European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ) - 2019 Update

Neutrophils to lymphocytes ratio as a predictor of BCG response in non-muscle invasive bladder cancer

AIM

To evaluate the role of preoperative neutrophils to lymphocytes ratio (NLR) as a predictor for the response to BCG in patients with non-muscle invasive bladder cancer (NMIBC).

MATERIALS

Nighty six patients with NMIBC were prospectively included in our study. Our study population was classified into two groups, based on pre-operative (NLR) either ⩽ or > 3. After receiving BCG, patients were followed up for 3 years to evaluate the correlation between BCG failure and (NLR).

RESULTS

Nighty two patients were evaluated at the end of our study. The NLR > 3 group of patients showed a higher age and T stage compared to the NLR ⩽ 3 group with a significant difference. BCG failure was reported to be higher in the NLR > 3 group with a failure rate of 66.7% compared to 28.3% in the other group (p-value < 0.001). Time to failure in NLR > 3 group compared to NLR ⩽ 3 group was 10.44 ± 4.3 and 15 ± 3.9 months respectively with a (p-value = 0.002). Univariate and multivariate logistic regression revealed that the most significant predictors of BCG failure were NLR > 3, Initial T stage, and age respectively.

CONCLUSION

BCG response is highly affected by the NLR, with a higher failure rate with NLR > 3.

Smoking behavior and the risks of tumor recurrence and progression in patients with non-muscle-invasive bladder cancer

Studies on the relationship of cigarette smoking with the risks of recurrence and progression of non-muscle-invasive bladder cancer (NMIBC) are inconsistent and prospective data are scarce. Therefore, we aimed to assess the association of smoking behavior with risks of NMIBC recurrence and progression. We used data of the prospective multi-center cohort study UroLife, including 1495 patients with NMIBC who reported information on smoking at 6 weeks post-diagnosis (baseline; reflecting present and pre-diagnosis). This included smoking status (also based on reporting 3 months post-diagnosis), intensity, duration, pack years, and time since smoking cessation, if applicable. Hazard ratios and 95% confidence intervals (CIs) for risks of first recurrence, multiple recurrences, and progression were computed using multivariable proportional hazards regression models. During a total median follow-up period of 4.6 years, 517 patients developed ≥1 recurrence and 163 had progression. Higher versus lowest categories of smoking intensities and pack years up to baseline were significantly associated with a higher risk of first recurrence. No significant linear associations were found, except for smoking intensity among BCG-treated patients (per 10 cigarettes/day increase: HR 1.23, 95%CI 1.02, 1.48). No associations for smoking status, duration, and time since cessation were observed. Analyses of multiple recurrence risk showed comparable results. Regarding progression risk, no consistent associations were found. In conclusion, heavier smoking was associated with higher recurrence risk, particularly among BCG-treated patients. This may be attributable to persistent damage through its carcinogenic compounds. Given the mixed results across different exposures, the effect of smoking behavior on NMIBC prognosis remains unclear.

Patient-Derived Bladder Cancer Organoids as a Valuable Tool for Understanding Tumor Biology and Developing Personalized Treatment

Bladder cancer (BC) is a heterogeneous disease with high recurrence rates and variable treatment responses. To address these clinical challenges, the world's first bladder cancer patient-derived organoids (PDOs) biobank is established based on an Asian population. Thirty-six BC-PDOs are generated from 56 patients and demonstrated that the BC-PDOs can replicate the histological and genomic features of parental tumors. Drug screening tests are conducted with a broad spectrum of conventional chemotherapeutic and targeted therapy drugs and identified differential drug sensitivities among the BC-PDOs. These in vitro results are consistently supported by the PDO xenograft animal studies and patients' clinical treatment outcomes, thereby verifying the predictive power of PDOs for drug responses in BC patients. By analyzing the genetic profiles of the PDOs, specific driver genes that correlate with drug sensitivity to two stand-of-care chemotherapeutics, cisplatin, and gemcitabine, are identified. Additionally, the practicality of PDOs in investigating the tumor microenvironment has been demonstrated. This study underscores the utility of PDOs in advancing the understanding of bladder cancer and the development of personalized therapeutic strategies. The BC-PDOs biobank provides an ideal preclinical platform for supporting the development of personalized treatment strategies for BC patients. This study also provides insights into the potential mechanisms of drug resistance, paves the way for subsequent region-specific research, and demonstrates the possibility of using PDO-related models to direct future research in developing drugs targeting tumor microenvironments.

An updated systematic review, meta-analysis, and trial sequential analysis of the efficacy and safety of en bloc transurethral resection vs. conventional transurethral resection for nonmuscle-invasive bladder tumor

OBJECTIVE

En bloc transurethral resection of bladder tumor (ERBT) for nonmuscular-invasive bladder tumor (NMIBC) has been used in clinical practice, but its efficacy and safety have not been conclusional. We aimed to evaluate the efficacy and safety of ERBT and conventional transurethral resection of bladder tumor (cTURBT) for NMIBC.

METHODS

Randomized controlled trials (RCTs) comparing ERBT and cTURBT in the treatment of NMIBC were searched in Pubmed, Embase, Clinicaltrials.gov, and Cochrane; 12 RCTs were included for systematic review and meta-analysis using RevMan 5.4.

RESULTS

A total of 12 RCTs involving 2097 patients with NMIBC were included and analyzed. The results showed the rate of identification of detrusor muscle in specimens [odds ratio (OR) 1.90; P = 0.03] was higher in ERBT group, and bladder perforation (OR 0.30; P = 0.004), obturator nerve reflex (OR 0.18; P = 0.001), catheter indwelling time (MD -0.64; P = 0.002), length of hospital stay (MD -0.58; P = 0.002), tumor recurrence rate 3 months after surgery (OR 0.42; P = 0.03), tumor recurrence rate 6 months after surgery (OR 0.21; P = 0.007), the recurrence rate of the same site 1 year after surgery (OR 0.23; P < 0.0001) and bleeding rate (OR 0.30; P = 0.0005) were significantly lower in ERBT group than that in cTURBT group. There was no significant difference in residual tumor (OR 0.62; P = 0.07), Re-TURBT (OR 0.71; P = 0.19), hemoglobin deficit (MD -0.81; P = 0.29), urethral stricture (OR 0.67; P = 0.42), resection time (MD 2.31; P = 0.16), operative time (MD 1.17; P = 0.49), 1 year (OR 0.61; P = 0.13), 2 years (OR 0.94; P = 0.76), 3-year tumor recurrence rate (OR 1.03; P = 0.86) and the risk of progression at 12 month (OR 0.68; P = 0.79) between the two groups.

CONCLUSIONS

Our results showed that ERBT can improve the rate of identification of detrusor muscle in specimens and reduce the 3-month, 6-month tumor recurrence rate and recurrence rate of the same site 1 year after surgery. In addition, ERBT has fewer complications, and shorter catheter indentation time and hospital stay. The laser ERBT can also decrease tumor residual rate and re-TURBT.

Development and psychometric evaluation of a patient-reported symptom index for patients with non-muscle invasive bladder cancer: the NMIBC-SI

BACKGROUND AND OBJECTIVE

Non-muscle invasive bladder cancer (NMIBC) is a chronic condition requiring frequent follow-up with endoscopic examinations, tumour resections and intravesical treatments. In this clinical context, patient-reported outcomes (PROs) have enormous potential to inform treatment assessment and recommendations for NMIBC. We aimed to develop and evaluate a patient-reported NMIBC Symptom Index (NMIBC-SI) to facilitate clinical research and enhance care.

METHODS

NMIBC-SI items were developed based on existing literature and qualitative interviews with patients and clinicians, and evaluated in two field tests: item reduction, using NMIBC-SI data from 220 patients on active treatment from nine Australian centres; reliability and validity evaluation of item-reduced version using NMIBC-SI data from 232 patients from five countries.

RESULTS

NMIBC-SI assesses disease and treatment-related symptom burden and two treatment-specific side-effects (cystoscopy, intravesical BCG/Chemotherapy). Composite analysis supported a single composite model including core symptom and cystoscopy index items (Intravesical index items were not tested due to small sample). Test-retest reliability was strong (range 0.894-0.91). As expected, the NMIBC-SI was able to discriminate between no treatment and any treatment groups, and no treatment and chemo/BCG groups, providing evidence towards validity.

CONCLUSIONS AND CLINICAL IMPLICATIONS

NMIBC-SI assesses patients' self-reported symptom burden and can be used to evaluate NMIBC treatments from the perspective of patients. The NMIBC-SI is acceptable to patients and has evidence for reliability and validity. Future validation work with patients with greater symptom burden is warranted.

mRNA-Based Urine Test Performance in High and Very-High Risk Non-Muscle-Invasive Bladder Cancer Patients Undergoing Contextual Endoscopic Follow-up (VERNAL: Vesical Tumor Early Monitoring: mRNA-Based Follow-up)

INTRODUCTION AND OBJECTIVES

Non-muscle-invasive bladder cancer (NMIBC) patients need a strict follow-up with cystoscopy (UCS) and voided urinary cytology (vUC) due to high rate of recurrence and progression. To reduce invasiveness and costs, a new diagnostic biomarker, namely Xpert Monitor BCⓇ-detecting 5 mRNAs in voided urine-, has been proposed. We test Xpert Monitor BCⓇ ability to detect tumor recurrence at an early point during follow-up of high risk (HR) or very high risk (VHR) NMIBC patients, aiming at evaluating reliability of this test as a single procedure.

MATERIALS AND METHODS

Between September 2022 and July 2023 included, 80 HR or VHR NMIBC patients were prospectively enrolled. Both naïve and previously treated patients (including Bacillus Calmette-Guérin-BCG-and/or systemic immunotherapy) were admitted. Patients with known upper urinary tract urothelial carcinoma (UTUC) were excluded. Xpert Monitor BCⓇ test was carried out on precystoscopy voided urine samples. In case of suspicious urethra-cystoscopy (UCS), a transurethral resection (TURB) or a biopsy was indicated. vUC was usually prescribed to be performed prior to UCS. Negative predictive value (NVP), positive predictive value (PPV), sensitivity (SE) and specificity (SP) of Xpert Monitor BCⓇ and vUC, were assessed and compared with UCS and secondarily with histology at TURB/bladder biopsy. Patients who proceeded with follow-up underwent a second evaluation with Xpert Monitor BCⓇ test.

RESULTS

Seventy-six patients were evaluable. Median age was 70 years (interquartile range [IQR] 65-78) and 62 (81.6%) patients were male. VHR patients were 14 (18.4%), 47 (61.8%) had a history of carcinoma in situ (CIS) and 37 (49.3%) had multifocal disease while 51 patients (67.1%) had recurrent bladder cancer (BC). BC recurred in 15 patients (19.7%): in 3 of them as a muscle-invasive bladder cancer (MIBC). Xpert Monitor BCⓇ showed a NPV, PPV, SE, SP of 95.3% (41/43), 57.6% (19/33), 90.5% (19/21) and 74.5% (41/55) respectively. When available, vUC displayed a NPV of 78.9% (30/38), a PPV of 75% (3/4), a SE of 27.3% (3/11) and a SP of 96.7% (30/31). Twenty patients underwent a subsequent Xpert Monitor BCⓇ test and UCS during their follow-up, and 3 had a bladder cancer recurrence. Of note Xpert Monitor BCⓇ was positive in all those 3 patients who previously tested positive despite a negative UC.

CONCLUSIONS

High NPV and SE of Xpert Monitor BCⓇ are confirmed in our HR and VHR NMIBC series. Apparent false positive tests may be regarded as suspicious for persistent/recurrent disease. Implementation of Xpert Monitor BCⓇ aiming at improving cancer detection is supported by these findings, and a single test based follow-up may be explored.

A novel therapeutic strategy utilizing EpCAM aptamer-conjugated gemcitabine for targeting bladder cancer and cancer stem cells

Gemcitabine (GEM) is a first line chemotherapy drug for bladder cancer (BCa). GEM's lack of specificity has led to disadvantages, resulting in low efficiency, especially when combined with the targeted treatment of BCa stem cells (CSCs), which is considered the cause of BCa recurrence and progression. To enhance the anti-cancer effect and reduce the side effects of GEM targeting of BCa cells/CSCs, an aptamer drug conjugate (ApDC) targeted delivery system was used to improve the efficiency of GEM in BCa therapy using EpCAM aptamer-GEM conjugates based on the epithelial cell adhesion molecule (EpCAM), which is highly expressed on the cell membrane of BCa cells/CSCs. We designed and synthesized EpCAM aptamer gemcitabine conjugates (EpCAM-GEMs, one aptamer carried three GEMs). The targeting effect of EpCAM-GEMs was examined in a xenograft model using an in vivo imaging system. To evaluate the antitumor activity and mechanism of EpCAM-GEMs, Cell Counting Kit-8, apoptosis and colony formation assays; BCa CSC xenotransplantation; xenotransplantation of subcutaneous tumors; a lung metastasis model; an in situ model; and biosafety assessment were used in vitro and in vivo. EpCAM is highly expressed on the surface of BCa cells/CSCs. EpCAM-GEMs were automatically synthesized using a DNA synthesizer, were stable in serum, and selectively delivered GEM to kill BCa cells/CSCs. EpCAM-GEMs entered BCa cells via macropinocytosis, released GEM to inhibit DNA synthesis, and degraded all BCa cells under the action of a BCa cell intracellular phosphatase; however, they did not kill normal cells because of their low EpCAM expression. EpCAM-GEMs inhibited BCa growth and metastasis in three bladder tumor models, with good biosafety. These results demonstrated the targeted anti-tumor efficiency and good biosafety of EpCAM-GEMs in BCa treatment, which will provide a new therapeutic strategy in BCa biomarker targeted therapy.

Development of a Technique for Diagnosis and Screening of Superficial Bladder Cancer by Cell-Pellet DNA From Urine Sample

Bladder cancer (BCa) is the most common malignancy of the urinary system with high incidence and recurrence rates. There are several ways to detect BCa. However, different approaches have different accuracy, which essentially depends on the sensitivity and specificity of the technique. Alternative noninvasive diagnostic tools for BCa are needed. We isolated and compared urinary cell-pellet DNA (cpDNA), cell-free DNA, and exosomal DNA from patients with localized BCa. Consequently, we analyzed 12 tissues and cpDNA samples by next-generation sequencing and then used bioinformatic tools to analyze genomic and transcriptomic alterations in coding and noncoding sequences. Then, cpDNA and tissue DNA from 12 patients were analyzed using next-generation sequencing to verify that the genomic characteristics of cpDNA are concordant with those of tissue. We also detected somatic mutation patterns between tissues and their corresponding cpDNA samples. An overlapping variant analysis was performed based on somatic mutation data and a high similarity was observed. Moreover, we identified frequently mutated signaling pathways. In these results, several point mutations were analyzed in FGFR3, TTN, and LEPROTL1 from the cpDNA of patients with BCa. Tumor mutational burden analysis showed that cpDNA had no significant difference in tumor mutational burden compared with tumor tissue. These results provide that cpDNA is a potential diagnostic source for detecting and managing BCa using alternative noninvasive methods from patient urine. Our findings may serve as a clinical tool for early detection or recurrence screening of nonmuscle invasive BCa using urinary cpDNA.

Phase II Pilot Trial of Tislelizumab plus Low-Dose Nab-Paclitaxel for Extensive Very High-Risk Non-Muscle-Invasive Bladder Cancer

PURPOSE

Combinations of immune checkpoint inhibitors and nab-paclitaxel have improved outcomes in advanced urothelial carcinoma and muscle-invasive bladder cancer. This study evaluates the safety and efficacy of tislelizumab combined with low-dose nab-paclitaxel in extensive very high-risk non-muscle-invasive bladder cancer.

PATIENTS AND METHODS

TRUCE-02 was a single-arm phase II trial that included 63 patients with visually incomplete resection and/or high-volume high-grade T1 tumors (with or without carcinoma in situ) who were ineligible for or declined radical cystectomy. Patients received intravenous tislelizumab (200 mg on day 1) and nab-paclitaxel (200 mg on day 2) every 3 weeks, with assessment approximately 3 months after initial administration. The primary endpoint was the complete response (CR) rate of high-risk disease. Main secondary endpoints included safety and duration of CR.

RESULTS

The safety analysis included all 63 patients, and the efficacy analysis included 59 patients. Thirty-seven patients (62.7%; 95% confidence interval, 49.1%-75.0%) achieved a CR of high-risk disease, with a 24-month sustained response rate of 96.3% (95% confidence interval, 89.4%-100.0%). Grade 3 to 4 treatment-related adverse events occurred in nine patients (14%), with no fatal events reported.

CONCLUSIONS

Tislelizumab plus low-dose nab-paclitaxel was well tolerated and showed promising antitumor activity, making it a potential alternative for patients with extensive very high-risk non-muscle-invasive bladder cancer who are ineligible for or decline radical cystectomy.

Multiparametric MRI-Based Deep Learning Radiomics Model for Assessing 5-Year Recurrence Risk in Non-Muscle Invasive Bladder Cancer

BACKGROUND

Accurately assessing 5-year recurrence rates is crucial for managing non-muscle-invasive bladder carcinoma (NMIBC). However, the European Organization for Research and Treatment of Cancer (EORTC) model exhibits poor performance.

PURPOSE

To investigate whether integrating multiparametric MRI (mp-MRI) with clinical factors improves NMIBC 5-year recurrence risk assessment.

STUDY TYPE

Retrospective.

POPULATION

One hundred ninety-one patients (median age, 65 years; age range, 54-73 years; 27 females) underwent mp-MRI between 2011 and 2017, and received ≥5-year follow-ups. They were divided into a training cohort (N = 115) and validation/testing cohorts (N = 38 in each). Recurrence rates were 23.5% (27/115) in the training cohort and 23.7% (9/38) in both validation and testing cohorts.

FIELD STRENGTH/SEQUENCE

3-T, fast spin echo T2-weighted imaging (T2WI), single-shot echo planar diffusion-weighted imaging (DWI), and volumetric spoiled gradient echo dynamic contrast-enhanced (DCE) sequences.

ASSESSMENT

Radiomics and deep learning (DL) features were extracted from the combined region of interest (cROI) including intratumoral and peritumoral areas on mp-MRI. Four models were developed, including clinical, cROI-based radiomics, DL, and clinical-radiomics-DL (CRDL) models.

STATISTICAL TESTS

Student's t-tests, DeLong's tests with Bonferroni correction, receiver operating characteristics with the area under the curves (AUCs), Cox proportional hazard analyses, Kaplan-Meier plots, SHapley Additive ExPlanations (SHAP) values, and Akaike information criterion for clinical usefulness. A P-value <0.05 was considered statistically significant.

RESULTS

The cROI-based CRDL model showed superior performance (AUC 0.909; 95% CI: 0.792-0.985) compared to other models in the testing cohort for assessing 5-year recurrence in NMIBC. It achieved the highest Harrell's concordance index (0.804; 95% CI: 0.749-0.859) for estimating recurrence-free survival. SHAP analysis further highlighted the substantial role (22%) of the radiomics features in NMIBC recurrence assessment.

DATA CONCLUSION

Integrating cROI-based radiomics and DL features from preoperative mp-MRI with clinical factors could improve 5-year recurrence risk assessment in NMIBC.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 3.

Performance of Urinary Markers in Patients With Suspicious Cystoscopy During Follow-up of Recurrent Non-muscle Invasive Bladder Cancer: BTA Stat, NMP22 BladderChek, UBC Rapid Test, CancerCheck UBC Rapid VISUAL, and Uromonitor in Comparison to Cytology

OBJECTIVE

To compare all available rapid tests on a large cohort of recurrent bladder cancer during follow-up in this multicentre-study is the first study. BTA stat, NMP22 BladderChek, UBC Rapid Test CancerCheck UBC rapid VISUAL, and uromonitor are urinary-based rapid tests for bladder cancer detection.

METHODS

In total, 187 urine samples were analyzed from patients with suspected recurrent non-muscle invasive urothelial bladder cancer on cystoscopy during follow-up in a real-world assessment. All suspicious lesions were resected with 110 samples showing recurrent urothelial cancer. Urine samples were analyzed by the BTA stat, NMP22 BladderChek, UBC Rapid Test, CancerCheck UBC rapid VISUAL, uromonitor, and cytology. Sensitivities and specificities were calculated by contingency analyses.

RESULTS

All investigated urinary markers could detect a higher percentage of pathological results in urine of bladder cancer patients compared to urine of tumor free patients. The calculated diagnostic sensitivities for BTA stat, NMP22 BladderChek, UBC Rapid Test, CancerCheck UBC rapid VISUAL, uromonitor, and cytology were 60.0%, 10.0%, 58.0%, 32.0%, 54.5%, and 41.5% for non-muscle invasive low-grade, and 64.0%, 40.0%, 77.8%, 50.0%, 56.0%, and 65.5% for non-muscle invasive high-grade bladder cancer. The specificity was 51.3%, 94.8%, 66.2%, 89.5%, 94.9%, and 66.2%, respectively.

CONCLUSION

During follow-up sensitivities and specificities of most urinary markers are higher compared to cytology for the detection of recurrent bladder cancer. BTA stat, UBC Rapid Test, and uromonitor appear useful in this setting.

Life Experience of Patients Living With Urostomy: A Meta-Synthesis of Qualitative Research

OBJECTIVE

Urostomy profoundly alters the body image of bladder cancer patients, leading to a series of physiological, psychological, social, and functional changes. This review aims to synthesize qualitative research on urostomy patients' life experiences to provide healthcare professionals with a complete understanding of the patient's problems and needs, thereby guiding the development of interventions and continuous care services.

METHODS

This review adhered to the ENTREQ guide. The Cochrane, EMBASE, Ovid (Medline), Web of Science Core Collection, PubMed, EBSCO, CNKI, VIP, and Wan Fang databases were searched for qualitative studies on the life experience of urostomy patients. The search period was from the earliest available records in each database to June 2024. This review selected studies based on the study's objectives and predetermined criteria. The data was synthesized using a meta-aggregation method.

RESULTS

A total of 17 studies were included in the synthesis. This review included 242 patients. The 32 qualitative findings were distilled into nine new categories and synthesized into three findings: (1) Facing multiple pressures and challenges that disrupt normalcy; (2) The existence of multidimensional unmet needs; and (3) Growing up after trauma and achieving life reconstruction.

CONCLUSIONS

Urostomy patients face complex physiological, psychological, and social challenges. These challenges require a comprehensive understanding of patients' experiences, life adjustments, and unmet needs. Healthcare professionals should address these aspects, support patients through their adjustment to stoma life, and enhance their self-care abilities to improve their quality of life.

Non-invasive diagnosis for urothelial carcinoma using a dual-target DNA methylation biomarker panel

BACKGROUND

Urothelial carcinoma (UC) is a common malignancy worldwide. Aberrant DNA methylation is implicated in UC carcinogenesis. This study sought to delineate the DNA methylation landscape in UC and identify DNA methylation-based biomarkers for early detection of UC.

METHODS

Whole genome bisulfite sequencing (WGBS) was conducted on bladder cancer tissues and paired normal tissues. By integrating WGBS data with The Cancer Genome Atlas (TCGA) UBC data, a DNA methylation-based biomarker was identified. When combined with a known UC biomarker AL021918.2, the performance of the dual-target test was evaluated in voided urine samples from 224 UC patients and 419 controls.

RESULTS

Notable hypomethylation was observed in UC samples compared to normal samples. Through differential methylation analysis, differential methylation CpG sites, regions, and genes were identified. Of these, Transmembrane protein 106A gene (TMEM106A) was screened as a new UC biomarker. In a dual-target test, using triplex quantitative methylation-specific PCR (qMSP) to examine TMEM106A and AL021918.2 methylation levels, the training set showed a sensitivity of 89.0 %, a specificity of 92.9 %, and an area under the curve (AUC) value of 0.941 (95 % confidence interval [CI]: 0.913-0.969). Similarly, the validation set showed a sensitivity of 90.0 %, a specificity of 91.1 %, and an AUC value of 0.922 (95 % CI: 0.881-0.962). In addition, our dual-target test demonstrated outstanding detection rates for low-grade or early-stage tumors.

CONCLUSIONS

We provide a comprehensive analysis of DNA methylation profiles in UC, and highlight the promising clinical potential of dual-target urine tests for UC detection.

Analysis the diagnostic performance of H4C6/SOX1-OT gene methylation in bladder cancer based on urine sample

Bladder cancer (BCa) is the second most common urological malignancy, but the techniques used today to detect and monitor BCa are frequently invasive and/or have inadequate sensitivity and specificity. Therefore, it is imperative to create a noninvasive test that is both sensitive and accurate for diagnosing BCa. This research introduces and validates the diagnostic performance of H4C6/SOX1-OT gene methylation in the diagnosis of BCa based on urine samples by designing two parts of studies: the case-control study and the prospective validation study. In the case-control study, the methylation test of H4C6/SOX1-OT achieved a sensitivity/specificity/positive predictive value (PPV)/negative predictive value (NPV) of 87.9%(95%CI, 79.4%-93.3%)/90.4%(95%CI, 80.7%-95.7%)/92.6%(95%CI, 84.8%-96.7%)/ 84.6%(95%CI, 74.3%-91.5%) (kappa value 77.6%). The sensitivities for low grade, high grade, Ta-T1, and T2-T4 were 85% (17/20), 88.6% (70/79), 85.4% (41/48) and 92.6% (25/27). Statistical analysis showed the diagnostic sensitivity of test was not affected by sex, age, tumor grade or tumor stage (P > 0.05). In the prospective validation study, the H4C6/SOX1-OT methylation test yielded an overall sensitivity/specificity/PPV/NPV of 84.8%(95%CI, 67.3%-94.3%)/90.0%(95%CI, 75.4%-96.7%)/87.5% (95%CI, 70.1%-95.9%)/84.6% (95%CI, 73.0%-95.4%) (kappa value 75.0%), indicating 38.4% of spared cystoscopy. These findings highlight the potential of the H4C6/SOX1-OT methylation in urine DNA as a promising molecular diagnostic tool for detecting BCa, especially for early-stage tumors, which may reduce the need for cystoscopy.

Intravesical BCG: A Double-Edged Sword? The Untold Story of Infection Risks

Background and Objectives: Intravesical Bacillus Calmette-Guérin (BCG) therapy remains a cornerstone in the treatment of non-muscle-invasive bladder carcinoma due to its efficacy in reducing recurrence and progression rates. However, its use is associated with various complications-including urinary tract infections (UTIs)-which necessitates further exploration. This study aims to analyze UTIs occurring during intravesical BCG treatment, emphasizing the microbial spectrum, resistance patterns, and risk factors from an infectious diseases and clinical microbiology perspective. Materials and Methods: A retrospective analysis was conducted on 240 patients diagnosed with non-muscle-invasive bladder carcinoma who received intravesical BCG therapy between 2010 and 2021. Data were collected from hospital records, including demographic characteristics, comorbidities, number of intravesical BCG cycles, and microbiological findings. UTIs were classified based on susceptibility patterns, and statistical analyses were performed to determine associations between clinical variables and UTI risk. Results: UTIs developed in 39.1% (n = 94) of patients, with 25.8% (n = 62) caused by susceptible pathogens and 13.3% (n = 32) by resistant pathogens. The most common causative agent was Escherichia coli (80.7% in susceptible UTIs, 43.8% in resistant UTIs), followed by Pseudomonas aeruginosa and Klebsiella pneumoniae. The presence of diabetes mellitus and chronic kidney disease significantly increased the risk of developing a UTI (p < 0.05). A higher number of intravesical BCG cycles correlated with increased UTI occurrence (p < 0.001). Serum C-reactive protein (CRP) levels were significantly elevated in patients with resistant UTIs, while procalcitonin levels were not a reliable predictor of UTI occurrence. Conclusions: Intravesical BCG therapy is associated with a significant incidence of UTIs, particularly among patients with predisposing comorbidities. The increasing prevalence of antibiotic-resistant infections underscores the need for careful monitoring and targeted antimicrobial stewardship strategies. CRP may serve as a useful adjunctive marker for UTI diagnosis in this setting. Future studies should focus on optimizing infection control measures and refining diagnostic criteria to differentiate between BCG-related inflammation and infectious complications.

Unsupervised neural network-based image stitching method for bladder endoscopy

Bladder endoscopy enables the observation of intravesical lesion characteristics, making it an essential tool in urology. Image stitching techniques are commonly employed to expand the field of view of bladder endoscopy. Traditional image stitching methods rely on feature matching. In recent years, deep-learning techniques have garnered significant attention in the field of computer vision. However, the commonly employed supervised learning approaches often require a substantial amount of labeled data, which can be challenging to acquire, especially in the context of medical data. To address this limitation, this study proposes an unsupervised neural network-based image stitching method for bladder endoscopy, which eliminates the need for labeled datasets. The method comprises two modules: an unsupervised alignment network and an unsupervised fusion network. In the unsupervised alignment network, we employed feature convolution, regression networks, and linear transformations to align images. In the unsupervised fusion network, we achieved image fusion from features to pixel by simultaneously eliminating artifacts and enhancing the resolution. Experiments demonstrated our method's consistent stitching success rate of 98.11% and robust image stitching accuracy at various resolutions. Our method eliminates sutures and flocculent debris from cystoscopy images, presenting good image smoothness while preserving rich textural features. Moreover, our method could successfully stitch challenging scenes such as dim and blurry scenes. Our application of unsupervised deep learning methods in the field of cystoscopy image stitching was successfully validated, laying the foundation for real-time panoramic stitching of bladder endoscopic video images. This advancement provides opportunities for the future development of computer-vision-assisted diagnostic systems for bladder cavities.

Intravesical chemotherapy in BCG waiting period may prolong time to recurrence for high-risk NMIBC patients

PURPOSE

This study aimed to determine whether administering intravesical chemotherapy (IVC) during the Bacillus Calmette - Guérin (BCG) waiting period after the second TURBT improves the recurrence-free survival (RFS) of patients with non - muscle - invasive bladder cancer (NMIBC).

METHODS

A retrospective analysis was performed on patients who had undergone a second TURBT and subsequent intravesical BCG immunotherapy (IBI) at the Affiliated Hospital of Xuzhou Medical University between January 2012 and December 2023. The patients were divided into two groups (A and B) based on whether they continued IVC during the BCG waiting period, and RFS was compared between the two groups.

RESULTS

A total of 164 patients were included in this study. The log-rank test results indicated that IVC administered during the BCG waiting period was associated with a more favorable RFS for patients with NMIBC, particularly those at high risk. Multivariate analysis revealed that pathological T-stage (HR 2.084, 95% CI [1.132, 3.834], p = 0.018) and IVC received during the BCG waiting period (HR 0.261, 95% CI [0.140, 0.488], p < 0.001) were significantly correlated with patient RFS.

CONCLUSIONS

Administering IVC during the BCG waiting period is recommended to prolong the time to recurrence in patients with high-risk NMIBC. Conversely, this additional treatment is unnecessary for patients at intermediate risk.

A Comprehensive Review of Current Approaches in Bladder Cancer Treatment

Bladder cancer is one of the most common malignant tumors of the urinary system globally. It is also one of the most expensive cancers to manage, due to the need for extensive treatment and follow-ups that often involve invasive and costly procedures. Although there have been some improvements in treatment options, the quality of life they offer has not improved at the same rate as other cancers. Therefore, there is an urgent need to find new alternatives to ease the burden of bladder cancer on patients. Recent discoveries have opened new avenues for the diagnosis and management of bladder cancer even though the clinical approach has largely remained the same for years. The decline in bladder cancer-specific mortality in regions that promote social awareness of risk factors and reduction of carcinogenic exposure demonstrates the effectiveness of such measures. New agents have been approved for patients who have undergone radical cystectomy after Bacillus Calmette-Guérin failure. Current best practices for diagnosing and treating bladder cancer are presented in this review. The review discusses radiation therapy, photodynamic therapy, gene therapy, chemotherapy, and nanomedicine in relation to non muscle-invasive cancers and muscle-invasive bladder cancers, as well as systemic treatments.

The Promise of Radiotherapy in High-Risk Non-Muscle Invasive Bladder Cancer

Global shortages, toxicities, and high levels of incomplete treatment with Bacillus Calmette Guerin (BCG) for non-muscle invasive bladder cancer has resulted in increasing interest in alternative treatments. Radiotherapy is not the standard of care for non-muscle invasive bladder cancer (NMIBC), despite being routinely used in muscle invasive bladder cancer. Modern techniques and advances in technology mean that radiotherapy can be delivered with increased precision in reducing normal tissue damage. Developing novel biomarker approaches, together with combination approaches with radiosensitisers and other systemic treatments, means that radiotherapy could offer greater benefits than current treatments with BCG or surgery. This review summarises the current landscape and future potential of radiotherapy for high-risk NMIBC.

Long-term outcomes of bladder-sparing therapy vs radical cystectomy in BCG-unresponsive non-muscle-invasive bladder cancer

OBJECTIVE

To quantify the oncological risks of bladder-sparing therapy (BST) in patients with Bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) compared to upfront radical cystectomy (RC).

PATIENTS AND METHODS

Pre-specified data elements were collected from retrospective cohorts of patients with BCG-unresponsive NMIBC from 10 international sites. After Institutional Review Board approval, patients were included if they had BCG-unresponsive NMIBC meeting United States Food and Drug Administration criteria. Oncological outcomes were collected following upfront RC or BST. BST regimens included re-resection or surveillance only, repeat BCG, intravesical chemotherapy, systemic immunotherapy, and clinical trials.

RESULTS

Among 578 patients, 28% underwent upfront RC and 72% received BST. The median (interquartile range) follow-up was 50 (20-69) months. There were no statistically significant differences in metastasis-free survival, cancer-specific survival, or overall survival between treatment groups. In the BST group, high-grade recurrence rates were 37% and 52% at 12 and 24 months and progression to MIBC was observed in 7% and 13% at 12 and 24 months, respectively. RC was performed in 31.7% in the BST group and nodal disease was found in 13% compared with 4% in upfront RC (P = 0.030).

CONCLUSION

In a selected cohort of patients, initial BST offers comparable survival outcomes to upfront RC in the intermediate term. Rates of recurrence and progression increase over time especially in patients treated with additional lines of BST.

Fluid intake and recurrence and progression risk of patients with non-muscle-invasive bladder cancer

OBJECTIVES

To evaluate the association of pre- and post-diagnosis fluid intake with non-muscle-invasive bladder cancer (NMIBC) recurrence and progression risk.

PATIENTS AND METHODS

Data were used from the multicentre prospective cohort study UroLife. Participants reported pre-diagnosis fluid intake at 6 weeks (food frequency questionnaire [FFQ]) (n = 1322) and post-diagnosis fluid intake at 3 and 15 months (FFQ and 4-day 24-h fluid diaries) (n = 1275) after diagnosis. Multivariable proportional hazard regression models were used to obtain hazard ratios (HRs) and 95% confidence intervals (CIs) for the association of fluid intake with risk of first and multiple recurrence(s) and progression.

RESULTS

During a median overall follow-up of 4.6 years, 474 patients had one or more recurrence and 142 had progression. A higher first recurrence risk was observed for patients with the highest pre-diagnosis fluid intakes (≥2300 vs 1500-1900 mL/day: HR 1.38, 95% CI 1.07-1.79), but not for those with the highest post-diagnosis fluid intakes. HRs were similar for multiple recurrence risk. For progression, each 150 mL/day increase in both pre- and post-diagnosis fluid intake was consistently associated with an increased risk (post-diagnosis [3 months] FFQ-based: HR 1.05, 95% CI 1.01-1.09 and diary-based: HR 1.04, 95% CI 0.99-1.09).

CONCLUSION

High fluid intakes may be associated with higher NMIBC recurrence and especially progression risk. These findings lack a clear explanation but may be related to extensive expansion of the bladder wall or urinary symptoms. Further research is warranted. Meanwhile, these findings do not support recommending high(er) fluid intakes to patients with NMIBC to decrease their recurrence or progression risk.

Combining a Risk Factor Score Designed From Electronic Health Records With a Digital Cytology Image Scoring System to Improve Bladder Cancer Detection: Proof-of-Concept Study

BACKGROUND

To reduce the mortality related to bladder cancer, efforts need to be concentrated on early detection of the disease for more effective therapeutic intervention. Strong risk factors (eg, smoking status, age, professional exposure) have been identified, and some diagnostic tools (eg, by way of cystoscopy) have been proposed. However, to date, no fully satisfactory (noninvasive, inexpensive, high-performance) solution for widespread deployment has been proposed. Some new models based on cytology image classification were recently developed and bring good perspectives, but there are still avenues to explore to improve their performance.

OBJECTIVE

Our team aimed to evaluate the benefit of combining the reuse of massive clinical data to build a risk factor model and a digital cytology image-based model (VisioCyt) for bladder cancer detection.

METHODS

The first step relied on designing a predictive model based on clinical data (ie, risk factors identified in the literature) extracted from the clinical data warehouse of the Rennes Hospital and machine learning algorithms (logistic regression, random forest, and support vector machine). It provides a score corresponding to the risk of developing bladder cancer based on the patient's clinical profile. Second, we investigated 3 strategies (logistic regression, decision tree, and a custom strategy based on score interpretation) to combine the model's score with the score from an image-based model to produce a robust bladder cancer scoring system.

RESULTS

We collected 2 data sets. The first set, including clinical data for 5422 patients extracted from the clinical data warehouse, was used to design the risk factor-based model. The second set was used to measure the models' performances and was composed of data for 620 patients from a clinical trial for which cytology images and clinicobiological features were collected. With this second data set, the combination of both models obtained areas under the curve of 0.82 on the training set and 0.83 on the test set, demonstrating the value of combining risk factor-based and image-based models. This combination offers a higher associated risk of cancer than VisioCyt alone for all classes, especially for low-grade bladder cancer.

CONCLUSIONS

These results demonstrate the value of combining clinical and biological information, especially to improve detection of low-grade bladder cancer. Some improvements will need to be made to the automatic extraction of clinical features to make the risk factor-based model more robust. However, as of now, the results support the assumption that this type of approach will be of benefit to patients.

Clinical value of combining epirubicin with mindfulness intervention in patients with urinary system tumors and depression

BACKGROUND

Urinary system tumors often cause negative psychological symptoms, such as depression and dysphoria which significantly impact immune function and indirectly affect cancer prognosis. While epirubicin (EPI) is recommended by the European Association of Urology and can improve prognosis, its long-term use can cause toxic side effects, reduce treatment compliance, and increase psychological burden. Therefore, an appropriate intervention mode is necessary.

AIM

To explore the clinical value of EPI combined with mindfulness intervention in patients with urinary system tumors and depression.

METHODS

This was a retrospective study including 110 patients with urinary system tumors and depression admitted to Zhumadian Central Hospital between March 2021 and July 2023. Patients were divided into conventional (n = 55) and joint intervention (n = 55) groups. The conventional group received mitomycin and routine nursing, while the joint intervention group received EPI and mindfulness intervention. Both groups underwent three cycles of chemotherapy. Immune function (CD4+ cells, CD8+ cells, CD4+/CD8+ ratio), tumor marker levels [urinary bladder cancer antigen (UBC), bladder tumor antigen (BTA) and nuclear matrix protein 22 (NMP22)], quality of life questionnaire-core 30 (QLQ-C30), 17-item Hamilton depression scale (HAMD-17), and cancer-related fatigue [cancer fatigue scale (CFS)] were assessed. Adverse reactions and nursing satisfaction were recorded and evaluated.

RESULTS

Post-intervention, CD4+, CD8+, and CD4+/CD8+ levels increased in both groups, with the joint intervention group showing more significant improvement (P < 0.05). Tumor marker levels (NMP22, BTA, and UBC) were lower in the joint intervention group compared to the conventional group (P < 0.05). The joint intervention group also showed a greater reduction in HAMD-17 scores (9.38 ± 3.12 vs 15.45 ± 4.86, P < 0.05), higher QLQ-C30 scores, and lower CFS scores (both P < 0.05). Additionally, the joint intervention group had a lower incidence of adverse reactions and higher nursing satisfaction (P < 0.05).

CONCLUSION

EPI combined with mindfulness intervention significantly improved clinical outcomes in patients with urinary system tumors and depression and is worthy of clinical application.

Predicting recurrence of non-muscle invasive bladder urothelial carcinoma: predictive value of the optimal cut-off value of Ki67

Objective

To investigate the optimal cut-off value of immunohistochemical marker Ki67 as a prognostic factor to predict the recurrence of non-muscle invasive bladder urothelial carcinoma (NMIBUC).

Methods

A total of 331 patients diagnosed with NMIBUC who underwent surgery in the Yongchuan Hospital and the Second Affiliated Hospital of Chongqing Medical University from January 2012 to January 2020 were finally included in this study. The optimal cut-off value of Ki67 for predicting recurrence of NMIBUC was calculated by ROC curve and Youden index. According to the cut-off value, the patients were divided into high ratio group and low ratio group, and the clinicopathological data of the two groups were compared. Univariate and multivariate regression analysis were used to analyze the relationship between the expression of Ki67 and postoperative recurrence of NMIBUC. The Kaplan-Meier curve was used for survival analysis.

Results

18% is the optimal cut-off value of Ki67 for predicting postoperative recurrence of NMIBUC. High Ki67 expression (Ki67>18%) was significantly correlated with tumor stage (P=0.001), tumor grade (P=0.014), immediate postoperative instillation (P=0.001), the expression of P53 (P=0.019) and CK20 (P=0.001). Ki67 expression greater than 18% was an independent risk factor for high recurrence rate of NMIBUC (P=0.001). Moreover, the 1-year and 3-year recurrence-free survival (RFS) of the high Ki67 group were 56.6% (95%CI 51.2%-62%) and 43.6% (95%CI 37.5%-49.7%) respectively, which were significantly lower than those in low Ki67 group which present as 92.9% (95%CI 89.0%-96.8%) and 88.3% (95%CI 82.4%-94.2%) respectively, and the difference was statistically significant (P<0.001).

Conclusions

18% is the optimal cut-off value of Ki67 for predicting recurrence of NMIBUC. Ki67>18% is an independent risk factor for high recurrence rate of NMIBUC. This cut-off value can more accurately predict the risk of recurrence and has the potential clinical value for guiding the postoperative adjuvant treatment and follow-up strategy of NMIBUC.

Serum metabolomic analysis identified serum biomarkers predicting tumour recurrence after Bacillus Calmette-Guérin therapy in patients with non-muscle invasive bladder cancer

Background

Metabolomic research and metabolomics-based biomarkers predicting treatment outcomes in bladder cancer remain limited.

Objective

We explored the serum metabolites potentially associated with the risk of recurrence after intravesical Bacillus Calmette-Guérin (BCG) therapy.

Methods

Two independent cohorts, a discovery cohort (n = 23) and a validation cohort (n = 40), were included in this study. Blood was collected before the induction of BCG therapy (pre-BCG blood; both discovery and validation cohorts) and after six doses of BCG (post-BCG blood; only discovery cohort). Metabolome analysis of serum samples was conducted using capillary electrophoresis time-of-flight mass spectrometry. The endpoint was intravesical recurrence-free survival, which was analysed using Kaplan-Meier estimates, the log-rank test, and the Cox proportional hazard model.

Results

Of the 353 metabolites quantified, nine (2.5%) and four (1.1%) were significantly upregulated and downregulated, respectively. The heatmap of hierarchical clustering analysis and principal coordinate analysis for the fold changes and in serum metabolites differentiated 10 recurrent cases and 13 non-recurrent cases in the discovery cohort. A metabolome response-based scoring model using 16 metabolites, including threonine and N6,N6,N6-trimethyl-lysine effectively stratified the risk of post-BCG recurrence. Additionally, pre-BCG metabolome-based score models using six metabolites, octanoylcarnitine, S-methylcysteine-S-oxide, theobromine, carnitine, indole-3-acetic acid, and valeric acid, were developed from the discovery cohort. Univariate and multivariate analyses confirmed a high predictive accuracy in the validation and combination cohorts.

Conclusions

We demonstrated that numerous types of serum metabolites were altered in response to intravesical BCG and developed high-performance score models which might effectively differentiated the risk of post-BCG tumour recurrence.

Optimizing cystoscopy and TURBT: enhanced imaging and artificial intelligence

Diagnostic cystoscopy in combination with transurethral resection of the bladder tumour are the standard for the diagnosis, surgical treatment and surveillance of bladder cancer. The ability to inspect the bladder in its current form stems from a long chain of advances in imaging science and endoscopy. Despite these advances, bladder cancer recurrence and progression rates remain high after endoscopic resection. This stagnation is a result of the heterogeneity of cancer biology as well as limitations in surgical techniques and tools, as incomplete resection and provider-specific differences affect cancer persistence and early recurrence. An unmet clinical need remains for solutions that can improve tumour delineation and resection. Translational advances in enhanced cystoscopy technologies and artificial intelligence offer promising avenues to overcoming the progress plateau.

Current Status of Magnetic Resonance Imaging Use in Bladder Cancer

ABSTRACT

Bladder cancer (BC) is a significant global health concern, with over 500,000 new cases and 200,000 deaths annually, emphasizing the need for accurate staging and effective management. Traditional diagnostic techniques, such as cystoscopy and transurethral resection, are fundamental but have limitations in accurately assessing the depth of invasion. These limitations include the possibility of understaging and procedural variability, which can significantly impact treatment decisions. This review focuses on the role of multiparametric magnetic resonance imaging (mpMRI) in the diagnosis and staging of BC, particularly emphasizing the Vesical Imaging-Reporting and Data System (VI-RADS) framework. By enhancing interpretive consistency and diagnostic accuracy, mpMRI and VI-RADS offer detailed visualization of tumor characteristics and depth of invasion, while reducing the need for more invasive traditional methods. These advancements not only improve staging accuracy but also enhance treatment planning, underscoring the importance of advanced imaging in evolving BC management and positively influencing patient outcomes.

Beta-human chorionic gonadotropin, carbohydrate antigen 19-9, cancer antigen 125, and carcinoembryonic antigen as prognostic and predictive biological markers in bladder cancer

INTRODUCTION

We evaluated the prognostic potential of the Beta-human chorionic gonadotropin (β-hCG), Carbohydrate Antigen 19-9 (CA19-9), Cancer Antigen 125 (CA125), and Carcinoembryonic Antigen (CEA) tumor markers for bladder cancer.

METHODS

We analyzed the records of 369 patients who underwent radical cystectomy for urothelial cancer (UC) between October 2012 until December 2019. Levels of CA19-9, CA125, CEA, and β-hCG before radical cystectomy were measured in all patient samples, and serum biomarker cutoff values were used as normal and elevated values.

RESULTS AND DISCUSSION

The proportion of abnormal β-hCG (P<0.001), CA19-9 (P<0.001), and CA125 (P=0.033) was significantly higher in locally advanced bladder UC than in organ-confined bladder UC. In patients with preoperative β-hCG and CA125 abnormality, there was poor prognosis of recurrence-free survival (RFS)(P=0.003, P=0.042) and overall survival (OS) (P=0.003, P=0.002). Using the Cox multivariate regression analysis, both β-hCG (HR: 3.88, 95% CI: 1.43-10.25) and CA125 (HR: 6.21, 95% CI: 1.34-32.16) were found to be significant independent factors for predicting OS and RFS. In addition, patients with a high number of increased tumor markers showed significantly worse OS ((P<0.001) and RFS (P=0.002) than patients with a low number of increased tumor markers. In conclusion, serum β-hCG and CA125 levels could potentially be used for UC prognosis in patients undergoing radical cystectomy. To assess their usefulness in evaluating long-term recurrence and survival, further treatment responses and large-scale additional studies are needed.

Towards Reliable Methodology: Microbiome Analysis of Fresh Frozen vs. Formalin-Fixed Paraffin-Embedded Bladder Tissue Samples: A Feasibility Study

Studies have shown that the human microbiome influences the response to systemic immunotherapy. However, only scarce data exist on the impact of the urinary microbiome on the response rates of bladder cancer (BC) to local Bacillus Calmette-Guérin instillation therapy. We launched the prospective SILENT-EMPIRE study in 2022 to address this question. We report the results of the pilot study of SILENT-EMPIRE, which aimed to compare the microbiome between fresh frozen (FF) and formalin-fixed paraffin-embedded (FFPE) samples in the cancerous tissue and adjacent healthy tissue of BC patients. Our results show that alpha diversity is increased in FF samples compared to FFPE (coverage index p = 0.041, core abundance index p = 0.008). No significant differences concerning alpha diversity could be detected between cancerous and non-cancerous tissue in the same BC patients. This study demonstrates that microbiome analysis from both FF and FFPE samples is feasible. Implementing this finding could aid in the translation of research findings into clinical practice.

Efficacy and safety of first-line immunotherapy-containing regimens compared with chemotherapy for advanced or metastatic urothelial carcinoma: a network meta-analysis of randomized controlled trials

Introduction

To assess the efficacy and safety of first-line immunotherapy-containing regimens compared with chemotherapy for advanced or metastatic urothelial carcinoma (UC).

Method

A comprehensive search was performed in four databases (Pubmed, Embase, Web of Science, and the Cochrane Library) to identify randomized controlled trials (RCTs) assessing the efficacy of first-line immunotherapy-containing regimens for advanced or metastatic UC. The search encompassed the time span from the inception of the databases to April 23, 2024. A network meta-analysis (NMA) was conducted to assess the rates of progression-free survival (PFS), overall survival (OS), complete response (CR), objective response rate (ORR), and grade ≥ 3 adverse events (AEs).

Results

We conducted a comprehensive analysis of five randomized controlled trials (RCTs) that included a total of 4749 patients. Nine different treatment regimens included in the study were ranked statistically and intuitively using NMA. The top five effective regimens, ranked by OS, were EV + Pembro (1.000), Nivol + Chemo (0.724), Atezo + Chemo (0.610), Durva + Treme (0.558), and Pembro + Chemo (0.530). The top five effective regimens, ranked by PFS, were EV + Pembro (0.999), Nivol + Chemo (0.640), Pembro + Chemo (0.484), Atezo + Chemo (0.373) and Chemo (0.003). The top five effective regimens, ranked by CR, were EV + Pembro (0.969), Nivol + Chemo (0.803), Atezo + Chemo (0.772), Pembro + Chemo (0.472), Durva + Treme (0.449). The top five effective regimens, ranked by ORR, were EV + Pembro (0.995), Nivol + Chemo (0.852), Pembro + Chemo (0.761), Atezo + Chemo (0.623), and Chemo (0.519).

Conclusion

Our results indicated that EV + Pembro as first-line therapy resulted in considerably improved efficacy and safety compared to chemotherapy for advanced or metastatic UC. ICI plus chemotherapy as first-line treatment resulted in a longer PFS, a greater ORR, but no longer OS compared to chemotherapy alone, as well as higher toxicity. ICI alone as first-line therapy provided similar OS and lower toxicity compared to chemotherapy, but lower ORR.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42024538546.

High-risk non-muscle invasive bladder cancer: Outcomes of patients who cannot benefit from standard of care

INTRODUCTION

High-grade non-muscle invasive bladder cancer (HG-NMIBC) exposes to a high risk of recurrence and progression. Standard of care includes repeated trans-urethral resection of bladder tumor (reTURBT) and bacillus Calmette-Guérin (BCG) therapy. Not following Standard of care (SOC) may be associated with a worse prognosis. We aimed to compare prognosis outcomes of patients with primary HG-NMIBC according to the respect of the SOC or not.

MATERIALS AND METHODS

We conducted an eleven-year retrospective observational study including all patients undergoing initial bladder resection for de novo HG-NMIBC at our institution. Exclusion criteria were prior urothelial carcinoma histology, low grade NMIBC or ≥T2 staging. Four groups were formed according to the treatment received.

RESULTS

Among 164 patients, 44.5% received standard of care, 18.3% received only BCG-therapy, 16.5% benefited only from reTURBT and 20.7% did not receive treatment. Upstaging to T2 tumor was found in 6% of reTURBT specimens. Presence of residual tumor (RT) on re-TURBT (P<10-4) and having benefited from SOC (P=0.016) impacted recurrence-free survival. Progression-free survival was impacted by presence of RT (P=0.001) but not by SOC (P=0.284).

CONCLUSION

Performing standard of care on patients with HG-NMIBC is associated with a lower risk of recurrence. We believe SOC should be provided for all HG-NMIBC patients, especially those with poor prognostic factors such as T1 tumor, or multiplicity or largeness of the bladder tumor.

LEVEL OF EVIDENCE: 4

Prognostic model based on disulfidptosis-related lncRNAs for predicting survival and therapeutic response in bladder cancer

Background

With poor treatment outcomes and prognosis, bladder cancer remains a focus for clinical research in the precision oncology era. However, the potential of disulfidptosis, a novel cell death mechanism, and its related long non-coding RNAs to support selective cancer cell killing in this disease is still unclear.

Methods

We identified key disulfidptosis-related lncRNAs in bladder cancer, constructed a prognostic risk model with potential therapeutic targets, and confirmed the findings through quantitative PCR analysis.

Results

We identified five crucial lncRNAs (AC005840.4, AC010331.1, AL021707.6, MIR4435-2HG and ARHGAP5-AS1) and integrated them into a predictive model centered on disulfidptosis-associated lncRNAs. Reliability and validity tests demonstrated that the lncRNA prediction index associated with disulfidptosis effectively discerns patients' prognosis outcomes. Additionally, high-risk patients exhibited elevated expression levels of genes involved in the PI3K-Akt signaling pathway, extracellular matrix organization, and immune escape mechanisms, which are associated with poor prognosis. Notably, high-risk patients demonstrated higher sensitivity to Sorafenib, Oxaliplatin and MK-2206, underscoring the promise of these lncRNAs as precise therapeutic targets in bladder cancer.

Conclusion

By revealing the predictive importance of disulfidptosis-associated lncRNAs in bladder cancer, our research offers new perspectives and pinpoints potential therapeutic targets in clinical environments.

Urine-based SERS and multivariate statistical analysis for identification of non-muscle-invasive bladder cancer and muscle-invasive bladder cancer

Bladder cancer (BC) is an epidemiological urologic malignancy that continues to increase each year. Early diagnosis and prognosis monitoring is always significant in clinical practice, especially in distinguishing non-muscle-invasive bladder cancer (NMIBC) from muscle-invasive bladder cancer (MIBC), due to the various depths of tumor invasion related to different therapeutic schedules and recurrence rates. Common diagnostic approaches are too invasive or generally inefficient in accuracy and specificity. In this work, a totally non-invasive and cost-effective method is established by investigating urine samples using surface-enhanced Raman spectroscopy (SERS) and multivariate statistical analysis. The comparison of urine SERS spectra shows the intensities of characteristic peaks for DNA/RNA, hypoxanthine, albumin, D-( +)-galactosamine, fatty acids, and some amino acids are distinguishable in BC occurrence and invasion progression. A PLS-LDA-based two-step binary classification scheme is performed on urine SERS spectra and the diagnostic accuracies were 97.7% and 96.3% for healthy individuals versus BC patients and NMIBC versus MIBC patients, respectively. Moreover, the impact of urine SERS spectral lengths in reaching high-precision recognition of BC is investigated. The results show that the Raman peaks at 803, 893, 1139, 1375, and 1466 cm-1 play an essential role in correctly categorizing healthy control, NMIBC, and MIBC patients, and SERS spectra ranges from 400 to 1600 cm-1 are enough for this identification task. These findings provide a sensitive, label-free, rapid, and totally non-invasive way for assessment of invasion depth of BC to its early diagnosis and prognosis monitoring, as well as valuable insights for selecting reasonable spectral range to enhance the measurement efficiency especially in large-scale sample datasets.

VI-RADS-based Algorithm for Bladder Cancer Management Randomized Retrospective Study

OBJECTIVE

To evaluate if VI-RADS can distinguish between nonmuscle-invasive bladder cancers (NMIBC), muscle-invasive bladder cancer (MIBC), and high-risk nonmuscle-invasive bladder cancers (HR-NMIBCs). It is unclear if the Vesical Imaging-Reporting and Data System (VI-RADS) can replace repeated transurethral resection of bladder tumor (Re-TURBT) as in the new VI-RADS-based algorithm.

METHODS

Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of the VI-RADS score were calculated for mpMRI performance in patients undergoing TURBT and HR-NMIBC patients for only Re-TURBT.

RESULTS

Of 283 cases, when VI-RADS ≥3 lesions were considered muscle-invasive, its sensitivity was 95.7% and specificity was 92.5%. PPV and NPV were 86.6% and 97.7%, respectively. The area under the curve (AUC) was 0.942 (P <.001). Of 89 patients undergoing post-Re-TURBT, 41 (46%) were tumor-free, 47 (50.5%) showed permanent HR-NMIBC, and 3 (2.2%) were upgraded to MIBC. Per the new VI-RADS-based approach, 73 (41%) of the 178 HR-NMIBCs with VI-RADS ≤2 would not undergo Re-TURBT. Of the 75 patients with VI-RADS ≥4, 6 (6) with HR-NMIBCs (8%) would not undergo Re-TURBT. When incomplete resections were excluded, 35 (60.3%) of the patients had complete resection, 23 (39.7%) had residual disease, and complete resection would not have been performed in these patients, and 2 (100%) still had residual disease.

CONCLUSION

The new VI-RADS-based algorithm helped VI-RADS ≥4 patients by switching to radical treatment. Since the residual disease is high in cases with VI-RADS ≤2, even if incomplete resections are excluded, TURBT should be continued.

The association between variant histology and prognostic, histomorphological and clinical aspects of bladder urothelial carcinoma

This study underscores the imperative consideration of histological subtypes and divergent differentiation in accurately estimating bladder urothelial carcinoma prognosis and guiding treatment decisions. A comparative analysis was conducted, examining clinical, histological, and prognostic factors between conventional urothelial carcinoma and urothelial carcinoma with variant histology in a clinical sample. A retrospective analysis of slides and other clinicopathologic data was conducted these cases, with an emphasis on key diagnostic elements. We examined 829 cases of urothelial carcinoma of the bladder, comprising of 744 transurethral resection (TUR) and 85 radical cystectomy (RS) specimens, an analysis that showed that 80.5 % (667 cases) were conventional urothelial carcinoma (CUC) and that 19.5 % (162 cases) exhibited variant histology (hereafter "urothelial carcinoma with subtype histology" [UCSH]). TNM classifications for the RS cases were as follows: 2 cases were stage group 0a, 11 stage group 1, 16 stage group 2, 45 stage group 3a, 2 stage group 3b, 1 stage group 4a, and 8 stage group 4b. Only 2 of the RS cases were found to be non-invasive. Among 744 TUR specimens, 387 were found to have a non-invasive tumor whereas 357 had invasive tumors. The most prevalent subtype in the UCSH group was urothelial carcinoma with squamous differentiation, accounting for 54.3 % (88 cases). Notably, 8.02 % (13 cases) exhibited more than one histological subtype. Papillary configuration, histological grade, lamina propria, muscularis mucosa and serosa invasion, lymphovascular invasion, presence of urothelial carcinoma in situ, and overall survival significantly differed between the UCSH and CUC groups (p < 0.05). However, mean age, gender, tumor size, lymphocytic response, disease-free survival, and survival status did not differ significantly (p > 0.05). Among the UCSH group, lower levels of papillary configuration, higher histological grade, higher degree of lamina propria, muscularis mucosa and serosa invasion, and the presence of carcinoma in situ corresponded to higher percentage of histological subtype morphology (p < 0.05). No significant difference in survival status was observed between the groups with and without subtype histology (p = 0.083). This study found that clinical and histopathological prognostic factors associated with a more aggressive disease were linked to the presence and percentage of histological subtypes. Recognizing histological subtype is crucial for treatment decisions and prognosis prediction in urothelial carcinoma cases with these subtypes.

Intra-arterial chemotherapy combined with BCG immunotherapy is more effective than intra-arterial chemotherapy plus intravesical chemotherapy or standard BCG immunotherapy in preventing the recurrence and progression of high-risk non-muscle-invasive bladder cancer

BACKGROUND

Up to 45% of patients with high-risk non-muscle-invasive bladder cancer (NMIBC) will not benefit from adjuvant intravesical instillation. We aimed to introduce intra-arterial chemotherapy (IAC) to existing intravesical treatment and evaluate its feasibility and safety.

MATERIALS AND METHODS

We collected data from 170 patients who had been diagnosed with high-risk NMIBC and underwent transurethral resection of bladder tumor (TURBT) over the last 5 years. Twenty-seven patients were excluded according to specific exclusion criteria. The remaining 143 patients were divided into 3 groups according to their treatment: intravesical instillation of Bacillus Calmette - Guerin (BCG), BCG+ intra-arterial chemotherapy (IAC), and intravesical chemotherapy (IVC)+IAC groups. All groups received standard intravesical instillation of BCG or chemotherapeutic agents. In contrast, both the BCG+IAC and IVC+IAC groups received four courses of IAC (injection of cisplatin [60 mg/m2] and epirubicin [50 mg/m2] in the internal iliac arteries via Seldinger's percutaneous technique).

RESULTS

The median follow-up time was 47 months, ranging from 20 to 60 months. The restricted mean survival time (RMST), which represents the recurrence and progression rate of the BCG+IAC group, differed significantly when compared with the BCG group (P = 0.029 and 0.004, respectively) and the IVC+IAC group (P = 0.004 and 0.006, respectively). Kaplan-Meier plots revealed that the recurrence and progression-free survival of the BCG+IAC group were significantly higher than the BCG and IVC+IAC groups (P = 0.033 and 0.028, respectively). In contrast, the BCG and IVC+IAC groups showed similar RMST (P = 0.156 and 0.935, respectively), recurrence (P = 0.627), and progression-free (P = 0.931) survival. A small proportion of patients (20%) suffered from the adverse effects of IAC while 65% suffered from adverse reactions to intravesical instillation. Most adverse effects were ranked as grade I or II according to the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0.

CONCLUSION

Analysis showed that tumor recurrence and progression rate in the BCG+IAC group was lower than the BCG and IVC+IAC groups while patients in the IVC+IAC group suffered from milder adverse effects in cystitis and flu-like symptoms. Our findings may provide a new perspective for urologists when treating patients with high-risk NMIBC.

Bladder-Preserving Trimodality Treatment for High-Grade T1 Bladder Cancer: Results From Phase II Protocol NRG Oncology/RTOG 0926

PURPOSE

To investigate the use of radiation with radiosensitizing chemotherapy following repeated transurethral resection (trimodality therapy) as an alternative to radical cystectomy in T1 bladder cancer which has failed Bacillus Calmette-Guerin (BCG).

PATIENTS AND METHODS

Patients with recurrent T1 bladders who had failed BCG and were recommended to undergo cystectomy were treated with trimodality therapy. The primary end point was 3-year freedom from cystectomy. Secondary end points were distant metastasis at 3 and 5 years, local recurrence, disease-specific and overall survival (OS), and safety.

RESULTS

This single-arm phase II study enrolled 37 patients. Efficacy and safety were evaluated in 34 patients after three exclusions. The median follow-up was 5.1 years. The 3-year freedom from cystectomy rate was 88% (lower one-sided 97.5% confidence limit [CI], 72%), meeting the primary study goal. OS at 3 and 5 years was 69% (95% CI, 54 to 85) and 56% (95% CI, 39 to 74), respectively. The distant metastasis rates at 3 and 5 years were 12% (95% CI, 4 to 26) and 19% (95% CI, 7 to 34), respectively. Eight patients died due to urothelial cancer, 12 exhibited local recurrence at 3 years (cumulative incidence: 32%; 95% CI, 17 to 48), 18 experienced grade 3 adverse events, mostly hematological, and one developed grade 4 neutropenia.

CONCLUSION

Trimodality therapy is an effective potential alternative to radical cystectomy for recurrent high-grade T1 urothelial cancer of the bladder. At 3 years, 88% of the patients remained free of cystectomy.

BCG therapy for bladder cancer: Exploring patient experiences and concerns through artificial intelligence-based social media analysis

Background

There is a notable disparity between the guidelines for BCG therapy in non-muscle invasive bladder cancer (NMIBC). Reddit has emerged as a popular online platform for individuals seeking information and exchanging their experiences related to bladder cancer.

Objective

To investigate and classify public opinions about intravesical BCG therapy as shared on Reddit, a popular social media platform.

Methods

This study employed an artificial intelligence-based approach to examine discussions related to intravesical BCG therapy on a social media platform over the past ten years. An artificial intelligence framework was developed to categorize these conversations into distinct topics and thematic categories. This framework included a partially supervised model for processing natural language (using BERT [Bidirectional Encoder Representations from Transformers]), a method for reducing data complexity, and an algorithm for clustering. Additionally, each conversation was assessed for sentiment.

Results

A total of 1223 unique discussions related to BCG therapy were analyzed, comprising 110 unique posts and 1113 comments from 268 distinct authors. We identified four overarching thematic groups: 1) BCG administration procedures, (2) hesitancy in initiating or maintaining BCG treatment, (3) issues related to BCG shortage and alternative treatments, and (4) side effects of BCG treatment. Sentiment analysis of the 1223 discussions revealed that 25.2% (308) exhibited a negative sentiment, 58.3% (713) were neutral, and 16.5% (202) showed a positive sentiment.

Conclusion

Online social media often contains detailed personal experiences with BCG therapy, not commonly found in medical literature. Understanding these experiences can help medical professionals improve care and treatment adherence in NMIBC.

Comprehensive analysis of single-cell and bulk RNA sequencing reveals postoperative progression markers for non-muscle invasive bladder cancer and predicts responses to immunotherapy

BACKGROUND

Non-muscle-invasive bladder cancer (NMIBC) is renowned for its high recurrence, invasiveness, and poor prognosis. Consequently, developing new biomarkers for risk assessment and investigating innovative therapeutic targets postoperative in NMIBC patients are crucial to aid in treatment planning.

APPROACHES

Differential gene expression analysis was performed using multiple Gene Expression Omnibus (GEO) datasets to identify differentially expressed genes (DEGs) between NMIBC and normal tissue, as well as between NMIBC and muscle-invasive bladder cancer (MIBC). Functional enrichment analysis was conducted based on the DEGs identified. Subsequently, prognosis-related genes were selected using Kaplan-Meier (KM) analysis and Cox regression analysis. The Boruta algorithm was utilized to further screen for core DEGs related to postoperative progression in NMIBC based on the aforementioned prognosis-related genes. Single-cell and clinical correlation studies were performed to verify their expression across various stages of bladder cancer. To investigate the link between core genes and the immune microenvironment, single-sample gene set enrichment analysis (ssGSEA) was utilized, and Receiver Operating Characteristic (ROC) and KM analyses were performed to confirm predictive power for immune therapy outcomes. Machine learning (ML) models were constructed using the DepMap dataset to predict the efficacy of core gene inhibitors in treating bladder cancers. The prognostic performance of the core genes was evaluated using ROC curve analysis. An online prediction tool was developed based on the core genes to provide prognostic predictions. Finally, RT-qPCR, CCK-8, and Transwell assays were used to verify the pro-tumor effects of the GINS2 in bladder cancer.

RESULTS

A total of 70 DEGs were identified, among which 11 prognostic genes were obtained through KM analysis, and an additional 8 prognostic genes were obtained through COX analysis. The Boruta algorithm selected AURKB, GINS2, and UHRF1 as the three core DEGs. Single-cell and clinical variable correlation analyses indicated that the core genes promoted the progression of bladder cancer. The analysis of immune infiltration revealed a strong positive association between the core genes and both activated CD4 T cells and Type 2 helper T cells. Two random forest (RF) models were constructed to effectively predict the treatment effect of bladder cancer after targeted inhibition of AURKB and GINS2. In addition, an online nomogram tool was developed to effectively predict the risk of postoperative progression in NMIBC patients undergoing TURBT. Finally, RT-qPCR, CCK8, and Transwell assays showed that GINS2 promoted the growth and progression of bladder cancer.

CONCLUSION

AURKB, GINS2, and UHRF1 have the potential to enhance postoperative management of NMIBC patients undergoing transurethral resection of bladder tumor (TURBT) and can predict immunotherapy response, establishing them as promising therapeutic targets.

Strategies for intravesical drug delivery: From bladder physiological barriers and potential transport mechanisms

Intravesical drug delivery (IDD), as a noninvasive, local pathway of administration, has great clinical significance for bladder diseases, especially bladder cancer. Despite the many advantages of IDD such as enhanced focal drug exposure and avoidance of systemic adverse drug reactions, the effectiveness of drug delivery is greatly challenged by the physiological barriers of the bladder. In this review, the routes and barriers encountered in IDD are first discussed, and attention is paid to the potential internal/mucosal retention and absorption-transport mechanisms of drugs. On this basis, the avoidance, overcoming and utilization of the "three barriers" is further emphasized, and current design and fabrication strategies for intravesical drug delivery systems (IDDSs) are described mainly from the perspectives of constructing drug reservoirs, enhancing permeability and targeting, with the hope of providing systematic understanding and inspirations for the research of novel IDDSs and their treatment of bladder diseases.

Impact of virtual monochromatic images of different low-energy levels in dual-energy CT on radiomics models for predicting muscle invasion in bladder cancer

OBJECTIVE

The purpose of this study was to investigate the impact of different low-energy virtual monochromatic images (VMIs) in dual-energy CT on the performance of radiomics models for predicting muscle invasive status in bladder cancer (BCa).

MATERIALS AND METHODS

A total of 127 patients with pathologically proven muscle-invasive BCa (n = 49) and non-muscle-invasive BCa (n = 78) were randomly allocated into the training and test cohorts at a ratio of 7:3. Feature extraction was performed on the venous phase images reconstructed at 40, 50, 60 and 70-keV (single-energy analysis) or in combination (multi-energy analysis). Recursive feature elimination (RFE) and the least absolute shrinkage and selection operator (LASSO) were employed to select the most relevant features associated with BCa. Models were built using a support vector machine (SVM) classifier. Diagnostic performance was assessed through receiver operating characteristic curves, evaluating sensitivity, specificity, accuracy, precision, and the area-under-the curve (AUC) values.

RESULTS

In the test cohort, the multi-energy model achieved the best diagnostic performance with AUC, sensitivity, specificity, accuracy, and precision of 0.917, 0.800, 0.833, 0.821, and 0.750, respectively. Conversely, the single-energy model exhibited lower AUC and sensitivity in predicting the muscle invasion status.

CONCLUSIONS

By combining information from VMIs of various energies, the multi-energy model displays superior performance in preoperatively predicting the muscle invasion status of bladder cancer.

French AFU Cancer Committee Guidelines - Update 2024-2026: Non-muscle invasive bladder cancer (NMIBC)

OBJECTIVE

To update the CCAFU recommendations for the management of non-muscle invasive bladder cancer (NMIBC).

METHODS

A systematic review (Medline) of the literature from 20222024 was performed, taking into account the elements of diagnosis, treatment options and monitoring of NMIBC and evaluating references with their level of evidence.

RESULTS

The diagnosis of NMIBC (Ta, T1, or CIS) is made after complete and deep tumour resection. The use of bladder photodynamic diagnosis and the indication for a second TURBT (4 to 6weeks later) help to improve the initial diagnosis. The risk of recurrence and/or tumour progression is assessed via the EORTC score. By stratifying patients into low-, intermediate- and high-risk groups, adjuvant treatment can be proposed, including endovesical instillations of chemotherapy (immediate postoperative regimen), BCG (induction and maintenance regimen), or even the indication of cystectomy for unresponsive patients.

CONCLUSION

Updating the CCAFU's recommendations should help improve patient management, as well as the diagnosis and treatment of NMIBC.

ACR Appropriateness Criteria® Pretreatment Staging of Urothelial Cancer: 2024 Update

Urothelial cancer is the second most common cancer, and cause of cancer death, related to the genitourinary tract. The goals of imaging for pretreatment staging of urothelial cancer are to evaluate for both local and distant spread of the cancer and assessing for synchronous sites of urothelial cancer in the upper tracts and bladder. For pretreatment staging of urothelial carcinoma, patients can be stratified into one of three groups: 1) nonmuscle invasive bladder cancer; 2) muscle invasive bladder cancer; and 3) upper urinary tract urothelial carcinoma. This document is a review of the current literature for urothelial cancer and resulting recommendations for pretreatment staging imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Cohort Profile: VZNKUL-NMIBC Quality Indicators Program: A Flemish Prospective Cohort to Evaluate the Quality Indicators in the Treatment of Non-Muscle-Invasive Bladder Cancer

Purpose: Bladder cancer (BC) is a heterogeneous disease with varying outcomes, influenced by disease heterogeneity and variability in treatment and follow-up. Risk groups have been established for non-muscle-invasive BC (NMIBC) to standardize therapy, and several quality control indicators (QCIs) monitor adherence to these risk group-based guidelines. However, controversial results had been obtained regarding the oncological benefits of these QCIs until recent high-quality studies from large registries showed their usefulness. To improve adherence to the European Association of Urology (EAU) Guidelines and benchmark current care in Flemish hospitals within Vlaams Ziekenhuisnetwerk-KU Leuven (VZNKUL), a QCI program for NMIBC was initiated in 2013. This study aims to describe the demographic, clinical, and treatment data of patients enrolled in this program. Participants: The VZNKUL-NMIBC Quality Indicators Program Registry is a prospective cohort including patients treated and followed up with at seven academic and non-academic Flemish hospitals since June 2013. Data collection includes patient characteristics, tumor data, treatment, and oncological outcomes. Findings to date: From June 2013 to December 2020, 4744 transurethral resections of bladder tumors (TURBTs) from 2237 unique patients were analyzed. Most patients (80%) were men with a median age of 73. The median time from diagnosis to TURBT was 19 days. A single tumor was detected in 37% of TURBTs. Tumors larger than 3 cm were found in 20.8% of cases. In 46% of TURBTs, a reTURBT was scheduled according to guidelines. The complication rates were 7.5% and 2.4% for bladder perforation and bleeding, respectively. Postoperative single intravesical instillation of chemotherapy (SIVIC) was administered to 56.9% of 1533 indicated patients with a median time to administration of 4.7 h. Among the cohort, 60.4% had NMIBC, and 9.3% had muscle-invasive BC. Of 972 high-risk patients, 60.7% received adequate BCG induction, while 39.4% received adequate maintenance. After BCG induction ± maintenance, 39.7% were tumor-free, with 17.7% recurrence and 4% progression to muscle-invasive BC. BCG treatment was terminated early for 17% of patients due to intolerance. Early cystectomy was performed for 2.4% of the BCG-naïve patients, and 27.7% of patients with BCG failure underwent a BCG rechallenge. For intermediate-risk patients, 2.1% received adequate BCG, and 23% received intravesical chemotherapy. The median follow-up was 57 months. Five-year recurrence-free, progression-free, cancer-free, overall, and cancer-specific survival rates were 53%, 91.6%, 89%, 70.6%, and 95.6%, respectively, for the NMIBC patients. Of 400 non-metastatic MIBC patients, 217 (54.3%) underwent radical cystectomy (RC), of whom 46% received neoadjuvant chemotherapy, while 18 (4.5%) refused RC, and 74 (18.5%) were considered unfit for the surgery. Future plans: The VZNKUL-NMIBC Quality Indicators Program Registry will continue collecting data to evaluate QCIs and monitor treatment quality, enabling hospitals to benchmark their performance and improve patient care. Additionally, the registry's real-world data can support research and international collaboration. Trial registration: The study was registered on ClinicalTrials.gov (NCT04167332).

Novel intravesical therapies and delivery systems for the management of bladder cancer

PURPOSE OF REVIEW

Bladder cancer is a substantial burden for public health worldwide. A risk-adapted treatment strategy is required for non muscle-invasive (NMIBC) and muscle-invasive bladder cancer (MIBC). To date, treatment includes surgery with or without peri-operative local or systemic treatment. The aim of this review was to explore novel intravesical therapies and delivery systems emerging in NMIBC and MIBC.

RECENT FINDINGS

Several novel intravesical therapies and delivery systems for NMIBC and MIBC treatment recently emerged. Hyperthermic intravesical chemotherapy (HIVEC) allows a reasonable cancer control in selected high-risk NMIBC. Novel intravesical drugs such as nadofaragene firadenovec, Oncofid-P-B or Nogapendekin alfa-inbakicept seem to be safe and well tolerated. However, their efficacy in high-risk NMIBC should be further investigated. Hydrogels appear to be safe, well tolerated and potentially efficient in primary chemoablation in selected cases of low-grade intermediate-risk NMIBC tumors. Drug-releasing intravesical systems (drug-RIS) such as TAR-200 are safe and well tolerated, providing high partial and complete response rate in both NMIBC and MIBC patients.

SUMMARY

The armamentarium for the treatment of bladder cancer patients is expanding, notably with HIVEC, hydrogels, drug-RIS and novel therapies. However, accurate patients' selection is key to prevent disease progression in any bladder-sparing strategy, and radical cystectomy remains the gold-standard to date.

Prediction of recurrence risk in patients with non-muscle-invasive bladder cancer

Objective

Non-muscle-invasive bladder cancer (NMIBC) remains a common challenge in uro-oncology with conflicting reports on recurrence risk. This study aimed to elucidate the recurrence rate of NMIBC in the Cancer Clinic of Shahid Beheshti Hospital in Iran and to investigate related parameters affecting recurrence risk.

Methods

The data of 143 patients with NMIBC, who underwent treatment between January 2017 and January 2020 and were followed up from the initial transurethral resection of bladder tumor until November 30, 2020 in our institution, were retrospectively assessed. The Cox regression analysis and Kaplan-Meier plot of recurrence-free survival were used to determine independent contributing factors for tumor recurrence.

Results

Among patients with NMIBC, 83.9% were male, and 16.1% were female, with a mean age of 64.4 (standard deviation [SD] 12.9) years. During the follow-up, 71 (49.7%) patients showed tumor recurrence, with a mean recurrence time of 11.5 (SD 6.9) months. In the Chi-square test or Fisher's exact test, the age (≥65 years) (p=0.037), obesity (body mass index ≥30 kg/m2) (p=0.004), no diabetes mellitus (p=0.005), smoking (current or former smoker) (p=0.001), immediate perfusion therapy (p=0.035), number of tumors (>3) (p<0.001), and tumor stage (Ta, T1, and Tis) (p=0.001) had independent significant effects on the recurrence of NMIBC. The multivariate Cox regression analysis indicated that preoperative obesity (hazards ratio [HR] 7.90; 95% confidential interval [CI] 4.01-15.55; p<0.001), current or former smoking (HR 1.85; 95% CI 1.07-3.20; p=0.027), and a high-grade tumor (HR 4.03; 95% CI 1.59-10.25; p=0.003) were significant predictors of tumor recurrence. The Kaplan-Meier plot of recurrence-free survival showed that obesity (log-rank p<0.001), current or former smoking (log-rank p=0.001), and a high-grade tumor (log-rank p=0.006) were associated with a shorter time interval until the first tumor recurrence.

Conclusion

The study found a high recurrence rate of NMIBC in Iran from January 2017 to January 2020, with the obesity, smoking history, and the high-grade tumor as contributing factors.

Evaluation of serum fibronectin levels and fibronectin gene polymorphism in patients receiving intravesical BCG therapy for non-muscle invasive bladder cancer and its prognostic value

BACKGROUND

Bladder cancer continues to be a significant health issue, leading to ongoing research into novel biomarkers and treatment strategies. This study aims to evaluate the potential of serum fibronectin levels and fibronectin gene polymorphisms as biomarkers for predicting the recurrence and treatment response in patients with NMIBC undergoing intravesical BCG therapy.

METHODS

Between June 2022 and December 2022, data of 73 patients who applied to the Mersin University Urology Clinic due to NMIBC and were followed and treated in our clinic, receiving intravesical BCG treatment, when necessary, as well as 56 individuals without any malignancy, were prospectively examined. Serum fibronectin levels were measured using the enzyme-linked immunosorbent assay method. PCR testing was applied for the fibronectin gene RS10202709 and RS 35,343,655 gene polymorphisms by using Real-Time PCR.

RESULTS

The mean serum fibronectin level in the patient group was 76.794 ± 66.998ng/ml. Simultaneously, it was 50.486 ± 25.156ng/ml in the control group, and these differences in serum fibronectin levels were statistically significant(p = 0.003). Out of the 73 patients included in the study, recurrence of bladder cancer was observed in 53 of them. They were divided into two groups based on the recurrence times: early recurrence and late recurrence. The mean fibronectin level in the early recurrence group was 102 ± 86.1 ng/ml, while it was 44.7 ± 11.8 ng/ml in the late recurrence group. Emphasize the significance of the higher fibronectin levels in the early recurrence group by stating, patients with early recurrence exhibited significantly higher serum fibronectin levels compared to those with late recurrence (p < 0.001), suggesting a potential role for fibronectin as a prognostic biomarker.

CONCLUSIONS

The statistically higher concentrations of serum fibronectin levels in patients with bladder cancer observed in our study are a noteworthy finding. These findings suggest that serum fibronectin levels could serve as a valuable prognostic biomarker for early recurrence in NMIBC patients, although their predictive value for BCG treatment response remains limited.

Gold nanorod-assisted theranostic solution for nonvisible residual disease in bladder cancer

Residual nonvisible bladder cancer after proper treatment caused by technological and therapeutic limitations is responsible for tumor relapse and progression. This study aimed to demonstrate the feasibility of a solution for simultaneous detection and treatment of bladder cancer lesions smaller than one millimeter. The α5β1 integrin was identified as a specific marker in 81% of human high-grade nonmuscle invasive bladder cancers and used as a target for the delivery of targeted gold nanorods (GNRs). In a preclinical model of orthotopic bladder cancer expressing the α5β1 integrin, the photoacoustic imaging of targeted GNRs visualized lesions smaller than one millimeter, and their irradiation with continuous laser was used to induce GNR-assisted hyperthermia. Necrosis of the tumor mass, improved survival, and computational modeling were applied to demonstrate the efficacy and safety of this solution. Our study highlights the potential of the GNR-assisted theranostic strategy as a complementary solution in clinical practice to reduce the risk of nonvisible residual bladder cancer after current treatment. Further validation through clinical studies will support the findings of the present study.

Anticoagulant-related bleeding as a sign of underlying tumoural lesions in patients with atrial fibrillation: a nationwide cohort study

Aims

Bleeding events are a well-known complication of oral anticoagulant (OAC) use in patients with atrial fibrillation (AF). While these are undesirable, bleedings could have a warning potential for underlying tumoural lesions. Therefore, we aimed to investigate the association between anticoagulant-related bleeding and newly diagnosed tumoural lesions in a nationwide cohort study.

Methods and results

Using Belgian nationwide data, AF patients without any tumoural lesions were included when initiating OACs between 2013 and 2019. The absolute and relative risks of newly diagnosed tumoural lesions were investigated in OAC users with vs. without an OAC-related bleeding event. Analyses were additionally stratified by tumoural lesion, location-specific bleeding, and OAC type. A total of 230 386 OAC users were included, among whom 35 192 persons were diagnosed with a tumoural lesion during follow-up. Persons with a clinically relevant bleeding during OAC use had a tumoural lesion incidence of 15.33 per 100 person-years compared to an incidence of 5.22 per 100 person-years in persons without bleeding. Site-specific gastrointestinal, urogenital, respiratory, and intracranial bleeding events were respectively associated with a significantly increased risk of incident gastrointestinal [adjusted hazard ratio (aHR) 8.13 (95% confidence interval (CI): 7.08-9.34)], urological [aHR 12.73 (95% CI: 10.56-15.35)], respiratory [aHR 4.91 (95% CI: 3.24-7.44)], and intracranial tumoural lesions [aHR 27.89 (95% CI: 16.53-47.04)].

Conclusion

Bleeding events in AF patients initiated on OAC were associated with an increased risk of tumoural lesions. Therefore, OAC-related bleeding events could unmask an underlying tumoural lesion.