Conservative treatment of invasive bladder cancer

Conservative Management of Muscle Invasive Bladder Cancer in Kidney-Pancreas Transplant Patient

Introduction. Solid organ transplant increases the risk for muscle-invasive bladder cancer (MIBC). Although a common tumor, urothelial cell carcinoma (UCC) of the bladder in patients with kidney-pancreas transplants is scarcely reported. Case Presentation. A 65-year-old male with history of type 1 diabetes and a 14-year status post deceased donor pancreas-kidney transplant presented with 3 weeks of gross hematuria. CT scan showed multiple bladder masses. Transurethral resection of bladder tumor (TURBT) showed papillary UCC. 5 months later, the patient reported new-onset gross hematuria. TURBT showed MIBC. The patient elected for bladder-preserving TMT. On cystoscopy there was no gross evidence of carcinoma at 3.5 years of follow up. Discussion. Currently, no specific management guidelines target this population with MIBC. The first-line treatment for MIBC is radical cystectomy (RC) with neoadjuvant chemotherapy. For patients that are medically unfit or unwilling to undergo RC, trimodal therapy (TMT) is an alternative. TMT for bladder cancer consists of complete tumor resection with chemotherapy and radiation. This report demonstrates a unique case of a patient with kidney-pancreas transplant diagnosed with MIBC treated with TMT that has no evidence of gross tumorigenesis at 3.5 years after diagnosis. Our findings suggest that trimodal therapy should be considered for treatment of MIBC in patients with kidney-pancreatic transplants to preserve the donated allografts.

Bladder Preservation with Neoadjuvant Chemotherapy Followed by Concurrent Chemoradiation for the Treatment of Muscle-invasive Carcinoma of the Bladder: A Single-Center Experience

Purpose  The purpose of the study was to evaluate the short-term response and acute toxicities in muscle-invasive carcinoma urinary bladder treated with neoadjuvant chemotherapy followed by concurrent chemoradiation.

Materials and Methods  Thirty patients with muscle-invasive bladder cancer were treated with three cycles of neoadjuvant chemotherapy every 3 weeks. Response assessment was done after 4 weeks with repeat cystoscopy and imaging. Responders were treated with concurrent chemoradiation 60 Gy/30# at 2 Gy/# along with weekly injection cisplatin 35 mg/m ² . Response assessment was done by new response evaluation criteria in solid tumors (version 1.1). Treatment-related acute toxicities were scored using common terminology criteria for adverse events version 4.0.

Results  Of the 30 patients, 25 patients responded to neoadjuvant chemotherapy with complete response in 17 patients (56.67%) and partial response in eight patients (26.66%). Five patients (16.66%) showed poor response and were advised radical cystectomy, of which four underwent radical cystectomy and one patient opted for concurrent chemoradiation. Of 26 patients who completed chemoradiation, complete response was seen in 21 patients (80.76%) and partial response was seen in four patients (15.38%). Only one patient developed progression of disease in the form of lung metastasis. All the patients with residual disease were advised to undergo salvage cystectomy. Among the patients receiving chemoradiation, grade 2 cystitis and diarrhea was seen in 10 patients (38.46%) and four patients (15.38%), respectively. Only one patient developed grade 3 diarrhea.

Conclusion  Bladder preservation treatment is an effective, safe, and convenient option for patients presenting with muscle-invasive carcinoma bladder. Neoadjuvant chemotherapy followed by chemoradiation was well-tolerated with an acceptable rate of complications.

Cisplatin-induced mitochondrial dysfunction is associated with impaired cognitive function in rats

PURPOSE

Chemotherapy-related cognitive impairment (CRCI) is commonly reported following the administration of chemotherapeutic agents and comprises a wide variety of neurological problems. No effective treatments for CRCI are currently available. Here we examined the mechanisms involving cisplatin-induced hippocampal damage following cisplatin administration in a rat model and in cultured rat hippocampal neurons and neural stem/progenitor cells (NSCs). We also assessed the protective effects of the antioxidant, N-acetylcysteine in mitigating these damages.

EXPERIMENTAL DESIGN

Adult male rats received 6mg/kg cisplatin in the acute studies. In chronic studies, rats received 5mg/kg cisplatin or saline injections once per week for 4 weeks. N-acetylcysteine (250mg/kg/day) or saline was administered for five consecutive days during cisplatin treatment. Cognitive testing was performed 5 weeks after treatment cessation. Cisplatin-treated cultured hippocampal neurons and NSCs were examined for changes in mitochondrial function, oxidative stress production, caspase-9 activation, and neuronal dendritic spine density.

RESULTS

Acute cisplatin treatment reduced dendritic branching and spine density, and induced mitochondrial degradation. Rats receiving the chronic cisplatin regimen showed impaired performance in contextual fear conditioning, context object discrimination, and novel object recognition tasks compared to controls. Cisplatin induced mitochondrial DNA damage, impaired respiratory activity, increased oxidative stress, and activated caspase-9 in cultured hippocampal neurons and NSCs. N-acetylcysteine treatment prevented free radical production, ameliorated apoptotic cellular death and dendritic spine loss, and partially reversed the cisplatin-induced cognitive impairments.

CONCLUSIONS

Our results suggest that mitochondrial dysfunction and increased oxidative stress are involved in cisplatin-induced cognitive impairments. Therapeutic agents, such as N-acetylcysteine, may be effective in mitigating the deleterious effects of cisplatin.

Decreased expression of let-7c is associated with non-response of muscle-invasive bladder cancer patients to neoadjuvant chemotherapy

The identification and development of biomarkers which predict response of muscle invasive bladder cancer (MIBC) patients to neoadjuvant chemotherapy would likely increase usage of this treatment option and thereby improve patient survival rates. MiRNA array and qRT-PCR validation was used to identify miRNA which are associated with response to neoadjuvant chemotherapy. RNA was extracted from a total of 41 archival, fully annotated, MIBC patient diagnostic biopsies (20 chemo-responders and 21 non-responders (response is defined as > 5 year survival rate and being pT0 post-chemotherapy)). Microarray and qPCR identified let-7c as being differentially expressed in chemo-responder versus non-responder patients. Patients with higher let-7c expression levels had significantly higher odds of responding to chemotherapy (p = 0.023, OR 2.493, 95% CI 1.121, 5.546), and assessment of let-7c levels allowed for prediction of patient response (AUC 0.72, positive predictive value 59%). Decreased let-7c was associated with MIBC incidence (p < 0.001), and significantly correlated with other related miRNA including those that were not differentially expressed between responders and non-responders. The combined data indicate let-7c plays a role in mediating chemoresistance to neoadjuvant chemotherapy in MIBC patients, and is a modest, yet clinically meaningful, predictor of patient response.

Organ preservation for muscle-invasive bladder cancer by preoperative intra-arterial chemotherapy and transurethral resection

The aim of this study was to evaluate the clinical outcomes achieved by use of preoperative intra-arterial chemotherapy and transurethral resection of bladder tumors as bladder preservation therapy in treatment of muscle-invasive bladder cancer. Patients with clinical stage T2-T4aN0M0 muscle-invasive bladder cancer were treated with 3 courses of preoperative cisplatin-based intra-arterial chemotherapy at 4-week intervals. Following treatment, the tumors were completely removed by transurethral resection, and all patients received epirubicin for intra-vesical instillation as a maintenance strategy. Patients showing a complete response received continuous monitoring, and radical cystectomy was strongly recommended for patients who did not achieve a complete response. Between August 2005 and October 2012, a total of 127 patients completed treatment with a bladder preservation therapy, and the median follow-up time for all patients was 31.9 months (range 5-87 months). Among these patients, 91 (71.7%) achieved a complete response, and the 5-year overall survival and disease-specific survival rates for all patients were 50.2 and 59.5%, respectively. Among the patients who demonstrated a complete response, 10 experienced a superficial relapse and 15 experienced an invasive cancer relapse. The 5-year recurrence-free and progression-free survival rates were 62.2 and 76.9%, respectively. An analysis of tumor-related factors suggested that clinical stage was significant for predicting both complete response and overall survival. These results suggest that preoperative intra-arterial chemotherapy combined with transurethral resection of the bladder tumor is useful for bladder preservation in certain patients with invasive bladder cancer. Patients with stage T2 tumors are best suited for this type of therapy.

Trimodality treatment in the conservative management of infiltrating bladder cancer: a critical review of the literature

Although radical cystectomy is still the treatment of choice for patients with infiltrating bladder cancer, there is growing evidence of the effectiveness of a conservative approach. Developed as a treatment of need for elderly or unfit patients unable to undergo radical cystectomy, conservative therapy is becoming a true alternative to surgery for highly selected patients. Although transurethral bladder resection, external radiotherapy and systemic chemotherapy can control the disease as single treatments, the best results have been observed when they are combined. Moreover, new irradiation techniques and new-generation drugs are now being tested in an attempt to improve disease control further. Conservative management requires the multidisciplinary involvement of different specialties in order to give patients a real alternative to surgical treatment.

Biomarkers for prognosis and treatment selection in advanced bladder cancer patients

PURPOSE OF REVIEW

Patients with locally 'advanced' or muscle invasive bladder cancer have higher mortality rates than patients with nonmuscle invasive ('superficial') bladder cancer. Biomarkers can stratify clinical outcomes and thus promise to more accurately prognosticate and thus help assign patients to the appropriate treatments. The aim of this review is to summarize biomarker developments in the past year and to discuss their implications in prognosis and treatment selection in locally advanced bladder cancer.

RECENT FINDINGS

Prognostic biomarkers for bladder cancer are identified at the DNA, RNA and/or protein levels. Some are new markers, whereas others are established markers with new roles in bladder cancer. Markers can report on the risk of disease recurrence or metastasis, or treatment responsiveness and thus are useful in determining 'who to treat' and 'what to treat with'.

SUMMARY

The list of biomarkers for prognosis and treatment selection for advanced bladder cancer is growing. For most, their clinical relevance is unclear due to their lack of validation in external datasets. MicroRNAs and new techniques including next-generation sequencing offer additional opportunities for biomarker discovery, validation, and clinical applications.

Update on chemotherapy in the treatment of urothelial carcinoma

Urothelial carcinoma is the fifth most common malignancy diagnosed each year in the United States. Neoadjuvant and adjuvant chemotherapy are given to decrease the risk of recurrent or metastatic disease with the more robust clinical data supporting the former. Bladder preservation utilizes a trimodality approach with maximal transurethral resection followed by concurrent chemotherapy and radiation and is appropriate for select patients. Gemcitabine and cisplatin is the current standard of care for first-line treatment in fit patients with metastatic disease. Optimal second-line therapy remains undefined, and targeted agents are under investigation. Clinical trial participation should be encouraged in patients with urothelial carcinoma of the bladder to help improve treatment regimens and outcomes. Synopsis. Chemotherapy is commonly used in the treatment of urothelial carcinoma of the bladder. This paper will review the role of chemotherapy in the neoadjuvant, adjuvant, bladder sparing, and metastatic settings.

Trimodality treatment for bladder cancer: does modern radiotherapy improve the end results?

With the advancement in endoscopic surgery, radiation treatment planning and execution, as well as the use of new chemotherapeutic regimens, bladder conservation has evolved into a competing alternative to radical cystectomy. Trimodality treatment has the great advantage of preserving a normally functioning urinary bladder. Despite the absence of direct randomized trials comparing both modalities, trimodality treatment comprising maximal transuretheral resection of bladder tumors followed by different regimens of combined radiochemotherapy achieved comparable results to radical cystectomy in many trials. Those who did not achieve complete remission after induction radiochemotherapy were salvaged by radical cystectomy. Improving the radiotherapeutic window is a challenging issue. In radiotherapy for bladder cancer, uncertainties include set-up errors, patient movement, internal organ movement and volume changes due to bladder filling (both inter- and intrafraction). The advancement in treatment verification procedures in modern radiotherapy and the use of fiducial markers reduces set-up errors, while adaptive radiotherapy could decrease the unnecessary irradiation of normal tissues by tracking bladder volume changes. In addition, new radiotherapeutic techniques, such as intensity-modulated radiotherapy and volume-modulated radiotherapy, permit dose escalation to the target without increasing the dose to the surrounding normal tissues.