The effectiveness of off-protocol adjuvant chemotherapy for patients with urothelial carcinoma of the urinary bladder

Evaluating the Survival Benefits of Perioperative Chemotherapy in Frail and Morbid Muscle-Invasive Bladder Cancer Patients

INTRODUCTION

Current guidelines endorse the use of perioperative chemotherapy (POC) in muscle-invasive bladder cancer (MIBC) to enhance the long-term overall survival (OS) compared to radical cystectomy (RC) alone. This study aims to assess the impact of POC on the OS in frail and morbid (F-M) patients undergoing RC.

METHODS

A retrospective multicenter study of 291 patients who underwent RC between 2015 and 2019 was performed. Patients with both a Charlson comorbidity index ≥ 4 and Modified Frailty Index ≥ 2 were classified as the F-M cohort. We compared the clinical and pathological characteristics and outcomes of the F-M patients who received POC to those who underwent RC alone. Univariable and multivariable analyses were performed to identify the predictors of the OS.

RESULTS

The F-M cohort included 102 patients. POC was administered to 44% of these patients: neoadjuvant (NAC) to 31%, adjuvant (AC) to 19%, and both to 6 (6%). The OS was significantly lower in the F-M cohort compared to in the healthier patients (median OS 42 months, p = 0.02). The F-M patients who received POC were younger, less morbid and had better renal function. Although POC was marginally associated with improved OS in the univariable analysis (p = 0.06), this was not significant in the multivariable analysis (p = 0.50). NAC was associated with improved OS in the univariable analysis (p = 0.004) but not after adjustment for competing factors (p = 1.00). AC was not associated with the OS.

CONCLUSIONS

POC does not improve the OS in F-M patients undergoing RC. Personalized treatment strategies and further prospective studies are needed to optimize care in this unique vulnerable population.

Survival of Patients with Chronic Kidney Disease Treated with Radical Cystectomy and Risk Factors of Glomerular Filtration Rate Loss Following Radical Cystectomy: Two Systematic Reviews and Meta-analyses of Interplay Between Radical Cystectomy and Renal Function

CONTEXT

There is no high-level evidence regarding the risk factors of glomerular filtration rate (GFR) loss following radical cystectomy (RC) and survival outcomes of patients with chronic kidney disease (CKD) undergoing RC.

OBJECTIVE

To identify the risk factors of CKD in patients treated with RC for bladder cancer and to assess overall and oncological survival of patients with CKD who underwent RC.

EVIDENCE ACQUISITION

According to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement, two systematic reviews were performed for studies published before September 30, 2022, assessing (1) risk factors of renal function (RF) decline following RC and (2) overall and oncological outcomes of CKD patients treated with RC.

EVIDENCE SYNTHESIS

A total of 21 and 17 studies were included for qualitative and quantitative syntheses, respectively. The first meta-analysis of ten studies (15 502 patients) identified these factors to be significantly associated with GFR loss following RC: advanced age, lower baseline RF, higher Charlson Comorbidity Index (CCI), diabetes mellitus, hypertension, postoperative hydronephrosis, ureteroenteric stricture, and locally advanced disease (hazard ratios [HRs] 1.03, 1.22, 1.5, 1.27, 1.24, 1.69, 1.92, and 5.13, respectively), while sex, preoperative hydronephrosis, perioperative chemotherapy, and diversion type were not. The second meta-analysis of seven studies (6900 patients) demonstrated significantly worse metastasis-free, cancer-specific, and overall survival in patients with higher CKD stages than in those with lower stages (HRs 1.54, 2.09, and 1.47, respectively).

CONCLUSIONS

Current evidence suggests that older age, lower baseline RF, higher CCI, diabetes mellitus, hypertension, postoperative hydronephrosis, ureteroenteric stricture, and locally advanced disease are associated with long-term GFR loss following RC. In addition, patients with higher stages of CKD have worse long-term overall and oncological outcomes following RC. These data may help in counseling and decision-making regarding therapy and preventive measures.

PATIENT SUMMARY

Several factors have been identified that can help identify patients at risk for glomerular filtration rate loss after radical cystectomy (RC). Chronic kidney disease is associated with poor cancer- and non-cancer-specific outcomes following RC.

Study Protocol of the Bladder Adjuvant RadioTherapy (BART) Trial: A Randomised Phase III Trial of Adjuvant Radiotherapy Following Cystectomy in Bladder Cancer

AIMS

To assess the efficacy and safety of adjuvant radiotherapy in patients with high-risk muscle-invasive bladder cancer (MIBC) following radical cystectomy (RC) and chemotherapy.

MATERIALS AND METHODS

The BART (Bladder Adjuvant RadioTherapy) trial is an ongoing multicentric, randomised, phase III trial comparing the efficacy and safety of adjuvant radiotherapy versus observation in patients with high-risk MIBC. The key eligibility criteria include ≥pT3, node-positive (pN+), positive margins and/or nodal yield <10, or, neoadjuvant chemotherapy for cT3/T4/N+ disease. In total, 153 patients will be accrued and randomised, in a 1:1 ratio, to either observation (standard arm) or adjuvant radiotherapy (test arm) following surgery and chemotherapy. Stratification parameters include nodal status (N+ versus N0) and chemotherapy (neoadjuvant chemotherapy versus adjuvant chemotherapy versus no chemotherapy). For patients in the test arm, adjuvant radiotherapy to cystectomy bed and pelvic nodes is planned with intensity-modulated radiotherapy to a dose of 50.4 Gy in 28 fractions using daily image guidance. All patients will follow-up with 3-monthly clinical review and urine cytology for 2 years and subsequently 6 monthly until 5 years, with contrast-enhanced computed tomography abdomen pelvis 6 monthly for 2 years and annually until 5 years. Physician-scored toxicity using Common Terminology Criteria for Adverse Events version 5.0 and patient-reported quality of life using the Functional Assessment of Cancer Therapy - Colorectal questionnaire is recorded pre-treatment and at follow-up.

ENDPOINTS AND STATISTICS

The primary endpoint is 2-year locoregional recurrence-free survival. The sample size calculation was based on the estimated improvement in 2-year locoregional recurrence-free survival from 70% in the standard arm to 85% in the test arm (hazard ratio 0.45) using 80% statistical power and a two-sided alpha error of 0.05. Secondary endpoints include disease-free survival, overall survival, acute and late toxicity, patterns of failure and quality of life.

CONCLUSION

The BART trial aims to evaluate whether contemporary radiotherapy after standard-of-care surgery and chemotherapy reduces pelvic recurrences safely and also potentially affects survival in high-risk MIBC.

Perioperative systemic therapy in muscle invasive bladder cancer: Current standard method, biomarkers and emerging strategies

Bladder cancer ranks as the 10th most common cancer type globally, and muscle-invasive disease accounts for approximately 25% of newly diagnosed bladder cancers. Despite definitive treatment, 50% of patients with muscle-invasive bladder cancer (MIBC) develop metastasis within 2 years, leading to death. Perioperative systemic therapy is generally recommended to control local relapse or distant metastasis after surgical resection for patients with MIBC. Cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy is the current standard treatment to improve oncologic control and survival outcomes. Adjuvant chemotherapy is recommended for patients with pathological T3-4 or positive lymph nodes after radical cystectomy if no neoadjuvant chemotherapy was given. Nonetheless, perioperative systemic therapy is not applied widely because of its toxicity, and less than 25% of patients receive cisplatin-based neoadjuvant chemotherapy. Therefore, the development of predictive biomarkers for neoadjuvant chemotherapy efficacy and alternative effective regimens for cisplatin-ineligible patients are important. Furthermore, recently, novel anticancer agents such as immune checkpoint inhibitors and antibody-drug conjugates have proven survival benefits in the metastatic setting, thereby expanding their therapeutic applications to the perioperative setting for non-metastatic MIBC. Herein, we discuss the current status and future perspectives of perioperative systemic strategies for MIBC.

Blood-Based Biomarkers as Prognostic Factors of Recurrent Disease after Radical Cystectomy: A Systematic Review and Meta-Analysis

Survival outcomes after radical cystectomy (RC) for bladder cancer (BCa) have not improved in recent decades; nevertheless, RC remains the standard treatment for patients with localized muscle-invasive BCa. Identification of the patients most likely to benefit from RC only versus a combination with systemic therapy versus systemic therapy first/only and bladder-sparing is needed. This systematic review and meta-analysis pools the data from published studies on blood-based biomarkers to help prognosticate disease recurrence after RC. A literature search on PubMed and Scopus was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Articles published before November 2022 were screened for eligibility. A meta-analysis was performed on studies investigating the association of the neutrophil-to-lymphocyte ratio (NLR), the only biomarker with sufficient data, with recurrence-free survival. The systematic review identified 33 studies, and 7 articles were included in the meta-analysis. Our results demonstrated a statistically significant correlation between elevated NLR and an increased risk of disease recurrence (HR 1.26; 95% CI 1.09, 1.45; p = 0.002) after RC. The systematic review identified various other inflammatory biomarkers, such as interleukin-6 or the albumin-to-globulin ratio, which have been reported to have a prognostic impact on recurrence after RC. Besides that, the nutritional status, factors of angiogenesis and circulating tumor cells, and DNA seem to be promising tools for the prognostication of recurrence after RC. Due to the high heterogeneity between the studies and the different cut-off values of biomarkers, prospective and validation trials with larger sample sizes and standardized cut-off values should be conducted to strengthen the approach in using biomarkers as a tool for risk stratification in clinical decision-making for patients with localized muscle-invasive BCa.

Perspectives on the future of urothelial carcinoma therapy: chemotherapy and beyond

INTRODUCTION

Despite recent developments in the landscape of urothelial carcinoma (UC) treatment, platinum combination chemotherapy still remains a milestone. Recently immunotherapeutic agents have gained ever-growing attractivity, particularly in the metastatic setting. Novel chemotherapeutic strategies and agents, such as antibody-drug conjugates (ADCs), and powerful combination regimens have been developed to overcome the resistance of most UC to current therapies.

AREAS COVERED

Herein, we review the current standard-of-care chemotherapy, the development of ADCs, the rationale for combining therapy regimens with chemotherapy in current trials, and future directions in UC management.

EXPERT OPINION

Immunotherapy has prompted a revolution in the treatment paradigm of UC. However, only a few patients experience a long-term response when treated with single-agent immunotherapies. Combination treatments are necessary to bypass resistance mechanisms and broaden the clinical utility of current options. Current evidence supports the intensification of standard-of-care chemotherapy with maintenance immunotherapy. However, the optimal sequence, combination, and duration must be determined to achieve individual longevity with acceptable health-related quality of life. In that regard, ADCs appear as a promising alternative for single and combination strategies in UC, as they specifically target the tumor cells, thereby, theoretically improving treatment efficacy and avoiding extensive off-target toxicities.

Prognostic nomogram for estimating survival in patients with resected muscle-invasive bladder cancer receiving chemotherapy

Background

Chemotherapy has been proven to bring survival benefit in patients with resected muscle-invasive bladder cancer (MIBC), which is increasingly recommended. Our objective was to establish an effective model for estimating the overall survival (OS) and cancer-specific survival (CSS) in these patients.

Methods

2,030 patients diagnosed with resected MIBC receiving chemotherapy were acquired from the Surveillance, Epidemiology, and End Result (SEER) database, which were randomized 7:3 into a primary set (1,421 patients) and an internal validation set (609 patients). Significant predictors for OS and CSS were identified by Cox regression models, which were then utilized to develop prognostic nomogram. The performance of the model was assessed by utilizing calibration, area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA).

Results

Six independent prognostic factors, including age, race, histology, T stage, N stage and regional nodes examined, made up the nomogram. The AUCs of the primary cohort was 0.751 and 0.753 for 3- and 5- year OS and 0.751 and 0.754 for 3-and 5- year CSS, respectively. The calibration plots proved the nomograms' satisfactory discrimination. The results of DCA manifested that our models had an excellent clinical applicability. In addition, a risk stratification system was established according to the nomogram' risk score. Obvious difference was found in different groups (P < 0.001).

Conclusion

The established prediction nomogram provides a simple-to-use tool for estimating the survival probability of resected MIBC patients treated with chemotherapy, which can assist clinicians make individualized treatment plans.

Management of Bladder Cancer Patients with Clinical Evidence of Lymph Node Invasion (cN+)

The purpose of this review is to present the current knowledge about the diagnostic and treatment options for bladder cancer (BCa) patients with clinically positive lymph nodes (cN+). This review shows compaction of CT and MRI performance in preoperative prediction of lymph node invasion (LNI) in BCa patients, along with other diagnostic methods. Most scientific societies do not distinguish cN+ patients in their guidelines; recommendations concern muscle-invasive bladder cancer (MIBC) and differ between associations. The curative treatment that provides the best long-term survival in cN+ patients is a multimodal approach, with a combination of neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) with extended pelvic lymph node dissection (ePLND). The role of adjuvant chemotherapy (AC) remains uncertain; however, emerging evidence indicates comparable outcomes to NAC. Therefore, in cN+ patients who have not received NAC, AC should be implemented. The response to ChT is a crucial prognostic factor for cN+ patients. Recent studies demonstrated the growing importance of immunotherapy, especially in ChT-ineligible patients. Moreover, immunotherapy can be suitable as adjuvant therapy in selected cases. In cN+ patients, the extended template of PLND should be utilized, with the total resected node count being less important than the template. This review is intended to draw special attention to cN+ BCa patients, as the oncological outcomes are significantly worse for this group.

Nkx2.8 promotes chemosensitivity in bladder urothelial carcinoma via transcriptional repression of MDR1

Multidrug resistance gene 1 (MDR1), a key factor contributing to drug insensitivity, has been associated with treatment failure and poor prognoses in various cancers, including bladder urothelial carcinoma (UC). Here we show that positive Nkx2.8 expression was associated with better prognosis of UC patients received chemotherapy. Patients with positive Nkx2.8 expression had promising prognosis from adjuvant chemotherapy. Enforced expression of Nkx2.8 promotes drug sensitivity of UC cells. Mechanistic investigations showed that Nkx2.8 negatively regulated expression of MDR1 by binds directly to the MDR1 promoter and transcriptionally represses MDR1 expression. P-gp inhibitor reversed chemosensitivity inhibition by Nkx2.8 scilencing. In clinical UC specimens, expression of Nkx2.8 inversely correlated with P-gp expression, and UC patients with Nkx2.8 positivity and low P-gp expression displayed the best prognosis. Our findings uncovered a new mechanism of chemosensitivity in UC cells and proposing Nkx2.8-MDR1 axis as a novel candidate target for therapeutic intervention of UC.

Prognostic value of hepatocyte growth factor for muscle-invasive bladder cancer

Purpose

The HGF/MET pathway is involved in cell motility, angiogenesis, proliferation, and cancer invasion. We assessed the clinical utility of plasma HGF level as a prognostic biomarker in patients with MIBC.

Methods

We retrospectively analyzed 565 patients with MIBC who underwent radical cystectomy. Logistic regression and Cox regression models were used, and predictive accuracies were estimated using the area under the curve and concordance index. To estimate the clinical utility of HGF, DCA and MCID were applied.

Results

Plasma HGF level was significantly higher in patients with advanced pathologic stage and LN metastasis (p = 0.01 and p < 0.001, respectively). Higher HGF levels were associated with an increased risk of harboring LN metastasis and non-organ-confined disease (OR1.21, 95%CI 1.12–1.32, p < 0.001, and OR1.35, 95%CI 1.23–1.48, p < 0.001, respectively) on multivariable analyses; the addition of HGF improved the predictive accuracies of a standard preoperative model (+ 7%, p < 0.001 and + 8%, p < 0.001, respectively). According to the DCA and MCID, half of the patients had a net benefit by including HGF, but the absolute magnitude remained limited. In pre- and postoperative predictive models, a higher HGF level was significant prognosticator of worse RFS, OS, and CSS; in the preoperative model, the addition of HGF improved accuracies by 6% and 5% for RFS and CSS, respectively.

Conclusion

Preoperative HGF identified MIBC patients who harbored features of clinically and biologically aggressive disease. Plasma HGF could serve, as part of a panel, as a biomarker to aid in preoperative treatment planning regarding intensity of treatment in patients with clinical MIBC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-021-03887-x.

Chemotherapy is superior to checkpoint inhibitors after radical surgery for urothelial carcinoma: a systematic review and network meta-analysis of oncologic and toxicity outcomes

OBJECTIVE

To determine the oncologic and toxicity outcomes of adjuvant immunotherapy with immune checkpoint inhibitors (ICIs) compared to adjuvant chemotherapy in patients treated with radical surgery for urothelial carcinoma (UC).

METHODS

We used the Bayesian approach in the network meta-analysis of different therapy regimens compared to observation or placebo.

RESULTS

Nine studies comprised of 2,444 patients met the eligibility criteria. In bladder UC, chemotherapy, atezolizumab, and nivolumab did not improve disease progression compared to observation/placebo. In upper tract UC (UTUC), chemotherapy was significantly associated with a lower likelihood of disease progression compared to observation/placebo, while atezolizumab and nivolumab were not. Based on the analysis of the treatment ranking, adjuvant chemotherapy appeared as the best treatment approach in both bladder UC and UTUC. The risk of adverse events with ICIs was comparable to that of observation/placebo.

CONCLUSION

Our analysis suggests a superior oncologic benefit to adjuvant chemotherapy over ICIs in patients treated with radical surgery for both bladder UC and UTUC.

Long noncoding RNAs to predict postoperative recurrence in bladder cancer and to develop a new molecular classification system

BACKGROUND

Reliable molecular markers are much needed for early prediction of recurrence in muscle-invasive bladder cancer (MIBC) patients. We aimed to build a long-noncoding RNA (lncRNA) signature to improve recurrence prediction and lncRNA-based molecular classification of MIBC.

METHODS

LncRNAs of 320 MIBC patients from the Cancer Genome Atlas (TCGA) database were analyzed, and a nomogram was established. A molecular classification system was created, and immunotherapy and chemotherapy response predictions, immune score analysis, immune infiltration analysis, and mutational data analysis were conducted. Survival analysis validation was also performed.

RESULTS

An eight-lncRNA signature classifed the patients into high- and low-risk subgroups, and these groups had significantly different (disease-free survival) DFS. The ability of the eight-lncRNA signature to make an accurate prognosis was tested using a validation dataset from our samples. The nomogram achieved a C-index of 0.719 (95% CI, 0.674-0.764). Time-dependent receiver operating characteristic curve (ROC) analysis indicated the superior prognostic accuracy of nomograms for DFS prediction (0.76, 95% CI, 0.697-0.807). Further, the four clusters (median DFS = 11.8, 15.3, 17.9, and 18.9 months, respectively) showed a high frequency of TTN (cluster 1), fibroblast growth factor receptor-3 (cluster 2), TP53 (cluster 3), and TP53 mutations (cluster 4), respectively. They were enriched with M2 macrophages (cluster 1), CD8⁺ T cells (cluster 2), M0 macrophages (cluster 3), and M0 macrophages (cluster 4), respectively. Clusters 2 and 3 demonstrated potential sensitivity to immunotherapy and insensitivity to chemotherapy, whereas cluster 4 showed potential insensitivity to immunotherapy and sensitivity to chemotherapy.

CONCLUSIONS

The eight-lncRNA signature risk model may be a reliable prognostic signature for MIBC, which provides new insights into prediction of recurrence of MIBC. The model may help clinical decision and eventually benefit patients.

Impact of preoperative systemic immune-inflammation Index on oncologic outcomes in bladder cancer patients treated with radical cystectomy

PURPOSE

To investigate the predictive and prognostic value of the preoperative systemic immune-inflammation index (SII) in patients undergoing radical cystectomy (RC) for clinically non-metastatic urothelial cancer of the bladder (UCB).

METHODS

Overall, 4,335 patients were included, and the cohort was stratified in two groups according to SII using an optimal cut-off determined by the Youden index. Uni- and multivariable logistic and Cox regression analyses were performed, and the discriminatory ability by adding SII to a reference model based on available clinicopathologic variables was assessed by area under receiver operating characteristics curves (AUC) and concordance-indices. The additional clinical net-benefit was assessed using decision curve analysis (DCA).

RESULTS

High SII was observed in 1879 (43%) patients. On multivariable preoperative logistic regression, high SII was associated with lymph node involvement (LNI; P = 0.004), pT3/4 disease (P <0.001), and non-organ confined disease (NOCD; P <0.001) with improvement of AUCs for predicting LNI (P = 0.01) and pT3/4 disease (P = 0.01). On multivariable Cox regression including preoperative available clinicopathologic values, high SII was associated with recurrence-free survival (P = 0.028), cancer-specific survival (P = 0.005), and overall survival (P = 0.006), without improvement of concordance-indices. On DCAs, the inclusion of SII did not meaningfully improve the net-benefit for clinical decision-making in all models.

CONCLUSION

High preoperative SII is independently associated with pathologic features of aggressive disease and worse survival outcomes. However, it did not improve the discriminatory margin of a prediction model beyond established clinicopathologic features and failed to add clinical benefit for decision making. The implementation of SII as a part of a panel of biomarkers in future studies might improve decision-making.

Bone Marrow Suppression during Postoperative Radiation for Bladder Cancer and Comparative Benefit of Proton Therapy—Phase 2 Trial Secondary Analysis

Purpose

For patients with high-risk bladder cancer (pT3⁺ or N⁺), local regional failure remains a challenge after chemotherapy and cystectomy. An ongoing prospective phase 2 trial (NCT01954173) is examining the role of postoperative photon radiation therapy for high-risk patients using volumetric modulated arc therapy. Proton beam therapy (PBT) may be beneficial in this setting to reduce hematologic toxicity. We evaluated for dosimetric relationships with pelvic bone marrow (PBM) and changes in hematologic counts before and after pelvic radiation therapy and explored the potential of PBT treatment plans to achieve reductions in PBM dose.

Materials and Methods

All enrolled patients were retrospectively analyzed after pelvic radiation per protocol with 50.4 to 55.8 Gy in 28 to 31 fractions. Comparative PBT plans were generated using pencil-beam scanning and a 3-beam multifield optimization technique. Changes in hematologic nadirs were assessed using paired t test. Correlation of mean nadirs and relative PBM dose levels were assessed using the Pearson correlation coefficient (CC).

Results

Eighteen patients with a median age of 70 were analyzed. Mean cell count values after radiation therapy decreased compared with preradiation therapy values for white blood cells (WBCs), absolute neutrophil count (ANC), absolute lymphocyte count (all P < .001), and platelets (P = .03). Increased mean PBM dose was associated with lower nadirs in WBC (Pearson CC −0.593, P = .02), ANC (Pearson CC −0.597, P = .02), and hemoglobin (Pearson CC −0.506, P = .046), whereas the PBM V30 to V40 correlated with lower WBC (Pearson CC −0.512 to −0.618, P < .05), and V20 to V30 correlated with lower ANC (Pearson CC −0.569 to −0.598, P < .04). Comparative proton therapy plans decreased the mean PBM dose from 26.5 Gy to 16.1 Gy (P < .001) and had significant reductions in the volume of PBM receiving doses from 5 to 40 Gy (P < .001).

Conclusion

Increased PBM mean dose and V20 to V40 were associated with lower hematologic nadirs. PBT plans reduced PBM dose and may be a valuable strategy to reduce the risk of hematologic toxicity in these patients.

Impact of the preoperative modified glasgow prognostic score on disease outcome after radical cystectomy for urothelial carcinoma of the bladder

BACKGROUND

To investigate the predictive and prognostic value of the preoperative modified Glasgow Prognostic Score (mGPS) in patients with urothelial carcinoma of the bladder (UCB) treated with radical cystectomy (RC).

METHODS

We conducted a retrospective analysis of an established multicenter database consisting of 4,335 patients who were treated with RC +/- adjuvant chemotherapy for UCB between 1979 and 2012. The mGPS of each patient was calculated on the basis of preoperative serum C-reactive protein and albumin. Uni- and multivariable logistic and Cox regression analyses were performed. The discriminatory ability of the models was assessed by calculating the area under receiver operating characteristics curves (AUC) and concordance-indices (C-Index). The additional clinical net-benefit was assessed using the decision curve analysis (DCA).

RESULTS

A mGPS of 0, 1, and 2 was observed in 3,158 (72.8%), 1,020 (23.5%), and 157 (3.6%) patients, respectively. On multivariable logistic regression analyses, mGPS of 1 or 2 were associated with an increased risk of pT3/4 disease at RC (OR 1.25, p=0.004 and OR 2.58, p<0.001, respectively) and/or lymph node metastasis (OR 1.7, p<0.001 and OR 3.9, p<0.001, respectively). Addition of the mGPS to a predictive model based on preoperatively available variables improved its accuracy for prediction of lymph node metastasis (change of AUC +3.7%, p<0.001). On multivariable Cox regression analyses, mGPS of 1 or 2 remained associated with worse recurrence-free survival (HR 1.14, p=0.03 and HR 1.89 p<0.001, respectively), cancer-specific survival (HR 1.16, p=0.032 and HR 2.1, p<0.001, respectively) and overall survival (HR 1.5, p=0.007 and HR 1.92 p<0.001, respectively) compared to mGPS of 0. The additional discriminatory ability of the mGPS for prognosis of survival outcomes in separate models that included either established pre- or postoperative variables did not improve the C-Index by a prognostically relevant degree (change of C-Index <2% for all models). On DCA, the inclusion of the mGPS did not meaningfully improve the net-benefit for clinical decision-making regarding survival outcomes.

CONCLUSIONS

We confirmed that an elevated mGPS is an independent risk factor for non-organ confined disease and poor survival outcomes in patients with UCB undergoing RC. However, the mGPS showed little value in improving the discriminatory ability of predictive and prognostic models that relied on either pre- or postoperative clinicopathological variables. The discriminatory ability of this biomarker in the age of immunotherapy warrants further evaluation.

Benefit of Adjuvant Chemotherapy After Radical Cystectomy for Treatment of Urothelial Carcinoma of the Bladder in the Elderly -An International Multicenter Study

BACKGROUND

Radical cystectomy (RC) is the standard treatment for muscle invasive bladder cancer, but approximately half of all patients will ultimately succumb to disease progression despite apparent cure with extirpative surgery. Elderly patients are at especially high risk of advanced disease and may benefit from perioperative systemic therapy.

OBJECTIVE

To assess the real-world benefit of adjuvant chemotherapy (AC) in patients ≥75 years old.

METHODS

We retrospectively reviewed patients who underwent RC for non-metastatic urothelial carcinoma of the bladder (UCB) from 12 participating international medical institutions. Kaplan-Meier survival curves and Cox regression models were used to assess the association between age groups, administration of AC and oncological outcome parameters such as recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS).

RESULTS

4,335 patients were included in the analyses, of which 820 (18.9%) were ≥75 years old. These elderly patients had a higher rate of adverse pathologic features. In an univariable subgroup analysis in patients ≥75 years with lymph node metastasis, 5-year OS was significantly higher in patients who had received AC (41% vs. 30.9%, p = 0.02). In a multivariable Cox model that was adjusted for several established outcome predictors, there was a significant favorable association between the administration of AC in elderly patients and OS, but no RFS or CSS.

CONCLUSIONS

In this large observational study, the administration of AC was associated with improved OS, but not RFS or CSS, in elderly patients treated with RC for UCB. This is of clinical importance, as elderly patients are more likely to have adverse pathologic features and experience worse survival outcomes. Treatment of UCB should include both a multidisciplinary approach and a geriatric evaluation to identify patients who are most likely to tolerate and benefit from AC.

Impact of preoperative plasma levels of interleukin 6 and interleukin 6 soluble receptor on disease outcomes after radical cystectomy for bladder cancer

Background

Preoperative plasma levels of Interleukin 6 (IL6) and its soluble receptor (IL6sR) have previously been associated with oncologic outcomes in urothelial carcinoma of the bladder (UCB); however, external validation in patients treated with radical cystectomy (RC) for UCB is missing.

Patients/methods

We prospectively collected preoperative plasma from 1,036 consecutive patients at two institutes. These plasma specimens were assessed for levels of IL6 and IL6sR. Logistic and Cox regression analyses were used to assess the correlation of plasma levels with pathologic and survival outcomes. The additional clinical net benefits of preoperative IL6 and IL6sR were evaluated using decision curve analysis (DCA).

Results

Median IL6 and IL6sR plasma levels were significantly higher in patients with adverse pathologic features. Elevated biomarker levels were independently associated with an increased risk for lymph node metastasis and ≥ pT3 disease. Both biomarkers were independently associated with recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). The addition to, respectively, fitted pre- and postoperative prognostic models improved the predictive accuracy for lymph node metastasis, ≥ pT3 disease, RFS and CSS on DCA.

Interpretation

We confirmed that elevated preoperative plasma levels of IL6 and IL6sR levels are associated with worse oncological disease survival in patients treated with RC for UCB in a large multicenter study. Both biomarkers hold potential in identifying patients with adverse pathological features that may benefit from intensified/multimodal therapy and warrant inclusion into predictive/prognostic models. They demonstrated the ability to improve the discriminatory power of such models and thus guide clinical decision making.

A panel of systemic inflammatory response biomarkers for outcome prediction in patients treated with radical cystectomy for urothelial carcinoma

Objectives

To determine the predictive and prognostic value of a panel of systemic inflammatory response (SIR) biomarkers relative to established clinicopathological variables in order to improve patient selection and facilitate more efficient delivery of peri‐operative systemic therapy.

Materials and Methods

The preoperative serum levels of a panel of SIR biomarkers, including albumin–globulin ratio, neutrophil–lymphocyte ratio, De Ritis ratio, monocyte–lymphocyte ratio and modified Glasgow prognostic score were assessed in 4199 patients treated with radical cystectomy for clinically non‐metastatic urothelial carcinoma of the bladder. Patients were randomly divided into a training and a testing cohort. A machine‐learning‐based variable selection approach (least absolute shrinkage and selection operator regression) was used for the fitting of several multivariable predictive and prognostic models. The outcomes of interest included prediction of upstaging to carcinoma invading bladder muscle (MIBC), lymph node involvement, pT3/4 disease, cancer‐specific survival (CSS) and recurrence‐free survival (RFS). The discriminatory ability of each model was either quantified by area under the receiver‐operating curves or by the C‐index. After validation and calibration of each model, a nomogram was created and decision‐curve analysis was used to evaluate the clinical net benefit.

Results

For all outcome variables, at least one SIR biomarker was selected by the machine‐learning process to be of high discriminative power during the fitting of the models. In the testing cohort, model performance evaluation for preoperative prediction of lymph node metastasis, ≥pT3 disease and upstaging to MIBC showed a 200‐fold bootstrap‐corrected area under the curve of 67.3%, 73% and 65.8%, respectively. For postoperative prognosis of CSS and RFS, a 200‐fold bootstrap corrected C‐index of 73.3% and 72.2%, respectively, was found. However, even the most predictive combinations of SIR biomarkers only marginally increased the discriminative ability of the respective model in comparison to established clinicopathological variables.

Conclusion

While our machine‐learning approach for fitting of the models with the highest discriminative ability incorporated several previously validated SIR biomarkers, these failed to improve the discriminative ability of the models to a clinically meaningful degree. While the prognostic and predictive value of such cheap and readily available biomarkers warrants further evaluation in the age of immunotherapy, additional novel biomarkers are still needed to improve risk stratification.

Immune checkpoint inhibition in muscle-invasive and locally advanced bladder cancer

PURPOSE OF REVIEW

Immune-checkpoint inhibitors (CPIs) have been implemented in the treatment algorithm of metastatic urothelial cancer as they have shown higher and more sustained responses compared with conventional second-line chemotherapy. Recently, several clinical trials have reported on CPIs in earlier disease stages such as muscle-invasive bladder cancer (MIBC). This review summarizes ongoing clinical trials and results from early phase clinical trials in muscle invasive and locally advanced bladder cancer.

RECENT FINDINGS

In phase II clinical trials, neoadjuvant use of CPIs as mono and combination therapy, in patients with MIBC planned for radical cystectomy, has shown promising pathological complete response rates. Whether this will translate in survival benefit remains to be assessed. Combination of CPIs and conventional chemotherapy or other targeted agents promises to increase the efficacy of perioperative systemic therapy with potentially additive toxicities. Recently, preclinical models of combined trimodal therapy with CPIs delivered the proof of principle leading to several ongoing trials in this setting.

SUMMARY

First results of clinical trials evaluating CPIs in MIBC demonstrate very promising results that warrant further investigation as they could revolutionize management of MIBC in the near future. The trend and hope are toward higher rates of safe and sustained bladder preservation.

Pre-therapy serum albumin-to-globulin ratio in patients treated with neoadjuvant chemotherapy and radical nephroureterectomy for upper tract urothelial carcinoma

PURPOSE

The accurate selection of patients who are most likely to benefit from neoadjuvant chemotherapy is an important challenge in oncology. Serum AGR has been found to be associated with oncological outcomes in various malignancies. We assessed the association of pre-therapy serum albumin-to-globulin ratio (AGR) with pathologic response and oncological outcomes in patients treated with neoadjuvant platin-based chemotherapy followed by radical nephroureterectomy (RNU) for clinically non-metastatic UTUC.

METHODS

We retrospectively included all clinically non-metastatic patients from a multicentric database who had neoadjuvant platin-based chemotherapy and RNU for UTUC. After assessing the pretreatment AGR cut-off value, we found 1.42 to have the maximum Youden index value. The overall population was therefore divided into two AGR groups using this cut-off (low, < 1.42 vs high, ≥ 1.42). A logistic regression was performed to measure the association with pathologic response after NAC. Univariable and multivariable Cox regression analyses tested the association of AGR with OS and RFS.

RESULTS

Of 172 patients, 58 (34%) patients had an AGR < 1.42. Median follow-up was 26 (IQR 11-56) months. In logistic regression, low AGR was not associated with pathologic response. On univariable analyses, pre-therapy serum AGR was neither associated with OS HR 1.15 (95% CI 0.77-1.74; p = 0.47) nor RFS HR 1.48 (95% CI 0.98-1.22; p = 0.06). These results remained true regardless of the response to NAC.

CONCLUSION

Pre-therapy low serum AGR before NAC followed by RNU for clinically high-risk UTUC was not associated with pathological response or long-term oncological outcomes. Biomarkers that can complement clinical factors in UTUC are needed as clinical staging and risk stratification are still suboptimal leading to both over and under treatment despite the availability of effective therapies.

Neoadjuvant therapy for muscle-invasive bladder cancer

INTRODUCTION

Muscle-invasive bladder cancer (MIBC) is generally a highly aggressive malignancy with early and mostly distant recurrences. Cisplatin-based combinations have been established as neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) providing overall survival as well as disease-free survival benefit. Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of metastatic urothelial carcinoma and are being tested in the neoadjuvant setting as well.

AREAS COVERED

This review covers the existing guidelines for the management of MIBC. It summarizes the use of different NAC regimens. It also discusses the published literature of ICIs in this setting and explores future perspectives.

EXPERT OPINION

Cisplatin-based NAC is the standard of care in MIBC prior to RC. Cisplatin-ineligible MIBC patients have not demonstrated to clearly benefit from a chemotherapy regimen and proceed directly to RC, although novel agents have been evaluated in this setting. Pembrolizumab and atezolizumab as monotherapy have shown feasibility and promising pathologic response rates. The combination of cisplatin-based chemotherapy with ICIs and chemotherapy-free ICI alone approaches are being investigated in randomized trials. Molecular subclassification and development of predictive biomarkers in MIBC will further help to identify optimal treatment strategies in these patients.

Effect of adjuvant chemotherapy in locally advanced urothelial carcinoma of the bladder treated with cystectomy

INTRODUCTION

Currently, the role of adjuvant chemotherapy (ADJ) in muscle invasive bladder tumor remains controversial.

OBJECTIVE

To evaluate the effect of ADJ on cancer specific survival of muscle invasive bladder tumor after radical cystectomy (RC).

MATERIAL AND METHODS

Retrospective analysis of 292 patients diagnosed with urothelial bladder tumor pT3-4pN0 / + cM0 stage, treated with RC between 1986-2009. Total cohort was divided in two groups: 185 (63.4%) patients treated with ADJ and 107 (36.6%) without ADJ. Median follow-up was 40.5 months (IQR 55-80.5). Comparative analysis was performed with Chi-square test and Student's t test /ANOVA. Survival analysis was carried out with the Kaplan-Meier method and log-rank test. Multivariate analysis (Cox regression) was made to identify independent predictors of cancer-specific mortality (CSM).

RESULTS

42.8% of the series presented lymph node involvement after RC. At the end of follow-up, 22.9% were BC-free and 54.8% had died due to this cause. The median cancer specific survival was 30 months. No significant differences were observed in cancer specific survival regarding the treatment with ADJ in pT3pN0 (p=.25) or pT4pN0 (p=.29) patients, but it was significant in pT3-4pN+ (p=.001). Multivariate analysis showed pathological stage (p=.0001) and treatment with ADJ (p=.007) as independent prognostic factors for CSM. ADJ reduced the risk of CSM (HR:0.59,95% CI 0.40-0.87, p=.007).

CONCLUSIONS

pT and pN stages were identified as independent predictors of CSM after RC. The administration of ADJ in our series behaved as a protective factor reducing the risk of CSM, although only pN+ patients were benefited in the stage analysis.

A novel gene signature combination improves the prediction of overall survival in urinary bladder cancer

Objectives: Bladder carcinoma is a clinical heterogeneous disease, which is with significant variability of the prognosis and high risk of death. This revealed prominently the need to identify high-efficiency cancer characteristics to predict clinical prognosis.

Methods: Gene expression profiles of 93 bladder tumor patients from Gene Expression Omnibus data sets was performed in this study, along with 408 bladder tumor patients retrieved from The Cancer Genome Atlas database. The relationship of gene signature and overall survival was analyzed in the training cohort (n = 46). The validation for that was performed in an internal validation cohort (n = 47) and an external validation cohort (n = 408).

Results: Four genes (TMPRSS11E, SCEL, KRT78, TMEM185A) were identified by univariable and multivariable Cox regression analysis. According to a risk score on the bases on the four-gene signature, we grouped these patients in high-risk group and low-risk group with significantly different overall survival in the training series and successfully validated it in both the internal and external validation cohorts. Subsequent studies demonstrated that the four-gene expression risk score was independent of radical cystectomy stage, chemotherapy and lymph node status. Higher rates of FAT4 mutation and MACF1 mutation in bladder tumors with high risk score were found compared with tumors with low risk score. Gene set enrichment analysis revealed high-risk score was associated with some tumor progression and recurrence associated pathways.

Conclusions: This four-gene risk score might have potential clinical implications in the selection of high-risk urinary bladder cancer patients for aggressive therapy. The selected four genes might become potential therapeutic targets and diagnostic markers for urinary bladder cancer.

Do Younger Patients with Muscle-Invasive Bladder Cancer have Better Outcomes?

Urothelial cancer of the bladder (UCB) is usually a disease of the elderly. The influence of age on oncological outcomes remains controversial. This study aims to investigate the impact of age on UCB outcomes in Europe focusing particularly on young and very young patients. We collected data of 669 UCB patients treated with RC at our tertiary care center. We used various categorical stratifications as well as continuous age to investigate the association of age and tumor biology as well as endpoints with descriptive statistics and Cox regression. The median age was 67 years and the mean follow-up was 52 months. Eight patients (1.2%) were ≤40 years old and 39 patients (5.8%) were aged 41-50 years, respectively. In multivariable analysis, higher continuous age and age above the median were independent predictors for disease recurrence, and cancer-specific and overall mortality (all p-values ≤ 0.018). In addition, patients with age in the oldest tertile group had inferior cancer-specific and overall survival rates compared to their younger counterparts. Young (40-50 years) and very young (≤40 years) patients had reduced hazards for all endpoints, which, however, were not statistically significant. Age remains an independent determinant for survival after RC. Young adults did, however, not have superior outcomes in our analyses. Quality of life and complications are endpoints that need further evaluation in patients undergoing RC.

Can Biomarkers Guide the Use of Neoadjuvant Chemotherapy in T2 Bladder Cancer?

Current guidelines recommend cisplatin-based neoadjuvant chemotherapy prior to radical cystectomy as the preferred treatment of muscle-invasive bladder cancer. Nevertheless, for multiple reasons compliance with this guideline recommendation is low. This is particularly evident in clinical T2 bladder cancer, where controversy exists regarding the role of proceeding with radical cystectomy alone. Novel biomarkers such as molecular phenotype and DNA damage repair and response gene alterations may be able to predict who will respond to cisplatin-based neoadjuvant chemotherapy. This clinical problem is discussed, and a recommendation is made given the current state of the art. PATIENT SUMMARY: Neoadjuvant chemotherapy improves survival for patients with muscle-invasive bladder cancer. In the future, perhaps validated biomarkers may predict who should and should not receive this treatment.

Treatment Options and Outcomes in Nonmetastatic Muscle Invasive Bladder Cancer

Muscle-invasive bladder cancer (MIBC) represents 25% of newly diagnosed bladder cancer. MIBC is aggressive and requires timely management. The current standard of care is neoadjuvant chemotherapy followed by radical cystectomy, an approach that could result in significant morbidities. Modifications in the chemotherapy regimens, as well as in perioperative care and surgical approach, have resulted in better overall toxicity profile and faster recovery. However, bladder-preservation in carefully selected patients can lead to acceptable oncological outcomes and better quality of life. Optimization of bladder-preservation protocols and proper identification of patients who tolerate and respond to various treatment modalities will significantly impact patient survival in the coming future.

Adjuvant chemotherapy versus observation after radical cystectomy in patients with node-positive bladder cancer

This retrospective study compared adjuvant chemotherapy (AC) versus observation after radical cystectomy (RC) in patients with node-positive bladder cancer (pN+). Outcomes were reviewed in patients with pTanyN1-3M0 bladder cancer who underwent RC with or without AC between 1995 and 2017. Baseline characteristics between the two groups were controlled with inverse probability of treatment weighting (IPTW)-adjusted analyses. Of 281 enrolled patients, the 3-year IPTW-adjusted rates of overall survival was higher in the AC group than the RC group (46.4% vs. 33.7%, p = 0.024). AC was an independent predictor of overall survival (hazard ratio = 0.48; P < 0.0001). When patients were subdivided by lymph node density (LND), the 3-year overall survival rates were similar between the AC and RC groups in patients with LND < 9%, but higher in the AC group in patients with LND 9–25% (53.4% vs. 23.7%) and LND ≥ 25% (27.4% vs. 16.1%). The numbers needed to treat to prevent one death at 3 years were three and nine in patients with LND 9–25% and ≥25%, respectively. In conclusion, AC after RC was associated with improved overall survival in patients with node-positive bladder cancer. Patients with an intermediate nodal burden may benefit most from AC.

Tumor stroma-infiltrating mast cells predict prognosis and adjuvant chemotherapeutic benefits in patients with muscle invasive bladder cancer

Which subgroups patients with muscle-invasive bladder cancer (MIBC) could benefit most from adjuvant chemotherapy (ACT) is blurred. Here we tried to stratify MIBC patients with tumor infiltrating mast cells (TIMs), explore the prognostic and predictive value of TIMs, and provide possible cellular explanations. We selected 259 MIBC patients who underwent radical cystectomy from two independent clinical centers between 2002 and 2014. TIMs were evaluated and prognostic and predictive value was assessed. The CIBERSORT method, Gene Set Enrichment Analysis (GSEA) and differential gene expression analyses were performed to explore the possible cellular mechanisms. TIMs infiltration was distinct between stromal and epithelial area of MIBC specimens. Patients with higher stromal TIMs had a significant worse overall survival and recurrence free survival (HR = 2.228, 95%CI: 1.467-3.550; P = 0.001 and HR = 1.984, 95%CI: 1.105-3.374; P = 0.016). More importantly, pT2 patients with low stromal TIMs tended to have a lower risk of death and recurrence after ACT (HR = 0.233, 95%CI: 0.020-0.814; P = 0.033 and HR = 0.180, 95%CI: 0.022-0.722; P = 0.031). A negative correlativity between TIMs and CD8 + T cells was identified on TCGA-BLCA cohort. Immunohistochemistry results validated that high stromal TIMs were negatively correlated with CD8 + T cells (Spearman's rho = -0.215, P < 0.001). Differential gene expression suggested that low TIMs might represent a state of immune activation in MIBC. To conclude, high stromal TIMs infiltration was an independent unfavorable prognosticator for MIBC patients. Patients with low stromal TIMs might benefit the most from ACT, especially in pT2 stage.

Emerging first line treatment options for bladder cancer: a review of phase II and III therapies in the pipeline

INTRODUCTION

The treatment of urothelial carcinoma (UC) had remained unchanged for several years until the recent FDA approval of immune checkpoint inhibitors (CPIs) in the salvage setting. Novel dual CPI-CPI and CPI-chemotherapy combinations are now being investigated aggressively as first line therapy for metastatic disease. Areas covered: We discuss the recent insights into the tumor biology of UC, which may impact the prognosis as well as assist in developing precision medicine. This is followed by an overview of existing treatment including conventional chemotherapy as well as the trials that led to the recent approval of PD-1 and PD-L1 inhibitors. Ongoing phase II and phase III trials developing PD-1/PD-L1 inhibitors, CTLA-4 inhibitors and VEGF inhibitors as first-line therapy are discussed. Expert opinion: The treatment paradigm for the first-line therapy of UC is expected to shift from conventional platinum-based combination chemotherapy towards novel therapy incorporating CPI immunotherapy. Finding the right combination of drugs in the appropriate disease setting and identifying the right patient population based on biomarkers are important questions to be answered. Another major challenge will be the financial burden associated with these new drugs.

Peri-operative chemotherapy for muscle-invasive bladder cancer: status-quo in 2017

The role of perioperative chemotherapy associated with radical cystectomy (RC) for muscle-invasive bladder cancer has been analyzed in several landmark randomized controlled trials (RCTs) over the past decades. With regard to neoadjuvant chemotherapy (NAC), a meta-analysis of level 1 evidence and long-term results from the largest RCTs support its use, which is currently advocated as the standard of care by most of the clinical guidelines worldwide. However, with regard to the delivery of adjuvant chemotherapy (AC), evidence is more contentious. Specifically, several meta-analyses demonstrated a survival benefit associated with the use of cisplatin-based regimen but investigators identified multiple methodological limitations in most of included RCTs. Nonetheless, AC is currently considered for fit patients with adverse pathological features at RC. It is noteworthy that the delivery of such cytotoxic treatment after surgery may maintain significant anti-tumor activity even in those patients who previously received NAC. Finally, given its greater response rate, the methotrexate, vinblastine, adriamycin plus cisplatin combination remains preferentially considered in the neoadjuvant setting, while the gemcitabine plus cisplatin combination is more commonly delivered in the adjuvant setting because of its better toxicity profile. However, no prospective evidence comparing efficacy of both regimens for NAC or AC is currently available.

Systemic, perioperative management of muscle-invasive bladder cancer and future horizons

Many patients diagnosed with muscle-invasive bladder cancer (MIBC) will develop distant metastatic disease. Over the past three decades, perioperative cisplatin-based chemotherapy has been investigated for its ability to reduce the number of deaths from bladder cancer. Insufficient evidence is available to fully support the use of such chemotherapy in the adjuvant setting; however, neoadjuvant cisplatin-based combination chemotherapy has become a standard of care for eligible patients based on the improved disease-specific and overall survival demonstrated in two randomized phase III trials, compared with surgery alone. For patients with disease downstaging to non-MIBC at the time of radical cystectomy as a result of neoadjuvant chemotherapy, outcomes are outstanding, with 5-year overall survival of 80-90%. Nevertheless, the inability to define before treatment the patients who will and those who will not achieve such a response has impeded the achievement of better outcomes for patients with MIBC. High-throughput DNA and RNA profiling technologies might help to overcome this barrier and enable a more-personalized approach to the use of cytotoxic neoadjuvant chemotherapy. In the past 2 years, trial results have demonstrated the unprecedented ability of immune- checkpoint blockade to induce durable remissions in patients with metastatic disease that has progressed after chemotherapy; studies are now urgently needed to determine how best to incorporate this powerful therapeutic modality into the care of patients with MIBC. Herein, we review the evolution of chemotherapy and immunotherapy for muscle-invasive bladder cancer.

Systemic therapy in bladder cancer

Systemic chemotherapy is essential for the management of muscle-invasive bladder cancer (MIBC) and metastatic bladder cancer (BCa). Neoadjuvant chemotherapy is key to the management of MIBC with many cisplatin-based regimens. Adjuvant chemotherapy may be considered for selected patients who did not receive neoadjuvant therapy. Systemic chemotherapy with radiotherapy is a critical component of a trimodal bladder-preserving approach and is superior to radiotherapy alone. Cisplatin-based chemotherapy has been the mainstay for metastatic BCa. Immunotherapy in the form of checkpoint inhibitors is a promising new drug for the treatment of BCa. Molecular characterization of each individual BCa is likely to lead to a target-directed therapeutic revolution.

Contemporary update on neoadjuvant therapy for bladder cancer

Administration of neoadjuvant chemotherapy preceding radical cystectomy in patients with bladder cancer remains a matter of debate. Results of prospective, randomized studies have demonstrated an overall absolute survival benefit of 5% at 5 years, provided cisplatin-based combination regimens are used. Owing to the perception of a modest survival benefit, the medical community has been slow to adopt the use of neoadjuvant chemotherapy. Other reasons for the underuse of neoadjuvant chemotherapy range from patient ineligibility to fear of delaying potentially curative surgery in nonresponders. Instead, several institutions have adopted an individualized, risk-adapted approach, in which the decision to administer chemotherapy is based on clinical stage and patient comorbidity profile. The development of new cytotoxic and targeted therapies, in particular immune checkpoint inhibitors, warrants well-designed prospective studies to test their efficacy alone or in combination in the neoadjuvant setting. Moving forward, genomic characterization of muscle-invasive bladder cancer could offer information that aids clinicians in selecting the appropriate chemotherapy regimen. Following neoadjuvant therapy, every effort should be made to ensure optimal surgery, as surgical margins and the number of removed lymph nodes are prognostic factors; thus, radical cystectomy and a meticulous extended pelvic lymph node dissection should be performed by expert surgeons.

Adjuvant Chemotherapy After Radical Cystectomy for Urothelial Bladder Cancer: Outcome and Prognostic Factors for Survival in a French Multicenter, Contemporary Cohort

BACKGROUND

In the past decade, adjuvant chemotherapy (AC) after radical cystectomy (RC) was preferred worldwide for patients with muscle-invasive urothelial bladder cancer. In this study we aimed to determine the outcome of patients who received AC and evaluated prognostic factors associated with survival.

PATIENTS AND METHODS

We retrospectively analyzed 226 consecutive patients treated in 6 academic hospitals between 2000 and 2009. Multivariate Cox proportional hazards regression adjusted for center to estimate adjusted hazard ratios (HRs) with 95% confidence intervals were used.

RESULTS

The median age was 62.4 (range, 35-82) years. Patients had pT3/pT4 and/or pN+ in 180 (79.6%) and 168 patients (74.3%), respectively. Median lymph node (LN) density was 25% (range, 3.1-100). Median time between RC and AC was 61.5 (range, 18-162) days. Gemcitabine with cisplatin, gemcitabine with carboplatin, and MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) regimens were delivered in 161 (71.2%), 49 (21.7%), and 12 patients (5.3%) of patients, respectively. The median number of cycles was 4 (range, 1-6). Thirteen patients (5.7%) with LN metastases also received adjuvant pelvic radiotherapy (ART). After a median follow-up of 4.2 years, 5-year overall survival (OS) was 40.7%. In multivariate analysis, pT ≥3 stage (HR, 1.73; P = .05), LN density >50% (HR, 1.94; P = .03), and number of AC cycles <4 (HR, 4.26; P = .001) were adverse prognostic factors for OS. ART (HR, 0.30; P = .05) tended to provide survival benefit.

CONCLUSION

Classical prognostic features associated with survival are not modified by the use of AC. Patients who derived benefit from AC had a low LN density and received at least 4 cycles of treatment.