOs) could reduce BLCA cell metastasis and enhance their sensitivity to chemotherapy.

Sex differences in bladder cancer: understanding biological and clinical implications

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

Consensus statements from the Hong Kong Urological Association and the Hong Kong Society of Uro-Oncology on the management of muscle-invasive and advanced urothelial carcinoma

Background

Muscle-invasive and advanced urothelial carcinoma (UC) are notorious for their high propensity for recurrence and metastasis. Recent advances in novel medications, surgical procedures, and radiotherapy techniques have substantially transformed the treatment landscape of muscle-invasive and advanced UC. It is crucial to navigate the optimal management approaches for muscle-invasive and advanced UC through the increasingly complex matrix of variables.

Methods

Two professional organisations convened a consensus panel of six urologists and six clinical oncologists with extensive experience in treating urological malignancies. They reviewed the literature on the management of i) non-metastatic, muscle-invasive, and locally advanced UC of the bladder; ii) locally advanced upper tract UC (UTUC); and iii) unresectable locally advanced or metastatic UC (mUC). The panel held multiple meetings to discuss and draft consensus statements using the modified Delphi method. Each drafted statement was anonymously voted on by every panellist. A consensus statement was accepted if ≥ 80% of the panellists chose 'accept completely' or 'accept with some reservation' from the five options, which also included 'accept with major reservation', 'reject with reservation', and 'reject completely'.

Results

The panel reached a consensus on 63 statements based on current evidence and expert insights. These statements addressed the considerations for different treatment modalities, including surgical approaches, radiotherapy, radiosensitisers, platinum-based chemotherapy, immune checkpoint inhibitors, and antibody-drug conjugates, in the management of different disease entities, including muscle-invasive UC of the bladder, cN1 disease, locally advanced UTUC, unresectable locally advanced/mUC, and oligometastatic bladder cancer.

Conclusion

These consensus statements are anticipated to serve as a practical recommendation for clinicians in Hong Kong, and possibly the Asia-Pacific region, regarding the management of muscle-invasive and advanced UC.

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

BACKGROUND/OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The first real-world evidence on dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin followed by switch maintenance avelumab in advanced urothelial carcinoma: a propensity score-matched study

BACKGROUND

Dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (dd-MVAC) is an established regimen for advanced urothelial carcinoma (aUC). Although platinum-based chemotherapy, typically gemcitabine and cisplatin, followed by switch maintenance avelumab has been a recommended strategy for aUC, no study has evaluated outcomes of dd-MVAC followed by avelumab therapy.

METHODS

We reviewed 71 patients treated with first-line dd-MVAC for aUC at two university hospitals between 2018 and 2024. Overall survival (OS) and progression-free survival (PFS) were assessed as endpoints. Additionally, among patients who achieved ≥ stable disease, we performed propensity score matching between patients with and without avelumab to balance their background characteristics.

RESULTS

Of 71 patients, 49 (69%) experienced disease progression and 30 (42%) died during the median follow-up of 13 months. Median OS and PFS were 24 and 7 months, respectively. Among 59 patients who achieved ≥ stable disease after completion of dd-MVAC, 35 received switch maintenance avelumab, while the remaining 24 did not. After propensity score matching, patients with avelumab had significantly longer OS and PFS (both: not reached) than those without (OS: 28 months; PFS: 7 months).

CONCLUSIONS

We herein report outcomes of dd-MVAC followed by switch maintenance avelumab in real-world patients with aUC for the first time. Avelumab therapy was significantly associated with longer survival in patients who achieved ≥ stable disease after first-line dd-MVAC. Given the excellent survival outcomes, dd-MVAC followed by switch maintenance avelumab may still be a valid option for aUC even in the new treatment paradigm as typified by enfortumab vedotin and pembrolizumab.

Influence of best objective response to first-line treatment on survival outcomes in advanced urothelial carcinoma in the era of sequential therapy with enfortumab vedotin

OBJECTIVE

This study evaluated whether first-line treatment affects survival outcomes in patients with advanced urothelial carcinoma undergoing sequential therapy with chemotherapy, immune checkpoint inhibitors, and enfortumab vedotin.

METHODS

This multicenter retrospective study included 57 patients treated at Hiroshima University Hospital and its affiliated institutions between 2009 and 2024. Patients received chemotherapy as a first-line treatment (gemcitabine plus cisplatin or carboplatin), followed by second-line immune checkpoint inhibitors (pembrolizumab or avelumab) and third-line enfortumab vedotin. Assessed outcomes included overall survival and time to treatment failure. Cox regression analysis identified prognostic factors for overall survival.

RESULTS

Over a median follow-up of 20.5 months, median overall survival was not reached after first-line treatment. Gemcitabine with cisplatin was selected in 31.6% of cases, while gemcitabine and carboplatin was chosen in 68.4% of cases as the first-line treatment; subsequently, 66.7% received pembrolizumab, and 33.3% received avelumab in the second-line treatment. Patients who achieved a complete or partial response with the first-line treatment had significantly longer overall survivals from both first-line and enfortumab vedotin initiation than those with stable or progressive disease. In cases that achieved complete or partial responses, avelumab was more frequently selected as a second-line therapy. However, in the first-line treatment, multivariate analysis identified only stable or progressive disease as a significant predictor of worse overall survival.

CONCLUSION

The best response to first-line treatment predicted both overall survival from first-line initiation and outcomes following enfortumab vedotin treatment, underscoring its prognostic value in sequential therapy for patients with advanced urothelial carcinoma.

Antibody-drug conjugates in urothelial carcinoma: current status and future

PURPOSE OF REVIEW

Antibody-drug conjugates (ADCs) are quickly becoming frontline standard of care in many tumor types, including urothelial carcinoma. This review summarizes recent clinical investigations into the use of ADCs targeting nectin-4, trophoblast cell surface antigen-2 (Trop-2), human epidermal growth factor receptor 2 (HER-2), and other antigens in urothelial carcinoma.

RECENT FINDINGS

This review covers efficacy and toxicity data of ADCs alone and in combination with immunotherapy; mechanisms of resistance; and preclinical studies that provide biological basis for clinical approaches.

SUMMARY

Enfortumab vedotin and sacituzumab govitecan can be used in an unselected group of patients with urothelial carcinoma whereas HER-2 ADCs have only been administered in those with high expression or amplification. Most are being studied in combination with immune checkpoint inhibitors. Data supports use of enfortumab vedotin in combination with pembrolizumab as first-line therapy in metastatic/unresectable locally advanced urothelial carcinoma. Sacituzumab govitecan may be used as later-line option in these patients. HER-2 therapy is still under investigation but has many recent promising results.

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.

Enfortumab vedotin and pembrolizumab: redefining the standard of care for previously untreated advanced urothelial cancer

Combination treatment with Enfortumab vedotin (EV), an antibody drug conjugate targeting Nectin-4 with a monomethyl auristatin E (MMAE) payload, and pembrolizumab, a programmed death 1 (PD-1) inhibitor, has become the new standard of care for previously untreated locally advanced or metastatic urothelial carcinoma. In the recently published phase III study, EV-302, EV and pembrolizumab demonstrated improved outcomes compared to platinum-based chemotherapy, including objective response rate, progression free survival, and an unprecedented median overall survival of 33.8 months (versus 15.9 months; hazard ratio for death 0.51; 95% confidence interval 0.43-0.61; p < 0.00001). We reviewed the mechanism of action, clinical efficacy, exploratory biomarkers, and safety profile of EV and pembrolizumab as monotherapies and combination in urothelial cancer.

Cabozantinib plus Pembrolizumab as First-line Therapy for Cisplatin-ineligible Advanced Urothelial Carcinoma: The PemCab Trial

BACKGROUND AND OBJECTIVE

Pembrolizumab monotherapy is approved for patients with platinum-ineligible metastatic urothelial carcinoma (mUC). Cabozantinib is a multireceptor tyrosine kinase inhibitor with activity against MET and VEGFR2 and is approved as monotherapy or in combination with a PD-1 inhibitor for other malignancies. The objective was to determine the safety and efficacy of pembrolizumab + cabozantinib as first-line treatment for patients with mUC.

METHODS

In this open-label, single-arm, multicenter, phase 2 study, patients received pembrolizumab 200 mg every 3 wk + cabozantinib 40 mg daily. Key inclusion criteria were locally advanced UC or mUC, Eastern Cooperative Oncology Group performance status 0-2, ineligible for or refused cisplatin, and no prior PD-1/L1 inhibitor. The primary endpoint was the objective response rate (ORR). Secondary endpoints included progression-free survival (PFS) and overall survival (OS). According to the statistical plan, in a cohort of 35 evaluable participants, the lower bound of the 95% confidence interval (CI) would extend no more than 26% from the ORR observed, and in a scenario with ≥17 objective responses, the CI would exclude 32%.

KEY FINDINGS AND LIMITATIONS

Responses were observed in 16 of 35 evaluable patients, with an ORR of 46% (95% CI 31-62%). Median PFS and OS were 8 mo (95% CI 5-13) and 17 mo (95% CI 13-not reached), respectively. The most common treatment-emergent adverse events (any grade) were diarrhea (58%), fatigue (56%), pruritus (39%), nausea (36%), palmar-plantar erythrodysesthesia (36%), and a decrease in appetite (33%).

CONCLUSIONS AND CLINICAL IMPLICATIONS

This phase 2 trial of pembrolizumab + cabozantinib demonstrated a manageable toxicity profile and promising efficacy as a first-line therapy combination for cisplatin-ineligible patients with mUC.

MIS18BP1 promotes bladder cancer cell proliferation and growth via inactivating P53 signaling pathway

MIS18 bonding protein 1 (MIS18BP1) is a subunit of MIS18 complex, accumulated specifically at telophase-G1 centromere and regulated apoptosis, proliferation and migration in cancer cells. The mechanisms about how MIS18BP1 regulate Bladder Cancer (BCa) cell development have not been previously unknown. We analyzed MIS18BP1 differential expression in BCa by The Cancer Genome Atlas (TCGA), Gene-Expression Omnibus (GEO) and Universal Protein database. The expression of MIS18BP1 mRNA was tested using qRT-PCR. The expression of MIS18BP1 protein was examined by western blot and immunohistochemistry (IHC) staining. T24 cells were transfected with an LV -MIS18BP1 -RNAi vector to decrease the MIS18BP1 expression. We used a series of experiments to detect the survival, proliferation and migration of T24. The apoptosis was analyzed by Flow cytometry assays. The expression of P53, BAX and Cleaved Casepase-3 was detected by western blot. P53 apoptosis-related proteins, proliferation and migration of cells were analyzed before and after treatment with P53 inhibitors. The expression of MIS18BP1 was higher in BCa tissues compared with control group. Its expression was in relation to clinical stage, depth of invasion and lymph node metastasis. We found that genes closely related to MIS18BP1 are mainly associated with cell cycle, chromosome separation and DNA repair in biological processes. After transfection, we found the proliferative capacity of T24 was significantly reduced. Transwell migration and scratch experiment demonstrated decreased migration. Meanwhile, downregulation of MIS18BP1 resulted in an increase in cell apoptosis. In addition, P53, BAX and Cleaved Casepase-3 were increased, whereas BCL2 protein was decreased in the MIS18BP1-downregulated T24. After treatment with Pifithrin-α, the phenotype of cell proliferation inhibition was restored. MIS18BP1 overexpression may be regulated to poor prognosis in BCa patients. MIS18BP1 may associated with cell apoptosis and proliferation in BC cells. This process may be mediated by P53 signal pathway.

Organ-specific tumor response to enfortumab vedotin in metastatic urothelial carcinoma: a multicenter retrospective study

BACKGROUND

Despite advancements in treatment options for metastatic urothelial carcinoma (mUC), therapeutic choices remain limited for patients with disease refractory to platinum-based chemotherapy (PBC) and immune checkpoint inhibitors (ICIs). Enfortumab vedotin (EV) has demonstrated significant efficacy in later lines of therapy for mUC; however, its organ-specific responses remain uncertain.

METHODS

We conducted a retrospective study of 69 patients with mUC who received EV following treatment with PBC and ICIs. Efficacy was assessed using Response Evaluation Criteria in Solid Tumors, with organ-specific response rates (OSRR) and organ-specific disease control rates (OSCR) calculated across different metastatic sites. Multivariate Cox regression analysis was performed to identify independent predictors of disease progression and survival.

RESULTS

The median progression-free survival (PFS) was 8.3 months, whereas the median overall survival (OS) was 18.0 months. The objective response rate (ORR) was 53.6%, and the disease control rate (DCR) was 82.6%. OSCR was ≥70% across all metastatic sites, confirming the broad efficacy of EV. Liver metastases exhibited the highest OSRR at 66.7%, whereas bone metastases had the lowest OSRR at 12.5%. Tumor burden reduction was significantly lower in bone metastases compared to other metastatic sites. Disease progression was predominantly observed at target lesions, with a median time to progression of 3 months. Eastern Cooperative Oncology Group performance status and serum C-reactive protein levels were identified as significant independent predictors of PFS and OS.

CONCLUSION

EV exhibited favorable organ-specific tumor responses in mUC, with particularly high efficacy against liver metastasis. However, response rates were lower in bone metastases. No significant differences in organ-specific overall survival were observed.

An evaluation of nivolumab plus gemcitabine and cisplatin in the treatment of advanced urothelial carcinoma

INTRODUCTION

For decades, first-line treatment for advanced/metastatic urothelial cancer has been platinum-based chemotherapy. However, many patients do not respond to platinum-based chemotherapy alone, and the vast majority do not have durable responses. While immune checkpoint blockade has demonstrated benefit in this setting, initial trials of concurrent chemotherapy and immune checkpoint blockade did not demonstrate improvements in overall survival.

AREAS COVERED

The recent CheckMate 901 trial compared gemcitabine, cisplatin, plus nivolumab to gemcitabine and cisplatin alone for first-line treatment of advanced/metastatic urothelial cancer. This was the first trial to demonstrate significant benefit in the combined chemotherapy and immune checkpoint blockade arm in advanced/metastatic urothelial cancer, most significantly showing an improvement in the primary outcomes of progression-free survival and overall survival, and the exploratory outcomes of objective response rate, complete response rate, and duration of complete response.

EXPERT OPINION

The combination of gemcitabine, cisplatin, plus nivolumab represents a new first-line treatment option for metastatic urothelial cancer. This article details the clinical benefit observed and how this establishes proof-of-concept for prior hypotheses related to the importance of the specific chemotherapy regimen combined with immune checkpoint blockade, revolving around immunomodulatory mechanisms of action of cisplatin, and synergy of these mechanisms with immunotherapy.

Cancer Cell and Cancer-Associated Fibroblast Communication-Mediated Molecular Subtypes Portray Non-Inflamed Tumor Microenvironment and Guide the Precision Treatment of Bladder Cancer

Cancer-associated fibroblasts (CAFs) drive tumor progression through restructuring of the tumor microenvironment. This investigation aim to elucidate the function of molecular subtypes (MS) derived from cancer cells communication with CAFs, depicting the hallmarks of the tumor microenvironment and precise bladder cancer (BLCA) treatment. The BLCA data from TCGA and several external sources are utilized to generate a novel ligand, receptor, and transcription factor (LRT) associated molecular subtype and their corresponding score (LRT score). The LRT-mediated molecular subtype is identified via unsupervised clustering. LRT score is measured by principal component analysis. Then, the association of LRT clusters to established MS, immunophenotypes, and medical endpoints, together with BLCA treatment strategies is investigated. Two LRT clusters (A and B) are identified. LRT cluster (LRT score) can precisely propose immunophenotypes, classical MS, clinical outcomes, and BLCA therapeutic strategies. Cluster B (Low LRT score) represent a basal subtype and inflamed phenotype specified by high immunity against tumors and unfavorable clinical outcomes. Furthermore, it is highly sensitive to cancer immunotherapy; however, it has low sensitivity to antiangiogenic and targeted therapies. The novel LRT clusters with a strong association with biological characteristics and precise BLCA treatment strategies are derived from the communication between cancer cells and cancer-associated fibroblasts. The LRT may be a useful clinician tool for developing individualized treatment strategies.

Advancements in systemic therapy for muscle-invasive bladder cancer: A systematic review from the beginning to the latest updates

Context

Several phase III randomized controlled trials (RCTs) have shown the importance of perioperative systemic therapy, especially for the efficacy of immune checkpoint inhibitors (ICIs) in both neoadjuvant and adjuvant settings for muscle-invasive bladder cancer (MIBC).

Objective

To synthesize the growing evidence on the efficacy and safety of systemic therapies for MIBC utilizing the data from RCTs.

Evidence acquisition

Three databases and ClinicalTrials.gov were searched in October 2024 for eligible RCTs evaluating oncologic outcomes in MIBC patients treated with systemic therapy. We evaluated pathological complete response (pCR), disease-free survival (DFS), progression-free survival (PFS), event-free survival (EFS), overall survival (OS), and adverse events (AEs).

Evidence synthesis

Thirty-three RCTs (including 14 ongoing trials) were included in this systematic review. Neoadjuvant chemotherapy improved OS compared to radical cystectomy alone. Particularly, the VESPER trial demonstrated that dd-MVAC provided oncological benefits over GC alone in terms of pCR rates, OS (HR: 0.71), and PFS (HR: 0.70). Recently, the NIAGARA trial showed that perioperative durvalumab plus GC outperformed GC alone in terms of pCR rates, OS (HR: 0.75), and EFS (HR: 0.68). Despite the lack of data on overall AE rates in the VESPER trial, differential safety profiles in hematologic toxicity were reported between dd-MVAC and durvalumab plus GC regimens. In the adjuvant setting, no study provided the OS benefit from adjuvant chemotherapy. However, only adjuvant nivolumab had significant DFS and OS benefits compared to placebo.

Conclusions

Neoadjuvant chemotherapy remains the current standard of care for MIBC. Durvalumab shed light on the promising impact of ICIs added to neoadjuvant chemotherapy. Nivolumab is the only ICI recommended as adjuvant therapy in patients who harbored adverse pathologic outcomes. Ongoing trials will provide further information on the impact of combination therapy, including chemotherapy, ICIs, and enfortumab vedotin, in both neoadjuvant and adjuvant settings.

Perioperative cisplatin-based chemotherapy for muscle-invasive bladder cancer: a decision analysis

PURPOSE

While meta-analyses of randomised studies suggest that neoadjuvant (NAC) or adjuvant (ACT) cisplatin-based chemotherapy improve overall survival in patients with muscle-invasive bladder cancer (MIBC), there are no trials comparing NAC against ACT in terms of quality-adjusted life years (QALYs) and costs. We aimed to evaluate the long-term QALYs, costs, and cost-effectiveness of different strategies for treating patients with MIBC.

METHODS

An individual-level state transition microsimulation model was developed for patients with urothelial non-metastatic MIBC eligible for surgery and NAC at diagnosis. Four treatment strategies were evaluated: (i) no treatment, (ii) radical cystectomy (RC) without perioperative chemotherapy, (iii) NAC followed by RC, and (iv) RC followed by ACT. Primary endpoints were QALYs and costs. Sensitivity analysis on the probability of being fit for ACT after surgery was conducted to account for the uncertainty of this parameter. The model was face-validated independently by two urologists.

RESULTS

Life-expectancy was 4.54 QALYs for ACT, 4.38 QALYs for NAC, 4.28 QALYs for RC without perioperative chemotherapy, and 2.84 QALYs for no treatment. Costs were lowest for ACT (US$45,805), compared to NAC (US$48,160), RC without perioperative chemotherapy (US$48,703), and no treatment (US$59,948). Sensitivity analysis suggested that NAC is associated with increased QALYs compared to ACT if the estimated probability of being fit for ACT is less than 38%. Limitations include the US-centric cost perspective.

CONCLUSIONS

In lack of comparative studies, simulated data suggests that ACT leads to increased QALYs and is cost-effective compared to NAC.

Patients with Metastatic or Locally Advanced Bladder Cancer Not Undergoing Systemic Oncological Treatment-Characteristics and Long-Term Outcome in a Single-Center Danish Cohort

BACKGROUND

A subset of patients with locally advanced or metastatic bladder cancer (la/mBC) do not receive systemic oncological treatment. The reasons for refraining from systemic treatment are poorly investigated, as are the characteristics of patients who turn out to be long-term survivors despite lack of treatment.

METHODS

This retrospective observational cohort study included patients with registration compatible with la/mBC who did not undergo systemic treatment. They were seen at a single tertiary university hospital covering one of 5 Danish regions in the study period from 1 January 2012 until 31 December 2022. Patients were identified through a coding system, and detailed patient information was obtained in the electronic medical records.

RESULTS

The initial study population consisted of 472 patients registered with la/mBC according to codes in the patient registries but with no registration of systemic oncological treatment. Out of the total cohort, 159 patients were registered correctly, while the rest of the population were excluded due to misclassification, as 10.8% did not have la/mBC and 55.5% had received oncological treatment. Among correctly registered patients, the median overall survival was 2.6 months (95% CI 0.26; 4.94) from being diagnosed with la/mBC. The most common reasons for lack of treatment were poor general condition (74.2%), patient preference (19.5%), and poor renal function (11.9%).

CONCLUSIONS

Our study found that a significant amount of patients in a cohort of suspected la/mBC not undergoing treatment either received oncological treatment or did not have la/mBC, demonstrating a misclassification in the system. This should be taken into consideration when evaluating data about survival time for this patient group. The poorest survival of untreated la/mBC is associated with a high tumor burden and specifically liver metastasis.

Swedish national guidelines on urothelial carcinoma: 2024 update on advanced and metastatic disease

OBJECTIVE

To overview and summarise the Swedish National Guidelines on Urothelial Carcinoma 2024.

METHODS

A narrative review of the updated guidelines was performed, highlighting new treatment recommendations for advanced and metastasized disease.  Results: Compared to the previous guideline version, the current update includes recommendations for standardised radiological reporting when urothelial carcinomas are detected at CT-urography (CTU), to early identify locally advanced patients and accelerate the care pathway for these patients. The Swedish guidelines apply a more structured and liberal recommendation for the use of 18F-fluorodeoxyglucose-positron emission tomography/computed tomography in patients with locally advanced urothelial carcinomas compared to the EAU-guidelines and recommend such examinations prior to transurethral resection. Improved outcomes for radical cystectomy in Sweden after centralised cystectomy care have led to a recommendation for performing more than six nephroureterectomies (NUs) per year for upper tract urothelial carcinomas (UTUC)-based associations with decreased use of invasive diagnostic modalities and better survival outcomes. Additionally, updated recommendations regarding adjuvant systemic therapies for muscle-invasive disease have been included. Whilst awaiting national regulatory approval for enfortumab vedotin/pembrolizumab, the present guideline version aligns with EAU-guidelines by endorsing cisplatin-gemcitabine-nivolumab as a new first-line treatment option in cisplatin-fit patients with unresectable or metastatic urothelial carcinoma.

CONCLUSIONS

The current version of the Swedish national guidelines on urothelial carcinoma introduces standardised reporting at CTU to facilitate early identification of advanced disease, includes recommendations for centralisation of NU for UTUC and updated recommendations for adjuvant systemic treatment of muscle-invasive disease and endorses cisplatin-gemcitabine-nivolumab as a new first-line treatment option for non-resectable locally advanced and metastatic disease.

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.

Repurposing ProTAME for Bladder Cancer: A Combined Therapeutic Approach Targeting Cell Migration and MMP Regulation

Bladder cancer, the fourth most common cancer type among men, remains a therapeutic challenge due to its heterogeneity and frequent development of chemoresistance. Cisplatin-based chemotherapy, often combined with gemcitabine, is the standard treatment, yet resistance and off-target effects in non-cancerous tissues limit its efficacy. This study evaluated the effects of cisplatin, gemcitabine, and the APC/C inhibitor proTAME, both individually and in combination, on cell migration and MMP2/MMP9 expression in RT4 bladder cancer and ARPE-19 normal epithelial cells. Molecular docking analyses were conducted to investigate the interactions of these compounds with MMP2 and MMP9. IC20 values for gemcitabine, cisplatin, and proTAME were applied in scratch-wound healing and quantitative real-time PCR (qRT-PCR) assays. Docking results predicted that proTAME may interact favorably with MMP2 (-9.2 kcal/mol) and MMP9 (-8.7 kcal/mol), showing high computational binding affinities and potential key hydrogen bonds; however, these interactions require further experimental validation. Scratch-wound healing and qRT-PCR assays demonstrated that proTAME-containing combinations were associated with reduced cell migration and decreased MMP2 and MMP9 expression in RT4 cells. Cisplatin combined with proTAME showed the most pronounced reduction in MMP expression and cell migration, with proTAME alone also exhibiting notable inhibitory effects. In ARPE-19 cells, gemcitabine and cisplatin upregulated MMP2 and MMP9 expression, suggesting a potential stress response, whereas proTAME mitigated this effect. These differential effects show the importance of tumor-specific responses in RT4 cells, where proTAME shows promise in enhancing the efficacy of chemotherapy by modulating MMP-related pathways involved in tumor migration and invasion. In conclusion, this study highlights the potential of proTAME as a repurposed agent in bladder cancer treatment due to its association with reduced cell migration and MMP downregulation. While these in vitro and in silico findings suggest a promising role for proTAME in combination therapies, further validation in advanced preclinical models is necessary to assess its therapeutic applicability and safety.

Individualizing first-line treatment for advanced urothelial carcinoma: A favorable dilemma for patients and physicians

The treatment landscape for patients with advanced urothelial carcinoma (UC) has evolved rapidly in recent years. In current guidelines, combination treatment with enfortumab vedotin plus pembrolizumab is the first-line (1L) standard of care, and other recommended 1L treatment options are platinum-based chemotherapy followed by avelumab as switch-maintenance treatment in patients without progression, or combination treatment with nivolumab, cisplatin, and gemcitabine for cisplatin-eligible patients only. Individual patients differ in terms of their health status, disease characteristics, expected toxicities, and treatment preferences; thus, a "one-size-fits-all" approach to treatment is unlikely to be optimal. The availability of several treatment options creates the potential for individualized treatment. In this review, we discuss factors that may be considered when selecting 1L treatment for patients with advanced UC, including efficacy and safety data from phase 3 trials and real-world studies, quality of life, patient priorities for treatment, patient and disease characteristics, treatment sequencing, biomarkers, and treatment access and cost. Patients and physicians should discuss the benefit-risk balance of all available 1L options to enable shared decision-making. Longer follow-up from clinical trials and additional real-world studies are needed to further inform treatment selection.

Efficacy and safety of enfortumab vedotin in older patients with metastatic urothelial carcinoma: A multicenter retrospective study

INTRODUCTION

We aimed to evaluate the efficacy and safety of enfortumab vedotin therapy for a cohort of older Japanese patients with metastatic urothelial carcinoma compared to younger patients.

MATERIALS AND METHODS

We retrospectively evaluated patients with metastatic urothelial carcinoma treated with enfortumab vedotin and recruited between April 2019 and February 2023. Older patients were defined as being ≥75 years old. Efficacy was evaluated by comparing overall survival, progression-free survival, and objective response rates between groups. Adverse events and relative dose intensity were also compared. Moreover, the prognostic factor for overall survival in the entire cohort was evaluated using multivariate analysis.

RESULTS

Of the 57 patients treated with enfortumab vedotin, 37 were younger and 20 were older, (median ages of 67.6 and 79.2, respectively). Median overall survival in older and younger patients was 407 and 365 days, respectively (P = 0.48). The objective response rate was 60.0 % and 54 % (P = 0.68) and median progression-free survival 228 and 223 days in older and younger patients, respectively (P = 0.76). Adverse events were equivalent between groups except for liver dysfunction, which frequently occurred in younger patients. The dose intensity for the older and younger patients did not differ (65.7 % vs. 63.5 %, P = 0.37, respectively). In multivariate analysis, neutrophil-to-lymphocyte ratio of 3 or more was the only risk factor for worse overall survival in the entire cohort (P = 0.04).

DISCUSSION

Our data demonstrated that enfortumab vedotin therapy can benefit older patients with metastatic urothelial carcinoma equivalent to younger patients without compromising safety profiles.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Association between antibiotics and treatment efficacy in metastatic urothelial carcinoma patients

BACKGROUND

Antibiotic therapy (ABT)-induced dysbiosis may affect the efficacy of immune checkpoint inhibitors (ICI) therapy. We investigated the association between ABT and real-world overall survival (rwOS) and progression-free survival (rwPFS) in patients with metastatic urothelial carcinoma (mUC) receiving ICI or cisplatin-based chemotherapy (CIS).

METHODS

Three thousand, one hundred seventy-nine patients were included from a nationwide electronic health record-derived de-identified database. Three-month landmark Kaplan-Meier methods and log-rank tests were used to estimate rwOS/PFS between treatment modalities based on ABT groups (stratified by exposure, timing, excretion mode, and administration route). Cox proportional models with time-varying coefficients were used to investigate the associations between ABT, treatment modality, and rwOS/PFS.

RESULTS

A total of 402 (27.1%) ICI and 655 (38.6%) CIS patients received ABT (p < 0.001). ICI receipt (OR 0.65, p < 0.001) and advanced age (OR 0.98, p < 0.001) were associated with lower ABT use. ICI exclusive findings included a negative correlation with rwOS in patients who received post-treatment initiated (ICI median: pre-13.2 vs post-7.9 vs none-13.3 months; p = 0.009), oral (median oral-9.6 vs none-13.3 months, p = 0.03), and renally cleared (median renal-9.9 vs none-13.3 months, p = 0.04) ABT. ABT's effect was negatively associated with rwOS in ICI patients within first 6 months (HR 1.36, 95% CI 1.107-1.74, p = 0.01) but not thereafter (p = 0.7).

CONCLUSIONS

This study identified a potential ICI-specific negative correlation between ABT and rwOS in patients with mUC, specifically those exposed to ABT pills and receipt before treatment initiation. These results emphasize the importance of antibiotic stewardship and continued investigation of the role of gut microbiome in mUC treatment efficacy.

4-Methylpyrazole-mediated inhibition of Cytochrome P450 2E1 protects renal epithelial cells, but not bladder cancer cells, from cisplatin toxicity

Cisplatin is an effective chemotherapeutic drug for the treatment of bladder cancer, though cisplatin-induced nephrotoxicity (CIN) occurs in approximately 20-30% of patients, limiting its clinical use. Evidence has shown that cytochrome P450 2E1 (CYP2E1), a drug metabolism enzyme expressed in proximal tubules, mediates the production of reactive oxygen species (ROS) during cisplatin-induced injury. Previously, we showed that the repurposed drug 4-methylpyrazole (4MP; fomepizole) blocks CYP2E1 activity and prevents acetaminophen-induced liver injury. Here, we investigated the potential protective effects of 4MP against CIN. Male and female C57BL/6J mice were treated with a single 20 mg/kg dose of cisplatin for 3 days (acute) or 9 mg/kg/week for 4 weeks (repeated dosing regimen) with or without a co-treatment of 50 mg/kg 4MP. Our findings revealed that acute treatment with cisplatin induced severe histological tubular damage and elevated plasma BUN and creatinine levels in male mice, but not in female mice. This difference correlated with higher basal CYP2E1 expression in the kidneys of male mice compared to female mice. We also found that cisplatin increased renal CYP2E1 activity and that inhibition of CYP2E1 with 4MP significantly reduced cisplatin induced cell death in male mice and primary normal human kidney cells. By contrast, human bladder cancer cells do not express CYP2E1, and treatment with 4MP did not interfere with cisplatin anti-cancer effects in human bladder cancer HTB9 cells. This study highlights the critical role of CYP2E1 in CIN and suggests that its inhibition with 4MP in the kidney is a potential prophylactic therapeutic option to prevent CIN in bladder cancer patients without affecting its anti-neoplastic effect.

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

Objective

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

Method

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

Results

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

Conclusion

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

Systematic review registration

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

Safety and efficacy of oral cancer vaccine B440 in patients with PD-1/PD-L1 inhibitor-resistant advanced urothelial cancer: a study protocol for a phase 1 multicenter, open-label, single-arm clinical trial

BACKGROUND

This is a multicenter, open-label, single-arm clinical trial to evaluate the safety and efficacy of oral cancer vaccine B440 in patients with PD-1/PD-L1 inhibitor-resistant advanced urothelial cancer.

METHODS

The trial will be performed at three university hospitals in Japan. The target number of patients will be 12. The patients will be treated orally with B440 once daily for 5 days followed by 2 days for four consecutive courses (4 weeks, 20 treatments). The low-dose group will receive 800 mg (4 capsules) per dose and the high-dose group will receive 1,600 mg (8 capsules) per dose. The primary outcome will be the number and incidence of DLT cases the start of treatment and Day 28. Secondary outcomes are the presence or absence of a response, the best overall response and PFS.

DISCUSSION

If this trial shows B440 to be safe and effective, it may lead to a late phase randomized controlled trial in advanced urothelial cancer. Ultimately, we hope to provide a new treatment option for such patients.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCT) identifier: jRCT2051220143. Registered on December 27, 2022.

Strength in Numbers: A Giant NIR-II AIEgen with One-for-All Phototheranostic Features for Exceptional Orthotopic Bladder Cancer Treatment

One-for-all phototheranostics that allows the simultaneous implementations of multiple optical imaging and therapeutic modalities by utilizing a single component, is growing into a sparkling frontier in cancer treatment. Of particular interest is phototheranostic agent with emission in the second near-infrared (NIR-II) window. Nevertheless, the practical uses of those conventional NIR-II agents are severely impeded by their unsatisfactory features including insufficient stability, low synthetic yield, to be extended absorption/ emission wavelengths, and inefficient phototheranostic outcomes. Developing exceptional phototheranostic agents is thus highly desirable yet remains formidably challenging. Herein, we synthesized two novel N-heteroacenes-based NIR-II luminogens, namely 2TT-PPT and 4TT-PBPT, by respectively employing pyrene-fused phenaziothiadiazoles and pyrene-fused bisphenaziothiadiazoles as acceptor skeletons. There is strength in numbers by increasing the fusing rings in N-heteroacenes moieties and numbers of appended donors. Compared to less ring-fused 2TT-PPT, the giant molecule 4TT-PBPT shows improved photophysical characteristics, such as enhanced light absorbance, red-shifted wavelengths, higher brightness, favorable reactive oxygen species (ROS) generation, and elevated photothermal conversion efficiency, which render 4TT-PBPT nanoparticles excellent fluorescence-photoacoustic-photothermal trimodal imaging guided photodynamic-photothermal synergistic therapy for orthotopic bladder cancer.

Enhanced Oxidative Phosphorylation Driven by TACO1 Mitochondrial Translocation Promotes Stemness and Cisplatin Resistance in Bladder Cancer

Chemoresistance poses a critical obstacle in bladder cancer (BCa) treatment, and effective interventions are currently limited. Elevated oxidative phosphorylation (OXPHOS) has been linked to cancer stemness, a determinant of chemoresistance. However, the mechanisms underlying increased OXPHOS during cancer cell chemoresistance remain unclear. This study revealed that the mitochondrial translational activator of cytochrome oxidase subunit 1 (TACO1) is linked to stemness and cisplatin resistance in BCa cells. Mechanistically, mitochondrial TACO1 enhances the translation of the mitochondrial cytochrome c oxidase I (MTCO1), promoting mitochondrial reactive oxygen species (mtROS) by upregulating OXPHOS, consequently driving cancer stemness and cisplatin resistance. Intriguingly, the mitochondrial translocation of TACO1 is mediated by the heat shock protein 90 β (HSP90β), a process that requires circFOXK2 as a scaffold for the TACO1-HSP90β interaction. The mutations at the binding sites of TACO1-circFOXK2-HSP90β disturb the ternary complex and inhibit cancer stemness and cisplatin resistance in BCa cells by suppressing the MTCO1/OXPHOS/mtROS axis. Clinically, BCa patients with increased mitochondrial TACO1 expression respond poorly to cisplatin treatment. This study elucidates the mechanisms by which TACO1 promotes BCa stemness and cisplatin resistance, providing a potential target for mitigating cisplatin resistance for BCa and a biomarker for predicting cisplatin response.

Outcomes by Retrospective Eligibility for Maintenance Therapy of Patients With Advanced Urothelial Carcinoma: Post Hoc Analysis of the Phase 3 KEYNOTE-361 Trial

INTRODUCTION

The phase 3 KEYNOTE-361 trial of first-line pembrolizumab with or without chemotherapy versus chemotherapy alone in patients with locally advanced or metastatic urothelial carcinoma (la/mUC) completed enrollment before the approval of postchemotherapy maintenance avelumab for patients without progressive disease. This post hoc analysis evaluated the outcomes of patients who received chemotherapy alone in KEYNOTE-361 by retrospective eligibility for subsequent maintenance therapy.

PATIENTS AND METHODS

Patients in the chemotherapy alone arm were retrospectively categorized as maintenance eligible (received ≥4 cycles of chemotherapy and did not die or experience disease progression within 10 weeks of chemotherapy completion), maintenance ineligible (received <4 cycles of chemotherapy or had progressive disease or died within 0-10 weeks after completion of ≥4 cycles of chemotherapy), and indeterminate eligibility for maintenance therapy (if neither maintenance eligible or ineligible). End points included progression-free survival per Response Evaluation Criteria in Solid Tumors version 1.1 by blinded independent central review and overall survival from randomization (start of chemotherapy).

RESULTS

Median follow-up was 31.7 months (range, 22.0-42.3). Among 342 patients who received chemotherapy alone, 172 (50.3%) were maintenance eligible, 108 (31.6%) were maintenance ineligible, and 62 (18.1%) had indeterminate eligibility for maintenance therapy. The median progression-free survival was 9.0 months (95% CI 8.4-10.4) in maintenance-eligible patients, 5.1 months (4.2-6.0) in maintenance-ineligible patients, and 2.3 months (1.9-3.8) in the indeterminate group; median overall survival was 23.3 months (95% CI 19.4-26.1), 10.2 months (9.1-11.6), and 5.5 months (3.7-8.5), respectively.

CONCLUSION

This post hoc analysis suggests that a majority of patients with untreated la/mUC who initiated chemotherapy in a clinical trial may have been considered eligible for maintenance therapy and had favorable survival outcomes compared with those considered maintenance ineligible.

Treatment of metastatic urothelial carcinoma in the United Kingdom, France, Germany, Italy, and Spain

INTRODUCTION

The treatment landscape of metastatic urothelial carcinoma (mUC) has evolved with the emergence of programmed cell death protein 1/ligand 1 (PD-1/L1) inhibitors. This study assessed mUC treatment patterns in Europe.

METHODS

Data were derived from the Adelphi mUC Disease Specific Programme™ (November 2020 to April 2021), a large, cross-sectional, patient record-based survey of physicians in France, Germany, Italy, Spain, and the United Kingdom. Patient characteristics, treatment patterns across lines of therapy, and treatment durations were assessed.

RESULTS

Physicians (N = 232) provided data for 1922 patients with mUC. Mean (SD) patient age at the time of data collection was 69.1 (7.9) years, and 81% presented with bladder tumors. Most patients received platinum-based chemotherapy in first-line (cisplatin plus gemcitabine, 43%; carboplatin plus gemcitabine, 28%), followed by PD-1/L1 inhibitors in second-line (pembrolizumab, 35%; atezolizumab, 19%). In third-line, 41% received best supportive care and 36% received single-agent chemotherapies. Mean treatment duration was longer in second-line than first-line (6.1 vs 4.8 months).

CONCLUSIONS

Most patients received platinum-based chemotherapy in first-line, followed by a PD-1/L1 inhibitor. A substantial proportion received best supportive care after second-line. Findings indicate unmet need for the later-line treatment of mUC and provide important context for the emergence of novel therapies.

Recent Advances in Immunotherapy for Bladder Cancer Treatment

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

Predictive Value of Neutrophil Extracellular Traps in Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer

Cisplatin-based chemotherapy is the recommended therapy for muscle-invasive bladder cancer (MIBC). However, the efficacy of MIBC for chemotherapy is only about 40%. Therefore, predictors of therapy response are urgently needed. Neutrophils form neutrophil extracellular traps (NETs), a network structure, and growing evidence indicated that it could be a prognostic and predictive marker in cancer. In MIBC, the predictive role of NETs in chemotherapy resistance is unclear. We used the Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression analyses to develop a NETs-associated signature score (NETs-score) for therapeutic response prediction in the discovery cohort (GSE169455). Then the NETs score-based risk stratification was verified in two validation cohorts (Taber et al.'s cohort, our institutional cohort). In the training cohort, high NETs-score was associated with poor chemotherapy response (AUC = 0.781) and reduced recurrence-free survival (RFS) (hazard ratio [HR] = 2.07, 95% confidence interval [CI]: [1.26-3.40], p = 0.003) in MIBC patients. The NETs-score was also demonstrated to be a predictive factor for the efficacy of neoadjuvant chemotherapy in the validation cohort (AUC = 0.731). The accuracy of the NETs-score was superior to other chemotherapy response predictors such as Ba/Sq expression subtype (AUC = 0.711), BRCA2 mutation (AUC = 0.692) and ERCC2 mutation (AUC = 0.548). Furthermore, in our center cohort, the expression level of H3Cit showed a significant difference between the response and no-response group (p = 0.01). Through immunohistochemical validation, NETs was an independent predictor of MIBC neoadjuvant chemotherapy efficacy as determined by the multivariate logistic regression analysis (OR = 5.94, 95% CI: 1.20-45.50, p = 0.045). Patients with high levels of NETs predicted poor response to neoadjuvant chemotherapy. This study was the first to reveal the correlation between the level of NETs in MIBC and the efficacy of chemotherapy, which may provide a theoretical basis regarding NETs inhibitors.

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

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

Acidic Microenvironment Enhances Cisplatin Resistance in Bladder Cancer via Bcl-2 and XIAP

Cisplatin (CDDP) remains a key drug for patients with advanced bladder cancer (BC), despite the emergence of new therapeutic agents; thus, the identification of factors contributing to CDDP treatment resistance is crucial. As acidity of the tumor microenvironment has been reported to be associated with treatment resistance and poor prognosis across various cancer types, our objectives in this study were to investigate the effects of an acidic environment on BC cells and elucidate the mechanisms behind CDDP resistance. Our findings show that BC cells cultured under acidic conditions developed cisplatin resistance as acidity increased. Notably, CDDP administered to BC cells in a pH 6.0 environment required double the concentration, compared to those in a pH 7.5 environment, to achieve equivalent toxicity. Using chloroquine and navitoclax, we identified the involvement of the Bcl-2 and LC3B pathways in the acquisition of CDDP resistance under acidic conditions. A Western blot analysis revealed that the activations of Bcl-2 and XIAP expression appear to inhibit both apoptotic and autophagic cell death. Taken together, these results suggest that alleviating the acidity of the tumor microenvironment in clinical settings might enhance BC sensitivity to CDDP.

[Enfortumab vedotin and pembrolizumab : Management of side effects during first line combined treatment for advanced or metastatic urothelial carcinoma]

The aim of this article is to raise awareness among healthcare providers about the adverse events (AEs) associated with the combined treatment with enfortumab vedotin and pembrolizumab. The differential diagnostic allocation of these AEs to the respective agents is discussed, overlaps between the side effect profiles of the two drugs are identified and strategies for an effective management of these AEs are presented. The recommendations are based on the currently valid prescription information for both drugs, the results of pivotal approval studies and the guidelines of recognized specialist organizations as well as the clinical experience of the authors.

Safety and Efficacy of Enfortumab Vedotin in a Patient With Metastatic Urothelial Carcinoma on Dialysis: A Case Report

Recently, enfortumab vedotin has emerged as a promising treatment option for metastatic urothelial carcinoma. Although it does not require dosage adjustments in patients with renal failure, its safety and efficacy, particularly in those undergoing dialysis, remain unclear. We report a case of metastatic urothelial carcinoma in a patient undergoing hemodialysis who achieved a complete response to enfortumab vedotin therapy without severe adverse events. This complete response was maintained for two years without any severe complications. Our case demonstrates that enfortumab vedotin can be safely administered long-term to patients undergoing hemodialysis.

Basal/squamous and mixed subtype bladder cancers present poor outcomes after neoadjuvant chemotherapy in the VESPER trial

BACKGROUND

Neoadjuvant chemotherapy (NAC) is the standard treatment for muscle-invasive bladder cancer (MIBC), yet 40% of patients progress, emphasizing the need for biomarkers predictive for response or chemoresistance. Gene expression-based subtypes may serve as biomarkers, though which subtypes will respond, notably when it comes to the basal subtype, remains contentious.

PATIENTS AND METHODS

This post hoc study analyzed 300 NAC-treated patients enrolled in the GETUG/AFU VESPER trial, with transurethral diagnostic formalin-fixed paraffin-embedded tissue which underwent pathological review before being sequenced. 'Mixed' subtype was defined for tumors displaying at least two different Consensus molecular subtypes in separate regions. We evaluated the association between molecular subtypes and outcome after NAC. Tumors with remaining tissue at cystectomy (n = 83) were compared with pre-treatment tumors.

RESULTS

Cases were classified basal/squamous (Ba/Sq) (n = 84), luminal unstable (n = 57), stroma-rich (n = 53), mixed (n = 48), luminal papillary (n = 39), luminal non-specific (n = 18), and neuroendocrine-like (n = 1), with 30/48 mixed cases including a Ba/Sq component. Compared with other molecular subtypes in a multivariate Cox model, Ba/Sq (pure or mixed) patients had an increased hazard ratio (HR) of progression-free survival [HR 2.0, 95% confidence interval (CI) 1.36-3.0]. Mixed tumors were associated with decreased metabolic activity that could account for chemoresistance. Ba/Sq and mixed non-responders mostly maintained their subtype at cystectomy and have fewer myeloid dendritic cells after NAC. Tumors classified luminal papillary at transurethral resection of the urinary bladder tumor exhibited an increase in T CD4+ and macrophage signatures after NAC. Other subtypes did not show significant immune changes after NAC. Our study design relied on detailed pathological review, which precluded evaluating the mixed subtype in published datasets. Furthermore, the sample size for post-NAC analyses constrained the statistical power of these findings.

CONCLUSIONS

Our findings underscore the importance of recognizing intra-tumor heterogeneity in MIBC and its role in chemoresistance associated with Ba/Sq subtype, and provide valuable insights that could help future treatment development and improve patient outcomes.

Establishment of potent TCR-T cells specific for cisplatin-resistance related tumor-associated antigen, CLSPN using codon-optimization

Adoptive T cell therapy, using T cell receptor-engineered T (TCR-T) cells and chimeric antigen receptor T (CAR-T) cells, is a potent immunotherapy option. Bladder cancer is a prevalent urological malignancy, particularly in cases of muscle invasion and metastasis, for which systemic therapy is crucial. Immunotherapy utilizing immune checkpoint blockade has been approved for bladder cancer treatment. The antitumor effect of an immune checkpoint blockade based on cytotoxic T cells (CTLs) and the patient's immune status is essential. The chemotherapeutic drug cisplatin (CDDP) is a key drug in bladder cancer treatment. However, it has been shown to suppress T cells, making combination therapy with CDDP and immunotherapy difficult. To address this, we developed TCR-T cells specific for bladder cancer cells. In previous studies, we found that the tumor-associated antigen CLSPN is overexpressed in CDDP-resistant bladder cancer cells and that the antigenic peptide HLA-A*02:01/CLSPN1254-1262, encoded by CLSPN, could be targeted by a CTL clone. The TCR was cloned from the HLA-A*02:01/CLSPN1254-1262 specific CTL clone yc3. We also designed a codon-optimized TCR sequence using GeneArt® GeneOptimizer® (Opt TCR) and compared the TCR-T cells using the original TCR sequence (Ori TCR-T cells) and the codon-optimized TCR sequence (Opt TCR-T cells). Opt TCR-T cells exhibited higher TCR transduction efficiency, higher TCR expression levels, higher avidity, and greater cytotoxicity than did Ori TCR-T cells. These results suggest that HLA-A*02:01/CLSPN1254-1262 specific Opt TCR-T cells are promising candidates for CDDP combination therapy.

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.

Evolving Treatment Landscape of Frontline Therapy for Metastatic Urothelial Carcinoma: Current Insights and Future Perspectives

Cisplatin-based chemotherapy has long been the standard first-line (1L) treatment for metastatic urothelial carcinoma (mUC). However, up to 50% of patients with mUC may be ineligible for cisplatin owing to comorbidities, necessitating alternative primary treatment options. Immune checkpoint inhibitors (ICIs) have emerged as a vital alternative for those unable to receive cisplatin. Nevertheless, the prognosis of advanced UC remains dire and challenges persist in optimizing 1L therapy. Recent medical advancements have redirected attention towards innovative drug combinations for the primary treatment of mUC. The combination of enfortumab vedotin (EV) and pembrolizumab has shown significantly improved overall and progression-free survival rates compared to those with chemotherapy alone. This combination can be used as a 1L treatment for patients with mUC who are cisplatin-ineligible or require alternatives to standard chemotherapy. While platinum-based chemotherapy continues to be essential for many patients, the approval of EV and pembrolizumab as 1L treatments for cisplatin-ineligible patients signifies a major breakthrough in primary cancer care. These therapies offer enhanced outcomes in terms of survival and response rates and highlight the increasing relevance of ICI-containing regimens in frontline cancer care. This review provides an exhaustive overview of the current frontline treatment landscape of mUC and explores new therapeutic strategies, with the aim of facilitating clinical decision-making and guiding therapeutic strategies in patients with mUC.