Bladder-sparing treatment for muscle-invasive bladder carcinoma using immune checkpoint inhibitors

Multimodal bladder preservation therapy is already an alternative for patients with muscle-invasive bladder cancer (MIBC) who are unable or unwilling to undergo radical cystectomy. Various bladder-preserving strategies that employ immune checkpoint inhibitors (ICIs) for MIBC have been investigated. There are three common modes of ICI-based bladder preservation therapy, of which the most studied is ICIs combined with chemoradiotherapy. The bladder-preserving strategy of ICIs combined with radiation has been investigated in patients who poorly tolerate chemotherapy. ICIs combined with chemotherapy have also been explored in patients who responded to neoadjuvant therapy with a clinical complete response. All the above-described strategies have shown promising efficacy and manageable safety profiles. However, the value of programmed death-ligand 1 (PD-L1) expression, tumor mutation burden and gene alterations for predicting the efficacy of immune-based bladder preservation therapy is still controversial. There remain some challenges for immune-based bladder preservation therapy, and large-sample randomized trials are needed.

Combination of radiation and immunotherapy in the treatment of genitourinary malignancies: A systematic review and meta-analysis

BACKGROUND

Due to possible synergistic effects, the combination of radiation therapy (RT) and immune checkpoint inhibitors (ICI) represents an interesting therapeutic option. An increasing number of clinical trials are ongoing to investigate this combination in genitourinary malignancies and the first results are available.

OBJECTIVES

To review and summarize available data on the combination of RT and ICI in genitourinary malignancies and update the evidence for this potential therapeutic approach.

EVIDENCE ACQUISITION

A study protocol was registered in the PROSPERO-Database. Terms of search were prostate cancer, bladder cancer, renal cell carcinoma, penile cancer, testicular cancer, radiotherapy, and immunotherapy in multiple literature databases and study registers. Clinical studies reporting on the combination treatment of RT and ICI were included. A systematic review of ongoing trials according to the PRISMA statement and a meta-analysis of available trials were performed.

EVIDENCE SYNTHESIS

Overall, 43 studies met the inclusion criteria examining the therapeutic effect of combined RT and ICI. For bladder cancer, renal cell carcinoma, prostate cancer, and penile cancer 28, 9, 5, and 1 trial could be identified, respectively. No study was found for testicular cancer. Three phases III trials were identified, all other trials were phase I or II. Twelve studies have been completed so far. The meta-analysis of available data indicates comparable toxicity of RT plus ICI vs. ICI alone for grade 3/4 AEs. Mature efficacy data is limited with interesting early results.

CONCLUSION

This article reviews the clinical trial landscape investigating RT and ICI in genitourinary malignancies. It provides an overview of ongoing trials and discusses available results. Actual data regarding efficacy is limited, while toxicities seem comparable to ICI alone. Especially in bladder and kidney cancer, further trial results might impact on the clinical use of the combination therapy.