Assessment of Predictive Genomic Biomarkers for Response to Cisplatin-based Neoadjuvant Chemotherapy in Bladder Cancer

Pathological response and survival outcomes after neoadjuvant chemotherapy with radical cystectomy in octogenarians for muscle-invasive bladder cancer: an observational database study

BACKGROUND

Neoadjuvant chemotherapy (NAC) with radical cystectomy (RC) is the preferred first-line treatment for localized muscle-invasive bladder cancer (MIBC). In recent years, octogenarians have been undergoing RC uneventfully, but studies showed older adults receive NAC less often. We studied the utilization and effect of RC with or without NAC in octogenarians and compared survival outcomes between responders and non-responders.

METHODS

In our retrospective study using the National Cancer Database (NCDB), we identified octogenarians with MIBC and urothelial histology who underwent RC with or without NAC between 2004 and 2018. The NAC cohort included patients who underwent RC with NAC, and the non-NAC cohort included those with or without adjuvant chemotherapy. The NAC cohort was subcategorized into responders and non-responders based on surgical pathology. Patients with comorbidity index > 1 were not included, thereby excluding patients with possible renal impairment. After propensity-matching, we compared the overall survival (OS) between NAC and non-NAC cohorts and responders and non-responders.

RESULTS

33924 patients underwent RC, and 3056 octogenarians met our selection. Among them, 396 received NAC, and 2660 did not receive NAC. Among those who received NAC, 112(28.3%) experienced downstaging, and 223(56.4%) exhibited upstaging or no change (p < 0.001). After propensity-matching, the median OS of the NAC and non-NAC cohorts were 51.6 months and 31.3 months, respectively (p<0.001). Similarly, the median OS of responders and non-responders were 89.4 months and 26.5 months, respectively(p < 0.0001).

CONCLUSION

In our study, we observed that NAC with RC for MIBC may help to improve OS among healthy octogenarians. Similarly, responders had better OS than non-responders.

Advances in preclinical assessment of therapeutic targets for bladder cancer precision medicine

PURPOSE OF REVIEW

Bladder cancer incidence is on the rise, and until recently, there has been little to no change in treatment regimens over the last 40 years. Hence, it is imperative to work on strategies and approaches to untangle the complexity of intra- and inter-tumour heterogeneity of bladder cancer with the aim of improving patient-specific care and treatment outcomes. The focus of this review is therefore to highlight novel targets, advances, and therapy approaches for bladder cancer patients.

RECENT FINDINGS

The success of combining an antibody-drug conjugate (ADC) with immunotherapy has been recently hailed as a game changer in treating bladder cancer patients. Hence, interest in other ADCs as a treatment option is also rife. Furthermore, strategies to overcome chemoresistance to standard therapy have been described recently. In addition, other studies showed that targeting genomic alterations (e.g. mutations in FGFR3 , DNA damage repair genes and loss of the Y chromosome) could also be helpful as prognostic and treatment stratification biomarkers. The use of single-cell RNA sequencing approaches has allowed better characterisation of the tumour microenvironment and subsequent identification of novel targets. Functional precision medicine could be another avenue to improve and guide personalized treatment options.

SUMMARY

Several novel preclinical targets and treatment options have been described recently. The validation of these advances will lead to the development and implementation of robust personalized treatment regimens for bladder cancer patients.

Predictive and Prognostic Biomarkers and Tumor Antigens for Targeted Therapy in Urothelial Carcinoma

Urothelial carcinoma (UC) is the fourth most prevalent cancer amongst males worldwide. While patients with non-muscle-invasive disease have a favorable prognosis, 25% of UC patients present with locally advanced disease which is associated with a 10-15% 5-year survival rate and poor overall prognosis. Muscle-invasive bladder cancer (MIBC) is associated with about 50% 5 year survival when treated by radical cystectomy or trimodality therapy; stage IV disease is associated with 10-15% 5 year survival. Current therapeutic modalities for MIBC include neoadjuvant chemotherapy, surgery and/or chemoradiation, although patients with relapsed or refractory disease have a poor prognosis. However, the rapid success of immuno-oncology in various hematologic and solid malignancies offers new targets with tremendous therapeutic potential in UC. Historically, there were no predictive biomarkers to guide the clinical management and treatment of UC, and biomarker development was an unmet need. However, recent and ongoing clinical trials have identified several promising tumor biomarkers that have the potential to serve as predictive or prognostic tools in UC. This review provides a comprehensive summary of emerging biomarkers and molecular tumor targets including programmed death ligand 1 (PD-L1), epidermal growth factor receptor (EGFR), human epidermal growth factor receptor 2 (HER2), fibroblast growth factor receptor (FGFR), DNA damage response and repair (DDR) mutations, poly (ADP-ribose) polymerase (PARP) expression and circulating tumor DNA (ctDNA), as well as their clinical utility in UC. We also evaluate recent advancements in precision oncology in UC, while illustrating limiting factors and challenges related to the clinical application of these biomarkers in clinical practice.

Natural History and Genomic Landscape of Chemotherapy-Resistant Muscle-Invasive Bladder Cancer

PURPOSE

Patients with residual invasive bladder cancer after neoadjuvant chemotherapy (NAC) and radical cystectomy have a poor prognosis. Data on adjuvant therapy for these patients are conflicting. We sought to evaluate the natural history and genomic landscape of chemotherapy-resistant bladder cancer to inform patient management and clinical trials.

METHODS

Data were collected on patients with clinically localized muscle-invasive urothelial bladder cancer treated with NAC and cystectomy at our institution between May 15, 2001, and August 15, 2019, and completed four cycles of gemcitabine and cisplatin NAC, excluding those treated with adjuvant therapies. Survival was estimated using the Kaplan-Meier method, and multivariable Cox proportional hazards models were used to identify predictors of recurrence-free survival (RFS). Genomic alterations were identified in targeted exome sequencing (Memorial Sloan Kettering Integrated Mutation Profiling of Actionable Cancer Targets) data from post-NAC specimens from a subset of patients.

RESULTS

Lymphovascular invasion (LVI) was the strongest predictor of RFS (hazard ratio, 2.15 [95% CI, 1.37 to 3.39]) on multivariable analysis. Patients with ypT2N0 disease without LVI had a significantly prolonged RFS compared with those with LVI (70% RFS at 5 years). Lymph node yield did not affect RFS. Among patients with sequencing data (n = 101), chemotherapy-resistant tumors had fewer alterations in DNA damage response genes compared with tumors from a publicly available chemotherapy-naïve cohort (15% v 29%; P = .021). Alterations in CDKN2A/B were associated with shorter RFS. PIK3CA alterations were associated with LVI. Potentially actionable alterations were identified in more than 75% of tumors.

CONCLUSION

Although chemotherapy-resistant bladder cancer generally portends a poor prognosis, patients with organ-confined disease without LVI may be candidates for close observation without adjuvant therapy. The genomic landscape of chemotherapy-resistant tumors is similar to chemotherapy-naïve tumors. Therapeutic opportunities exist for targeted therapies as adjuvant treatment in chemotherapy-resistant disease.

Patients With Muscle-Invasive Bladder Cancer With Lymphovascular Invasion in Transurethral Resection Specimen Benefits Most From Platinum-Based Neoadjuvant Chemotherapy

PURPOSE

The survival benefit of neoadjuvant chemotherapy (NAC) before definitive radical cystectomy (RC) varied among patients, suggesting proper selection of patients for NAC to maximize the survival benefit. This study aimed to investigate the role of lymphovascular invasion (LVI) in transurethral resection (TUR) specimens in selecting patients with MIBC for NAC.

METHODS

Two retrospective cohorts of patients with cT2-4aN0 MIBC who underwent RC from 2004 to 2015 provided by Lund University were included. Inverse probability weighting was applied to make the NAC-treated (NAC) and untreated (non-NAC) cohorts comparable. Survival benefits were estimated with Kaplan-Meier curves and Cox proportional hazards models. The primary endpoint was cancer-specific survival (CSS). LVI in TUR specimens and molecular taxonomies (BASE47, UNC, and LundTax) were examined, and bulk RNA-seq datasets were explored for LVI-relevant signatures.

RESULTS

A total of 341 patients with cT2-4aN0 MIBC were included. The NAC cohort included 125 patients, whereas the non-NAC cohort included 216 patients. The 3-year CSS benefit of NAC was 7.1%. For patients with positive LVI in TUR specimens, the 3-year CSS benefit of NAC was 26.2% (48.1% vs. 74.3%), with a risk reduction of 56% (HR = 0.44, P = .03). A sensitivity analysis confirmed a significant interaction between LVI and NAC. This study failed to identify the molecular subtypes that maximized the survival benefit of NAC. Exploration of LVI-relevant signatures remains inconclusive.

CONCLUSIONS

LVI in TUR specimens could help identify patients with MIBC who would derive maximal survival benefit from NAC. Further prospective validation is necessary.

A bibliometric insight into neoadjuvant chemotherapy in bladder cancer: trends, collaborations, and future avenues

Background

Neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) remains the cornerstone of treatment for muscle-invasive bladder cancer (MIBC). While platinum-based regimens have demonstrated benefits in tumor downstaging and improved long-term survival for selected patients, they may pose risks for those who are ineligible or unresponsive to chemotherapy.

Objective

We undertook a bibliometric analysis to elucidate the breadth of literature on NAC in bladder cancer, discern research trajectories, and underscore emerging avenues of investigation.

Methods

A systematic search of the Web of Science Core Collection (WoSCC) was conducted to identify articles pertaining to NAC in bladder cancer from 1999 to 2022. Advanced bibliometric tools, such as VOSviewer, CiteSpace, and SCImago Graphica, facilitated the examination and depicted the publication trends, geographic contributions, institutional affiliations, journal prominence, author collaborations, and salient keywords, emphasizing the top 25 citation bursts.

Results

Our analysis included 1836 publications spanning 1999 to 2022, indicating a growing trend in both annual publications and citations related to NAC in bladder cancer. The United States emerged as the predominant contributor in terms of publications, citations, and international collaborations. The University of Texas was the leading institution in publication output. "Urologic Oncology Seminars and Original Investigations" was the primary publishing journal, while "European Urology" boasted the highest impact factor. Shariat, Shahrokh F., and Grossman, H.B., were identified as the most prolific and co-cited authors, respectively. Keyword analysis revealed both frequency of occurrence and citation bursts, highlighting areas of concentrated study. Notably, the integration of immunochemotherapy is projected to experience substantial growth in forthcoming research.

Conclusions

Our bibliometric assessment provides a panoramic view of the research milieu surrounding neoadjuvant chemotherapy for bladder cancer, encapsulating the present state, evolving trends, and potential future directions, with a particular emphasis on the promise of immunochemotherapy.

Gemcitabine with cisplatin and nivolumab: Redefining standard of care for first-line metastatic urothelial carcinoma?

Nivolumab with gemcitabine/cisplatin in the CheckMate 901 trial improved overall and progression-free survival in front-line locally advanced/metastatic urothelial cancer. The EV-302 trial establishes enfortumab-vedotin plus pembrolizumab as the preferred standard in this setting. Personalized decisions are crucial given patient eligibility and economics. Ongoing trials and predictive biomarkers will further refine treatment strategies.

Three versus four cycles of neoadjuvant chemotherapy for muscle-invasive bladder cancer: a systematic review and meta-analysis

OBJECTIVE

The optimal cycle of neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (MIBC) remains controversial. This study aimed to compare the efficacy of three and four cycles of NAC in the treatment of MIBC through a systematic review and meta-analysis of the literature.

MATERIALS AND METHODS

Relevant studies were systematically collected and reviewed in PubMed, Medline, Embase, Web of Science Databases, and the Cochrane Library. Relative ratios (RRs), Hazard ratios (HRs) and their 95% confidence intervals (CIs) were used to estimate outcome measures. Studies comparing the pathological response and prognosis of three versus four cycles of NAC for MIBC were included.

RESULTS

Five studies were included in this meta-analysis, including 2190 patients, of whom 1016 underwent three cycles of NAC and 1174 underwent four cycles of NAC. All studies were retrospective cohort studies. We found that 4 cycles of NAC had significantly better cancer-specific survival than 3 cycles (HR = 1.31, 95%CI,1.03-1.67, p = 0.029). There was no significant difference in overall survival between patients who received 3 and 4 cycles of chemotherapy (HR = 1.18, 95%CI = 0.83-1.69, p = 0.345). Similarly, no significant difference was observed in pathological objective response (RR = 0.95, 95%CI= 0.81-1.11, p = 0.515) and complete response rates (RR = 0.87, 95%CI = 0.69-1.11, p = 0.256) in MIBC after 3 or 4 cycles of NAC.

CONCLUSIONS

Three and four cycles of NAC had similar pathological responses and prognosis for MIBC, although the cancer-specific survival rate of four cycles was better than that of three cycles.

Gemcitabine and cisplatin plus nivolumab as organ-sparing treatment for muscle-invasive bladder cancer: a phase 2 trial

Cystectomy is a standard treatment for muscle-invasive bladder cancer (MIBC), but it is life-altering. We initiated a phase 2 study in which patients with MIBC received four cycles of gemcitabine, cisplatin, plus nivolumab followed by clinical restaging. Patients achieving a clinical complete response (cCR) could proceed without cystectomy. The co-primary objectives were to assess the cCR rate and the positive predictive value of cCR for a composite outcome: 2-year metastasis-free survival in patients forgoing immediate cystectomy or Collapse

Key Words

• phase ii trials
• translational research
• bladder cancer
• cancer immunotherapy
• chemotherapy

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MESH Headings

• Humans
• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Cisplatin/therapeutic use
• Deoxycytidine/therapeutic use
• Disease-Free Survival
• Gemcitabine
• Muscles
• Neoadjuvant Therapy
• Neoplasm Invasiveness
• Nivolumab/therapeutic use
• Urinary Bladder Neoplasms/drug therapy
• Urinary Bladder Neoplasms/pathology
• Xeroderma Pigmentosum Group D Protein

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Grants

• U24 CA224319 NCI NIH HHS
• U01 DK124165 NIDDK NIH HHS
• U24 CA224285 NCI NIH HHS
• T32 CA078207 NCI NIH HHS
• S10 OD030463 NIH HHS
• P30 CA196521 NCI NIH HHS
• S10 OD026880 NIH HHS
• U24 CA224316 NCI NIH HHS
• U24 CA224331 NCI NIH HHS
• R01 CA249175 NCI NIH HHS
• V Foundation for Cancer Research (V Foundation)
• Bristol-Myers Squibb (Bristol-Myers Squibb Company)
• U.S. Department of Health & Human Services | NIH | National Cancer Institute (NCI)
• Foundation for the National Institutes of Health (FNIH)/Partnership for Accelerating Cancer Therapies (PACT)

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Affiliation(s)

Matthew D Galsky Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA. Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Siamak Daneshmand Department of Urology, Keck School of Medicine of USC, Norris Comprehensive Cancer Center, Los Angeles, CA, USA
Sudeh Izadmehr Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Edgar Gonzalez-Kozlova Department of Oncological Sciences, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Kevin G Chan Department of Urology, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
Sara Lewis Department of Radiology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Bassam El Achkar Department of Radiology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Tanya B Dorff Department of Medical Oncology & Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
Jeremy Paul Cetnar Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR, USA
Brock O Neil Department of Urology, University of Utah, Salt Lake City, UT, USA
Anishka D'Souza Division of Hematology and Medical Oncology, Keck School of Medicine of USC, Norris Comprehensive Cancer Center, Los Angeles, CA, USA
Ronac Mamtani Division of Hematology and Medical Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, USA
Christos Kyriakopoulos Division of Hematology and Medical Oncology, University of Wisconsin Carbone Cancer Center, Madison, WI, USA
Tomi Jun Genentech, South San Francisco, CA, USA Formerly with the Icahn School of Medicine at Mount Sinai, New York, NY, USA
Mahalya Gogerly-Moragoda Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Rachel Brody Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA Department of Pathology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Hui Xie Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Kai Nie Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Geoffrey Kelly Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Amir Horowitz Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Yayoi Kinoshita Department of Pathology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Ethan Ellis Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Yohei Nose Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Giorgio Ioannou Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Rafael Cabal Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Diane M Del Valle Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
G Kenneth Haines Department of Pathology, Molecular and Cell-based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Li Wang Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA Gene Dx, Stamford, CT, USA
Kent W Mouw Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
Robert M Samstein Department of Radiation Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Reza Mehrazin Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Nina Bhardwaj Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Menggang Yu Department of Biostatistics and Medical Informatics, University of Wisconsin Carbone Cancer Center, Madison, WI, USA
Qianqian Zhao Department of Biostatistics and Medical Informatics, University of Wisconsin Carbone Cancer Center, Madison, WI, USA
Seunghee Kim-Schulze Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Robert Sebra Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Jun Zhu Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA Gene Dx, Stamford, CT, USA
Sacha Gnjatic Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
John Sfakianos Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Sumanta K Pal Department of Medical Oncology & Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA

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Codelivery of ERCC2 small interfering RNA and cisplatin with macrophage-derived mimetic nanovesicles for enhanced bladder cancer treatment

Cisplatin-based chemotherapy plays a vital role in the management of muscle-invasive bladder cancer (MIBC); however, off-tumor toxicity and resistance often lead to cancer recurrence and eventual treatment failure. The loss of function of the nucleotide excision repair gene excision repair cross-complementing rodent repair deficiency gene 2 ( ERCC2 ) in cancer cells correlates with sensitivity to cisplatin, while its overexpression causes cisplatin resistance. Small interfering RNA (siRNA) knockdown of ERCC2 combined with cisplatin treatment may improve therapeutic outcomes in patients with bladder cancer. Here, we aimed to develop macrophage-derived mimetic nanovesicles (MNVs) as a nanoplatform for the simultaneous delivery of cisplatin and ERCC2 siRNA for enhancing the efficacy of bladder cancer chemotherapy. The cellular uptake, gene down-regulation, tumor inhibition effects, and biosafety of the synthesized nanodrugs (MNV-Co) as a synergistic therapeutic strategy for MIBC were evaluated in vitro and in vivo . The results indicated high efficacy of MNV-Co against MIBC and low off-tumor toxicity. Furthermore, by down-regulating ERCC2 mRNA and protein levels, MNV-Co improved chemosensitivity, promoted cancer cell apoptosis, and effectively suppressed tumor growth. This study presents a potential approach for delivering cisplatin and ERCC2 siRNA concurrently to treat bladder cancer using a biomimetic nanosystem.

Cell-free DNA Methylation as a Predictive Biomarker of Response to Neoadjuvant Chemotherapy for Patients with Muscle-invasive Bladder Cancer in SWOG S1314

BACKGROUND

Neoadjuvant chemotherapy (NAC) is the standard of care in muscle-invasive bladder cancer (MIBC). However, treatment is intense, and the overall benefit is small, necessitating effective biomarkers to identify patients who will benefit most.

OBJECTIVE

To characterize cell-free DNA (cfDNA) methylation in patients receiving NAC in SWOG S1314, a prospective cooperative group trial, and to correlate the methylation signatures with pathologic response at radical cystectomy.

DESIGN, SETTING, AND PARTICIPANTS

SWOG S1314 is a prospective cooperative group trial for patients with MIBC (cT2-T4aN0M0, ≥5 mm of viable tumor), with a primary objective of evaluating the coexpression extrapolation (COXEN) gene expression signature as a predictor of NAC response, defined as achieving pT0N0 or ≤pT1N0 at radical cystectomy. For the current exploratory analysis, blood samples were collected prospectively from 72 patients in S1314 before and during NAC, and plasma cfDNA methylation was measured using the Infinium MethylationEPIC BeadChip array.

INTERVENTION

No additional interventions besides plasma collection.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Differential methylation between pathologic responders (≤pT1N0) and nonresponders was analyzed, and a classifier predictive of treatment response was generated using the Random Forest machine learning algorithm.

RESULTS AND LIMITATIONS

Using prechemotherapy plasma cfDNA, we developed a methylation-based response score (mR-score) predictive of pathologic response. Plasma samples collected after the first cycle of NAC yielded mR-scores with similar predictive ability. Furthermore, we used cfDNA methylation data to calculate the circulating bladder DNA fraction, which had a modest but independent predictive ability for treatment response. In a model combining mR-score and circulating bladder DNA fraction, we correctly predicted pathologic response in 79% of patients based on their plasma collected at baseline and after one cycle of chemotherapy. Limitations of this study included a limited sample size and relatively low circulating bladder DNA levels.

CONCLUSIONS

Our study provides the proof of concept that cfDNA methylation can be used to generate classifiers of NAC response in bladder cancer patients.

PATIENT SUMMARY

In this exploratory analysis of S1314, we demonstrated that cell-free DNA methylation can be profiled to generate biomarker signatures associated with neoadjuvant chemotherapy response. With validation in additional cohorts, this minimally invasive approach may be used to predict chemotherapy response in locally advanced bladder cancer and perhaps also in metastatic disease.

Eph receptor B6 shapes a cold immune microenvironment, inhibiting anti-cancer immunity and immunotherapy response in bladder cancer

Background

The role of Eph receptors and related ephrin (EFN) ligands (as the largest family of transmembrane-bound RTKs) in immunomodulation in many types of cancer, especially bladder cancer (BLCA), is scarcely known.

Methods

A pan-cancer dataset was retrieved from The Cancer Genome Atlas (TCGA) to explore the relation between Eph receptor/EFN ligand family genes and immunomodulators and tumor-infiltrated immune cells (TIICs). Local BLCA, GSE32894, and GSE31684 cohorts were applied to validate. The IMvigor210 cohort was employed to explore the relationship between EPHB6 and immunotherapy response. Moreover, association between EPHB6 and molecular subtype was investigated to explore potential therapeutic strategies. Immunohistochemical staining of CD8 and CD68 was performed to validate the correlation between EPHB6 and TIICs.

Results

The pan-cancer analysis revealed variations in the immunological effects of Eph receptor/EFN ligand family genes across different types of cancer. EPHB6 expression negatively correlated with the expression of the majority of immunomodulators (including HLA and immune checkpoints), and CD8 T cells and macrophages in both the TCGA-BLCA and validation BLCA cohorts, shaping a cold immune microenvironment with inhibited immunity. In the IMvigor210 cohort, patients with high-EPHB6 highly correlated with a non-inflamed, low PD-L1 expression immune phenotype, and correspondingly, with less responders to immunotherapy. The high-EPHB6 group, enriched with the basal subtype, presented significantly fewer TP53 and more FGFR3 genomic alterations. Finally, a novel EPHB6-related Genes signature, with reliable and robust ability in prognosis prediction, was constructed.

Conclusions

This study comprehensively investigated the immunological effects of Eph receptor/EFN ligand family genes pan-cancer, and specially identified the immunosuppressive role of EPHB6 in BLCA. Furthermore, EPHB6 may predict the molecular subtype and prognosis of BLCA, and serve as a novel therapeutic target to improve the sensitivity of immunotherapy.

Predictive signature of response to neoadjuvant chemotherapy in muscle-invasive bladder cancer integrating mRNA expression, taxonomic subtypes, and clinicopathological features

Background and objective

Neoadjuvant chemotherapy (NAC) followed by cystectomy is the standard of care in muscle-invasive bladder cancer (MIBC). Pathological response has been associated with longer survival, but no currently available clinicopathological variables can identify patients likely to respond, highlighting the need for predictive biomarkers. We sought to identify a predictive signature of response to NAC integrating clinical score, taxonomic subtype, and gene expression.

Material and methods

From 1994 to 2014, pre-treatment tumor samples were collected from MIBC patients (stage T2-4N0/+M0) at two Spanish hospitals. A clinical score was determined based on stage, hydronephrosis and histology. Taxonomic subtypes (BASQ, luminal, and mixed) were identified by immunohistochemistry. A custom set of 41 genes involved in DNA damage repair and immune response was analyzed in 84 patients with the NanoString nCounter platform. Genes related to pathological response were identified by LASSO penalized logistic regression. NAC consisted of cisplatin/methotrexate/vinblastine until 2000, after which most patients received cisplatin/gemcitabine. The capacity of the integrated signature to predict pathological response was assessed with AUC. Overall survival (OS) and disease-specific survival (DSS) were analyzed with the Kaplan-Meier method.

Results

LASSO selected eight genes to be included in the signature (RAD51, IFNγ, CHEK1, CXCL9, c-MET, KRT14, HERC2, FOXA1). The highest predictive accuracy was observed with the inclusion in the model of only three genes (RAD51, IFNɣ, CHEK1). The integrated clinical-taxonomic-gene expression signature including these three genes had a higher predictive ability (AUC=0.71) than only clinical score plus taxonomic subtype (AUC=0.58) or clinical score alone (AUC=0.56). This integrated signature was also significantly associated with OS (p=0.02) and DSS (p=0.02).

Conclusions

We have identified a predictive signature for response to NAC in MIBC patients that integrates the expression of three genes with clinicopathological characteristics and taxonomic subtypes. Prospective studies to validate these results are ongoing.

Approaches to Clinical Complete Response after Neoadjuvant Chemotherapy in Muscle-Invasive Bladder Cancer: Possibilities and Limitations

In the surgical oncology field, the change from a past radical surgery to an organ preserving surgery is a big trend. In muscle-invasive bladder cancer treatment, neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is the standard of care for muscle-invasive bladder cancer (MIBC) patients eligible for cisplatin. There is a growing interest in bladder preserving strategies after NAC because good oncologic outcome has been reported for pathologic complete response (pCR) patients after NAC, and many studies have continued to discuss whether bladder preservation treatment is possible for these patients. However, in actual clinical practice, decision-making should be determined according to clinical staging and there is a gap that cannot be ignored between clinical complete response (cCR) and pCR. Currently, there is a lack in a uniform approach to post-NAC restaging of MIBC and a standardized cCR definition. In this review, we clarify the gap between cCR and pCR at the current situation and focus on emerging strategies in bladder preservation in selected patients with MIBC who achieve cCR following NAC.

Current and Future Landscape of Perioperative Treatment for Muscle-Invasive Bladder Cancer

Cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy is the current standard of care for muscle-invasive bladder cancer (MIBC). However, less than half of patients are candidates for this treatment, and 50% will develop metastatic disease. Adjuvant chemotherapy could be offered if neoadjuvant treatment has not been administered for suitable patients. It is important to reduce the risk of systemic recurrence and improve the prognosis of localized MIBC. Systemic therapy for metastatic urothelial carcinoma has evolved in recent years. Immune checkpoint inhibitors and targeted agents, such as antibody-drug conjugates or FGFR inhibitors, are new therapeutic alternatives and have shown their benefit in advanced disease. Currently, several clinical trials are investigating the role of these drugs, as monotherapy and in combination with chemotherapy, in the neoadjuvant and adjuvant settings with promising outcomes. In addition, the development of predictive biomarkers could predict responses to neoadjuvant therapies.

Predictive Biomarkers of Response to Neoadjuvant Therapy in Muscle Invasive Bladder Cancer

Neoadjuvant cisplatin-based chemotherapy is recommended prior to surgical removal of the bladder for patients with non-metastatic muscle invasive bladder cancer. Despite a survival benefit, approximately half of patients do not respond to chemotherapy and are exposed potentially unnecessarily to substantial toxicity and delay in surgery. Therefore, biomarkers to identify likely responders before initiating chemotherapy would be a helpful clinical tool. Furthermore, biomarkers may be able to identify patients who do not need subsequent surgery after clinical complete response to chemotherapy. To date, there are no clinically approved predictive biomarkers of response to neoadjuvant therapy. Recent advances in the molecular characterization of bladder cancer have shown the potential role for DNA damage repair (DDR) gene alterations and molecular subtypes to guide therapy, but these need validation from prospective clinical trials. This chapter reviews candidate predictive biomarkers of response to neoadjuvant therapy in muscle invasive bladder cancer.