Neoadjuvant systemic therapy in patients undergoing nephroureterectomy for urothelial cancer: a multidisciplinary systematic review and critical analysis

INTRODUCTION

The benefit of neoadjuvant systemic therapy (NAST) is not yet supported by randomized controlled trials in upper tract urothelial carcinoma (UTUC), but the evidence is increasing. This narrative systematic review was conducted to evaluate the available evidence on the role of NAST in patients undergoing radical nephroureterectomy (RNU) for UTUC.

EVIDENCE ACQUISITION

We searched for all relevant articles or conference abstracts published and indexed in PubMed, Embase, and Scopus on July 19, 2021. The study was reported according to the PRISMA criteria and designed within the PICOS framework. We included studies comparing patients with non-metastatic UTUC who received neoadjuvant chemotherapy (NAC) or immunotherapy (NAI) with patients who underwent definitive surgery alone or surgery plus adjuvant systemic therapy. Prospective uncontrolled studies were also included.

EVIDENCE SYNTHESIS

We identified 27 reports (NAC, N.=24 and NAI, N.=3) published between 2010 and 2021. Twenty of the 24 studies on NAC were retrospective comparative analyses, whereas the remaining four were prospective single-arm studies. One of the three NAI studies exclusively enrolled patients with UTUC. NAC was associated with improved survival and better pathological response relative to surgery alone, but there was no clear advantage when compared to surgery plus adjuvant chemotherapy. Overall, the drug-induced toxicity and risk of disease progression were acceptable but the inherent bias across study designs, inadequate reporting and heterogeneous definition of primary outcomes render it difficult to synthesize results, compare centers, and inform practice.

CONCLUSIONS

The current level of evidence supporting NAST for UTUC is relatively low and the inability to predict responsiveness and thereby pinpoint the optimal candidates remains a major challenge. There is a need to compare NAST to adjuvant therapies using clearly defined primary endpoints as minimum reporting standards developed by a multidisciplinary team.

Induction docetaxel-cisplatin followed by extended-field radiotherapy in patients with cervical metastases from unknown primary carcinoma

BACKGROUND

Cervical metastases from unknown primary tumors are rare and no clear therapeutic options are available. This retrospective analysis aimed to evaluate toxicity and activity of a sequential chemoradiation regimen consisting of induction chemotherapy followed by extended-field radiotherapy in patients with cervical metastases from unknown primary tumors.

PATIENTS AND METHODS

Patients with cytological or histological diagnosis of latero-cervical lymph-node metastasis from carcinoma with unknown origin treated with sequential chemotherapy (3 cycles of docetaxel and cisplatin, each administered as intravenous infusion at the dose of 75 mg/m(2) on day 1, every 21 days) and radiotherapy (cumulative dose of 70 Gy) were included in this study. The radiological response was assessed by central review according to the revised RECIST criteria.

RESULTS

Fifteen patients received three cycles of induction chemotherapy with the combination of docetaxel and cisplatin. Patients were subsequently treated with extended-field radiotherapy. Three complete responses were observed after induction chemotherapy and 13 after the chemoradiation treatment. The overall response rate after chemoradiation, was 93.3% (14 of 15 evaluable patients). One year disease-free-survival was 83.3% (10 of 12 evaluable patients). Treatment was well-tolerated; two cases of grade 4 neutropenia, two of grade 3 mucositis and eight of grade 2 nausea were the worst, most clinically-relevant side-effects.

CONCLUSION

Induction chemotherapy followed by extended-field radiotherapy showed good activity and manageable toxicity in patients with cervical metastases from unknown primary tumors.

Classification of atrial fibrillation as a model of decisional analysis for the treatment of patients with current atrial fibrillation observed in the emergency department

Atrial fibrillation (AF) is the most common cardiac arrhythmia observed in the emergency room (ER). We propose a new classification of AF which is useful for the standardization of terms to be used for future clinical trials and for clinical management of this arrhythmia in the ER. We recognized three categories: (1) atrial fibrillation lasting less than 72 hours (AF < 72 h); (2) persistent atrial fibrillation and (3) permanent atrial fibrillation. Atrial fibrillation lasting less than 72 hours can be reconverted to sinus rhythm spontaneously or with pharmacological or electrical cardioversion. If AF < 72 h is not treated and the arrhythmia persists for more than 72 hours we recognize persistent AF. In persistent AF the systemic thrombo-embolism is a significant risk and therapeutic anticoagulation must be associated to pharmacological or electrical cardioversion even though transoesophageal echocardiography does not visualize thrombi or spontaneous echocontrast in the cardiac chambers. These treatments can reconvert the persistent AF to sinus rhythm, but, in the absence of treatment, or if treatment fails, the arrhythmia goes into the permanent category. In permanent AF ventricular rate control and anticoagulation, if suitable, are the first choice for stroke prevention.