First- and second-line therapy for metastatic urothelial carcinoma of the bladder

Clinical applications of recent molecular advances in urologic malignancies: no longer chasing a "mirage"?

As our understanding of the molecular events leading to the development and progression of genitourologic malignancies, new markers of detection, prognostication, and therapy prediction can be exploited in the management of these prevalent tumors. The current review discusses the recent advances in prostate, bladder, renal, and testicular neoplasms that are pertinent to the anatomic pathologist.

The role of c-FLIP in cisplatin resistance of human bladder cancer cells

PURPOSE

We investigated the mechanisms underlying cisplatin resistance in human bladder cancer cells to provide novel molecular targets for the treatment of cisplatin resistant bladder cancer.

MATERIALS AND METHODS

The differential gene expression of cisplatin sensitive (T24) and resistant (T24R2) human bladder cancer cell lines was analyzed and validated by microarray and Western blot analysis. Changes in cisplatin sensitivity by c-FLIP knockdown and related mechanisms in T24R2 cells were assessed using the Cell Counting Kit-8 assay (Dojindo Molecular Technologies, Gaithersburg, Maryland) and Western blot. siRNA oligonucleotides that specifically target c-FLIP were prepared and siRNA transfection was done.

RESULTS

Microarray analysis revealed that the expression of 1,086 and 322 genes showed more than twofold and fourfold changes in the T24R2 and T24 cell lines, respectively. Especially genes involved in the c-FLIP related death receptor apoptosis pathway, including caspase 2 and 9, NF-kB, BID, c-FLIP, XIAP, and cIAP1 and 2, showed differential expression in the 2 cell lines. Western blot demonstrated complete cisplatin mediated suppression of c-FLIP expression in T24 cells but no change in c-FLIP expression was observed in T24R2 cells after cisplatin treatment in the same dose range. Suppression of c-FLIP expression in T24R2 cells by siRNA transfection rendered these cells significantly more sensitive to cisplatin treatment than untransfected T24R2 cells (p <0.05).

CONCLUSIONS

Results reveal that c-FLIP has an important role in the cisplatin resistance of human bladder cancer cells and c-FLIP modulation may at least partially reverse cisplatin resistance in bladder cancer cells.

Molecular Pathology of Bladder Cancer

This article focuses on several promising candidate biomarkers that may soon make their transition to the realm of clinical management of bladder cancer. Presented are superficial and muscle-invasive urothelial carcinoma of the bladder and the genetic tests currently available in testing for diagnosis and prognosis of these diseases.

Methotrexate-paclitaxel-epirubicin-carboplatin as second-line chemotherapy in patients with metastatic transitional cell carcinoma of the bladder pretreated with cisplatin-gemcitabine: a phase II study

AIMS

To assess the efficacy and toxicity of methotrexate-paclitaxel-epirubicin-carboplatin combination as second-line chemotherapy in patients with metastatic transitional cell carcinoma (TCC) of the bladder pretreated with cisplatin-gemcitabine.

METHODS

In this prospective phase II study, patients with metastatic TCC of the bladder pretreated with first-line cisplatin-gemcitabine received on progression paclitaxel 175 mg/m(2) i.v. and carboplatin (area under curve of 5) on day 1, and methotrexate 40 mg/m(2) and epirubicin 40 mg/m(2) on day 15. The whole course was repeated every 28 days. The end-points included clinical tumor response, treatment toxicity, quality of life and survival.

RESULTS

A total of 40, predominantly male, patients were enrolled (median age 62 years [range 46-69]). Efficacy and survival were assessed in 38 patients only, as two patients refused treatment after the first cycle. Grade 3 neutropenia was the commonest acute severe toxicity (12/40 patients; 30%). The overall response rate was 39% (15/38 patients). The median follow up was 14 months (range 3-45). The median progression-free and overall survival were 12 and 12.5 months, respectively. The 1-year progression-free and overall survival were 24 and 35%, respectively.

CONCLUSION

Methotrexate-paclitaxel-epirubicin-carboplatin combination as second-line chemotherapy in patients with metastatic TCC of the bladder results in a modest response rate with acceptable toxicity.

Emerging critical role of molecular testing in diagnostic genitourinary pathology

CONTEXT

The unprecedented advances in cancer genetics and genomics are rapidly affecting clinical management and diagnostics in solid tumor oncology. Molecular diagnostics is now an integral part of routine clinical management in patients with lung, colon, and breast cancer. In sharp contrast, molecular biomarkers have been largely excluded from current management algorithms of urologic malignancies.

OBJECTIVE

To discuss promising candidate biomarkers that may soon make their transition to the realm of clinical management of genitourologic malignancies. The need for new treatment alternatives that can improve upon the modest outcome so far in patients with several types of urologic cancer is evident. Well-validated prognostic molecular biomarkers that can help clinicians identify patients in need of early aggressive management are lacking. Identifying robust predictive biomarkers that will stratify response to emerging targeted therapeutics is another crucially needed development. A compiled review of salient studies addressing the topic could be helpful in focusing future efforts.

DATA SOURCES

A PubMed (US National Library of Medicine) search for published studies with the following search terms was conducted: molecular , prognostic , targeted therapy , genomics , theranostics and urinary bladder cancer , prostate adenocarcinoma , and renal cell carcinoma . Articles with large cohorts and multivariate analyses were given preference.

CONCLUSIONS

Our recent understanding of the complex molecular alterations involved in the development and progression of urologic malignancies is yielding novel diagnostic and prognostic molecular tools and opening the doors for experimental targeted therapies for these prevalent, frequently lethal solid tumors.

Fibroblast growth factor receptor-3 in urothelial tumorigenesis

Fibroblast growth factor receptor-3 (FGFR3) is a receptor tyrosine kinase implicated in the tumorigenesis of multiple malignancies, including bladder and other urothelial cancers, multiple myeloma, and cervical cancer. In urothelial carcinoma (UC), constitutive receptor activation occurs most commonly through substitution of a wild-type residue with cysteine in the extracellular domain of FGFR3, thereby resulting in dimerization (through disulfide bridge formation) and subsequent stimulation of tyrosine kinase activity. Activating mutations of FGFR3 have been observed in up to 70% of non-muscle-invasive bladder tumors, while overexpression of a wild-type receptor, found in approximately 40% of tumors, has been correlated with more invasive disease. The identification of FGFR3 mutations in UC has sparked substantial interest in the therapeutic exploitation of these aberrations, and in vitro studies have provided evidence that such alterations may represent driver oncogenic lesions. In this review, we discuss the biologic and prognostic impact of FGFR3 mutations in UC as well as FGFR3 as a potential target for novel therapeutics.

Molecular biomarkers in urothelial carcinoma of the bladder: are we there yet?

The unprecedented advances in cancer genetics and genomics are rapidly affecting the clinical management of solid tumors. Molecular diagnostics are now an integral part of routine clinical management for patients with lung, colon, and breast cancer. In sharp contrast, molecular biomarkers have been largely excluded from current management algorithms for urologic malignancies. The need for new treatment options that can improve upon the modest outcomes currently associated with muscle-invasive bladder cancer is evident, and validated prognostic molecular biomarkers that can help clinicians to identify patients in need of early, aggressive management are lacking. Robust predictive biomarkers that are able to forecast and stratify responses to emerging targeted therapies are also needed.

Translational research to realize the full potential of novel agents--an opportunity for vinflunine?

In the past few years, innumerable novel anti-cancer agents have been developed. Some of them have successfully entered into clinical practice while some of them have failed for different reasons. Although, nowadays, cancer treatment still relies heavily on conventional chemotherapy and surgery, with increasing evidence of novel biologic agents which demonstrate its higher anti-cancer activity and fewer side effects, more and more efforts have been spent on development of different types of novel agents. Vinflunine, a novel fluorinated vinca alkaloid, carries mitotic-arresting and tubulin-interacting properties and was just approved for treating transitional cell carcinoma of the urothelial tract (TCCU) in Europe. It, however, took quite a long time to get an approval. Needless to say, TCCU, similar to other types of cancer, is a very complex and heterogeneous disease and therefore, a single drug can hardly eradicate a cancer. Translational research, a new scientific research method, creates a link between clinical and laboratory studies. The link helps us to investigate the change in tumor environment in response to treatment, select patients who are more responsive to a particular treatment and predict prognosis of a group of patients with similar tumor characteristics. It can not only improve the success of a treatment, but also maximize the potential of novel anti-cancer agents.

The enlightenment of bladder cancer treatment: origin and progress of photodynamic diagnosis

Compared with prostate cancer, which exclusively affects male patients, urothelial bladder cancer is the most common urogenital carcinoma affecting both men and women. In approximately 75% of cases, bladder cancer occurs as multifocal nonmuscle-invasive papillary tumor that demonstrates high rates of recurrence, leading to frequent transurethral resections with the need of hospitalization. These cases have paved the way for photodynamic diagnosis. Since the 1990s, this technique has been used to identify bladder tumors, especially highly aggressive carcinoma in situ, in an easier and more complete way compared with conventional white-light cystoscopy. This article gives an up-to-date review of the method, indication and results of photodynamic diagnosis for treatment of urothelial bladder cancer.