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

Efficacy of brachytherapy for locally advanced bladder cancer: a single-center retrospective clinical study

To explore the feasibility, safety, and effectiveness of brachytherapy of locally advanced bladder cancer, clinical data of 86 patients with locally advanced bladder cancer treated in the Department of Urology Surgery, Shanxi Provincial Cancer Hospital, between January 2015 and June 2019 were analyzed retrospectively. The patients were categorized into the study (n = 45) and control (n = 41) groups according to the treatment methods. Patients in the study group were treated with brachytherapy (intraoperative implantation of radioactive particles) + neoadjuvant chemotherapy (NAC), and those in the control group were treated with NAC. Patients in both groups underwent radical cystectomy (RC) + pelvic lymph node dissection. Postoperative pathological examinations proved that patients in both groups had urothelial carcinoma at stage pT3-pT4. The endpoints included 3-y locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), overall survival (OS), and adverse events after treatment. The efficacy and safety of interstitial implantation of radioactive particles for the treatment of locally advanced bladder cancer were assessed. The patients were followed up for 9-42 months. The 3-y LRFS was significantly higher in the study group (88.9%) than in the control group (60.9%) (p = .003). The 3-y DMFS in the study group (71.1%) and the control group (73.2%) was statistically similar (p = .945). The 3-y DFS and OS were not statistically significant between the two groups (DFS: study group 64.4% vs. control group 51.2%, p = .073; OS: study group 66.7% vs. control group 58.5%, p = .180). Local shifting of the particles was detected in three patients at 1 week to 1 month after the operations in the study group, but no related complications were observed. Blood events (anemia, leukocytopenia, and thrombocytopenia), liver and renal dysfunction, vomiting, diarrhea, and weakness were the major adverse reactions, which were alleviated after symptomatic treatments. The results have not statistically significant differences between the two groups in major adverse reactions. Compared to the NAC group, brachytherapy + NAC significantly prolongs the LRFS of patients with locally advanced urothelial bladder carcinoma who underwent RC + pelvic lymph node dissection. This surgery increases the LRFS, develops better personalized treatment plans, and improves treatment effectiveness. In addition, the treatment is safe and effective, with only limited adverse effects.

State of the art of adjuvant immunotherapy in urothelial cancer: New developments and upcoming changes

In recent years, several clinical trials focused on the potential role of immune-checkpoint inhibitors (ICIs) in the adjuvant treatment of muscle-invasive urothelial cancer (UC). Heretofore, only the anti-programmed death protein 1 (anti-PD1) nivolumab received European Medical Agency (EMA) approval for cisplatin-unfit patients. In our work, we deeply analyzed the results of the three pivotal studies in view of the rapidly evolving therapeutic advanced UC's scenario. Furthermore, there are several ongoing research to investigate ICIs and other emerging immune agents in this setting; results are awaited. Additionally, current efforts have been made to assess the role of these agents in earlier disease settings, particularly in high-risk non-muscle-invasive bladder cancer (NMIBC). In our review, we analyzed the potential role of predictive and/or prognostic biomarkers that may improve patient selection and treatment efficacy. To conclude, we highlighted the upcoming changes that could redefine the standard of care for patients with early-stage UC.

Advancing Perioperative Treatment Options for Localized Muscle-Invasive Bladder Cancer: A Step Forward

Muscle-invasive bladder cancer (MIBC) is an aggressive disease, with substantial recurrence risk after radical cystectomy and pelvic lymph node dissection alone. In cisplatin-eligible patients, administration of neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy has been shown to improve overall survival (OS) and has become the standard of care. Nevertheless, approximately 40%-50% of patients will still experience disease recurrence after curative-intent treatment. Moreover, a significant proportion of patients with MIBC are ineligible for cisplatin and represent a challenging clinical scenario. In recent years, different strategies aiming to improve patient outcomes by incorporating immune checkpoint inhibitors in the treatment paradigm were explored. Two key management approaches emerged: neoadjuvant chemotherapy with risk-adapted adjuvant immunotherapy and universal perioperative immunotherapy-based treatment. We review the rationale, current evidence, challenges, and future directions for the perioperative management of muscle-invasive urothelial carcinoma.

Significance of Body Surface Area Correction for Cisplatin Eligibility Based on Renal Function of Patients With Muscle-Invasive Bladder Cancer

INTRODUCTION

Creatinine clearance (CCr) ≥60 mL/min without body surface area (BSA) correction is commonly applied to determine the cisplatin (CDDP) eligibility of patients with bladder cancer. However, since CDDP dosages are calculated according to BSA, there is concern that applying renal function without BSA correction may underestimate CDDP eligibility, especially of patients with low BSA. The purpose of this study was to determine whether BSA correction for renal function affects the decision of CDDP eligibility and oncological outcomes.

PATIENTS AND METHODS

The data of 294 patients who received platinum-based neoadjuvant chemotherapy (NAC) and underwent radical cystectomy for muscle-invasive bladder cancer were retrospectively analyzed. Patients with BSA below and above the median BSA value (1.70 m2) were divided into low-BSA and high-BSA groups. Patients who received ≥20% dose reduction of CDDP or replacement by carboplatin at the first NAC cycle were categorized as "inadequate-CDDP" recipients. "CDDP-eligibility underestimation" was defined as CCr with BSA correction >60 mL/min/1.73 m2 while CCr without BSA correction <60 mL/min. The association of BSA with inadequate-CDDP was evaluated using multivariate analysis. Additionally, differences in clinical outcomes, namely cancer-specific survival (CSS) and objective response rate (ORR) to NAC, between the low- and high-BSA groups were evaluated.

RESULTS

CDDP-eligibility underestimation was more frequent in the low-BSA group than in the high-BSA group (17% vs. 0%; P < .001). Multivariate analysis revealed that low-BSA was independently associated with the risk of inadequate CDDP (odds ratio, 2.07; P = .012). CSS from initiation of NAC was significantly shorter in the low-BSA group than in the high-BSA group (hazard ratio, 2.24; P = .002). The ORR for NAC was also significantly lower in the low-BSA group (40.8% vs. 57.1%; P = .007).

CONCLUSIONS

When determining CDDP eligibility for renal function in patients with low BSA, renal function values corrected by standard BSA should be applied to prevent inappropriate dosing reductions.

The role of neoadjuvant systemic therapy for high grade upper tract urothelial carcinoma: Results from the upper tract collaborative network (UCAN)

INTRODUCTION

Utilization of neoadjuvant systemic therapy (NAT) prior to radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) is inconsistent, and optimal patient selection for NAT is unclear. The purpose of this study was to evaluate the clinical benefit of NAT in high grade UTUC undergoing RNU.

MATERIALS AND METHODS

The UTUC Collaborative Network (UCAN) identified patients who underwent RNU for high grade UTUC between 2000 and 2022. NAT was examined as a primary exposure. NAT was defined as any systemic therapy prior to RNU. The outcomes of interest were extra-urothelial recurrence free survival (euRFS), cancer-specific survival (CSS), and overall survival (OS).

RESULTS

Among 461 patients meeting criteria, 51.2% received NAT. At a median follow-up of 2.9 years, 24.1% experienced extra-urothelial recurrence at a median of 2.4 (1.0-5.2) years. On multivariable Cox proportional hazards models, NAT was associated with improved CSS (HR 0.58; 95% CI 0.36-0.94). In clinically node negative patients receiving NAT, Kaplan-Meier analysis showed improved euRFS (P = 0.01), cancer-specific survival (P = 0.002), and overall survival (P = 0.002). A statistically significant benefit was not observed for clinically node positive patients receiving NAT in euRFS (P = 0.667), CSS (P = 0.200), or OS (P = 0.313).

CONCLUSIONS

NAT was associated with improved survival outcomes in patients with clinically node negative disease. These benefits were not consistently observed in those with clinically node positive disease, although there was trend toward improved outcomes on multivariable Cox models. Further prospective investigations regarding risk stratification and multimodal management are needed in patients with high grade UTUC.

Analysis of Neoadjuvant Immunotherapy and Chemotherapy for Muscle-Invasive Bladder Cancer in a National Registry

BACKGROUND

Based on remarkable success in the metastatic/locally advanced space, Neoadjuvant Immunotherapy (NIO) is a promising novel treatment option for Muscle-Invasive Bladder Cancer (MIBC). Here, we assess factors associated with NIO and describe survival outcomes following NIO use in MIBC patients.

METHODS

The NCDB was used to identify 5,823 qualifying patients with a diagnosis of urothelial bladder cancer, T2-4N0-3M0 clinical stage and who received NIO or NAC prior to radical cystectomy between 2006 and 2019. NAC and NIO patient groups with similar clinical and demographic characteristics were defined using a 1:1 propensity score matching method.

RESULTS

Mean age at diagnosis was significantly higher in NIO patients compared to NAC patients (70.22 ± 9.2 vs. 65.33 ± 9.1 years, P < .001). NAC administration correlated with an increased odds of pathologic complete response (pCR) compared to NIO in the unmatched (OR: 3.825, 95% CI: 1.972-7.417, P < .001) and matched (OR: 6.771, 95% CI: 2.624-17.473, P < .001) analyses. Finally, Cox proportional hazard model and Kaplan-Meier analysis revealed no difference in overall survival between NAC and NIO administration in the unmatched or matched analysis.

CONCLUSION

In this study, older age, higher income and longer distance to facility were associated with the use of NIO compared to NAC. NIO administration was less effective at achieving pR and pCR compared to NAC. There was no observed difference in overall survival between patients that received NIO and those that received NAC. The ongoing phase III trials in this space should help to clarify the role of NIO.

Survival in Responders and Nonresponders of Neoadjuvant and Induction Chemotherapy in Invasive Urothelial Carcinoma of the Urinary Bladder: A Clinical and Pathological Stage-Matched Analysis

INTRODUCTION/BACKGROUND

A recent study reported that patients with residual urothelial carcinoma of the bladder subsequent to neoadjuvant/induction chemotherapy (NAIC) prior to RC exhibited inferior oncological outcomes in comparison to pathological stage-matched patients who underwent upfront RC. Our hypothesis is that this may be ascribed to variations in preoperative CT-stage rather than the impact of chemotherapy.

PATIENTS AND METHODS

This retrospective multicentre study included 513 patients who underwent RC for cT2-4N0-3M0 disease between 2010 and 2017. Patients were categorized based on pathological outcomes: pathological complete response (pCR, (y)pT0N0), complete downstaging (pCD, (y)pT0/is/a/1N0) and residual muscle-invasive and/or node positive disease (rMIBC, (y)pT2-4N0 and/or (y)pN1-3).

RESULTS

Of the total cohort, 175 (34.1%) patients underwent NAIC+RC, while 338 (65.9%) underwent upfront RC. NAIC+RC patients exhibited lower age and CCI-scores, along with higher cT&N-stage (all P-values < .001). The mOS was 60.5 months for NAIC+RC and 49.4 months for upfront RC (P-value = .171). In patients with rMIBC, survival was inferior after NAIC+RC compared to upfront RC. However, the clinical stage distribution between NAIC+RC and upfront RC was imbalanced, with 3% versus 49% cT2N0 patients and 47% versus 9% cT4b and/or N+ patients, respectively. Following adjustments for cT & N-stage, age, and CCI-scores in multivariable Cox proportional-hazards analysis, worse OS was associated with upfront RC (HR 1.52, [95% CI, 1.11-2.10], P-value = .009).

CONCLUSION

The observed inferior survival in cT2-4N0-3M0 patients with rMIBC after NAIC+RC compared to those undergoing upfront RC resulted from worse preoperative characteristics, including clinical stage. The representation of clinical disease stage should not be overlooked in survival analyses.

Avelumab-based neoadjuvant therapy in patients with muscle-invasive bladder cancer (AURA Oncodistinct-004): a phase 2 multicenter clinical trial

BACKGROUND

Immunotherapy is becoming a standard of care for non-metastatic muscle-invasive bladder cancer (MIBC). The optimal chemotherapy partner for chemo-immunotherapy combinations remains unknown. We evaluated the efficacy and safety of neoadjuvant avelumab-based regimens in patients with MIBC.

METHODS

The multicenter phase 2 AURA trial (NCT03674424) enrolled patients with non-metastatic MIBC undergoing radical cystectomy. Cisplatin-eligible patients were randomized to receive avelumab with either dose-dense methotrexate-vinblastine-doxorubicin-cisplatin (ddMVAC-A) or gemcitabine-cisplatin (GC-A). Cisplatin-ineligible patients received either avelumab alone (A) or combined with paclitaxel-gemcitabine (PG-A). The primary endpoint was pathological complete response (pCR). Secondary endpoints included safety, event-free survival, and overall survival (OS).

RESULTS

Between July 2018 and September 2021, 137 eligible patients were enrolled in the trial. In the cisplatin-eligible cohort (n=79), pCR rates were 58% (95% CI: 42% to 72%) in the ddMVAC-A arm and 53% (95% CI: 37% to 68%) in the GC-A arm. The 36-month OS rates were 87% (95% CI: 76% to 98%) for ddMVAC-A and 67% (95% CI: 53% to 84%) for GC-A. In the cisplatin-ineligible cohort (n=58), pCR rates were 14% (95% CI: 6% to 31%) in the PG-A arm and 32% (95% CI: 18% to 51%) in the A arm. The 36-month OS rates were 48% (95% CI: 33% to 71%) for PG-A and 42% (95% CI: 27% to 65%) for A. Overall, 51 (38%) patients experienced grade 3-4 treatment-related adverse events.

CONCLUSIONS

Avelumab combined with cisplatin-based neoadjuvant chemotherapy showed promising efficacy in MIBC with a favorable safety profile, also with the ddMVAC regimen. Among cisplatin-ineligible patients, avelumab monotherapy showed encouraging activity, with no additional benefit observed from the PG-A regimen. These results support the use of the ddMVAC regimen as a potential chemotherapy partner for neoadjuvant chemo-immunotherapy combinations in future phase 3 trials, providing an alternative to the GC regimen currently under investigation.

TRIAL REGISTRATION NUMBER

NCT03674424.

Survival outcomes and prognostic factors in bladder cancer treated with radiotherapy

This study evaluated survival outcomes and prognostic factors in patients with bladder cancer treated with radiotherapy. A retrospective analysis was conducted on 488 patients across all cancer stages who received radiotherapy at two institutions between 1 January 2000 and 31 December 2022. Overall survival (OS) was assessed based on treatment intent (radical or palliative) and cancer stage. Among these patients, 304 with Stage II-III disease who underwent radical radiotherapy were further analyzed for OS and prognostic factors using Kaplan-Meier methods and Cox regression analysis. In the radical radiotherapy group, median survival times (MSTs) were 43 months for Stage 0-I, 29 months for Stage II-III, and 17 months for Stage IV (M0). In the palliative radiotherapy group, MSTs were 16 months (95% confidence interval [CI]: 11-25) for M0 and 9 months (95% CI: 7-15) for M1. Among the 304 patients with Stage II-III disease treated with radical radiotherapy, the 3-year OS rate was 43.0%. Hydronephrosis was the only independent prognostic factor significantly associated with worse OS (hazard ratio: 1.915, P < 0.001). Age, sex, stage, treatment era, prophylactic pelvic radiotherapy, chemotherapy and prescribed dose had no significant impact on OS. Radiotherapy remains a viable treatment option for patients at any stage of cancer. Although hydronephrosis negatively affects survival, it should not preclude the use of radiotherapy.

Role of Adjuvant Therapy in Current Perioperative Immunotherapy-based Trials in Bladder Cancer: A Justified Standard

None of the ongoing phase 3 trials are evaluating the impact of the adjuvant component of perioperative PD1/PDL1 inhibition combined with neoadjuvant chemotherapy for muscle-invasive bladder cancer. Biomarkers of benefit are not validated. Hence, omission of the adjuvant component cannot be supported. Prospective investigation is required to evaluate this question.

Prognostic significance of pathologic response to neoadjuvant chemotherapy in muscle-invasive urothelial carcinoma of the bladder with histologic subtype

INTRODUCTION

Patients with histologic subtypes (HS) of urothelial cancers are often excluded from neoadjuvant chemotherapy (NAC) trials for muscle-invasive bladder cancer (MIBC). Additionally, there exist conflicting data regarding the inherent chemotherapeutic sensitivity of individual HS. Herein, we assess the prognostic significance of pathologic response to NAC, a common surrogate endpoint of success in NAC trials, in patients with HS versus pure urothelial carcinoma (PUC).

METHODS

The National Cancer Database (NCDB) was queried for patients with cT2-4N0M0 MIBC who received NAC and radical cystectomy (RC) between 2004 and 2020. Pathologic response to NAC was defined as complete (ypT0N0), partial (

RESULTS

5,372 patients were included, with 345 (6.4%) having HS. Nonresponse rates to NAC in HS patients were significantly higher than those with PUC (65.2% vs. 55.8%, P = 0.003). Patients with squamous and glandular differentiation exhibited the highest rates of nonresponse (79% and 72.2%, respectively). In unstratified analysis, patients with HS exhibited shorter OS (P < 0.0001). Patients with HS had uniformly worse OS even after controlling for pathologic response (P = 0.013), with the most notable discrepancy in partial responders (HR = 4.88, 95% CI 2.29-10.38, P < 0.001; 3-year OS 91% vs. 66% for partial response in PUC vs. HS, respectively).

CONCLUSIONS

Patients with HS MIBC exhibit poor survival when treated with NAC followed by RC compared with PUC, even when controlling for pathologic response. These data suggest that pathologic response is a less accurate surrogate endpoint in patients with HS relative to PUC, and may suggest a role for therapeutic intensification in the adjuvant setting for patients with HS.

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Key Words

• Bladder cancer
• Histologic subtype
• Neoadjuvant
• Outcomes
• Radical cystectomy
• Survival
• Urothelial carcinoma
• Variant histology

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Affiliation(s)

Seth L Teplitsky Department of Urology, University of Kentucky College of Medicine, Lexington, KY
Will Cranford Department of Biostatistics, University of Kentucky College of Medicine, Lexington, KY
Joon Kyung Kim Department of Urology, University of Kentucky College of Medicine, Lexington, KY
Spencer Bell Department of Urology, University of Kentucky College of Medicine, Lexington, KY
Sydney Strup Department of Urology, University of Kentucky College of Medicine, Lexington, KY
Derek Allison Department of Pathology, University of Kentucky College of Medicine, Lexington, KY
Amanda Buchanan Department of Urology, University of Kentucky College of Medicine, Lexington, KY
Zin Myint Division of Medical Oncology, University of Kentucky College of Medicine, Lexington, KY
Stephen E Strup Department of Urology, University of Kentucky College of Medicine, Lexington, KY
Frances Martin Department of Urology, University of Kentucky College of Medicine, Lexington, KY
Akshay Sood Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH
Ashish M Kamat Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX
Christopher J McLouth Department of Biostatistics, University of Kentucky College of Medicine, Lexington, KY
Patrick J Hensley Department of Urology, University of Kentucky College of Medicine, Lexington, KY; Department of Pathology, University of Kentucky College of Medicine, Lexington, KY.

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Real-world comparison of neoadjuvant chemoimmunotherapy and chemotherapy in muscle-invasive bladder cancer

Muscle-invasive bladder cancer (MIBC) continues to pose a significant health challenge, as conventional neoadjuvant chemotherapy (NAC) has shown limited improvements in efficacy outcomes. Recent clinical trials suggest that combining NAC with immune checkpoint blockade (NAC.NICB) may enhance therapeutic efficacy. This study aimed to explore the short-term therapeutic efficacy and outcomes of NAC.NICB compared to NAC in real-world settings for the treatment of MIBC. A total of 100 patients with MIBC who received either NAC or NAC.NICB were included in the study. The treatment efficacy of the NAC and NAC.NICB groups was evaluated based on pathological complete response (pCR) and the rate of pathological downstaging through post treatment pathological assessment. In the NAC.NICB group, clinical characteristics were compared between patients who achieved pCR and those who did not, using the independent samples t-test or the Mann-Whitney U test. Overall, 71 patients received NAC and 29 patients received NAC.NICB. At baseline, the NAC.NICB group exhibited higher T and N stages compared to the NAC group. However, 48.3% (14/29) of the patients in the NAC.NICB group achieved pCR, which was significantly higher than that observed in the NAC group (18/71, 25.4%; p = 0.034). In addition, the pathological downstaging rate in the NAC.NICB group was higher than that of the NAC group (75.9% vs. 47.9%; p = 0.014). The disease control rate (DCR) in the NAC.NICB group was higher than that observed in the NAC group (96.6% vs. 77.5%; p = 0.020). Higher pretreatment hemoglobin levels (p = 0.018) or lower platelet levels (p = 0.026) in patients undergoing NAC.NICB therapy may serve as a potential predictor for achieving a higher pCR rate. Neoadjuvant chemotherapy combined with immune checkpoint blockade improves pCR and pathological downstaging rates in MIBC, highlighting the benefits of neoadjuvant chemoimmunotherapy for MIBC.

Low T cell diversity associates with poor outcome in bladder cancer: A comprehensive longitudinal analysis of the T cell receptor repertoire

T cells are crucial effector cells in the endogenous defense against cancer, yet the clinical impact of their quantity, diversity, and dynamics remains underexplored. Here, we investigate the clinical relevance of the T cell receptor (TCR) repertoire in patients with bladder cancer. In advanced-stage disease, low pre-treatment peripheral TCR diversity is associated with worse overall survival (p = 0.024), particularly when coupled with low circulating T cell fractions (p = 0.00049). These low-diversity repertoires are dominated by hyper-expanded clones that persist throughout treatment. Further longitudinal analysis reveals reductions in TCR diversity after treatment, indicating adverse effects on the immune system. In early-stage disease, immunotherapy increases TCR diversity in patients with good outcomes. Furthermore, single-cell sequencing identifies most hyper-expanded clones as cytotoxic T cells, while non-expanded clones are predominantly naive T cells. Overall, this highlights TCR diversity as a promising biomarker, offering opportunities for tailored oncological treatments to enhance clinical outcomes.

Sex differences in bladder cancer: understanding biological and clinical implications

Bladder cancer (BC) remains a significant global health concern, with substantial sex and racial disparities in incidence, progression, and outcomes. BC is the sixth most common cancer among males and the seventeenth most common among females worldwide. Over 90% of BC cases are urothelial carcinoma (UC) with high degrees of pathological heterogeneity. Molecular subtyping of BC has also revealed distinct luminal, basal, and neuroendocrine subtypes, each with unique genetic and immune signatures. Emerging research uncovers the biasing effects of the sex hormones with androgens increasing BC risk through both tumor cell intrinsic and extrinsic mechanisms. The sex chromosomes, including both the X and Y chromosomes, also contribute to the sex differences in BC. The effect of sex chromosome is both independent from and synergistic with the effects of sex hormones. Loss of the Y chromosome is frequently observed in BC patients, while an extra copy of the X chromosome confers better protection against BC in females than in males. Advent of advanced technologies such as multiomics and artificial intelligence will likely further improve the understanding of sex differences in BC, which may ultimately lead to personalized preventative and treatment strategies depending on the biological sex of patients. This review delves into the impacts of biology of sex on BC, emphasizing the importance of further research into sex-specific biology to improve cancer prevention and care.

Treatment Efficacy and Molecular Dynamics of Neoadjuvant Durvalumab and Olaparib in Resectable Urothelial Bladder Cancer: The NEODURVARIB Trial

PURPOSE

Neoadjuvant treatment of bladder cancer is evolving, with immunotherapy demonstrating promising activity. PARP inhibition combined with immune activation has been proposed as a synergistic strategy. We conducted a comprehensive molecular characterization of tumors treated with this combination in the neoadjuvant setting to provide crucial results for rational development.

PATIENTS AND METHODS

A phase II clinical trial was designed to evaluate the combination of anti-PDL1 inhibitor durvalumab and PARP inhibitor olaparib, focusing on biomarker dynamics in both pre- and post-treatment settings. A total of 29 patients were enrolled. Genomic and transcriptomic profiling, as well as analyses of immune cell populations, was conducted at baseline and at the time of cystectomy.

RESULTS

Of the 29 patients treated, a pathologic complete response was observed in 13 cases (44.8%). No major safety concerns were associated with the treatment, and 26 patients (90%) underwent cystectomy. Mutational patterns, tumor mutation burden, and homologous recombination deficiency remained stable throughout treatment and were not predictive of outcomes. However, a shift toward stromal phenotypes and increased expression of epithelial-mesenchymal transition signatures were observed following therapy, particularly in resistant tumors. Moreover, an increase in circulating CD4+ CD27- CD28- T cells was noted among responders.

CONCLUSIONS

The combination of neoadjuvant durvalumab and olaparib shows therapeutic activity in bladder cancer. Resistance mechanisms seem to be driven by transcriptional adaptations rather than the emergence of new mutations.

TAR-200: Investigational intravesical drug delivery system for bladder cancer

Bladder cancer is second among the most common urothelial malignancy and one of the most expensive in terms of treatment. Localized bladder cancer is classified into non-muscle invasive bladder cancer (NMIBC) and muscle invasive bladder cancer (MIBC). First line approach for treatment of NMIBC is transurethral resection of bladder tumor (TURBT) followed by intravesical instillation of immuno/chemotherapeutic agents to prevent or delay recurrence or progression. Historically intravesical Bacillus Calmette Geurin (BCG) instillation has been a mainstay of therapy for NMIBC post-TURBT. Commonly followed drug delivery is intravesical instillation that maximizes exposure of the drug to the lesion and minimizes systemic side effects. Gemcitabine used in bladder cancer due to its pharmacological properties making it appropriate for intravesical instillation. Limitations of intravesical instillation is low bladder permeability leading to decreased drug concentration in bladder tissues and frequent urination causing drug wash out or dilution reducing the effect of treatment. Effective intravesical therapy depends on the penetration of the drug into the tumor. TAR200 is a novel drug delivery system that facilitates sustained release of continuous low dose gemcitabine over an indwelling period providing a uniform concentration of drug after each voiding cycle and exposure of drug to the bladder tumor. There are completed and ongoing clinical trials to evaluate the efficacy of TAR200 alone or in combination with other chemotherapeutic agents in NMIBC and MIBC. FDA has granted breakthrough therapy designation (BTD) for TAR-200 in December 2023. This review highlights the potential of TAR-200 and clinical trials that improve bladder cancer treatment outcome.

Prognostic biomarker PSMD14 facilitates bladder cancer tumorigenesis and progression by regulating Nucleolin-YAP1 axis

Deubiquitinating enzymes (DUBs) significantly contribute to tumor progression and treatment resistance in bladder cancer. However, the mechanisms by which DUBs promote malignant behavior in patients with bladder cancer remain poorly understood. Using online databases such as TCGA, GSE13507, and GSE23894, along with clinical sample validation, the expression profiles of PSMD14 in patients with bladder cancer were identified. The analysis revealed correlations among PSMD14, nucleolin (NCL), and YAP1, which were verified using TCGA data and clinical sample studies. In this study, PSMD14 was identified as a novel DUB involved in bladder cancer malignancy. PSMD14 expression is upregulated in the tissues of patients with bladder cancer and is associated with poor clinical outcomes. Both in vitro and in vivo experiments demonstrated that PSMD14 inhibition significantly reduced bladder cancer cell proliferation, metastasis, and cisplatin resistance. Mechanistic investigations revealed that PSMD14 enhances protein stability and NCL expression through deubiquitination. NCL, an RNA-binding protein, exerts oncogenic effects in patients with bladder cancer by binding to and stabilizing YAP1 mRNA, leading to increased YAP1 expression and activation of downstream YAP1-related pathways. Notably, the tumor-suppressive effects of PSMD14 inhibition were partially reversed by the overexpression of either NCL or YAP1. In conclusion, the PSMD14/NCL/YAP1 axis plays a pivotal role in the malignant behavior of bladder cancer, including proliferation, metastasis, and chemoresistance. These findings suggest that PSMD14 is a critical biomarker for predicting bladder cancer prognosis and is a potential target for therapeutic interventions.

Impact of Immune Checkpoint Inhibitors as Neoadjuvant Therapy for Muscle-invasive Bladder Cancer: A Systematic Review, Meta-analysis, and Network Meta-analysis

BACKGROUND AND OBJECTIVE

The availability of immune checkpoint inhibitors (ICIs) has expanded perioperative treatment options for urothelial carcinoma. Our aim was to evaluate the effect of neoadjuvant ICI-based regimens on oncological outcomes for patients with muscle-invasive bladder cancer (MIBC).

METHODS

We systematically searched MEDLINE, Embase, Web of Science, and ClinicalTrials.gov in September 2024 for studies on neoadjuvant therapies for MIBC. A proportion meta-analysis and network meta-analysis (NMA) using random-effect models were conducted to evaluate pooled pathological complete response (pCR) rates and to compare overall survival (OS) and adverse events. The review is registered on PROSPERO (CRD42024587964).

KEY FINDINGS AND LIMITATIONS

We included 12 randomized controlled trials (RCTs; 5004 patients) and 35 non-RCTs (2964 patients). ICI-chemotherapy combination therapy was associated with a significantly higher pCR rate versus chemotherapy alone (40.6% vs 17.9%; p < 0.01). In the two phase 3 RCTs included (1556 patients) there was no significant difference in OS between dose-dense methotrexate + vinblastine + Adriamycin + cisplatin (ddMVAC) and durvalumab + gemcitabine + cisplatin (GC; hazard ratio 1.06, 95% confidence interval [CI] 0.72-1.55; p = 0.8). ddMVAC significantly increased the risk of grade ≥3 anemia (risk ratio [RR] 2.81, 95% CI 1.62-4.88) and asthenia (RR 3.46, 95% CI 1.68-7.14) in comparison to GC, while durvalumab + GC did not. Limitations include data heterogeneity across studies and the limited number of studies included in the NMA.

CONCLUSIONS AND CLINICAL IMPLICATIONS

ICI addition to chemotherapy in the neoadjuvant MIBC setting significantly increased pCR rates in comparison to chemotherapy alone. However, there was no difference in OS between durvalumab + GC and ddMVAC. Further studies are needed to clarify the OS benefit of ICI-based combination therapy in comparison to the current standard chemotherapy regimen.

Geriatric Nutritional Risk Index Predicts Postoperative Complications in Elderly Patients Undergoing Robot-Assisted Radical Cystectomy

OBJECTIVE

Malnutrition is a common condition among elderly cancer patients. The Geriatric Nutritional Risk Index (GNRI) is a simple screening tool used to predict the risk of postoperative complications in patients undergoing radical cystectomy. This study aimed to evaluate the effectiveness of preoperative GNRI as a marker for predicting 90-day postoperative complications in elderly patients undergoing robot-assisted radical cystectomy (RARC).

METHODS

We retrospectively evaluated 385 patients who underwent RARC at four affiliated institutes of Tokushima University between 2014 and 2023. Patient background characteristics, pathological findings, and 90-day postoperative complications were analyzed. Preoperative GNRI was calculated using serum albumin and body mass index, with an abnormal nutritional status defined as GNRI < 92.

RESULTS

A total of 166 patients aged ≥ 75 years who underwent RARC were included in the study. Among these, 26 patients (15.7%) had an abnormal GNRI. Eighty-four patients (50.6%) experienced complications within 90 days postoperatively, including 29 patients (17.5%) with major complications (Clavien-Dindo classification ≥ 3). The 90-day postoperative mortality rate was 3.0% (five patients). Patients with an abnormal GNRI had a significantly higher rate of 90-day postoperative complications (p < 0.001). Multivariable logistic regression analysis identified abnormal GNRI as a significant predictor of 90-day postoperative complications (odds ratio: 9.963; 95% confidence interval: 2.125-46.718; p = 0.004).

CONCLUSIONS

Poor nutritional status is associated with a higher rate of 90-day postoperative complications in elderly patients undergoing RARC. Preoperative GNRI may be a useful tool for assessing the risk of complications in this patient population.

A pilot study of [18F]F-fluciclovine positron emission tomography/computed tomography for staging muscle invasive bladder cancer preceding radical cystectomy

AIM

To assess the ability of [18F]F-fluciclovine-PET/CT to stage muscle invasive bladder cancer (MIBC) before radical cystectomy.

METHODS

This single-site prospective pilot study enrolled patients with MIBC and T2-T4, N0 disease on CT/MRI slated to undergo radical cystectomy (RC). Dynamic and static [18F]F-fluciclovine-PET/CT images were acquired. Clinical readers assessed for confirmation of the primary bladder lesion on imaging and the presence of pelvic nodal metastases. Findings were compared to pathology at RC. Kinetic parameters from dynamic PET/CT were compared across bladder lesions of different clinical stages.

RESULTS

The study enrolled sixteen patients (median age: 73 years, range: 57-88 years, 11 males, 5 females), twelve receiving neoadjuvant chemotherapy before RC. There was high specificity amongst all three readers for detecting lymph node metastases (overall specificity: 0.91, 95%CI: 0.81-1.00) with good overall agreement rate with pathology (0.67, 95%CI: 0.44-0.83). The overall PPV for all readers for identifying node-positive disease was 0.4 (95%CI: 0-1.00), and the overall sensitivity was 0.13 (95%CI: 0-0.44). The overall PPV for detecting the primary tumor was 0.69 (95%CI: 0.47-0.88), and the sensitivity was 0.89 (95%CI: 0.78-1.00), with NPV and specificity being 0.70 (95%CI: 0.33, 1.00) and 0.39 (95%CI: 0.33, 0.50), respectively. Compartmental analysis of the primary bladder tumor revealed that k1 and vb parameters significantly differentiated between low (pT0-pT1) and high (pT2-pT4) risk disease (p < 0.05). Immunohistochemical assessment showed no significant correlation of tumor [18F]F-fluciclovine uptake nor kinetic parameter with amino acid transporter expression.

CONCLUSIONS

[18F]F-fluciclovine demonstrates good specificity and agreement rate for MIBC staging, with sensitivity like CT/MRI. Kinetic parameters such as k1 was able to delineate higher-stage ( ≥ = pT2) primary lesions. Heterogeneous amino acid transporter expression can be seen across lesions. Further studies are warranted to understand [18F]F-fluciclovine PET/CT use in the context of other imaging modalities in this disease.

CLINICAL TRIAL REGISTRATION

NCT04018053 Registered 2/26/2020.

Differential Outcomes in Bladder Cancer After Neoadjuvant Chemotherapy: An International Multi-Institutional Study Comparing Isolated Nodal Disease vs Persistent Muscle-Invasive Disease

OBJECTIVE

To evaluate clinical outcomes based on patterns of residual disease in patients undergoing cystectomy after neoadjuvant chemotherapy (NAC), focusing on those with residual tumor only in lymph nodes.

METHODS

We retrospectively analyzed 174 patients who underwent post-NAC radical cystectomy between 2010 and 2023 at academic centers from the United States and Europe. Patients were stratified into two groups: those with isolated lymph node disease despite complete local response (n=35) and those with persistent muscle-invasive or locally advanced disease without lymph node involvement (n=139). Primary outcomes included recurrence, disease-specific mortality (DSM), and survival. Median follow-up was 27.0months (interquartile range: 9.0-60.0).

RESULTS

Recurrence occurred in 33% of patients, with higher risk in patients with residual disease only in lymph nodes compared to those with persistent disease in the bladder and negative lymph nodes (adjusted OR: 0.43, 95% CI: 0.20-0.95, P=.036). DSM was 24%, with no significant difference between groups (adjusted OR: 0.70, 95% CI: 0.29-1.64, P=.407). Disease-related events occurred in 41% of patients, with lower risk in the group with residual disease in the bladder (adjusted OR: 0.46, 95% CI: 0.21-0.99, P=.048). Survival analyses showed no significant differences in DSM between groups (HR: 1.03, 95% CI: 0.48-2.20, P=0.947). Variant histology (present in 36% of cases) did not influence outcomes.

CONCLUSION

Patients with isolated lymph node disease, despite complete local response after NAC, demonstrate higher recurrence risk compared to those with persistent muscle-invasive disease, although this does not translate into survival differences. These findings suggest the need for risk-adapted surveillance strategies and consideration of additional therapeutic interventions in patients with isolated residual nodal disease.

Tumor-Educated Platelets in Urological Tumors: A Novel Biosource in Liquid Biopsy

Platelets, traditionally recognized for their role in hemostasis, have emerged as pivotal players in cancer biology. They actively contribute to tumor proliferation, angiogenesis, immune evasion, and metastasis and thus play a significant role in cancer progression. Tumor-educated platelets (TEPs) acquire protumorigenic phenotypes through RNA, protein, and receptor profile alterations driven by interactions with tumors and their microenvironment. These modifications enable TEPs to enhance tumor growth and dissemination and to play a critical role throughout the metastatic process. Moreover, TEPs are promising biomarkers that can easily be analyzed in liquid biopsies. Since they dynamically mirror tumor activity through transcriptomic and proteomic changes, their analysis offers a non-invasive method for determining cancer detection and diagnosis, patient prognosis, therapy monitoring, and personalization of treatment. Their demonstrated accuracy in identifying cancer types and predicting treatment responses underscores their ability to provide real-time insights into tumor biology, including in urological malignancies. Their diagnostic potential and their accessibility as blood-sourced biomarkers position TEPs as transformative tools in advancing personalized oncology. Here, we focus on the role of TEPs in urological tumors, exploring their applications in early cancer detection, disease monitoring, and the design of tailored therapeutic strategies.

The practical roadmap for peri-cystectomy approaches in muscle-invasive bladder cancer

The management of muscle-invasive bladder cancer (MIBC) remains a challenging topic since it is witnessing rapidly evolving changes and new drug approvals. In fact, more effective approaches are now available to improve the outcomes of patients with MIBC who are candidates for cystectomy. Neo-adjuvant cisplatin-based chemotherapy was the standard approach for patients who were deemed cisplatin-eligible. Also, adjuvant cisplatin-based chemotherapy was considered for high-risk operated patients who did not receive the standard neo-adjuvant chemotherapy. It was only recently that adjuvant immune checkpoint inhibitors were proved effective in adjuvant settings and were approved for high-risk MIBC patients after neo-adjuvant chemotherapy followed by cystectomy or for those who did not receive neo-adjuvant chemotherapy and were not eligible for adjuvant cisplatin-based chemotherapy. More recently, adding immune checkpoint inhibitors to neo-adjuvant chemotherapy and to post-cystectomy adjuvant therapy seemed to be very promising. In this review article, all current peri-cystectomy options are briefly described with an attempt to guide and simplify choices by drawing a roadmap covering all the practical scenarios.

Management of Patients with Muscle-Invasive Bladder Cancer Achieving A Clinical Complete Response after Neoadjuvant Therapy: Evidence and Consideration for Active Surveillance

PURPOSE OF REVIEW

To review the landscape of bladder preservation management and active surveillance for those who achieve clinical complete response to neoadjuvant chemotherapy.

RECENT FINDINGS

Multiple cohorts of patients with clinical complete response report overall survival rates over 80% multiple years after treatment without cystectomy. Most recently, prospective clinical trials have been pursuing clinical complete response as a valid primary endpoint. Recent advances in immunotherapy and molecular biomarkers present new horizons in expanding the potential patient population as well as accuracy in prediction of pathologic complete response. While neoadjuvant chemotherapy followed by radical cystectomy is the standard of care for muscle-invasive bladder cancer, interest in active surveillance is growing as evidenced by the increasing number of studies. Accumulating evidence and new prospective data suggest this could be a plausible option in the future. These cohorts remain highly selected, thus generalizability is still under investigation.

The importance of maximal TURBT in trimodality therapy for muscle-invasive bladder cancer (MIBC)

Trimodality therapy (TMT), consisting of maximal transurethral resection of bladder tumor (TURBT) followed by concurrent chemoradiotherapy, has emerged as a bladder-sparing alternative to radical cystectomy for select patients with muscle-invasive bladder cancer (MIBC). While each component of TMT plays a critical role, maximal TURBT is foundational to its success. This review examines the importance of maximal TURBT in optimizing oncological outcomes in TMT, discusses its technical nuances, and explores the evidence supporting its role in achieving durable local control and improving survival outcomes in MIBC.

Advancements in systemic therapy for muscle-invasive bladder cancer: A systematic review from the beginning to the latest updates

Context

Several phase III randomized controlled trials (RCTs) have shown the importance of perioperative systemic therapy, especially for the efficacy of immune checkpoint inhibitors (ICIs) in both neoadjuvant and adjuvant settings for muscle-invasive bladder cancer (MIBC).

Objective

To synthesize the growing evidence on the efficacy and safety of systemic therapies for MIBC utilizing the data from RCTs.

Evidence acquisition

Three databases and ClinicalTrials.gov were searched in October 2024 for eligible RCTs evaluating oncologic outcomes in MIBC patients treated with systemic therapy. We evaluated pathological complete response (pCR), disease-free survival (DFS), progression-free survival (PFS), event-free survival (EFS), overall survival (OS), and adverse events (AEs).

Evidence synthesis

Thirty-three RCTs (including 14 ongoing trials) were included in this systematic review. Neoadjuvant chemotherapy improved OS compared to radical cystectomy alone. Particularly, the VESPER trial demonstrated that dd-MVAC provided oncological benefits over GC alone in terms of pCR rates, OS (HR: 0.71), and PFS (HR: 0.70). Recently, the NIAGARA trial showed that perioperative durvalumab plus GC outperformed GC alone in terms of pCR rates, OS (HR: 0.75), and EFS (HR: 0.68). Despite the lack of data on overall AE rates in the VESPER trial, differential safety profiles in hematologic toxicity were reported between dd-MVAC and durvalumab plus GC regimens. In the adjuvant setting, no study provided the OS benefit from adjuvant chemotherapy. However, only adjuvant nivolumab had significant DFS and OS benefits compared to placebo.

Conclusions

Neoadjuvant chemotherapy remains the current standard of care for MIBC. Durvalumab shed light on the promising impact of ICIs added to neoadjuvant chemotherapy. Nivolumab is the only ICI recommended as adjuvant therapy in patients who harbored adverse pathologic outcomes. Ongoing trials will provide further information on the impact of combination therapy, including chemotherapy, ICIs, and enfortumab vedotin, in both neoadjuvant and adjuvant settings.

Chaetoglobosin A induces apoptosis in T-24 human bladder cancer cells through oxidative stress and MAPK/PI3K-AKT-mTOR pathway

Chaetoglobosin A (ChA) is an antitumor compound produced by Chaetomium globosum. However, the mechanism of its antitumor effect has been rarely reported. In this study, we evaluated the anti-proliferative effect of ChA on T-24 human bladder cancer cells and explored its mechanism of action. ChA was found to have a good inhibitory effect on T-24 cells by MTT assay with an IC50 value of 48.14 ± 10.25 μΜ. Moreover, it was found to have a migration inhibitory ability and a sustained proliferation inhibitory effect on tumor cells by cell aggregation assay and cell migration assay. The cells morphological changes were determined by Hoechst33342 assay. While Annexin V-FITC/PI double-staining assay also demonstrated that the number of apoptotic cells increased with the increase of drug concentration. Flow cytometry results showed that ChA treatment increased reactive oxygen species (ROS) and decreased mitochondrial membrane potential (MMP) in T-24 cells and inhibited cell mitosis, resulting in an increase in the number of sub-G1 phase cells. Further western blot experiments demonstrated that MAPK and PI3K-AKT-mTOR pathways were activated after drug treatment in addition to endogenous and exogenous apoptotic pathways. The addition of the ROS inhibitor N-acetylcysteine (NAC) upregulated the expression level of Bcl-2 protein, decreased p38 phosphorylation, increased ERK phosphorylation and restored the levels of PI3K and p-mTOR after ChA treatment. These suggest that ChA induces apoptosis by regulating oxidative stress, MAPK, and PI3K-AKT-mTOR signaling pathways in T-24 cells.

Spatial relationships and interactions of immune cell niches are linked to the pathologic response of muscle-invasive bladder cancer to neoadjuvant therapy

BACKGROUND

The identification of the complex spatial architecture of immune cell infiltration and its interaction mechanisms within tumor ecosystems provides crucial insights into therapeutic responses to neoadjuvant therapy in muscle-invasive bladder cancer (MIBC). This study aims to characterize the spatial features of distinct cell-type niches within the tumor microenvironment (TME) of patients with varying responses to neoadjuvant therapy.

METHODS

We performed spatial transcriptomic profiling on six MIBC specimens obtained from a registered clinical trial (ChiCTR2000032359), generating whole-transcriptome spatial atlases to map the TME architecture. High-throughput analytical frameworks were employed to deconstruct the TME, and key findings were validated through immunohistochemistry and mouse model experiments.

RESULTS

Our analysis revealed that tissues from complete responders exhibited greater infiltration of T and B cells, with the formation of tertiary lymphoid structure (TLS). Trajectory analysis identified CCL19/CCL21 as the key signaling molecules driving TLS formation in MIBC. Mouse experiments demonstrated that recombinant CCL19/CCL21 protein injections promoted intratumoral TLS formation and enhance the efficacy of immunotherapy. Furthermore, we observed significant intrinsic heterogeneity within individual tumors, which may contribute to the lack of therapeutic efficacy in MIBC.

CONCLUSIONS

This study underscores the critical role of TLS formation in the response to neoadjuvant therapy in MIBC. We identified CCL19/CCL21 as key drivers of TLS formation within MIBC tumors and potential immune-sensitizing agents. Additionally, the intrinsic heterogeneity of tumor should be considered a significant factor influencing therapeutic efficacy.

Phase II Trial of Risk-Enabled Therapy After Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer (RETAIN 1)

PURPOSE

Cisplatin-based neoadjuvant chemotherapy (NAC) followed by cystectomy is the standard of care for patients with muscle-invasive bladder cancer (MIBC). Mutations in DNA damage repair genes are associated with pathologic downstaging after NAC. We hypothesized that a combination of biomarker selection and clinical staging would identify patients for cystectomy-sparing active surveillance (AS).

PATIENTS AND METHODS

We conducted a single-arm, phase II, noninferiority trial to evaluate a risk-adapted approach for MIBC. Patients with cT2-T3N0M0 MIBC underwent NAC with accelerated methotrexate, vinblastine, doxorubicin, and cisplatin (AMVAC). Pre-NAC transurethral bladder tumor specimens were sequenced for mutations in ATM, ERCC2, FANCC, and RB1. Patients with ≥1 mutation and cT0 post-NAC began AS. The primary end point was metastasis-free survival (MFS) at 2 years for the entire cohort with the null hypothesis rejected if the lower bound exact one-sided 95% CI exceeds 64%.

RESULTS

Seventy patients were enrolled, 33 (47%) had a mutation, and 25 (36%) began per-protocol AS. With a median follow-up of 40 months, the 2-year MFS for all patients was 72.9% (lower bound exact one-sided 95% CI, 62.8). The 2-year MFS was 76.0% in the AS group (95% CI, 54.2 to 88.4) and 71.1% (95% CI, 55.5 to 82.1) in the remaining patients. In the AS group, 17 patients (68%) had some recurrence and 12 (48%) were metastasis-free with an intact bladder. The 2-year overall survival (OS) was 84.3% (95% CI, 73.4 to 91.0); OS was 88.0% (95% CI, 67.3 to 96.0) and 82.2% (95% CI, 67.6 to 90.7) in the AS and not-AS groups, respectively.

CONCLUSION

Patients with MIBC treated with AMVAC followed by a risk-adapted approach to local consolidation achieved a 2-year MFS rate of 73%. The primary end point was not met, but 17% of all enrolled patients and 48% of the AS group avoided cystectomy without metastatic disease.

Nivolumab adjuvant to chemo-radiation in localized muscle-invasive urothelial cancer: primary analysis of a multicenter, single-arm, phase II, investigator-initiated trial (NEXT)

BACKGROUND

Muscle-invasive urothelial cancer (UC) has a high risk of recurrence after definitive treatment. Nivolumab adjuvant to radical surgery improves disease-free survival in patients with UC with a high risk of recurrence; however, its role adjuvant to chemoradiation therapy (CRT) is unknown.

METHODS

The NEXT trial is a single-arm, phase-2 study evaluating the efficacy and tolerability of nivolumab adjuvant to CRT in patients with localized or locoregional UC. The primary endpoint is failure-free survival (FFS) at 2 years. Secondary endpoints include patterns of recurrence, toxicity and quality of life (QoL). Plasma cell-free DNA (cfDNA) was subjected to shallow whole-genome sequencing to correlate with outcomes.

RESULTS

28 patients were enrolled and received 480 mg of nivolumab intravenously every 4 weeks for up to 12 cycles adjuvant to CRT. The FFS at 2 years was 33.2% (95% CI 18.5% to 59.6%). Nine (32%) patients had localized progression, and eight (29%) had distant progression. 25 (89%) had one or more high-risk features (ie, plasmacytoid differentiation, T4, N+, multiple tumors, tumors >5 cm, residual disease before CRT, carcinoma in situ, and hydronephrosis). Patients with ≤2 high-risk features had a median FFS of 45.2 months (95% CI 14.56 to not reached (NR)) compared with 8.2 months (95% CI 7.1 to NR) in those with three or more risk features (p=0.0024). Nivolumab-associated treatment-related adverse events occurred in 18 (64.3%) patients, only 3 had grade 3 TRAEs, with significant changes in QoL. Plasma cfDNA copy number instability (CNI) scores ≤25 before the first dose of adjuvant nivolumab and at cycle 4 were associated with better overall survival compared with CNI scores ≥26 (49.6 months vs 20.5 months, p=0.0024). Genome copy number changes indicated chromatin remodeling and tyrosine kinase pathways, among others, as oncogenic drivers implicated in progression.

CONCLUSION

Nivolumab adjuvant to CRT in localized or locally advanced UC is well tolerated. Stratification by risk factors and correlation with plasma cfDNA analyses generate hypotheses for potential patient selection and putative therapeutic targets for future study.

TRIAL REGISTRATION NUMBER

NCT03171025.

Comparative analysis of oncological outcomes between trimodal therapy and radical cystectomy in muscle-invasive bladder cancer utilizing propensity score matching

BACKGROUND

Bladder preservation therapy for muscle-invasive bladder cancer is reported to yield outcomes comparable to those of radical cystectomy, although it receives a relatively low recommendation grade in Japanese guidelines. This study aims to compare the outcomes of trimodal therapy versus radical cystectomy in the treatment of muscle-invasive bladder cancer.

METHODS

This study is a single-center retrospective analysis that included patients treated with either trimodal therapy or radical cystectomy for muscle-invasive bladder cancer (cT2-4N0-2M0) at our institution between January 1998 and December 2022. Trimodal therapy is administered in cases where radical cystectomy is either unfeasible or declined by the patient, and both treatments are performed with the intent of curative outcomes. Propensity score matching was used to compare cancer-specific survival and overall survival rates.

RESULTS

A total of 93 patients who underwent trimodal therapy and 84 who underwent radical cystectomy for muscle-invasive bladder cancer were analyzed. Using propensity score matching, 66 patients from each treatment group were selected for a comparative analysis of oncological outcomes. The 5-year distant metastasis-free, cancer-specific and overall survival rates were 64.3 and 51.8% (P = 0.096), 83.3 and 69.2% (P = 0.104) and 77.8 and 64.2% (P = 0.274) for trimodal therapy and radical cystectomy, respectively. Subgroup analyses revealed that trimodal therapy for primary tumors significantly improved cancer-specific survival rates compared with radical cystectomy. The two treatment types had similar adverse events related to hematologic toxicity during perioperative chemotherapy.

CONCLUSION

Trimodal therapy exhibited oncological outcomes comparable to those of radical cystectomy in the treatment of muscle-invasive bladder cancer, indicating that trimodal therapy provides favorable outcomes, particularly in cases of primary muscle-invasive bladder cancer.

Bladder Adjuvant Radiation Therapy (BART): Acute and Late Toxicity From a Phase III Multicenter Randomized Controlled Trial

PURPOSE

To report toxicity from the multicenter phase III randomized trial of Bladder Adjuvant Radiation Therapy (BART) after radical cystectomy and chemotherapy in high-risk muscle-invasive bladder cancer (MIBC).

METHODS AND MATERIALS

Patients with nonmetastatic urothelial MIBC with ≥1 high-risk feature after radical cystectomy- pT3-4, pN1-3, nodal yield <10, positive margin, or ≥cT3 downstaged with neoadjuvant chemotherapy- were randomized 1:1 to observation (Obs) or adjuvant radiation therapy (RT) at 4 centers, stratified by pN stage (N0, N+) and chemotherapy (neoadjuvant, adjuvant, none). Stoma-sparing image guided intensity modulated RT 50.4 Gy in 28# was prescribed to the cystectomy bed and pelvic nodes. Acute toxicity (≤3 months of RT/randomization) and late toxicity were assessed per protocol using Common Terminology Criteria for Adverse Event v5.0. Patients progressing within 3 or 6 months of randomization were excluded from acute or late toxicity analysis, respectively.

RESULTS

The BART trial enrolled 153 patients (Obs = 76, RT = 77). About half (49%) had pN+. Nearly 90% received chemotherapy (70% neoadjuvant; most commonly gemcitabine plus cisplatin). In the RT arm, 63/77 completed RT per protocol with no toxicity-related RT termination. Of the 134 patients analyzable for acute toxicity, no difference was observed in grade 3 (Obs 4.2% vs RT 1.6%, P = .34). Grade 2 effects were higher with RT (17.5% vs 1.1%, P < .001), mainly diarrhea/enteritis or proctitis. Late toxicity was analyzable for 104 patients (Obs = 57, RT = 47) with a median follow-up of 27 months. Grades 3 to 4 toxicity were about 10% (Obs 10.5% vs RT 8.4%, P = .62), and cumulative late grade 2+ toxicity was similar in both groups (17.5% vs 23.3%, P = .27).

CONCLUSIONS

In the largest trial of adjuvant RT for high-risk urothelial MIBC, severe acute and late toxicity were low and similar with obervation or radiation therapy. The oncological outcomes are awaited.

Molecular Subtyping for Predicting Pathological Upstaging and Survival Outcomes in Clinically Organ-confined Bladder Cancer Patients Undergoing Radical Cystectomy

Background and objective

Many patients with bladder cancer are understaged. Previous work revealed that molecular subtyping using Decipher Bladder improves clinical staging. This multicenter validation study evaluated Decipher Bladder for upstaging in patients who underwent radical cystectomy (RC) without neoadjuvant therapy.

Methods

The Decipher Bladder genomic subtyping classifier (GSC; Veracyte, San Diego, CA, USA) was performed on bladder tumor specimens from patients with high-grade, clinically organ-confined (cTa-T2N0M0) urothelial carcinoma who subsequently underwent RC without neoadjuvant chemotherapy. The primary endpoint was pathological upstaging to non-organ-confined (NOC) disease (pT3+ and/or N+) at RC. The secondary endpoints included overall survival (OS) and pathological upstaging to MIBC+ disease (pT2+ and/or N+) at RC within clinically non-muscle-invasive bladder cancer (cNMIBC) cases.

Key findings and limitations

A total of 226 patients (134 cNMIBC [cTa/Tis/T1] and 92 cT2) were analyzed from eight participating institutions. Upstaging to NOC disease was observed in 33% of patients (19% for cNMIBC and 53% for cT2). Molecular subtyping identified 138 luminal and 88 nonluminal tumors. Rates of upstaging to NOC were 41% in nonluminal and 28% in luminal tumors (univariable p = 0.04), which was not independently significant after adjusting for clinical variables. Upstaging to MIBC+ in cNMIBC patients was lower in luminal versus nonluminal tumors (32% vs 51%, multivariable p = 0.03). Patients with nonluminal tumors had worse OS on multivariable analyses (p < 0.05). Limitations include retrospective design and sample size.

Conclusions and clinical implications

Luminal tumors represent less aggressive disease, reflected by lower rates of pathological upstaging and favorable OS with RC compared with nonluminal tumors.

Patient summary

Molecular subtyping suggests that in clinically non-muscle-invasive bladder cancer, luminal tumors harbor less aggressive disease, as reflected by lower rates of pathological upstaging to muscle-invasive disease and favorable outcomes with radical cystectomy, in comparison with nonluminal bladder cancer.

Biomarkers for predicting bladder cancer therapy response

The advent of precision medicine has underscored the importance of biomarkers in predicting therapy response for bladder cancer, a malignancy marked by considerable heterogeneity. This review critically examines the current landscape of biomarkers to forecast treatment outcomes in bladder cancer patients. We explore a range of biomarkers, including genetic, epigenetic, proteomic, and transcriptomic indicators, from multiple sample sources, including urine, tumor tissue and blood, assessing their efficacy in predicting responses to chemotherapy, immunotherapy, and targeted therapies. Despite promising developments, the translation of these biomarkers into clinical practice faces significant challenges, such as variability in biomarker performance, the necessity for large-scale validation studies, and the integration of biomarker testing into routine clinical workflows. We also highlight the need for standardized methodologies and robust assays to ensure consistency and reliability. Future directions point towards longitudinal studies and the development of combination biomarker panels to enhance predictive accuracy. This review emphasizes the transformative potential of predictive biomarkers in improving patient outcomes and advocates for continued collaborative efforts to overcome existing barriers in this rapidly evolving field.

Disitamab vedotin vs. gemcitabine-cisplatin regimen with immunotherapy: a comparative analysis of efficacy and safety in muscle-invasive bladder cancer

Introduction

Muscle-invasive bladder cancer (MIBC) is an aggressive bladder cancer characterized by invasion of the muscular bladder wall, often necessitating a multimodal treatment approach for optimal outcomes. This study aimed to compare the real-world efficacy and safety of disitamab vedotin (RC48), an antibody-drug conjugate (ADC), combined immunotherapy targeting programmed cell death protein-1 (PD-1), against the gemcitabine and cisplatin (GC) regimen with PD-1 immunotherapy in the treatment of MIBC.

Methods

This single-center, retrospective study was conducted at the First Affiliated Hospital of Soochow University and included 38 patients with MIBC treated with either RC48 plus immunotherapy or GC regimen plus immunotherapy, between January 2022 and December 2023. Patients were divided into two groups: the RC48 with immunotherapy (ADC + PD-1) group and the GC regimen with immunotherapy (GC + PD-1) group. Efficacy was evaluated based on their pathological complete response rates (PCRR) and pathological downstaging rates (PDR). Adverse events (AEs) were assessed to compare safety profiles.

Results

Of the 38 patients, 17 were in the ADC + PD-1 group and 21 were in the GC + PD-1 group. The PCRR was significantly higher in the ADC + PD-1 group (82.35%, 14/17) compared to the GC + PD-1 group (47.62%, 10/21; P = 0.043). The PDR was also higher in the ADC + PD-1 group (94.12%, 16/17) than in the GC + PD-1 group (80.95%, 17/21), although the difference was not statistically significant (P = 0.355). No serious allergic reactions or fatal AEs were reported in either group. No Grade 4 AEs were reported, while Grade 3 AEs occurred at a rate of 5.71% in the ADC + PD-1 group and 12.20% in the GC + PD-1 group (P = 0.260).

Conclusion

RC48 combined with immunotherapy demonstrated a significantly higher PCRR compared to the GC regimen with immunotherapy, while maintaining a comparable safety profile. These findings highlight the potential of RC48 combined with immunotherapy as an effective treatment option for MIBC in clinical practice.

Adjuvant Radiotherapy After Radical Cystectomy for Muscle-invasive Bladder Cancer: A Phase 2 Trial-Results of Secondary Endpoints

BACKGROUND AND OBJECTIVE

Patients with muscle-invasive bladder cancer (MIBC) who develop a recurrence after radical cystectomy (RC) have poor outcomes. This study aims to evaluate the safety and efficacy of adjuvant radiotherapy (ART) in mitigating pelvic recurrences in high-risk MIBC patients. We report on survival outcomes, health-related quality of life (HRQoL), and hematological toxicity for these patients.

METHODS

A multicentric phase 2 trial was conducted from August 2014 to October 2020, in which 72 high-risk MIBC patients received ART after RC. High risk was defined by the presence of one or more of the following criteria: pT3 stage and lymphovascular invasion, pT4 stage, fewer than ten lymph nodes removed, positive lymph nodes, and positive surgical margins. Using intensity-modulated radiotherapy, patients with pelvic lymph nodes ± cystectomy bed (in case of a positive surgical margin) received 50 Gy in 25 fractions. Outcomes were local relapse-free rate (LRFR), clinical relapse-free survival (CRFS), overall survival (OS) (Kaplan-Meier statistics), HRQoL (European Organisation for Research and Treatment of Cancer QLQ-C30/QLQ-BLM30 surveys), and hematological toxicity (Common Terminology Criteria for Adverse Events grading).

KEY FINDINGS AND LIMITATIONS

The median follow-up of patients without a recurrence was 39 mo. At 2 and 5 yr, LRFRs were 81% (95% confidence interval [CI] 71-91%) and 79% (95% CI 68-89%), CRFS rates were 32% (95% CI 21-42%) and 20% (95% CI 11-30%), and OS rates were 48% (95% CI 36-59%) and 34% (95% CI 22-45%), respectively. At the end of ART, several symptoms worsened, most returning to baseline within the first few months. Diarrhea showed the greatest deterioration, recovering to baseline score only partially. Hematological toxicity of incidence grade ≥2 included lymphopenia (75%), neutropenia (2%), thrombopenia (2%), and anemia (17%). Limitations include the single-arm design and the limited availability of blood samples and surveys.

CONCLUSIONS AND CLINICAL IMPLICATIONS

ART after RC is well tolerated and leads to a favorable local control rate, supporting its use in clinical practice.

Mcl-1 downregulation enhances BCG treatment efficacy in bladder cancer by promoting macrophage polarization

BACKGROUND

Bacillus Calmette-Guérin (BCG) is the primary method of postoperative perfusion treatment for bladder cancer. The myeloid cell leukemia gene-1 (Mcl-1) is closely associated with the development of malignant tumors. Previous research by our group has demonstrated that downregulating Mcl-1 using shRNA can enhance the efficacy of BCG treatment in bladder cancer. This study aims to investigate the impact of Mcl-1 downregulation in combination with BCG treatment on bladder cancer, macrophage polarization, and the underlying mechanism of action, with the goal of reducing recurrence and metastasis in bladder cancer.

METHODS

The GSE190529 dataset was analyzed to identify differential genes for enrichment analysis. The WGCNA algorithm was then employed to pinpoint gene modules closely associated with the Mcl-1 gene. The overlapping genes between these modules and the differentially expressed genes were subjected to enrichment analysis in GO and KEGG pathways to unveil crucial signaling pathways. In vitro experiments involved the co-culture of Raw264.7 macrophages and MB49 to establish a tumor microenvironment model, while in vivo experiments utilized an MNU-induced rat bladder cancer model. Various methods including Enzyme-Linked Immunosorbent Assay (ELISA), Western blot, immunofluorescence, HE staining, etc. were utilized to assess macrophage polarization and the expression of proteins linked to the ASK1/MKK7/JNK/cJUN signaling pathway.

RESULTS

Bioinformatics analysis indicates that the therapeutic mechanism of Mcl-1 in BCG treatment for bladder cancer may be linked to the Mitogen-Activated Protein Kinase (MAPK) signaling pathway. Both in vivo and in vitro experiments have demonstrated that the combination of BCG treatment and Mcl-1shRNA intervention results in elevated expression of M1 markers (TNF-α, CD86, INOS) and reduced expression of M2 markers (IL-10, CD206, Arg-1). Moreover, there was a notable increase in protein levels of P-ASK1, P-MKK7, P-JNK, P-cJUN, and CX43, leading to a significant rise in the apoptosis rate of bladder cancer cells and diminished proliferation, migration, and invasion capabilities. The expression of these markers can be reversed by employing the JNK signaling pathway inhibitor SP600125.

CONCLUSION

Down-regulation of Mcl-1 promotes the polarization of macrophages towards the M1 type through activation of the ASK1/MKK7/JNK signaling pathway. This enhances intercellular communication and improves the efficacy of BCG in bladder cancer treatment.

Neoadjuvant Chemotherapy in Muscle-Invasive Bladder Cancer: A Nationwide Analysis of Eligibility, Utilization, and Outcomes

OBJECTIVES

To investigate neoadjuvant chemotherapy (NAC) eligibility, utilization, and survival outcomes for muscle-invasive bladder cancer patients undergoing radical cystectomy (RC) in a Finnish population.

MATERIALS AND METHODS

Data from the Finnish National Cystectomy Database (2005-2017) was combined with Finnish Cancer Registry survival data. NAC utilization rates were reported, and downstaging rates were calculated based on final pathological staging. Logistic regression analyzed NAC usage and complete response (CR) predictors.

RESULTS

Since 2011, 29% of 1157 patients received NAC. Its usage remained consistent, and the number of eligible patients not receiving NAC decreased during the study period. Among NAC patients, pathology T-category was pT0 (34%), pT1-Ta-Tis (16%), pT2 (23%), pT3 (20%), and pT4 (7%) tumors, with pN0 in 82%. In the RC + NAC group, the 5-year overall survival (OS) rates were 89% for patients with no residual disease (pT0N0), 82% for those with organ-confined residual disease (pT1, Tis, Ta, T2/N0), and 49% for patients with non-organ-confined residual disease (pT3+/N+). The corresponding cancer-specific survival (CSS) rates were 93%, 86%, and 57%, respectively. Patients with organ-confined residual disease after NAC had survival outcomes comparable to those who underwent RC alone. Higher age; odds ratio (OR) 0.93, [95% Confidence Interval (CI): 0.90-0.95] and Charlson Co-morbidity Index-score [OR 0.88 (0.79-0.98)] reduced the likelihood of receiving NAC, while a smaller center size increased the probability [OR 1.82 (1.02-3.28)]. More treatment cycles [OR 0.70, (95% CI: 0.51-0.93)] and a favorable GFR [OR 0.38 (0.16-0.88)] were associated with achieving CR.

CONCLUSION

We report that NAC is well-utilized across Finland, with CR rates comparable to recent trials. Additionally, our survival rates are reasonable, and even with organ-confined residual disease after NAC, survival outcomes are similar to those who underwent RC alone.

Differential Analysis of Surgical Treatment Modalities in T2N0M0 Bladder Cancer Patients: A Novel Propensity Score-Based Cohort Study

OBJECTIVE

This study explored prognostic differences between radical cystectomy (RC), tri-modality treatment (TURBt combined with radiotherapy and chemotherapy, TMT), electrocautery (EC) and partial cystectomy (PC) for T2N0M0 MIBC.

MATERIALS AND METHODS

Using SEER data (2004-2015, 2018-2020), we identified T2N0M0 MIBC patients treated with RC, TMT, EC, or PC. Propensity score matching (PSM, 1:1, caliper=0.1) minimized confounding. Kaplan-Meier analysis and Cox regression identified independent prognostic factors, stratified by tumor size and age.

RESULT

This study included 6526 patients with T2N0M0 MIBC. Among them, 348(5.33%) underwent PC, 309(4.73%)underwent EC, 1833(28.09%)received TMT, and 4036(61.84%) RC. After 1:1 propensity score matching, RC showed improved CSS (HR=0.67, 95%CI 0.47-0.95 , and PC also benefited (HR=0.97, 95%CI 0.69-1.36) compared to EC. While TMT showed a worse end (HR=1.41, 95%Cl 1.03-1.92) compared to EC. Cox analysis was used to stratify tumor size and age for subgroup analysis. Results for tumor size subgroups were aligned with PSM findings. In the age-stratified subgroups, patients aged <67 years, both RC (HR=0.54, P=0.107) and TMT(HR=0.91, P=0.785) showed better prognoses compared to EC treatment, while PC treatment showed worse prognoses compared to EC treatment (HR=1.23, P=0.542).; for 68-77 years, RC(0.64, P=0.1436) and PC(HR=0.46, P=0.0283)had advantages, and PC is more recommended. For >78 years, RC had superior CSS over EC and PC, whereas TMT had the poorest prognosis.

CONCLUSION

In clinical T2N0M0 MIBC, overall, RC outperformed focal-tumor therapy and PC, irrespective of tumor size. However, considering age, we recommend PC treatment for patients aged 68-77 and EC for those aged >78 years.

Proteomic profiling identifies muscle-invasive bladder cancers with distinct biology and responses to platinum-based chemotherapy

Platinum-based neoadjuvant chemotherapy prior to radical cystectomy is the preferred treatment for muscle-invasive bladder cancer despite modest survival benefit and significant associated toxicities. Here, we profile the global proteome of muscle-invasive bladder cancers pre- and post-neoadjuvant chemotherapy treatment using archival formalin-fixed paraffin-embedded tissue. We identify four pre-neoadjuvant chemotherapy proteomic clusters with distinct biology and response to therapy and integrate these with transcriptomic subtypes and immunohistochemistry. We observe proteomic plasticity post-neoadjuvant chemotherapy that is associated with increased extracellular matrix and reduced keratinisation compared to pre-neoadjuvant chemotherapy. Post-neoadjuvant chemotherapy clusters appear to be differentially enriched for druggable proteins. For example, MTOR and PARP are over-expressed at the protein level in tumours identified as neuronal-like. In addition, we determine that high intra-tumoural proteome heterogeneity in pre-neoadjuvant chemotherapy tissue is associated with worse prognosis. Our work highlights aspects of muscle-invasive bladder cancer biology associated with clinical outcomes and suggests biomarkers and therapeutic targets based on proteomic clusters.

Treatment Patterns and Radical Cystectomy Outcomes in Patients Diagnosed With Urothelial Nonmetastatic Muscle-Invasive Bladder Cancer in the United States

PURPOSE

To characterize trends and patterns in treatment characteristics and perioperative outcomes of patients with urothelial muscle-invasive bladder cancer (MIBC).

MATERIALS AND METHODS

We utilized the National Cancer Database to assess trends and patterns in treatment modalities (radical cystectomy [RC] with or without neoadjuvant/adjuvant treatments, trimodal bladder-sparing treatment [trimodal treatment], and others) among MIBC patients diagnosed between 2004 and 2017. We also assessed trends and patterns of short-term post-surgery outcomes, including 30-day and 90-day mortality, and readmissions.

RESULTS

Among 83,259 MIBC patients, those who received RC, trimodal treatment, and transurethral resection of bladder tumor (TURBT) plus chemotherapy were 34,715 (41.7%), 7,372 (8.9%), and 6,171 (7.4%), respectively. A substantial proportion (29,314; 35.2%) of MIBC patients received other treatments, including TURBT-only. From 2004 through 2017, the proportion of MIBC patients who utilized guideline-recommended treatments, whether RC (from 36.4% to 42.8%) or trimodal treatment (from 7.9% to 10.2%), increased. Among those who received RC, there was a substantial increase in neoadjuvant chemotherapy (NAC) utilization, from 7.8% to 29.4%. Conversely, utilization of RC without perioperative treatments decreased from 62.3% to 32.7%. There was a significant decrease in 30-day (2.8%-1.8%) and 90-day (7.1%-5.3%) mortality rates among RC recipients.

CONCLUSION

There was a shift in treatment modalities for MIBC, with increased utilization of RC with NAC. A decrease in post-surgery mortality rates may indicate improved outcomes, although the unmet need for NAC utilization requires further investigation.

Phase 2 Study of Preoperative Tislelizumab in Combination with Low-dose Nab-Paclitaxel in Patients with Muscle-invasive Bladder Cancer

BACKGROUND AND OBJECTIVE

Combinations of immune checkpoint inhibitors and nab-paclitaxel have achieved significant therapeutic effects in the treatment of advanced urothelial carcinoma. Our aim was to assess the efficacy and safety of tislelizumab combined with low-dose nab-paclitaxel in patients with muscle-invasive bladder cancer (MIBC).

METHODS

TRUCE-01 was a single-arm phase 2 study that included 62 patients with T2-4a N0/X M0 MIBC tumors with predominant urothelial carcinoma histology. Eligible patients received three 21-d cycles of intravenous 200 mg tislelizumab on day 1 plus intravenous 200 mg nab-paclitaxel on day 2, followed by surgical assessment. The primary study endpoint was a clinical complete response (cCR). Treatment-related adverse event (TRAE) profiles were recorded according to Common Terminology Criteria for Adverse Events version 5.0.

KEY FINDINGS AND LIMITATIONS

The safety analysis included all 62 patients and the efficacy analysis included 48 patients. The primary efficacy endpoint (cCR) was met by 25 patients (52%) patients. Among the 62 patients in the safety analysis, six (9.7%) had grade ≥3 TRAEs.

CONCLUSIONS

Tislelizumab combined with low-dose nab-paclitaxel showed promising antitumor effectiveness and was generally well tolerated, which makes it an excellent preoperative therapy option for MIBC.

PATIENT SUMMARY

We found that a combination of the drugs tislelizumab and low-dose nab-paclitaxel had satisfactory efficacy and safety for preoperative treatment of muscle-invasive bladder cancer.

Predictive Value of Neutrophil Extracellular Traps in Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer

Cisplatin-based chemotherapy is the recommended therapy for muscle-invasive bladder cancer (MIBC). However, the efficacy of MIBC for chemotherapy is only about 40%. Therefore, predictors of therapy response are urgently needed. Neutrophils form neutrophil extracellular traps (NETs), a network structure, and growing evidence indicated that it could be a prognostic and predictive marker in cancer. In MIBC, the predictive role of NETs in chemotherapy resistance is unclear. We used the Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression analyses to develop a NETs-associated signature score (NETs-score) for therapeutic response prediction in the discovery cohort (GSE169455). Then the NETs score-based risk stratification was verified in two validation cohorts (Taber et al.'s cohort, our institutional cohort). In the training cohort, high NETs-score was associated with poor chemotherapy response (AUC = 0.781) and reduced recurrence-free survival (RFS) (hazard ratio [HR] = 2.07, 95% confidence interval [CI]: [1.26-3.40], p = 0.003) in MIBC patients. The NETs-score was also demonstrated to be a predictive factor for the efficacy of neoadjuvant chemotherapy in the validation cohort (AUC = 0.731). The accuracy of the NETs-score was superior to other chemotherapy response predictors such as Ba/Sq expression subtype (AUC = 0.711), BRCA2 mutation (AUC = 0.692) and ERCC2 mutation (AUC = 0.548). Furthermore, in our center cohort, the expression level of H3Cit showed a significant difference between the response and no-response group (p = 0.01). Through immunohistochemical validation, NETs was an independent predictor of MIBC neoadjuvant chemotherapy efficacy as determined by the multivariate logistic regression analysis (OR = 5.94, 95% CI: 1.20-45.50, p = 0.045). Patients with high levels of NETs predicted poor response to neoadjuvant chemotherapy. This study was the first to reveal the correlation between the level of NETs in MIBC and the efficacy of chemotherapy, which may provide a theoretical basis regarding NETs inhibitors.

"Modernized" en Bloc Radical Cystectomy Versus Standard Radical Cystectomy: A Nationwide Multi-Institutional Propensity Score Matched Analysis

Background: Pelvic lymph node dissection during standard radical cystectomy (stdRC) for muscle invasive bladder cancer is performed as separate templates. In the modernized en bloc radical cystectomy (mEbRC), the bladder is removed together with all its associated lymphatic tissue as one specimen. Our aim was to evaluate the oncological and surgical outcomes of mEbRC with a propensity-matched national cohort of stdRC cases. Methods: 935 patients (mEbRC: 214 and stdRC: 721) were eligible for analysis, and 1:2 propensity score matching was performed regressing mEbRC treatment on the variables age, gender, neoadjuvant chemotherapy, Charlson Comorbidity Index, lymph node metastases at final pathology, carcinoma in situ, and pT-stage. The primary outcome was recurrence-free survival (RFS). Secondary endpoints were overall survival (OS) and cancer-specific survival (CSS), survival for female patients. and perioperative measures. Results: There were no significant differences between the groups regarding complications, 30-day readmission rates, and 30- and 90-day mortality rates. In the propensity score matched groups, the 5-year RFS was 83% in the mEbRC group vs. 67% in the stdRC group (p < 0.001), the CSS was 89% and 78% (p ≤ 0.001), and OS 81% vs. 68% (p < 0.001) in the same groups, respectively. The results were confirmed by Cox regression analyses with hazard ratios ranging from 0.41 to 0.50 and p-values ≤ 0.001, favoring mEbRC. The 5-year OS for female patients was 86% for mEbRC and 60% for stdRC (p = 0.022). Conclusions: Performing mEbRC over stdRC might yield significantly better oncological outcomes, with equal survival rates for both genders.

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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The Role of SWI/SNF Complex in Bladder Cancer

Bladder cancer originates from bladder tissues and is the ninth most common type of cancer worldwide. The SWI/SNF (SWItch/sucrose non- fermentable) complex plays a crucial role in regulating various biological processes, such as cell cycle control, DNA damage repair and transcription regulation. The purpose of this article is to examine the functional studies of the SWI/SNF complex in bladder cancer, highlighting new pathways for creating personalised treatment approaches for bladder cancer patients with mutations in the SWI/SNF complex. By acquiring a comprehensive understanding of the mechanisms of the SWI/SNF complex in bladder cancer, we can offer more precise and effective solutions to treat this disease.

Advances in research on the carcinogenic mechanisms and therapeutic potential of YAP1 in bladder cancer (Review)

Bladder cancer is the most common malignant tumor of the urinary system with high morbidity and no clear pathogenesis. The Hippo signaling pathway is an evolutionarily conserved pathway that regulates organ size and maintains tissue homeostasis. Yes‑associated protein 1 (YAP1) is a key effector of this pathway and regulates downstream target genes by binding to transcriptional co‑activators with PDZ binding sequences (TAZ). Several studies have demonstrated that YAP1 is overexpressed in bladder cancer and is involved in adverse outcomes such as bladder cancer occurrence, progression, resistance to cisplatin and the recurrence of tumours. The present review summarized the involvement of YAP1 in bladder cancer disease onset and progression, and the mechanism of YAP1 involvement in bladder cancer treatment. In addition, this study further explored the potential of YAP1 in the diagnosis and treatment of bladder cancer. This study aimed to explore the potential mechanism of YAP1 in the treatment of bladder cancer.

Adjuvant Immune Checkpoint Inhibitors for Muscle-Invasive Urothelial Carcinoma: An Updated Systematic Review, Meta-analysis, and Network Meta-analysis

CONTEXT

Adjuvant immune checkpoint inhibitors (ICIs) have recently emerged as guideline-recommended treatments of high-risk muscle-invasive urothelial carcinoma (MIUC). However, there is limited evidence regarding the optimal candidates and the differential efficacy of adjuvant ICI regimens.

OBJECTIVE

To synthesize and compare the efficacy and safety of adjuvant ICIs for high-risk MIUC using updated data from phase III randomized controlled trials.

EVIDENCE ACQUISITION

In April 2024, three databases were searched for eligible randomized controlled trials that evaluated oncologic outcomes in patients with MIUC treated with adjuvant ICIs. Pairwise meta-analysis (MA) and network meta-analyses were performed to compare the hazard ratios of oncological outcomes, including disease-free survival (DFS), overall survival (OS), and adverse events. Subgroup analyses were conducted on the basis of predefined clinicopathological features.

EVIDENCE SYNTHESIS

Three randomized controlled trials that assessed the efficacy of adjuvant nivolumab, pembrolizumab, and atezolizumab were included in the MAs and network meta-analyses groups. Pairwise MAs showed that treatment with adjuvant ICIs significantly improved DFS [hazards ratio: 0.77, 95% confidence interval (CI): 0.66-0.90] as well as OS (hazards ratio: 0.87, 95% CI 0.76-1.00) in patients with MIUC compared with in the placebo/observation group. The DFS benefit was prominent in patients who underwent neoadjuvant chemotherapy (P = 0.041) and in those with bladder cancer (P = 0.013) but did not differ across programmed death-ligand 1 and lymph node status. Adjuvant ICI therapy was associated with increased risk of any (OR: 2.98, 95% CI 2.06-4.33) and severe adverse events (OR: 1.78, 95% CI 1.49-2.13). The treatment rankings revealed that pembrolizumab for DFS (84%) and nivolumab for OS (93%) had the highest likelihood of improving survival.

CONCLUSIONS

Our analyses demonstrated the DFS and OS benefits of adjuvant ICIs for high-risk MIUC. Furthermore, patients with bladder cancer who underwent neoadjuvant chemotherapy appeared to be the optimal candidates for adjuvant ICIs regarding prolonged DFS. Adjuvant ICIs are the standard of care for high-risk MIUC, and differential clinical behaviors and efficacy will enrich clinical decision-making.