Chemotherapy and cystectomy for invasive transitional cell carcinoma of bladder

Evolving Role of Adjuvant Systemic Therapy for Kidney and Urothelial Cancers

The role of adjuvant therapy in renal cell carcinoma and urothelial carcinoma is rapidly evolving. To date, the U.S. Food and Drug Administration has approved sunitinib and pembrolizumab in the adjuvant setting for renal cell carcinoma and nivolumab for urothelial carcinoma based on disease-free survival benefit. The U.S. Food and Drug Administration held a joint workshop with the National Cancer Institute and the Society of Urologic Oncology in 2017 to harmonize design elements, including eligibility and radiologic assessments across adjuvant trials in renal cell carcinoma and urothelial carcinoma. Considerations from the discussion at these workshops led the U.S. Food and Drug Administration to draft guidances to help inform subsequent adjuvant trial design for renal cell carcinoma and urothelial carcinoma. Patient-centered decision-making is crucial when determining therapeutic choices in the adjuvant setting; utility functions can be used to help quantify each patient's goals, values, and risk/benefit trade-offs to ensure that the decision regarding adjuvant therapy is informed by their preferences and the evolving outcomes data.

New and promising strategies in the management of bladder cancer

Bladder cancer is a complex and aggressive disease for which treatment strategies have had limited success. Improvements in detection, treatment, and outcomes in bladder cancer will require the integration of multiple new approaches, including genomic profiling, immunotherapeutics, and large randomized clinical trials. New and promising strategies are being tested in all disease states, including nonmuscle-invasive bladder cancer (NMIBC), muscle-invasive bladder cancer (MIBC), and metastatic urothelial carcinoma (UC). Efforts are underway to develop better noninvasive urine biomarkers for use in primary or secondary detection of NMIBC, exploiting our genomic knowledge of mutations in genes such as RAS, FGFR3, PIK3CA, and TP53 and methylation pathways alone or in combination. Recent data from a large, randomized phase III trial of adjuvant cisplatin-based chemotherapy add to our knowledge of the value of perioperative chemotherapy in patients with MIBC. Finally, bladder cancer is one of a growing list of tumor types that respond to immune checkpoint inhibition, opening the potential for new therapeutic strategies for treatment of this complex and aggressive disease.

Recent advances in the treatment of bladder cancer

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

Clinical factors determining the efficacy of urinary bladder tumour treatments in dogs: surgery, chemotherapy or both?

In a study of 44 canine patients suffering from histopathologically proven urinary bladder tumour with a high incidence of transitional cell carcinoma (TCC) (n = 35), a close relationship was found either between the disease-free period and the age (r = -0.40) of animals or between the survival times and the age (r = -0.62) of animals after treatment. In addition to the dog breeds known to be prone to have urinary bladder tumour, we found an additional potentially sensitive breed, the Hungarian Vizsla. The median survival times obtained by the applied treatment types were as follow: 'surgery and chemotherapy' (n = 8/44) 475 days, 'surgery alone' (n = 19/44) 240 days, 'chemotherapy alone' (n = 7/44) 31 days, and 'no treatment' (n = 10/44) 7 days (P < 0.001). According to the findings, chemotherapy combined with surgery completed in time is the most effective protocol in the treatment of urinary bladder tumour cases in dogs. A rational and more effective procedure for the assessment and treatment of urinary bladder tumour cases is presented.

Effectiveness of Adjuvant Chemotherapy in Transitional Cell Carcinoma of the Urinary Bladder with Lymph Node Involvement and/or Lymphovascular Invasion Treated by Radical Cystectomy

OBJECTIVES

To assess the effect of adjuvant chemotherapy on the postoperative survival of patients with transitional cell carcinoma of the bladder and lymph node involvement and/or lymphovascular invasion (LVI).

METHODS

We retrospectively analyzed the data from 260 patients who had undergone radical cystectomy for transitional cell carcinoma of the bladder. Of these 260 patients, 85 (33%) had nodal involvement and 125 (48%) had LVI. Chemotherapy, consisting of three to six cycles of either methotrexate, vinblastine, cisplatin, and doxorubicin or gemcitabine and cisplatin, was administered to 17 (26.6%) of 64 patients with pT3-4N0 disease and 43 (50.6%) of 85 patients with node-positive disease. We determined the factors influencing cancer-specific survival and the effect of chemotherapy according to pathologic stage, LVI, and nodal status. The mean follow-up was 43.8 months (range, 3 to 180; median 33.6).

RESULTS

The overall 5-year cancer-specific survival rate was 65.6%. When we considered nodal involvement and LVI simultaneously, the 5-year survival rate was 92.2% for the node and LVI-negative patients, 60.7% for the node-negative but LVI-positive patients, and 32.5% for the node-positive patients. Chemotherapy was beneficial in the node-positive patients (5-year survival rate of 37.4% versus 26.9%; P = 0.0035) but not beneficial in the node-negative patients, regardless of LVI status. When subclassifying node-positive patients with regard to N stage or LVI status, the effect of chemotherapy was limited to those with Stage N2 (P = 0.002) or LVI-positive status (P = 0.001).

CONCLUSIONS

Adjuvant chemotherapy would be beneficial in patients with node-positive transitional cell carcinoma, especially those with a high nodal disease burden (Stage N2) or LVI, after radical cystectomy.

Systemic chemotherapy for advanced bladder cancer: update and controversies

Despite improvements in surgical techniques and outcomes, 5-year survival rates for patients with muscle-invasive bladder cancer remain suboptimal. Almost 50% of patients will eventually progress and develop systemic disease. Although various single agents have shown activity in patients with advanced or metastatic disease, randomized trials have demonstrated the utility of cisplatin-based combinations regimens. Despite relatively high objective response rates, the impact on survival in patients with advanced disease has been quite limited. Surgical resection in selected patients achieving significant objective response to cytotoxic therapy can contribute to long-term survival rates. The role of salvage therapy in advanced disease remains undefined. Evaluation of several active compounds has yielded unimpressive results with low objective response rates and overlapping CIs. Recognition that the maximum benefit from conventional cytotoxics has been achieved has led to the recent initiation of a number of clinical trials evaluating targeted agents in the management of advanced urothelial cancer.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Cancer Specific Outcomes in Patients With PT0 Disease Following Radical Cystectomy

PURPOSE

We assessed clinical outcomes in patients found to have no evidence of disease, ie pT0, in the cystectomy specimen following radical cystectomy for transitional cell carcinoma.

MATERIALS AND METHODS

Between 1984 and 2003, 955 consecutive patients underwent bilateral pelvic lymphadenectomy and radical cystectomy for bladder cancer at 3 institutions, namely The Johns Hopkins Hospital, University of Texas Southwestern Medical Center and Baylor College of Medicine. Excluding nonTCC histology and patients with missing data resulted in 888 evaluable cases. Primary end points were recurrence-free survival and bladder cancer specific survival.

RESULTS

Final pathological evaluation revealed absent transitional cell carcinoma in the cystectomy specimen, ie pT0, in 59 patients (7%), of whom 2 (3%) had pathologically positive lymph nodes. Transurethral resection stage or clinical stage data were available on 56 patients (95%), including Tis in 5 (9%), Ta in 2 (4%), T1 in 18 (32%), T2 in 29 (52%) and T3 in 2 (4%). Overall 6 recurrences (10%) were noted, including cTis in 1 case, cT1 in 1, cT2 in 3 and cT3 in 1. Median followup in patients with pT0 disease was 56 months (range 3 to 183). Three patients (5%) died of bladder cancer and another 4 (7%) died of other causes. Five and 10-year bladder cancer progression-free and cancer specific survival estimates in patients with pT0 disease were 90% and 81%, and 95% and 85%, respectively.

CONCLUSIONS

Despite excellent clinical outcomes in the majority of patients with no evidence of tumor on final pathological evaluation not all patients with pT0 disease in the cystectomy specimen are cured of bladder cancer. These events may even occur in patients with nonmuscle invasive or muscle invasive organ confined pathology at staging transurethral resection. Further study is needed to identify prognostic factors in this population.

Intravenously administered vitamin C as cancer therapy: three cases

Early clinical studies showed that high-dose vitamin C, given by intravenous and oral routes, may improve symptoms and prolong life in patients with terminal cancer. Double-blind placebo-controlled studies of oral vitamin C therapy showed no benefit. Recent evidence shows that oral administration of the maximum tolerated dose of vitamin C (18 g/d) produces peak plasma concentrations of only 220 micromol/L, whereas intravenous administration of the same dose produces plasma concentrations about 25-fold higher. Larger doses (50-100 g) given intravenously may result in plasma concentrations of about 14,000 micromol/L. At concentrations above 1000 micromol/L, vitamin C is toxic to some cancer cells but not to normal cells in vitro. We found 3 well-documented cases of advanced cancers, confirmed by histopathologic review, where patients had unexpectedly long survival times after receiving high-dose intravenous vitamin C therapy. We examined clinical details of each case in accordance with National Cancer Institute (NCI) Best Case Series guidelines. Tumour pathology was verified by pathologists at the NCI who were unaware of diagnosis or treatment. In light of recent clinical pharmacokinetic findings and in vitro evidence of anti-tumour mechanisms, these case reports indicate that the role of high-dose intravenous vitamin C therapy in cancer treatment should be reassessed.

Antisense oligodeoxynucleotide therapy for bladder cancer: recent advances and future prospects

Despite remarkable progress in therapeutic options for the management of bladder cancer, it remains a challenge for urologists to achieve successful outcomes in the treatment of both superficial and invasive bladder cancers. In this review, recent advances in the field of antisense oligodeoxynucleotide therapy targeting several genes playing functionally important roles in the progression and recurrence of bladder cancer are summarized. Data showing the synergistic antitumor activities of antisense oligodeoxynucleotide therapy, combined with several treatments, including cytotoxic chemotherapy, radiation and other molecular targeting therapies, are also presented. Finally, the future direction of antisense oligodeoxynucleotide therapy in the therapeutic strategy of bladder cancer is discussed. These findings may help clarify the significance of antisense oligodeoxynucleotide therapy as an attractive alternative to conventional strategies.

Treatment of muscle-invasive bladder cancer: progress and new challenges

The management of muscle-invasive bladder cancer has evolved over the last 20 years. Radical surgery, while curative for a significant number of patients, is inadequate for a subgroup with aggressive features including, but not limited to, advanced local stage, lymphovascular invasion on transurethral resection specimen, or variant histology such as small cell carcinoma. It is now clear that chemotherapy can improve the outcome for such patients. Combination platinum-based neoadjuvant chemotherapy is associated with a survival advantage of 5-8% at 5 years over local therapy alone. Improvements in surgical technique are also important and need to be further refined. Biologic-based staging and targeted therapies hold promise for the future. The critical issue in multimodal therapy for this very heterogeneous disease is individualized patient selection. In this review, data are presented with emphasis on the practical application of current knowledge to the management of patients with muscle-invasive bladder cancer.

Evaluation for Surrogacy of End Points by Using Data from Observational Studies: Tumor Downstaging for Evaluating Neoadjuvant Chemotherapy in Invasive Bladder Cancer

PURPOSE

In clinical cancer trials for evaluating neoadjuvant chemotherapy, tumor downstaging is frequently used as a surrogate end point for overall survival. We evaluated the surrogacy of tumor downstaging using data from a follow-up observational study in bladder cancer.

EXPERIMENTAL DESIGN

A total of 586 patients (from 32 Japanese hospitals) who underwent radical cystectomy for invasive bladder cancer (clinical T2 to T4) between 1990 and 2000 were analyzed. We considered changes over time in clinical stage at diagnosis and pathologic stage at cystectomy as a surrogate end point, and survival time after cystectomy as a true end point. First, we developed a new criterion for tumor downstaging. Second, we statistically evaluated surrogacy for the criterion using Prentice's criteria.

RESULTS

To develop the criterion of end points based on tumor downstaging, we selected the best classification among all possible classifications in an attempt to separate prognosis for patients. The hazard ratios after adjustment for prognostic factors in the intermediate effect patients and the poor effect patients were 1.9 (95% confidence interval, 1.0-3.7) and 5.0 (95% confidence interval, 2.6-9.8), respectively, compared with that in the good effect patients. The conditions for correlation and conditional independency of Prentice's criteria were satisfied approximately. Neoadjuvant chemotherapy has a statistically significant tumor downstaging effect, whereas there was no difference on survival between treatment groups.

CONCLUSIONS

The tumor downstaging effect could be an appropriate intermediate end point for screening novel neoadjuvant chemotherapy for invasive bladder cancer. The dataset from follow-up studies were useful for evaluating the surrogacy of end points.

Bladder cancer

PURPOSE OF REVIEW

This article reviews the recent literature concerning important issues in the management of patients with bladder cancer. A brief overview of all aspects of bladder cancer including the etiology, diagnosis, and treatment are discussed with a focus on recent advances.

RECENT FINDINGS

Bladder cancer is a significant cause of morbidity and mortality. The treatment for bladder cancer should be based on individual patient risk assessment and should include a multidisciplinary approach. In patients with superficial bladder cancer, research has focused on improving and optimizing intravesical therapy to reduce tumor recurrence and progression as well as on methods to better select the most appropriate treatment for patients with high-risk features. The important prognostic and therapeutic role of lymphadenectomy during radical cystectomy has become apparent and recent work has attempted to better define what should be considered the standard for lymph node dissection. Finally, in an attempt to improve survival, advances have been made using systemic chemotherapy in both the perioperative settings as well as for treatment of metastatic bladder cancer.

SUMMARY

Research continues to improve our understanding of bladder cancer. This ongoing investigation is currently being translated to the bedside with refinements in the diagnosis and treatment of patients with bladder cancer.

Adjuvant and Neoadjuvant Chemotherapy in Muscle Invasive Bladder Cancer: Literature Review

Radical cystectomy is the standard treatment for patients with clinically localized muscle invasive bladder cancer, providing a 5-year survival rate of approximately 50%. Failure to cure is often due to the presence of occult metastases beyond the margins of local therapy, indicating a need for eradication of micrometastatic disease with systemic treatment, in order to improve survival. Combined chemotherapy regimens, such as methotrexate-vinblastine-cisplatin (CMV), methotrexate-vinblastine-cisplatin-doxorubicin (M-VAC) and gemcitabine-cisplatin (GC) have already demonstrated their effectiveness in patients with advanced or metastatic disease and have been considered as appropriate regimens in the peri-operative setting. Large randomized studies with a prolonged follow-up have been able to confirm a modest survival benefit with neoadjuvant therapy. A recent meta-analysis, including all previous reported randomized trials, concluded that neoadjuvant chemotherapy administration provides a significant survival benefit and can be administered without adverse outcomes resulting from delayed local therapy. Adjuvant chemotherapy trials, although promising, have failed to show statistically improved survival, mostly due to small sample sizes and absent or inconclusive data on overall survival. A multi-center randomized-controlled trial is currently ongoing, in order to elucidate the role of post-operative chemotherapy administration.

Metastasis markers in bladder cancer: a review of the literature and clinical considerations

Cancer invasion and metastasis develop through a sequence of processes involving loss of cell-cell and cell-matrix adhesions, proteolysis and induction of angiogenesis. We reviewed the current literature on the molecules that have been shown to play a significant role in these three steps of metastatisation in bladder cancer (BC) cells and their host microenvironment. Particular emphasis was given to markers that are assessable through immunohistochemistry and for which an additional prognostic value over the TNM variables has been recognized, in order to identify a subset of tumour markers readily available for application in daily clinical practice. We conclude that markers such as E-cadherin, Sialosyl-LeX, laminin, collagen IV, TSP-1 and MVD are useful prognostic markers, alpha, beta, and gamma catenin, MMP-2 and -9, uPAR, PD-ECGF and Bfgf can be considered potentially useful, while research on CD44, MMP-1 and -3, uPA, cathepsin D and VEGF has proved inconclusive. Further research in this field should concentrate on the molecules listed in the first group.