Advanced bladder and urothelial cancers

Modified MVAC as a Second-Line Treatment for Patients with Metastatic Urothelial Carcinoma after Failure of Gemcitabine and Cisplatin Treatment

Purpose

There is no established standard second-line chemotherapy for patients with advanced or metastatic urothelial carcinoma (UC) who failed gemcitabine and cisplatin (GC) chemotherapy. This study was conducted in order to investigate the efficacy and toxicity of modified methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) in patients with metastatic UC previously treated with GC.

Materials and Methods

We retrospectively analyzed 28 patients who received modified MVAC between November 2004 and November 2012. All patients failed prior, first-line GC chemotherapy.

Results

The median age of patients was 64.0 years (range, 33.0 to 77.0 years), and 23 (82.1%) patients had an Eastern Cooperative Oncology Group performance status of 0 or 1. The overall response rate and the disease control rate were 36.0% and 64.0%, respectively. After a median follow-up period of 38 weeks (range, 5 to 182 weeks), median progression free survival was 21.0 weeks (95% confidence interval [CI], 6.3 to 35.7 weeks) and median overall survival was 49.0 weeks (95% CI, 18.8 to 79.3 weeks). Grade 3 or 4 hematological toxicities included neutropenia (n=21, 75.0%) and anemia (n=9, 32.1%). Grade 3 or 4 non-hematological toxicities did not occur and there was no treatment-related death.

Conclusion

Modified MVAC appears to be a safe and active chemotherapy regimen in patients with stable physical status and adequate renal function after GC treatment.

Hydroxyurea decreases gemcitabine resistance in pancreatic carcinoma cells with highly expressed ribonucleotide reductase

OBJECTIVES

This study aimed to determine whether the treatment of pancreatic carcinoma can be defined on the basis of the expression of genes involved in gemcitabine metabolism and whether combination treatment is more effective than conventional treatment.

METHODS

Four pancreatic carcinoma cell lines (Panc-1, MIAPaCa-2, BxPC-3, and Capan-2) were used to determine the patterns of gemcitabine-metabolizing genes and mesenchymal marker gene expressions using quantitative real-time polymerase chain reaction. Chemosensitivity and cell proliferation were measured using colorimetric assay. Gemcitabine was combined with hydroxyurea or small interfering RNA targeting ribonucleotide reductase to assess changes in chemoresistance.

RESULTS

Panc-1 and MIAPaCa-2 cell lines were profoundly chemoresistant and expressed genes corresponding to cells with distinct mesenchymal phenotypes. In addition, Panc-1 highly expressed ribonucleotide reductase and showed a 4-fold increase in gemcitabine sensitivity after treatment with hydroxyurea.

CONCLUSIONS

Combination treatment tailored to cells with highly expressed ribonucleotide reductase was more effective than treatment with gemcitabine alone. Moreover, phenotype and gemcitabine metabolism may independently confer chemoresistance.

Solitary skin metastasis from sarcomatoid carcinoma of the bladder: a case report

INTRODUCTION

Cutaneous metastases from carcinomas of the bladder are very rare. They are related to advanced stages of the disease and have poor prognosis with low survival rates. The common treatment modality of cutaneous metastases from a primary bladder cancer is wide local excision followed by chemotherapy.

CASE PRESENTATION

We report a case of solitary skin metastasis from a rare type of urinary bladder carcinoma in a 68 year-old Caucasian man. Urinary bladder carcinoma metastasizing to the skin is an uncommon finding despite the high incidence of this tumor. Skin metastasis generally presents in the late stages of this disease and indicates a poor outcome.

CONCLUSIONS

Because of the extremely aggressive malignant potential of sarcomatoid carcinomas, the indications for a transurethral resection of the bladder should be carefully assessed and suitable therapeutic strategies should be examined further.

Phase 2 trial of sorafenib in patients with advanced urothelial cancer: a trial of the Eastern Cooperative Oncology Group

BACKGROUND

There is no effective second-line systemic chemotherapy for patients with disease progression after cisplatin-based chemotherapy. A phase 2 trial of sorafenib was performed to determine the activity and toxicity of this agent in a multi-institutional setting in patients previously treated with 1 prior chemotherapy regimen.

METHODS

Twenty-seven patients with advanced urothelial carcinoma were treated with sorafenib 400 mg orally twice daily continuously until progression or unacceptable toxicity.

RESULTS

There were no objective responses observed. The 4-month progression-free survival (PFS) rate was 9.5%; median overall survival of the group was 6.8 months. There were no therapy-related deaths, and common grade 3 toxicities included fatigue and hand-foot syndrome.

CONCLUSIONS

Although sorafenib as a single agent has minimal activity in patients with advanced urothelial cancer in the second-line setting, further investigation of tyrosine kinase inhibitors using different trial designs with PFS endpoints is warranted.

Phase 2 trial of epothilone B analog BMS-247550 (ixabepilone) in advanced carcinoma of the urothelium (E3800)

BACKGROUND

Paclitaxel and docetaxel are active agents in advanced urothelial cancer. BMS-247550 (ixabepilone) has activity in preclinical models in paclitaxel resistant models. A phase 2 trial of this epothilone was performed to determine the activity and toxicity of this agent in a multi-institutional setting in patients previously treated with 1 prior chemotherapy regimen.

METHODS

Forty-five patients with advanced urothelial carcinoma were treated with BMS-247550 40 mg/m(2) over 3 hours intravenously on Day 1 of a 21-day cycle and continued therapy until progression or unacceptable toxicity.

RESULTS

Five patients obtained an objective partial response (PR) among the 42 eligible patients for an overall response rate of 11.9% (90% confidence interval [5.3%, 26.5%]). Median overall survival of the group was 8 months. Toxicity was moderate with granulocytopenia, fatigue, and sensory neuropathy being the most common side effects noted.

CONCLUSIONS

BMS-247550 (ixabepilone) has very modest activity as a second-line therapy for advanced urothelial cancer. Responses in visceral, nodal, and soft tissues sites were observed. Granulocytopenia without fever, fatigue, and sensory neuropathy was common.

Twenty-three years of disease-free survival following cutaneous metastasis from a primary bladder transitional cell carcinoma

We present a case of cutaneous metastases from a primary bladder transitional cell carcinoma (TCC), with a prolonged survival of 23 years. Cutaneous metastases from primary bladder TCC are uncommon and, like all metastases, have a poor prognosis. The common modality of treatment of cutaneous metastases from a primary bladder cancer is wide local excision of the metastases followed by combination chemotherapy. Here, we present a case of a solitary cutaneous metastasis from a primary bladder TCC, which was treated with wide local excision and single agent chemotherapy. Twenty-three years on, the patient remains disease and recurrence free.

Phase II trial of gemcitabine and docetaxel in patients with advanced carcinoma of the urothelium: a trial of the Eastern Cooperative Oncology Group

BACKGROUND

Gemcitabine and docetaxel are active agents in advanced urothelial carcinoma. A Phase II trial of this combination was performed to determine the activity and toxicity of these agents in a multiinstitutional setting in patients previously treated with one prior chemotherapy regimen.

METHODS

Twenty-nine eligible patients with advanced urothelial carcinoma were treated with docetaxel at a dose of 40 mg/m(2) over 1 hour followed by gemcitabine, 800 mg/m(2), over 30 minutes, both intravenously (i.v.) on Days 1 and 8. Cycles were repeated every 21 days until disease progression or a maximum of 6 cycles.

RESULTS

Five patients obtained an objective response for an overall response rate of 17% (90% confidence interval, 7-33%). One patient achieved a complete clinical response. The median overall survival of the group was 7.7 months. Toxicity was moderate with granulocytopenia, anorexia, and fatigue being the most commonly noted side effects.

CONCLUSIONS

Gemcitabine and docetaxel is an active second-line combination in patients with advanced urothelial carcinoma. Responses in visceral, lymph node, and soft tissues sites were observed. Granulocytopenia without fever, fatigue, and anorexia was common. Thromboembolic symptoms were reported and are of concern. The combination of gemcitabine and docetaxel has the potential to palliate a subset of previously treated patients with an adequate performance status.

Novel gemcitabine-containing triplets in the management of urothelial cancer

Chemotherapy has been the cornerstone of treatment of advanced urothelial cancer. For a decade, the combination regimen of methotrexate/vinblastine/doxorubicin/cisplatin has been considered the standard for these patients. The need for improved efficacy and reduced toxicity of a predominantly palliative therapy has propelled efforts for new drug development. Of the newly identified agents with documented activity, both gemcitabine and paclitaxel have been evaluated with a platinum and have been incorporated into multiagent chemotherapy combinations. Phase II data from two gemcitabine-based triplets are currently available. Combination gemcitabine/paclitaxel/cisplatin and gemcitabine/paclitaxel/carboplatin have high levels of activity with overall and complete response rates of 76% and 26%, respectively, for the former and 68% and 32%, respectively, for the latter combination. The role of gemcitabine-based multiagent combinations compared with standard therapy awaits evaluation in prospectively randomized trials.

Second-line treatment of advanced transitional cell carcinoma of the urothelial tract

Cisplatin-based combination chemotherapy such as methotrexate, vinblastine, adriamycin and cisplatin produces durable improvements in survival in only a minority of patients. Therefore, other therapeutic options and strategies are clearly needed. Strategies include increasing the dose of chemotherapy, modifying the sequencing of chemotherapy, and new therapeutic agents. This paper reviews recent work on high-dose chemotherapy, currently available chemotherapeutic agents and combinations, with an emphasis on gemcitabine and the taxanes. New strategies such as monoclonal antibody therapy and molecular targeted small molecule therapy are becoming a reality in the treatment of many diseases. The rationale for using epidermal growth factor receptor targeted therapies is also reviewed.