Variant histology in bladder cancer: how it should change the management in non-muscle invasive and muscle invasive disease?

Clinicopathological features and treatment outcomes of urothelial carcinoma variant histologies and non-urothelial bladder cancers

PURPOSE

Most bladder cancers are pure urothelial carcinomas, but a small portion, approximately 5-10%, have variant histology or are non-urothelial in nature. This research sought to examine the features of and treatment strategies for different types of urothelial carcinoma with variant histologies and non-urothelial bladder cancer.

METHODS

The study cohort comprised individuals with non-urothelial and variant urothelial bladder cancers treated at two medical centres in Ankara, Turkey, between 2005 and 2024.

RESULTS

A total of 104 individuals were reviewed, with 88 having urothelial cancer with variant histology and 16 having non-urothelial cancer. Non-urothelial cancers included neuroendocrine, undifferentiated, adenocarcinoma, squamous, sarcoma, and carcinosarcoma, with a median overall survival (OS) of 8 months. The most frequent urothelial carcinoma variants were squamous (43 cases), plasmacytoid (9 cases), and sarcomatoid (6 cases). Individuals with operable variants of urothelial malignancies had a median disease-free survival (DFS) of 16.5 months, while individuals with inoperable/metastatic variants experienced a median progression-free survival (PFS) of 8.9 months. The median OS in the operable cohort was 18.5 months, compared to 10.8 months in the inoperable/metastatic group.

CONCLUSION

The present study reveals that variant urothelial and non-urothelial bladder cancers are aggressive in nature and have poor prognosis. Given the significant heterogeneity observed in OS, DFS, and PFS among these rare and diverse tumor subtypes, large-scale multicenter investigations are required to establish a consensus on patient handling and treatment.

An Unusual Presentation of Bladder Carcinoma in a Visceral Hernia: A Case Report and Literature Review

INTRODUCTION

Bladder carcinoma (BC) is the most prevalent malignancy of the urinary system. These cancers are primarily seen in adults > 60 years old and mostly present with microscopic or frank hematuria or obstruction of the urinary system. However, these rare cancers can be found in hernias.

CASE PRESENTATION

This report discusses a rare, localized bladder urothelial carcinoma (UC) manifestation. The patient had presented with lower abdominal pain several times. However, no accurate diagnosis was made due to the unspecified pain features. After being referred to a radiologic evaluation with ultrasonography, a bladder hernia was detected entering the abdominal wall, and it contained an unusual mass. Further evaluations revealed the malignant feature of the tumor. The abdominal wall hernia was replaced, and a TURP procedure was performed. The resulting sample showed UC without the involvement of the muscle layer.

CONCLUSION

One of the most common malignancies of the urogenital and reproductive systems in male patients is BCs. They are most commonly seen in men older than 60 years old with a history of smoking. The prevalent manifestations of cancer are microscopic or macroscopic hematuria, urinary obstruction, and abdominal pain. A rare but previously reported bladder cancer location is within inguinal or abdominal hernias. The diagnosis of this cancer is not always straightforward, and delays can result in the spread of malignancy and the transition of the patient's clinical condition to a poorer prognosis.

CLINICAL KEY MESSAGE

The presentation of bladder cancer is not always accompanied by typical symptoms such as hematuria or urinary obstruction. Patients with persistent lower abdominal pain should be evaluated to rule out bladder malignancy. These tumors might be hidden within abdominal or inguinal hernias, and more radiologic accuracy is demanded for their diagnosis.

Advances in Therapy for Urothelial and Non-Urothelial Subtype Histologies of Advanced Bladder Cancer: From Etiology to Current Development

Urothelial carcinoma (UC) is the most common histological subtype of bladder tumors; however, bladder cancer represents a heterogeneous group of diseases with at least 40 distinct histological subtypes. Among these, the 2022 World Health Organization classification of urinary tract tumors identifies a range of less common subtypes of invasive UC, formerly known as variants, which are considered high-grade tumors, including squamous cell, small-cell, sarcomatoid urothelial, micropapillary, plasmacytoid, and urachal carcinomas, and adenocarcinoma. Their accurate histological diagnosis is critical for risk stratification and therapeutic decision-making, as most subtype histologies are associated with poorer outcomes than conventional UC. Despite the importance of a precise diagnosis, high-quality evidence on optimal treatments for subtype histologies remains limited owing to their rarity. In particular, neoadjuvant and adjuvant chemotherapy have not been well characterized, and prospective data are scarce. For advanced-stage diseases, clinical trial participation is strongly recommended to address the lack of robust evidence. Advances in molecular pathology and the development of targeted therapies and immunotherapies have reshaped our understanding and classification of bladder cancer subtypes, spurring efforts to identify predictive biomarkers to guide personalized treatment strategies. Nevertheless, the management of rare bladder cancer subgroups remains challenging because they are frequently excluded from clinical trials. For localized disease, curative options such as surgical resection or radiotherapy are available; however, treatment options become more limited in recurrence or metastasis, where systemic therapy is primarily used to control disease progression and palliate symptoms. Herein, we present recent advances in the management of urothelial and non-urothelial bladder cancer subtypes and also explore the current evidence guiding their treatment and emphasize the challenges and perspectives of future therapeutic strategies.

Integrated enhanced recovery after surgery protocol in radical cystectomy for bladder tumour-A retroprospective study

Introduction

Enhanced recovery after surgery (ERAS) is a patient-centerd, evidence-based approach to improve postoperative outcomes. The protocol involves multidisciplinary collaboration and standardisation of perioperative interventions. ERAS has shown positive results in reducing hospitalisation and complications.

Methods

The study conducted in the Department of Urology was a retro-prospective study. It included an ERAS cohort group of 47 patients, studied prospectively from May 2021 to May 2023. These patients were compared to a historical cohort of 47 consecutive patients who underwent radical cystectomy with traditional care before the ERAS pathway was implemented. The primary outcome was hospital length of stay (LOS). Secondary outcomes included perioperative management, time to recovery milestones and complications.

Results

Implementation of ERAS pathway for radical cystectomy was associated with reduced hospital LOS (mean LOS 16.19 ± 2.53 days vs. 10.26 ± 3.33 days 7 days; p < 0.0001), reduced time to key recovery milestones, including days to first flatus (3.17 vs. 2.68; p = 0.013) and days to first solid food (5.19 vs. 3.45 p value < 0.0001), first stool (5.53 vs. 4.23; p < 0.0001), reductions in some complications like postoperative ileus (p value = 0.021) and need for total parental nutrition (p value = 0.023).

Conclusion

In conclusion, the implementation of the integrated approach facilitates a more efficient recovery process, potentially reducing healthcare costs and enhancing patient comfort.

Assessment of pathological grade and variants of bladder cancer with a continuous-time random-walk diffusion model

Purpose

To evaluate the efficacy of high b-value diffusion-weighted imaging (DWI) with a continuous-time random-walk (CTRW) diffusion model in determining the pathological grade and variant histology (VH) of bladder cancer (BCa).

Methods

A total of 81 patients (median age, 70 years; range, 35-92 years; 18 females; 66 high grades; 30 with VH) with pathologically confirmed bladder urothelial carcinoma were retrospectively enrolled and underwent bladder MRI on a 3.0T MRI scanner. Multi-b-value DWI was performed using 11 b-values. Three CTRW model parameters were obtained: an anomalous diffusion coefficient (D) and two parameters reflecting temporal (α) and spatial (β) diffusion heterogeneity. The apparent diffusion coefficient (ADC) was calculated using b0 and b800. D, α, β, and ADC were statistically compared between high- and low-grade BCa, and between pure urothelial cancer (pUC) and VH. Comparisons were made using the Mann-Whitney U test between different pathological states. Receiver operating characteristic curve analysis was used to assess performance in differentiating the pathological states of BCa.

Results

ADC, D, and α were significantly lower in high-grade BCa compared to low-grade, and in VH compared to pUC (p < 0.001), while β showed no significant differences (p > 0.05). The combination of D and α yielded the best performance for determining BCa grade and VH (area under the curves = 0.913, 0.811), significantly outperforming ADC (area under the curves = 0.823, 0.761).

Conclusion

The CTRW model effectively discriminated pathological grades and variants in BCa, highlighting its potential as a noninvasive diagnostic tool.

Urinary tract cytology showing variant morphology and divergent differentiation

Urothelial carcinoma represents a diverse group of tumours with distinct histologic subtypes, each exhibiting unique cytomorphologic features, architectural growth patterns, and/or well-developed aberrant differentiation. In fact, there are more than 13 subtypes of urothelial carcinoma recognized in the 2022 WHO classification of tumours in the urinary tract. The identification of these subtypes is crucial for an accurate diagnosis of urothelial carcinoma, and many have important clinical implications. Variant/divergent features may coexist with conventional high-grade urothelial carcinoma (HGUC) or present with 100% variant morphology. In urinary tract cytology (UTC), urothelial carcinoma can display divergent differentiation, such as squamous, glandular, or small cell carcinoma differentiation. The use of cell block preparations and immunohistochemistry with available residual urine can enhance diagnostic accuracy. On the other hand, identifying urothelial carcinoma variants, including nested, micropapillary, and plasmacytoid subtypes, poses significant challenges in UTC. Many cases of these variants are only detected retrospectively after variant histology has been established from resection specimens. Moreover, some variants exhibit features inconsistent with the diagnostic criteria for HGUC according to the Paris System for Reporting Urinary Tract Cytology. Nevertheless, the rarity of pure variant morphology and the occurrence of some false negatives for these variant cases are essential to maintain the specificity of UTC overall. This review covers the histology, cytomorphology, and important clinical aspects observed in urothelial carcinoma exhibiting divergent differentiation and various urothelial carcinoma variants detected in UTC.

MRI-based radiomics analysis of bladder cancer: prediction of pathological grade and histological variant

AIM

To develop magnetic resonance imaging (MRI)-based radiomics models for the prediction of the pathological grade and histological variant of bladder cancer.

MATERIALS AND METHODS

A total of 227 patients who underwent bladder MRI and had histopathologically confirmed grades and variants were included retrospectively from January 2017 to March 2022. They were assigned to a training set (n=131) and a testing set (n=96) based on the MRI system. MRI-based radiomics features were extracted from manually segmented volumes of interest from high-b-value DWI images and ADC maps. The radiomics models were trained with all possible pipelines in the training set. One optimal model was selected using the fivefold cross-validation method and verified by the testing set according to the pathological results. Univariate and multivariate analyses were performed to identify the significant clinical and imaging factors for developing clinical-radiomics models.

RESULTS

The radiomics model for grade prediction had area under the curve (AUC) values of 0.784, 0.786, and 0.733 in the training, cross-validation, and testing sets, respectively. The radiomics model for variant prediction had AUC values of 0.748, 0.757, and 0.789 in the training, cross-validation, and testing sets, respectively. The performance of the clinical-radiomics model was significantly improved compared with the radiomics models alone for the total dataset (AUC for grade: 0.846 versus 0.756; AUC for variant: 0.810 versus 0.757, p<0.05).

CONCLUSION

MRI-based radiomics models could be used to predict the pathological grade and histological variants of bladder cancer with relatively good performance.

The Many Faces of Urothelial Carcinomas: An Update From Pathology to Clinical Approach and Challenges in Practice

Urothelial carcinoma is a heterogeneous disease with histomorphological and genomic variations throughout the same tumor or between tumors from different patients. It has been shown that most of these histologic and genetic differences have prognostic significance and may have a guiding role in determining the appropriate treatment choice for the patient. Therefore, it is crucial for both the pathologist and the clinician to be conscious of these variations and to consider them in patient management. Recently, a consensus molecular classification has been developed and categorized urothelial carcinomas into 6 subclasses. These molecular subclasses seem to be associated with prognosis and/or response to certain therapeutic approaches like chemotherapy or immune checkpoint inhibitory therapy; however, it has not yet been sufficiently validated and has some limitations for routine application. As is well known, there are therapeutic limitations in locally advanced or metastatic urothelial carcinomas, especially those inappropriate for standard therapy with platinum-based chemotherapy regimens. Emerging new therapeutic approaches and testing for appropriate patient selection for those are discussed in this article.

Perioperative systemic therapy in muscle invasive bladder cancer: Current standard method, biomarkers and emerging strategies

Bladder cancer ranks as the 10th most common cancer type globally, and muscle-invasive disease accounts for approximately 25% of newly diagnosed bladder cancers. Despite definitive treatment, 50% of patients with muscle-invasive bladder cancer (MIBC) develop metastasis within 2 years, leading to death. Perioperative systemic therapy is generally recommended to control local relapse or distant metastasis after surgical resection for patients with MIBC. Cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy is the current standard treatment to improve oncologic control and survival outcomes. Adjuvant chemotherapy is recommended for patients with pathological T3-4 or positive lymph nodes after radical cystectomy if no neoadjuvant chemotherapy was given. Nonetheless, perioperative systemic therapy is not applied widely because of its toxicity, and less than 25% of patients receive cisplatin-based neoadjuvant chemotherapy. Therefore, the development of predictive biomarkers for neoadjuvant chemotherapy efficacy and alternative effective regimens for cisplatin-ineligible patients are important. Furthermore, recently, novel anticancer agents such as immune checkpoint inhibitors and antibody-drug conjugates have proven survival benefits in the metastatic setting, thereby expanding their therapeutic applications to the perioperative setting for non-metastatic MIBC. Herein, we discuss the current status and future perspectives of perioperative systemic strategies for MIBC.

Bladder Preservation for Muscle-Invasive Bladder Cancer With Variant Histology

A growing body of evidence has shown bladder-preservation with chemo-radiotherapy achieves comparable survival to Radical Cystectomy (5-year OS 50%-70%) and superior quality of life outcomes for patients with muscle-invasive urothelial carcinoma of the bladder (UC). However, up to 55% of patients harbor variant histology and in this review we aim to clarify the role of bladder-preservation for this group. We first draw the distinction between urothelial carcinoma with divergent differentiation (UCDD) and non-urothelial carcinoma (NUC). UCDD is common, increasing in prevalence, and whilst each subtype may have its own characteristics current evidence suggests comparable outcomes with radical cystectomy and bladder-preservation. Non-urothelial carcinoma is a collection of distinct pathologies each deserving of its own management strategy. However, these tumors are rare, and evidence is generated from retrospective studies with significant inherent bias. Small cell carcinoma of the bladder has good evidence for bladder-preservation; however, other pathologies such as Squamous Cell Carcinoma and Adenocarcinoma are not well supported. We recommend careful multidisciplinary appraisal of the evidence for each subtype and honest patient discussion about the limited evidence before reaching management decisions. As we look to the future molecular-profiling may help better characterize these tumors and aid in treatment selection.

Non-urothelial and urothelial variants of bladder cancer

Non-urothelial bladder cancers make up a rare minority of all genitourinary (GU) tract histologic cancers since urothelial cancer (UC) makes up the most common histologic subtype. Bladder cancer variant histology (BCVH) or urothelial variants also occur rarely though distinction is important given aggressive presentation and natural history. While methods for diagnosis and treatment of typical urothelial cancers (UC) are well-established, there are no clear guidelines with regard to the diagnosis of non-urothelial bladder cancers, which often results in misdiagnosis and treatment delay. This review will focus on the clinicopathologic characteristics of the most common non-urothelial bladder cancers, to be distinguished from bladder cancer variant histology containing a UC component. The role of genomics in non-urothelial bladder cancers is evolving and the use of biomarkers to guide the diagnosis and treatment of these tumors remains a key area of unmet need. Treatment of these cancers will be discussed in a companion review.

Preoperative monocyte-to-lymphocyte ratio as a potential predictor of bladder cancer

OBJECTIVES

The aim of this study was to investigate the role of preoperative Monocyte-to-Lymphocyte ratio (MLR) as a potential predictor of bladder cancer (BC).

METHODS

Clinical data of patients who underwent TURBT at our institution between 2017 and 2021 were collected and retrospectively analysed. MLR was obtained from preoperative blood analyses performed within 1 month from hospital admission. The association of MLR with different clinic-pathological features obtained from histological reports was further analysed. Statistical analysis was performed using the Kruskal Wallis test for non-parametric variables, assuming p<0.05 as statistically significant.

RESULTS

510 patients were included in the study (81% males, 19% females), with a mean age of 71.66 ± 11.64 years. Mean MLR was higher in patients with any-type bladder cancer, reporting an MLR of 0.41 ± 0.11 compared to 0.38 ± 0.43 in patients without bladder cancer (p=0.043). In the subsequent comparison among low-grade and high-grade bladder cancer, MLR did not report statistically significant differences, with 0.29 ± 0.12 for low-grade BC and 0.51 ± 0.81 for high-grade BC (p=0.085).

CONCLUSIONS

Our findings reported elevated preoperative MLR should be considered a potential biomarker predicting malignancy for bladder tumours. Furthermore, research are necessary to assess its role in discerning low-grade from high-grade patients.

Comparing Pathologic and Survival Outcomes Between Primary and Secondary Muscle Invasive Bladder Cancer when treated by Radical Cystectomy With or Without Neoadjuvant Chemotherapy

OBJECTIVE

To compare pathologic and survival outcomes between primary muscle invasive (pMIBC) and secondary muscle invasive (sMIBC) bladder cancer patients who were treated with or without cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC).

METHODS

We reviewed cT2-T4/N0 MIBC patients at our institution between 2010-2019. pMIBC was defined as presenting with > cT2 disease on initial or restaging TURBT with no prior history of bladder cancer. sMIBC was defined as prior history of NMIBC that was treated with at least one induction course of BCG that progressed to MIBC. Outcomes analyzed included pathologic downstaging rates defined as <pT2/N0, pathologic complete response rates (pT0/N0), and survival outcomes (RFS, CSS, OS). Survival outcomes were analyzed using the Kaplan-Meier Method or Gray's test with log rank. Cox Proportional Hazards and semiparametric hazards models proposed by Fine and Gray were constructed to identify predictors of oncologic outcomes.

RESULTS

333 patients were included in the analysis (sMIBC: 48 vs pMIBC: 285). There were no differences in pathologic downstaging (sMIBC: 54% vs. pMIBC: 51%, p=0.67) or pathologic complete response (sMIBC: 33% vs. pMIBC: 28, p=0.46). Survival analysis showed no differences when patients were treated with NAC+RC in oncologic outcomes. On regression analysis, only >pT2 and N+ disease were predictors of poorer CSS and OS. Separate analysis of sMIBC patients whom underwent RC only (N=61), demonstrated inferior oncologic outcomes to other cohorts (p<0.01).

CONCLUSION

There were no differences in pathologic response or survival between pMIBC and sMIBC patients when managed with NAC and RC.

Bladder cancer histological variants: which parameters could predict the concordance between transurethral resection of bladder tumor and radical cystectomy specimens?

Introduction

The concordance rate of bladder cancer (BCa) histological variants (HV) between transurethral resection of bladder tumor (TURBT) and radical cystectomy (RC) is sub-optimal and is unclear which factors may influence it. The aim of this study was to identify factors that may be correlated to a higher TURBT-RC concordance rate.

Material and methods

Consecutive patients who had undergone RC between 2000 and 2019 at a single Institution with pathological evidence of HV were included. Patients with diagnosis of HV both at RC and at the previous TURBT were enlisted in the TURBT-RC Concordance Group (CG), whereas patients with only evidence of HV at RC in the TURBT-RC Non-Concordance Group (NCG). Surgical factors evaluated were the source of energy (mono- vs bipolar), surgeon’s experience (</≥100), execution of re-TURBT, number and size of specimens at TURBT.

Results

A total of 81 patients were included, 49 (60.5%) in the CG and 32 (39.5%) in the NCG. Among the surgical factors, maximal core length (MCL) was significantly higher in the CG (12.5 vs 10 mm, p = 0.014) (Table 1). At uni- and multivariable analyses, MCL>10 mm represented an independent predictor of concordance [OR 2.95; CI (1.01–8.61); p = 0.048]. Tumor recurrence, focality and dimension, source of energy, surgeon’s experience, performance of re-TURBT and total number of specimens at TURBT did not significantly predict the concordance.

Conclusions

Longer specimens at TURBT yield a higher chance to detect HV before RC. In this light, improving the quality of bladder resection means improving the management of BCa.

Proteomics as a Complementary Technique to Characterize Bladder Cancer

Simple Summary

Although immunohistochemistry is a routine technique in clinics, and genomics has been rapidly incorporated, proteomics is a step behind. This general situation is also the norm in bladder cancer research. This review shows the contributions of proteomics to the molecular classification of bladder cancer, and to the study of histopathology due to tissue insults caused by tumors. Furthermore, the importance of proteomics for understanding the cellular and molecular changes as a consequence of the therapy of bladder cancer cannot be neglected.

Abstract

Bladder cancer (BC) is the most common tumor of the urinary tract and is conventionally classified as either non-muscle invasive or muscle invasive. In addition, histological variants exist, as organized by the WHO-2016 classification. However, innovations in next-generation sequencing have led to molecular classifications of BC. These innovations have also allowed for the tracing of major tumorigenic pathways and, therefore, are positioned as strong supporters of precision medicine. In parallel, immunohistochemistry is still the clinical reference to discriminate histological layers and to stage BC. Key contributions have been made to enlarge the panel of protein immunomarkers. Moreover, the analysis of proteins in liquid biopsy has also provided potential markers. Notwithstanding, their clinical adoption is still low, with very few approved tests. In this context, mass spectrometry-based proteomics has remained a step behind; hence, we aimed to develop them in the community. Herein, the authors introduce the epidemiology and the conventional classifications to review the molecular classification of BC, highlighting the contributions of proteomics. Then, the advances in mass spectrometry techniques focusing on maintaining the integrity of the biological structures are presented, a milestone for the emergence of histoproteomics. Within this field, the review then discusses selected proteins for the comprehension of the pathophysiological mechanisms of BC. Finally, because there is still insufficient knowledge, this review considers proteomics as an important source for the development of BC therapies.

A candidate antineoplastic herbal agent for bladder cancer: Ankaferd Blood Stopper

BACKGROUND AND AIMS

Ankaferd Blood Stopper (ABS) was used for in vitro studies of osteosarcoma and colon carcinoma cancer cell lines to reveal the apoptotic and antineoplastic effects. The aim of this study is to evaluate the antineoplastic effect of ABS on bladder cancer cell cultures.

METHODS

We prospectively collected minimum 0.5 cm parts of fresh frozen tumour samples from patients with bladder tumour from 2015 to 2017. Primary bladder cancer cultures were produced from the frozen tumour samples. Two different doses of ABS were used on cancer cell cultures. Viability tests of each cell cultures were performed. Flow cytometry was used for the determination of apoptosis and necroptosis. We also checked the effect of ABS on different stages, grade and variant histology of bladder cancer cells. The results of all cancer cell cultures were compared with their own controls.

RESULTS

This study included 24 patients. Mean age of patients was 66.2 ± 11.7 years (34-83 years), where 19 of them (79.5%) were males and five (20.5%) were females. When we compared the data, we found decreased cancer cell viability ratio in each ABS group compared with their own controls. Necroptosis was observed in the great majority of ABS groups, and necroptosis and apoptosis were observed in some cell cultures.

CONCLUSIONS

In this study, we demonstrated the cytotoxic effect of ABS on bladder cancer cells. The results of this study suggests planning of animal model of bladder cancer for ABS with intravesical application as an antineoplastic agent. In the future, ABS may be a candidate intravesical treatment agent for bladder cancer.

The Genitourinary Pathology Society Update on Classification of Variant Histologies, T1 Substaging, Molecular Taxonomy, and Immunotherapy and PD-L1 Testing Implications of Urothelial Cancers

The Genitourinary Pathology Society (GUPS) undertook a critical review of the recent advances in bladder cancer focusing on important topics of high interest for the practicing surgical pathologist and urologist. This review represents the second of 2 manuscripts ensuing from this effort. Herein, we address the effective reporting of bladder cancer, focusing particularly on newly published data since the last 2016 World Health Organization (WHO) classification. In addition, this review focuses on the importance of reporting bladder cancer with divergent differentiation and variant (subtypes of urothelial carcinoma) histologies and the potential impact on patient care. We provide new recommendations for reporting pT1 staging in diagnostic pathology. Furthermore, we explore molecular evolution and classification, emphasizing aspects that impact the understanding of important concepts relevant to reporting and management of patients.

Waterpipe Smoking among Bladder Cancer Patients: A Cross-Sectional Study of Lebanese and Jordanian Populations

Background

Bladder cancer (BC) is the second most reported cancer in Lebanon and the fifth in Jordan. Its risk factors are mainly smoking and occupational exposure to aromatic amines. In these countries where smoking and bladder cancer are highly prevalent, the role of waterpipe smoking (WPS) in bladder cancer is less investigated. We aim to compare two sets of patients between Lebanon and Jordan, focusing on their smoking habits, WP use, occupational exposure, and the grade/invasiveness of their bladder cancer.

Methods

This is a cross-sectional study that compares the smoking culture between two sets of populations with bladder cancer, from two different countries. We recruited 274 bladder cancer patients over the 18 years of age at the American University of Beirut Medical Center (AUBMC), and 158 bladder cancer patients over the age of 18 years at the King Hussein Cancer Center (KHCC).

Results

7.7% of Lebanese patients had significantly more positive family history of bladder cancer compared to 13.9% of Jordanian patients (p = 0.045). Another significant finding is that the majority of Lebanese patients 70.7% reported being frequently exposed to secondhand smoking, mainly cigarettes, versus only 48.6% of Jordanian patients (p < 0.001). The increasing smoking trend among Lebanese females is remarkably the highest in the region, which contributed to the overall increase in smoking rates in the country. 17.1% of the Lebanese smoking patients are mainly but not exclusively WP smokers of which 6.3% are daily WP smokers, similarly 17.1% of the Jordanian patients of which 3.2% are daily WP smokers. There were 71.5% of Lebanese patients who had a noninvasive BC versus 40% of Jordanian patients (p < 0.001), and more than one-third reported an occupational exposure to one of the risk factors of BC in both groups.

Conclusions

Bladder cancer incidence is on the rise in both Jordan and Lebanon along with different smoking types. It is necessary to impose prevention policies to prevent and control the high smoking prevalence. Bladder cancer invasiveness is higher in Jordan compared to universal data.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

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

RESULTS AND LIMITATIONS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Histologically confirmed distant metastatic urothelial carcinoma from the urinary bladder: a retrospective review of one institution's 20-year experience

Background

Urothelial carcinoma (UC) accounts for roughly 90% of bladder cancer, and has a high propensity for diverse differentiation. Recently, certain histologic variants of UC have been recognized to be associated with unfavorable clinical outcomes. Several UC studies have also suggested that tumor budding is a poor prognostic marker. Distant metastasis of UC after radical cystectomy is not uncommon. However, these metastatic lesions are not routinely confirmed with histology.

Methods

We investigated the histopathologic features of 13 cases of UC with biopsy-proven distant metastases, with a special emphasis on histologic variants and tumor budding.

Results

Lymph nodes (6/13, 46%) were the most common metastatic sites, followed by the lung (4/13, 31%), liver (4/13, 31%), and the adrenal gland (2/13, 15%). The histologic variants including squamous (n = 1), micropapillary (n = 4), and plasmacytoid (n = 1) variants in five cases of UC. Most histologic variants (4/5, 80%) of primary UCs appeared in the metastatic lesions. In contrast, high-grade tumor budding was detected in six cases (46%), including one case of non-muscle invasive UC. Our study demonstrates that histologic variants are not uncommonly detected in distant metastatic UCs. Most histologic variants seen in primary UCs persist in the distant metastatic lesions. In addition, high-grade tumor budding, which occurs frequently in primary tumors, may contribute to the development of distant metastasis.

Conclusions

Therefore, assessing the presence or absence of histologic variants and tumor budding in UCs of the urinary bladder, even in non-muscle invasive UCs, may be useful to predict distant metastasis.

Increased PD-L1 expression in high-grade bladder cancer with squamous cell differentiation in Bulgarian and French patients' samples

Urothelial carcinomas (UC) of the bladder are biologically and clinically heterogeneous and the most common malignancy of the urinary tract in developed countries worldwide, where several checkpoint targets as programmed death ligand-1 (PD-L1) and programmed cell death protein (PD-1) have received the most attention in the treatment of bladder cancer. However, the clinicopathological impact of this biomarker has not yet been established enough.

OBJECTIVE

To evaluate programmed death ligand-1 (PD-L1) expression in UCs of the bladder in Bulgarian and French patients' samples.

MATERIALS AND METHODS

Urothelial bladder carcinomas cases from 2016-2020 were retrospectively were analyzed. The cohort included 105 cases: 42 (40%) low grade and 63 (60%) high grade. Immunohistochemical (IHC) staining for PD-L1 expression was performed using an anti-PD-L1 primary antibody clone 22C3pharmDx only to 73/105 cases.

RESULTS

Approximately 21/73 cases (28.8%) of urothelial bladder carcinomas demonstrated positive PD-L1 expression, and in 52/73 cases (71.2%) were negative. Positive PD-L1 expression was associated with high grade and high pathologic stage (p < 0.001). We found that PD-L1 was expressed in a significant percentage in UC with squamous differentiation (40%), followed by classic UC (30%). An association between histological grading systems of bladder UC (WHO1973 and WHO 2016) and the TNM-staging system, estimated by Pearson correlation coefficients (r = 0.590 and r = 0.583, respectively, p < 0.001) was observed.

CONCLUSIONS

We found that PD-L1 expression is increased in patients with muscle-invasive UC, and PD-L1 might be a new biomarker that correlates with the pathological stage of urothelial bladder cancer and might predict recurrence-free survival.

The Value of Preoperative Alpha-L-Fucosidase Levels in Evaluation of Malignancy and Differential Diagnosis of Urothelial Neoplasms

Purpose

To evaluate the role of Alpha-L-fucosidase (AFU) in diagnosis and differential diagnosis of pure urothelial carcinoma (UC), urothelial carcinoma with squamous differentiation (UCSD), and squamous cell carcinoma (SqCC).

Methods

A retrospective study was performed for 599 patients who were histologically confirmed with urothelial tumor. Preoperative AFU levels were compared across the distinct subgroups with different clinicopathological parameters. ROC curve analysis and logistic regression analysis were performed to further evaluate the clinical application value of serum AFU levels in diagnosis and differential diagnosis of urothelial tumors.

Results

There were no statistically significant differences in the AFU levels between different groups with different malignant degrees (UC versus papilloma and papillary urothelial neoplasm of low malignant potential [PUNLMP], high-grade UC versus low-grade UC, invasive versus noninvasive malignant uroepithelial tumor) and different pathological types (UC, UCSD, and SqCC) (all P > 0.05). ROC curve analysis and logistic regression analysis showed that there was no statistically significant association between AFU levels and the tumor characteristics (all P > 0.05).

Conclusions

Preoperative AFU levels cannot serve as a reliable predictor for malignant degree and differential diagnosis, including pure UC, UCSD, and SqCC of urothelial tumors.

Bladder Cancer: A Comparison Between Non-urothelial Variant Histology and Urothelial Carcinoma Across All Stages and Treatment Modalities

BACKGROUND

The purpose of this study was to evaluate stage at presentation, treatment rates, and cancer-specific mortality (CSM) of non-urothelial variant histology (VH) bladder cancer (BCa) relative to urothelial carcinoma of the urinary bladder (UCUB).

MATERIALS AND METHODS

Within the Surveillance, Epidemiology, and End Results registry (SEER, 2004-2016), patients with VH BCa and UCUB were identified. Stage at presentation and treatment rates, as well as multivariably adjusted and matched CSM rates according to TNM stage within each histologic subtype, were reported.

RESULTS

Of all 222,435 eligible patients with BCa, 11,147 (5.0%) harbored VH. Among those, squamous cell carcinoma accounted for 3666 (1.6%) patients, adenocarcinoma for 1862 (0.8%), neuroendocrine carcinoma for 1857 (0.8%), and other VH BCa for 3762 (1.7%) of the study cohort. Patients with VH BCa showed invariably more advanced TNM stage at presentation compared with patients with UCUB. Treatment rates according to TNM stages showed similar distribution of cystectomy rates in VH BCa and UCUB. However, important differences in the distribution of radiotherapy and chemotherapy rates existed within VH BCa and in comparison with UCUB. Furthermore, even after multivariable adjustment and matching with UCUB, squamous cell carcinoma exhibited higher CSM (hazard ratios, 1.43-1.95; all P < .01) across all stages. All other VH predominantly exhibited higher CSM than UCUB in either non-muscle-invasive or muscle-invasive nonmetastatic stages.

CONCLUSION

TNM stage at diagnosis is invariably more advanced in all patients with VH BCa versus patients with UCUB. Of all VH BCa, in multivariably adjusted stage for stage analyses, squamous cell carcinoma appears to have the worst natural history. All other VH subgroups exhibited more aggressive natural history than UCUB in nonmetastatic stages only.

Atezolizumab in patients with renal insufficiency and mixed variant histology: analyses from an expanded access program in platinum-treated locally advanced or metastatic urothelial carcinoma

Background

Atezolizumab is a treatment for locally advanced/metastatic urothelial carcinoma (mUC). However, its use in patients with renal insufficiency or UC with mixed variant histology (MVH) is not well characterized.

Objective

To report efficacy and safety of atezolizumab in these special subpopulations from an expanded access program (EAP).

Design, setting, and participants

A total of 218 patients were enrolled at 36 US study sites (November 2015–August 2016), and the trial ended following the approval of atezolizumab by the US Food and Drug Administration. This post hoc analysis investigated outcomes in specific study subgroups.

Intervention

Atezolizumab 1200 mg was administered intravenously every 3 weeks until loss of clinical benefit, unacceptable toxicity, death, consent withdrawal, decision to discontinue, commercial availability, or study closure.

Outcome measurements and statistical analysis

Response Evaluation Criteria in Solid Tumors V.1.1 responses and safety were evaluated by baseline renal function and histology.

Results and limitations

Objective responses occurred in 0/6 (0%), 4/19 (21%), 1/27 (3.7%), and 12/62 (19%) of evaluable patients with creatinine clearance (CrCl) <30, 30–45, 45–60, and ≥60 mL/min, respectively, and stable disease was seen in three patients with CrCl <30 mL/min. Objective responses were seen in 13/102 patients (13%) with urothelial carcinoma (UC) histology only and in 4/12 patients (33%) with UC with MVH. Treatment-related adverse event frequencies ranged from 35% to 54% across the earlier indicated CrCl subgroups and they were also similar in patients with pure UC or UC with MVH (46%).

Conclusions

In this EAP mUC subgroup analysis, clinical benefit of atezolizumab occurred in patients with compromised renal function or MVH UC tumors. Safety was comparable across subgroups.

Patient summary

We examined the efficacy and safety of atezolizumab for UC in certain patients participating in an EAP. We found that responses to atezolizumab occurred, and safety was similar, in most patient subgroups with varying levels of kidney functioning or less common types of tumor tissue histology.

Histologic Variants of Urothelial Carcinoma: Morphology, Molecular Features and Clinical Implications

Bladder cancer is a heterogeneous disease including conventional urothelial carcinoma (UC) and its histologic variants, and non-urothelial carcinoma, including squamous and glandular neoplasms. Urothelial carcinoma accounts for the majority of bladder cancer cases, but morphologic variants are common and include nested, microcystic, micropapillary, lymphoepithelioma-like, plasmacytoid, sarcomatoid, giant cell, undifferentiated, clear cell and lipoid. Certain variants of UC tend to be associated with a poor prognosis and have diagnostic and potential treatment implications that make the identification of variant histology crucial to clinical decision making. While there is still uncertainty regarding the prognostic implications of many of these variants, identifying and reporting variant histology is important to develop our understanding of their biology. Unique molecular features accompany many of these morphologic variants and to better understand these tumors, we review the molecular and clinical implications of histologic variants of bladder cancer. Major efforts are underway to include variant histology and divergent differentiation of UC in clinical trials to develop evidence based approaches to treatment. The purpose of this article is to review the current literature on variant histology of urothelial cancer and to highlight molecular findings and the clinical relevance of these tumors.

Neoadjuvant Chemotherapy in Variant Histology Bladder Cancer: Current Evidence

The role of neoadjuvant chemotherapy in variant histology bladder cancers has yet to be validated in randomized control trials. Several case series have reported experience with NAC in the setting of variant histology. PATIENT SUMMARY: We reviewed outcomes for patients with variant histology muscle-invasive bladder cancer who received chemotherapy before cystectomy. Outcomes varied significantly in the current literature. The best outcomes are associated with neoadjuvant chemotherapy (NAC) for small cell variants, while there is potential benefit with the use of NAC for squamous cell and adenocarcinoma variants.

Silica and asbestos exposure at work and the risk of bladder cancer in Canadian men: a population-based case-control study

Background

Silica and asbestos are recognized lung carcinogens. However, their role in carcinogenesis at other organs is less clear. Clearance of inhaled silica particles and asbestos fibers from the lungs may lead to translocation to sites such as the bladder where they may initiate carcinogenesis. We used data from a Canadian population-based case-control study to evaluate the associations between these workplace exposures and bladder cancer.

Methods

Data from a population-based case-control study were used to characterize associations between workplace exposure to silica and asbestos and bladder cancer among men. Bladder cancer cases (N = 658) and age-frequency matched controls (N = 1360) were recruited within the National Enhanced Cancer Surveillance System from eight Canadian provinces (1994–97). Exposure concentration, frequency and reliability for silica and asbestos were assigned to each job, based on lifetime occupational histories, using a combination of job-exposure profiles and expert review. Exposure was modeled as ever/never, highest attained concentration, duration (years), highest attained frequency (% worktime) and cumulative exposure. Odds ratios (OR) and their 95% confidence intervals (CI) were estimated using adjusted logistic regression.

Results

A modest (approximately 20%) increase in bladder cancer risk was found for ever having been exposed to silica, highest attained concentration and frequency of exposure but this increase was not statistically significant. Relative to unexposed, the odds of bladder cancer were 1.41 (95%CI: 1.01–1.98) times higher among men exposed to silica at work for ≥27 years. For asbestos, relative to unexposed, an increased risk of bladder cancer was observed for those first exposed ≥20 years ago (OR:2.04, 95%CI:1.25–3.34), those with a frequency of exposure of 5–30% of worktime (OR:1.45, 95%CI:1.06–1.98), and for those with < 10 years of exposure at low concentrations (OR:1.75, 95%CI:1.10–2.77) and the lower tertile of cumulative exposure (OR:1.69, 95%CI:1.07–2.65). However, no clear exposure-response relationships emerged.

Conclusions

Our results indicate a slight increase in risk of bladder cancer with exposure to silica and asbestos, suggesting that the effects of these agents are broader than currently recognized. The findings from this study inform evidence-based action to enhance cancer prevention efforts, particularly for workers in industries with regular exposure.

Molecular and histological correlations in liver cancer

Hepatocellular carcinoma (HCC) is a highly heterogeneous cancer, both at the molecular and histological level. High-throughput sequencing and gene expression profiling have identified distinct transcriptomic subclasses and numerous recurrent genetic alterations; several HCC subtypes characterised by histological features have also been identified. HCC phenotype appears to be closely related to particular gene mutations, tumour subgroups and/or oncogenic pathways. Non-proliferative tumours display a well-differentiated phenotype. Among this molecular subgroup, CTNNB1-mutated HCCs constitute a homogeneous subtype, exhibiting cholestasis and microtrabecular and pseudoglandular architectural patterns. Another non-proliferative subtype has a gene expression pattern similar to that of mature hepatocytes (G4) and displays a steatohepatitic phenotype. In contrast, proliferative HCCs are most often poorly differentiated, and notably include tumours with progenitor features. A novel morphological variant of proliferative HCC - designated "macrotrabecular-massive" - was recently shown to be associated with angiogenesis activation and poor prognosis. Altogether, these findings may help to translate our knowledge of HCC biology into clinical practice, resulting in improved precision medicine for patients with this highly aggressive malignancy. This manuscript reviews the most recent data in this exciting field, discussing future directions and challenges.

Nivolumab in patients with unresectable locally advanced or metastatic urothelial carcinoma: CheckMate 275 2-year global and Japanese patient population analyses

BACKGROUND

Nivolumab has demonstrated antitumor activity and manageable safety in the single-arm, phase II CheckMate 275 study in patients with unresectable locally advanced or metastatic platinum-resistant urothelial carcinoma. We report updated results of the global population and a subanalysis of Japanese patients from this study.

METHODS

Patients received nivolumab 3 mg/kg intravenously every 2 weeks until progression or unacceptable toxicity. The primary endpoint was objective response rate (ORR) confirmed by blinded independent review committee (BIRC) per Response Evaluation Criteria in Solid Tumors v1.1. Secondary endpoints included progression-free survival (PFS) by BIRC and overall survival (OS). Safety was also reported. The minimum follow-up was 21 months.

RESULTS

Overall, 270 patients were treated with nivolumab globally; 23 patients were Japanese. In the global and Japanese populations, respectively, ORR per BIRC was 20.4% and 21.7%; median PFS was 1.9 (95% confidence interval [CI] 1.9-2.3) and 3.8 months (95% CI 1.9-7.2); and median OS was 8.6 (95% CI 6.1-11.3) and 21.0 months (95% CI 7.2-not reached). The most common any grade treatment-related adverse events were fatigue (18.1%) and diarrhea (12.2%) in the global population; the most common in the Japanese population were diarrhea (26.1%) and pyrexia (13.0%). Grade 3 or 4 treatment-related adverse events occurred in 61 (22.6%) and seven (30.4%) of the global and Japanese patients, respectively.

CONCLUSIONS

Nivolumab continues to show antitumor activity and survival in the global population of CheckMate 275. Meaningful clinical benefit was also observed in Japanese patients. No new safety signals were identified.

Impact of histologic variants on the oncological outcomes of patients with upper urinary tract cancers treated with radical surgery: a multi-institutional retrospective study

BACKGROUND

No definitive evidence exists regarding the clinical significance of histologic variants (HV) in upper urinary tract cancer. We investigated the impact of HV on prognosis in patients with upper urinary tract cancer following radical surgery.

PATIENTS AND METHODS

We retrospectively analyzed 451 patients with upper urinary tract cancer who underwent radical nephroureterectomy at six affiliated hospitals from 1990 to 2015. Patients with distant metastatic disease prior to surgery and those who received neoadjuvant chemotherapy were excluded, leaving 441 eligible patients. Patients were classified into two groups: pure urothelial carcinoma (UC) and HV. The clinicopathological variables of each group were examined using Kaplan-Meier plots and proportional Cox hazard ratios (HR) to compare the oncological outcomes between the two groups.

RESULTS

HV included 37 patients (8%). Compared with the pure UC patients, HV patients had significantly worse recurrence-free survival (RFS) and cancer-specific survival (CSS; RFS p = 0.0002, CSS p = 0.0001). Multivariate analysis for RFS revealed HV were independent predictors (HR 1.92; p = 0.026), but the association did not remain significant for CSS. There was no significant difference in CSS between the adjuvant chemotherapy (AC) group and the non-AC group for all HV patients, except in patients with ≥ pT3 tumor or positive lymph node status where the AC group had significantly favorable CSS.

CONCLUSIONS

HV in upper urinary tract cancer are independent predictors for RFS, but not for CSS. AC improved CSS for HV patients with ≥ pT3 tumor or positive lymph node status.

Histologic variants associated with biological aggressiveness and poor prognosis in patients treated with radical cystectomy

BACKGROUND

The prognostic value of histologic variants (HV) after radical cystectomy (RC) remains controversial. We evaluated the clinicopathological features and prognosis in patients with pure urothelial carcinoma (UC) and HV following RC.

METHODS

From 1990 to 2015, 286 patients with bladder cancer were treated with RC at six Kitasato University-affiliated hospitals. All patients were divided into two groups: pure UC and HV, which contained pure variants and mixed-type UC with variant pattern. A comparison of patient characteristics between the two groups was made to assess the clinicopathological features, and statistical analyses were performed to investigate prognosis in the two groups.

RESULTS

Of the 286 patients, 226 (79%) had pure UC, while 60 (21%) had HV. Of all HV, pure variants accounted for 45% (n = 27). The prevalence of lymph node involvement, locally advanced stage (≥ pT3), positive soft tissue surgical margin and lymphovascular invasion were significantly higher in patients with HV than in those with pure UC. Patients with HV showed worse disease-free survival and cancer-specific survival than those with pure UC (P = 0.009 and 0.003, respectively). In multivariate analysis, HV and lymph node involvement were independent predictors of worse disease-free survival (P = 0.017 and 0.001, respectively). HV, locally advanced stage, lymph node involvement, and positive soft tissue surgical margin were also confirmed as independent predictors of worse cancer-specific survival (P = 0.011, 0.012, 0.003 and 0.010, respectively.).

CONCLUSIONS

HV was associated with greater biological aggressiveness and worse prognosis than pure UC.

The pathologist's role in the detection of rare variants of bladder cancer and analysis of the impact on incidence and type detection

BACKGROUND

Histology is one of the most important factors determining the prognosis of bladder cancers and rare variants are generally associated with decreased disease specific survival compared to pure transitional cell carcinomas. We believe that rare bladder cancer variants are likely underdiagnosed in the absence of a dedicated uro-pathologist in many centers. The objective of this study is to evaluate the contribution of a dedicated uro-pathologist on the identification of rare bladder cancer variants.

METHODS

We retrospectively analyzed the clinical and histological records of all patients which underwent a radical cystectomy and lymph node dissection between January 2000 and September 2015. The sample was divided in two groups: Group A, consists of patients who underwent radical cystectomy in the absence of a dedicated uro-pathologist at our institution, whereas the Group B consists of patients who underwent surgery when a dedicated uro-pathology service was available. We then evaluated the impact of a dedicated uro-pathologist on rare variants detection.

RESULTS

One hundred thirty-seven out of 551 (24.9%) of patients who underwent RC had at least one rare variant. In Group A 38/238 (16%) of patients showed a rare variant, while 99/313 (31.6%; P<0.001) in group B. Furthermore, the diagnosis of sarcomatoid variant was statistically significantly less common in group A (P=0.0026). The concordance between final radical cystectomy histology and previous transurethral resection of bladder tumor (TURBT) histology was poor in both groups (overall 50.4%).

CONCLUSIONS

The presence of a dedicated urological anatomical pathologist is of paramount importance and significantly increases the detection rate of non-transitional cell carcinoma bladder cancer types, but it does not increase the concordance rate between histological diagnoses in TURBT and radical cystectomy specimens.

A Real-World Data Study to Evaluate Treatment Patterns, Clinical Characteristics and Survival Outcomes for First- and Second-Line Treatment in Locally Advanced and Metastatic Urothelial Cancer Patients in Germany

Background: Worldwide, urothelial carcinoma (UC) is a common cause of morbidity and mortality. In particular, the incidence of bladder cancer varies widely across Europe; Germany has the ninth highest international age-standardized incidence. For advanced UC or metastatic UC (mUC), platinum-based combination chemotherapy is the standard first-line (1L) treatment; however, there is wide heterogeneity of second-line (2L) treatments, ranging from vinflunine in parts of Europe to taxanes and other agents elsewhere in Europe, in the United States and globally. Limited data exist on treatment patterns and outcomes in patients with advanced UC or mUC in the routine clinical setting in Germany. The objective of this study was to describe clinical characteristics, treatment patterns and subsequent outcomes in this setting. Methods: This retrospective observational cohort analysis evaluated 1L and 2L treatment patterns and overall survival (OS) in patients aged ≥18 years with advanced UC or mUC (T4b, N2-3 and/or M1) at office-based urology and academic as well as nonacademic urology clinics throughout Germany between 1 November 2009 and 2 June 2016. Data were obtained through the GermanOncology database and additional treatment centers using similar electronic case report forms. Results: Among the 435 patients included in the analysis, 435 received 1L treatment and 125 received 2L treatment. Median age at start of 1L treatment was 69 years, 75% of patients were male, 75% were current or ex-smokers, 15% had hemoglobin <10 g/dL and 44% had creatinine clearance<60 mL/min/1.73; proportions were similar with 2L treatment. Cardiovascular disease was the most frequently reported comorbidity (65%), followed by diabetes (19%). Most patients (77%) received 1L platinum-based combination treatment (most commonly gemcitabine + cisplatin, 83%). Of those treated with 2L treatment, 66% received a single agent (most commonly vinflunine, 71%). Median OS (95% CI) with 1L treatment was 16.1 months (13.7-19.2) overall and 17.7 months (14.4-24.2) with 1L cisplatin + gemcitabine. In the 1L setting, 12-month OS was 61%, 24-month OS was 39% and 36-month OS was 26%. Median (95% CI) OS with 2L treatment was 9.2 months (5.5-11.6) overall and 5.9 months (4.1-12.6) with 2L vinflunine. In the 2L setting, OS rates for the same time periods were 40%, 22% and 8%, respectively. Median (95% CI) progression-free survival was 7 months (6.4-8.1) and 4 months (3.0-4.8), respectively, in the 1L and 2L settings. Objective response rates were 34% in the 1L setting and 14% in the 2L setting. No difference in OS by sex or smoking status was noted. Patients with or without renal impairment had a 12-month OS of 54% or 69%, respectively. OS at 12 months was 63% among patients with an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0 to 1 vs 53% among patients with an ECOG PS of ≥2. Cox regression analysis found no difference in OS between vinflunine and other 2L treatments (P = 0.69). Conclusions: This study provides a contemporary multicenter assessment of real-world treatment patterns and outcomes among palliatively treated patients with UC in Germany. The findings were generally consistent with the poor treatment outcomes observed globally, underscoring the need for effective 1L and 2L treatment for advanced UC or mUC.

New Developments and Challenges in Rare Genitourinary Tumors: Non-Urothelial Bladder Cancers and Squamous Cell Cancers of the Penis

The diagnosis and treatment of rare genitourinary tumors is inherently challenging. The Rare Diseases Act of 2002 initially defined a rare disorder as one that affects fewer than 200,000 Americans. The lack of widely available clinical guidelines, limited research funding, and inaccessible clinical trials often lead to difficulty with treatment decisions to guide practitioners in rendering effective care for patients with rare genitourinary cancers. This article will discuss basic tenets of diagnosis and treatment as well as recent developments and clinical trials in rare non-urothelial bladder cancers and penile squamous cell cancers.