Targeted therapies in the treatment of urothelial cancers

Health-related quality of life in the randomized phase 3 study of ramucirumab plus docetaxel versus placebo plus docetaxel in platinum-refractory advanced urothelial carcinoma (RANGE)

BACKGROUND

To evaluate patient-reported outcomes with ramucirumab plus docetaxel, a regimen which improved progression-free survival in platinum-refractory advanced urothelial carcinoma (aUC).

METHODS

RANGE-a randomized, double-blinded, phase 3 trial in patients with platinum-refractory aUC. Ramucirumab (10 mg/kg) plus docetaxel (75 mg/m2) or placebo plus docetaxel were administered every 21 days until disease progression or unacceptable toxicity. Patients received maximum 10 cycles of docetaxel. European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) and EuroQoL five-dimensions (EQ-5D-5L) were administered at baseline, start of each cycle, and 30-day follow-up visit. A ≥ 10-point change in QLQ-C30 scores was considered meaningful. Rates of improved/stable scores were compared between treatment arms using Fisher's exact test. Time to deterioration (TtD) was estimated and compared using Kaplan-Meier estimation and log-rank test.

RESULTS

Of the 530 patients, ~ 97% patients in each arm provided baseline QLQ-C30 data. On-treatment compliance was ≥ 88% for first 8 cycles. Mean baseline QLQ-C30 scores were similar between arms, with global quality of life (QoL), fatigue, pain, and insomnia having greatest impairment. Postbaseline rates of improved/stable QLQ-C30 scores were similar between treatment arms except for greater improvement in pain score with ramucirumab. TtD of QLQ-C30 scales favored ramucirumab arm. Baseline EQ-5D-5L index and visual analogue scale scores were similar between arms, followed by relatively stable on-treatment scores. EQ-5D-5L scores worsened at post-discontinuation follow-up visit.

CONCLUSIONS

Ramucirumab plus docetaxel did not negatively impact QoL compared with docetaxel alone in platinum-refractory aUC. Improved TtD and tumor associated rates of pain favored ramucirumab treatment.

CLINICAL TRAIL REGISTRATION

NCT02426125. https://clinicaltrials.gov/ct2/show/NCT02426125 . Date of registration: April 24th 2015.

Immunotherapy in Bladder Cancer: Current Methods and Future Perspectives

Bladder cancer is one of the most significant genitourinary cancer, causing high morbidity and mortality in a great number of patients. Over the years, various treatment methods for this type of cancer have been developed. The most common is the highly efficient method using Bacillus Calmette-Guerin, giving a successful effect in a high percentage of patients. However, due to the genetic instability of bladder cancer, together with individual needs of patients, the search for different therapy methods is ongoing. Immune checkpoints are cell surface molecules influencing the immune response and decreasing the strength of the immune response. Among those checkpoints, the PD-1 (programmed cell death protein-1)/PD-L1 (programmed cell death protein ligand 1) inhibitors aim at blocking those molecules, which results in T cell activation, and in bladder cancer the use of Atezolizumab, Avelumab, Durvalumab, Nivolumab, and Pembrolizumab has been described. The inhibition of another pivotal immune checkpoint, CTLA-4 (cytotoxic T cell antigen), may result in the mobilization of the immune system against bladder cancer and, among anti-CTLA-4 antibodies, the use of Ipilimumab and Tremelimumab has been discussed. Moreover, several different approaches to successful bladder cancer treatment exists, such as the use of ganciclovir and mTOR (mammalian target of rapamycin) kinase inhibitors, IL-12 (interleukin-12) and COX-2 (cyclooxygenase-2). The use of gene therapies and the disruption of different signaling pathways are currently being investigated. Research suggests that the combination of several methods increases treatment efficiency and the positive outcome in individual.

Protosappanin B promotes apoptosis and causes G1 cell cycle arrest in human bladder cancer cells

The aim of the study was to investigate the effects of protosappanin B on the proliferation and apoptosis of bladder cancer cells. The effects of protosappanin B (12.5, 25, 50, 100, or 200 μg/mL, 48 h) on proliferation of SV-HUC-1, T24 and 5637 cells was assessed using the MTT assay. The effects of protosappanin B (100, 150, 200, 250, or 300 μg/mL, 48 h) on cell apoptosis and cell cycle were analyzed using flow cytometry. T24 and 5637 cells treated with 200 µg/mL protosappanin B showed morphological changes (shrinkage, rounding, membrane abnormalities, and reduced adhesion), but protosappanin B had no proliferation arrest effect on SV-HUC-1 cells. Protosappanin B caused concentration-dependent inhibition of cell growth, with IC₅₀ of 82.78 µg/mL in T24 cells and 113.79 µg/mL in 5637 cells. Protosappanin B caused concentration-dependent increases in T24 and 5637 cell apoptosis (100–300 µg/mL). The effects of protosappanin B on the cell cycle in both cell types was G₁ arrest with reductions in the proportion of S-phase cells and proliferation index. A proteomics analysis showed that protosappanin B modulated a number of genes involved in the cell cycle. In conclusion, protosappanin B inhibits the proliferation and promotes the apoptosis of T24 and 5637 human bladder cancer cells in a concentration-dependent manner, possibly via interference with cell cycle regulation, preventing G₁-to-S transition.

MicroRNA-325 Is a Potential Biomarker and Tumor Regulator in Human Bladder Cancer

Purpose:

We evaluated whether human microRNA-325 may be a potential biomarker and tumor regulator in bladder cancer.

Methods:

Human microRNA-325 expression was probed by quantitative real-time polymerase chain reaction in both in vitro bladder cancer cell lines and in vivo bladder carcinoma tissues retrieved from patients with cancer. The prognostic potential of human microRNA-325 in predicting postoperative overall survival of patients with bladder cancer was estimated. Endogenous human microRNA-325 was overexpressed by lentiviral transduction in bladder cancer cell lines, T24 and 5637 cells. The tumor regulatory effects of human microRNA-325 upregulation on T24 and 5637 cells were evaluated both in vitro and in vivo.

Results:

Human microRNA-325 was aberrantly downregulated in both bladder cell lines and human bladder carcinomas. Lowly expressed human microRNA-325 in bladder carcinoma was closely associated with poor postoperative overall survival of patients with cancer. In T24 and 5637 cells, virally transduced cells had markedly upregulated human microRNA-325 expressions. Biochemical assays demonstrated that human microRNA-325 upregulation in bladder cancer had tumor-suppressive functions by decreasing cancer proliferation, cisplatin chemoresistance, and cancer migration in vitro and hindering transplantation growth in vivo and cell cycle transition.

Conclusion:

Human microRNA-325 is lowly expressed and may serve as a potential prognostic biomarker in human bladder cancer. After further validation, human microRNA-325 may be a novel therapeutic target for suppressing carcinoma in patients with bladder cancer.

Monoclonal Antibodies for the Treatment of Multiple Myeloma: An Update

The past two decades have seen a revolution in multiple myeloma (MM) therapy with the introduction of several small molecules, mostly orally effective, whose mechanisms are based on proteasome inhibition, histone deacetylase (HDAC) blockade, and immunomodulation. Immunotherapeutic approaches to MM treatment using monoclonal antibodies (mAbs), while long in development, began to reap success with the identification of CD38 and SLAMF7 as suitable targets for development, culminating in the 2015 Food and Drug Administration (FDA) approval of daratumumab and elotuzumab, respectively. This review highlights additional mAbs now in the developmental pipeline. Isatuximab, another anti-CD38 mAb, currently is under study in four phase III trials and may offer certain advantages over daratumumab. Several antibody-drug conjugates (ADCs) in the early stages of development are described, including JNJ-63723283, which has attained FDA breakthrough status for MM. Other mAbs described in this review include denosumab, recently approved for myeloma-associated bone loss, and checkpoint inhibitors, although the future status of the latter combined with immunomodulators has been clouded by unacceptably high death rates that caused the FDA to issue clinical holds on several of these trials. Also highlighted are the therapies based on the B Cell Maturation Antigen (BCMA), another very promising target for anti-myeloma development.

Emerging biomarkers and targeted therapies in urothelial carcinoma

The use of immunotherapy has revolutionized the management of patients with locally advanced, unresectable, and metastatic urothelial carcinoma (UC); however, platinum-based chemotherapy remains a therapeutic cornerstone both in localized muscle-invasive and advanced UC. There is still no predictive molecular biomarker with clinical utility to help guide treatment and select patients most likely to derive benefit from a particular therapeutic modality or regimen. However, recent research has further characterized the inherent biology and immunology landscapes of UC leading to the development of potential biomarkers and therapeutic targets that could be used upon further validation. Emerging interrogation of The Cancer Genome Atlas (TCGA) and other molecular profiling datasets has led to the identification of distinct molecular subtypes with diverse clinical behaviors with potential sensitivity to various therapies. It has also led to the discovery of multiple frequently altered genes and proteins that could lead to perturbation of intracellular signaling pathways and of the dynamic interactions between tumor cells, their "microenvironment", and the host "macro-environment". The advent of molecular profiling and deeper next-generation sequencing has the potential to change biomarker and "real time" drug sensitivity assessment, introducing and testing the premise of "precision oncology" and personalized medicine. Within this review, we summarize emerging biomarkers that may predict response to cisplatin-based chemotherapy, immunotherapy, emerging targeted therapies, and promising combination strategies. We also highlight a few examples of 'precision medicine' trials aiming to improve outcomes in UC. Since our review is not exhaustive we strongly recommend the readers to follow the continuously changing literature in the very interesting and dynamic field of UC.

Challenges and advances in the diagnosis, biology, and treatment of urothelial upper tract and bladder carcinomas

Urothelial carcinomas span the bladder, ureter, and renal pelvis, and while there had been stagnation in the field of drug approval for the past two decades, there is now accelerated and regular US FDA approval of 5 immunotherapy agents. However, patients who inherently do not respond or progress on such therapies still represent an area of increased unmet need. In this special Seminars issue, we explore varying aspects of bladder urothelial carcinoma treatment with targeted therapies, the unique presentation and challenges in the treatment of upper tract and renal pelvis tumors, as well as new and emerging diagnostic imaging tools for varying genitourinary cancers.

Precision medicine for urothelial bladder cancer: update on tumour genomics and immunotherapy

Effective management of advanced urothelial bladder cancer is challenging. New discoveries that improve our understanding of molecular bladder cancer subtypes have revealed numerous potentially targetable genomic alterations and demonstrated the efficacy of treatments that harness the immune system. These findings have begun to change paradigms of bladder cancer therapy. For example, DNA repair pathway mutations in genes such as ERCC2, FANCC, ATM, RB1, and others can predict responses to neoadjuvant platinum-based chemotherapies and to targeted therapies on the basis of mutation status. Furthermore, an increasing number of pan-cancer clinical trials (commonly referred to as basket or umbrella trials) are enrolling patients on the basis of molecular and genetic predictors of response. These studies promise to provide improved insight into the true utility of personalized medicine in the treatment of bladder cancer and many other cancer types. Finally, therapies that modulate immune responses have shown great benefit in many cancer types. Several immune checkpoint inhibitors that target programmed cell death protein 1 (PD1), its ligand PDL1, and cytotoxic T lymphocyte-associated protein 4 (CTLA4) have already been approved for use in bladder cancer, representing the most important change to the urological oncologist's tool-kit in over a decade. These advances also provide opportunities for personalization of bladder cancer therapy.