Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer

Effect of neoadjuvant chemotherapy on survival in patients with T1 high-grade non-muscle-invasive bladder cancer who underwent radical cystectomy

Patients with non-muscle-invasive bladder cancer (NMIBC) who are at high and very high risk of disease progression are recommended for radical cystectomy (RC). However, the impact of neoadjuvant chemotherapy (NAC) on survival outcomes in NMIBC patients undergoing RC remains unclear. Patients diagnosed with T1 high-grade NMIBC who underwent RC were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Overall survival (OS) was assessed using the Kaplan-Meier technique, and multivariable Cox regression analysis was conducted to determine the independent factors of OS. A total of 1268 T1 high-grade NMIBC patients who underwent RC between 2004 and 2015 were included in the study. NAC was administered to 76 (6.0%) patients. At a median follow-up of 75 months, there was no significant difference in the OS between the NAC and non-NAC groups (HR = 0.89, 95% CI 0.61-1.30, P = .539). However, in the multivariate Cox regression model, NAC demonstrated a more pronounced improvement in OS approaching statistical significance (HR = 0.7, 95% CI 0.47-1.05, P = .088). Subgroup analysis revealed a survival benefit of NAC in patients with lymph node metastasis. In summary, the results of this study suggest that NAC has the potential to confer a survival advantage in patients diagnosed with T1 high-grade NMIBC who undergo RC, but additional studies are needed. Nonetheless, the survival benefits of NAC in patients with lymph node involvement are apparent.

Comparison between different neoadjuvant chemotherapy regimens and local therapy alone for bladder cancer: a systematic review and network meta-analysis of oncologic outcomes

PURPOSE

The present systematic review and network meta-analysis (NMA) compared the current different neoadjuvant chemotherapy (NAC) regimes for bladder cancer patients to rank them.

METHODS

We used the Bayesian approach in NMA of six different therapy regimens cisplatin, cisplatin/doxorubicin, (gemcitabine/cisplatin) GC, cisplatin/methotrexate, methotrexate, cisplatin, and vinblastine (MCV) and (MVAC) compared to locoregional treatment.

RESULTS

Fifteen studies comprised 4276 patients who met the eligibility criteria. Six different regimes were not significantly associated with a lower likelihood of overall mortality rate compared to local treatment alone. In progression-free survival (PFS) rates, cisplatin, GC, cisplatin/methotrexate, MCV and MVAC were not significantly associated with a higher likelihood of PFS rate compared to locoregional treatment alone. In local control outcome, MCV, MVAC, GC and cisplatin/methotrexate were not significantly associated with a higher likelihood of local control rate versus locoregional treatment alone. Nevertheless, based on the analyses of the treatment ranking according to SUCRA, it was highly likely that MVAC with high certainty of results appeared as the most effective approach in terms of mortality, PFS and local control rates. GC and cisplatin/doxorubicin with low certainty of results was found to be the best second options.

CONCLUSION

No significant differences were observed in mortality, progression-free survival and local control rates before and after adjusting the type of definitive treatment in any of the six study arms. However, MVAC was found to be the most effective regimen with high certainty, while cisplatin alone and cisplatin/methotrexate should not be recommended as a neoadjuvant chemotherapy regime.

[Preoperative chemotherapy for patients with upper tract urothelial carcinoma: Impact on renal function]

PURPOSE

Upper tract urothelial carcinoma (UTUC) are rare tumors with a poor prognosis. The standard treatment for localized disease is based on total nephroureterectomy (NUT) followed by platinum-based adjuvant chemotherapy for eligible patients at risk of recurrence. However, many patients have renal failure after surgery preventing chemotherapy. Thus, the place of preoperative chemotherapy (POC) is questioned with little information available about renal toxicity and efficacity.

METHODS

A single center retrospective study was performed on patients with UTUC who received POC.

RESULTS

In all, 24 patients with localized UTUC were treated with POC between 2013 and 2022. Twenty-one (91%) had secondarily NUT. In this cohort, POC did not result in degradation of median renal function (pre-POC median GFR: 70mL/min, post-POC median GFR: 77mL/min, P=0.79), unlike NUT (post-NUT median GFR: 51.5mL/min, P<0.001). In addition, the rate of complete pathological response to pathological examination was 29%. After a median follow-up of 27.4 months, the overall survival rate was 74% and the recurrence-free survival rate was 46%.

CONCLUSION

POC for UTUC shows a very reassuring renal toxicity profile and encouraging histological results. These data encourage prospective studies assessing its place for UTUC management.

LEVEL OF EVIDENCE: 3

Gender, Racial and Ethnic Differences in Pathologic Response Following Neoadjuvant Chemotherapy for Bladder Cancer Patients

OBJECTIVE

To evaluate trends and racial variations of pathologic complete response (CR) in patients with muscle-invasive bladder cancer undergoing cystectomy.

MATERIALS AND METHODS

The National Cancer Database was queried for patients with non-metastatic muscle-invasive bladder cancer who underwent neoadjuvant chemotherapy and surgery. The primary endpoints, CR and mortality, were evaluated using the Cochran-Armitage test, multivariable regression, and Kaplan-Meier analyses.

RESULTS

The cohort comprised 9955 patients. Non-Hispanic Black (NHB) patients were younger (P < .001), had a higher clinical tumor (P < .001), and had higher clinical node (P = .029) stages at presentation. CR for non-Hispanic White (NHW), NHB, and Hispanic patients were 12.6%, 10.1%, and 11.8%, respectively (P = .030). There was a significant increase in CR trends for NHW patients (P < .001) and increases in NHB (P = .311) and Hispanic patients (P = .236). On multivariable analysis, NHW females had lower odds of achieving CR (odds ratio: 0.83, 95% CI: 0.71-0.97); however, NHB males (hazard ratio: 1.21, 1.01-1.44) and NHB females (hazard ratio: 1.25, 1.03-1.53) had higher overall mortality in adjusted analysis. Survival differences were not observed in patients who achieved CR, regardless of racial background; however, for those with residual disease, the 2-year survival probabilities were 60.7%, 62.5%, and 51.1% for NHW, HW, and NHB patients, respectively (log-rank P = .010).

CONCLUSION

Our findings revealed differences in chemotherapy response based on gender and race or ethnicity. The CR trends for all racial or ethnic groups increased over time. However, Black patients were found to have worse survival, particularly when residual disease was present. Clinical studies with more underrepresented minorities are needed to verify biological differences in response to neoadjuvant chemotherapy.

Neoadjuvant Chemotherapy with Accelerated Methotrexate, Vinblastine, Doxorubicin, and Cisplatin in Patients with Muscle-invasive Bladder Cancer: A Retrospective Age-stratified Analysis on Safety and Efficacy

BACKGROUND

The standard of care (SOC) for muscle-invasive bladder cancer (MIBC) includes cisplatin-based combination chemotherapy in the neoadjuvant setting followed by radical cystectomy. Older patients often do not receive SOC due to perceived toxicity concerns despite guideline-directed recommendations.

OBJECTIVE

To characterize the safety and efficacy of neoadjuvant accelerated methotrexate, vinblastine, adriamycin, and cisplatin (aMVAC) in MIBC patients as a function of age.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis was conducted in 186 MIBC patients treated at Fox Chase Cancer Center between January 1, 2002 and December 31, 2018. Adults with histologically proven muscle-invasive urothelial cancer were eligible. The exclusion criteria included nonurothelial histology, lack of muscularis propria invasion, and primary upper tract or metastatic disease.

INTERVENTION

Neoadjuvant chemotherapy with aMVAC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Patients were stratified by age (<65, 65-74, and >75 yr old). Renal function was assessed at baseline and at time points after treatment. Clinicopathologic variables were compared between age groups to determine efficacy.

RESULTS AND LIMITATIONS

There were no statistically significant differences in dose reductions, treatment interruptions, time to surgery, or adverse events when patients were stratified by age in univariate and multivariate analyses. Full safety data were not available due to the retrospective nature of the study. Baseline renal function was significantly worse among older patients, and the percent decline in creatinine clearance was greater with older age. We found comparable efficacy of aMVAC regardless of age.

CONCLUSIONS

Accelerated MVAC was safe and demonstrated efficacy in MIBC irrespective of age in this single-center, retrospective study. Careful selection based on clinical variables, and not age, should identify patients able to receive neoadjuvant chemotherapy.

PATIENT SUMMARY

We examined the feasibility of the standard cisplatin-based chemotherapy regimen given prior to surgery in patients with muscle-invasive bladder cancer. Elderly patients experienced a greater decline in kidney function with treatment but not more complications than younger patients and tolerated therapy with minimal dose changes, resulting in benefit regardless of age.

Perioperative outcomes of open versus robot-assisted radical cystectomy in octogenarians: a population based analysis

Octogenarians undergoing cystectomy experience higher morbidity and mortality compared to younger patients. Though the non-inferiority of robot-assisted radical cystectomy (RARC) compared to open radical cystectomy (ORC) has been established in a generalized population, the benefits of the robotic approach have not been well studied in an aged population. The National Cancer Database (NCDB) was queried for all patients who underwent cystectomy for bladder cancer from 2010 to 2016. Of these, 2527 were performed in patients age 80 or older; 1988 and 539 underwent ORC and RARC, respectively. On Cox regression analysis, RARC was associated with significantly reduced odds for both 30- and 90-day mortality (HR 0.404, p = 0.004; HR 0.694, p = 0.031, respectively), though the association with overall mortality was not significant (HR 0.877, p = 0.061). The robotic group had a significantly shorter length of stay (LOS) compared to open surgery (10.3 days ORC vs. 9.3 days RARC, p = 0.028). The proportion of cases performed robotically increased over the study period from 12.2% in 2010 to 28.4% in 2016 (p = 0.009, R2 = 0.774). The study is limited by a retrospective design and a section bias, which was not completely control for in the analysis. In conclusion, RARC provides improved perioperative outcomes in aged patients compared to ORC and a trend toward greater utilization of this technique was observed.

Nationwide analysis of survival after radical cystectomy for bladder cancer in Finland

BACKGROUND

Population-based survival results after radical cystectomy (RC) are limited. Our objective was to report short and long-term survival results after RC for bladder cancer from Finland in a population-based setting.

MATERIALS AND METHODS

The Finnish National Cystectomy Database containing retrospectively collected essential RC data covering the years 2005-2017 was combined with the survival data from the Finnish Cancer Registry. Kaplan-Meier plots were used to estimate survival and the survival graphs were illustrated according to the final pathological staging. Centers were divided according to operational volume, and the results were then compared using Pearsons's Chi-squared test.

RESULTS

A total of 2047 patients were included in the study. 30-, and 90-day mortality was 1.3%, and 3.8%, respectively. The OS of the entire RC population at 5- and 10 years was 66% and 55%, and CSS was 74% and 72%, respectively. Center volume did not significantly associate with surgical mortality or long-term survival. The 5- and 10-year OS according to pT-category was 87% and 74% for pT0, 85% and 69% for pTa-pTis-pT1, 70% and 58% for pT2, 50% and 42% for pT3 and 41% and 30% for pT4. The corresponding 5- and 10-year CSS rates were 96% and 93% for pT0, 91% and 90% for pTa-pTis-pT1, 78% and 75% for pT2, 56% and 55% for pT3 and 47% and 44% for pT4. The 5- and 10-year OS rates in patients with no lymph node metastases (pN-) were 74% and 62%, and CSS 82% and 80%, respectively. If lymph nodes were positive (pN+), the corresponding OS rates were 44% and 34% and CSS 49% and 48%, respectively.

CONCLUSION

RC survival results have improved in contemporary series and are associated with the pTNM-status. The nationwide results from Finland demonstrate outcome comparable to high volume single-center series.

Systemic Treatment-Decision Algorithms in Muscle-Invasive Bladder Cancer: Clinical Complexities and Navigating for Improved Outcomes

Muscle-invasive bladder cancer has poor prognosis. If organ confined, it is potentially curable; however, across all prognostic groups, approximately half of patients will relapse. For patients with advanced disease, the median overall survival remains under two years. Systemic treatment options are centered on the use of platinum-based combination chemotherapy, with the choice of cisplatin- or carboplatin-based regimens determined on the basis of criteria including performance status and renal function. PD-1/PD-L1 checkpoint-directed immunotherapy has been established for use in advanced disease with modest overall improvements in survival outcomes. Based on current data, optimal utilization appears to be a switch maintenance strategy on completion of chemotherapy. In the curative setting, cisplatin-based chemotherapy provides modest improvements in cure rates in those fit to receive it. Data on the use of adjuvant immunotherapy are currently contradictory, with disease-free survival demonstrated for adjuvant nivolumab, but not atezolizumab, and no overall survival benefit has yet been confirmed. The Nectin-4 directed antibody drug conjugate enfortumab vedotin is an established treatment option for patients previously treated with both chemotherapy and immunotherapy. The emerging therapeutic targets under evaluation include Trop-2 with sacituzumab govitecan, fibroblast growth factor receptors, HER2, and DNA repair deficiency in biomarker-selected patients. The development of properly validated predictive biomarkers has proven challenging for this disease and should be a central priority in the future development of treatment options. This review summarizes the available systemic treatment options in both palliative and curative disease settings, and highlights the available evidence and current limitations for making treatment recommendations.

Muscle invasive bladder cancer: where is the field headed?

INTRODUCTION

The standard treatment for muscle-invasive bladder cancer (MIBC) is cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy or upfront radical cystectomy for cisplatin-ineligible patients. In those who are ineligible for or refuse radical cystectomy, trimodal therapy with chemoradiation is offered. However, with the success of immune checkpoint inhibitors (ICI) and antibody-drug conjugates such as enfortumab vedotin in the metastatic setting, several trials are implementing these drugs in the neoadjuvant setting for cisplatin ineligible patients. Indeed, nivolumab is approved as adjuvant therapy for high-risk muscle-invasive urothelial carcinoma.

AREAS COVERED

Clinical trials using ICI, ICI/ICI, and ICI/chemotherapy combination therapies in the perioperative setting have been completed. These clinical trials have demonstrated that neoadjuvant ICI are safe and have encouraging pCR, making them promising treatment options. Neoadjuvant enfortumab vedotin alone and in combination with pembrolizumab is also being studied, and preliminarily to have promising activity. ICI is also being combined with radiation therapy (RT) and early data indicate that ICI combined with RT or chemo-RT may be safe with promising activity.

EXPERT OPINION

Biomarkers are urgently needed to identify appropriate treatment options for individual patients. The use of novel treatment approaches and biomarkers will help shape the future of precision therapy for MIBC and enable bladder preservation.

Extended pelvic lymph node dissection in muscle invasive bladder cancer

PURPOSE OF REVIEW

Bilateral pelvic lymph node dissection (PLND) at the time of radical cystectomy (RC) provides important staging information and oncologic benefit in patients with bladder cancer. The optimal extent of the PLND remains controversial. Our aim is to highlight nodal mapping studies and the data that guides optimization of both staging and oncologic outcomes. We then review contemporary randomized trials studying the extent of PLND.

RECENT FINDINGS

A recent randomized trial (RCT) powered for a 15% improvement in recurrence-free survival (RFS) of extended (e) over limited (l)PLND was completed but failed to identify this large difference in outcome. Concerns over study design limit the ability to interpret the oncologic results. Importantly, ePLND minimally changed surgical morbidity. An ongoing, similar RCT (SWOG S1011) powered to detect a 10% difference in RFS has completed accrual, but no published outcomes are available.

SUMMARY

RC and ePLND can provide cure in 33% of LN positive bladder cancer patients. Current data support a 5% improvement in RFS if ePLND is routinely used in MIBC patients. Two randomized trials powered to identify much larger (15 and 10%) improvements in RFS are unlikely to identify such an ambitious benefit by extending the PLND.

Oncological outcomes of visibly complete transurethral resection prior to neoadjuvant chemotherapy for bladder cancer

PURPOSE

To evaluate the potential oncologic benefit of a visibly complete transurethral resection of a bladder tumor (TURBT) prior to neoadjuvant chemotherapy (NAC) and radical cystectomy (RC).

MATERIALS AND METHODS

We identified patients who received NAC and RC between 2011-2021. Records were reviewed to assess TURBT completeness. The primary outcome was pathologic downstaging (

RESULTS

We identified 153 patients, including 116 (76%) with a complete TURBT. Sixty-four (42%) achieved

CONCLUSIONS

A visibly complete TURBT was not associated with pathologic downstaging, cancer-specific or recurrence-free survival following NAC and RC. These data do not support the need for repeat TURBT to achieve a visibly complete resection if NAC and RC are planned.

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Key Words

• Cystectomy
• Neoadjuvant Therapy
• Transurethral Resection of Bladder

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MESH Headings

• Humans
• Treatment Outcome
• Neoadjuvant Therapy
• Urinary Bladder Neoplasms/drug therapy
• Urinary Bladder Neoplasms/surgery
• Urinary Bladder Neoplasms/pathology
• Urologic Surgical Procedures
• Cystectomy
• Retrospective Studies
• Neoplasm Invasiveness

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Affiliation(s)

Bryce Baird Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Ahmet Bilgili Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Augustus Anderson Tulane UniversitySchool of MedicineNew OrleansLAUSATulane University School of Medicine, New Orleans, LA, USA
Gianpiero Carames University of AlabamaDepartment of PathologyBirminghamALUSADepartment of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
Ram A. Pathak Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Colleen T. Ball Mayo ClinicDepartment of Quantitative Health SciencesJacksonvilleFLUSADepartment of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
Raymond Pak Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Andrew Zganjar Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Paul R. Young Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Timothy D. Lyon Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA

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Predictive Value of 18 F-FDG PET/CT for Assessment of Tumor Response to Neoadjuvant Chemotherapy in Bladder Cancer

OBJECTIVE

The purpose of the current study was to evaluate the diagnostic accuracies of 18 F-FDG PET/CT for prediction of tumor response to neoadjuvant chemotherapy in bladder cancer (BC) patients through a systematic review and meta-analysis.

PATIENTS AND METHODS

The PubMed, Cochrane database, and Embase database were searched from inception through November 30, 2022 for studies evaluating diagnostic performance of 18 F-FDG PET/CT for prediction of tumor response to neoadjuvant chemotherapy in BC patients. Based on data extracted from patient-based and lesion-based analysis, we calculated the pooled sensitivity and specificity with the 95% confidence intervals (CIs). Also, we calculated positive and negative likelihood ratios (LR+ and LR-), and constructed summary receiver operating characteristic curves.

RESULTS

Across 5 studies (12 results), the pooled sensitivity of 18 F-FDG PET/CT was 0.84 (95% CI, 0.72-0.91), and the pooled specificity was 0.75 (95% CI, 0.59-0.86). Likelihood ratio (LR) syntheses gave an overall positive likelihood ratio (LR+) of 3.3 (95% CI, 2.0-5.6) and negative likelihood ratio (LR-) of 0.22 (95% CI, 0.12-0.38). The pooled diagnostic odds ratio was 15 (95% CI, 7-36). The pooled sensitivity of 18 F-FDG PET/CT for prediction of pathologic complete response was 0.68 (95% CI, 0.56-0.78), and the pooled specificity was 0.77 (95% CI, 0.60-0.88). The pooled sensitivity of 18 F-FDG PET/CT for prediction of clinical response and nonresponse was 0.94 (95% CI, 0.85-0.98), and a pooled specificity was 0.73 (95% CI, 0.42-0.91).

CONCLUSIONS

18 F-FDG PET/CT showed a good diagnostic performance for prediction of tumor response to neoadjuvant chemotherapy in BC patients.

Selective multimodal bladder-sparing therapy for muscle-invasive bladder cancer: the present and the future

INTRODUCTION

Despite the lack of level 1 evidence, selective bladder-sparing therapy using trimodal therapy is currently recommended by guidelines as a standard of care in patients with non-metastatic, muscle-invasive bladder cancer who are eligible for the treatment.

AREAS COVERED

This article reviews major studies of selective, bladder-sparing therapy utilizing multiple modalities for muscle-invasive bladder cancer and those comparing the oncological outcomes between bladder-sparing therapy and radical cystectomy. Also discussed are predictive biomarkers potentially capable of guiding treatment decisions by patients with muscle-invasive bladder cancer and a novel strategy for boosting the antitumor immune response in bladder-sparing therapy. PubMed databases were searched for records of 30 June 2023 or earlier.

EXPERT OPINION

Selective, bladder-sparing therapy appears to be underutilized at present. To promote its use, measures should be taken to facilitate the referral of eligible patients to specialist centers and broaden the number of facilities providing the therapy. Recent studies have suggested a prognostic benefit of radiotherapy for the primary lesion in patients with metastatic bladder cancer. Given that irradiation can induce the abscopal effect, particularly in combination with immune checkpoint inhibitors, demand for bladder-sparing therapies may increase in the context of treatments for metastases.

Effect of decreased renal function on poor oncological outcome after radical cystectomy

PURPOSE

To evaluate the impact of preoperative renal impairment on the oncological outcomes of patients with urothelial carcinoma who underwent radical cystectomy.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients with urothelial carcinoma who underwent radical cystectomy from 2004 to 2017. All patients who underwent preoperative ^99mTc-diethylenetriaminepentaacetic acid renal scintigraphy (DTPA) were identified. We divided the patients into two groups according to their glomerular filtration rates (GFRs): GFR group 1, GFR≥90 mL/min/1.73 m²; GFR group 2, 60≤GFR<90 mL/min/1.73 m². We included 89 patients in GFR group 1 and 246 patients in GFR group 2 and compared the clinicopathological characteristics and oncological outcomes between the two groups.

RESULTS

The mean time required for recurrence was 125.5±8.0 months in GFR group 1 and 85.7±7.4 months in GFR group 2 (p=0.030). The mean cancer-specific survival was 131.7±7.8 months in GFR group 1 and 95.5±6.9 months in GFR group 2 (p=0.051). The mean overall survival was 123.3±8.1 months in GFR group 1 and 79.5±6.6 months in GFR group 2 (p=0.004).

CONCLUSIONS

Preoperative GFR values in the range of 60≤GFR<90 mL/min/1.73 m² are independent prognostic factors for poor recurrence-free survival, cancer-specific survival, and overall survival in patients after radical cystectomy compared with GFR values of ≥90 mL/min/1.73 m².

Predictive Value of Computed Tomography Following Neoadjuvant Chemotherapy for Muscle Invasive Bladder Cancer

BACKGROUND

Neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) remains standard treatment for select patients with muscle-invasive bladder cancer (MIBC). Although computed tomography (CT) is often obtained prior to RC, its ability to predict pathologic response is poorly characterized.

OBJECTIVE

The purpose of this study is to evaluate the predictive value of CT in assessing disease burden after NAC.

METHODS

Patients with MIBC having received NAC prior to RC were identified. Pre- and post-NAC CT scans were reviewed by an abdominal radiologist. The correlation between pathologic complete response (PCR) and radiologic complete response (RCR) was determined as the primary aim. As a secondary aim, the correlation between pathologic partial response (PPR) and radiologic partial response (RPR) was determined. Logistic regression analysis was utilized to determine the predictive value of CT in determining disease burden at RC.

RESULTS

A total of 141 patients were identified for analysis. PCR and PPR was achieved in 34% and 16% of patients, respectively. The positive predictive value of post-NAC CT was 53.5% for PCR and 28.8% for PPR. The negative predictive value of post-NAC CT was 73.5% for PCR and 46.2% for PPR. There was no significant association between RCR and PCR (OR 1.13, p = 0.67). Similarly, there was no meaningful association between RPR and PPR, lymph node involvement, or presence of extravesical disease.

CONCLUSIONS

CT findings correlate poorly with final pathology at RC and should not be used to evaluate local disease burden.

The Development of a Video-based Nutrition Education Curriculum for Patients Undergoing Radical Cystectomy

BACKGROUND

The treatment for patients with muscle-invasive bladder cancer includes neoadjuvant chemotherapy followed by radical cystectomy. The American Urological Association guidelines stress the optimization of patient performance status in the perioperative setting. Therefore, implementation of nutrition education is critical for the multi-disciplinary care of this vulnerable patient population and wide distribution of information is critical.

OBJECTIVE

The goal of our study was to create a nutrition-based video education series for patients undergoing chemotherapy and radical cystectomy for bladder cancer.

METHODS

Scripts for the videos were developed through an iterative process by experts in nutrition, urology, and communication. Providers and patient advocates were recruited to perform semi-structured interviews and surveys for additional feedback. Performer facial emotion recognition (Noldus™) was used to assess displayed emotion by the presenters. Mangold VisionPlayer software was used for participant eye movement tracking of the video content. A knowledge survey was created, and Item Content Validity Index (I-CVI) was calculated with a nutrition expert advisory board. Participants were recruited for cognitive interviewing to understand the mental processes and interpretations while answering questions.

RESULTS

The video series is available to the public on the Bladder Cancer Advocate Network (BCAN) website at the following URL: https://bcan.org/facing-bladder-cancer/nutrition-bladder-cancer/eating-healthy-bladder-cancer/. Cinematic filming methods, (smaller depth of field, lighting, and camera movement) enhanced message delivery along with music and text on screen to anchor important concepts.

CONCLUSIONS

This study can be a framework for the development of a patient education video library accessible through electronic medical records, health care applications, and patient advocacy websites.

Conditional Reprogramming Modeling of Bladder Cancer for Clinical Translation

The use of advanced preclinical models has become increasingly important in drug development. This is particularly relevant in bladder cancer, where the global burden of disease is quite high based on prevalence and a relatively high rate of lethality. Predictive tools to select patients who will be responsive to invasive or morbid therapies (chemotherapy, radiotherapy, immunotherapy, and/or surgery) are largely absent. Patient-derived and clinically relevant models including patient-derived xenografts (PDX), organoids, and conditional reprogramming (CR) of cell cultures efficiently generate numerous models and are being used in both basic and translational cancer biology. These CR cells (CRCs) can be reprogrammed to maintain a highly proliferative state and reproduce the genomic and histological characteristics of the parental tissue. Therefore, CR technology may be a clinically relevant model to test and predict drug sensitivity, conduct gene profile analysis and xenograft research, and undertake personalized medicine. This review discusses studies that have utilized CR technology to conduct bladder cancer research.

Targeting bladder cancer: A sex sensitive perspective in mutations and outcomes

The incidence of bladder cancer (BC) is more common in males, however, the clinical outcome for females tends to be more unfavorable, as demonstrated by a 21% increase in mortality compared to males within two years of diagnosis. While it was previously believed that the differences in outcome were solely the result of differences in sex chromosomes and hormones, it is now acknowledged that a more intricate interplay of factors is at play. By acquiring a more comprehensive understanding of these sex-specific effects, future efforts in precision medicine can be customized to an individual's biological sex. This narrative review aims to summarize our knowledge of the molecular classification of sex differences in BC by compiling the existing evidence on genetic disparities between males and females and evaluating these disparities in both noninvasive bladder cancer (NMIBC) and muscle invasive bladder cancer (MIBC). Our findings emphasize the significance of considering sex as a factor in future clinical trials and registry studies due to established differences in immune composition, molecular profiling, and genetic mutations between males and females. Further investigation into the molecular processes involved in the evasion or resistance of immune-based therapies, such as Bacillus Calmette-Guérin and other immunotherapies, is essential to identify markers of response or resistance that vary between male and female patients. This will aid in optimizing treatment and promoting equitable outcomes, particularly in NMIBC cases.

The CHASIT study: sequential chemo-immunotherapy in patients with locally advanced urothelial cancer - a non-randomized phase II clinical trial

BACKGROUND

Patients with locally advanced irresectable or clinically node positive urothelial cancer (UC) have a poor outcome. Currently, these patients can only be cured by receiving induction chemotherapy and, if an adequate radiological response is obtained, radical surgical resection. Long-term survival, however, strongly depends on the absence of residual tumor in the surgical resection specimen, i.e. a pathological complete response (pCR). The reported pCR rate following induction chemotherapy in locally advanced or clinically node-positive UC is 15%. The 5-year overall survival rate for patients achieving a pCR is 70-80% versus 20% for patients who have residual disease or nodal metastases. This clearly demonstrates the unmet need to improve clinical outcome of these patients. Recently, the JAVELIN Bladder 100 study demonstrated an overall survival benefit of sequential chemo-immunotherapy in patients with metastatic UC. The CHASIT study aims to translate these findings to the induction setting by assessing the efficacy and safety of sequential chemo-immunotherapy in patients with locally advanced or clinically node-positive UC. In addition, patient biomaterials are collected to investigate biological mechanisms of response and resistance to chemo-immunotherapy.

METHODS

This multicenter, prospective phase II clinical trial includes patients with stage cT4NxM0 or cTxN1-N3M0 UC of the bladder, upper urinary tract or urethra. Patients who do not experience disease progression after 3 or 4 cycles of platinum-based chemotherapy are eligible for inclusion. Included patients receive 3 cycles of anti-PD-1 immunotherapy with avelumab followed by radical surgery. Primary endpoint is the pCR rate. It is hypothesized that sequential chemo-immunotherapy results in a pCR rate of ≥ 30%. To obtain a power of 80%, 64 patients are screened and 58 patients are included in the efficacy analysis. Secondary endpoints are toxicity, postoperative surgical complications, progression-free, cancer-specific and overall survival at 24 months.

DISCUSSION

This is the first study to assess the potential benefit of sequential chemo-immunotherapy in patients with locally advanced or node positive UC. If the primary endpoint of the CHASIT study is met, i.e. a pCR rate of ≥ 30%, a randomized controlled trial is foreseen to compare this new treatment regimen to standard care.

TRIAL REGISTRATION

NCT05600127 at Clinicaltrials gov, registered on 31/10/2022.

Novel sequential treatment strategy for patients with muscle-invasive bladder cancer (MIBC): intravesical recombinant BCG, followed by neoadjuvant chemoimmunotherapy, radical cystectomy plus pelvic lymphadenectomy and adjuvant immunotherapy - protocol of a multicentre, single arm phase 2 trial (SAKK 06/19)

INTRODUCTION

The combination of checkpoint inhibition and cisplatin-based chemotherapy is investigated in muscle invasive bladder cancer (MIBC) and results from phase 2 trials have been presented. Intravesical BCG has been used for non-MIBC (NMIBC) in patients with carcinoma in situ and high-grade Ta/T1 tumours. BCG induces innate and adapted immune response and upregulation of PD-L1 in preclinical models. The proposed trial is intended to implement a new immuno-immuno-chemotherapy induction therapy for MIBC. The combination of BCG and checkpoint inhibition with chemotherapy aims at higher intravesical responses and better local and systemic control of disease.

METHODS AND ANALYSIS

SAKK 06/19 is an open-label single-arm phase II trial for patients with resectable MIBC T2-T4a cN0-1. Intravesical recombinant BCG (rBCG: VPM1002BC) is applied weekly for three instillations followed by four cycles of neoadjuvant cisplatin/gemcitabine every 3 weeks. Atezolizumab 1200 mg every 3 weeks is started together with rBCG and given for four cycles. All patients then undergo restaging and radical cystectomy and pelvic lymphadenectomy. Atezolizumab is continued as maintenance therapy after surgery every 3 weeks for 13 cycles. Pathological complete remission is the primary endpoint. Secondary endpoints include pathological response rate (

TRIAL REGISTRATION NUMBER

NCT04630730.

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Key Words

• CHEMOTHERAPY
• IMMUNOLOGY
• ONCOLOGY
• Urological tumours

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MESH Headings

• Humans
• Cisplatin/therapeutic use
• BCG Vaccine/therapeutic use
• Cystectomy
• Neoadjuvant Therapy
• Urinary Bladder Neoplasms/drug therapy
• Urinary Bladder Neoplasms/pathology
• Immunotherapy
• Administration, Intravesical
• Muscles/pathology
• Lymph Node Excision
• Multicenter Studies as Topic
• Clinical Trials, Phase II as Topic

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Grants

• F. Hoffmann–La Roche Ltd

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Affiliation(s)

Ulf Petrausch OnkoZentrum, Zurich, Switzerland
Martin Spahn Lindenhof Group, Bern, Switzerland
Martina Schneider Competence Center, SAKK, Bern, Switzerland
Stefanie Hayoz Competence Center, SAKK, Bern, Switzerland
Cyrill A Rentsch Department of Urology, University Hospital, Basel, Switzerland
Sacha Rothschild Department of Medical Oncology, Cantonal Hospital, Baden, Switzerland
Aurelius Omlin OnkoZentrum, Zurich, Switzerland
Richard Cathomas Division of Oncology/Hematology, Cantonal Hospital Graubünden, Chur, Switzerland

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Utility of Patient-Reported Symptom and Functional Outcomes to Indicate Recovery after First 90 Days of Radical Cystectomy: A Longitudinal Study

This is a longitudinal prospective study that tracked multiple symptom burden and functioning status for bladder cancer (BLC) patients for 3 months post-radical cystectomy at The University of Texas MD Anderson Cancer Center, using a validated disease-specific patient-reported outcome measure (PROM) tool, the MD Anderson Symptom Inventory (the MDASI-PeriOp-BLC). The feasibility of collecting an objective measure for physical functioning, using "Timed Up & Go test" (TUGT) and PRO scores at baseline, discharge and end of study, was tested. Patients (n = 52) received care under an ERAS pathway. The more severe scores of fatigue, sleep disturbance, distress, drowsiness, frequent urination and urinary urgency at baseline predicted poor functional recovery postoperatively (OR = 1.661, 1.039-2.655, p = 0.034); other more severe symptoms at discharge (pain, fatigue, sleep disturbance, lack of appetite, drowsiness, bloating/abdominal tightness) predicted poor functional recovery (OR = 1.697, 1.114-2.584, p = 0.014) postoperatively. Compliance rates at preoperative, discharge and end of study were 100%, 79% and 77%, while TUGT completion rates were 88%, 54% and 13%, respectively. This prospective study found that more severe symptom burden at baseline and discharge is associated with poor functional recovery post-radical cystectomy for BLC. The collection of PROs is more feasible than using performance measures (TUGT) of function following radical cystectomy.

The role of malnutrition universal screening tool in predicting outcomes after radical cystectomy

PURPOSE

The Malnutrition Universal Screening Tool integrates body mass index, unintentional weight loss and present illness to assess risk for malnutrition. The predictive role of 'MUST' among patients undergoing radical cystectomy is unknown. We investigated the role of 'MUST' in predicting postoperative outcomes and prognosis among patients after RC.

MATERIALS AND METHODS

We conducted a multicenter retrospective analysis of 291 patients who underwent radical cystectomy in 6 medical centers between 2015 and 2019. Patients were stratified to risk groups according to the 'MUST' score [low risk (n = 242) vs. medium-to-high risk (n = 49)]. Baseline characteristics were compared between groups. Endpoints were 30-day postoperative complications rate, cancer-specific-survival and overall survival. Kaplan-Meier curves and Cox-regression analyses were used to evaluate survival and identify predictors of outcomes.

RESULTS

Median age of the study cohort was 69 years (IQR 63-74). Median duration of follow up for survivors was 33 months (IQR 20-43). Thirty-day major postoperative complications rate was 17%. Baseline characteristics were not different between the 'MUST' groups, and there was no difference in early post-operative complication rates. CSS and OS were significantly lower (p ≤ 0.02) in the medium-to-high-risk group ('MUST' score≥1) with estimated 3-year CSS and OS rates of 60% and 50% compared to 76% and 71% in the low-risk group, respectively. On multivariable analysis, 'MUST'≥1 was an independent predictor of overall- (HR = 1.95, p = 0.006) and cancer-specific-mortality (HR = 1.74, p = 0.05).

CONCLUSIONS

High 'MUST' scores are associated with decreased survival in patients after radical cystectomy. Thus, the 'MUST' score may serve as a preoperative tool for patient selection and nutritional intervention.

Biodynamic prediction of neoadjuvant chemotherapy response: Results from a prospective multicenter study of predictive accuracy among muscle-invasive bladder cancer patients

BACKGROUND

Biodynamic signatures (temporal patterns of microscopic motion within a 3-dimensional tumor explant) offer phenomic biomarkers that are highly predictive for therapeutic response.

OBJECTIVE

By utilizing motility contrast tomography, which provides a simple, fast assessment of motion patterns in living tissue, we evaluated the predictive accuracy of a biodynamic drug response classifier in muscle-invasive bladder cancer (MIBC) patients undergoing neoadjuvant chemotherapy (NAC).

DESIGN, SETTING, AND PARTICIPANTS

One hundred five consecutive bladder cancer patients suspected of having MIBC were screened in a multi-institutional prospective observational study (NCT03739177) from July 2018 to June 2020, of whom, 30 completed NAC and radical cystectomy.

INTERVENTION(S)

Biodynamic signatures from treatment-naïve fresh bladder tumor specimens obtained after transurethral resection were measured in living tumor fragments challenged by standard-of-care cytotoxins. Patients received gemcitabine and cisplatin or dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin per institutional guidelines and were followed through radical cystectomy.

OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS

A 4-level classifier was developed to predict pathologic complete response (pCR) vs. incomplete response utilizing a one-left-out cross-validation protocol to minimize over-fitting. Area under the curve evaluated predictive utility.

RESULTS

Thirty percent (9 of 30) achieved pCR. Utilizing the 4-level classifier, biodynamically "favored" (scoring ≥ 3) and "strongly favored" (scoring 4) regimens accurately predicted pCR at rates of 66.7% (4 of 6 patients) and 100% (4 of 4 patients), respectively. Biodynamically "favored" scores predicted pCR with 88% sensitivity and 95% negative predictive value, P < 0.0001. Only 5.0% (1 of 20 patients) achieved pCR from regimens scoring 1 or 2, indicating poor to no response from NAC. Area under the receiver operating curve was 96% (95% Confidence Interval: 79%-99%, P < 0.0001). Future direction involves validating this model prospectively.

PRINCIPAL CONCLUSIONS

Biodynamic scoring accurately predicts response in MIBC patients receiving NAC and holds promise to substantially improve the scope of appropriate management intervention.

Neoadjuvant Chemotherapy Followed by Cystectomy: a Single-Center Experience

Nearly 50% of patients with muscle-invasive bladder cancer treated with cystectomy alone will progress to metastatic disease. Surgery alone is not a sufficient therapy in a large number of patients with invasive bladder cancer. Systemic therapy with cisplatin-based chemotherapy has been shown to provide response rates in several bladder cancer studies. There have been multiple randomized controlled studies undertaken to define further the effectiveness of neoadjuvant cisplatin-based chemotherapy in advance of cystectomy. In this study, we have retrospectively reviewed our series of patients who underwent neoadjuvant chemotherapy followed by radical cystectomy for muscle-invasive disease. Between Jan 2005 and Dec 2019, 72 patients underwent radical cystectomy following neoadjuvant chemotherapy over a 15-year period. The data was retrospectively collected and analyzed. The median age was 59.84 ± 8.967 years (range, 43 to 74), and the ratio of male to female patients was 5:1. Of the 72 patients, 14 (19.44%) completed all the three cycles, 52 (72.22%) completed at least two cycles, and the remaining 6 (8.33%) completed only one cycle of neoadjuvant chemotherapy. A total of 36 (50%) patients died during the follow-up period. The mean and median survival of the patients was 84.85 ± 4.25 months and 91.0 ± 5.83 months respectively. Neoadjuvant MVAC should be offered to patients with locally advanced bladder cancer and who are candidates for radical cystectomy. It is safe and effective in patients with adequate renal function. The patients need to be carefully monitored for chemotherapy-induced toxic effects, and appropriate intervention is necessary in the event of severe adverse effects.

Adjuvant chemotherapy after radical cystectomy: Do all patients who need chemotherapy after surgery actually receive it?

Background

Compliance with the guideline recommendations for neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer is incomplete. The adjuvant chemotherapy approach has the advantage of pathology-based decision-making, allowing for patient selection. In addition, radical surgery is not delayed and treatment-related toxicity does not impair surgical fitness. The proportion of patients who completed chemotherapy after cystectomy among those who were fit and in need of treatment were evaluated. The reasons for not completing adjuvant chemotherapy were determined.

Materials and methods

We retrospectively evaluated all patients who had undergone radical cystectomy at our center over the last 7 years. Indications for adjuvant chemotherapy included pathological T > 2, any node+, or surgical margin involvement. Only patients who were fit for chemotherapy before surgery were included in the study.

Results

Of the 52 patients with muscle-invasive bladder cancer, 14 received neoadjuvant chemotherapy or unfit for chemotherapy were excluded. Of the remaining 38 patients, 14 (37%) had bladder-confined cancers and did not require additional chemotherapy. Of the 24 patients who needed chemotherapy and were fit to receive it, 8 patients completed treatment (33%), and 3 discontinued treatment due to toxicity. Twelve patients (50%) declined chemotherapy, whereas 1 patient became unfit for chemotherapy after surgery.

Conclusions

While the adjuvant chemotherapy approach could save unnecessary treatment in 37% of patients, two-thirds of those who needed chemotherapy did not complete it. Patient refusal was the primary reason for not receiving treatment.

Medicarpin induces G1 arrest and mitochondria-mediated intrinsic apoptotic pathway in bladder cancer cells

Bladder cancer (BC) is the tenth most commonly diagnosed cancer. High recurrence, chemoresistance, and low response rate hinder the effective treatment of BC. Hence, a novel therapeutic strategy in the clinical management of BC is urgently needed. Medicarpin (MED), an isoflavone from Dalbergia odorifera, can promote bone mass gain and kill tumor cells, but its anti-BC effect remains obscure. This study reve aled that MED effectively inhibited the proliferation and arrested the cell cycle at the G1 phase of BC cell lines T24 and EJ-1 in vitro. In addition, MED could significantly suppress the tumor growth of BC cells in vivo. Mechanically, MED induced cell apoptosis by upregulating pro-apoptotic proteins BAK1, Bcl2-L-11, and caspase-3. Our data suggest that MED suppresses BC cell growth in vitro and in vivo via regulating mitochondria-mediated intrinsic apoptotic pathways, which can serve as a promising candidate for BC therapy.

A Systematic Review of Oncological Outcomes Associated with Bladder-sparing Strategies in Patients Achieving Complete Clinical Response to Initial Systemic Treatment for Localized Muscle-invasive Bladder Cancer

CONTEXT

Bladder-sparing strategies (BSSs) have been proposed for the treatment of muscle-invasive bladder cancer (MIBC) patients achieving clinical complete response (cCR) to initial systemic treatment to avoid toxicity related to radical cystectomy.

OBJECTIVE

To systematically review the current literature evaluating oncological outcomes of BSSs in patients achieving cCR to initial systemic treatment for localized MIBC.

EVIDENCE ACQUISITION

A computerized bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting oncological outcomes of MIBC patients undergoing either surveillance or radiation therapy after achieving cCR to initial systemic treatment. Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we identified 23 noncomparative prospective or retrospective studies published between 1990 and 2021. The mean bladder and metastatic recurrence rates (range) as well as the mean bladder preservation rate (BPR; range) were calculated, and overall survival (OS) was extracted from included reports.

EVIDENCE SYNTHESIS

Overall, 16 and seven studies evaluated surveillance (n = 610) and radiation therapy (n = 175) in MIBC patients achieving cCR to initial systemic treatment, respectively. With regard to surveillance, the median follow-up ranged from 10 to 120 mo, with a mean bladder recurrence rate of 43% (0-71%), including 65% of non-muscle-invasive bladder cancer (NMIBC) and 35% of MIBC recurrences. The mean BPR was 73% (49-100%). The mean metastatic recurrence rate was 9% (0-27%), while 5-yr OS rates ranged from 64% to 89%. With regard to radiation therapy, the median follow-up ranged from 12 to 60 mo, with a mean bladder recurrence rate of 15% (0-29%), including 24% of NMIBC, 43% of MIBC, and 33% of unspecified recurrences. The mean BPR was 74% (71-100%). The mean metastatic recurrence rate was 17% (0-22%), while the 4-yr OS rate was 79%.

CONCLUSIONS

Our systematic review showed that only low-level evidence supports the effectiveness of BSSs in selected patients achieving cCR to initial systemic treatment for localized MIBC. These preliminary findings highlight the need for further prospective comparative research to demonstrate its efficacy.

PATIENT SUMMARY

We reviewed studies evaluating bladder-sparing strategies in patients achieving complete clinical response to initial systemic treatment for localized muscle-invasive bladder cancer. Based on low-level evidence, we observed that selected patients could benefit from surveillance or radiation therapy in this setting, but prospective comparative research is requested to confirm their efficacy.

Adjuvant vs. progression-triggered treatment with gemcitabine in platinum-ineligible high-risk bladder cancer patients: Long-term follow-up of a randomized phase 3 trial

BACKGROUND

Cisplatin-based chemotherapy (ChT) is the preferred perioperative treatment in muscle-invasive urothelial carcinoma of the urinary bladder (UCUB). Nevertheless, a certain number of patients are ineligible for platinum-based ChT. This trial compared immediate adjuvant vs. delayed gemcitabine ChT at progression in platinum-ineligible patients with high-risk UCUB.

METHODS

High-risk platinum-ineligible UCUB patients (n = 115) were randomized 1:1 to adjuvant gemcitabine (n = 59) or gemcitabine at progression (n = 56). Overall survival was analyzed. Additionally, we analyzed progression-free survival (PFS), toxicity and quality of life (QoL).

RESULTS

After a median follow-up of 3.0 years (inter quartile range [IQR]: 1.3-11.6), adjuvant ChT did not significantly prolong overall survival (OS) (HR: 0.84; 95% CI: 0.57-1.24; P = 0.375), with 5-year OS of 44.1% (95% CI: 31.2-56.2) and 30.4% (95% CI: 19.0-42.5), respectively. We noted no significant difference in PFS (HR: 0.76; 95% CI: 0.49-1.18; P = 0.218), with 5-year PFS of 36.2% (95% CI: 22.8-49.7) in the adjuvant group and 22.2% (95% CI: 11.5%-35.1%) when treated at progression. Patients with adjuvant treatment showed a significantly worse QoL. The trial was prematurely closed after recruitment of 115 of the planned 178 patients.

CONCLUSIONS

There was no statistically significant difference in terms of OS and PFS for patients with platinum-ineligible high-risk UCUB receiving adjuvant gemcitabine compared to patients treated at progression. These findings underline the importance of implementing and developing new perioperative treatments for platinum-ineligible UCUB patients.

Evolving systemic management of urothelial cancers

PURPOSE OF REVIEW

Bladder cancer is the 12th most common cancer worldwide. Historically, the systemic management of urothelial carcinoma has been confined to platinum-based chemotherapy. In this review, we discuss the evolving landscape of systemic treatment for urothelial carcinoma.

RECENT FINDINGS

Since 2016, when the Food and Drug Administration approved the first immune checkpoint inhibitor (CPI), programmed cell death 1 and programmed cell death ligand 1 inhibitors have been evaluated in the nonmuscle invasive bladder cancer, localized muscle invasive bladder cancer as well as advanced/metastatic bladder cancer settings. Newer approved treatments such as fibroblast growth factor receptor (FGFR) inhibitors and antibody-drug conjugates (ADCs) represent second-line and third-line options. These novel treatments are now being assessed in combination as well as with older traditional platinum-based chemotherapy.

SUMMARY

Novel therapies continue to improve bladder cancer outcomes. Personalized approach with well validated biomarkers are important to predict response to therapy.

Comparative Effectiveness of Radiation Versus Radical Cystectomy for Localized Muscle-Invasive Bladder Cancer

Purpose

Radical cystectomy (RC) with neoadjuvant chemotherapy is the most commonly recommended treatment for muscle-invasive bladder cancer (MIBC), yet RC with urinary diversion remains an invasive treatment. Although some patients with MIBC gain good cancer control with radiation therapy (RT), its effectiveness remains under discussion. Therefore, we aimed to reveal the effectiveness of RT compared with RC for MIBC.

Methods and Materials

Using cancer registry and administrative data from 31 hospitals in our prefecture, we recruited patients with bladder cancer (BC) initially registered between January 2013 and December 2015. All patients received RC or RT, and none had metastases. Prognostic factors for overall survival (OS) were analyzed by Cox proportional hazards model and log-rank test. Propensity score matching between the RC and RT groups was performed to examine the association of each factor with OS.

Results

Among the patients with BC, 241 received RC and 92 received RT. Median ages of the patients receiving RC and RT were 71.0 and 76.5 years, respectively. Five-year OS rates were 44.8% for patients receiving RC and 27.6% for patients receiving RT (P < .001). Multivariate analysis for OS showed that older age, poorer functional disability, clinical node positive, and pathology of nonurothelial carcinoma were significantly associated with worse prognosis. A propensity score-matching model identified 77 patients with RC and 77 with RT. In this arranged cohort, there were no significant differences in OS between the RC and RT groups (P = .982).

Conclusions

Prognostic analysis with matched characteristics showed that patients with BC receiving RT were not significantly different from those receiving RC. These findings could contribute to proper treatment strategies for MIBC.

Carboplatin Induction Chemotherapy in Clinically Lymph Node–positive Bladder Cancer

Background

There are currently no guideline recommendations regarding the treatment of cisplatin-ineligible, clinically lymph node-positive (cN+) bladder cancer (BCa).

Objective

To investigate the oncological efficacy of gemcitabine/carboplatin induction chemotherapy (IC) in comparison to cisplatin-based regimens in cN+ BCa.

Design setting and participants

This was an observational study of 369 patients with cT2-4 N1-3 M0 BCa.

Intervention

IC followed by consolidative radical cystectomy (RC).

Outcome measurements and statistical analysis

The primary endpoints were the pathological objective response (pOR; ypT0/Ta/Tis/T1 N0) rate and the pathological complete response (pCR; ypT0N0) rate. We applied 3:1 propensity score matching (PSM) to reduce selection bias. Overall survival (OS) and cancer-specific survival (CSS) were compared across groups using the Kaplan-Meier method. Associations between the treatment regimen and survival endpoints were tested in multivariable Cox regression analyses.

Results and limitations

After PSM, a cohort of 216 patients was available for analysis, of whom 162 received cisplatin-based IC and 54 gemcitabine/carboplatin IC. At RC, 54 patients (25%) had a pOR and 36 (17%) had a pCR. The 2-yr CSS was 59.8% (95% confidence interval [CI] 51.9-69%) for patients who received cisplatin-based IC versus 38.8% (95% CI 26-57.9%) for those who received gemcitabine/carboplatin. For the pOR (p = 0.8), ypN0 status at RC (p = 0.5), and cN1 BCa subgroups (p = 0.7), there was no difference in CSS between cisplatin-based IC and gemcitabine/carboplatin. In the cN1 subgroup, treatment with gemcitabine/carboplatin was not associated with shorter OS (p = 0.2) or CSS (p = 0.1) on multivariable Cox regression analysis.

Conclusions

Cisplatin-based IC seems to be superior to gemcitabine/carboplatin and should be the standard for cisplatin-eligible patients with cN+ BCa. Gemcitabine/carboplatin may be an alternative treatment for selected cisplatin-ineligible patients with cN+ BCa. In particular, selected cisplatin-ineligible patients with cN1 disease may benefit from gemcitabine/carboplatin IC.

Patient summary

In this multicenter study, we found that selected patients with bladder cancer and clinical evidence of lymph node metastasis who cannot receive standard cisplatin-based chemotherapy before surgery to remove their bladder may benefit from chemotherapy with gemcitabine/carboplatin. Patients with a single lymph node metastasis may benefit the most.

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

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

[Perioperative systemic treatment of urothelial cancer]

In 2020 the number of cases of newly diagnosed urothelial cancer in Germany was approximately 35,000, making urothelial cancer the fifth most common form of cancer in this country in terms of incidence. If systemic recurrence occurs the risk of dying from urothelial cancer is high. For this reason, perioperative concepts that improve the overall survival around curatively intended cystectomy are becoming increasingly more important as part of multimodal concepts for urothelial cancer. In the neoadjuvant setting, platinum-based chemotherapy currently remains the gold standard and can also be used in the adjuvant setting. Recently, immunotherapy has gained in importance for adjuvant treatment. Further innovations, such as the use of immunotherapy in the neoadjuvant setting or combination therapies in both situations can be expected. This article provides insights into the current recommendations and highlights possible new concepts.

Management of surgically inoperable muscle-invasive bladder cancer in a resource constraint setting at a tertiary care center by bladder preservation protocol: Case series

Introduction

Urinary bladder cancer is a major cause of morbidity and mortality worldwide. As per the data from the US cancer registry, it was diagnosed in nearly 71,000 patients and led to 14000 deaths in 2013. The Indian data in this regard are lacking with few case reports and epidemiological data only. The paucity of treatment data in this regard led us to undertake this prospective study at our radiation oncology canter. Carcinoma urinary bladder is a heterogeneous disease with variable natural history. Male preponderance and association with cigarette smoking appears to be the foremost in natural history of the disease. Our data analyzed the management of muscle-invasive medically and surgically inoperable carcinoma urinary bladder in a resource constraint setting at a tertiary care center by bladder preservation protocol (BPP).

Materials and Methods

This prospective study was aimed to evaluate the treatment outcome in surgically inoperable muscle-invasive carcinoma urinary bladder in a resource constraint setting at a tertiary care center by BPP. All patients were treated with telecobalt 60 machine up to a dose of 60-66 Gy along with concurrent chemotherapy. Interim assessment was done at 40 Gy.

Results

A total of nine patients were taken up for treatment with BPP. All patients were evaluated with standard evaluation protocol. All patients were followed up till any event occurred and till 6 years. Out of nine patients treated, six patients are still alive without any progression of disease and are disease free with standard evaluation on follow-up. Two patients died during the 1st year of follow-up. One patient progressed with lung and abdominal metastases 5 months after the completion of treatment and one patient was lost to follow-up.

Conclusion

BPP using trimodality therapy is a suitable alternative to radical cystectomy in medically and surgically inoperable carcinoma urinary bladder. These patients should be highly compliant for regular follow-up, and acute and long-term toxicity should be evaluated in detail at each visit. BPP gives a ray of hope in such settings and should be done with caution. In our study, we treated all these patients in our resource constraint settings with good results and high survival rates. Our integrated team of radiation oncologists, medical oncologists, and urologists closely followed up these patients in order to optimize outcomes.

Neoadjuvant therapy with Disitamab vedotin in treating muscle-invasive bladder cancer: A case report

Purpose

Platinum-based regimens are regarded as the preferred alternative for neoadjuvant chemotherapy for muscle-invasive bladder cancer (MIBC) patients. However, some patients cannot tolerate platinum-based regimens. We report an MIBC case with severe renal insufficiency treated by neoadjuvant therapy with gemcitabine and Disitamab Vedotin.

Materials and Methods

A 68-year-old man with severe renal insufficiency was admitted to our department and diagnosed with cT3N0M0 MIBC. Immunohistochemical staining of the biopsy tissues showed human epidermal growth factor receptor 2 expression (1+). This patient received neoadjuvant therapy with gemcitabine 1600 mg and DV 120 mg intravenously every three weeks 3 times. We compared the imaging results of the patient before and after neoadjuvant therapy. In addition, the white blood cell count, alanine aminotransferase, aspartate aminotransferase, and serum creatinine were followed up during neoadjuvant therapy. Abnormal symptoms such as hair loss, fatigue, and hypoesthesia were also recorded.

Results

According to the imaging examinations, the lesions were significantly reduced after receiving neoadjuvant therapy. Significant adverse side effects did not occur during neoadjuvant therapy.

Conclusions

In this T3N0M0 cisplatin-ineligible patient, gemcitabine combined with DV as neoadjuvant therapy achieved radiological partial response, and no significant adverse events were observed during neoadjuvant therapy.

Is There A Benefit of Restaging Transurethral Resection of Bladder Tumor Prior to Radical Cystectomy With or Without Neoadjuvant Chemotherapy?

BACKGROUND

One of the best predictors of positive outcomes in bladder cancer (BC) is pT0 following radical cystectomy (RC). Discordance between clinical and pathologic staging affects decision-making in patients with clinical absence of disease (cT0).

OBJECTIVES

We sought to determine whether a restaging transurethral resection of bladder tumor (re-TURBT) improves clinical staging accuracy relative to pathologic stage RC in patients treated with neoadjuvant chemotherapy (NAC) versus those who did not receive NAC.

METHODS

We queried our prospectively maintained IRB approved institutional database to identify 129 patients who underwent RC from 2013 to 2019 with a re-TURBT prior to RC. 53 patients were treated with NAC between their initial and re-TURBT and 76 patients were not treated with NAC.

RESULTS

The overall upstaging rate from re-TURBT to RC was 34.9%. There was no significant difference in the upstaging rate between the NAC and no-NAC groups - 31.0% vs. 37.0%, respectively. In patients who were cT0 on re-TURBT, the NAC group did not show a significantly greater rate of pathologic clinical CR (pT0) than the no NAC group - 38.5% vs. 37.5%, respectively. Re-TURBT with staging < rT2 as a predictor for absence of MIBC on pathologic staging (

CONCLUSIONS

Re-TURBT after NAC does not show statistically significant improvement in staging accuracy relative to pathologic stage at RC compared to re-TURBT in patients not treated with NAC.

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Key Words

• Bladder Cancer
• neoadjuvant chemotherapy
• radical cystectomy
• transurethral resection of bladder tumor

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Affiliation(s)

Justin P Mehr Scott Department of Urology, Dan L Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
Jenna N Bates Scott Department of Urology, Dan L Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
Seth P Lerner Scott Department of Urology, Dan L Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA

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Prospective Evaluation of FDG-PET/CT for On-treatment Assessment of Response to Neoadjuvant or Induction Chemotherapy in Invasive Bladder Cancer

BACKGROUND

Neoadjuvant/induction chemotherapy (NAIC) improves survival in patients with muscle-invasive bladder carcinoma (MIBC). On-treatment response assessment may aid in decisions to continue or cease NAIC.

OBJECTIVE

We investigated whether 18F-fluoro-2-deoxy-D-glucose-Positron Emission Tomography/Computed Tomography (FDG-PET/CT) could predict response to NAIC and compared to contrast-enhanced Computed Tomography (CECT).

METHODS

We prospectively included 83 patients treated for MIBC (i.e. high-risk cT2-4N0M0 or cT1-4N+M0-1a) between 2014 and 2018. Response to NAIC was assessed after 2-3 cycles with FDG-PET/CT (Peter-Mac and EORTC criteria) and CECT (RECIST1.1 criteria). We assessed prediction of complete pathological response (pCR; ypT0N0), complete pathological down-staging (pCD;≤ypT1N0), any down-staging from baseline (ypTN < cTN) and progression (inoperable tumor/ypN+/M+). The reference standard was histopathological assessment or clinical follow-up. Sensitivity, specificity, and accuracy were calculated.

RESULTS

Pathological response rates were 21% for pCR, 29% for pCD, and 10% progressed. All patients underwent FDG-PET/CT and 61 patients also underwent CECT (73%). Accuracy of FDG-PET/CT for prediction of pCR, pCD, and progression were 73%, 48%, and 73%, respectively. Accuracy of CECT for prediction of pCR, pCD, and progression were 78%, 65%, and 67%, respectively. Specificity of CECT was significantly higher than FDG-PET/CT for prediction of pCD and any down-staging (p = 0.007 and p = 0.022). In all other analyses, no significant differences between FDG-PET/CT and CECT were found.

CONCLUSIONS

Routine FDG-PET/CT has insufficient predictive power to aid in response assessment compared to CECT.

Identifying novel biomarkers associated with bladder cancer treatment outcomes

Bladder cancer is a complex disease with variable prognosis. Recent investigations into the molecular landscape of bladder cancer have revealed frequent genetic alterations and molecular subtypes with therapeutic implications. Consequently, a shift toward personalized treatment of bladder cancer is underway. To this end, several biomarkers have been developed and tested in their ability to predict response to treatment in patients with bladder cancer and potentially help direct therapy. We performed a search of recently published PubMed articles using terms "biomarker," "bladder cancer," and the respective treatment discussed (i.e., "neoadjuvant" or "BCG"). In this review, we summarize the latest studies on novel biomarkers in bladder cancer with a focus on those intended to improve risk stratification and treatment selection.

Refining the Characterization and Outcome of Pathological Complete Responders after Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer: Lessons from the Randomized Phase III VESPER (GETUG-AFU V05) Trial

Neoadjuvant cisplatin-based chemotherapy (NAC) followed by radical cystectomy and pelvic lymph node dissection is the optimal treatment for patients with muscle-invasive bladder cancer. In recent years, the VESPER trial showed a statistically significant higher progression-free survival with dd-MVAC (dose dense methotrexate, vinblastine, doxorubicin, and cisplatin) compared to GC (gemcitabine and cisplatin). In the present report, we refine the characterization and outcome of patients whose cystectomy specimens were pathologically free of cancer (pathological complete response, pCR). We confirm that these patients portend a better outcome as compared to patients with invasive disease (≥pT1N0) at cystectomy. Nested variant and lymphovascular invasion were identified as adverse predictive factors of pCR. Progression-free survival probability three years after pCR on cystectomy was about 85%, regardless of the NAC regimen. A lower creatinine clearance and the delivery of less than four cycles were associated with a higher risk of relapse. Predicting the efficacy of NAC remains a major challenge. The planned analysis of molecular subtypes in the VESPER trial could help predict which patients may achieve complete response and better outcome.

Current Status of Perioperative Therapy in Muscle-Invasive Bladder Cancer and Future Directions

PURPOSE OF REVIEW

Cisplatin-based combination chemotherapy has been a standard of care in the perioperative management of muscle-invasive bladder cancer for years, but several novel therapies are under active investigation. This review aims to provide an update on recent relevant literature and a forward look at the future landscape of adjuvant and neoadjuvant therapy in muscle-invasive bladder cancer patients who opt for radical cystectomy.

RECENT FINDINGS

The recent approval of nivolumab as adjuvant therapy established a new treatment option for high-risk patients with muscle-invasive bladder cancer after radical cystectomy. Several phase II studies of chemo-immunotherapy combinations and immunotherapy alone have reported pathological complete responses in the 26-46% range, including studies in cisplatin-ineligible patients. Randomized studies of perioperative chemo-immunotherapy, immunotherapy alone, and enfortumab vedotin are ongoing. Muscle-invasive bladder cancer remains a challenging disease associated with significant morbidity and mortality; however, increasing options in systemic therapy and an increasingly personalized approach to cancer treatment suggest continued future improvements in patient care.

Multicenter Phase II Clinical Trial of Gemcitabine and Cisplatin as Neoadjuvant Chemotherapy for Patients With High-Grade Upper Tract Urothelial Carcinoma

PURPOSE

Neoadjuvant chemotherapy (NAC) has proven survival benefits for patients with invasive urothelial carcinoma of the bladder, yet its role for upper tract urothelial carcinoma (UTUC) remains undefined. We conducted a multicenter, single-arm, phase II trial of NAC with gemcitabine and split-dose cisplatin (GC) for patients with high-risk UTUC before extirpative surgery to evaluate response, survival, and tolerability.

METHODS

Eligible patients with defined criteria for high-risk localized UTUC received four cycles of split-dose GC before surgical resection and lymph node dissection. The primary study end point was rate of pathologic response (defined as < ypT2N0). Secondary end points included progression-free survival (PFS), overall survival (OS), and safety and tolerability.

RESULTS

Among 57 patients evaluated, 36 (63%) demonstrated pathologic response (95% CI, 49 to 76). A complete pathologic response (ypT0N0) was noted in 11 patients (19%). Fifty-one patients (89%) tolerated at least three complete cycles of split-dose GC, 27 patients (47%) tolerated four complete cycles, and all patients proceeded to surgery. With a median follow up of 3.1 years, 2- and 5-year PFS rates were 89% (95% CI, 81 to 98) and 72% (95% CI, 59 to 87), while 2- and 5-year OS rates were 93% (95% CI, 86 to 100) and 79% (95% CI, 67 to 94), respectively. Pathologic complete and partial responses were associated with improved PFS and OS compared with nonresponders (≥ ypT2N any; 2-year PFS 100% and 95% v 76%, P < .001; 2-year OS 100% and 100% v 80%, P < .001).

CONCLUSION

NAC with split-dose GC for high-risk UTUC is a well-tolerated, effective therapy demonstrating evidence of pathologic response that is associated with favorable survival outcomes. Given that these survival outcomes are superior to historical series, these data support the use of NAC as a standard of care for high-risk UTUC, and split-dose GC is a viable option for NAC.

Circulating Tumor Cells Predict Response of Neoadjuvant Chemotherapy in Patients with Bladder Cancer: A Preliminary Study

This study aimed to explore the existence of circulating tumor cells (CTCs) in patients with muscle-invasive bladder cancer (MIBC) and their predictive potential for response to neoadjuvant chemotherapy (NAC). From 33 blood samples of MIBC patients, CTCs were isolated by cell surface markers and enriched by the IsoFlux™ device, followed by morphological and immunofluorescent identification. CTCs were detected at baseline in all samples. Immunofluorescence confirmed the tumor origin. MIBC patients were stratified by NAC response into the disease control (DC) and progressive disease (PD) groups. In the DC group, the number of CTCs decreased significantly after four courses of NAC (p < 0.0001). CTC counts in 7.5 mL after four NAC cycles were highly correlated with postoperative pathological T stage (p < 0.0001). Our study demonstrated that CTCs might represent a valuable predictive marker for NAC response in MIBC. CTC detection in MIBC patients could allow early arrangement of radical cystectomy for NAC non-responders to prevent disease progression while receiving the NAC courses.

Neoadjuvant-Adjuvant or Adjuvant-Only Pembrolizumab in Advanced Melanoma

BACKGROUND

Whether pembrolizumab given both before surgery (neoadjuvant therapy) and after surgery (adjuvant therapy), as compared with pembrolizumab given as adjuvant therapy alone, would increase event-free survival among patients with resectable stage III or IV melanoma is unknown.

METHODS

In a phase 2 trial, we randomly assigned patients with clinically detectable, measurable stage IIIB to IVC melanoma that was amenable to surgical resection to three doses of neoadjuvant pembrolizumab, surgery, and 15 doses of adjuvant pembrolizumab (neoadjuvant-adjuvant group) or to surgery followed by pembrolizumab (200 mg intravenously every 3 weeks for a total of 18 doses) for approximately 1 year or until disease recurred or unacceptable toxic effects developed (adjuvant-only group). The primary end point was event-free survival in the intention-to-treat population. Events were defined as disease progression or toxic effects that precluded surgery; the inability to resect all gross disease; disease progression, surgical complications, or toxic effects of treatment that precluded the initiation of adjuvant therapy within 84 days after surgery; recurrence of melanoma after surgery; or death from any cause. Safety was also evaluated.

RESULTS

At a median follow-up of 14.7 months, the neoadjuvant-adjuvant group (154 patients) had significantly longer event-free survival than the adjuvant-only group (159 patients) (P = 0.004 by the log-rank test). In a landmark analysis, event-free survival at 2 years was 72% (95% confidence interval [CI], 64 to 80) in the neoadjuvant-adjuvant group and 49% (95% CI, 41 to 59) in the adjuvant-only group. The percentage of patients with treatment-related adverse events of grades 3 or higher during therapy was 12% in the neoadjuvant-adjuvant group and 14% in the adjuvant-only group.

CONCLUSIONS

Among patients with resectable stage III or IV melanoma, event-free survival was significantly longer among those who received pembrolizumab both before and after surgery than among those who received adjuvant pembrolizumab alone. No new toxic effects were identified. (Funded by the National Cancer Institute and Merck Sharp and Dohme; S1801 ClinicalTrials.gov number, NCT03698019.).

Role of Perioperative Immune Checkpoint Inhibitors in Muscle Invasive Bladder Cancer

OBJECTIVE

We aim to describe and highlight the current use of immune checkpoint inhibitors (ICIs) in the muscle invasive bladder cancer (MIBC) treatment landscape, particularly focusing on the perioperative setting. We provide a comprehensive review of key trials of the use of ICI in the perioperative setting, discussing trial outcomes and limitations and reviewing the role of biomarkers.

INTRODUCTION

ICIs have recently been integrated into the treatment algorithm for metastatic urothelial carcinoma. More than 30 published studies have investigated the role of these agents in the radical treatment of MIBC. Some studies have demonstrated conflicting results, affecting widespread adoption in clinical practice.

METHODS

We performed a narrative overview of the literature from databases including PubMed, MEDLINE, Embase, European society of Medical Oncology/American Society of Clinical Oncology Annual Proceedings, and clinicaltrials.gov databases up until December 2021.

DISCUSSION

We described the results of key trials in the neoadjuvant and adjuvant setting, some of the reasons for conflicting study results, and the implications for clinical practice. Relevant biomarkers in the field are discussed, alongside a brief overview of the immune microenvironment in bladder cancer.

CONCLUSIONS

Perioperative ICIs have shown promising efficacy with low toxicity in the neoadjuvant setting. The two large trials in the adjuvant setting have been contradictory. The efficacy of perioperative ICIs combined with favorable tolerability and better toxicity profile compared with chemotherapy, with the potential for biomarker-driven patient selection, may lead to a change in future practice. There is, however, a lack of long-term survival and toxicity data for those treated with ICIs, and this needs to be developed further to demonstrate an added survival benefit by using ICIs.

IMvigor011: a study of adjuvant atezolizumab in patients with high-risk MIBC who are ctDNA+ post-surgery

The standard-of-care for muscle-invasive bladder cancer is radical surgery with neoadjuvant cisplatin-based chemotherapy. Despite curative intent from these interventions, relapse rates post-surgery remain high, with approximately 50% of patients developing local or distant recurrence within 2 years of surgery and a 5-year survival of only 50-60%. Identifying patients who are high risk for relapse post-surgery is a priority. Monitoring patients for circulating tumor DNA (ctDNA) is a minimally invasive approach that appears attractive for selecting patients potentially suitable for adjuvant treatment with checkpoint inhibitors. IMvigor011 (NCT04660344) is a global, double-blind, randomized phase III study assessing the efficacy of atezolizumab (anti-PD-L1) versus placebo in patients with high-risk muscle-invasive bladder cancer who are ctDNA positive post-cystectomy. The primary end point is disease-free survival in participants who are ctDNA positive within 20 weeks of cystectomy.

Approaches to Clinical Complete Response after Neoadjuvant Chemotherapy in Muscle-Invasive Bladder Cancer: Possibilities and Limitations

In the surgical oncology field, the change from a past radical surgery to an organ preserving surgery is a big trend. In muscle-invasive bladder cancer treatment, neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is the standard of care for muscle-invasive bladder cancer (MIBC) patients eligible for cisplatin. There is a growing interest in bladder preserving strategies after NAC because good oncologic outcome has been reported for pathologic complete response (pCR) patients after NAC, and many studies have continued to discuss whether bladder preservation treatment is possible for these patients. However, in actual clinical practice, decision-making should be determined according to clinical staging and there is a gap that cannot be ignored between clinical complete response (cCR) and pCR. Currently, there is a lack in a uniform approach to post-NAC restaging of MIBC and a standardized cCR definition. In this review, we clarify the gap between cCR and pCR at the current situation and focus on emerging strategies in bladder preservation in selected patients with MIBC who achieve cCR following NAC.

Combined Modality Bladder-Sparing Therapy for Muscle-Invasive Bladder Cancer: How (Should) We Do It? A Narrative Review

Organ-sparing combined-modality treatment for muscle-invasive bladder cancer remains underutilized despite high-quality evidence regarding its efficacy, safety, and preservation of quality of life. It may be offered to patients unwilling to undergo radical cystectomy, as well as those unfit for neoadjuvant chemotherapy and surgery. The treatment plan should be tailored to each patient's characteristics, with more intensive protocols offered to patients who are fit for surgery but opt for organ-sparing. After a thorough, debulking transurethral resection of the tumor and neoadjuvant chemotherapy, the response evaluation should trigger further management with either chemoradiation or early cystectomy in non-responders. A hypofractionated, continuous radiotherapy regimen of 55 Gy in 20 fractions with concurrent radiosensitizing chemotherapy with gemcitabine, cisplatin, or 5-fluorouracil and mitomycin C is currently preferred based on clinical trials. The response should be evaluated with repeated transurethral resections of the tumor bed and abdominopelvic-computed tomography after chemoradiation, with quarterly assessments during the first year. Salvage cystectomy should be offered to patients fit for surgery who failed to respond to treatment or developed a muscle-invasive recurrence. Non-muscle-invasive bladder recurrences and upper tract tumors should be treated in line with guidelines for respective primary tumors. Multiparametric magnetic resonance can be used for tumor staging and response monitoring, as it may distinguish disease recurrence from treatment-induced inflammation and fibrosis.

Which Patients To Consider for Bladder Preservation After a Complete Response to Neoadjuvant Chemotherapy

The decision on which patients with muscle-invasive bladder cancer to consider for bladder preservation remains controversial. New promising technologies and biomarkers may allow to precise selection of patients for bladder preservation in the future. Currently, bladder preservation should only be considered in highly selected cases and in the setting of clinical trials.