Smoking cessation and survival in lung, upper aero-digestive tract and bladder cancer: cohort study

BACKGROUND

The aim was to examine the association between smoking cessation and prognosis in smoking-related cancer as it is unclear that cessation reduces mortality.

METHODS

In this retrospective cohort study from 1999 to 2013, we assessed the association between cessation during the first year after diagnosis and all-cause and cancer-specific mortality.

RESULTS

Of 2882 lung, 757 upper aero-digestive tract (UAT) and 1733 bladder cancer patients 27%, 29% and 21% of lung, UAT and bladder cancer patients quit smoking. In lung cancer patients that quit, all-cause mortality was significantly lower (HR: 0.82 (0.74-0.92), while cancer-specific mortality (HR: 0.89 (0.76-1.04) and death due to index cancer (HR: 0.90 (0.77-1.05) were non-significantly lower. In UAT cancer, all-cause mortality (HR: 0.81 (0.58-1.14), cancer-specific mortality (HR: 0.84 (0.48-1.45), and death due to index cancer (HR: 0.75 (0.42-1.34) were non-significantly lower. There was no evidence of an association between quitting and mortality in bladder cancer. The HRs were 1.02 (0.81-1.30) for all-cause, 1.23 (0.81-1.86) for cancer specific, and 1.25 (0.71-2.20) for death due to index cancer. These showed a non-significantly lower risk in sensitivity analyses.

CONCLUSIONS

People with lung and possibly UAT cancer who quit smoking have a lower risk of mortality than people who continue smoking.

Oncologic Outcomes and Predictive Factors for Recurrence Following Robot-Assisted Radical Cystectomy for Urothelial Carcinoma: Multicenter Study from Korea

The aim of our study was to evaluate intermediate-term oncologic outcomes, predictive factors for recurrence, and recurrence patterns in a multicenter series of patients treated with robot-assisted radical cystectomy (RARC) for urothelial carcinoma (UC) of the bladder. Between 2007 and 2015, 346 patients underwent RARC at multiple tertiary referral centers in Korea. Descriptive statistics were used for demographics and perioperative variables. Survival and recurrence were estimated with Kaplan-Meier analysis. Logistic regression models were used to determine predictors of recurrence. Median follow-up was 33 months (interquartile range [IQR], 7-50). The numbers of patients with organ-confined and lymph node (LN)-positive disease were 237 (68.4%) and 68 (19.7%), respectively. LN density (1-20 vs. > 20) was 13.6% and 6.1%, with a median of 17 nodes removed (IQR, 9-23). In logistic regression analysis, type of LN dissection, and pathologic tumor stage were significant predictors of cancer recurrence and death from cancer. Local, distal recurrence and secondary UC occurred in 7 (2.0%), 53 (15.3%), and 4 (1.2%) patients, respectively. The 5-year overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were 78%, 84%, and 73%, respectively. At last follow-up, RFS for extended pelvic LN dissection vs. standard pelvic LN dissection was 70% and 47% (P = 0.038). In addition, at last follow-up, LN density (0 vs. 1-20 vs. over 20) was 67%, 41%, and 29%, respectively (P < 0.001). Patients undergoing RARC in this multi-institutional cohort demonstrated intermediate-term oncologic outcomes, predictive factors for recurrence, and recurrence patterns that were not unusual.

Intravesical electromotive drug administration for non-muscle invasive bladder cancer

BACKGROUND

Electromotive drug administration (EMDA) is the use of electrical current to improve the delivery of intravesical agents to reduce the risk of recurrence in people with non-muscle invasive bladder cancer (NMIBC). It is unclear how effective this is in comparison to other forms of intravesical therapy.

OBJECTIVES

To assess the effects of intravesical EMDA for the treatment of NMIBC.

SEARCH METHODS

We performed a comprehensive search using multiple databases (CENTRAL, MEDLINE, EMBASE), two clinical trial registries and a grey literature repository. We searched reference lists of relevant publications and abstract proceedings. We applied no language restrictions. The last search was February 2017.

SELECTION CRITERIA

We searched for randomised studies comparing EMDA of any intravesical agent used to reduce bladder cancer recurrence in conjunction with transurethral resection of bladder tumour (TURBT).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the literature, extracted data, assessed risk of bias and rated quality of evidence (QoE) according to GRADE on a per outcome basis.

MAIN RESULTS

We included three trials with 672 participants that described five distinct comparisons. The same principal investigator conducted all three trials. All studies used mitomycin C (MMC) as the chemotherapeutic agent for EMDA. 1. Postoperative MMC-EMDA induction versus postoperative Bacillus Calmette-Guérin (BCG) induction: based on one study with 72 participants with carcinoma in situ (CIS) and concurrent pT1 urothelial carcinoma, we are uncertain (very low QoE) about the effect of MMC-EMDA on time to recurrence (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.64 to 1.76; corresponding to 30 more per 1000 participants, 95% CI 180 fewer to 380 more). There was no disease progression in either treatment arm at three months' follow-up. We are uncertain (very low QoE) about serious adverse events (RR 0.75, 95% CI 0.18 to 3.11). 2. Postoperative MMC-EMDA induction versus MMC-passive diffusion (PD) induction: based on one study with 72 participants with CIS and concurrent pT1 urothelial carcinoma, postoperative MMC-EMDA may (low QoE) reduce disease recurrence (RR 0.65, 95% CI 0.44 to 0.98; corresponding to 147 fewer per 1000 participants, 95% CI 235 fewer to 8 fewer). There was no disease progression in either treatment arm at three months' follow-up. We are uncertain (very low QoE) about the effect of MMC-EMDA on serious adverse events (RR 1.50, 95% CI 0.27 to 8.45). 3. Postoperative MMC-EMDA with sequential BCG induction and maintenance versus postoperative BCG induction and maintenance: based on one study with 212 participants with pT1 urothelial carcinoma of the bladder with or without CIS, postoperative MMC-EMDA with sequential BCG may result (low QoE) in a longer time to recurrence (hazard ratio (HR) 0.51, 95% CI 0.34 to 0.77; corresponding to 181 fewer per 1000 participants, 95% CI 256 fewer to 79 fewer) and time to progression (HR 0.36, 95% CI 0.17 to 0.75; corresponding to 63 fewer per 1000 participants, 95% CI 82 fewer to 24 fewer). We are uncertain (very low QoE) about the effect of MMC-EMDA on serious adverse events (RR 1.02, 95% CI 0.21 to 4.94). 4. Single-dose, preoperative MMC-EMDA versus single-dose, postoperative MMC-PD: based on one study with 236 participants with primary pTa and pT1 urothelial carcinoma, preoperative MMC-EMDA likely (moderate QoE) results in a longer time to recurrence (HR 0.47, 95% CI 0.32 to 0.69; corresponding to 247 fewer per 1000 participants, 95% CI 341 fewer to 130 fewer) for a median follow-up of 86 months. We are uncertain (very low QoE) about the effect of MMC-EMDA on time to progression (HR 0.81, 95% CI 0.00 to 259.93; corresponding to 34 fewer per 1000 participants, 95% CI 193 fewer to 807 more) and serious adverse events (RR 0.79, 95% CI 0.30 to 2.05). 5. Single-dose, preoperative MMC-EMDA versus TURBT alone: based on one study with 233 participants with primary pTa and pT1 urothelial carcinoma, preoperative MMC-EMDA likely (moderate QoE) results in a longer time to recurrence (HR 0.40, 95% CI 0.28 to 0.57; corresponding to 304 fewer per 1000 participants, 95% CI 390 fewer to 198 fewer) for a median follow-up of 86 months. We are uncertain (very low QoE) about the effect of MMC-EMDA on time to progression (HR 0.74, 95% CI 0.00 to 247.93; corresponding to 49 fewer per 1000 participants, 95% CI 207 fewer to 793 more) or serious adverse events (HR 1.74, 95% CI 0.52 to 5.77).

AUTHORS' CONCLUSIONS

While the use of EMDA to administer intravesical MMC may result in a delay in time to recurrence in select patient populations, we are uncertain about its impact on serious adverse events in all settings. Common reasons for downgrading the QoE were study limitations and imprecision. A potential role for EMDA-based administration of MMC may lie in settings where more established agents (such as BCG) are not available. In the setting of low or very low QoE for most comparisons, our confidence in the effect estimates is limited and the true effect sizes may be substantially different from those reported here.

Stalk versus base invasion in pT1 papillary cancers of the bladder: improved substaging system predicting the risk of progression

AIMS

Pathological stage pT1 bladder cancers constitute a clinically heterogeneous group. However, current staging guidelines for superficially invasive cancers do not acknowledge the variability in type and extent of lamina propria invasion in papillary urothelial carcinomas (PUCs), and historically proposed substaging systems showed either high interobserver variation or limited value in predicting patient outcomes. The aim of this study was to reappraise pT1 PUC substaging, with the objective of identifying a novel scheme that is reproducible and prognostically meaningful.

METHODS AND RESULTS

pT1 PUCs diagnosed during 1999-2015 were retrospectively reviewed and characterized as focal invasion confined to the papillary stalk, focal invasion of the tumour base, or extensive invasion of the tumour base. Cases with concurrent flat carcinoma in situ, angiolymphatic invasion, absent muscularis propria or clinically advanced disease were excluded. We calculated cumulative incidence rates of recurrence, progression and death by tumour subtype, and evaluated differential risks by using log-rank tests and Kaplan-Meier curves stratified by type and extent of invasion. Among 62 patients satisfying the inclusion criteria, 22 of 29 patients with base-extensive invasion progressed, whereas four of 13 with base-focal and none of 20 with stalk-only invasion progressed. There was strong evidence that base-extensive patients had a higher risk of progression and death resulting from bladder cancer than base-focal or stalk-only patients (P < 0.0001). However, tumour subtype was not significantly associated with risk of recurrence (P = 0.21).

CONCLUSIONS

We propose an innovative substaging approach for reporting the site and extent of lamina propria invasion in patients with pT1 PUC, allowing patient stratification for risk of progression.

[Prognostic factors of patients with T2N0M0 upper tract urothelial carcinoma: a single-center retrospective study of 235 patients]

OBJECTIVE

To evaluate the impacts of the prognostic factors of T2N0M0 upper tract urothelial carcinoma (UTUC) for Chinese patients.

METHODS

A retrospective study was conducted including 235 patients who were diagnosed with T2N0M0 UTUC in our hospital and received radical nephroureterectomy (RNU) or partial ureterectomy during January 2000 and December 2013. The 3 and 5-year cancer-specific survival rates and bladder recurrence-free survival rates of all the patients were valued using Kaplan-Meier method, and the survival curves with statistical significance between the two were compared using the Log-rank test. Variables with significant differences in the univariate analysis were subjected to the multivariate analysis by Cox regression model.

RESULTS

A total of 235 patients were included in this study, including 95 (40.4%) male patients and 140 (59.6%) female patients. The mean age was 66.73±10.49 years.The median follow-up time was 53 (rang: 3-142) months, and during the follow-up, 74 (31.5%) patients died of UTUC after a median of 35 months,and 96 (40.9%) patients developed intravesical recurrence after a median of 19.5 months. The 3 and 5-year cancer-specific survival rates of all the patients were 89.1% and 85.9%, respectively; the bladder recurrence-free survival rates were 85.5% and 80.2%, respectively. The independent prognostic factors of cancer-specific mortality were tumor age elder than 55 years (HR=3.138, 95%CI: 1.348-7.306, P=0.008) and diameter larger than 5 cm (HR=3.320, 95%CI: 1.882-5.857, P<0.001). The independent prognostic factors of bladder recurrence-free survival were ureter tumor (HR=1.757, 95%CI: 1.159-2.664, P=0.008) and lower tumor grade (HR=1.760, 95% CI: 1.151-2.692, P=0.009).

CONCLUSION

T2N0M0 UTUC has a better cancer-specific survival. The intravesical recurrence was equivalent to non-muscle invasive UTUC but earlier. The tumor diameter larger than 5 cm and the patient age elder than 55 years were independently associated with cancer-specific mortality; the primary tumor located in ureter and lower tumor grade were more likely to develop intravesical recurrence.

[The role of immunotherapy in the modern treatment of urothelial carcinoma]

By the emergence of modern immunotherapies with active agents like PD-1 (nivolumab, pembrolizumab) and PD-L1 immune checkpoint blockers (atezolizumab, avelumab, durvalumab), new therapeutic options have become available for the treatment of patients with locally advanced and metastatic urothelial carcinoma. According to the recent publications, they have been effective in case of progression after platinum therapy, in or after second-line and in firstline therapies for cisplatin ineligible patients, respectively. Patient survival and tumor response data are very promising; in particular stages, they seem to be more effective than the previously administered chemotherapies. Their toxicity profiles also appear to be more favorable. Immunological side effects are rare; their identification and management require preparedness and multidisciplinary thinking. Current and ongoing trials are investigating the combinations of new remedies with other immunotherapeutic agents (e.g., CTLA-4 inhibitor ipilimumab, tremelimumab) or chemotherapies as well as trying to identify biomarkers in order to further increase effectiveness. In our review, we summarize the recently published data about urothelial carcinoma therapy and give a brief overview of the ongoing clinical trials.

Clinical Outcomes of Image Guided Adaptive Hypofractionated Weekly Radiation Therapy for Bladder Cancer in Patients Unsuitable for Radical Treatment

PURPOSE AND OBJECTIVES

We report on the clinical outcomes of a phase 2 study assessing image guided hypofractionated weekly radiation therapy in bladder cancer patients unsuitable for radical treatment.

METHODS AND MATERIALS

Fifty-five patients with T2-T4aNx-2M0-1 bladder cancer not suitable for cystectomy or daily radiation therapy treatment were recruited. A "plan of the day" radiation therapy approach was used, treating the whole (empty) bladder to 36 Gy in 6 weekly fractions. Acute toxicity was assessed weekly during radiation therapy, at 6 and 12 weeks using the Common Terminology Criteria for Adverse Events version 3.0. Late toxicity was assessed at 6 months and 12 months using Radiation Therapy Oncology Group grading. Cystoscopy was used to assess local control at 3 months. Cumulative incidence function was used to determine local progression at 1 at 2 years. Death without local progression was treated as a competing risk. Overall survival was estimated using the Kaplan-Meier method.

RESULTS

Median age was 86 years (range, 68-97 years). Eighty-seven percent of patients completed their prescribed course of radiation therapy. Genitourinary and gastrointestinal grade 3 acute toxicity was seen in 18% (10/55) and 4% (2/55) of patients, respectively. No grade 4 genitourinary or gastrointestinal toxicity was seen. Grade ≥3 late toxicity (any) at 6 and 12 months was seen in 6.5% (2/31) and 4.3% (1/23) of patients, respectively. Local control after radiation therapy was 92% of assessed patients (60% total population). Cumulative incidence of local progression at 1 year and 2 years for all patients was 7% (95% confidence interval [CI] 2%-17%) and 17% (95% CI 8%-29%), respectively. Overall survival at 1 year was 63% (95% CI 48%-74%).

CONCLUSION

Hypofractionated radiation therapy delivered weekly with a plan of the day approach offers good local control with acceptable toxicity in a patient population not suitable for radical bladder treatment.

Prognostic significance of urothelial carcinoma with divergent differentiation in upper urinary tract after radical nephroureterectomy without metastatic diseases: A retrospective cohort study

To evaluate the impact of urothelial carcinoma with divergent differentiation (UCDD) on the prognosis of patients for primary upper urinary tract urothelial carcinoma (UTUC) with pN0/x status treated with radical nephroureterectomy (RNU) and to evaluate the prognostic value of UCDD in different tumor locations (renal pelvis and ureter).Data from a total of 346 patients with UTUC who received RNU between January 2012 and March 2016 in the institution were retrospectively analyzed. Clinicopathological features and prognostic factors age, sex, complaint, height, weight, blood pressure, tumor grade, stage, smoking status, history of adjuvant chemotherapy, tumor location, history of bladder cancer, tumor necrosis, degree of hydronephrosis, tumor size, tumor focality, and preoperative anemia were compared between patients with pure UTUC and patients with UCDD. The endpoints were cancer-specific survival (CSS), overall survival (OS), and intraluminal recurrence-free survival (IRFS).Overall, divergent differentiation was present in 50 patients (14.5%). UCDD was related to different tumor location (P = .01), smoking (P = .04), higher body mass index (P = .02), and advanced tumor grade (P = .01). By Kaplan-Meier analysis, UCDD was found to be significantly correlated with worse IRFS, CSS, and OS (all P < .01). Multivariate analysis demonstrated that UCDD was an independent predictor of IRFS (P < .01), CSS (P = .01), and OS (P = .01). However, 40 patients died for various reasons and the 5-year OS rates were 91.9% in UCDD- group and 68.0% in UCDD+ group, respectively. In patients with ureteral tumors, UCDD was the significant predictor for IRFS, CSS, and OS. However, the prognostic value of UCDD was not observed in pyelocaliceal tumors.The presence of divergent differentiation is associated with inferior survival. UCDD may identify patients at high risks for poor prognosis especially in patients with ureteral tumors. As a result, more attention and follow-up should be given to patients with ureteric urothelial carcinoma.

Impact of BCL2 polymorphisms on survival in transitional cell carcinoma of the bladder

PURPOSE

To evaluate the impact of three BCL2 single-nucleotide polymorphisms, i.e., c.-938C>A (rs2279115), c.21G>A (rs1801018), and c.*2203A>G (rs4987853) on survival in patients with transitional cell carcinoma of the bladder.

METHODS

We analyzed 179 patients who underwent surgical treatment for bladder cancer at the Clinic of Urology, University Hospital Essen, Germany. Genomic DNA was extracted and genotyped for the polymorphisms. For all polymorphisms, linkage analysis was performed. Kaplan-Meier and Cox regression analyses were used to determine the putative impact of the three polymorphisms on outcome.

RESULTS

c.-938C>A and c.21G>A, but not c.*2203A>G, are in strong linkage disequilibrium (D' 0.96). We found a significant association between c.-938C>A and relapse-free survival (p = 0.024) with an allele dose effect. In the same way, c.21G>A had a significant impact on both relapse-free survival (p = 0.009) and progression-free survival (p = 0.012), as well as a pronounced allele dose effect. Regression analysis proved c.21G>A and c.-938C>A, to be an independent risk factor in univariate and multivariable analyses.

CONCLUSIONS

In our cohort, both c.-938C>A and c.21G>A showed a significant impact on outcome with TCC of the bladder. Due to the linkage disequilibrium of both SNPs, maybe, only one of them could mediate this effect. In multivariable analysis, however, both proved to be independently associated with overall survival. Contrary to other findings which found the c.-938C>A mainly influencing outcome, our data may suggest that the main effect on TCC could be due to the c.21G>A polymorphism.

Prognostic implications of preoperative anemia in urothelial carcinoma: A meta-analysis

The prognostic significance of preoperative anemia (PA) has been identified in various malignancies. However, its predictive role in urothelial carcinoma (UC) remains controversial. The aim of this study was to investigate the prognostic value of PA in UC patients. We performed a meta-analysis of the association between PA and survival outcome in UC patients. Electronic databases were searched up to June 30, 2016. Study characteristics and prognostic data were extracted from each included study. Cancer-specific survival (CSS), recurrence-free survival (RFS), and overall survival (OS) were pooled using hazard ratio (HR) with corresponding 95% confidence intervals (CI). Herein, 12 studies comprising 3815 patients were included in the meta-analysis. There were 1593 (41.76%) patients in the PA group and 2222 (58.24%) in the control group. The overall pooled HRs of PA for CSS, RFS, and OS were significant at 2.21, (95% CI: 1.83-2.65, Pheterogeneity = 0.49, I2 = 0%), 1.87 (95% CI: 1.59-2.20, Pheterogeneity = 0.22, I2 = 28%), and 2.04(95% CI: 1.76-2.37, Pheterogeneity = 0.36, I2 = 9%) respectively. Stratified analyses indicated that PA was a predictor of poor prognosis based on ethnicity, sample size, tumor T stage, G grade, lymphovascular invasion (LVI), concomitant carcinoma in situ (CIS), and follow-up values. Our findings show that PA has negative prognostic effects on the survival outcome (CSS, RFS, and OS) in UC patients and can serve as a useful and cost-effective marker to aid prognosis prediction.

Impact of the ASA Physical Status Score on Adjuvant Chemotherapy Eligibility and Survival of Upper Tract Urothelial Carcinoma Patients: a Multicenter Study

The aim of the present multi-institutional study was to assess the influence of the American Society of Anesthesiologists Physical Status (ASA-PS) classification on adjuvant chemotherapy eligibility and survival in a multi-institutional cohort of patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). We retrospectively reviewed data from 416 patients who underwent RNU for UTUC at four Korean institutions between 2001 and 2013. The ASA-PS classification was obtained from the anesthesia chart. Locally advanced UTUC was defined as ≥ pT3 and/or pN1 disease. The influence of ASA-PS score on survival was evaluated by Kaplan-Meier analyses and a multivariate Cox regression model. Patients with a higher ASA-PS class were less likely to be eligible for adjuvant chemotherapy in locally advanced UTUC (P = 0.016). Kaplan-Meier estimates showed that the high-risk ASA-PS group has a poorer overallsurvival (OS) and cancer-specific survival (CSS) compared to low risk ASA-PS groups in both the total and locally advanced UTUC cohorts. Based on multivariate Cox regression analysis, the high-risk ASA-PS category was an independent predictor for overall mortality (OM) (hazard ratio [HR], 1.919; 95% confidence interval [CI], 1.017-3.619; P = 0.044) and cancer-specific mortality (CSM) (HR, 2.120; 95% CI, 1.023-4.394; P = 0.043). In conclusion, high-risk ASA-PS score was independently associated with a lower survival rate in patients with UTUC after RNU. However, the influence of ASA-PS classification on survival was limited to locally advanced UTUC. The lower eligibility of patients in the high-risk ASA category for adjuvant chemotherapy may contribute to the lower survival rate in this group.

Preoperative Pyuria Is a Poor Prognostic Factor in Patients With Urothelial Carcinoma of the Upper Urinary Tract After Surgery

INTRODUCTION

The purpose of this study was to determine the prognostic significance of preoperative pyuria in patients with upper urinary tract urothelial carcinoma after surgery.

PATIENTS AND METHODS

We retrospectively evaluated data on 157 patients with nonmetastatic upper urinary tract urothelial carcinoma who had undergone surgery at our institution. The associations between clinical features and advanced pathological findings were evaluated using a logistic regression model. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were assessed with the Kaplan-Meier method and Cox regression analysis. The influence of pyuria on the predictive accuracy of the multivariate model was assessed using the concordance index.

RESULTS

The median postoperative follow-up among patients who survived was 48.1 months. Preoperative pyuria was significantly correlated with worse RFS, CSS, and OS (P < .001 each). Pyuria was also associated with significantly increased risk of a high pathological T stage (≥ pT3; odds ratio, 2.99; P = .003), high tumor Grade (G3; odds ratio, 2.25; P = .038), and lymphovascular invasion (odds ratio, 2.25; P = .008). Moreover, multivariate Cox regression analyses showed that pyuria was an independent prognostic factor for RFS (hazard ratio, 3.02; P < .001), CSS (hazard ratio, 2.15; P = .043), and OS (hazard ratio, 2.10; P = .019). For CSS, the addition of pyuria to the multivariate model increased its predictive accuracy from 0.87 to 0.90.

CONCLUSION

Preoperative pyuria is significantly associated with CSS, OS, and increased risk of locally advanced disease and subsequent disease recurrence in patients with upper urinary tract urothelial carcinoma who undergo surgery.

[Preoperative prognostic factors and preoperative risk stratification of upper tract urothelial carcinoma]

OBJECTIVE

To identify the preoperative prognostic factors of upper tract urothelial carcinoma (UTUC) and construct preoperative risk stratification system.

METHODS

A retrospective study including 686 patients who were diagnosed with UTUC and received radical nephroureterectomy or partial ureterectomy in Peking University First Hospital during 2003 and 2013.

RESULTS

Of the 686 UTUC patients, 303 (44.2%) were male and 383 (55.8%) female. The postoperative pathological examination showed that 203 (29.6%) had high tumor stages (T3, T4), 300 (43.7%) had high tumor grades (G3) and 54 (7.9%) had lymph nodes metastasis (N1). After multivariate analysis, renal pelvic tumor, large tumor, estimated glomerular filtration rate (eGFR)≥30 mL/min, and male were associated with high tumor stage. Ureteral tumor, large tumor, and non-smoking history were associated with high tumor grade. Renal pelvis tumor, large tumor, and preoperative anemia were associated with positive N status. During the follow-up, 208 (30.3%) died for cancer and 210 (30.6%) developed intravesical recurrence. Multivariate analysis showed: large tumor (P=0.001), concomitant ipsilateral hydronephrosis (P=0.041), and preoperative anemia (P=0.001) were independently associated cancer-specific mortality after surgery, while ureteral tumor (P=0.04), multiple tumor (P=0.005), and high preoperative creatinine (P=0.036) were independent risk factors for intravesical recurrence.

CONCLUSION

Of the preoperative clinical parameters of UTUC patients, the large tumor, concomitant ipsilateral hydronephrosis, and preoperative anemia were independently associated with cancer-specific mortality after surgery. Ureteral tumor, multiple tumor, and high preoperative creatinine were independently associated with intravesical recurrence after surgery.

Prognostic value of vascular mimicry in patients with urothelial carcinoma of the bladder after radical cystectomy

Vascular mimicry (VM) refers to the plasticity of aggressive cancer cells forming de novo vascular networks, which promoted tumor metastasis. The aim of this study was evaluate the impact of VM on recurrence-free survival (RFS) in urothelial carcinoma of the bladder (UCB). Records from 202 patients treated with radical cystectomy (RC) for UCB at Zhongshan Hospital between 2002 and 2014 were reviewed. The presence of VM was identified by CD31-PAS double staining. Positive VM staining occurred in 19.3% (39 of 202) UCB cases, and it was associated with increased risks of recurrence (Log-Rank p<0.001). VM was identified as an independent prognostic factor (p=0.002). In the cohort with MIBC, patients with VM negative got CSS benefit from the use of ACT (p = 0.048). As for lung metastasis, the combination of VM and TNM stage (AUC 0.792) showed a better prognostic value than TNM stage alone (AUC 0.748, p = 0.008) or VM alone (AUC 0.714, p = 0.023). Vascular mimicry could be a potential prognosticator for recurrence-free survival in patients with UCB after RC. Vascular mimicry seems to predict risk of developing lung metastases after RC. The presence of VM identified a subgroup of patients with MIBC who appeared to benefit from adjuvant chemotherapy.

Relationship of smoking status to genomic profile, chemotherapy response and clinical outcome in patients with advanced urothelial carcinoma

Smoking has been linked to urothelial carcinoma (UC), but the implications on genomic profile and therapeutic response are poorly understood. To determine how smoking history impacts genomic profile and chemotherapy response, clinicopathologic data was collected for patients with metastatic UC (mUC) across 3 academic medical centers and comprehensive genomic profiling (CGP) was performed through a CLIA-certified lab. Unsupervised hierarchical clustering based on smoking status was used to categorize the frequency of genomic alterations (GAs) amongst current smokers (CS), ex-smokers (ES) and non-smokers (NS), and survival was compared in these subsets. Fisher's exact test identified significant associations between GAs and smoking status. Amongst 83 patients, 23%, 55% and 22% were CS, ES, and NS, respectively, and 95% of patients had stage IV disease. With a median follow up of 14.4 months, the median overall survival (OS) was significantly higher in NS and ES (combined) as compared to CS (51.6 vs 15.6 months; P = 0.04). Of 315 cancer-related genes and 31 genes often related to rearrangement tested, heatmaps show some variations amongst the subsets. GAs in NSD1 were more frequent in CS as compared to other groups (P < 0.001). CS status negatively impacts OS in patients with mUC and is associated with genomic alterations that could have therapeutic implications.

A Review of Outcomes for Stage Ta Bladder Tumors

OBJECTIVES

Using data from former reports, this study reviews and analyzes the outcomes of tumor recurrence, tumor progression, and tumor-specific survival of patients with stage Ta bladder tumors.

METHODS

Data were collected from 19 longitudinal studies of outcomes after the first diagnosis of tumor and collected as individual patient results, that is, as failure times from the first tumor to any of the three outcomes. Altogether, there were 14,252 patients, including 4,050 for the outcome of tumor recurrence, 2,937 for the outcome of tumor progression, and 11,595 for the outcome of disease-specific survival (some patients were available for more than one outcome).

RESULTS

In these data, the mean time to additional tumors was 7.8 years, the mean time to an invasive tumor was 19.5 years, and the mean tumor-specific survival time was 27.2 years. All three outcomes were significantly related to the 2004 World Health Organization (WHO) tumor grades.

CONCLUSIONS

Although greater than 50% of those with stage Ta bladder tumors have additional bladder tumors, approximately 80% appear to follow a benign course without developing invasive tumors or dying of bladder cancer. The 2004 WHO grading scheme accounts for some but not all of the prognostic information.

Comparative analysis of the effect of prostatic invasion patterns on cancer-specific mortality after radical cystectomy in pT4a urothelial carcinoma of the bladder

PURPOSE

To evaluate the prognostic relevance of different prostatic invasion patterns in pT4a urothelial carcinoma of the bladder (UCB) after radical cystectomy.

MATERIALS AND METHODS

Our study comprised a total of 358 men with pT4a UCB. Patients were divided in 2 groups-group A with stromal infiltration of the prostate via the prostatic urethra with additional muscle-invasive UCB (n = 121, 33.8%) and group B with continuous infiltration of the prostate through the entire bladder wall (n = 237, 66.2%). The effect of age, tumor grade, carcinoma in situ, lymphovascular invasion, soft tissue surgical margin, lymph node metastases, administration of adjuvant chemotherapy, and prostatic invasion patterns on cancer-specific mortality (CSM) was evaluated using competing-risk regression analysis. Decision curve analysis was used to evaluate the net benefit of including the variable invasion pattern within our model.

RESULTS

The estimated 5-year CSM-rates for group A and B were 50.1% and 66.0%, respectively. In multivariable competing-risk analysis, lymph node metastases (hazard ratio [HR] = 1.73, P<0.001), lymphovascular invasion (HR = 1.62, P = 0.0023), soft tissue surgical margin (HR = 1.49, P = 0.026), absence of adjuvant chemotherapy (HR = 2.11, P<0.001), and tumor infiltration of the prostate by continuous infiltration of the entire bladder wall (HR = 1.37, P = 0.044) were significantly associated with a higher risk for CSM. Decision curve analysis showed a net benefit of our model including the variable invasion pattern.

CONCLUSIONS

Continuous infiltration of the prostate through the entire bladder wall showed an adverse effect on CSM. Besides including these patients into clinical trials for an adjuvant therapy, we recommend including prostatic invasion patterns in predictive models in pT4a UCB in men.

Determinants of Survival for Adolescents and Young Adults with Urothelial Bladder Cancer: Results from the California Cancer Registry

PURPOSE

Bladder cancer is a common malignancy often diagnosed in older adults. Previous studies have reported racial/ethnic disparities in bladder cancer survival outcomes but have not focused on younger patients. We identified whether factors influencing cause specific survival in adolescents and young adults (ages 15 to 39) differed from older adults, and defined prognostic factors specifically in adolescents and young adults using the California Cancer Registry.

MATERIALS AND METHODS

Patients diagnosed with bladder cancer between 1988 through 2012 were included in the study. The primary outcome measure was cause specific survival. A multivariable Cox proportional hazards regression model was used to evaluate predictors of cause specific survival in patients of all ages and in adolescents/young adults. Interactions of age and other variables between younger and older adult patients were assessed.

RESULTS

Of 104,974 patients with bladder cancer we identified 1,688 adolescent and young adult patients (1.6%). Compared to older patients these patients had a 58% reduced risk of bladder cancer death (HR 0.42, p <0.001). Significant age interactions were identified involving race/ethnicity and histology. Among adolescents and young adults, nonHispanic African-American patients with low socioeconomic status had poor cause specific (HR 7.1, p <0.001) and overall (HR 5.02, p <0.001) survival.

CONCLUSIONS

Racial/ethnic and socioeconomic disparities exist in adolescent and young adult patients with bladder cancer in California. Further studies are warranted to identify the underlying causes in order to overcome these disparities.

Increased expression of SUMO1P3 predicts poor prognosis and promotes tumor growth and metastasis in bladder cancer

Bladder cancer is one of the most common malignancies worldwide. Long non-coding RNAs (lncRNAs) are a class of non-coding RNAs that play crucial roles in diverse biological processes. The pseudogene-expressed lncRNA is one major type of lncRNA family. Small ubiquitin-like modifier (SUMO) 1 pseudogene 3, (SUMO1P3) is a novel indentified lncRNA that was previously reported to be up-regulated in gastric cancer. However, we know nothing about the biological function and underlying mechanism of SUMO1P3 in tumor. Furthermore, the relationship between SUMO1P3 and bladder cancer is completely unknown. We hypothesized that SUMO1P3 also have roles in bladder cancer.In this study, we found that SUMO1P3 was significantly up-regulated in bladder cancer tissues compared with paired-adjacent nontumorous tissues in a cohort of 55 bladder cancer patients. Moreover, up-regulated SUMO1P3 expression was positively correlated with greater histological grade (P<0.05) and advanced TNM stage (P<0.05). Furthermore, we found cell proliferation / migration inhibition and apoptosis induction were also observed in SUMO1P3 siRNA-transfected bladder cancer cells. Our data suggest that SUMO1P3 plays oncogenic roles in bladder cancer and can be used as a potential prognostic and therapeutic target.

Prognostic impact of perioperative lymphocyte-monocyte ratio in patients with bladder cancer undergoing radical cystectomy

Various systemic inflammatory response biomarkers are associated with oncological outcome. We evaluated the superiority of prognostic predictive accuracy between neutrophil-lymphocyte ratio (NLR) and lymphocyte-monocyte ratio (LMR), and the prognostic significance of their perioperative change in patients with bladder cancer undergoing radical cystectomy (RC). We retrospectively analyzed 302 patients who had undergone RC in four institutions. Comparison of predictive accuracy between NLR and LMR was performed using receiver operating characteristic curve analysis. Overall survival (OS) and cancer-specific survival (CSS) were assessed with the Kaplan-Meier method and Cox regression analysis. Preoperative and postoperative LMR showed higher predictive accuracy for OS than NLR did (p = 0.034). Applying a cutoff of 3.41, change in perioperative LMR stratified patients into three groups (low, intermediate, and high risk), showing a significant difference in OS and CSS (p < 0.001, each), and pathological outcomes. Multivariable analyses for OS and CSS showed that poor changes in LMR (high risk) were an independent prognostic factor (hazard ratio 5.70, 95 % confidence interval 3.49-9.32, p < 0.001; hazard ratio 4.53, 95 % confidence interval 2.63-7.82, p < 0.001; respectively). Perioperative LMR is significantly associated with survival in patients with bladder cancer after RC, and it is possibly superior to NLR as a prognostic factor.

Integrative Pathway Analysis of Metabolic Signature in Bladder Cancer: A Linkage to The Cancer Genome Atlas Project and Prediction of Survival

Purpose

We used targeted mass spectrometry to study the metabolic fingerprint of urothelial cancer and determine whether the biochemical pathway analysis gene signature would have a predictive value in independent cohorts of patients with bladder cancer.

Materials and Methods

Pathologically evaluated, bladder derived tissues, including benign adjacent tissue from 14 patients and bladder cancer from 46, were analyzed by liquid chromatography based targeted mass spectrometry. Differential metabolites associated with tumor samples in comparison to benign tissue were identified by adjusting the p values for multiple testing at a false discovery rate threshold of 15%. Enrichment of pathways and processes associated with the metabolic signature were determined using the GO (Gene Ontology) Database and MSigDB (Molecular Signature Database). Integration of metabolite alterations with transcriptome data from TCGA (The Cancer Genome Atlas) was done to identify the molecular signature of 30 metabolic genes. Available outcome data from TCGA portal were used to determine the association with survival.

Results

We identified 145 metabolites, of which analysis revealed 31 differential metabolites when comparing benign and tumor tissue samples. Using the KEGG (Kyoto Encyclopedia of Genes and Genomes) Database we identified a total of 174 genes that correlated with the altered metabolic pathways involved. By integrating these genes with the transcriptomic data from the corresponding TCGA data set we identified a metabolic signature consisting of 30 genes. The signature was significant in its prediction of survival in 95 patients with a low signature score vs 282 with a high signature score (p = 0.0458).

Conclusions

Targeted mass spectrometry of bladder cancer is highly sensitive for detecting metabolic alterations. Applying transcriptome data allows for integration into larger data sets and identification of relevant metabolic pathways in bladder cancer progression.

Vascular endothelial growth factor (VEGF) and cyclooxygenase 2 (COX 2) immunostaining in ovarian cancer

PURPOSE OF INVESTIGATION

Vascular endothelial growth factor (VEGF) and cyclooxygenase-2 (COX 2) are markers of angiogenesis and potential therapeutic targets. Previous studies demonstrate that VEGF is upregulated in some ovarian cancers. The purpose of this study was to determine the correlation of VEGF and COX 2 staining with survival in ovarian cancer patients.

MATERIALS AND METHODS

One hundred forty-three consecutive patients with ovarian carcinoma underwent primary staging or cytoreduction prior to platinum-based chemotherapy. Their tumors were immunohistochemically stained for expression of VEGF and COX 2. FIGO stage, grade, cytoreduction status, and histology were also analyzed as prognostic factors.

RESULTS

Twenty-seven patients had Stage I tumors, three Stage II, 87 Stage III, and 26 Stage IV. Median follow-up was 74 months (mean 79 months). One hundred nineteen patients (83.2%) had tumors that were positive for VEGF and 110 patients (76.9%) had tumors that were positive for COX 2. Patients with tumors staining positive for both VEGF and COX 2 (68.5%) had a significantly increased risk of dying from their ovarian cancer (Chi-square p = 0.011, Log rank p = 0.037). Multivariate logistic regression analysis revealed FIGO stage, grade, cytoreduction status, and VEGF/COX 2 expression to be independent prognostic indicators of survival. Conclusion: VEGF and COX 2 staining are frequently positive in ovarian cancer. Patients whose tumors are positive for both VEGF and COX 2 have a decreased survival. These patients may benefit from anti-angiogenesis targeted therapy.

Preoperative Underweight Patients with Upper Tract Urothelial Carcinoma Survive Less after Radical Nephroureterectomy

The prognostic impact of body mass index (BMI) in patients with upper tract urothelial carcinoma (UTUC) is an ongoing debate. Our study aimed to investigate the prognostic role of BMI in patients treated with radical nephroureterectomy (RNU) for UTUC from a multi-institutional Korean collaboration. We retrospectively reviewed data from 440 patients who underwent RNU for UTUC at four institutions in Korea. To avoid biasing the survival estimates, patients who had previous or concomitant muscle-invasive bladder tumors were excluded. BMI was categorized into approximate quartiles with the lowest quartile assigned to the reference group. Kaplan-Meier and multivariate Cox regression analyses were performed to assess the influence of BMI on survival. The lower quartile BMI group showed significantly increased overall mortality (OM) and cancer specific mortality (CSM) compared to the 25%-50% quartiles and upper quartile BMI groups. Kaplan-Meier estimates showed similar results. Based on multivariate Cox regression analysis, preoperative BMI as a continuous variable was an independent predictor for OM and CSM. In conclusion, preoperative underweight patients with UTUC in Korea survive less after RNU. Preoperative BMI may provide additional prognostic information to establish risk factors.

A Phase II Study of Weekly Docetaxel as Second-Line Chemotherapy in Patients With Metastatic Urothelial Carcinoma

The present multicenter phase II study evaluated the efficacy and safety of weekly docetaxel as second-line chemotherapy for metastatic urothelial carcinoma. Weekly docetaxel was well tolerated but demonstrated modest activity, with a response rate of 6%, a median progression-free survival (PFS) of 1.4 months, and a median overall survival (OS) of 8.3 months. The dichotomy between PFS and OS was likely associated with subsequent platinum-based chemotherapy received by 58% of the patients.

BACKGROUND

Docetaxel is commonly used for second-line therapy for metastatic urothelial carcinoma (UC). However, myelosuppression is a substantial concern when the traditional 3-week docetaxel cycle is used. The present multicenter phase II study evaluated the efficacy and safety of weekly docetaxel as second-line chemotherapy for metastatic UC.

PATIENTS AND METHODS

Patients with progression after previous platinum-based chemotherapy for advanced or metastatic disease were treated with docetaxel 30 mg/m(2) on days 1 and 8 every 21 days. The primary endpoint was the response rate.

RESULTS

The study enrolled 31 patients. Their median age was 64 years (range, 40-79 years). An Eastern Cooperative Oncology Group performance status of 1, liver metastasis, and a hemoglobin level < 10 g/dL were observed in 100%, 32%, and 23% of patients, respectively. Previous platinum-based chemotherapy had been administered for metastatic disease in 29 patients (94%). Although fatigue (13%) and anorexia (6%) were the most frequently observed grade 3 to 4 toxicities, the safety profiles were generally mild and manageable. Two patients (6%) achieved an objective response, which was maintained for 3.0 to 7.8 months. Eight patients experienced disease stabilization (disease control rate, 32%). The median progression-free survival (PFS) and overall survival (OS) were 1.4 months (95% confidence interval [CI], 1.3-1.6) and 8.3 months (95% CI, 5.9-10.6), respectively. A relatively long OS was associated with further salvage platinum-based chemotherapy (n = 18, 58%) showing an encouraging activity (response rate, 44%; median PFS, 4.0 months).

CONCLUSION

Second-line chemotherapy with weekly docetaxel was well tolerated but demonstrated modest activity in patients with metastatic UC. A platinum-based combination as second-line treatment might be considered for selected patients.

Effects of Previous or Synchronous Non-Muscle Invasive Bladder Cancer on Clinical Results after Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Multi-Institutional Study

PURPOSE

To evaluate the effects of the presence of previous or synchronous non-muscle invasive bladder cancer (NMIBC) on the oncologic outcomes of radical nephroureterectomy in patients with upper tract urothelial carci­noma (UTUC).

MATERIALS AND METHODS

In total, 505 patients with UTUC were enrolled from four different institutions. The clinicopathologic parameters of patients with and without previous or synchronous NMIBC were compared, and Kaplan-Meier estimates and multivariate Cox regression analyses were performed.

RESULTS

The median follow-up period was 38.4 months. In all, 408 patients had primary UTUC, 45 (8.9%) had a history of NMIBC, 59 (11.7%) had concomitant bladder cancer, and seven (1.4%) had experienced both. Tumors in patients with associated NMIBC were more commonly multifocal (P = .001) and associ­ated with surgical margin positivity (P = .001). Kaplan-Meier estimates revealed that previous or synchro­nous NMIBC was significantly associated with bladder recurrence (P < .001) and locoregional recurrence/distant metastasis (P = .008). A multivariate Cox regression model identified previous or synchronous NMIBC as an independent predictor of bladder recurrence (P < .001). However, the presence of previ­ous or synchronous NMIBC was not a prognostic indicator of locoregional recurrence/distant metastasis.

CONCLUSION

In patients with UTUC, previous or synchronous NMIBC was significantly associated with an increased risk of cancer recurrences in the bladder after radical nephroureterectomy. The present find­ings suggest that a close monitoring should be required for the patients with previous or concomitant NMIBC.