Trimodality Treatment and Selective Organ Preservation for Bladder Cancer

Efficacy and Safety of Bladder Preservation Therapy in Combination with Atezolizumab and Radiation Therapy (BPT-ART) for Invasive Bladder Cancer: Interim Analysis from a Multicenter, Open-label, Prospective Phase 2 Trial

PURPOSE

To evaluate the safety and pathologic complete response (pCR) rate of radiation therapy with atezolizumab as bladder-preserving therapy for invasive bladder cancer.

METHODS AND MATERIALS

A multicenter, phase 2 study was conducted with patients with clinically T2-3 or very-high-risk T1 bladder cancer who were poor candidates for or refused radical cystectomy. The interim analysis of pCR is reported as a key secondary endpoint ahead of the progression-free survival rate primary endpoint. Radiation therapy (41.4 Gy to the small pelvic field and 16.2 Gy to the whole bladder) was given in addition to 1200 mg intravenous atezolizumab every 3 weeks. After 24 treatment weeks, response was assessed after transurethral resection, and tumor programmed cell death ligand-1 (PD-L1) expression was assessed using tumor-infiltrating immune cell scores.

RESULTS

Forty-five patients enrolled from January 2019 to May 2021 were analyzed. The most common clinical T stage was T2 (73.3%), followed by T1 (15.6%) and T3 (11.1%). Most tumors were solitary (77.8%), small (<3 cm) (57.8%), and without concurrent carcinoma in situ (88.9%). Thirty-eight patients (84.4%) achieved pCR. High pCR rates were achieved in older patients (90.9%) and in patients with high PD-L1-expressing tumors (95.8% vs 71.4%). Adverse events (AEs) occurred in 93.3% of patients, with diarrhea being the most common (55.6%), followed by frequent urination (42.2%) and dysuria (20.0%). The frequency of grade 3 AEs was 13.3%, whereas no grade 4 AEs were observed.

CONCLUSIONS

Combination therapy with radiation therapy and atezolizumab provided high pCR rates and acceptable toxicity, indicating it could be a promising option for bladder preservation therapy.

["Surgery only" is not enough: potential of multimodal therapy in urothelial bladder carcinoma]

Radical cystectomy is the standard treatment for muscle invasive bladder cancer. Using perioperative cisplatin-based chemotherapy, 5‑year overall survival rates are 5% higher with neoadjuvant chemotherapy compared to local therapy alone. New multimodal concepts have been developed to improve oncologic efficacy and to reduce treatment-related morbidity. Perioperative use of checkpoint inhibitors aims at improving efficacy, while bladder-preserving concepts try to avoid cystectomy in good responders. This article reviews new developments in radioimmunotherapy and perioperative combination therapies as well as bladder-preserving concepts like trimodal bladder therapy.

Bite-on-bite biopsies for the detection of residual esophageal cancer after neoadjuvant chemoradiotherapy

BACKGROUND

Active surveillance after neoadjuvant treatment is increasingly implemented. The success of this strategy relies on the accurate detection of residual cancer. This study aimed to assess the diagnostic value of a second (bite-on-bite) biopsy for the detection of residual esophageal cancer and to correlate outcomes to the distribution of residual cancer found in the resection specimen.

METHODS

A multicenter prospective study of esophageal cancer patients undergoing active surveillance after neoadjuvant chemoradiotherapy was performed. At clinical response evaluations, an upper gastrointestinal (GI) endoscopy was performed with at least four bite-on-bite biopsies of the primary tumor site. First and second biopsies were analyzed separately. Patients with histopathological evidence of residual cancer were included in the primary analysis. Two pathologists blinded for biopsy outcome examined all resection specimens.

RESULTS

Between October 2017 and July 2020, 626 upper GI endoscopies were performed in 367 patients. Of 138 patients with residual cancer, 112 patients (81 %) had at least one positive biopsy. In 14 patients (10 %) only the first biopsy was positive and in 25 patients (18 %) only the second biopsy (P = 0.11). Remarkably, the rates of patients with tumor-free mucosa and deeper located tumors were higher in patients detected by the first biopsy. The second biopsy increased the false-positive rate by 3 percentage points. No adverse events occurred.

CONCLUSIONS

A second (bite-on-bite) biopsy improves the detection of residual esophageal cancer by almost 20 percentage points, at the expense of increasing the false-positive rate by 3 percentage points. The higher detection rate is explained by the higher number of biopsies obtained rather than by the penetration depth.

Tetramodal therapy with transurethral resection followed by chemoradiation in combination with hyperthermia for muscle-invasive bladder cancer: early results of a multicenter phase IIB study

BACKGROUND

Transurethral resection of bladder tumor (TUR-BT) followed by chemoradiation (CRT) is a valid treatment option for patients with muscle-invasive bladder cancer (MIBC). This study aimed to investigate the efficacy of a tetramodal approach with additional regional hyperthermia (RHT).

METHODS

Patients with stages T2-4 MIBC were recruited at two institutions. Treatment consisted of TUR-BT followed by radiotherapy at doses of 57-58.2 Gy with concurrent weekly platinum-based chemotherapy and weekly deep RHT (41-43 °C, 60 min) within two hours of radiotherapy. The primary endpoint was a complete response six weeks after the end of treatment. Further endpoints were cystectomy-free rate, progression-free survival (PFS), local recurrence-free survival (LRFS), overall survival (OS) and toxicity. Quality of life (QoL) was assessed at follow-up using the EORTC-QLQ-C30 and QLQ-BM30 questionnaires. Due to slow accrual, an interim analysis was performed after the first stage of the two-stage design.

RESULTS

Altogether 27 patients were included in the first stage, of these 21 patients with a median age of 73 years were assessable. The complete response rate of evaluable patients six weeks after therapy was 93%. The 2-year cystectomy-free rate, PFS, LRFS and OS rates were 95%, 76%, 81% and 86%, respectively. Tetramodal treatment was well tolerated with acute and late G3-4 toxicities of 10% and 13%, respectively, and a tendency to improve symptom-related quality of life (QoL) one year after therapy.

CONCLUSION

Tetramodal therapy of T2-T4 MIBC is promising with excellent local response, moderate toxicity and good QoL. This study deserves continuation into the second stage.

Multifunctional Self-Assembly with NIR Light-Activated Cascade Effect for Improving Local Treatment on Solid Tumors

Incomplete local treatment of solid tumors is the main cause of tumor difficult to cure, and easily leads to tumor metastasis and recurrence. The dense external matrix and hypoxic microenvironment of solid tumors severely restrict the therapy efficacy of local tumors. Enhancing the infiltration ability of agents to tumor tissues and adapting the therapy mode favored to hypoxic microenvironments are beneficial to improve the cure rate of tumors. In this work, we designed and developed a self-assembled biomaterial with a cascade effect triggered by near-infrared light. The self-assembly was combined of biotin, phase change material (PNIPAM), photochemical agent (ATT-2), and alkyl radical generator (AIPH). In the assembly, biotin acted as a targeted group. ATT-2 was used to provide heat to synergistically induce the phase change and decompose alkyl radicals. The superficial and deep tumors were ablated by heat and alkyl radicals with white light irradiation of the assembly, respectively. The assay in vivo showed that the self-assembly could effectively eliminate local lesions of solid tumors. This work provides new insights for improving the cure rate of tumors, which not only develops biomaterials adapted to the tumor microenvironment, but also proposes new therapies for complete elimination of solid tumors.

[Complete response after neoadjuvant therapy for gastric cancer: implications for surgery]

BACKGROUND

Perioperative or neoadjuvant therapy is the mainstay of treatment for locally advanced gastric cancer in Europe; however, data regarding possible modifications in the surgical strategy depending on the response to preoperative treatment are lacking.

METHODS

This review was carried out based on a search of the relevant contemporary literature regarding neoadjuvant or perioperative treatment for gastric adenocarcinoma and the implications of tumor response for the subsequent surgical treatment.

RESULTS

The most recent randomized trials showed a survival benefit after perioperative or neoadjuvant treatment for gastric cancer. Due to the variable response to the preoperatively administered part of the therapy, including complete response, it appears reasonable to develop an individualized surgical approach; however, scientific results supporting this approach are limited due to the variable quality of the surgical resection provided in these studies and the limited rate of complete response to preoperative treatment. Moreover, the reliability of clinical restaging after preoperative treatment is also limited. On the other hand, there is currently evidence that supports a re-evaluation of the necessary resection margins for partial gastrectomy in advanced gastric cancer with the help of intraoperative frozen sections and new reconstruction methods.

CONCLUSION

The current evidence does not support the implementation of a complete organ-sparing strategy with active follow-up surveillance for gastric cancer.; however, stomach-preserving partial gastrectomy techniques could be applied for advanced disease more often in the future.

Diagnostic performance of contrast-enhanced dynamic and diffusion-weighted MR imaging in the assessment of tumor response to neoadjuvant therapy in muscle-invasive bladder cancer

OBJECTIVES

To evaluate the diagnostic performance of DCE MRI and DWI in the assessment of pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in patients with muscle-invasive bladder cancer (MIBC).

METHODS

This prospective study included 90 patients with MIBC who finished NAC. Two radiologists independently assessed MRI for the determination of semi-quantitative parameters (wash-in rate and wash-out rate) and apparent diffusion coefficient (ADC) value. The correlation between pCR and wash-in rate, wash-out rate, ADC value were analyzed. The area under the ROC curve (AUC) was used to evaluate the diagnostic performance for detecting pCR. Inter-reader agreement was assessed using the ICC statistics.

RESULTS

On cystectomy specimens, pCR was confirmed in (43.3%, 39/90). pCR is negatively correlated with wash-out rate (r = - 0.701, p = 0.01) and ADC value (r = - 0.621, p = 0.01). ADC value is positively correlated with wash-out rate (r = 0.631, p = 0.001). The diagnostic accuracy of ADC value (cut-off value: 0.911 × 10^-3mm²/s) and wash-out rate (cut-off value: 0.677 min^-1) in the identification of pCR was (92% for reader 1, 91% for reader 2), and (90% for reader 1, 88% for reader 2), respectively. The sensitivity, specificity for predicting pCR using ADC value + washout rate cut off values were 95.4%, 97.7% for reader 1, and 96%, 97% for reader 2, respectively. AUC was 0.981 for reader 1, 0.971 for reader 2. The overall reproducibility of the mean ADC value and wash out rate was excellent (ICC = 0.83-0.90). The ICC values for the mean ADC value, washout rate was 0.89 (95% CI 0.84-0.89) and 0.87 (95% CI 0.86-0.91), respectively.

CONCLUSION

Semi-quantitative parameter (wash-out) derived from DCE-MRI and ADC has the potential to assess the tumor's complete pathologic response. The two parameters using together can offer the best possibility to identify complete response to NAC in MIBC.

Surgical challenges and considerations in Tri-modal therapy for muscle invasive bladder cancer

Trimodal therapy (TMT) for muscle invasive bladder cancer has become an accepted alternative to radical cystectomy and has become integrated into national guidelines as standard a treatment option. The urologist plays a critical role in proper patient selection, thorough transurethral resection, ongoing cystoscopic surveillance and management of local recurrences. There exists multiple patient related and tumor related factors, which contribute to the selection of TMT vs. radical cystectomy for a patient with muscle invasive bladder cancer. Although the ideal patient for TMT has a tumor which can undergo a visibly complete resection, has no associated hydronephrosis, does not invade the prostatic urethra and is not associated with diffuse carcinoma in situ throughout the bladder, select patients who do not meet all these criteria can still be successfully treated with this approach. A multidisciplinary approach including urology, radiation oncology and medical oncology is paramount with clear communication of tumor location, timing of chemoradiation and repeat cystoscopic resection followed by surveillance. Nonmuscle invasive bladder cancer recurrences can occur in up to 26% of patients after completion of TMT, with many being treated by routine and standard therapy for non-muscle invasive bladder cancer. However, in this population after TMT, early salvage cystectomy should be considered in those with adverse features, including T1 disease, tumor greater than 3 cm, CIS, or lymphovascular invasion. Salvage cystectomy can be performed for local recurrences with acceptable oncologic control and no clear evidence of any greater risk of early complications; however, there may be a slightly increased risk for late complications, namely small bowel obstruction, ureteral stricture, and parastomal hernia. An understanding of these surgical considerations is of utmost importance to the treating urologist in selecting and managing a patient through TMT.

Trimodal Therapy vs. Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Meta-Analysis

Background: To compare the difference between trimodal therapy (TMT) and radical cystectomy (RC) in treating muscle-invasive bladder cancer, we performed a meta-analysis for data from the following database.

Methods: We searched PubMed, Chinese biomedicine literature database, the Cochrane Library, China National Knowledge Internet databases, Wanfang databases, and Google Scholar up to December 2019. The main outcome measures assessed were overall survival (OS), cancer-specific survival (CSS), mortality, and Charlson comorbidity score (CCS). Two authors independently evaluated the study quality and extracted data. All data were analyzed using Review Manager (version 5.3).

Results: After database retrieval, article selection, data extraction, and quality assessment, nine articles comprising 5,721 cases from the TMT group and 48,262 cases from the RC group were included in this study. The data showed that there was no statistical difference between TMT and RC at <10 years OS [pooled hazard ratio (HR) = 1.26, 95% confidence interval (CI): 0.92–1.73, Z = 1.46, P = 0.14], while OS of the RC group was higher than that of the TMT group at more than 10 years (pooled HR = 1.34, 95% CI: 1.18–1.54, Z = 4.33, P < 0.0001). As for CSS, compared with the TMT group, the patients in the RC group had longer CSS (pooled HR = 1.50, 95% CI: 1.29–1.76, Z = 5.15, P < 0.00001). Compared with RC, TMT is linked to an obvious increase in all-cause mortality and bladder-specific cancer mortality (pooled HR = 1.30, 95% CI: 1.16–1.46, Z = 4.55, P < 0.00001; pooled HR = 1.32, 95% CI: 1.15–1.51, Z = 3.92, P < 0.0001). The bladder cancer patients belonging to CCS “0” score preferred RC [pooled relative risk (OR) = 0.94, 95% CI: 0.89–0.98, Z = 2.79, P = 0.005], while CCS “2” score's patients were prone to TMT (pooled OR = 1.40, 95% CI: 1.29–1.53, Z = 7.73, P < 0.00001).

Conclusions: Overall, this meta-analysis suggests that the efficacy of TMT is non-inferior to that of RC at <10-year OS, and RC is superior to TMT at more than 10-year OS. Therefore, TMT may be a reasonable treatment option in well-selected patients who are unsuitable for surgery or are not willing to experience surgery. In the future, more high-quality, large-sample randomized controlled trials (RCTs) are needed to verify the results.

Injectable and NIR-Responsive DNA-Inorganic Hybrid Hydrogels with Outstanding Photothermal Therapy

Surgical excision is one of the main treatments for malignant tumors. However, high risk of tumour recurrence is a major challenge. Near-infrared (NIR)-light-induced tumor photothermal therapy has been studied, while its clinical applications are still restricted due to the limited therapeutic effects. To address this, here, a novel NIR-light-responsive and injectable DNA-mediated upconversion and Au nanoparticle hybrid (DNA-UCNP-Au) hydrogel is developed. Due to the confined and concentrated environment induced by the interaction between adjacent DNA strands and UCNP-Au NPs, an ultrastrong photothermal effect is observed. A photothermal efficiency as high as 42.7% is realized in the hydrogel, which is superior to pristine inorganic particles. Upon direct peritumoral injection of the hydrogel and with the treatment of 808 nm laser irradiation, tumors are eradicated and no recurrence is observed. Meanwhile, there are no side effects on normal tissues due to the local treatment. Taking advantage of the high phototherapeutic effect, biocompatibility, and flexible operability in this system, a novel approach for malignant tumor therapy is demonstrated.

Retz* M, Rödel C, E. Gschwend J. The Diagnosis and Treatment of Patients With Bladder Carcinoma

BACKGROUND

In Germany, bladder carcinoma accounts for 3-4 % of all malignant tumors. New study findings in the fields of endoscopy, surgery, and systemic therapy have led to multimodal treatment approaches for bladder cancer that can prolong overall survival and improve the affected patients' quality of life.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, with special attention to the German Clinical Practice Guideline on the Early Detection, Diagnosis, Treatment, and Continuing Care of Bladder Carcinoma, along with data available on the websites of the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA). The bladder carcinoma guideline of the Onkopedia guidelines program was used as well.

RESULTS

75% of all urothelial carcinomas are diagnosed in the non-muscle-invasive stage. These carcinomas should be resected via the endoscopic transurethral approach whenever possible. Next, depending on the patient's risk profile, intravesical therapy may be needed. Patients with carcinoma in the muscle-invasive stage should be given multimodal treatment, including radical cystectomy with urinary diversion and perioperative systemic therapy; alternatively, bladder-preserving chemoradiotherapy can be offered in selected cases. For patients with metastatic bladder carcinoma, immunotherapy with checkpoint inhibitors has become well established for first- and second-line therapy alongside classic cytostatic treatment and has been shown to prolong patients' lives significantly. The administration of checkpoint inhibitors can prolong the overall survival of patients with metastases to 15-17 months.

CONCLUSION

The treatment of bladder carcinoma in all stages calls for interdisciplinary collaboration to ensure the provision of effective, individual multimodal treatment.

The Challenge of Managing Bladder Cancer and Upper Tract Urothelial Carcinoma: A Review with Treatment Recommendations from the Spanish Oncology Genitourinary Group (SOGUG)

Bladder cancer is the fourth most common cancer in men and the ninth most common in women in the Western world. The management of bladder carcinoma requires a multidisciplinary approach. Optimal treatment depends on several factors, including histology, stage, patient status, and possible comorbidities. Here we review recent findings on the treatment of muscle-invasive bladder carcinoma, advanced urothelial carcinoma, upper tract urothelial carcinoma, non-urothelial carcinoma, and urologic complications arising from the disease or treatment. In addition, we present the recommendations of the Spanish Oncology Genitourinary Group for the treatment of these diseases, based on a focused analysis of clinical management and the potential of current research, including recent findings on the potential benefit of immunotherapy. In recent years, whole-genome approaches have provided new predictive biomarkers and promising molecular targets that could lead to precision medicine in bladder cancer. Moreover, the involvement of other specialists in addition to urologists will ensure not only appropriate therapeutic decisions but also adequate follow-up for response evaluation and management of complications. It is crucial, however, to apply recent molecular findings and implement clinical guidelines as soon as possible in order to maximize therapeutic gains and improve patient prognosis.

The effect of miR-124-3p on cell proliferation and apoptosis in bladder cancer by targeting EDNRB

INTRODUCTION

Endothelin receptor type B (EDNRB) is a potential target gene of miR-124-3p, but the association between miR-124-3p and EDNRB has not yet been reported. The aim of this study was to investigate the role of miR-124-3p in bladder cancer (BC) and to determine whether miR-124-3p regulates cell proliferation by targeting EDNRB.

MATERIAL AND METHODS

Bladder cancer tissues and cell lines were obtained in order to analyze the miR-124-3p and EDNRB expression through quantitative RT-PCR (qRT-PCR) and western blotting analysis. The dual-luciferase reporter assay was employed to confirm the relationship between miR-124-3p and EDNRB. The manipulation of miR-124-3p and EDNRB expression was achieved through cell transfection. Cell proliferation and apoptosis were evaluated by MTS assay, colony forming assay and flow cytometry. A nude mouse tumorigenicity assay was used to detect the effects of miR-124-3p in vivo.

RESULTS

There was an inverse correlation between the expression of miR-124-3p and EDNRB; miR-124-3p was down-regulated and EDNRB was up-regulated in BC tissues and cell lines. MiR-124-3p was observed to target EDNRB and suppress its expression. Other studies have suggested that the transfection of miR-124-3p mimics and EDNRB siRNA can suppress BC cell proliferation and induce cell apoptosis.

CONCLUSIONS

miR-124-3p regulates the proliferation and apoptosis of BC cells by suppressing EDNRB expression.

Prognostic value of nutritional indices and body composition parameters including sarcopenia in patients treated with radiotherapy for urothelial carcinoma of the bladder

PURPOSE

To assess the prognostic importance of sarcopenia in survival in patients with high-risk urothelial carcinoma of the bladder (UCB) who were unfit for radical cystectomy or systemic chemotherapy and were, therefore, treated with radiotherapy only.

METHODS

We evaluated 94 patients treated with transurethral resection of the bladder and radiotherapy for UCB. Sarcopenia, identified from pretreatment computed tomography scans, was defined as a skeletal muscle index of <39 cm²/m² for women and <55 cm²/m² for men. Body mass index -adjusted definition of sarcopenia was used to evaluate for sarcopenic obesity. Univariate models were used to assess the association between body composition and nutritional parameters with survival outcomes.

RESULTS

Overall, 68 patients were eligible for the final analysis, and 49 (72%) patients were sarcopenic. After body mass index adjustment of the definition of sarcopenia, its prevalence changed to 53.8% in women and 52.7% in men. Median age was 82 (interquartile range [IQR] 75-86) years, with a median, age-adjusted comorbidity index of 7.5 (IQR 6-10). The median time of follow-up was 12.5 (IQR 5.1-23.5) months. There were 42 (61.7%) patients who died of any cause and 19 (45.2%) who died because of UCB during the study period. Of all the body composition and nutritional parameters investigated, sarcopenic obesity was associated with cancer-specific survival (hazard ratio 5.0, 95% confidence interval 1.4-16.7, P = 0.01) and a low prognostic nutritional index was associated with overall survival (hazard ratio 0.46, 95% confidence interval 0.2-0.9, P = 0.02).

CONCLUSION

In patients who are too high risk for the standard treatment of UCB, sarcopenia is highly prevalent, but not prognostic of survival. Nevertheless, sarcopenic obesity and the prognostic nutritional index might act as prognostic markers for patients with UCB undergoing radiotherapy.

Predictive Value of CD44 in Muscle-Invasive Bladder Cancer and Its Relationship with IL-6 Signaling

BACKGROUND

CD44, a cancer stem cell surface marker, is associated with treatment resistance and prognosis in some cancers. In the present study, we examined the predictive value of CD44 in muscle-invasive bladder cancer (MIBC).

METHODS

We retrospectively analyzed the clinical outcomes of 105 MIBC patients and correlated these outcomes with the expression of CD44. Furthermore, the bladder cancer cell lines HT1197 and MB49 were selected for cellular and animal experiments to investigate the correlation between CD44 and tumor aggressiveness.

RESULTS

Analysis of clinical specimens indicated that CD44 staining was significantly associated with a higher clinical stage, higher locoregional failure rate, and lower disease-specific survival rate for MIBC patients. Using cellular experiments and orthotopic tumor models, we showed that CD44+ bladder cancer cells had a higher invasion ability and augmented epithelial-mesenchymal transition (EMT) compared with CD44 cells. There was a significant correlation between interleukin (IL)-6 and CD44 levels noted by in vitro testing, and clinical samples. Blockade of IL-6 attenuated the expression of CD44, cancer stem-cell-like properties, and aggressive tumor behavior in vitro and in vivo. The related changes included the attenuated STAT3 activation and EMT, and decreased programmed death ligand 1-mediated T-cell suppression.

CONCLUSION

Our findings suggest that CD44 expression is positively associated with tumor aggressiveness in bladder cancer, and activated IL-6 signaling provides a suitable microenvironment for the induction of CD44 expression.

Patients' preferences for treatment after neoadjuvant chemoradiotherapy for oesophageal cancer

Background

After neoadjuvant chemoradiotherapy (nCRT) plus surgery for oesophageal cancer, 29 per cent of patients have a pathologically complete response in the resection specimen. Active surveillance after nCRT (instead of standard oesophagectomy) may improve health-related quality of life (HRQoL), but patients need to undergo frequent diagnostic tests and it is unknown whether survival is worse than that after standard oesophagectomy. Factors that influence patients' preferences, and trade-offs that patients are willing to make in their choice between surgery and active surveillance were investigated here.

Methods

A prospective discrete-choice experiment was conducted. Patients with oesophageal cancer completed questionnaires 4–6 weeks after nCRT, before surgery. Patients' preferences were quantified using scenarios based on five aspects: 5-year overall survival, short-term HRQoL, long-term HRQoL, the risk that oesophagectomy is still necessary, and the frequency of clinical examinations using endoscopy and PET–CT. Panel latent class analysis was used.

Results

Some 100 of 104 patients (96·2 per cent) responded. All aspects, except the frequency of clinical examinations, influenced patients' preferences. Five-year overall survival, the chance that oesophagectomy is still necessary and long-term HRQoL were the most important attributes. On average, based on calculation of the indifference point between standard surgery and active surveillance, patients were willing to trade off 16 per cent 5-year overall survival to reduce the risk that oesophagectomy is necessary from 100 per cent (standard surgery) to 35 per cent (active surveillance).

Conclusion

Patients are willing to trade off substantial 5-year survival to achieve a reduction in the risk that oesophagectomy is necessary.

Detection of residual disease after neoadjuvant chemoradiotherapy for oesophageal cancer (preSANO): a prospective multicentre, diagnostic cohort study

BACKGROUND

After neoadjuvant chemoradiotherapy for oesophageal cancer, roughly half of the patients with squamous cell carcinoma and a quarter of those with adenocarcinoma have a pathological complete response of the primary tumour before surgery. Thus, the necessity of standard oesophagectomy after neoadjuvant chemoradiotherapy should be reconsidered for patients who respond sufficiently to neoadjuvant treatment. In this study, we aimed to establish the accuracy of detection of residual disease after neoadjuvant chemoradiotherapy with different diagnostic approaches, and the optimal combination of diagnostic techniques for clinical response evaluations.

METHODS

The preSANO trial was a prospective, multicentre, diagnostic cohort study at six centres in the Netherlands. Eligible patients were aged 18 years or older, had histologically proven, resectable, squamous cell carcinoma or adenocarcinoma of the oesophagus or oesophagogastric junction, and were eligible for potential curative therapy with neoadjuvant chemoradiotherapy (five weekly cycles of carboplatin [area under the curve 2 mg/mL per min] plus paclitaxel [50 mg/m² of body-surface area] combined with 41·4 Gy radiotherapy in 23 fractions) followed by oesophagectomy. 4-6 weeks after completion of neoadjuvant chemoradiotherapy, patients had oesophagogastroduodenoscopy with biopsies and endoscopic ultrasonography with measurement of maximum tumour thickness. Patients with histologically proven locoregional residual disease or no-pass during endoscopy and without distant metastases underwent immediate surgical resection. In the remaining patients a second clinical response evaluation was done (PET-CT, oesophagogastroduodenoscopy with biopsies, endoscopic ultrasonography with measurement of maximum tumour thickness, and fine-needle aspiration of suspicious lymph nodes), followed by surgery 12-14 weeks after completion of neoadjuvant chemoradiotherapy. The primary endpoint was the correlation between clinical response during clinical response evaluations and the final pathological response in resection specimens, as shown by the proportion of tumour regression grade (TRG) 3 or 4 (>10% residual carcinoma in the resection specimen) residual tumours that was missed during clinical response evaluations. This study was registered with the Netherlands Trial Register (NTR4834), and has been completed.

FINDINGS

Between July 22, 2013, and Dec 28, 2016, 219 patients were included, 207 of whom were included in the analyses. Eight of 26 TRG3 or TRG4 tumours (31% [95% CI 17-50]) were missed by endoscopy with regular biopsies and fine-needle aspiration. Four of 41 TRG3 or TRG4 tumours (10% [95% CI 4-23]) were missed with bite-on-bite biopsies and fine-needle aspiration. Endoscopic ultrasonography with maximum tumour thickness measurement missed TRG3 or TRG4 residual tumours in 11 of 39 patients (28% [95% CI 17-44]). PET-CT missed six of 41 TRG3 or TRG4 tumours (15% [95% CI 7-28]). PET-CT detected interval distant histologically proven metastases in 18 (9%) of 190 patients (one squamous cell carcinoma, 17 adenocarcinomas).

INTERPRETATION

After neoadjuvant chemoradiotherapy for oesophageal cancer, clinical response evaluation with endoscopic ultrasonography, bite-on-bite biopsies, and fine-needle aspiration of suspicious lymph nodes was adequate for detection of locoregional residual disease, with PET-CT for detection of interval metastases. Active surveillance with this combination of diagnostic modalities is now being assessed in a phase 3 randomised controlled trial (SANO trial; Netherlands Trial Register NTR6803).

FUNDING

Dutch Cancer Society.

[Radiochemotherapy for invasive bladder cancer : An update]

BACKGROUND

The standard treatment for muscle-invasive bladder cancer is radical cystectomy with pelvic lymphadenectomy. Primary organ-preservation by means of multimodal therapy, however, can be a viable alternative to radical surgery.

OBJECTIVES

The concept and results of multimodal therapy, consisting of initial transurethral resection of the bladder tumor (TUR-B), followed by simultaneous radiochemotherapy (RCT), are presented.

MATERIALS AND METHODS

Evaluation of retrospective cohorts and prospective therapy optimization studies on organ-preservation treatment regimens. Comparative meta-analyses comparing cystectomy with multimodal treatment are presented.

RESULTS

Complete TUR-B, including bladder mapping and tumor biopsy, should precede simultaneous RCT. Radiosensitization should be cisplatin-based or consist of a combination of 5‑fluorouracil and mitomycin C. Complete response rates after TUR-B plus RCT are generated in 60-90% of patients along with 5‑year survival rates of 40-75% and preservation of the bladder in approximately 80% of surviving patients.

CONCLUSIONS

Multimodal therapy by means of TUR-B followed by simultaneous RCT is a viable alternative to radical cystectomy for patients with muscle-invasive urinary bladder carcinoma. Patients with early tumors (cT2/3N0) are particularly suitable in whom initial TUR-B leads to complete tumor resection (R0).

Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for urothelial cell carcinoma of the urinary bladder 2017

This is an update to the previously published Saudi guidelines for the evaluation and medical/surgical management of patients diagnosed with urothelial cell carcinoma of the urinary bladder. It is categorized according to the stage of the disease using the tumor node metastasis staging system, 7^th edition. The guidelines are presented with their accompanying supporting evidence level, which is based on comprehensive literature review, several internationally recognized guidelines, and the collective expertise of the guidelines committee members (authors) who were selected by the Saudi Oncology Society and Saudi Urological Association. Considerations to the local availability of drugs, technology, and expertise have been regarded. These guidelines should serve as a roadmap for the urologists, oncologists, general physicians, support groups, and health-care policymakers in the management of patients diagnosed with urothelial cell carcinoma of the urinary bladder.

Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for urothelial cell carcinoma of the urinary bladder 2017

This is an update to the previously published Saudi guidelines for the evaluation and medical/surgical management of patients diagnosed with urothelial cell carcinoma of the urinary bladder. It is categorized according to the stage of the disease using the tumor node metastasis staging system, 7^th edition. The guidelines are presented with their accompanying supporting evidence level, which is based on comprehensive literature review, several internationally recognized guidelines, and the collective expertise of the guidelines committee members (authors) who were selected by the Saudi Oncology Society and Saudi Urological Association. Considerations to the local availability of drugs, technology, and expertise have been regarded. These guidelines should serve as a roadmap for the urologists, oncologists, general physicians, support groups, and health-care policymakers in the management of patients diagnosed with urothelial cell carcinoma of the urinary bladder.

Impact of CD44 expression on radiation response for bladder cancer

Background Identification of potential factors that can stratify tumors' response to specific therapies will aid in the selection of cancer therapy. Radioresistance is the major obstacles to positive outcomes in bladder cancer patients after definite chemotherapy. CD44, a cancer stem cell surface marker, is relevant in treatment resistance. In the present study, we examined the role of CD44 in bladder cancer.

Methods We retrospectively analyzed the clinical outcomes of 85 bladder cancer patients treated with definite chemoradiotherapy, and correlated the expressions of CD44 with IL-6 and treatment response. Furthermore, the bladder cancer cell lines HT1197 and MB49 were selected for cellular and animal experiments to investigate the links between the CD44, IL-6 and radiation response.

Results Analyzing the clinical specimen, the staining of CD44 was significantly linked with higher clinical stage, lower complete response rates, higher loco-regional failure rate and lower survival rate with intact bladder for patients treated with definite CCRT. In addition, the frequency of CD44 immunoreactivity was significantly higher in IL-6-positive bladder cancer specimens. By cellular experiments, the expression of CD44 was stimulated by IL-6 and linked with the cancer stem cell-like property. As demonstrated through in vitro and animal experiments using immunocompromised and immunocompetent hosts, CD44+ bladder cancer cells appeared more resistant to irradiation, associated with less RT-induced cell death.

Conclusions Our findings suggested that CD44 is important in predicting the radiation response of bladder tumor cells. If overexpressed CD44 and/or IL-6 were noted in pre-surgical specimens, radical cystectomy is more likely to be preferred.

[When should the primary tumor of metastatic bladder or prostate cancer be treated using a nonsurgical regimen?]

BACKGROUND

Patients with metastatic and locally advanced bladder or prostate cancer may suffer from pelvic symptoms such as pain, obstruction, and hemorrhage. Local tumor growth is associated with significant morbidity and systemic therapy is often ineffective. Local therapies such as bladder irrigation, transurethral resection of the prostate, and fulguration of bleeding vessels provide relief but often require repeated treatments.

OBJECTIVES

The aim of this work was to review the current status of palliative pelvic radiotherapy for metastatic bladder and prostate cancer.

MATERIALS AND METHODS

The available literature was evaluated and treatment recommendations are proposed depending on different clinical scenarios.

RESULTS

To date, no standard regimen exists for the delivery of palliative pelvic radiotherapy. Various radiotherapy schedules manage successful and long-term palliation of pelvic symptoms in most patients and result in acceptable toxicity. For bladder cancer, the most common dose and fractionation regimens range from 20 Gy in 5 fractions to 40 Gy in 20 fractions. Some retrospective studies evaluated 6 weekly fractions of 6 Gy to a total dose of 36 Gy. For prostate cancer, the most common dose and fractionation regimes range from 30 Gy in 10 fractions to 50 Gy in 25 fractions. The symptomatic response rate is between 70 and 95%.

CONCLUSIONS

Pelvic radiotherapy for patients with metastatic and locally advanced bladder or prostate cancer provides effective and long-term palliation of a variety of symptoms such as pain, obstruction, and hemorrhage, with acceptable toxicity. Future studies should investigate the optimal target dose and fractionation schedule.

Comparison of outcomes between trimodal therapy and radical cystectomy in muscle-invasive bladder cancer: a propensity score matching analysis

Although radical cystectomy (RC) is considered as the standard therapy for muscle-invasive bladder cancer (MIBC), trimodal therapy (TMT) combining transurethral resection of the tumor with radiotherapy and chemotherapy is increasingly recommended as an alternative approach for bladder preservation. In the absence of randomized trials, we compared the clinical outcomes between RC and TMT using propensity score matching with 50 patients in the RC arm and 29 patients in the TMT arm. With respective median follow-up periods of 23 and 32 months for the RC and TMT groups, 5-year distant metastasis-free survival (58% vs. 67%), overall survival (56% vs. 57%), and cancer-specific survival (69% vs. 63%) rates between the RC and TMT groups, respectively, were similar. However, the 5-year local recurrence-free survival was significantly better in the RC group than in the TMT group (74% vs. 35%). Following TMT, acute grade 3 hematological (n = 2) and late grade 3 genitourinary (n = 1) toxicities were reported. These findings demonstrated that oncological outcomes of TMT were comparable with those of RC, except for poorer local control. Large-scale, randomized trials are warranted to confirm the findings of the present retrospective comparison and to guide toward best treatment options.

Analysis of inter- and intra fractional partial bladder wall movement using implanted fiducial markers

Background

Current adaptive and dose escalating radiotherapy for muscle invasive bladder cancer requires knowledge of both inter-fractional and intra-fractional motion of the bladder wall involved. The purpose of this study is to characterize inter- and intra-fractional movement of the partial bladder wall using implanted fiducial markers and a real-time tumor-tracking radiotherapy system.

Methods

Two hundred fifty one sessions with 29 patients were analysed. After maximal transurethral bladder tumor resection and 40 Gy of whole bladder irradiation, up to six gold markers were implanted transurethrally into the bladder wall around the tumor bed and used for positional registration. We compared the systematic and random uncertainty of positions between cranial vs. caudal, left vs. right, and anterior vs. posterior tumor groups. The variance in intrafractional movement and the percentage of sessions where 3 mm and 5 mm or more of intrafractional wall movement occurring at 2, 4, 6, 8, 10, and at more than 10 min until the end of a session were determined.

Results

The cranial and anterior tumor group showed larger interfractional uncertainties in the position than the opposite side tumor group in the CC and AP directions respectively, but these differences did not reach significance. Among the intrafractional uncertainty of position, the cranial and anterior tumor group showed significantly larger systematic uncertainty of position than the groups on the opposite side in the CC direction. The variance of intrafractional movement increased over time; the percentage of sessions where intrafractional wall movement was larger than 3 mm within 2 min of the start of a radiation session or larger than 5 mm within 10 min was less than 5%, but this percentage was increasing further during the session, especially in the cranial and anterior tumor group.

Conclusions

More attention for intrafractional uncertainty of position is required in the treatment of cranial and anterior bladder tumors especially in the CC direction. The optimal internal margins in each direction should be chosen or a precise intrafractional target localization system is required depending on the tumor location and treatment delivery time in the setting of partial bladder radiotherapy.

Incidental Dose to Pelvic Nodes in Bladder-Only Radiotherapy: Is It Clinically Relevant?

Background and Purpose:

Although there is a strong biological rationale to electively treat the pelvic nodes during bladder preservation, its clinical benefit is uncertain. This may be explained by the incidental dose received by the nodal regions when treating the bladder alone. This study was conducted to investigate the doses received by the different pelvic nodal regions when the bladder alone is treated by standard conformal radiotherapy.

Methods and Materials:

The computed tomography data sets of 20 patients with node-negative muscle-invasive bladder cancer treated in a bladder preservation protocol were studied. Patients were originally treated with conformal radiotherapy to the bladder alone. Replanning was done with additional delineation of the pelvic nodal regions namely common iliac (upper and lower), presacral, internal iliac, obturator, and external iliac. Dose volume parameters such as Dmean, Dmax, D100%, D66%, D33%, V40, and V50 to each of the nodal regions were estimated for all patients.

Results:

The obturator nodes received the highest dose among all nodal regions. The mean dose received by obturator, external iliac, and internal iliac regions was 59, 45, and 36 Gy, respectively. The dose received by these 3 regions in the full bladder state was 63, 52, and 47 Gy, respectively. The dose received by all other pelvic nodal regions was low and not clinically relevant.

Conclusion:

The incidental dose received by obturator and external iliac nodes is clinically significant in bladder-only radiation, possibly enough to influence micrometastatic disease. This may be a reason for the lack of clear benefit seen with nodal irradiation in bladder cancer.

Advances in Knowledge:

This study highlights that the incidental dose received by obturator and external iliac nodes is clinically significant in bladder-only radiation. The obturator nodes received the highest dose among all nodal regions with mean dose of 59 Gy.

Diffusion-Weighted Genitourinary Imaging

This review article aims to provide an overview on of diffusion-weighted MR imaging (DW-MR imaging) in the urogenital tract. Compared with conventional cross-sectional imaging methods, the additional value of DW-MR imaging in the detection and further characterization of benign and malignant lesions of the kidneys, bladder, prostate, and pelvic lymph nodes is discussed as well as the role of DW-MR imaging in the evaluation of treatment response.

The Role of Transurethral Resection in Trimodal Therapy for Muscle-Invasive Bladder Cancer

While radical cystectomy (RC) with pelvic lymph node dissection (PLND) represents the accepted gold standard for the treatment of muscle-invasive bladder cancer, this treatment approach is associated with significant morbidity. As such, bladder preservation strategies are often utilized in patients who are either deemed medically unfit due to significant comorbidities or whom decline management with RC and PLND secondary to its associated morbidity. In a select group of patients, meeting strict criteria, bladder preservation approaches may be employed with curative intent. Trimodal therapy, consisting of complete transurethral resection of bladder tumor (TURBT), chemotherapy, and radiation therapy has demonstrated durable oncologic control and long-term survival in a number of studies. The review presented here provides a description of trimodal therapy and the role of TURBT in bladder preservation for patients with muscle-invasive bladder cancer.

Patterns of Bladder Preservation Therapy Utilization for Muscle-Invasive Bladder Cancer

Background: Trimodality bladder preservation therapy (BPT) in muscle invasive bladder cancer (MIBC) includes a maximal transurethral resection followed by concurrent chemoradiotherapy as an alternative to radical cystectomy (RC) in appropriately selected patients, or as a treatment option in non-cystectomy candidates. Several chemotherapy regimens can be used in BPT, but little is known about current practice patterns. Objective: To describe utilization patterns of BPT and associated survival outcomes in MIBC. Methods: Data were collected from the Retrospective International Study of Cancers of the Urothelial Tract (RISC), a database of 3,024 consecutive patients from 29 international academic centers from 2005 to 2013. Patients with clinical T2-T4aN0M0 urothelial cancer of the bladder were included. Results: 265 patients received BPT. Compared with the 1,447 patients who received RC, BPT patients were older, had poorer performance status, and had more comorbidities (p < 0.01 for all). Median overall survival (OS) was similar for patients treated with curative radiation doses in BPT and patients treated with RC (41 vs 46 months, p = 0.33, respectively). 45% of BPT patients received concurrent chemotherapy with radiation. The most common regimens included cisplatin alone (23%), carboplatin alone (22%), gemcitabine alone (10%), paclitaxel alone (9%), and 5-FU+mitomycin (5%). There were no significant differences in survival among chemotherapy regimens. Only 10 patients (4% of BPT patients) underwent salvage cystectomy. Conclusions: In clinical practice, BPT patients have similar survival to RC patients when treated with curative radiotherapy doses. Choice of concurrent chemotherapy regimen varied widely with no clear standard. Salvage cystectomy is rarely performed. Continued research is needed on the comparative effectiveness among BPT and RC, and among chemotherapy regimens in BPT.

Management of muscle-invasive bladder cancer in the elderly

PURPOSE OF REVIEW

The number of cases of muscle-invasive bladder cancer is increasing along with the age of the population. Management of muscle-invasive bladder cancer in the elderly is complex, requiring a multidisciplinary team approach and a comprehensive assessment of each individual patient.

RECENT FINDINGS

A geriatric assessment should be used to inform treatment decisions in elderly patients with bladder cancer. There is increasing evidence to support aggressive therapy in appropriate elderly patients, including radical cystectomy and neoadjuvant chemotherapy. Adjuvant chemotherapy also has a role in patients with high-risk disease after cystectomy. A bladder preservation approach with trimodality therapy is a well tolerated and effective alternative to cystectomy in appropriately selected patients.

SUMMARY

Treatment decisions should not be based on chronologic age alone and advanced age should not preclude aggressive or curative therapy. The recent molecular characterization of bladder cancer and several recent immunotherapy trials provide hope of a more targeted approach to treatment of bladder, potentially improving both effectiveness and tolerability of treatment regimens in the elderly.

Rationale of hyperthermia for radio(chemo)therapy and immune responses in patients with bladder cancer: Biological concepts, clinical data, interdisciplinary treatment decisions and biological tumour imaging

Bladder cancer, the most common tumour of the urinary tract, ranks fifth among all tumour entities. While local treatment or intravesical instillation of bacillus Calmette-Guerin (BCG) provides a treatment option for non-muscle invasive bladder cancer of low grade, surgery or radio(chemo)therapy (RT) are frequently applied in high grade tumours. It remains a matter of debate whether surgery or RT is superior with respect to clinical outcome and quality of life. Surgical resection of bladder cancer can be limited by acute side effects, whereas, RT, which offers a non-invasive treatment option with organ- and functional conservation, can cause long-term side effects. Bladder toxicity by RT mainly depends on the total irradiation dose, fraction size and tumour volume. Therefore, novel approaches are needed to improve clinical outcome. Local tumour hyperthermia is currently used either as an ablation therapy or in combination with RT to enhance anti-tumour effects. In combination with RT an increase of the temperature in the bladder stimulates the local blood flow and as a result can improve the oxygenation state of the tumour, which in turn enhances radiation-induced DNA damage and drug toxicity. Hyperthermia at high temperatures can also directly kill cells, particularly in tumour areas which are poorly perfused, hypoxic or have a low tissue pH. This review summarises current knowledge relating to the role of hyperthermia in RT to treat bladder cancer, the induction and manifestation of immunological responses induced by hyperthermia, and the utilisation of the stress proteins as tumour-specific targets for tumour detection and monitoring of therapeutic outcome.

Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for urothelial cell carcinoma of the urinary bladder

This is an update to the previously published Saudi guidelines for the evaluation, medical, and surgical management of patients diagnosed with urothelial cell carcinoma of the urinary bladder. It is categorized according to the stage of the disease using the tumor node metastasis staging system 7(th) edition. The guidelines are presented with supporting evidence level, they are based on comprehensive literature review, several internationally recognized guidelines, and the collective expertise of the guidelines committee members (authors) who were selected by the Saudi Oncology Society and Saudi Urological Association. Considerations to the local availability of drugs, technology, and expertise have been regarded. These guidelines should serve as a roadmap for the urologists, oncologists, general physicians, support groups, and health care policy makers in the management of patients diagnosed with urothelial cell carcinoma of the urinary bladder.

Hypoxia-inducible proteins HIF1α and lactate dehydrogenase LDH5, key markers of anaerobic metabolism, relate with stem cell markers and poor post-radiotherapy outcome in bladder cancer

PURPOSE

To assess whether anaerobic metabolism, proliferation activity and stem cell content are linked with radioresistance in bladder cancer.

MATERIALS AND METHODS

Tissue sections from 66 patients with invasive transitional cell bladder cancer treated with hypofractionated accelerated radiotherapy, was immunohistochemically analyzed for the Hypoxia-Inducible Factor 1α (HIF1α) and the anaerobic glycolysis enzyme lactate dehydrogenase 5 (LDH5). Proliferation index (Ki-67) and stem-cell marker (cluster of differentiation CD44, aldehyde dehydrogenase ALDH1) expression was also examined.

RESULTS

Both HIF1α and LDH5 expression were linked with high CD44 stem cell population (p = 0.001 and 0.05, respectively), while high Ki-67 proliferation index was linked with nuclear LDH5 expression (p = 0.03) and high histological grade (p = 0.02). A strong significant association of HIF1α (p = 0.0009) and of LDH5 (p < 0.0001) with poor local relapse free survival (LRFS) was noted, which was also confirmed in multivariate analysis. A significant association with overall survival was also noted. Silencing of lactate dehydrogenase LDHA gene in the human RT112 bladder cancer cell line, or exposure to oxamate (LDH activity inhibitor), resulted in strong radio-sensitization.

CONCLUSIONS

HIF1α and LDH5 are markers of poor outcome in patients with bladder cancer treated with radiotherapy. Blockage of anaerobic metabolism may prove of importance in clinical radiotherapy.

Concurrent chemoradiotherapy improves survival outcome in muscle-invasive bladder cancer

Purpose

To evaluate survival rates and prognostic factors related to treatment outcomes after bladder preserving therapy including transurethral resection of bladder tumor, radiotherapy (RT) with or without concurrent chemotherapy in bladder cancer with a curative intent.

Materials and Methods

We retrospectively studied 50 bladder cancer patients treated with bladder-preserving therapy at Keimyung University Dongsan Medical Center from January 1999 to December 2010. Age ranged from 46 to 89 years (median, 71.5 years). Bladder cancer was the American Joint Committee on Cancer (AJCC) stage II, III, and IV in 9, 27, and 14 patients, respectively. Thirty patients were treated with concurrent chemoradiotherapy (CCRT) and 20 patients with RT alone. Nine patients received chemotherapy prior to CCRT or RT alone. Radiation was delivered with a four-field box technique (median, 63 Gy; range, 48.6 to 70.2 Gy). The follow-up periods ranged from 2 to 169 months (median, 34 months).

Results

Thirty patients (60%) showed complete response and 13 (26%) a partial response. All patients could have their own bladder preserved. Five-year overall survival (OS) rate was 37.2%, and the 5-year disease-free survival (DFS) rate was 30.2%. In multivariate analysis, tumor grade and CCRT were statistically significant in OS.

Conclusion

Tumor grade was a significant prognostic factor related to OS. CCRT is also considered to improve survival outcomes. Further multi-institutional studies are needed to elucidate the impact of RT in bladder cancer.

The Role of Population-Based Observational Research in Bladder Cancer

While clinical trials have led to many advances in the treatment of bladder cancer, important gaps in knowledge persist. Population-based studies have made important contributions to what is known about bladder cancer and can contribute unique insights to practice and policy. In addition to evaluating effectiveness of interventions in routine practice, population-based studies can identify gaps between evidence and practice, and generate knowledge that cannot be gained from clinical trials. In this review we will highlight how population-based research has informed practice, policy, and the research agenda for bladder cancer.

Hypofractionated palliative radiotherapy for bladder cancer

PURPOSE

The aim of this study was to evaluate hematuria-free survival as well as acute and late toxicity after hypofractionated palliative radiotherapy for bladder cancer.

METHODS AND MATERIALS

Between September 2004 and January 2013, 44 patients with biopsy-proven urothelial carcinoma of the bladder were irradiated according to a palliative schedule to a total dose of 34.5 Gy in six fractions of 5.75 Gy given once a week.

RESULTS

After a mean follow-up of 10 months, 91% of patients were still hematuria free, with a mean hematuria-free survival of 13 months. Severe (≥ grade 3) acute and late urinary toxicity was observed in 9 and 19% of patients, respectively.

CONCLUSION

This hypofractionated radiotherapy schedule appears to result in acceptable toxicity and manages successful and long-term palliation of hematuria in most patients.

Outcomes of trimodality approach in the management of T2N0M0 bladder cancer

AIMS AND BACKGROUND

The main objective of this study is to evaluate outcomes of bladder preservation treatment for patients with muscle-invasive bladder cancer.

METHODS AND STUDY DESIGN

38 patients with histologically proven muscle-invasive bladder cancer treated at our department between January 2008 and December 2013 were analyzed retrospectively. Age, gender, pathology, stage, 3-year overall survival, 3-year disease-free survival, radiotherapy (RT) dose, genitourinary and gastrointestinal toxicity scores and response evaluation of the patients were recorded. 3-year overall survival and 3-year disease-free survivals were calculated by Kaplan-Meier method along with the analysis of gender, pathology, stage and therapy response of the study group.

RESULTS

33 patients (86.8%) were managed with concomitant chemoradiotherapy whereas 5 patients (13.2%) received only radiation therapy due to renal insufficency and comorbid diseases. 6 (15.8%) out of 38 patients had partial response (PR) and remaining 32 (84.2%) patients experienced complete response (CR). The PR group underwent salvage cystectomy and CR group had been followed-up after radical radiotherapy. Mean age of the group was 70.9 (range 45-90) years. 26 of all patients were male (68.4%) and 12 were female (31.6%). Mean follow-up time after completion of radiotherapy was 24.7 months (range 12-40). Mean RT dose was 64 Gy (range 60-66). 3-year overall survival was 64% and 3-year disease free survival was 73%.

CONCLUSIONS

Bladder preserving approach is an alternative definitive therapy solution to radical cystectomy in the treatment of muscle-invasive bladder cancer with less morbidity, preserved natural bladder, and high quality of life.

Combined chemoradiotherapy with gemcitabine in patients with locally advanced inoperable transitional cell carcinoma of the urinary bladder and/or in patients ineligible for surgery: a phase I trial

BACKGROUND

We conducted a phase I trial of gemcitabine (gem) with concurrent radiotherapy in patients with muscle-invasive bladder cancer (BC) ineligible for surgery or cisplatin or refusing organ loss.

PATIENTS AND METHODS

Patients with urothelial cancer, cT2-T4, cN0-1, M0, ineligible for surgery due to local tumor extension, PS, age or co-morbidities or who refused surgery were included. After maximal transurethral resection, the treatment schedule included: twice-weekly i.v. infusion of gem [dose levels (DL) 1-6: 20, 27, 30, 33, 50 and 40 mg/m(2), respectively] for 30 min and concurrent radiotherapy (RT) to the bladder with 55.5 Gy. The primary end point was to determine the maximum-tolerated dose (MTD) and the dose recommended (RD) for further studies of this gem schedule. The secondary end point was late toxicity. The MTD was defined by dose-limiting toxicity (DLT) in 2 or more of 6 patients, discontinuation of RT and/or gem for >1 week in 2 or more of 6 patients due to grade (G) 3/4 acute and/or late toxicity in more than 2 of 18 patients.

RESULTS

Thirty-five of 44 patients were assessable for toxicity and thus the primary end point. DLTs occurred in two of five patients at dose level 5: one G3 alanine aminotransferase elevation and one G3 fatigue. The MTD, therefore, was 50 mg/m(2) gem twice weekly. At DL 6 with 40 mg/m(2), the RD was established: only one of six patients developed G3 fatigue and diarrhea. Late toxicity was rare and of low grade (only G1-2). The 2-year locoregional failure rate was 32% (9/28); 10 of 28 patients (38%) were alive with an intact bladder and no evidence of recurrent disease, 9 patients developed distant metastases and 6 died of their disease.

CONCLUSIONS

Gemcitabine in combination with RT is well tolerated in BC patients ineligible for surgery and/or cisplatin. The RD of gemcitabine for subsequent trials is 40 mg/m(2) twice weekly with concurrent radiation.

Current clinical practice guidelines on chemotherapy and radiotherapy for the treatment of non-metastatic muscle-invasive urothelial cancer: a systematic review and critical evaluation by the Hellenic Genito-Urinary Cancer Group (HGUCG)

Radical cystectomy is the treatment of choice in localized muscle-invasive urothelial cancer. Nevertheless, relapses are frequent and systemic chemotherapy has been employed in order to reduce this risk. In addition, bladder preservation strategies are appealing. During the last decade, there has been a difficulty in conducting and completing large-scale trials in urothelial cancer. This has resulted in relatively few changes in the existing guidelines. Recent studies have created renewed interest in certain fields, such as the role of chemo-radiotherapy and management of unfit patients. In addition, application of certain guidelines has been limited in everyday practice. We conducted a systematic review of the existing guidelines and recent randomized trials not included in these guidelines, and developed a treatment algorithm, regarding non-surgical therapies for non-metastatic, muscle-invasive urothelial cancer based predominantly on patients' fitness for the available therapeutic modalities.

Trimodality therapy for bladder preservation in the elderly population with invasive bladder cancer

Bladder cancer is considered as primarily a disease of the elderly, typically aged in their 70s or 80s and often with associated medical comorbidities. Unfortunately, fewer elderly patients receive radical treatment for muscle-invasive bladder cancer (MIBC) that their younger counterparts. Over the last decades, several studies have shown that the use of trimodality therapy consisting of transurethral bladder resection followed by concomitant chemotherapy and radiation therapy results in comparable outcomes to radical cystectomy, considered the gold standard for this disease. In this review, we revised the literature on bladder-preservation treatments using the trimodality approach in the elderly population with MIBC.

A three-dimensional head-mounted display system (RoboSurgeon system) for gasless laparoendoscopic single-port partial cystectomy

We developed a new three-dimensional (3D) head-mounted display (HMD) system (RoboSurgeon system) that combines a high-definition 3D organic electroluminescent HMD with a high-definition 3D endoscope and applies it to minimally invasive surgery. This system presents the surgeon with a higher quality of magnified 3D imagery in front of the eyes, regardless of head position. We report 5 cases of RoboSurgeon gasless laparoendoscopic single-port partial cystectomy, which is carried out as part of our selective bladder-sparing protocol, with a technique utilizing both an intravesical and extravesical approach. While carrying out the surgery, the system provides the surgeon with both excellent 3D imagery of the operative field and clear imagery of the cystoscopy. All procedures were safely completed and there were no complications except for a case of postoperative lymphorrhea. Our experience shows that the 3D HMD system might facilitate maneuverability and safety in various minimally invasive procedures.