Epidemiology of Bladder Cancer

Moving Beyond the Silos of Opportunistic Pathogen and Disinfection Byproduct Research to Improve Drinking Water System Management

Drinking water opportunistic pathogens (OPs) and disinfection byproducts (DBPs) both pose risks to public health, and their variable occurrence from source to tap complicates efforts to control them simultaneously. Management of OPs and DBPs is further hindered by the historical division between microbial and chemical research. This review brings together the current knowledge regarding OPs and DBPs, identifies factors that influence the occurrence of both, and highlights areas where research is needed to better understand their health risks. First, we examine the current understanding of how OPs and DBPs are jointly influenced by physicochemical parameters, source water characteristics, treatment processes including disinfection, and distribution system properties. Temperature, for example, can affect OP and DBP occurrence, where higher temperatures can promote the growth of some OPs, such as Legionella pneumophila, but temperature's effect on DBPs is species-dependent. Methods for quantifying the risks associated with OPs (quantitative microbial risk assessment) and DBPs (chemical risk assessment) are compared, finding that the numerous assumptions and data gaps associated with each method limit comparability across contaminant types. We highlight the urgent need to fill existing data gaps and develop a more unified risk framework so as to move toward holistic assessment of microbial and chemical risks. This review provides suggestions for future research, highlighting ways that researchers might utilize established practices in OP or DBP studies to further our understanding of the other. For example, analysis of source water organic matter composition, which has advanced our understanding of DBP formation, could be utilized to elucidate how source water characteristics influence OPs. This review bridges the gap between the OP and DBP disciplines, arguing that collaboration between the two is needed to address the pressing challenges facing water systems today.

Real-world treatment patterns, survival outcomes, and health care resource utilization for locally advanced or metastatic urothelial carcinoma in Spain

PURPOSE

Real-world evidence on locally advanced or metastatic urothelial carcinoma (la/mUC) management in Spain is limited. This study describes patient characteristics, treatment patterns, survival, and health care resource utilization (HCRU) in this population.

METHODS/PATIENTS

This retrospective observational study included all adults with a first diagnosis/record of la/mUC (index date) from January 2015 to June 2020 at nine university hospitals in Spain. Data were collected up to December 31, 2020 (end of study), death, or loss to follow-up. Patient characteristics, treatment patterns, median overall survival (OS) and progression-free survival (PFS) from index date (Kaplan-Meier estimates), and disease-specific HCRU were described.

RESULTS

Among 829 patients, median age at diagnosis was 71 years; 70.2% had ≥ 1 comorbidity, and 52.5% were eligible for cisplatin. Median follow-up was 12.7 months. Most (84.7%) patients received first-line systemic treatment; of these, 46.9% (n = 329) received second-line and 16.6% (n = 116) received third-line therapy. Chemotherapy was the most common treatment in all lines of therapy, followed by programmed cell death protein 1/ligand 1 inhibitors. Median (95% confidence interval) OS and PFS were 18.8 (17.5-21.5) and 9.9 (8.9-10.5) months, respectively. Most patients required ≥ 1 outpatient visit (71.8%), inpatient admission (56.6%), or emergency department visit (56.5%).

CONCLUSIONS

Therapeutic patterns were consistent with Spanish guideline recommendations. Chemotherapy had a role in first-line treatment of la/mUC in Spain during the study period. However, the disease burden remains high, and new first-line treatments recommended in the latest European guidelines should be made available to patients in Spain.

Spectral CT for non-invasive evaluation of bladder cancer grade

OBJECTIVE

To investigate the potential role of dual-energy spectral computer tomography (CT) quantitative parameters in the definition of bladder cancer (BCa) pathological grading.

METHODS

This retrospective study evaluated the use of spectral CT imaging features for BCa. From 2021 to 2023, 63 patients with histologically-confirmed BCa diagnosis were examined at our Institution. The patients were pathologically divided, following international guidelines, into two groups: low-grade (n = 24) and high-grade urothelial carcinoma group (n = 39). The iodine concentrations (IC), the normalized iodine concentrations (NIC), and the slope of the spectrum curve (SLOPE) were calculated along with the measure of each lesion CT value on the monochromatic image from 40 to 120 keV. The diagnostic performance was assessed by Receiver operator characteristic curve (ROC) analysis.

RESULTS

The high-grade group showed significantly higher mean values of IC, SLOPE, and HU in 40 KeV monoenergetic images (VMI40 HU). AUC values for NIC, SLOPE, IC, and VMI40 HU were 0,677, 0,745, 0,745, and 0,755 respectively. In multivariate logistic regression models with backward stepwise, including all quantitative parameters, only VMI40 HU remained statistically significant to correlate with high-grade tumors.

CONCLUSION

Preliminary data shows that quantitative parameters of dual-energy spectral CT can be helpful to characterize low-grade and high-grade urothelial bladder tumors. The prediction of high-grade BCa with non-invasive methods (e.g. dlCT) can aid in early detection of muscle-invasive and worse prognostic tumors that need more aggressive and timely treatments, personalizing the management on the risk of recurrence.

The role of angiogenin in bladder cancer: where are we in 2025?

PURPOSE

The diagnosis of bladder cancer (BCa), a condition that represents approximately 4% of new cancer cases in the United States, could be greatly improved by the development of non-invasive biomarker-based testing. Current diagnostic methods include cystoscopy and cytology; however, these techniques are overly invasive and may cause patient discomfort. Angiogenin (ANG), a member of the RNase A superfamily, was implicated in tumor growth due to its role in angiogenesis. ANG pathophysiology and potential diagnostic and therapeutic role in BCa are discussed.

METHODS

A narrative review was conducted on the relationship between ANG and BCa. Articles were retrieved from PubMed and Google Scholar between the years of 2000 and 2024. The authors reviewed the included articles and summarized findings.

RESULTS

In BCa, ANG interacts with matrix metallopeptidase 2 (MMP2) through the ERK1/2 signaling pathway and contributes to extracellular matrix (ECM) degradation. This review, including 9 articles that directly assessed biomarker-based tests with ANG, suggests that ANG may be suitable for developing novel diagnostic urine biomarker tests. The overexpression of ANG in patients with BCa may also suggest the potential for developing therapeutics that target this protein. Some articles indicate that ribonuclease inhibitors could successfully target ANG by limiting nuclear translocation or limiting ANG activation of phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) pathways, thus limiting BCa progression.

CONCLUSIONS

The results of this review warrant further investigation into both the diagnostic and therapeutic potential of ANG in BCa. Future case-control studies and clinical trials are needed.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

International multicenter study of stereotactic radiosurgery for bladder cancer brain metastases

PURPOSE

Bladder cancer rarely metastasizes to the brain. This study was performed to evaluate stereotactic radiosurgery (SRS) for the management of bladder cancer brain metastases.

METHODS

Cases of bladder cancer brain metastases treated with SRS were collected by members of the International Radiosurgery Research Foundation (IRRF) and outcome data was analyzed for patients with at least one clinical or imaging follow-up.

RESULTS

103 patients received SRS for 301 brain metastases. Median age at SRS was 68 and 73.8% of patients were male. Median KPS was 80%. Median time from primary to brain metastases diagnosis was 18 months. At the time of SRS, 50% of patients had other systemic metastases. The median number of metastases treated was 1, and median cumulative SRS volume was 1.16 cc. Most patients had single fraction SRS using a median margin dose of 18 Gy. At the time of analysis, 9.7% of patients were alive. Median survival after SRS was 7 months. Local control was achieved for 89.3% of metastases, 42% of patients developed new remote brain metastases, and 4.9% had leptomeningeal dissemination. Subsequent management included repeat SRS in 21.7%, surgical resection in 8.8% and WBRT in 7.6% of patients. At last follow-up, 32.1% of patients had improvement of their symptoms, whereas 38.5% remained stable. Adverse radiation effects occurred in 4.3% of treated metastases. On multivariate analyses, KPS ≥ 80% and non-urothelial histology predicted improved survival, while absence of corticosteroid intake predicted longer tumor control.

CONCLUSION

Bladder cancer brain metastases can be safely managed with SRS.

Proteomic and In Silico Analyses Highlight Complement System's Role in Bladder Cancer Immune Regulation

Background and Objectives: Bladder cancer (BLCA), intimately associated with the immune system, represents a substantial global health burden due to its high recurrence rates and limited therapeutic effectiveness. Although immunotherapy shows promise, challenges persist due to the lack of reliable therapeutic targets. This study aims to investigate potential immune-related biomarkers that could influence the tumor microenvironment in BLCA, using proteomic and in silico approaches. Materials and Methods: Tissue samples from BLCA patients (n = 27) and controls (n = 27) were collected from Şişli Hamidiye Etfal Training and Research Hospital. Proteomic analysis was performed by liquid chromatography/mass spectrometry (LC-MS)/MS to reveal the identities of differentially regulated proteins. Protein network analysis and hub protein detection were performed using Cytoscape (v.3.10.3), while functional annotation was carried out using EnrichR. The immunological analysis of hub proteins was performed in Sangerbox platform, and prognostic associations were evaluated through the Kaplan-Meier Plotter tool. Results: LC-MS/MS analysis identified 120 differentially regulated immune-related proteins. STRING analysis, using an immune response dataset (GO:0006955), highlighted the complement cascade as a significantly enriched pathway (p < 0.05). Proteins, namely C4A, CFB, C4B, C8B, CFH, CFI, C5, C4BPA, C3, and C2, that are known to play key roles in the complement system were identified. Immunological analysis with these proteins revealed the phenomena of immune infiltration and immune checkpoint gene associations (p < 0.05). Four hub genes-CFB, C4B, CFI, and C2-demonstrated a significant prognostic value for BLCA (p < 0.05). Conclusions: This study highlights the pivotal role of the complement system in the immune regulation of BLCA. CFI, C4A, and C4B emerged as potential target proteins for BLCA treatment, particularly in immunotherapy, for enhancing survival. Future research on these proteins and the complement system specifically focusing on BLCA may facilitate the development of targeted immunotherapies, ultimately improving treatment outcomes.

Pulsed Electromagnetic Field Therapy Alters the Genomic Profile of Bladder Cancer Cell Line HT-1197

Background/Objectives: Pulsed electromagnetic field (PEMF) therapy involves the use of magnetic waveform energy for targeted treatment delivery. This technique has shown promising results in the treatment of various cancers. Currently, treatment of bladder cancer is highly invasive, involving intravesical chemotherapy or radical cystectomy. The potential therapeutic effects of PEMF therapy on bladder cancer are a relatively new and understudied area; therefore, the goal of this investigation was to gain mechanistic insight by examining the effects of PEMF therapy on a bladder cancer cell line in vitro. Methods: Cells from the bladder cancer cell line HT-1197 were cultured and incubated with (treatment group) or without (control group) PEMF therapy for one hour each day for five days. Cell counts were compared using Incucyte® data to determine proliferation rates. At days 1 and 5, total RNA was isolated from cells, and following quantity and quality checks, gene expression was compared between the two groups. Proliferation rates from cell line HT-1197 were compared to prior published results on the bladder cancer cell line HT-1376. Results: HT-1197 cells treated with PEMF therapy had slower proliferation rates compared to controls (p < 0.05), but HT-1376 cells did not (p > 0.05). Principal component analysis showed complete separation of treated and untreated cells, with PEMF treatment accounting for 76% of the variation between the groups. Expression of numerous genes and cancer-related pathways was altered in the treated cells relative to the controls. Conclusions: Bladder cancer HT-1197 cells treated with PEMF therapy had slower proliferation and corresponding changes in gene expression. Several cancer-relevant pathways were differentially regulated following PEMF treatment. The conclusions are limited by the lack of a control healthy urothelial cell line in the experiments. Despite this shortcoming, our results suggest that PEMF therapy may be a promising avenue for further research in the treatment of bladder cancer.

Eligibility Criteria in Advanced Urothelial Cancer Clinical Trials: An Assessment of Modernization and Inclusion

INTRODUCTION

In a joint statement, Friends of Cancer Research and the American Society of Clinical Oncology affirmed the need for broadening clinical trial eligibility criteria to expand patient access to investigational treatments and enroll cohorts more representative of the general population. Our study aimed to characterize and analyze the prevalence of overly exclusionary eligibility criteria in contemporary clinical trials involving patients with locally advanced and metastatic urothelial cancer.

METHODS

Utilizing MeSH query terms "(metastatic OR advanced OR stage IV OR unresectable) AND (bladder cancer OR upper tract urothelial carcinoma OR upper tract urothelial cancer)" in ClinicalTrials.gov, we identified 205 interventional urothelial cancer trials activated between June 30, 2012 through June 30, 2022. We investigated the prevalence of four potentially restrictive criteria: the presence of brain metastases, HIV infection, hepatitis B/C infection, and the presence of concurrent malignancies. Fisher's Exact test was utilized to ascertain significant associations between criteria and trial characteristics.

RESULTS

Of 205 trials found initially, 37 (18%) contained sufficient data for analysis. Overall, HIV infection and Hepatitis B/C infection were most restrictive, with most trials completely excluding patients with these conditions (89.2%; 56.8%). Restrictiveness for HIV infection and type of therapy were significantly associated, with most exclusionary trials involving combination or immunotherapies (39.4%; 33.3%; p = 0.003). Brain metastases were totally excluded by 35.1% of trials and had 18.9% of trials provide no explicit criteria or guidelines. Most trials specified conditions for the inclusion of patients with concurrent malignancies (91.9%). Variant histology was also underrepresented, with most trials not specifying or totally excluding all variant histology (43.2%; 8.1%).

CONCLUSION

HIV infection and hepatitis B/C infection were commonly identified in exclusion criteria across these trials despite limited evidence suggesting these criteria significantly impact therapy efficacy and tolerability. Broadening and modernization of eligibility criteria will ensure more inclusive clinical trials.

From Bench to Bladder: The Rise in Immune Checkpoint Inhibition in the Treatment of Non-Muscle Invasive Bladder Cancer

Non-muscle invasive bladder cancer (NMIBC) represents a significant clinical challenge due to its high recurrence rate and need for frequent monitoring. The current treatment modality is bacillus Calmette-Guérin (BCG) therapy combined with chemotherapy after transurethral resection of the bladder tumor (TURBT), which is highly effective in most patients. Yet, the cancer becomes resistant to these treatments in 30-40% of patients, necessitating the need for new treatment modalities. In the cancer world, the development of immune checkpoint inhibitors that target molecules, such as programmed cell death protein-1 (PD-1), its ligand, PD-L1, and Cytotoxic T-lymphocyte-associated protein-4 (CTLA-4), have revolutionized the treatment of many cancer types. PD-1/PD-L1 and CTLA-4 are shown to be upregulated in NMIBC in certain circumstances. PD-1/PD-L1 interactions play a role in immune evasion by suppressing T cell activity within the tumor microenvironment (TME), while the binding of CTLA-4 on T cells leads to downregulation of the immune response, making these pathways potential immunotherapeutic targets in NMIBC. This review seeks to understand the role of these therapies in treating NMIBC. We explore the cellular and non-cellular immune landscape in the TME of NMIBC, including Tregs, T effector cells, macrophages, B cells, and relevant cytokines. We also discuss the biological role of PD-1/PD-L1 and CTLA-4 while covering the rationale for these immunotherapies in NMIBC. Finally, we cover key clinical trials that have studied these treatments in NMIBC clinically. Such a study will be helpful for urologists and oncologists to manage patients with NMIBC more effectively.

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

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

Comprehensive analysis of RNA methylation-related genes to identify molecular cluster for predicting prognosis and immune profiles in bladder cancer

m6A, m5C and m7G are common types of RNA methylation modifications that are widely involved in key mechanisms regulating malignancy. However, the role of RNA methylation-related genes in the immune microenvironment of bladder cancer (BLCA) remains elusive. In this study, we established RNA methylation molecular subtypes by analyzing the TCGA and GEO datasets. Risk model and nomogram were constructed by LASSO and multivariate Cox regression analysis and validated by external datasets. Genetic variations, functional enrichment analysis and immune cell infiltration were analyzed. The expression levels of hub genes were detected by real-time polymerase chain reaction (qRT-PCR) and immunohistochemistry (IHC). The effect of FN1 on cellular function was determined using experimental assays. Finally, we identified a 7-gene signature associated with BLCA prognosis. GSE19423 validated the predictive value of the risk model. The IMvigor210 data showed the model had promising predictive efficacy for BLCA immunotherapy. Significant differences in biological function, immune cell infiltration and drug sensitivity were observed between high- and low-risk groups. Furthermore, FN1 was upregulated in BLCA, as determined by qRT-PCR and IHC. Depletion of FN1 using siRNA impaired cell motility in T24 and 5637 cells. In conclusion, RNA methylation-related risk model can predict the prognosis, immune landscape and response to immunotherapy in BLCA. Among the 7-gene signature, FN1 is a pivotal gene that promotes the migration of bladder cancer cells.

Comparative Analysis of Prognostic Potential of Pretreatment Blood-Based Biomarkers in Metastatic Bladder Cancer: Modified Glasgow Prognostic Score

Background: Metastatic bladder cancer (mBC) presents a significant global health challenge with a poor prognosis and considerably limited survival. Despite advancements in therapies, long-term survival remains difficult to predict. This study aimed to evaluate the prognostic potential of various pretreatment blood-based biomarkers, including the NLR, dNLR, LMR, PLR, SII, mGPS, CAR, AGR, PNI, PIV, and Bellmunt score, in mBC patients. Methods: A retrospective cohort of 133 patients from Hacettepe University Cancer Institute was analyzed. Kaplan-Meier survival analysis and Cox regression models were used to assess overall survival (OS) and progression-free survival (PFS). Results: There was a significant association between multiple biomarkers and OS in the univariate analysis, with a higher NLR, PLR, and SII linked to worse outcomes. However, in the multivariate analysis, only the modified Glasgow Prognostic Score (mGPS) maintained independent prognostic significance for OS (HR: 1.984, p = 0.013). This suggests that the mGPS, which reflects systemic inflammation and nutritional status, is a robust predictor of survival in mBC. Conclusions: This study highlights the potential of integrating blood-based biomarkers into clinical decision-making to improve personalized treatment strategies. However, prospective studies are needed to validate these findings and assess their applicability to newer therapies such as immune checkpoint inhibitors and antibody-drug conjugates.

Urinary microbiota changes among NMIBC patients during BCG therapy: comparing BCG responders and non-responders

The gold standard for treating high-risk non-muscle-invasive bladder cancer involves the transurethral removal of cancerous tissue followed by BCG immunotherapy. So far, there is no reliable biomarker for predicting BCG efficacy and identifying patients who will or will not respond to BCG treatment. Emerging evidence suggests that urinary microbiota may play a crucial role in BCG efficacy. This study aimed to explore (i) changes in urinary microbiota during the six induction cycles of BCG and (ii) its potential predictive role in determining the outcome of BCG treatment. To this end, catheterized urine samples were collected before each of the six BCG doses and bacterial composition was analyzed using 16S rRNA gene sequencing. Patient inclusion criteria were male gender, no previous history of urothelial cancer, no other malignancies, no active infection, and no antibiotic usage for at least 20 days before the first BCG dose. We observed a significant decrease in biodiversity, measured by the Shannon Index, during the first week of therapy in 10 out of 12 patients (p=0.021). Additionally, differences in microbiota composition before the start of BCG therapy were noted between responders and non-responders to BCG therapy. Non-responders exhibited a 12 times higher abundance of genus Aureispira (p<0.001), and, at the species level, a 27-fold lower abundance of Negativicoccus succinivorans (p<0.001). Throughout the treatment, the abundance of the genus Aureispira decreased, showing an eightfold reduction by the end of therapy among non-responders (p<0.001). Our findings suggest that urinary microbiota plays an active role before and during the course of BCG therapy. However, this is a preliminary study, and further research involving larger patient cohorts is needed.

Real-world treatment patterns and clinical outcomes in patients with locally advanced or metastatic urothelial carcinoma in Germany: retrospective CONVINCE study

PURPOSE

CONVINCE is a retrospective medical chart review study that examined demographics, treatment patterns, and outcomes in patients who received first-line (1L) treatment for locally advanced or metastatic urothelial carcinoma (la/mUC) in Germany.

METHODS

Eligible patients were adults with confirmed la/mUC who received any systemic 1L anticancer treatment between January 1, 2019, and September 30, 2021, outside of a clinical trial. Patients were grouped by type of 1L treatment: platinum-based chemotherapy (PBC), immune checkpoint inhibitor (ICI), or other treatments. Follow-up was ≥ 6 months after end of PBC or start of ICI or other treatments. The primary objective was measurement of real-world progression-free survival (rwPFS).

RESULTS

Data were collected from 188 patients treated at 27 sites (hospitals or office-based practices). First-line treatment was PBC in 76.1% of patients, ICI in 19.1%, and other treatments in 4.8%. The most common PBC regimen was cisplatin + gemcitabine (72.7%), and the most common ICI was atezolizumab (44.4%); 4.2% of PBC-treated patients received avelumab 1L maintenance. In patients who received 1L PBC, ICI treatment, or other treatments, median (95% CI) rwPFS was 10.5 months (9.2-11.6), 12.6 months (8.9-22.9), and not evaluable; median (95% CI) real-world overall survival was 18.1 months (16.5-19.0), 15.9 months (11.1-24.5), and not evaluable; and objective response rates were 56.6%, 60.0%, and 83.3%, including complete response in 14.0%, 20.0%, and 0%, respectively.

CONCLUSION

PBC was the most common 1L treatment in patients with la/mUC in Germany, consistent with treatment guidelines. Future studies are needed to assess outcomes with newer treatments.

Recent animal models of bladder cancer and their application in drug discovery: an update of the literature

INTRODUCTION

Bladder cancer presents a significant health problem worldwide, with environmental and genetic factors contributing to its incidence. Histologically, it can be classified as carcinoma in situ, non-muscle invasive and muscle-invasive carcinoma, each one with distinct genetic alterations impacting prognosis and response to therapy. While traditional transurethral resection is commonly performed in carcinoma in situ and non-muscle invasive carcinoma, it often fails to prevent recurrence or progression to more aggressive phenotypes, leading to the frequent need for additional treatment such as intravesical chemotherapy or immunotherapy. Despite the advances made in recent years, treatment options for bladder cancer are still lacking due to the complex nature of this disease. So, animal models may hold potential for addressing these limitations, because they not only allow the study of disease progression but also the evaluation of therapies and the investigation of drug repositioning.

AREAS COVERED

This review discusses the use of animal models over the past decade, highlighting key discoveries and discussing advantages and disadvantages for new drug discovery.

EXPERT OPINION

Over the past decade animal models have been employed to evaluate new mechanisms underlying the responses to standard therapies, aiming to optimize bladder cancer treatment. The authors propose that molecular engineering techniques and AI may hold promise for the future development of more precise and effective targeted therapies in bladder cancer.

Spontaneous Necrosis of a High-Risk Bladder Tumor Under Immunotherapy for Concurrent Malignant Melanoma: Role of BRAF Mutations and PD-L1 Expression

Background: Bladder cancer (BC) is a heterogeneous malignancy, and predicting response to immune checkpoint inhibitors (ICIs) remains a challenge. Herein, we investigate a high-risk bladder tumor, which developed during anti-BRAF/MEK therapy for a concurrent advanced BRAF-V600E-positive malignant melanoma (MM) and subsequently underwent complete spontaneous necrosis following Nivolumab immunotherapy, only to recur thereafter while still under the same treatment. This unique scenario provided an opportunity to investigate the roles of BRAF gene mutations in BC pathogenesis, respectively, of PD-L1 expression in immunotherapy response prediction. Methods: We retrospectively analyzed BC specimens obtained via transurethral resection at two critical time-points: prior to the complete spontaneous necrosis under Nivolumab (prenecrosis) and after tumor recurrence postnecrosis (postnecrosis). The BRAF gene mutation status was evaluated using quantitative polymerase chain reaction (qPCR). PD-L1 expression was assessed by immunohistochemistry (IHC), quantified using the combined positive score (CPS), and a cutoff of ≥10 for positivity. Results: Neither pre- nor postnecrosis BC samples harbored BRAF gene mutations. Prenecrosis PD-L1 expression (CPS = 5) indicated a minimal likelihood of response to immunotherapy. However, complete spontaneous necrosis occurred under Nivolumab, followed by recurrence with further reduced PD-L1 expression (CPS = 1). Conclusions: The complete BC regression challenges the conventional role of PD-L1 as a sole predictive biomarker for immunotherapy. This study also highlights the potential role of BRAF/MEK inhibitors in BC oncogenesis and underscores the need for alternative biomarkers, such as tumor mutation burden (TMB) and circulating tumor DNA (ctDNA), to guide treatment selection in BC better.

Amyloids in bladder cancer hijack cancer-related proteins and are positive correlated to tumor stage

Despite the current diagnostic and therapeutic approaches to bladder cancer being widely accepted, there have been few significant advancements in this field over the past decades. This underscores the necessity for a paradigm shift in the approach to bladder cancer. The role of amyloids in cancer remains unclear despite their identification in several other pathologies. In this study, we present evidence of amyloids in bladder cancer, both in vitro and in vivo. In a murine model of bladder cancer, a positive correlation was observed between amyloids and tumor stage, indicating an association between amyloids and bladder cancer progression. Subsequently, the amyloid proteome of the RT4 non-invasive and HT1197 invasive bladder cancer cell lines was identified and included oncogenes, tumor suppressors, and highly expressed cancer-related proteins. It is proposed that amyloids function as structures that sequester key proteins. Therefore, amyloids should be considered in the study and diagnosis of bladder cancer.

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.

Preclinical evaluation of bozepinib in bladder cancer cell lines: modulation of the NPP1 enzyme

Bladder cancer (BC) is the most common cancer of the urinary tract. Bozepinib (BZP), a purine-derived molecule, is a potential compound for the treatment of cancer. Purinergic signaling consists of the activity of nucleosides and nucleotides present in the extracellular environment, modulating a variety of biological actions. In cancer, this signaling is mainly controlled by the enzymatic cascade involving the NTPDase/E-NPP family and ecto-5'-nucleotidase/CD73, which hydrolyze extracellular adenosine triphosphate (ATP) to adenosine (ADO). The aim of this work is to evaluate the activity of BZP in the purinergic system in BC cell lines and to compare its in vitro antitumor activity with cisplatin, a chemotherapeutic drug widely used in the treatment of BC. In this study, two different BC cell lines, grade 1 RT4 and the more aggressive grade 3 T24, were used along with a human fibroblast cell line MRC-5, a cell used to predict the selectivity index (SI). BZP shows strong antitumor activity, with notable IC50 values (8.7 ± 0.9 µM for RT4; 6.7 ± 0.7 µM for T24), far from the SI for cisplatin (SI for BZP: 19.7 and 25.7 for RT4 and T24, respectively; SI for cisplatin: 1.7 for T24). BZP arrests T24 cells in the G2/M phase of the cell cycle, inducing early apoptosis. Moreover, BZP increases ATP and ADP hydrolysis and gene/protein expression of the NPP1 enzyme in the T24 cell line. In conclusion, BZP shows superior activity compared to cisplatin against BC cell lines in vitro.

Rectal Metastasis Causing Rectal Constriction From High-Grade Urothelial Carcinoma

Urothelial carcinoma arises from the urothelial cells that line the urinary tract, which extends from the renal pelvis to the urethra. Bladder cancer commonly metastasizes to the lymph nodes, bones, liver, and lungs. In rare cases, such as in this case report, it can metastasize to the rectum. In this case report, a 62-year-old male patient presented initially with constipation, anal discharge, perineal pain, mild difficulty urinating, and a rectal mass. The first CT abdomen and pelvis with IV contrast revealed the rectum, sigmoid colon, and proximal descending colon to have circumferential wall thickening with retroperitoneal enlarged lymph nodes. An MRI pelvis with and without contrast revealed marked concentric mass-like wall thickening of the entire rectum, with extensive mesorectal and pelvic lymphadenopathy. A second CT pelvis with IV contrast again revealed extensive rectal wall thickening and irregular thickening of the bladder wall. Rectal endoscopic ultrasound (EUS) with biopsy was performed and found the rectal mass to be high-grade metastatic urothelial carcinoma. Transurethral resection of bladder tumor (TURBT) found high-grade urothelial carcinoma involving the bladder trigone. This case provides a unique observation of a patient whose presenting symptoms were due to metastatic disease and who did not begin suffering major urinary symptoms suggesting bladder cancer until later in the course of the disease. It is important for the differential of a rectal mass to include the possibility of it being a rectal metastasis even if the patient only presents with rectal symptoms initially.

Emerging roles of CircRNA-miRNA networks in cancer development and therapeutic response

The complex interplay of epigenetic factors is essential in regulating the hallmarks of cancer and orchestrating intricate molecular interactions during tumor progression. Circular RNAs (circRNAs), known for their covalently closed loop structures, are non-coding RNA molecules exceptionally resistant to enzymatic degradation, which enhances their stability and regulatory functions in cancer. Similarly, microRNAs (miRNAs) are endogenous non-coding RNAs with linear structures that regulate cellular biological processes akin to circRNAs. Both miRNAs and circRNAs exhibit aberrant expressions in various cancers. Notably, circRNAs can function as sponges for miRNAs, influencing their activity. The circRNA/miRNA interaction plays a pivotal role in the regulation of cancer progression, including in brain, gastrointestinal, gynecological, and urological cancers, influencing key processes such as proliferation, apoptosis, invasion, autophagy, epithelial-mesenchymal transition (EMT), and more. Additionally, this interaction impacts the response of tumor cells to radiotherapy and chemotherapy and contributes to immune evasion, a significant challenge in cancer therapy. Both circRNAs and miRNAs hold potential as biomarkers for cancer prognosis and diagnosis. In this review, we delve into the circRNA-miRNA circuit within human cancers, emphasizing their role in regulating cancer hallmarks and treatment responses. This discussion aims to provide insights for future research to better understand their functions and potentially guide targeted treatments for cancer patients using circRNA/miRNA-based strategies.

The Urogenital System Microbiota: Is It a New Gamechanger in Urogenital Cancers?

The human microbiome, which encompasses microbial communities and their genetic material, significantly influences health and disease, including cancer. The urogenital microbiota, naturally present in the urinary and genital tracts, interact with factors such as age, lifestyle, and health conditions to affect homeostasis and carcinogenesis. Studies suggest that alterations in this microbiota contribute to the development and progression of genitourinary cancers, emphasizing the concept of oncobiome, which refers to microbial genetic contributions to cancer. Similarly, gut microbiota can influence hormone levels and systemic inflammation, impacting cancers such as cervical and prostate cancer. Advanced studies indicate that microbial communities in genitourinary cancers have distinct profiles that may serve as diagnostic biomarkers or therapeutic targets. Dysbiosis of the urinary microbiota correlates with bladder and kidney cancer. Additionally, gut microbiota influence the effectiveness of cancer treatments. However, further research is necessary to clarify causality, the role of microbial metabolites, and hormonal regulation. The aim of this review is to understand that these dynamics present opportunities for innovative cancer diagnostics and therapies, highlighting the need for integration of microbiology, oncology, and genomics to explore the role of microbiota in genitourinary cancers. For this, a comprehensive search of relevant databases was conducted, applying specific inclusion and exclusion criteria to identify studies examining the association between microbiota and urogenital cancers. Research into the mechanisms by which microbiota influence urogenital cancers may pave the way for new diagnostic and therapeutic approaches, ultimately improving patient outcomes.

Enfortumab vedotin as a salvage option as 5th line therapy for metastatic urothelial bladder cancer

A 67-year-old female patient with a muscle-invasive, non-metastatic urothelial bladder cancer (UC) (pT2 G3 cN0 cM0) developed metachronous metastases within 6 months after radical cystectomy with ileal conduit urinary diversion. After a good primary response to platinum-based chemotherapy, treatment was switched to the immune checkpoint inhibitor (ICI) pembrolizumab due to progressive disease. Subsequently the patient underwent selective internal radiotherapy (SIRT) of the liver and received vinflunine as well as a re-challenge with pembrolizumab. Two years after the initial diagnosis, rapid disease progression ultimately led to a switch to 5th line therapy with enfortumab vedotin (EV), which had only been approved in the United States at that time. The antibody-drug conjugate was well tolerated by the patient after dose reduction to 1.0 mg/ kg body weight. Simultaneous irradiation of newly occurring precardiac, hepatic and cerebral metastases were necessary. After 10 months of therapy with EV, tumour regression was observed accompanied with good symptom control. The presented case illustrates the efficacy and tolerability of EV in a heavily pre-treated patient with metastatic UC (mUC).

A novel nomogram for predicting post-operative recurrence for patients with intermediate and high-risk non-muscle invasive bladder cancer after thulium laser resection of bladder tumors or conventional transurethral resection of bladder tumors followed by intravesical bacille Calmette-Guérin immunotherapy

Background

Post-operative recurrence for patients with intermediate and high-risk non-muscular invasive bladder cancer (NMIBC) is common. This study aims to evaluate the potential factors of tumor recurrence, and construct a novel nomogram to predict the probability of tumor recurrence.

Methods

We retrospectively enrolled patients with intermediate and high-risk NMIBC who received thulium laser resection of bladder tumors (TmLRBT) or transurethral resection of the bladder tumor (TURBT) followed by intravesical bacille Calmette-Guérin (BCG) immunotherapy. The risk factors were screened by the least absolute shrinkage and selection operator (LASSO) regression method. And multivariate logistic regression was applied to recognize the independent risk factors of bladder cancer recurrence. A nomogram was established, and the recurrence probability was calculated based on the model scores.

Results

A total of 90 patients with intermediate and high-risk NMIBC were included in this study, of whom 53 underwent TURBT and 37 underwent TmLRBT. During the follow-up period, 22 patients (24.4%) experienced bladder cancer recurrence. Three variables were screened out in the LASSO regression. The multivariate logistic analysis suggested that surgery of TURBT [odds ratio (OR) =6.86760; 95% confidence interval (CI): 1.5048-31.34300] and previous bladder tumor (OR =14.73600; 95% CI: 2.81180-77.23000) were independent risk factors of recurrence, while more BCG treatment sessions (OR =0.26504; 95% CI: 0.12455-0.56398) was independent protective factor of recurrence.

Conclusions

Patients with TURBT and previous bladder tumor history were more likely to develop recurrent bladder cancer, while more BCG treatment sessions was independent protective factor of recurrence.

Examining Patient Characteristics in Bladder Cancer Clinical Trials Involving Immunotherapy

Background/Objectives: Comprehending the patient composition of bladder cancer (BC) clinical trials is crucial for effectively designing clinical trials and contextualizing the generated science. In this study, we reviewed publicly available data and explored the demographic information of BC studies administering immune checkpoint inhibitors (ICIs). Methods: Trial eligibility was irrespective of government or private sponsorship, and trial activation dates were limited to between 2013 and 2023. The main inclusion criteria were use of ICIs and trials reporting endpoints that include progression-free survival (PFS), overall survival (OS), disease-free survival (DFS), and event-free survival (EFS). The key exclusion terms were review articles and meta-analysis. Results: We identified a total of 109 clinical trials with an aggregate total of 8936 enrolled patients. Ninety-six percent identified as Caucasian or White European, and 23% identified as female. Further analyses revealed that 65% of the patients were aged 65 years or older. One-third of the trials listed similar comorbidities, such as cardiovascular disease and diabetes, that were exhibited by approximately 30 percent of the patients. Conclusions: Our data suggest that recruitment strategies should be mindful of comorbidities that may interfere with ICI treatments. Additionally, our results are consistent with findings from other reviews that indicate that certain patient groups may be under-represented in BC trials.

Development and Validation of a Competitive Risk Model in Elderly Patients with Transitional Cell Bladder Carcinoma

BACKGROUND Transitional cell bladder carcinoma (tcBC) is the predominant form of bladder cancer, making up around 95% of reported cases. Prognostic factors for older individuals with tcBC differ from those affecting younger patients. The main purpose of this study was to establish a prognostic competing risk model for elderly patients with tcBC. MATERIAL AND METHODS We conducted a retrospective analysis using data from the SEER database, randomly assigning patients to training and validation groups. We applied proportional subdistribution hazard (SH) to assess risk factors for cancer-related mortality (CSM). A competitive risk model was created to predict cancer-specific survival in elderly patients with tcBC. Model validation involved evaluating the area under the receiver operating curve, the consistency index, and a calibration curve. The Kaplan-Meier (K-M) curve was then used to compare mortality risk between high-risk and low-risk groups identified by the model. RESULTS This study randomly assigned 61 293 patients from the SEER database into training (42 905 patients) and validation (18 388 patients) groups in a 7: 3 ratio. Using a proportional subdistribution hazards model, we identified prognostic risk factors such as age, race, sex, marital status, TNM staging, grade, and metastatic status in brain, bone, liver, and lung. We developed a competitive risk model to predict 5-year cancer-specific survival (CSS) in elderly tcBC patients, achieving consistency index (C-index) values of 0.814 and 0.815 for the training and validation groups, respectively. Kaplan-Meier (K-M) analysis revealed 5-year survival probabilities of 35.1% (high-risk) and 42.2% (low-risk) in the training group, with similar rates of 35.7% and 42.0% in the validation group, both showing statistically significant differences (log-rank P<0.01). CONCLUSIONS We successfully established a competitive risk model for forecasting cancer-specific survival in elderly tcBC patients, primarily relying on these identified risk factors. The validation outcomes indicate the model's accuracy and dependability, making it a highly efficient predictive instrument. This tool enables making personalized clinical decisions for both medical professionals and patients.

Combining a Risk Factor Score Designed From Electronic Health Records With a Digital Cytology Image Scoring System to Improve Bladder Cancer Detection: Proof-of-Concept Study

BACKGROUND

To reduce the mortality related to bladder cancer, efforts need to be concentrated on early detection of the disease for more effective therapeutic intervention. Strong risk factors (eg, smoking status, age, professional exposure) have been identified, and some diagnostic tools (eg, by way of cystoscopy) have been proposed. However, to date, no fully satisfactory (noninvasive, inexpensive, high-performance) solution for widespread deployment has been proposed. Some new models based on cytology image classification were recently developed and bring good perspectives, but there are still avenues to explore to improve their performance.

OBJECTIVE

Our team aimed to evaluate the benefit of combining the reuse of massive clinical data to build a risk factor model and a digital cytology image-based model (VisioCyt) for bladder cancer detection.

METHODS

The first step relied on designing a predictive model based on clinical data (ie, risk factors identified in the literature) extracted from the clinical data warehouse of the Rennes Hospital and machine learning algorithms (logistic regression, random forest, and support vector machine). It provides a score corresponding to the risk of developing bladder cancer based on the patient's clinical profile. Second, we investigated 3 strategies (logistic regression, decision tree, and a custom strategy based on score interpretation) to combine the model's score with the score from an image-based model to produce a robust bladder cancer scoring system.

RESULTS

We collected 2 data sets. The first set, including clinical data for 5422 patients extracted from the clinical data warehouse, was used to design the risk factor-based model. The second set was used to measure the models' performances and was composed of data for 620 patients from a clinical trial for which cytology images and clinicobiological features were collected. With this second data set, the combination of both models obtained areas under the curve of 0.82 on the training set and 0.83 on the test set, demonstrating the value of combining risk factor-based and image-based models. This combination offers a higher associated risk of cancer than VisioCyt alone for all classes, especially for low-grade bladder cancer.

CONCLUSIONS

These results demonstrate the value of combining clinical and biological information, especially to improve detection of low-grade bladder cancer. Some improvements will need to be made to the automatic extraction of clinical features to make the risk factor-based model more robust. However, as of now, the results support the assumption that this type of approach will be of benefit to patients.

Neoadjuvant Accelerated Methotrexate, Vinblastine, Doxorubicin, and Cisplatin Chemotherapy for Muscle-Invasive Urothelial Cancer: Large, Single-Center Analysis of Consecutive Patients' Data

Background/Objectives: Bladder cancer is a significant clinical problem with approximately 500,000 new cases worldwide annually. In approximately 25% of cases, disease is diagnosed at a stage of invasion of the muscle layer of the bladder. The current standard approach in this disease is preoperative chemotherapy followed by radical cystectomy. Dose-dense MVAC (ddMVAC), a two-day chemotherapy regimen, is the reference treatment protocol in this setting. The presented study evaluated the effectiveness and safety of accelerated MVAC (aMVAC) chemotherapy-a one-day regimen given before the resection of the bladder due to muscle-invasive disease. Methods: A retrospective analysis included 119 consecutive patients diagnosed with urothelial muscle-invasive bladder cancer (MIBC) who underwent preoperative chemotherapy with the aMVAC regimen. The planned treatment included 4-6 cycles of preoperative chemotherapy. The analysis of the degree of histopathological response to treatment was based on the three-grade TRG (tumor regression grade) classification. Results: A complete pathological response (TRG1) was observed in 44 patients (36.7%), and a major pathologic response ( Collapse

Key Words

• aMVAC
• bladder cancer
• neoadjuvant chemotherapy
• urothelial cancer

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Affiliation(s)

Łukasz Kwinta Oncology Department, Faculty of Medicine, Jagiellonian University Medical College, 31-501 Krakow, Poland; (Ł.K.) Clinical Department of Oncology, University Hospital in Krakow, 31-501 Kraków, Poland
Kamil Konopka Oncology Department, Faculty of Medicine, Jagiellonian University Medical College, 31-501 Krakow, Poland; (Ł.K.) Clinical Department of Oncology, University Hospital in Krakow, 31-501 Kraków, Poland
Krzysztof Okoń Pathomorphology Department, Faculty of Medicine, Jagiellonian University Medical College, 31-531 Krakow, Poland Department of Pathomorphology, University Hospital in Krakow, 30-688 Kraków, Poland
Mateusz Łobacz Clinical Department of Oncology, University Hospital in Krakow, 31-501 Kraków, Poland
Piotr Chłosta Urology Department, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Krakow, Poland Clinical Department of Urology and Oncological Urology, University Hospital in Krakow, 30-688 Kraków, Poland
Przemysław Dudek Urology Department, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Krakow, Poland Clinical Department of Urology and Oncological Urology, University Hospital in Krakow, 30-688 Kraków, Poland
Anna Buda-Nowak Oncology Department, Faculty of Medicine, Jagiellonian University Medical College, 31-501 Krakow, Poland; (Ł.K.) Clinical Department of Oncology, University Hospital in Krakow, 31-501 Kraków, Poland
Paweł Potocki Oncology Department, Faculty of Medicine, Jagiellonian University Medical College, 31-501 Krakow, Poland; (Ł.K.) Clinical Department of Oncology, University Hospital in Krakow, 31-501 Kraków, Poland
Piotr J. Wysocki Oncology Department, Faculty of Medicine, Jagiellonian University Medical College, 31-501 Krakow, Poland; (Ł.K.) Clinical Department of Oncology, University Hospital in Krakow, 31-501 Kraków, Poland

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Volatile Organic Metabolites as Potential Biomarkers for Genitourinary Cancers: Review of the Applications and Detection Methods

Cancer is one of the leading causes of death globally, and is ranked second in the United States. Early detection is crucial for more effective treatment and a higher chance of survival rates, reducing burdens on individuals and societies. Genitourinary cancers, in particular, face significant challenges in early detection. Finding new and cost-effective diagnostic methods is of clinical need. Metabolomic-based approaches, notably volatile organic compound (VOC) analysis, have shown promise in detecting cancer. VOCs are small organic metabolites involved in biological processes and disease development. They can be detected in urine, breath, and blood samples, making them potential candidates for sensitive and non-invasive alternatives for early cancer detection. However, developing robust VOC detection methods remains a hurdle. This review outlines the current landscape of major genitourinary cancers (kidney, prostate, bladder, and testicular), including epidemiology, risk factors, and current diagnostic tools. Furthermore, it explores the applications of using VOCs as cancer biomarkers, various analytical techniques, and comparisons of extraction and detection methods across different biospecimens. The potential use of VOCs in detection, monitoring disease progression, and treatment responses in the field of genitourinary oncology is examined.

A Predictive Nomogram for Development of Lymph Node Metastasis in Muscle-Invasive Bladder Cancer Following Neoadjuvant Therapy

Purpose

Pelvic lymph node metastases (ypN+) after multiagent neoadjuvant chemotherapy (NAC) is a poor prognostic sign in nonmetastatic muscle-invasive bladder cancer (nmMIBC). We sought to create a nomogram predicting probability of ypN+ after NAC for cN0 nmMIBC and determine association with overall survival (OS).

Methods and Materials

We reviewed the National Cancer Database for patients with cT2-4N0M0 urothelial carcinoma of the bladder receiving multiagent NAC and surgery from 2004 to 2020. Following a data split, univariate logistic regression identified variables associated with ypN+ at P < .05. Eligible variables were used for multivariate logistic regression and nomogram generation. A threshold for 95% sensitivity defined high- and low-risk groups for ypN+. Fine-Gray models assessed ypN+ risk group and OS, accounting for competing risks of surgical mortality.

Results

A total of 6194 patients were identified with a median follow-up of 39.5 months (interquartile range [IQR], 20.5-67.2 months). Most patients had high-grade (97.7%) cT2 disease (70.8%) with nonpapillary urothelial histology (67.3%) and initiated NAC at a median of 41.0 days after diagnosis (IQR, 28.0-59.0 days).The nomogram included age in decades (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.87-1.03; P = .172), weeks from diagnosis to NAC (OR, 1.02; 95% CI, 1.01-1.04; P = .004), nonpapillary histology (OR, 1.17; 95% CI, 0.99-1.39; P = .068), and clinical T-stage. Within the testing cohort, ypN+ was found in 392 (22.8%) high-risk and 12 (8.0%) low-risk patients (P < .001), with median OS of 36.1 and 74.0 months, respectively (P < .001). High-risk patients had worse OS despite competing risks of 30-day (subdistribution hazard ratio [SHR], 1.80; 95% CI, 1.49-2.18; P < .001) and 90-day surgical mortality (SHR, 1.68; 95% CI, 1.39-2.04; P < .001).

Conclusions

This is the first study to provide a tool for predicting ypN+ and prognosticate worse OS in primarily high-grade nmMIBC and could select patients for alternative neoadjuvant therapy and facilitate future study.

Comprehensive Analysis of Prognostic Alternative Splicing Signatures in Tumor Immune Infiltration in Bladder Cancer

BACKGROUND

Bladder cancer exhibits substantial heterogeneity encompassing genetic expressions and histological features. This heterogeneity is predominantly attributed to alternative splicing (AS) and AS-regulated splicing factors (SFs), which, in turn, influence bladder cancer development, progression, and response to treatment.

OBJECTIVE

This study aimed to explore the immune landscape of aberrant AS in bladder cancer and establish the prognostic signatures for survival prediction.

METHODS

Bladder cancer-related RNA-Seq, transcriptome, and corresponding clinical information were downloaded from The Cancer Genome Atlas (TCGA). Gene set enrichment analysis (GSEA) was used to identify significantly enriched pathways of cancer-related AS events. The underlying interactions among differentially expressed genes (DEGs) and cancer-related AS events were assessed by a protein-protein interaction network. Univariate and multivariate Cox regression analyses were performed to identify crucial prognostic DEGs that co-occurred with cancer-related AS events (DEGAS) for overall survival. The area under the curve (AUC) of receiver operating characteristic (ROC) curves was used to assess the efficiency of the prognostic signatures. The CIBERSORT algorithm was used to explore the abundance of immune infiltrating cells.

RESULTS

A total of 3755 cancer-related AS events and 3110 DEGs in bladder cancer were identified. Among them, 379 DEGs co-occurred with cancer-related AS events (DEGAS), of which 102 DEGAS were associated with 14 dysregulated SFs. GSEA and KEGG analysis showed that cancer-related AS events were predominantly enriched in pathways related to immunity, tumorigenesis, and treatment difficulties of bladder cancer. Multivariate Cox regression analysis identified 8 DEGAS (CABP1, KCNN2, TNFRSF13B, PCDH7, SNRPA1, APOLD1, CX3CL1, and DENND5A) significantly associated with OS, and they were further integrated into the prediction model with good AUCs at 3-year, 5-year and 7-year ROC curves (all>0.7). Immune infiltration analysis revealed the significant enrichment of three immune cell types (B cells naïve, dendritic cells resting, and dendritic cell activated) in high-risk bladder cancer patients.

CONCLUSION

This study not only unveiled comprehensive prognostic signatures of AS events in bladder cancer but also established a robust prognostic model based on survival-related DEGAS. These aberrant AS events, dysregulated SFs, and the identified 8 DEGAS may have significant clinical potential as therapeutic targets for bladder cancer.

Unveiling FDA-approved Drugs and Formulations in the Management of Bladder Cancer: A Review

Urological cancers are one of the most prevalent malignancies around the globe. Specifically, bladder cancer severely threatens the health of humans because of its heterogeneous and aggressive nature. Extensive studies have been conducted for many years in order to address the limitations associated with the treatment of solid tumors with selective substances. This article aims to provide a summary of the therapeutic drugs that have received FDA approval or are presently in the testing phase for use in the prevention or treatment of bladder cancer. In this review, FDA-approved drugs for bladder cancer treatment have been listed along with their dose protocols, current status, pharmacokinetics, action mechanisms, and marketed products. The article also emphasizes the novel preparations of these drugs that are presently under clinical trials or are in the approval stage. Thus, this review will serve as a single point of reference for scientists involved in the formulation development of these drugs.

Identification and validation of the nicotine metabolism-related signature of bladder cancer by bioinformatics and machine learning

Background

Several studies indicate that smoking is one of the major risk factors for bladder cancer. Nicotine and its metabolites, the main components of tobacco, have been found to be strongly linked to the occurrence and progression of bladder cancer. However, the function of nicotine metabolism-related genes (NRGs) in bladder urothelial carcinoma (BLCA) are still unclear.

Methods

NRGs were collected from MSigDB to identify the clusters associated with nicotine metabolism. Prognostic differentially expressed genes (DEGs) were filtered via differentially expression analysis and univariate Cox regression analysis. Integrative machine learning combination based on 10 machine learning algorithms was used for the construction of robust signature. Subsequently, the clinical application of signature in terms of prognosis, tumor microenvironment (TME) as well as immunotherapy was comprehensively evaluated. Finally, the biology function of the signature gene was further verified via CCK-8, transwell migration and colony formation.

Results

Three clusters associated with nicotine metabolism were discovered with distinct prognosis and immunological patterns. A four gene-signature was developed by random survival forest (RSF) method with highest average Harrell's concordance index (C-index) of 0.763. The signature exhibited a reliable and accurate performance in prognostic prediction across TCGA-train, TCGA-test and GSE32894 cohorts. Furthermore, the signature showed highly correlation with clinical characteristics, TME and immunotherapy responses. Suppression of MKRN1 was found to reduce the migration and proliferation of bladder cancer cell. In addition, enhanced migration and proliferation caused by nicotine was blocked down by loss of MKRN1.

Conclusions

The novel nicotine metabolism-related signature may provide valuable insights into clinical prognosis and potential benefits of immunotherapy in bladder cancer patients.

New Challenges in Bladder Cancer Diagnosis: How Biosensing Tools Can Lead to Population Screening Opportunities

Bladder cancer is one of the most common cancers worldwide. Despite its high incidence, cystoscopy remains the currently used diagnostic gold standard, although it is invasive, expensive and has low sensitivity. As a result, the cancer diagnosis is mostly late, as it occurs following the presence of hematuria in urine, and population screening is not allowed. It would therefore be desirable to be able to act promptly in the early stage of the disease with the aid of biosensing. The use of devices/tools based on genetic assessments would be of great help in this field. However, the genetic differences between populations do not allow accurate analysis in the context of population screening. Current research is directed towards the discovery of universal biomarkers present in urine with the aim of providing an approach based on a non-invasive, easy-to-perform, rapid, and accurate test that can be widely used in clinical practice for the early diagnosis and follow-up of bladder cancer. An efficient biosensing device may have a disruptive impact in terms of patient health and disease management, contributing to a decrease in mortality rate, as well as easing the social and economic burden on the national healthcare system. Considering the advantage of accessing population screening for early diagnosis of cancer, the main challenges and future perspectives are critically discussed to address the research towards the selection of suitable biomarkers for the development of a very sensitive biosensor for bladder cancer.

Bioactivation, Mutagenicity, DNA Damage, and Oxidative Stress Induced by 3,4-Dimethylaniline

3,4-Dimethylaniline (3,4-DMA) is present in cigarette smoke and widely used as an intermediate in dyes, drugs, and pesticides. Nucleotide excision repair-deficient Chinese hamster ovary (CHO) cells stably transfected with human CYP1A2 and N-acetyltransferase 1 (NAT1) alleles: NAT1*4 (reference allele) or NAT1*14B (the most common variant allele) were utilized to assess 3,4-DMA N-acetylation and hypoxanthine phosphoribosyl transferase (HPRT) mutations, double-strand DNA breaks and reactive oxygen species (ROS). CHO cells expressing NAT1*4 exhibited significantly (p < 0.001) higher 3,4-DMA N-acetylation rates than CHO cells expressing NAT1*14B both in vitro and in situ. In CHO cells expressing CYP1A2 and NAT1, 3,4-DMA caused concentration-dependent increases in reactive oxygen species (ROS), double-stranded DNA damage, and HPRT mutations. CHO cells expressing NAT1*4 and NAT1*14B exhibited concentration-dependent increases in ROS following treatment with 3,4-DMA (linear trend p < 0.001 and p < 0.0001 for NAT1*4 and NAT1*14B, respectively) that were lower than in CHO cells expressing CYP1A2 alone. DNA damage and oxidative stress induced by 3,4-DMA did not differ significantly (p >0.05) between CHO cells expressing NAT1*4 and NAT1*14B. CHO cells expressing NAT1*14B showed higher HPRT mutants (p < 0.05) than CHO cells expressing NAT1*4. These findings confirm 3,4-DMA genotoxicity consistent with potential carcinogenicity.

Prognostic model based on disulfidptosis-related lncRNAs for predicting survival and therapeutic response in bladder cancer

Background

With poor treatment outcomes and prognosis, bladder cancer remains a focus for clinical research in the precision oncology era. However, the potential of disulfidptosis, a novel cell death mechanism, and its related long non-coding RNAs to support selective cancer cell killing in this disease is still unclear.

Methods

We identified key disulfidptosis-related lncRNAs in bladder cancer, constructed a prognostic risk model with potential therapeutic targets, and confirmed the findings through quantitative PCR analysis.

Results

We identified five crucial lncRNAs (AC005840.4, AC010331.1, AL021707.6, MIR4435-2HG and ARHGAP5-AS1) and integrated them into a predictive model centered on disulfidptosis-associated lncRNAs. Reliability and validity tests demonstrated that the lncRNA prediction index associated with disulfidptosis effectively discerns patients' prognosis outcomes. Additionally, high-risk patients exhibited elevated expression levels of genes involved in the PI3K-Akt signaling pathway, extracellular matrix organization, and immune escape mechanisms, which are associated with poor prognosis. Notably, high-risk patients demonstrated higher sensitivity to Sorafenib, Oxaliplatin and MK-2206, underscoring the promise of these lncRNAs as precise therapeutic targets in bladder cancer.

Conclusion

By revealing the predictive importance of disulfidptosis-associated lncRNAs in bladder cancer, our research offers new perspectives and pinpoints potential therapeutic targets in clinical environments.

The role of autophagy dysregulation in low and high-grade nonmuscle invasive bladder cancer: A survival analysis and clinicopathological association

INTRODUCTION

Bladder cancer disproportionately affects men and often presents as nonmuscle-invasive bladder cancer (NMIBC). Despite initial treatments, the recurrence and progression of NMIBC are linked to autophagy. This study investigates the expression of autophagy genes (mTOR, ULK1, Beclin1, and LC3) in low and high-grade NMIBC, providing insights into potential prognostic markers and therapeutic targets.

MATERIAL AND METHODS

A total of 115 tissue samples (n = 85 NMIBC (pTa, pT1, and CIS) and n = 30 control from BPH patients) were collected. The expression level of autophagy genes (mTOR, ULK1, Beclin1, and LC3) and their proteins were assessed in low and high-grade NMIBC, along with control tissue samples using quantitative real-time polymerase chain reaction and western blotting. Association with clinicopathological characteristics and autophagy gene expression was analyzed by multivariate and univariate survival analysis using SPSS.

RESULT

In high-grade NMIBC, ULK1, P = 0.0150, Beclin1, P = 0.0041, and LC3, P = 0.0014, were substantially downregulated, whereas mTOR, P = 0.0006, was significantly upregulated. The KM plots show significant survival outcomes with autophagy genes. The clinicopathological characters, high grade (P = 0.019), tumor stage (CIS P = 0.039, pT1 P = 0.018, P = 0.045), male (P = 0.010), lymphovascular invasion (P = 0.028) and autophagy genes (ULK1 P = 0.002, beclin1 (P = 0.010, P = 0.022) were associated as risk factors for survival outcome in NMIBC patients.

CONCLUSION

The upregulated mTOR, downregulated ULK1, and beclin1 expression is linked to a high-grade, CIS and pT1 stage, resulting in poor recurrence-free survival and progression-free survival and highlights the prognostic significance of autophagy gene in nonmuscle-invasive bladder cancer.

Hyperthermia reduces cancer cell invasion and combats chemoresistance and immune evasion in human bladder cancer

Bladder cancer (BC) is a common malignancy and its most prevalent type is urothelial carcinoma, which accounts for ~90% of all cases of BC. The current treatment options for BC are limited, which necessitates the development of alternative treatment strategies. Hyperthermia (HT), as an adjuvant cancer therapy, is known to improve the efficacy of chemotherapy or radiotherapy. The present study aimed to investigate the anti‑tumor effects of HT on cell survival, invasiveness, chemoresistance and immune evasion in human BC cell lines (5637, T24 and UMUC3). Calcein AM staining was performed to analyze the cytotoxicity of natural killer (NK) cells against human BC cells following HT treatment. Cell migration and invasion affected by HT were analyzed using Transwell migration and invasion assays. It was found that HT inhibited the proliferation of BC cells by downregulating the phosphorylation of protein kinase B. Moreover, HT effectively enhanced the sensitivity of BC cells to the chemotherapy drug cisplatin (DDP) and reduced the chemoresistance of DDP‑resistant cells by downregulating the expression of cadherin‑11. It was further demonstrated that HT inhibited the migration and invasion of BC cells and enhanced the cytotoxic effects of NK cells. In summary, the antineoplastic effects of HT were mediated through three main mechanisms: Enhancement of the chemosensitivity of BC cells and mitigation of DDP‑induced chemoresistance, suppression of the invasive potential of BC cells and reinforcement of the anticancer response of NK cells. Thus, HT appears to be a promising adjunctive therapy for human BC.

An overview of immune checkpoint inhibitor toxicities in bladder cancer

Bladder cancer is the tenth most prevalent malignancy worldwide, with a significant mortality burden. Urothelial carcinoma (UC) is the most common histological subtype, and treatment options are guided by whether the disease is muscle-invasive (MIBC) or non-muscle-invasive (NMIBC), with subsequent risk group stratification. The growing popularity of immune checkpoint inhibitors (ICIs) to treat MIBC and NMIBC as either monotherapy or combined with intravesical agents, may radically change the treatment paradigm of UC. Current treatments for NMBIC includes intravesical chemotherapy after trans-urethral resection of the bladder tumour, intravesical bacillus Calmette-Guerin (BCG) or radical cystectomy. Cisplatin-based chemotherapy is widely regarded as the first-line treatment for metastatic UC due to its beneficial response and survival rates when compared to alternative therapies. However, up to 70 % of metastatic UC patients are ineligible, and the prognosis of these patients remains poor, with a median survival of 13-16 months. For NMIBC and MIBC, ICIs provide a promising alternative for cisplatin-ineligible patients. In UC, ICIs including atezolizumab, nivolumab, avelumab, and pembrolizumab are Food and Drug Administration (FDA)-approved for monotherapy, and have demonstrated promising results, particularly in those who cannot receive cisplatin-based chemotherapy, and as a second-line treatment option for recurrent UC following platinum-based chemotherapy. It is important to consider that some patients may experience adverse events (AEs) with limited clinical benefit. Infusion-related reactions and immune-mediated AEs (imAEs) such as colitis, endocrinopathies, hepatitis, pneumonitis, interstitial lung disease, renal dysfunction, nephritis, cutaneous and neurological toxicities must be monitored for. Currently, there is no clear consensus on the role of a 'two-year stopping rule' in reducing the risk of imAEs, with further research on the optimal treatment duration of ICIs required. With increased ICI use, vigilance regarding their side effects is imperative. This review aims to provide an updated overview of ICI toxicities in bladder cancer, to assist clinicians in their therapeutic decision-making, with consideration of patient characteristics and the clinical context.

Bladder cancer biomarkers: current approaches and future directions

Bladder cancer is a significant health concern worldwide, necessitating effective diagnostic and monitoring strategies. Biomarkers play a crucial role in the early detection, prognosis, and treatment of this disease. This review explores the current landscape of bladder cancer biomarkers, including FDA-approved molecular biomarkers and emerging ones. FDA-approved molecular biomarkers, such as BTA stat, BTA TRAK, and NMP22, have been instrumental in diagnosing and monitoring bladder cancer. These biomarkers are derived from urinary samples and are particularly useful due to their sensitivity and specificity. As we move forward, we should continue to seek ways to optimize our processes and outcomes, these markers remain seriously challenged in the detection of early bladder cancer due to their limited sensitivity and specificity. For instance, sensitivities of BTA stat in bladder tumor detection have varied between 40-72%, while its specificities vary from 29-96%. In the same way, 70% sensitivity and 80% specificity have been recorded for BTA TRAK, while 11-85.7% sensitivity and 77-100% specificity have been documented for NMP22 BladderChek. The given variations, especially the low sensitivity in the diagnosis of bladder cancer at an early stage call for the invention of better diagnostic systems. Moreover, different sample collection and handling procedures applied in different laboratories further contribute to inconsistent results obtained. Extracellular vesicles (EVs) and exosomes, which carry a vast number of proteins, are being considered as potential biomarkers. Although these markers show promise, challenges remain due to non-standardized isolation techniques and lack of reproducibility across studies. Moreover, the discovery of new potential biomarkers is ongoing. For instance, the UBC® Rapid test and UBC ELISA kit, the XPERT BC Monitor, BC UroMark, TaqMan® Arrays, Soluble FAS (sFAS), Bladder tumor fibronectin (BTF), and IGF2 and MAGE-A3 are among the newest biomarkers under investigation. In conclusion, while bladder cancer biomarkers have shown great promise, more research is needed to standardize the testing procedures and validate these biomarkers in a clinical setting. This will pave the way for more accurate and efficient diagnosis and monitoring of bladder cancer, ultimately improving patient outcomes.

Peripheral Mechanisms Underlying Bacillus Calmette-Guerin-Induced Lower Urinary Tract Symptoms (LUTS)

Non-muscle invasive bladder cancer (NMIBC) accounts for approximately 70-75% of all bladder cancer cases. The standard treatment for high-risk NMIBC involves transurethral tumour resection followed by intravesical Bacillus Calmette-Guerin (BCG) immunotherapy. While BCG immunotherapy is both safe and effective, it frequently leads to the development of lower urinary tract symptoms (LUTS) such as urinary urgency, frequency, dysuria, and pelvic discomfort. These symptoms can significantly diminish patients' quality of life and may result in the discontinuation of BCG treatment, adversely affecting oncological outcomes. Despite the considerable clinical impact of BCG-induced LUTS, the underlying mechanisms remain unclear, hindering the implementation or development of effective treatments. This review provides novel insights into the potential mechanisms underlying BCG-induced LUTS, focusing on the integrated roles of afferent and efferent nerves in both normal and pathological bladder sensation and function. Specifically, this review examines how the body's response to BCG-through the development of inflammation, increased urothelial permeability, and altered urothelial signalling-might contribute to LUTS development. Drawing from known mechanisms in other common urological disorders and data from successful clinical trials involving NMIBC patients, this review summarises evidence supporting the likely changes in both sensory nerve signalling and bladder muscle function in the development of BCG-induced LUTS. However, further research is required to understand the intricate mechanisms underlying the development of BCG-induced LUTS and identify why some patients are more likely to experience BCG intolerance. Addressing these knowledge gaps could have profound implications for patients' quality of life, treatment adherence, and overall outcomes in NMIBC care.

Gut microbiota as a biomarker and modulator of anti-tumor immunotherapy outcomes

Although immune-checkpoint inhibitors (ICIs) have significantly improved cancer treatment, their effectiveness is limited by primary or acquired resistance in many patients. The gut microbiota, through its production of metabolites and regulation of immune cell functions, plays a vital role in maintaining immune balance and influencing the response to cancer immunotherapies. This review highlights evidence linking specific gut microbial characteristics to increased therapeutic efficacy in a variety of cancers, such as gastrointestinal cancers, melanoma, lung cancer, urinary system cancers, and reproductive system cancers, suggesting the gut microbiota's potential as a predictive biomarker for ICI responsiveness. It also explores the possibility of enhancing ICI effectiveness through fecal microbiota transplantation, probiotics, prebiotics, synbiotics, postbiotics, and dietary modifications. Moreover, the review underscores the need for extensive randomized controlled trials to confirm the gut microbiota's predictive value and to establish guidelines for microbiota-targeted interventions in immunotherapy. In summary, the article suggests that a balanced gut microbiota is key to maximizing immunotherapy benefits and calls for further research to optimize microbiota modulation strategies for cancer treatment. It advocates for a deeper comprehension of the complex interactions between gut microbiota, host immunity, and cancer therapy, aiming for more personalized and effective treatment options.

Correlation analysis of preoperative renal insufficiency with major complications in patients who received a radical cystectomy and pelvic lymph node dissection: results of a retrospective observational analysis from a single center

Objective

The aim of this study was to explore the factors affecting the major complications and the impacts of preoperative renal function on the incidence of complications in radical cystectomy procedures.

Methods

A retrospective review of 705 patients who received radical cystectomy between 2006 and 2021 was conducted. The 90-day complications of patients after a radical cystectomy were reported and the Clavien-Dindo classification (CDC) was used for grading complications. The clinical characteristics and preoperative outcomes were compared among patients with different preoperative renal functions. A logistic regression analysis of all patients was used to identify the risk factors associated with the major complications. Spearman's correlation analysis was used to examine the relationship between the classification of renal insufficiency and the CDC. In order to reduce the selection bias, one-to-one propensity score matching was performed, and the comparison of complications after matching was carried out for the sensitivity analysis.

Results

Within 90 days post-surgery, 71% of patients experienced complications, with 4.8% of them being major. Patients with preoperative renal insufficiency had a higher CDC and had a higher rate of major complications (16.7% vs 3.7%, p < 0.001). There was a linear relationship between preoperative serum creatinine and complications. Spearman's correlation analysis showed a slightly positive correlation between the classification of renal insufficiency and the CDC (r=0.094, p = 0.013). Preoperative renal insufficiency was a risk factor for major complications (OR = 6.805 [95%CI: 2.706-17.112]; p < 0.001). After matching, the patients in the preoperative renal insufficiency group had a higher CDC and a higher incidence of major complications (16.9% vs 1.7%, p = 0.004).

Conclusions

In our cohort, patients with preoperative renal insufficiency exhibited a higher incidence of complications following a radical cystectomy, and renal insufficiency was a significant risk factor for major complications.

Content-Based Image Retrieval and Image Classification System for Early Prediction of Bladder Cancer

BACKGROUND/OBJECTIVES

Bladder cancer is a type of cancer that begins in the cells lining the inner surface of the bladder. Although it usually begins in the bladder, it can spread to surrounding tissues, lymph nodes, and other organs in later stages. Early detection of bladder cancer is, therefore, of great importance.

METHODS

Therefore, this study developed two systems based on classification and Content-Based Image Retrieval (CBIR). The primary purpose of CBIR systems is to compare the visual similarities of a user-provided image with the images in the database and return the most similar ones. CBIR systems offer an effective search and retrieval mechanism by directly using the content of the image data.

RESULTS

In the proposed CBIR system, five different CNNs, two different textural-based feature extraction methods, and seven different similarity measurement metrics were tested for feature selection and similarity measurement. Successful feature extraction methods and similarity measurement metrics formed the infrastructure of the developed system. Densenet201 was preferred for feature extraction in the developed system. The cosine metric was used in the proposed CBIR system as a similarity measurement metric, the most successful among seven different metrics.

CONCLUSIONS

As a result, it was seen that the proposed CBIR model showed the highest success using the Densenet201 model for feature extraction and the Cosine similarity measurement method.

Exploring the Immunoresponse in Bladder Cancer Immunotherapy

Bladder cancer (BC) represents a wide spectrum of diseases, ranging from recurrent non-invasive tumors to advanced stages that require intensive treatments. BC accounts for an estimated 500,000 new cases and 200,000 deaths worldwide every year. Understanding the biology of BC has changed how this disease is diagnosed and treated. Bladder cancer is highly immunogenic, involving innate and adaptive components of the immune system. Although little is still known of how immune cells respond to BC, immunotherapy with bacillus Calmette-Guérin (BCG) remains the gold standard in high-risk non-muscle invasive BC. For muscle-invasive BC and metastatic stages, immune checkpoint inhibitors targeting CTLA-4, PD-1, and PD-L1 have emerged as potent therapies, enhancing immune surveillance and tumor cell elimination. This review aims to unravel the immune responses involving innate and adaptive immune cells in BC that will contribute to establishing new and promising therapeutic options, while reviewing the immunotherapies currently in use in bladder cancer.

Bladder Cancer Treatments in the Age of Personalized Medicine: A Comprehensive Review of Potential Radiosensitivity Biomarkers

Bladder cancer is one of the most frequently diagnosed cancers in men. While cystectomy remains the primary treatment, advances in radiotherapy and chemotherapy have highlighted the value of bladder-preserving strategies, which can also enhance patients' quality of life. Despise these advances, around 20% of patients may still require salvage cystectomy due to tumor radioresistance. This underscores the need to develop radiosensitivity predictive assays. Radiotherapy acts by inducing DNA damage, primarily through DNA double-strand breaks, which can significantly affect treatment outcomes if left unrepaired. In addition to activating DNA repair pathways, the response to radiation also involves the tumor microenvironment, cell death pathways, immune responses and different types of cell death and proliferation receptors. In recent years, personalized medicine, which tailors treatments to individual patients, has gained increasing attention in cancer care. The development of chemo- and radiosensitivity predictive assays has become a key focus of cancer research. Despite the potential impact of such assays on bladder cancer treatment, there is still no reliable test that can help clinicians and informs patients in choosing the best treatment. This review aims to highlight studies that attempted to characterize bladder cancer radiosensitivity and to discuss the potential biomarkers that could be used to develop bladder cancer radiosensitivity predictive assays.

Penoscrotal Extension and Fistulation From Urothelial Carcinoma of the Bladder

The commonest malignancy of the urinary tract is bladder cancer, with the commonest presentation being painless visible haematuria. Just like other malignancies, it can spread, commonly to surrounding tissues like the prostate, seminal vesicles, and vagina, distantly to lymph nodes, lungs, liver, and bone, and less commonly to the skin and subcutaneous tissues. This is a case of a man with muscle-invasive bladder cancer who underwent radical radiotherapy. He presented nine days into the course of his radiotherapy with new symptoms of pain, swelling, and discharge, particularly at the penoscrotal junction. Ultrasound scans of the testes were normal, and he was treated as a case of scrotal skin abscess with antibiotics. His symptoms persisted and worsened over time despite treatment and multiple hospital attendances. He developed a discharge of fluid from multiple sinuses in the area. Further cross-sectional imaging and direct visualisation with cystoscopy led to the conclusion that there was a urethral recurrence of his urothelial carcinoma which had extended locally into the soft tissues in the penoscrotal area and caused urocutaneous fistulous tracts. An extensive literature review showed no documented cases of vesicocutaneous fistula from urothelial carcinoma, making this the first reported case of penoscrotal extension of bladder cancer and fistulation after radiotherapy.

An evaluation of durvalumab across the spectrum of urothelial carcinoma

INTRODUCTION

Urothelial carcinoma is a common malignancy affecting the urinary system, with the spectrum of disease encompassing non-muscle invasive, muscle-invasive and metastatic disease. On a background of almost half a century of immunogenic management with BCG, various immune checkpoint inhibitors, including durvalumab, have now demonstrated clinical efficacy in the treatment of urothelial carcinoma.

AREAS COVERED

This article reviews the available literature on durvalumab in the treatment of urothelial carcinoma for all stages of the disease including mechanisms of action, pharmacokinetics, efficacy and safety and covers a broad portfolio of reported and ongoing trials.

EXPERT OPINION

The management of UC is rapidly evolving, which is reflected in the diverse range of upcoming pivotal trials incorporating durvalumab with additional immunomodulatory agents and therapeutics targeting key oncogenic pathways, each with the potential to change the standard of care. As the complexity of UC management increases, future efforts should be directed at identifying better predictive biomarkers and selecting rational synergistic combinations from the novel treatments available. This will allow the addressing of existing gaps, facilitate the exploitation of new techniques of treatment delivery and ultimately deliver more personalized and efficacious care to the individual patient.