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Abufaraj M, Al Karmi J, Bdeir A. Is there a role for metastasis-directed therapy in bladder cancer? Curr Opin Urol 2024; 34:273-280. [PMID: 38587010 DOI: 10.1097/mou.0000000000001174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
PURPOSE OF REVIEW This article aims to comprehensively review and critique the existing literature on the role of metastatic-directed therapy in patients with metastatic bladder cancer, particularly in oligometastatic disease state. RECENT FINDINGS The role of metastasectomy in metastatic bladder cancer is still controversial. Several studies have demonstrated improved outcomes, particularly in a highly selected patients with small metastatic lesions or with lung or brain metastases, whereas others show no significant survival benefit. Combining metastasectomy with systemic therapies, such as immunotherapy and chemotherapy, has also shown benefits. Metastasis-directed radiotherapy is evolving as a potentially effective approach with minimal toxicity in achieving local control and improving survival, particularly in patients with oligometastatic disease. The evidence regarding the impact of several factors such as performance status, metastatic burden, and the presence of visceral metastases on outcomes is mixed. Concurrent treatment with systemic therapy may potentiate the effectiveness of metastasis-directed therapy. SUMMARY In patients with metastatic deposits amenable to surgical resection, metastasectomy stands as a promising avenue. Metastatic-directed radiotherapy has demonstrated local control and improved survival in the evolving landscape of oligometastatic bladder cancer management. Further, well designed multicenter prospective studies are needed to support these findings and better understand the synergy between radiotherapy and systemic treatments, especially immunotherapy.
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Affiliation(s)
- Mohammad Abufaraj
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Division of Urology, Department of Special Surgery, Jordan University Hospital
| | - Joud Al Karmi
- Faculty of Medicine, The University of Jordan, Amman, Jordan
| | - Adan Bdeir
- Faculty of Medicine, The University of Jordan, Amman, Jordan
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Svedman FC, Holmsten K, Jawdat F, Hailom W, Alm D, Grozman V, Ullén A. Stereotactic body radiation therapy is beneficial for a subgroup of patients with urothelial cancer and solitary metastatic disease: a single institution real-world experience. Radiat Oncol 2024; 19:74. [PMID: 38880908 PMCID: PMC11181669 DOI: 10.1186/s13014-024-02465-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/06/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Standard treatment options for patients with metastatic urothelial cancer (mUC) include systemic platinum-based chemotherapy, immunotherapy, antibody-drug-conjugates, and targeted therapy. Oligometastatic disease (OMD) may be an intermediate state between localized and generalized cancer. The best treatment strategy for OMD and oligoprogressive (OPD) disease is poorly studied in mUC but local stereotactic body radiation therapy (SBRT) could be an option to avoid or delay systemic treatment. The aim of this study was to assess the efficacy and feasibility of SBRT given in a real-world patient population. METHODS All patients with mUC treated with SBRT at Karolinska University Hospital, Stockholm, Sweden between 2009 and 2022 were included in this study. Baseline clinical characteristics, treatment data, SBRT dosimetry data and treatment outcome were collected retrospectively. The study endpoints were local control rate (LCR), progression-free-survival (PFS), overall survival (OS) and feasibility of SBRT. RESULTS In total 39 patients were treated with SBRT. The median follow-up was 25.6 months. The LCR was 82%. PFS and OS were 4.1 and 26.2 months, respectively. Treatment was well tolerated; all patients but one (treatment related pain) completed the planned SBRT. Number of metastases irradiated with SBRT was significantly associated with outcome; patients with only one irradiated lesion had more favourable PFS compared to individuals with 2 or more metastases (HR 4.12, 95% CI: 1.81-9.38, p = 0.001). A subgroup of patients (15%) achieved a sustained long-term survival benefit and never required systemic treatments after SBRT. CONCLUSIONS SBRT was well tolerated and associated with high LCR. A subpopulation of patients with single metastatic lesion achieved long-term OS and never required subsequent systemic treatment after SBRT. Prospective randomized studies are warranted to discover treatment predictive biomarkers and to investigate the role of SBRT in oligometastatic UC.
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Affiliation(s)
- Fernanda Costa Svedman
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden.
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Theme Cancer, Karolinska University Hospital, Stockholm, 171 76, Sweden.
| | - Karin Holmsten
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Oncology, Capio S:t Göran Hospital, Stockholm, Sweden
| | - Faith Jawdat
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Theme Cancer, Karolinska University Hospital, Stockholm, 171 76, Sweden
| | - Wehazit Hailom
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Theme Cancer, Karolinska University Hospital, Stockholm, 171 76, Sweden
| | - Daniel Alm
- Department of Radiation Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Vitali Grozman
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Anders Ullén
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Theme Cancer, Karolinska University Hospital, Stockholm, 171 76, Sweden
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Poon DMC, Ho LY, Kwong YM. Avelumab maintenance therapy for node-positive muscle invasive bladder cancer: a report of two cases. Front Oncol 2024; 14:1397738. [PMID: 38863626 PMCID: PMC11165194 DOI: 10.3389/fonc.2024.1397738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/10/2024] [Indexed: 06/13/2024] Open
Abstract
Background Muscle-invasive bladder cancer (MIBC) with nodal involvement is associated with poor prognosis and high mortality. Treatment of node-positive MIBC is complex due to disease heterogeneity and a lack of evidence-based treatment options, especially alternatives to radical cystectomy. We describe a bladder-sparing management approach involving systemic therapy followed by maintenance therapy, illustrated with two cases of node-positive MIBC. Case presentation Two patients with node-positive MIBC received upfront gemcitabine/cisplatin chemotherapy, concurrent chemoradiotherapy (cCRT), and avelumab (immune checkpoint inhibitor) maintenance therapy. Both patients achieved complete remission without recurrence or distant metastasis post-avelumab maintenance therapy. At the last follow-up, Patient 1 (45-year-old male) was in remission for over two years, and Patient 2 (57-year-old male) was in complete remission for over one year post-chemotherapy. Avelumab treatment was well-tolerated, with no immune-related adverse events, and quality of life (QoL) was maintained. Conclusion Both cases showed a good response and extended remission on avelumab maintenance, supporting its use in conjunction with local consolidation therapy as a bladder-preserving approach in node-positive MIBC. Further research, such as the ongoing INSPIRE trial, is required to refine treatment strategies for this patient group.
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Affiliation(s)
- Darren M. C. Poon
- Comprehensive Oncology Centre, Hong Kong Sanatorium & Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Lap Yin Ho
- J ABLE Medical Center, Hong Kong, Hong Kong SAR, China
| | - Yiu Ming Kwong
- Urology Center, Hong Kong Sanatorium & Hospital, Hong Kong, Hong Kong SAR, China
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Liu MA, Li JW, Runcie K. Management of Oligometastatic and Locally Recurrent Urothelial Carcinoma. Curr Oncol Rep 2024; 26:496-503. [PMID: 38602581 DOI: 10.1007/s11912-024-01523-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/12/2024]
Abstract
PURPOSE OF REVIEW To summarize and evaluate the literature on treatment approaches for oligometastatic and locally recurrent urothelial cancer. RECENT FINDINGS There is no clear definition for oligometastatic urothelial cancers due to limited data. Studies focusing on oligometastatic and locally recurrent urothelial cancer have been primarily retrospective. Treatment options include local therapy with surgery or radiation, and generalized systemic therapy such as chemotherapy or immunotherapy. Oligometastatic and locally recurrent urothelial cancers remain challenging to manage, and treatment requires an interdisciplinary approach. Systemic therapy is nearly always a component of current care in the form of chemotherapy, but the role of immunotherapy has not been explored. Consideration of surgical and radiation options may improve outcomes, and no studies have compared directly between the two localized treatment options. The development of new prognostic and predictive biomarkers may also enhance the treatment landscape in the future.
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Affiliation(s)
- Michael A Liu
- Division of Hematology and Oncology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Jennifer W Li
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Karie Runcie
- Division of Hematology and Oncology, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA.
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Calleris G, von Deimling M, Kesch C, Soria F, Gontero P, Ploussard G, Laukhtina E, Pradere B. Definitions, outcomes and perspectives for oligometastatic bladder cancer: towards a standardized terminology. Curr Opin Urol 2024; 34:217-224. [PMID: 38426242 DOI: 10.1097/mou.0000000000001170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
PURPOSE OF REVIEW Oligometastatic (om) cancer is considered as a transitional state in between locally confined disease and widespread metastases, accessible to a multimodal treatment, combining systemic and local therapy. In urothelial bladder cancer (BCa), the definitions and the approaches to this condition are poorly standardised and mainly based on retrospective data. We aim to portray the framework for uro-oncologic terminology in omBCa and go through the latest evidence and the future perspectives. RECENT FINDINGS Retrospective and registry data support the potential benefits of multimodality treatment for carefully selected omBCa patients, especially following a good response to systemic treatment. In 2023, a Delphi consensus has defined omBCa, allowing maximum three metastatic lesions, theoretically amenable to radical local treatment. In de-novo omBCa, surgical treatment of primary tumour might improve overall survival (OS), according to a matched registry analysis; also, consolidative radiotherapy was associated with better OS in two recent cohorts. Furthermore, metastasis-directed therapy (MDT) has shown high local control rates and promising OS (14.9-51 months) in a meta-analysis; benefits might be more pronounced for single-site omBCa and nodal or lung lesions. SUMMARY From a clinical perspective, in de-novo omBCa, the local treatment of primary and metastatic sites might improve disease control and survival, in selected patients; in the oligorecurrent setting, MDT achieves good local symptom control with limited side effects; in selected cases, it could convey a survival benefit, too. From a research perspective, well designed prospective evidence is eagerly awaited, based on recently adopted shared definitions for omBCa.
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Affiliation(s)
- Giorgio Calleris
- Department of Urology UROSUD, La Croix du Sud Hospital, Quint-Fonsegrives, France
- Polytechnic and University of Turin, Turin, Italy
| | - Markus von Deimling
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Claudia Kesch
- Department of Urology UROSUD, La Croix du Sud Hospital, Quint-Fonsegrives, France
- Department of Urology and West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Guillaume Ploussard
- Department of Urology UROSUD, La Croix du Sud Hospital, Quint-Fonsegrives, France
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Benjamin Pradere
- Department of Urology UROSUD, La Croix du Sud Hospital, Quint-Fonsegrives, France
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Ashley S, Choudhury A, Hoskin P, Song Y, Maitre P. Radiotherapy in metastatic bladder cancer. World J Urol 2024; 42:47. [PMID: 38244091 PMCID: PMC10799782 DOI: 10.1007/s00345-023-04744-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/30/2023] [Indexed: 01/22/2024] Open
Abstract
PURPOSE To review available and emerging evidence of radiotherapy for symptom management and disease control in metastatic bladder cancer. METHODS A literature search and subsequent cross-referencing were carried out for articles in the PubMed and Scopus databases using terms 'radiotherapy' OR 'palliative radiation therapy' with 'metastatic bladder cancer' OR 'advanced bladder cancer' between 1990 and 2023, excluding articles with no English translation. RESULTS Palliative radiotherapy is an effective and accessible treatment for the alleviation of haematuria and pain due to the primary and metastatic disease. With growing recognition of oligometastatic disease state at diagnosis, response, or progression, radiotherapy can consolidate response by ablating residual or resistant lesions. Experience with other primary cancers supports positive impact of radiotherapy on disease control, quality of life, and survival in oligometastatic stage, without significant adverse effects. Alongside immune checkpoint inhibitors, fibroblast growth receptor inhibitors, and antibody-drug conjugates, the immunomodulatory potential of radiotherapy is being explored in combination with these systemic therapies for metastatic bladder cancer. CONCLUSION Radiotherapy is an effective, safe, and accessible treatment modality for palliation as well as disease control in various clinical settings of metastatic bladder cancer. Its role in oligometastatic stage in combination with systemic therapy is expected to expand with emerging evidence.
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Affiliation(s)
- Sophie Ashley
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Ananya Choudhury
- The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Manchester Biomedical Research Centre, Manchester, United Kingdom
| | - Peter Hoskin
- The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - YeePei Song
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Priyamvada Maitre
- The Christie NHS Foundation Trust, Manchester, United Kingdom.
- Department of Radiation Oncology, Tata Memorial Hospital and Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Ernest Borges Road, Parel, Mumbai, India.
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Bamias A, Stenzl A, Zagouri F, Andrikopoulou A, Hoskin P. Defining Oligometastatic Bladder Cancer: A Systematic Review. EUR UROL SUPPL 2023; 55:28-37. [PMID: 37662704 PMCID: PMC10468799 DOI: 10.1016/j.euros.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Context Unlike other cancers, the concept of oligometastatic disease (OMD) in bladder cancer (BC) has not been systematically investigated. There is therefore a need to develop universally accepted definitions and guidelines for the management of oligometastatic BC (OMBC). Objective To conduct a systematic review to assist a European consensus group in producing a definition of OMBC and to provide recommendations on staging and local therapies. Evidence acquisition The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. Abstracts for articles focused on BC that addressed the issue of OMBC and provided a definition of oligometastatic status were selected. We collected data on the number of metastases, the number of metastases per organ, the number of organs involved, and metastatic sites that were excluded. Evidence synthesis Sixteen eligible articles were retrieved (9 retrospective series involving 330 patients, 4 reviews, 1 consensus statement, 1 guideline paper, and 1 ongoing prospective phase 2 trial). A maximum of three to five metastatic lesions were compatible with the definition of OMBC. The number of organs involved and lesion size were not universally included in the OMBC definitions. OMD categories studied included synchronous OMBC, oligorecurrence, and oligoprogression. 18F-Fluorodeoxyglucose positron emission tomography combined with computed tomography was used in addition to conventional imaging for OMD detection. Surgery and radiotherapy were both used. Systemic chemotherapy was also used in all studies. Conclusions There is little information on OMBC in the literature. Our systematic review revealed that only three to five metastatic sites amenable to surgery or radiotherapy that respond to systemic therapy is the setting most frequently chosen for a combination of systemic treatment and metastases-directed therapy. This setting could represent a basis for future prospective studies on OMBC. Patient summary Oligometastatic bladder cancer is a disease state in which favorable outcomes can be expected after a treatment combination of systemic therapy, plus surgery and/or radiotherapy for sites of bladder cancer metastasis. Our systematic review showed a lack of meaningful evidence to define this disease state. There is an urgent need to develop organized research in this field.
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Affiliation(s)
- Aristotelis Bamias
- Second Propaedeutic Department of Internal Medicine, National & Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
- Hellenic GU Cancer Group, Athens, Greece
| | - Arnulf Stenzl
- Department of Urology, University Medical Centre, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Flora Zagouri
- Hellenic GU Cancer Group, Athens, Greece
- Department of Clinical Therapeutics, National & Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Angeliki Andrikopoulou
- Department of Clinical Therapeutics, National & Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Peter Hoskin
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
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