A meta-analysis of randomised trials suggests a survival benefit for combined radiotherapy and radical cystectomy compared with radical radiotherapy for invasive bladder cancer: are these data relevant to modern practice?

MicroRNA-940 Targets INPP4A or GSK3β and Activates the Wnt/β-Catenin Pathway to Regulate the Malignant Behavior of Bladder Cancer Cells

In this report, we aimed to explore the role and regulatory mechanism of microRNA-940 (miR-940) in bladder cancer development. The expressions of miR-940 in bladder cancer tissues and cells were measured. miR-940 mimics, miR-940 inhibitor small interference RNA against INPP4A (si-INPP4A), and GSK3β (si-GSK3β) and their corresponding controls were then transfected into cells. We investigated the effects of miR-940, INPP4A, or GSK3β on cell proliferation, migration, invasion, and apoptosis. Additionally, target prediction and luciferase reporter assays were performed to investigate the targets of miR-940. The regulatory relationship between miR-940 and the Wnt/β-catenin pathway was also investigated. miR-940 was upregulated in bladder cancer tissues and cells. Overexpression of miR-940 significantly increased bladder cancer cell proliferation, promoted migration and invasion, and inhibited cell apoptosis. INPP4A and GSK3β were the direct targets of miR-940, and knockdown of INPP4A or GSK3β significantly increased cancer cell proliferation, migration, and invasion and inhibited cell apoptosis. After miR-940 overexpression, the protein expression levels of c-Myc, cyclin D1, and β-catenin were significantly increased, and the expression levels of p27 and p-β-catenin were markedly decreased. The opposite effects were obtained after suppression of miR-940. XAV939, a tankyrase 1 inhibitor that could inhibit Wnt/β-catenin signaling, significantly reversed the effects of miR-940 overexpression on cell migration and invasion. Our results indicate that overexpression of miR-940 may promote bladder cancer cell proliferation, migration, and invasion and inhibit cell apoptosis via targeting INPP4A or GSK3β and activating the Wnt/β-catenin pathway. Our findings imply the key roles of suppressing miRNA-940 in the therapy of bladder cancer.

The Role of Population-Based Observational Research in Bladder Cancer

While clinical trials have led to many advances in the treatment of bladder cancer, important gaps in knowledge persist. Population-based studies have made important contributions to what is known about bladder cancer and can contribute unique insights to practice and policy. In addition to evaluating effectiveness of interventions in routine practice, population-based studies can identify gaps between evidence and practice, and generate knowledge that cannot be gained from clinical trials. In this review we will highlight how population-based research has informed practice, policy, and the research agenda for bladder cancer.

Outcomes of trimodality approach in the management of T2N0M0 bladder cancer

AIMS AND BACKGROUND

The main objective of this study is to evaluate outcomes of bladder preservation treatment for patients with muscle-invasive bladder cancer.

METHODS AND STUDY DESIGN

38 patients with histologically proven muscle-invasive bladder cancer treated at our department between January 2008 and December 2013 were analyzed retrospectively. Age, gender, pathology, stage, 3-year overall survival, 3-year disease-free survival, radiotherapy (RT) dose, genitourinary and gastrointestinal toxicity scores and response evaluation of the patients were recorded. 3-year overall survival and 3-year disease-free survivals were calculated by Kaplan-Meier method along with the analysis of gender, pathology, stage and therapy response of the study group.

RESULTS

33 patients (86.8%) were managed with concomitant chemoradiotherapy whereas 5 patients (13.2%) received only radiation therapy due to renal insufficency and comorbid diseases. 6 (15.8%) out of 38 patients had partial response (PR) and remaining 32 (84.2%) patients experienced complete response (CR). The PR group underwent salvage cystectomy and CR group had been followed-up after radical radiotherapy. Mean age of the group was 70.9 (range 45-90) years. 26 of all patients were male (68.4%) and 12 were female (31.6%). Mean follow-up time after completion of radiotherapy was 24.7 months (range 12-40). Mean RT dose was 64 Gy (range 60-66). 3-year overall survival was 64% and 3-year disease free survival was 73%.

CONCLUSIONS

Bladder preserving approach is an alternative definitive therapy solution to radical cystectomy in the treatment of muscle-invasive bladder cancer with less morbidity, preserved natural bladder, and high quality of life.

[Radiation therapy in locally advanced and/or relapsed urological tumors]

Radiation therapy (RT) plays a fundamental role in the treatment of locally advanced and/or relapsed urological tumors, as well as in palliation, or as definitive treatment, and even where integrated into a multi-modal approach. In operated renal tumors, positive margins or extracapsular extension show a positive impact of postoperative RT, with a reduction of relapses between 100% and 30%, while, in the case of palliation, treatments with RT at high doses are preferred. In advanced cancers of the upper urinary tract, RT plays a limited role, even if it seems to increase the level of disease control locally and, with the combination of cisplatin, survival rates too. An important reduction in the recurrence is also observed in locally advanced tumors of the urethra, with a recurrence of 60% after surgery, 36% after RT and 25% after pairing of the two. In locally advanced tumors of the penis, RT shows poorer results than surgery, and the addition of postoperative RT does not seem to add any further outcome, except where, in the presence of a positive inguinal dissection, the postoperative RT reduces lymph node recurrences by 60%-11%. Interesting data for the preservation of the organ are reported with reference to the combination with chemotherapy. In the tumors of the testis, it is still disputable whether the treatment of residual masses after chemotherapy may be appropriate, with a view to a possible salvage radiotherapy. In the treatment of the prostate, the role of RT is consolidated and evolving with the progress of dose escalation, the association with hormonal therapy, new technologies, new possibilities of IMRT and proton therapy and various studies on multi-modal approaches (hormone therapy, surgery, radiotherapy, chemotherapy). Cystectomy is the gold standard for the treatment of locally advanced bladder cancer, even though there is a revived interest in multimodal treatments (transurethral resection, chemotherapy, RT) that may allow the organ preservation. Postoperative radiotherapy, which can reduce by 50% to 20%-5% local recurrences that are highly correlated with distance failure and with survival, should be revised in the light of modern RT techniques that can further increase local control levels and reduce the toxicity significantly.

Recent advances in the treatment of bladder cancer

Bladder cancer continues to provide urologists and researchers with a clinical and scientific challenge. Several urinary markers used in the detection and screening of patients with bladder cancer are currently under investigation. Improvements in intravesical therapy are proving to help decrease both tumor recurrence and progression in patients with high-risk disease. In patients with organ-confined, node-negative bladder cancer, radical cystectomy provides excellent local control and long-term disease-free survival. The use of an extended lymphadenectomy at the time of cystectomy may yield improved prognostic information as well as a potential survival benefit. Neoadjuvant chemotherapy and less toxic combination chemotherapy regimens are offering potential improvements in patients with extravesical or nodal extension. The current methods of detection, as well as available therapeutic treatment options are reviewed.

Trimodality treatment in the conservative management of infiltrating bladder cancer: a critical review of the literature

Although radical cystectomy is still the treatment of choice for patients with infiltrating bladder cancer, there is growing evidence of the effectiveness of a conservative approach. Developed as a treatment of need for elderly or unfit patients unable to undergo radical cystectomy, conservative therapy is becoming a true alternative to surgery for highly selected patients. Although transurethral bladder resection, external radiotherapy and systemic chemotherapy can control the disease as single treatments, the best results have been observed when they are combined. Moreover, new irradiation techniques and new-generation drugs are now being tested in an attempt to improve disease control further. Conservative management requires the multidisciplinary involvement of different specialties in order to give patients a real alternative to surgical treatment.

Update on the management of invasive bladder cancer 2012

Muscle-invasive bladder cancer is a deadly disease for which a number of new approaches have become available to improve prognosis. A recent review emphasized the importance of timely indication of surgery and highlighted current views regarding the adequate extent of the surgery and the importance of lymph node dissection. Furthermore, treatment using neoadjuvant and adjuvant systemic chemotherapy has become more prominent, while cystectomy and diversion should be conducted only in experienced centers. Optimal methods of urinary diversion and the use of robot-assisted laparoscopic cystectomy require further study.

MicroRNA-143 functions as a tumor suppressor in human bladder cancer T24 cells

MicroRNA (miR)-143 and -145 were down-regulated in human bladder cancer T24 cells. The enforced expression of miR-143 induced growth-suppression in T24 cells through down-regulation of ERK5 and Akt expression at translational level, and chemically-modified synthetic miR-143 (miR-143/BP) exhibited a greater growth inhibitory effect than wild-type miR-143. In addition, the synthetic miR-143/BP induced apoptotic cell death in some of the transfected cells. Furthermore, co-treatment with the synthetic miR-143/BP and cisplatin showed the additive growth-suppressing effect on T24 cells. These findings suggest that the chemically-modified synthetic miR-143 functions as a tumor suppressor in T24 cells by targeting ERK5 and/or Akt.

MicroRNA-221 silencing predisposed human bladder cancer cells to undergo apoptosis induced by TRAIL

OBJECTIVES

Bladder cancer is the most common type of urologic cancer in Chinese males. The 5-year survival rate of advanced bladder cancer is approximately 20%-40%. There is an obvious urgent need for novel and effective therapies against bladder cancer. MicroRNAs (miRNAs) are a recently discovered class of noncoding RNAs; suppressing miRNA-221 might prove beneficial in several cancers. To explore novel and effective therapies against bladder cancer, we explored the effects of miRNA-221 silencing on the survival of bladder cancer cells.

MATERIALS AND METHODS

Northern blot analysis was used to determine miRNA-221 expression levels in bladder cancer T24 cells, RT4 cells and human normal urothelial cells. miRNA-221 was silenced with antisense oligonucleotides in T24 cells and pro-apoptotic effect of necrosis factor related apoptosis-inducing ligand (TRAIL) on miRNA-221-silenced cells was assessed with flow cytometry. The p27(kip1) protein expression in miRNA-221-silenced cells exposed to TRAIL was detected by Western blotting. The role of miRNA-221 silencing on T24 cell cycle phase distribution was investigated through flow cytometric analysis.

RESULTS

Human miRNA-221 was significantly up-regulated in bladder cancer T24 cells and RT4 cells compared to human normal urothelial cells. T24 cell was TRAIL-resistant cell line. MiRNA-221 silencing predisposed T24 cells to undergo apoptosis induced by TRAIL and resulted in an up-modulation of cyclin-dependent kinase inhibitor p27Kip1. MiRNA-221 suppression promoted the activation of caspase 3 induced by TRAIL in T24 cells.

CONCLUSIONS

MiRNA-221 silencing rendered human bladder cancer T24 cells to undergo apoptosis induced by TRAIL. Our findings suggest a potential role of suppressing miRNA-221 in human bladder cancer therapy.

The type 1 insulin-like growth factor receptor is over-expressed in bladder cancer

OBJECTIVE

To analyse bladder cancer biopsies and investigate the pattern of expression of the type 1 insulin-like growth factor receptor (IGF1R), a receptor tyrosine kinase that mediates tumour cell proliferation, motility and protection from apoptosis.

MATERIALS AND METHODS

Formalin-fixed specimens of bladder cancer (40 whole-mount, 80 cores on a tumour microarray) and normal bladder (15 samples) were stained immunohistochemically for the IGF1R. The IGF1R expression was also measured by quantitative reverse transcription-polymerase chain reaction (Q-RT-PCR) on RNA extracted from fresh frozen bladder cancers (61) and benign bladder (12).

RESULTS

Of the 15 samples of normal bladder, 14 showed negligible (1+) or light (2+) IGF1R immunostaining. By contrast moderate (3+) or heavy (4+) staining for IGF1R was detected in 89 (74%) of the 120 samples of malignant urothelium. Q-RT-PCR showed significantly higher levels of steady-state IGF1R mRNA in tumours (all cases, Ta-T4) than in normal bladder (P < 0.05), indicating up-regulation at the transcriptional level. This difference was particularly evident when comparing normal urothelium with superficial (Ta-T1) or invasive (T2-4) tumours; only the latter showed significant IGF1R over-expression at the RNA level (P < 0.05 vs normal bladder).

CONCLUSION

The IGF1R is up-regulated in bladder cancer compared with non-malignant bladder, and might contribute to a propensity for invasion.

Anaemia is associated with poor overall survival but not with inferior local control in patients with muscle invasive bladder carcinoma treated by radical external beam radiotherapy. A retrospective study

AIMS

The treatment of muscle invasive transitional cell carcinoma of the bladder with radiotherapy allows organ preservation and is frequently used in the UK, especially in patients not medically fit for cystectomy. Anaemia is known to be an indicator of a poor response to radiotherapy in head and neck and cervical carcinomas. Here we describe the prevalence and type of anaemia in patients with transitional cell carcinoma of the bladder and determine the effect anaemia has on treatment outcome.

MATERIALS AND METHODS

A retrospective review of notes was carried out on patients treated radically between 1992 and 1997. Potential patient, tumour and treatment prognostic indicators were reported. Patients were labelled as being anaemic if their pre-treatment haemoglobin level was below the normal range (below 13.5 g/dl for men and below 11.5 g/dl for women). The time to local failure, metastases and overall survival were recorded. Recurrence-free survival and overall survival actuarial estimations were carried out using the Kaplan-Meier method and compared by Log-rank testing. A multivariate analysis was carried out using the Cox regression method.

RESULTS

Data on 100 patients were available for analysis. Most of the patients were not adequately staged by today's standards. Fifty-two patients were anaemic, with 75% of them having a normochromic, normocytic anaemia. The univariate analysis showed no significant difference in the time to local recurrence, a trend towards a shorter time to metastases and a significant reduction in overall survival in anaemic patients (P = 0.001). Two-year survival was 43% and 22% for non-anaemic and anaemic patients, respectively. A multivariate analysis using the covariates tumour stage, grade and serum creatinine found anaemia to be a poor prognostic indicator for overall survival (P = 0.005).

CONCLUSION

Anaemia is highly prevalent in patients with bladder cancer. This retrospective study showed anaemic patients to have a worse outcome with radiotherapy treatment than patients with a normal haemoglobin level. This was not accounted for by a difference in local control, which may be expected from hypoxic radiobiological principles. Anaemia may be indicative of more aggressive malignancy or subclinical metastases.

Radiotherapy for Bladder Cancer

The radiotherapy panel met to develop international consensus about the optimal use of radiotherapy, alone or in combination with surgery and chemotherapy, in the radical treatment of patients with bladder cancer. A consensus meeting of experts in the treatment of bladder cancer was convened by the Société Internationale d'Urologie (SIU). The radiotherapy committee, which had international representation from 6 countries, performed a critical review of the English-language literature and developed evidence-based guidelines for the use of radiotherapy in the treatment of patients with bladder cancer. The strength of the evidence supporting each recommendation was ranked according to a 4-point scale. Consensus statements were developed that address (1) the effectiveness of radiotherapy in the treatment of bladder cancer, (2) the most appropriate patients for curative treatment with radiotherapy, (3) the optimal method of delivery of radiotherapy, (4) the best radiation prescription for treating bladder cancer, and (5) optimal management of the patient's condition after radiotherapy has been provided. Radiotherapy is effective treatment for selected patients with bladder cancer; it produces long-term disease control with preservation of normal bladder function. Modern radiotherapy treatment techniques offer the potential to improve cure rates and reduce adverse effects. All patients in whom the condition is newly diagnosed should be assessed in a multidisciplinary setting, where the relative merits of surgery, radiotherapy, and chemotherapy can be considered on an individual basis with the aim of optimizing overall outcomes.

A fourteen-year review of radical cystectomy for transitional cell carcinoma demonstrating the usefulness of the concept of lymph node density

OBJECTIVE

We studied the long-term outcome of radical cystectomy for transitional cell carcinoma and evaluated prognostic factors for disease specific survival.

MATERIALS AND METHODS

A retrospective review was carried out for all cystectomies performed for transitional cell carcinoma between 1989 and 2002. Disease specific survival was correlated to patient, pathological and operative factors as well as to adjuvant therapy.

RESULTS

Of the 133 cystectomies included, 100 were male and 33 were female patients. The median age was 69 years (range 43 to 86). The median follow up was 20 months (range 0 to 158). With univariate analysis, pT stage, N stage, lymph node density, carcinoma in-situ, surgical margin and post-operative radiotherapy to distant metastasis were predictive of disease specific survival. On the other hand, with multivariate analysis, only pT stage, lymph node density and post-operative radiotherapy to distant metastasis were predictive of disease specific survival. Within the group of node positive disease, lymph node density also predicted disease specific survival with both univariate and multivariate analyses. Patients with lymph node density 20% or below showed better disease specific survival.

CONCLUSIONS

pT stage and lymph node density were found to be the most important predictive factors for disease specific survival after cystectomy in the Asian population.

Radical radiotherapy for urinary bladder cancer: treatment outcomes

The exact value of radiotherapy in the treatment of muscle-invasive bladder cancer is difficult to establish, as most studies exploring this issue are retrospective with different procedures for selecting patients for treatment, as well as varying treatment strategies. An estimate of the 5-year overall survival rate following radiotherapy is approximately 35% in consecutive-selected patients and approximately 25% in negative-selected patients.