Intravesical therapies for bladder cancer - indications and limitations

An evaluation of durvalumab across the spectrum of urothelial carcinoma

INTRODUCTION

Urothelial carcinoma is a common malignancy affecting the urinary system, with the spectrum of disease encompassing non-muscle invasive, muscle-invasive and metastatic disease. On a background of almost half a century of immunogenic management with BCG, various immune checkpoint inhibitors, including durvalumab, have now demonstrated clinical efficacy in the treatment of urothelial carcinoma.

AREAS COVERED

This article reviews the available literature on durvalumab in the treatment of urothelial carcinoma for all stages of the disease including mechanisms of action, pharmacokinetics, efficacy and safety and covers a broad portfolio of reported and ongoing trials.

EXPERT OPINION

The management of UC is rapidly evolving, which is reflected in the diverse range of upcoming pivotal trials incorporating durvalumab with additional immunomodulatory agents and therapeutics targeting key oncogenic pathways, each with the potential to change the standard of care. As the complexity of UC management increases, future efforts should be directed at identifying better predictive biomarkers and selecting rational synergistic combinations from the novel treatments available. This will allow the addressing of existing gaps, facilitate the exploitation of new techniques of treatment delivery and ultimately deliver more personalized and efficacious care to the individual patient.

Mathematical model of MMC chemotherapy for non-invasive bladder cancer treatment

Mitomycin-C (MMC) chemotherapy is a well-established anti-cancer treatment for non-muscle-invasive bladder cancer (NMIBC). However, despite comprehensive biological research, the complete mechanism of action and an ideal regimen of MMC have not been elucidated. In this study, we present a theoretical investigation of NMIBC growth and its treatment by continuous administration of MMC chemotherapy. Using temporal ordinary differential equations (ODEs) to describe cell populations and drug molecules, we formulated the first mathematical model of tumor-immune interactions in the treatment of MMC for NMIBC, based on biological sources. Several hypothetical scenarios for NMIBC under the assumption that tumor size correlates with cell count are presented, depicting the evolution of tumors classified as small, medium, and large. These scenarios align qualitatively with clinical observations of lower recurrence rates for tumor size ≤ 30[mm] with MMC treatment, demonstrating that cure appears up to a theoretical x[mm] tumor size threshold, given specific parameters within a feasible biological range. The unique use of mole units allows to introduce a new method for theoretical pre-treatment assessments by determining MMC drug doses required for a cure. In this way, our approach provides initial steps toward personalized MMC chemotherapy for NMIBC patients, offering the possibility of new insights and potentially holding the key to unlocking some of its mysteries.

Comparing fluorodeoxyglucose positron emission tomography with computed tomography in staging for nodal and distant metastasis in urothelial/bladder cancer

Objectives

We aim to assess the clinical value of 18F-fluorodeoxyglucose positron (18F-FDG-PET) scan in detecting nodal and distant metastasis compared with computed tomography (CT) scan in patients with urothelial carcinoma or bladder cancer, aiming to improve staging accuracy and thereby better prognosticate and determine therapy.

Methods

A retrospective review of 75 patients with invasive bladder cancer (≥T1) who were staged with both CT and 18F-FDG-PET within an 8-week interval was performed for the period between 2015 and 2020. Seventy-two per cent (54/75) had formal pelvic lymph node (LN) dissection or biopsy of lesions suspicious for metastases. FDG-PET definitions for positive sites were assessed depending on SUV Max (nodes with SUVmax >4 at any size, SUV > 2 for lymph nodes >8 mm, or any SUV if the lymph node was >10 mm on axial images). For CT scanning, enlarged LN by RECIST 1.1 criteria (>10 mm) as well as qualitative findings suggesting metastasis were considered positive. The analysis was based on the comparison of CT and 18F-FDG-PET findings to histopathology results from LN dissection or biopsies.

Results

Sensitivity, specificity, positive predictive values (PPV) and negative predictive value (NPV) of CT versus FDG-PET for detecting metastasis, in patients who underwent pelvic LN dissection or biopsy of lesions suspicious of metastases, were 46.6% (95% CI: 21%-70%) versus 60% (95% CI: 32%-84%), 100% (95% CI: 91%-100%) versus 83.78% (95% CI: 69%-94%), 100% (95% CI: 63%-100%) versus 60% (95% CI: 32%-84%), and 82.2% (95% CI: 68%-92%) versus 83.78% (95% CI: 69%-94%), respectively. 7/75 (9.3%) patients avoided cystectomy due to 18F-FDG-PET features of metastases that were not detected by CT.

Conclusion

FDG-PET may be more sensitive than CT for metastases in the staging of bladder cancer, which resulted in significant avoidance of aggressive local management in cases with occult metastasis.

Diminished Short-Term Efficacy of Reduced-Dose Induction BCG in the Treatment of Non-Muscle Invasive Bladder Cancer

The ongoing Bacillus Calmette-Guérin (BCG) shortage has created challenges for the treatment of non-muscle invasive bladder cancer (NMIBCa). Our objective was to evaluate the efficacy of reduced-dose induction BCG (RD-iBCG) compared to full-dose induction BCG (FD-iBCG) regarding recurrence rates. We hypothesized that patients receiving RD-iBCG may recur at a higher rate compared to those who received FD-iBCG therapy. A retrospective review of all patients with NMIBCa treated with intravesical therapy at our institution between 2015-2020 was conducted. Inclusion criteria consisted of having a diagnosis of AUA intermediate or high-risk NMIBCa with an indication for a six-week induction course of FD or RD-BCG with at least 1 year of documented follow up. The data were censored at one year. Propensity score matching for age, sex, tumor pathology, and initial vs. recurrent disease was performed. The primary endpoint was bladder cancer recurrence, reported as recurrence-free survival. A total of 254 patients were reviewed for this study. Our final cohort was 139 patients after exclusion. Thirty-nine percent of patients had HGT1 disease. 38.6% of patients receiving RD-BCG developed a recurrence of bladder cancer within a one-year follow-up as compared to 33.7% of patients receiving FD therapy. After propensity matching, this value remained statistically significant (p = 0.03). In conclusion, RD-iBCG for NMIBCa is associated with a significantly greater risk of recurrence than full-dose induction therapy, suggesting that RD-iBCG may not be equivalent or non-inferior to full-dose administration in the short term.

Device-assisted intravesical chemotherapy treatment for nonmuscle invasive bladder cancer: 2022 update

PURPOSE OF REVIEW

To critically analyze the oncological outcomes and safety profile of device-assisted intravesical chemotherapy studies reported in 2021. Studies were considered eligible if they included patients with nonmuscle invasive blood cancer (NMIBC), had a prospective or retrospective design, included at least 10 patients, were published in 2021, and assessed the oncological impact of device-assisted intravesical chemotherapy and/or reported standardized adverse effects (AEs).

RECENT FINDINGS

Eight new studies reported oncological outcomes after hyperthermic intravesical chemotherapy (HIVEC). In Bacillus Calmette-Guérin (BCG) naive patients, the reported 2-yr. recurrence-free survival (RFS) ranged from 70.7% to 82.4%, with one study reporting 2 yr. progression free survival (PFS) of 92%. In both BCG naive and BCG refractory patients, the reported 1-yr. RFS ranged from 60.5% to 70% and PFS was 94% in one study. For radiofrequency-induced HIVEC, the reported 5-yr. estimates were 38%for RFS and 91.5%for PFS. Regarding AEs, 10.2% of patients had severe AEs. Six studies reported AEs after HIVEC; the majorities were grade 1-2 AEs.

SUMMARY

Data coming from the studies published in the last years provides support for a consolidating role of device-assisted intravesical chemotherapy as a safe and effective alternative first- or second-line adjuvant treatment of patients with NMIBC.

Adjuvant therapies for non-muscle-invasive bladder cancer: advances during BCG shortage

Non-muscle-invasive bladder cancer (NMIBC) represents a significant global therapeutic challenge, particularly in the era of Bacillus Calmette-Guérin (BCG) shortage. High-risk NMIBC can progress to muscle invasive or metastatic disease in 25% of patients. Optimal treatment selection, according to risk stratification, is imperative. International guidelines slightly differ in their categorisation of low, intermediate and high-risk NMIBC. Nonetheless, a single post-operative instillation of chemotherapy with Mitomycin C (MMC) or Gemcitabine improves relapse-free survival (RFS) in low-risk NMIBC. Induction and maintenance intravesical BCG remains the historical gold standard for patients with intermediate or high-risk NMIBC. However, clinicians may be forced to consider alternatives given the current BCG shortage. Both intravesical MMC and Gemcitabine have been associated with similar efficacy to BCG, albeit in smaller studies. MMC may also be manipulated using a variety of methods to potentiate its effects. BCG treatment delivery may also be modified without affecting efficacy through dose reduction and abbreviation or omission of maintenance therapy. Preliminary data also highlight that directly proceeding to radical cystectomy may not adversely affect long-term quality of life measures. Access to new systemic and intravesical therapies must be prioritised for patients with BCG recurrent or unresponsive disease. When used in conjunction with molecularly defined biomarkers, these agents herald the potential for improved survival outcomes and alleviation of the current BCG shortage.

Comparing adverse effects, short term outcomes, and cost implications of hyperthermic intravesical chemotherapy with Mitomycin-C and intravesical bacillus Calmette-Guerin instillation (Moscow-I strain) in the management of intermediate and high-risk nonmuscle invasive bladder cancer

Introduction:

The recommended treatment for intermediate and high-risk nonmuscle invasive bladder cancer (NMIBC) is adjuvant intravesical bacillus Calmette–Guerin (BCG) instillation. However, up to 50% experience tumor recurrences even after adjuvant BCG, and many patients develop local or systemic adverse effects. Our study compared adverse effects, short-term recurrence rates, and cost-implications of BCG therapy to Hyperthermic Intra-VEsical Chemotherapy (HIVEC) with Mitomycin-C (MMC) in these patients.

Materials and Methods:

Retrospective analysis of intermediate and high-risk NMIBC patients who received either intravesical BCG or HIVEC^® after transurethral resection of bladder tumor in our institute (January 2017 to March 2020) was done. Twenty-two patients who received HIVEC and 29 who received BCG were analyzed. We used SPSS Statistics v20.0 (IBM Corp., Armonk, NY, USA) software for the statistical analysis.

Results:

Nineteen (86.4%) patients in the HIVEC group had no adverse effects. Two (9.1%) patients had Grade I lower urinary tract symptoms (LUTS) treated symptomatically. One patient developed UTI after HIVEC, and further cycles were stopped (Grade II). BCG group had a higher rate of Grade III adverse effects in six (20.7%) patients. Median follow-up was 10.5 and 22 months. The tumor recurred in one (4.5%) and six (20.7%) patients in HIVEC and BCG groups, respectively. There was no difference in recurrence-free survival at 18 months and the cost for the HIVEC therapy was more.

Conclusions:

HIVEC with MMC is a reasonable adjuvant treatment option in NMIBC, which is well tolerated, albeit increased cost of the treatment. Randomized trials with more follow-up are required for further conclusion.

Bacillus Calmette-Guérin Salvage Therapy: Definitions and Context

High-risk non-muscle invasive bladder cancer is marked by frequent disease recurrences and risk of stage progression, contributing to high surveillance, treatment-related costs, and patient anxiety. Although the mainstay of high-risk non-muscle invasive bladder cancer clinical management remains transurethral resection followed by intravesical bacillus Calmette-Guérin (BCG), patients who develop BCG-unresponsive disease have few salvage options outside of a radical cystectomy with pelvic lymphadenectomy. This article provides a historical context relevant to the development of the BCG-unresponsive definition, an overview of current clinical trial expectations, and an introduction to this issue of Urologic Clinics.

Bladder cancer: overview and disease management. Part 1: non-muscle-invasive bladder cancer

Part 1 of this two-part article provides an overview of bladder cancer and discusses its management. Since publication of a previous article entitled 'Understanding the role of smoking in the aetiology of bladder cancer' ( Anderson, 2009 ), the author has received many requests for an update. This article provides an overview of bladder cancer and its current management practices, underlining the continued role of smoking as the predominant risk factor in the disease's development. The management of bladder cancer is governed by specific guidelines. Management of non-muscle-invasive cancers, including surgical intervention with transurethral resection, and intravesical therapy using chemotherapy and immunotherapy agents, is discussed. Cystectomy (removal of the bladder), is sometimes necessary. Treatments are effective in reducing tumour recurrence, but the effects of the risks and side-effects on the individual's quality of life can be significant. The prevalence of bladder cancer, and the nature of its management make this cancer one of the most expensive for the NHS to treat. The effectiveness of health promotional strategies in increasing peoples' awareness of their risk of developing the disease, and in enabling them to change long-term health behaviours is discussed. The role of the multidisciplinary team is explored, along with that of the uro-oncology cancer nurse specialist. Part 2 will consider the management of muscle-invasive and metastatic bladder cancer.

Miliary tuberculosis induced by intravesical instillation of bacillus Calmette-Guérin

The intravesical instillation of bacillus Calmette-Guérin (BCG) is an efficacious complementary treatment for superficial bladder cancer after transurethral resection. This treatment delays progression, decreases the probability that the patient will have to undergo cystectomy in the future, and improves survival; it is generally efficacious and well tolerated. Among the most common local complications are irritative symptoms, hematuria, local genitourinary infection. Systemic complications are much less common. We present the case of a 71-year-old man who developed miliary tuberculosis secondary to treatment with intravesical bacillus Calmette-Guérin for bladder cancer. This is exceptionally uncommon complication is potentially lethal and requires the immediate discontinuation of treatment.

Beyond BCG: the approaching era of personalised bladder-sparing therapies for non-muscle-invasive urothelial cancers

Progress in the management of non-muscle invasive bladder cancer has been slow. Despite longstanding use of intravesical therapies (e.g., Bacille Calmette-Guerin; BCG) to complement cystoscopic resection of high-grade lesions, many patients still develop recurrences requiring cystectomy, while others suffer side-effects of BCG without definite benefit. Many questions remain: for example, how many patients receive intravesical prophylaxis without efficacy? Which high-risk patients are best managed with early cystectomy? Could systemic therapies and/or radiotherapy extend bladder preservation times? Such questions may soon be refined by clinicopathologic non-muscle invasive bladder cancer signatures that predict sensitivity to cytotoxic, immune and targeted therapies. Hypothesis-based trials using these signatures should lead to more rational adjuvant treatments, longer bladder preservation times, and better quality of life for patients.

Chemoablation with Intensive Intravesical Mitomycin C Treatment: A New Approach for Non-muscle-invasive Bladder Cancer

BACKGROUND

Mitomycin C (MMC) is widely used, but the optimal dose and schedule have not been established.

OBJECTIVE

To evaluate the ablative power and patient safety of a short-term intensive schedule of intravesical MMC in patients with recurrent non-muscle-invasive bladder cancer (NMIBC).

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective, single-center, nonrandomized study that compared 47 patients (group 1) with a history of low- to intermediate-risk NMIBC with long free-recurrence intervals, recurrence of ≤1cm in maximum diameter, and negative cytology to 47 consecutive patients with the same baseline characteristics (group 2).

INTERVENTION

Intravesical MMC three times per week for 2 wk for group 1. Transurethral resection of bladder tumor (TUR-BT) and early instillation and a weekly schedule of intravesical MMC for group 2. All cancer-free patients underwent monthly MMC maintenance. Follow-up included bladder mapping, voiding and washing urinary cytology, TUR of suspected area, TUR of previous tumor location, and ultrasound or computed tomography/magnetic resonance imaging.

OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS

We used χ² and Student's t test for comparison of categorical and continuous variables, respectively. Kaplan-Meier curves were plotted to estimate cancer-free survival. The significance level was set to p<0.05.

RESULTS AND LIMITATIONS

The complete response rate at 39 mo was 61.7% in group 1 and 70.2% in group 2 (p=0.38). Kaplan-Mayer analysis revealed no difference in cancer-free survival rates overall (log-rank <3.84), according to tumor size in each group (log-rank <3.84), or between the groups (log-rank <7.82). No cases of systemic toxicity were observed. Local toxicities did not differ between the groups (p=0.32) and resolved on treatment of symptoms, and no patient discontinued their treatment. Limitations include the small number of patients, selection bias because of the single tertiary center, and short follow-up.

CONCLUSIONS

The proposed MMC schedule had good ablative power that can be explained by better concordance between the scheduled timing and the tumor cell duplication rate. The short-term intensive schedule could be considered as a therapeutic strategy to replace TUR-BT in selected NMIBC patients.

PATIENT SUMMARY

We report our experience of a tailored intravesical therapy schedule for bladder cancer. This schedule could be considered a therapeutic strategy to replace surgery for selected patients.

Lidocaine enhances the effects of chemotherapeutic drugs against bladder cancer

This study aimed to investigate whether lidocaine, alone or in combination with other chemotherapeutic agents, inhibits the growth of human bladder cancer cells in vitro and orthotopically transplanted bladder tumors in vivo. The effects of lidocaine (1.25, 2.5 or 5 mg/mL), mitomycin C (MMC, 0.66 mg/mL), pirarubicin (0.75 mg/mL) and Su Fu’ning lotion (SFN, 0.0625 mg/mL) on the proliferation of human bladder cancer (BIU-87) cells were studied using the MTT assay. A Balb/c nude mouse model of bladder cancer was developed by orthotopic transplantation of BIU-87 cells, and the effects of intravesical instillation of lidocaine and MMC on bladder wet weight (a measure of tumor size) and survival (over 60 days) were studied. Lidocaine inhibited proliferation of BIU-87 cells in a concentration-dependent manner and (when given in combination) enhanced the actions of each of the other antiproliferative agents. In tumor-bearing mice, MMC alone had no effect on mean survival or bladder wet weight. However, the combination of 0.66 mg/mL MMC and 5 mg/mL lidocaine prolonged survival (from 34.62 ± 6.49 to 49.30 ± 6.72 days; n = 8, P < 0.05) and reduced bladder wet weight (from 68.94 ± 53.61 to 20.26 ± 6.07; n = 8, P < 0.05). Intravesical instillation of lidocaine combined with other chemotherapeutic agents potentially could be an effective therapy for bladder cancer.

Transperineal cryotherapy for unresectable muscle invasive bladder cancer: preliminary experience with 7 male patients

BACKGROUND

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) and urinary diversion (UD) is considered the standard treatment for muscle invasive bladder cancer (MIBC). In a part of patients, RC procedure is aborted due to unresectable disease, other followed treatment like systemic chemotherapy, radiotherapy or cryotherapy may be a better option. The aim of present study was to report the preliminary results of transperineal cryotherapy for unresectable muscle invasive bladder cancer.

METHODS

From January 2011 to August 2013, 7 male patients with pT4b unresectable bladder cancer underwent bilateral ureterocutaneostomy. Two performed a pelvic lymph node dissection (PLND). Then primary transperineal cryosurgery for preserved bladder at the guidance of transrectal ultrasound (TRUS) was performed. All patients underwent a dual freeze-thaw cycle using third-generation cryotechnology with ultrathin 17-gauge cryoneedles. Computer tomography (CT) and/or magnetic resonance image (MRI)were performed at 3 month intervals after cryosurgery to determine whether progression or recurrence occurred.

RESULTS

All cryosurgery was performed successfully, mean operation time was 76.43 ± 25.12 min (range 50-120 min), mean blood loss was 19.29 ± 15.92 ml (range 5-50 ml). Mean hospital stay was 3.86 ± 1.68 day (range 2-7 days). No operative related deaths occurred. Four patients dead due to the metastasis disease at the follow up time of 8, 15, 18 and 37 months, respectively. Six patients received postoperative therapy, of whom 5 patients were treated with combined chemoradiation, and the other one received chemotherapy alone. The progression free survival (PFS) of the 7 patients was 22.00 ± 14.61 months (range 3-40 months). The one, two and three year overall survival (OS) was 85.7%, 57.1% and 42.9%, respectively.

CONCLUSION

Our results suggest that cryosurgery combination with chemoradiotherapy provide a safe and effective alternative method for unresectable pT4b bladder cancer. Longer follow-up is necessary to determine the sustained efficacy.

Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Instillation for the Treatment of Superficial Transitional Cell Carcinoma of the Bladder

BACKGROUND

Intravesical instillation of Bacillus Calmette–Guérin (BCG) remains a first-line treatment for superficial transitional cell carcinoma of the bladder. Although its use is relatively safe, severe complications such as granulomatous hepatitis, osteomyelitis, pneumonitis, and sepsis occur in few patients. Complications of intravesical instillation of BCG can be local or systemic, with early or late presentation.

CASE PRESENTATION

Here, we report an 88-year-old man who developed fever, rigors, and episodes of syncope following fourth intravesical BCG instillation for the treatment of superficial transitional cell carcinoma of the bladder. Pancytopenia, disseminated intravascular coagulation, ground glass appearance on computerized tomography of the chest scan in addition to multiple bone marrow granulomas, suggested the diagnosis of disseminated BCG infection. All these features recovered on antituberculosis treatment.

CONCLUSION

Our case study highlights the importance of early recognition and prompt treatment of patients with disseminated BCG infection following intravesical instillation. Although isolation of mycobacterium is desirable to make the diagnosis, it is not unusual to have negative smears and cultures and this should not be used to dismiss the possibility of BCG infection.

Oncolytic virotherapy for urological cancers

Oncolytic virotherapy is a cancer treatment in which replication-competent viruses are used that specifically infect, replicate in and lyse malignant tumour cells, while minimizing harm to normal cells. Anecdotal evidence of the effectiveness of this strategy has existed since the late nineteenth century, but advances and innovations in biotechnological methods in the 1980s and 1990s led to a renewed interest in this type of therapy. Multiple clinical trials investigating the use of agents constructed from a wide range of viruses have since been performed, and several of these enrolled patients with urological malignancies. Data from these clinical trials and from preclinical studies revealed a number of challenges to the effectiveness of oncolytic virotherapy that have prompted the development of further sophisticated strategies. Urological cancers have a range of distinctive features, such as specific genetic mutations and cell surface markers, which enable improving both effectiveness and safety of oncolytic virus treatments. The strategies employed in creating advanced oncolytic agents include alteration of the virus tropism, regulating transcription and translation of viral genes, combination with chemotherapy, radiotherapy or gene therapy, arming viruses with factors that stimulate the immune response against tumour cells and delivery technologies to ensure that the viral agent reaches its target tissue.

Treatment options in non-muscle-invasive bladder cancer after BCG failure

Bladder cancer is the ninth-most prevalent cancer worldwide. Most patients with urothelial cell carcinoma of the bladder present with non-muscle-invasive disease and are treated with bacillus Calmette-Guérin (BCG) intravesical therapy. Many of these patients experience disease recurrence after BCG failure. Radical cystectomy is the recommended treatment for high-risk patients failing BCG. However, many patients are unfit for or unwilling to undergo this procedure. We searched the published literature on the treatment of non-muscle-invasive bladder cancer (NMIBC) after BCG failure. We review current evidence regarding intravesical therapy with gemcitabine, mitomycin combined with thermo-chemotherapy, docetaxel, nab-paclitaxel, photodynamic therapy (PDT), BCG with interferon (IFN), and combination sequentially administered chemotherapy.

c-Fos is involved in inhibition of human bladder carcinoma T24 cells by brazilin

Crude brazilin extract from Sappan wood has demonstrated strong anti tumor activity in the mouse model of human bladder carcinoma and clinical trial for intravesical therapy. Purified brazilin was confirmed the most active molecule in inhibition of bladder carcinoma T24 cells. Brazilin decreased proliferation and viability of T24 cells in a dose- and time-dependent manner, with a calculated LC50 of 32 µg/mL. More than 1,000 of genes were found upregulated and down regulated by brazilin treatment in digital gene expression profiling. Gene ontology analysis indicated that stress response, apoptosis, and cell cycle regulatory pathways were highly enriched. Among the regulated genes, c-Fos was the most and specifically upregulated. Overexpression of c-Fos in T24 cells resulted in tumor cell specific changes in cell morphology and viability. Over expression of stress-responsive gene, HSP70, and other highly upregulated genes did not have any effect on cell growth. Brazilin may inhibit T24 cell growth and trigger cell death through a c-Fos-mediated and tumor cell specific signaling pathway. Further studies of its down stream mediators may help to identify better tumor cell type specific drug targets.

The effects and effectiveness of electromotive drug administration and chemohyperthermia for treating non-muscle invasive bladder cancer

INTRODUCTION

Preliminary studies show that device assisted intravesical therapies appear more effective than passive diffusion intravesical therapy for the treatment of non-muscle invasive bladder cancer (NMIBC) in specific settings, and phase III studies are now being conducted. Consequently, we have undertaken a non-systematic review with the objective of describing the scientific basis and mechanisms of action of electromotive drug administration (EMDA) and chemohyperthermia (CHT).

METHODS

PubMed, ClinicalTrials.gov and the Cochrane Library were searched to source evidence for this non-systematic review. Randomised controlled trials, systematic reviews and meta-analyses were evaluated. Publications regarding the scientific basis and mechanisms of action of EMDA and CHT were identified, as well as clinical studies to date.

RESULTS

EMDA takes advantage of three phenomena: iontophoresis, electro-osmosis and electroporation. It has been found to reduce recurrence rates in NMIBC patients and has been proposed as an addition or alternative to bacillus Calmette-Guérin (BCG) therapy in the treatment of high risk NMIBC. CHT improves the efficacy of mitomycin C by three mechanisms: tumour cell cytotoxicity, altered tumour blood flow and localised immune responses. Fewer studies have been conducted with CHT than with EMDA but they have demonstrated utility for increasing disease-free survival, especially in patients who have previously failed BCG therapy.

CONCLUSIONS

It is anticipated that EMDA and CHT will play important roles in the management of NMIBC in the future. Techniques of delivery should be standardised, and there is a need for more randomised controlled trials to evaluate the benefits of the treatments alongside quality of life and cost-effectiveness.

Novel green-light KTP laser en bloc enucleation for nonmuscle-invasive bladder cancer: technique and initial clinical experience

BACKGROUND AND PURPOSE

The standard procedure for staging and treating nonmuscle-invasive bladder cancer (NMIBC) is still transurethral resection of bladder tumor (TURBT) via a wire loop. However, TURBT is associated with serious disadvantages that facilitate tumor recurrence. Recently, lasers have been explored as treatment tools for bladder tumors. Here, we report a novel tumor en bloc enucleation using a front-firing green-light potassium-titanyl-phosphate laser and its initial clinical application.

PATIENTS AND METHODS

From March through June 2013, 45 patients with NMIBC received modified transurethral resection using a front-firing green-light laser. En bloc enucleation was performed on all tumors. Preoperative and intraoperative data were retrospectively collected.

RESULTS

All patients successfully went through a session of treatment with front-firing green-light laser enucleation of the bladder tumor. Complications such as bladder hemorrhage, vesicle perforation, and obturator nerve reflex were not encountered during the treatment. The tumor diameter ranges from 0.3 to 3.0 cm with a mean value of 1.8 cm. Mean operative time and enucleation time were 21 (12-38) and 12 (4-23) minutes, respectively. Serum hemoglobin decreased 1.1 (0.1-2.4) mg/dL averagely. Mean catheter time was 2.0 (1.0-3.0) days, and mean postoperative hospital stay was 2.5 (1.5-4.0) days. The stages of bladder cancer included 27 Ta, 15 T1, and 3 T2a. No tumor recurrence was observed at the initial 6-month follow-up.

CONCLUSIONS

The modified technique using a front-firing green-light laser to en bloc enucleate bladder tumors is effective and safe for treatment of NMIBC. Moreover, it may improve the accurate valuation of tumor stage and prediction of postoperative prognosis, although long-term outcomes and prospective clinical trials are needed.

Recent advances and the emerging role for chemoradiation in nonmuscle invasive bladder cancer

PURPOSE OF REVIEW

The management of nonmuscle invasive bladder cancer (NMIBC) recurrent after bacillus Calmette-Guérin therapy is complex and further complicated by high numbers of patients who are not candidates for cystectomy. This article reviews data supporting the use of chemoradiation in NMIBC and discusses emerging biomarkers of treatment response.

RECENT FINDINGS

Radiotherapy, especially when combined with chemotherapy, has shown great promise for treating bladder cancer. Recent studies have identified that many patients with bladder cancer do not receive potentially curative therapies. Many such patients are elderly or infirm and represent an unmet need for curative therapeutic alternatives to radical cystectomy. Although radiotherapy alone does not appear superior to intravesical therapy in NMIBC, at least one series with long-term follow-up has shown excellent results in patients treated with radiation and concurrent chemotherapy. A clinical trial investigating the role for chemoradiation in T1 disease that has recurred is underway. Biomarkers able to predict radiotherapy response may allow for personalized therapy in the near future.

SUMMARY

Chemoradiation is an emerging treatment option for selected patients with NMIBC. Prospective validation of currently identified biomarkers is needed along with further research to identify which patients may benefit the most from such therapy.

Advanced urothelial carcinoma: next-generation sequencing reveals diverse genomic alterations and targets of therapy

Although urothelial carcinoma (UC) of the urinary bladder generally portends a favorable prognosis, metastatic tumors often follow an aggressive clinical course. DNA was extracted from 40 μm of formalin-fixed, paraffin-embedded (FFPE) sections from 35 stage IV UCs that had relapsed and progressed after primary surgery and conventional chemotherapy. Next-generation sequencing (NGS) was performed on hybridization-captured, adaptor ligation-based libraries for 3320 exons of 182 cancer-related genes plus 37 introns from 14 genes frequently rearranged in cancer to at an average sequencing depth of 1164 × and evaluated for all classes of genomic alterations (GAs). Actionable GAs were defined as those impacting the selection of targeted anticancer therapies on the market or in registered clinical trials. A total of 139 GAs were identified, with an average of 4.0 GAs per tumor (range 0-10), of which 78 (56%) were considered actionable, with an average of 2.2 per tumor (range 0-7). Twenty-nine (83%) cases harbored at least one actionable GA including: PIK3CA (9 cases; 26%); CDKN2A/B (8 cases; 23%); CCND1 (5 cases; 14%); FGFR1 (5 cases; 14%); CCND3 (4 cases; 11%); FGFR3 (4 cases; 11%); MCL1 (4 cases; 11%); MDM2 (4 cases; 11%); EGFR (2 cases, 6%); ERBB2 (HER2/neu) (2 cases, 6%); NF1 (2 cases, 6%) and TSC1 (2 cases, 6%). Notable additional alterations included TP53 (19 cases, 54%) and RB1 (6 cases; 17%). Genes involved in chromatin modification were altered by nonsense mutation, splice site mutation or frameshift indel in a mutually exclusive manner in nearly half of all cases including KDM6A (10 cases; 29%) and ARID1A (7 cases; 20%). Comprehensive NGS of 35 UCs of the bladder revealed a diverse spectrum of actionable GAs in 83% of cases, which has the potential to inform treatment decisions for patients with relapsed and metastatic disease.

Percutaneous cryotherapy for metastatic bladder cancer: experience with 23 patients

Bladder cancer is the most common malignancy of the urinary tract and in many patients is metastatic at diagnosis. Chemotherapy is the standard treatment for these patients but has serious side effects and in many patients is not tolerated. To avoid the side effects of systemic chemotherapy, patients with late stage bladder cancer have sought cryotherapy in our hospital. We reviewed data for the past 4 years to evaluate the safety and efficiency of percutaneous cryotherapy in 23 patients. Within 3 days after cryosurgery, all complications of bladder cancer (e.g. hematuria, urinary irritation, hypogastralgia, lumbago) had decreased to some degree. No new complications (e.g. bladder perforation) occurred and all complications had disappeared completely after 2 weeks. The progression-free survival (PFS) of these patients was 14 ± 8 months. There was no effect on PFS of tumor location or histopathology; however, differentiation status and tumor size influenced the therapeutic effect of percutaneous cryoablation. In conclusion, percutaneous cryotherapy may be a safe and efficacious therapeutic option in the treatment of metastatic bladder cancer.

TERT promoter mutations in bladder cancer affect patient survival and disease recurrence through modification by a common polymorphism

The telomerase reverse transcriptase (TERT) promoter, an important element of telomerase expression, has emerged as a target of cancer-specific mutations. Originally described in melanoma, the mutations in TERT promoter have been shown to be common in certain other tumor types that include glioblastoma, hepatocellular carcinoma, and bladder cancer. To fully define the occurrence and effect of the TERT promoter mutations, we investigated tumors from a well-characterized series of 327 patients with urothelial cell carcinoma of bladder. The somatic mutations, mainly at positions -124 and -146 bp from ATG start site that create binding motifs for E-twenty six/ternary complex factors (Ets/TCF), affected 65.4% of the tumors, with even distribution across different stages and grades. Our data showed that a common polymorphism rs2853669, within a preexisting Ets2 binding site in the TERT promoter, acts as a modifier of the effect of the mutations on survival and tumor recurrence. The patients with the mutations showed poor survival in the absence [hazard ratio (HR) 2.19, 95% confidence interval (CI) 1.02-4.70] but not in the presence (HR 0.42, 95% CI 0.18-1.01) of the variant allele of the polymorphism. The mutations in the absence of the variant allele were highly associated with the disease recurrence in patients with Tis, Ta, and T1 tumors (HR 1.85, 95% CI 1.11-3.08). The TERT promoter mutations are the most common somatic lesions in bladder cancer with clinical implications. The association of the mutations with patient survival and disease recurrence, subject to modification by a common polymorphism, can be a unique putative marker with individualized prognostic potential.