Erdafitinib in BCG-treated high-risk non-muscle-invasive bladder cancer

BACKGROUND

Treatment options are limited for patients with high-risk non-muscle-invasive bladder cancer (NMIBC) with disease recurrence after bacillus Calmette-Guérin (BCG) treatment and who are ineligible for/refuse radical cystectomy. FGFR alterations are commonly detected in NMIBC. We evaluated the activity of oral erdafitinib, a selective pan-fibroblast growth factor receptor (FGFR) tyrosine kinase inhibitor, versus intravesical chemotherapy in patients with high-risk NMIBC and select FGFR3/2 alterations following recurrence after BCG treatment.

PATIENTS AND METHODS

Patients aged ≥18 years with recurrent, BCG-treated, papillary-only high-risk NMIBC (high-grade Ta/T1) and select FGFR alterations refusing or ineligible for radical cystectomy were randomized to 6 mg daily oral erdafitinib or investigator's choice of intravesical chemotherapy (mitomycin C or gemcitabine). The primary endpoint was recurrence-free survival (RFS). The key secondary endpoint was safety.

RESULTS

Study enrollment was discontinued due to slow accrual. Seventy-three patients were randomized 2 : 1 to erdafitinib (n = 49) and chemotherapy (n = 24). Median follow-up for RFS was 13.4 months for both groups. Median RFS was not reached for erdafitinib [95% confidence interval (CI) 16.9 months-not estimable] and was 11.6 months (95% CI 6.4-20.1 months) for chemotherapy, with an estimated hazard ratio of 0.28 (95% CI 0.1-0.6; nominal P value = 0.0008). In this population, safety results were generally consistent with known profiles for erdafitinib and chemotherapy.

CONCLUSIONS

Erdafitinib prolonged RFS compared with intravesical chemotherapy in patients with papillary-only, high-risk NMIBC harboring FGFR alterations who had disease recurrence after BCG therapy and refused or were ineligible for radical cystectomy.

[Value of immunotherapy in the perioperative treatment of localized muscle invasive bladder cancer]

Immune checkpoint inhibitors are standard of care in the treatment of metastatic and locally advanced urothelial cancer. Their use in perioperative treatment is currently under investigation as monotherapy as well as in combination with chemotherapy or radiation regimens. This article provides an overview of recent trials, current data as well as an outlook on future developments in the perioperative management of urothelial cancer.

Advances in targeted alpha therapy for prostate cancer

Amongst therapeutic radiopharmaceuticals, targeted alpha therapy (TαT) can deliver potent and local radiation selectively to cancer cells as well as the tumor microenvironment and thereby control cancer while minimizing toxicity. In this review, we discuss the history, progress, and future potential of TαT in the treatment of prostate cancer, including dosimetry-individualized treatment planning, combinations with small-molecule therapies, and conjugation to molecules directed against antigens expressed by prostate cancer cells, such as prostate-specific membrane antigen (PSMA) or components of the tumor microenvironment. A clinical proof of concept that TαT is efficacious in treating bone-metastatic castration-resistant prostate cancer has been demonstrated by radium-223 via improved overall survival and long-term safety/tolerability in the phase III ALSYMPCA trial. Dosimetry calculation and pharmacokinetic measurements of TαT provide the potential for optimization and individualized treatment planning for a precision medicine-based cancer management paradigm. The ability to combine TαTs with other agents, including chemotherapy, androgen receptor-targeting agents, DNA repair inhibitors, and immuno-oncology agents, is under investigation. Currently, TαTs that specifically target prostate cancer cells expressing PSMA represents a promising therapeutic approach. Both PSMA-targeted actinium-225 and thorium-227 conjugates are under investigation. The described clinical benefit, safety and tolerability of radium-223 and the recent progress in TαT trial development suggest that TαT occupies an important new role in prostate cancer treatment. Ongoing studies with newer dosimetry methods, PSMA targeting, and novel approaches to combination therapies should expand the utility of TαT in prostate cancer treatment.

[Internet use after prostate cancer : Search for information and trust in disease-related information in long-term survivors]

BACKGROUND AND OBJECTIVE

The internet provides numerous sources of information about prostate cancer (PCa). The present study investigated internet use among long-term PCa survivors, trust in online PCa-related information, and associated factors.

MATERIALS AND METHODS

Based on the German national research project Familial Prostate Cancer long-term PCa survivors were asked about their internet use in 2017. Associations with sociodemographic (age at survey, children, intimate relationship, education) and disease-related parameters (time since diagnosis, PCa family history, progress) were analyzed using multivariable logistic regression.

RESULTS

In all, 4636 long-term PCa survivors were included in the analysis (mean age 76.9 years; standard deviation 6.6 years). Mean follow-up was 14.0 years. Of long-term PCa survivors, 62.1% were using the internet. Among non-users 23.5% expressed strong concerns, among users only 2.8%. Furthermore, 47.2% of internet users sought information about PCa, 18.0% of them indicated difficulties while searching for information. More than half of the users found the online information inappropriate. Lower age, shorter time since diagnosis, progress, and a more frequent internet use were associated with search for information. Only one-third fully trusted online information. Trust in online information was associated with high age, higher educational level, and frequent search for online information. Many survivors stressed that they were primarily trusting their treating urologist.

CONCLUSIONS

Two-thirds of long-term PCa survivors are using the internet. A significant proportion expressed difficulties finding proper and reliable information. Urologists should be familiar with online resources on PCa in order to offer advice to patients and to recommend adequate information on the internet.

[Efficacy of a ketogenic diet in urological cancers patients : A systematic review]

BACKGROUND

Beside the classical anticancer treatment tumor patients try to find proactive alternative therapies to fight their disease. Lifestyle changes such as introducing a ketogenic diet is one of the most popular among them. The German Association of Urological Oncology (AUO, Arbeitsgemeinschaft Urologische Onkologie) presents a systematic review investigating the evidence of ketogenic diet in cancer patients.

MATERIALS AND METHODS

A systematic literature research was conducted in the databases Medline, Livivo, and the Cochrane Library. Only clinical studies of tumor patients receiving chemotherapy while on a ketogenic diet were included. The assessment of the results was performed according to the predefined primary endpoints overall survival and progression-free survival and secondary endpoints quality of life and reduction of adverse effects induced by cytostatics.

RESULTS

Nine studies met the inclusion criteria: eight prospective and one retrospective study case series respectively cohort-studies, with a total of 107 patients. Currently there is no evidence of a therapeutic effect of a ketogenic diet in patients with malignant tumors regarding the clinical outcome or quality of life.

CONCLUSION

Based on the current data, a ketogenic diet can not be recommended to cancer patients because prospective, randomized trials are missing.

Intraindividual comparison of [11C]acetate and [11C]choline PET for detection of metastases of prostate cancer

In a pilot trial we investigated whether significant differences in prostate cancer (PCA) imaging would be observed using [11C]acetate and [11C]choline positron emission tomography (PET). Methods: Twelve patients were studied with both radiotracers. Whole body PET without attenuation correction was performed after injection of 0.95 ± 0.15 GBq [11C]acetate and 0.84 ± 0.13 GBq [11C]choline, respectively, from 5 to 60 min p. i. Focally increased uptake in bone, below the urinary bladder or in a lymph node region was considered as tumour. Primary tumour, lymph node involvement, bone metastases, local recurrence; and no evidence of disease were known in 2, 4, 2, 2; and 2 patients, respectively. Results: [11C]Acetate uptake was highest in spleen and pancreas while [11C]choline uptake was predominant in liver and kidney parenchyma. However, interindividual variation was high. The potential of both radiotracers to detect known bone lesions, lymph node metastases, and imaging of the primary tumour was identical. However, both failed to detect a small local recurrence in two patients as well as to demonstrate lymph node involvement in one patient, which was confirmed by surgery. Conclusions: In this preliminary study, uptake of both radiotracers in prostate cancer or its metastases was nearly identical and none of them should be favoured. At present, both radiotracers influence patient management by detection of local recurrence, lymph node, or bone metastases of PCA.

[Metastatic castration-resistant prostate cancer : Use of cabazitaxel taking into consideration current data]

BACKGROUND

At the 2016 ASCO annual meeting, new data from two randomized phase III studies concerning taxane-based chemotherapy as a treatment option for patients with metastatic castration-resistant prostate cancer (mCRPC) were presented.

OBJECTIVES

The focus is on the clinical impact of these data.

MATERIALS AND METHODS

A group of German experts in the field of urogenital-oncologic expertise discussed the clinical impact with respect to the current data.

RESULTS

The study results support the current clinical data. They confirm the efficacy and safety of cabazitaxel beyond first-line therapy with docetaxel for patients with mCRPC.

CONCLUSIONS

Cabazitaxel is an important treatment option after docetaxel progression. With respect to the performance status of a patient, it is adequate to reduce the dosage to 20 mg/m² cabazitaxel.

[Intravesical radioimmunotherapy of carcinoma in situ of the urinary bladder after BCG failure]

BACKGROUND

In failure to respond to bacillus Calmette-Guérin (BCG) in patients with carcinoma in situ (CIS) of the urinary bladder, radical cystectomy remains the mainstay after BCG failure.

OBJECTIVES

The aim of this pilot study was to evaluate tolerability and safety of the α‑emitter radioimmunoconjugate instillation in patients after BCG failure.

MATERIALS AND METHODS

Nine patients were included. After emptying the bladder via a transurethral catheter, Bi-213-anti-EGFR-mAb was instilled. Treatment was terminated by emptying of the radioimmunoconjugate from the bladder 120 min after instillation. Efficacy was evaluated via endoscopy and histology 6 weeks after instillation.

RESULTS

All patients showed excellent toleration of the treatment without any side effects. Treatment resulted in complete eradication of tumor cells in 3 patients and persistent tumor detection in the other 6 patients.

CONCLUSIONS

Intravesical instillation of Bi-213-anti-EGFR-mAb is a promising therapeutic option for treatment of in situ bladder cancer after BCG failure for patients who wish to preserve the bladder.

[Self-concept and erectile dysfunction in 45-year-old men : Results of a corollary study of the PROBASE trial]

BACKGROUND

Self-concept consists of self-perceptions and is influenced by the life course of the person.

OBJECTIVES

This study investigated associations between self-concept and erectile dysfunction (ED) in 45-year-old German men.

MATERIALS AND METHODS

Forty-five-year-old, heterosexual men who had participated in the PROBASE-study were included. Erectile Function was evaluated using the International Index of Erectile Function (IIEF-6). The presence of ED was defined by IIEF-6 score ≤ 25. Self-concept was assessed using the facets "body image" (three items from the Dresden Body Image Inventory, DKB-35), "perception of masculinity" (three items from the Male Role Norms Scale, MRNS), "perceived social pressure with regard to sexual performance" (four newly constructed items), and "sexual self-esteem" (three newly constructed items). Scores for these facets of self-concept can range from 1 to 5. Higher scores indicate a more positive body image, higher sexual self-esteem, a more modern understanding of masculinity, and greater perceived social pressure. Differences in self-concept between men with ED and without ED were analyzed using the Mann-Whitney-U-test. Furthermore, Cohen's d effect sizes (ES d) were calculated.

RESULTS

The responses of 3143 men were analyzed. Men with ED (16.2 %) have significantly lower scores regarding body image (mean 3.6 ± 0.6 vs 3.8 ± 0.5; p < 0.001; ES d = -0.5), perception of masculinity (mean 3.4 ± 0.7 vs 3.7 ± 0.6; p < 0.001; ES d = -0.4), and sexual self-esteem (mean 3.6 ± 0.6 vs 3.9 ± 0.5; p < 0.001, ES d = -0.4) than men without ED. Furthermore, they had significantly higher scores for perceived social pressure (mean 2.1 ± 0.7 vs 1.5 ± 0.5; p < 0.001; ES d = 1.2).

CONCLUSIONS

Self-concept and ED are associated in 45-year-old men. Men with ED have a more negative body image, a more traditional understanding of masculinity, more negative sexual self-esteem, and greater perceived social pressure with regard to sexual performance than men without ED.

The Role of PD-L1 Expression and Intratumoral Lymphocytes in Response to Perioperative Chemotherapy for Urothelial Carcinoma

Introduction: Immunological pathways are relevant for the effectiveness of conventional cytotoxic chemotherapy. Recently, checkpoint inhibition of the PD-1/PD-L1 axis has been shown to be therapeutically relevant in urothelial carcinoma. Objective: To monitor PD-L1 expression on tumor cells and intratumoral infiltration with CD8 positive lymphocytes during perioperative chemotherapy for urothelial cancer and to evaluate their use as potential predictive markers for chemotherapy. Patients and Methods: Sixty-four patients with muscle-invasive urothelial cancer were included in the analysis. Twenty-two patients received preoperative chemotherapy and 42 were treated in an adjuvant setting for locally advanced disease or lymph node metastases. PD-L1 status and the density of infiltration with CD8-positive cells were assessed by immunohistochemistry and analysed for their association with survival (adjuvant group) and response to chemotherapy (preoperative group). For PD-L1 positivity we used a cutoff of 10% positive tumor cells. Results: In the adjuvant group, 11 of 42 patients (26.2%) had PD-L1 positive tumor cells. Twenty-six of 42 (61.9%) patients were highly infiltrated with CD8 + lymphocytes. There was no significant evidence of an association with overall survival for PD-L1 status nor for CD8 infiltration density (p = 0.63 and 0.71). In the preoperative group, eight of the 22 (36.4%) patients were PD-L1 positive and 13 (59%) were highly infiltrated with CD8 + lymphocytes before chemotherapy. There was no evidence of associations with response or survival. Eight patients showed a pathological response to preoperative treatment. These had a significantly longer overall survival than non-responders (p = 0.01). In the preoperative group the pre-treatment expression of the immunologic markers could be compared to the post-treatment status. Only one patient showed a changed PD-L1 status and three patients a changed CD8 status. Conclusions: The tumoral expression of PD-L1 in urothelial carcinoma does not seem to be largely influenced by chemotherapy. Our data do not provide evidence that tumoral expression of PD-L1 and CD8 are useful as prognostic or predictive markers. Small sample size is the major limitation of our study.

[Positron-emission tomography in urooncology]

The use of positron emission tomography (PET) is an established method for the diagnosis of urological malignancies. Several tracers are currently available to obtain metabolic information or directly detect molecular targets. While (18)F-FDG-PET is recognized in current guidelines for the staging of seminoma, PET is not used in clinical routine in renal malignancies due to the lack of specific tracers. Despite initial promising results in bladder cancer, no relevant additional diagnostic value with PET using (18)F-FDG or choline-based tracers could be obtained in most patients and therefore should be used with caution or only within clinical trials. In prostate cancer, however, after development of new tracers that, for example, target prostate-specific membrane antigen (PSMA), a paradigm shift in imaging can be recognized. Here, (68)Ga-PSMA-PET might be included in the future as part of standard imaging work-up.

[Update 2016 - Immunotherapy for urothelial carcinoma]

Advanced urothelial carcinoma of the bladder is an aggressive tumor with a poor prognosis. Besides surgical therapy, classical chemotherapy with platinum compounds is the mainstay of advanced bladder cancer treatment. In recent years, immune modulating therapies have come into the focus of clinical trials. This review provides an overview of the biological mechanisms and immuno-oncological drugs that are currently being analyzed in clinical trials as well as established standard therapies.

[YB-1-based virotherapy: A new therapeutic intervention for transitional cell carcinoma of the bladder?]

Therapeutic intervention using oncolytic viruses is called virotherapy. This type of virus is defined by the ability to replicate in tumor cells only and to destroy these cells upon replication. In addition, this virus type is able to induce a tumor-directed immune response. Early clinical trials have confirmed the safety profile of oncolytic viruses. Currently, different groups are working on the development of oncolytic viruses with a focus on treatment of nonmuscle invasive bladder cancer (NMIBC). A preliminary active recruiting clinical phase II/III trial ongoing in patients with a NMIBC was recently implemented in the United States. Our research group developed an oncolytic adenovirus that will soon enter a clinical phase I trial in patients diagnosed with glioma. This virus is being further modified for the treatment of NMIBC. In this review article, recent developments in the design and use of virotherapy in bladder cancer are summarized.

The prognostic effect of tumour-infiltrating lymphocytic subpopulations in bladder cancer

BACKGROUND

Intratumoural lymphocytic infiltration is strongly associated with the outcome of many human epithelial cancers. The current paper investigated whether subpopulations of tumour-infiltrating T lymphocytes are associated with certain clinicopathological parameters and the prognosis of patients with invasive bladder cancer (BCa).

PATIENTS AND METHODS

The infiltration densities of the adaptive immune markers CD3 (the whole T cell population), FOXP3 (regulatory T cells; Tregs), CD8 (T effector cells) and CD45R0 (T effector memory cells) were analysed by immunohistochemistry and image analysis with tissue microarrays of tumour tissues from 149 patients with invasive BCa treated with radical cystectomy. The findings were correlated with certain clinicopathological parameters.

RESULTS

Higher FOXP3/CD3 [OS: p = 0.016, HR 1.29, 95% confidence intervals (95% CIs 1.05-1.59)] and FOXP3/CD8 (OS: p = 0.013, HR 1.32, 95% CIs 1.06-1.65) ratios were significantly associated with briefer overall survival and time to cancer-specific death; the latter ratio represented an independent prognostic factor according to a multivariate analysis adjusted for pathological T and N stages (HR 1.32, 95% CIs 1.05-1.67, p = 0.018). The infiltration densities of individual markers (CD3, CD8, FOXP3 and CD45R0) were not significantly associated with clinicopathological parameters or survival; however, a trend towards a better outcome was observed for higher log-transformed CD8 (p = 0.070, HR 0.80, 95% CIs 0.63-1.02) and CD3 (p = 0.113, HR 0.84, 95% CIs 0.68-1.04) infiltration values.

CONCLUSIONS

A high fraction of Tregs amongst CD3- and CD8-positive lymphocytes indicated a poor prognosis, thereby emphasising the important role that Tregs play in the suppression of the anti-tumour immune response. No single lymphocytic marker was significantly correlated with clinical outcomes, but high CD3 and CD8 infiltration showed trends towards better prognosis.

Circulating tumor cells versus objective response assessment predicting survival in metastatic castration-resistant prostate cancer patients treated with docetaxel chemotherapy

PURPOSE

Circulating tumor cell (CTC) counts might display a superior prognostic value for overall survival (OS) compared to objective response criteria (OR) in metastatic castration-resistant prostate cancer (mCRPC) patients.

METHODS

CTCs were detected using the CellSearch™ System out of 122 samples during docetaxel chemotherapy (75 mg/m(2)) at baseline (q0) and after 1 (q1), 4 (q4) and 10 (q10) cycles, in mCRPC patients (n = 33). OR was evaluated by morphologic RECIST and clinical criteria after 4 (q4) and 10 (q10) cycles.

RESULTS

For OS, analyses revealed a significant prognostic value for categorical (<5 vs. ≥5) CTC counts (q0, p = 0.005; q1, p = 0.001; q4, p < 0.001; q10, p = 0.002), RECIST (q4, p < 0.001; q10, p = 0.02) and clinical criteria (q4, p < 0.001; q10, p = 0.02). Concordance of CTC counts with OR revealed a sensitivity of 83.3-87.5 % and a specificity of 68.0-76.5 % with complementary discriminatory power for OS. Comparing CTC counts with concomitant OR at q4 in multivariate analyses, an independent prognostic value for OS was found for CTC counts (HR 3.3; p = 0.02) similar to clinical (HR 4.9; p = 0.02) and radiologic response (HR 3.4; p = 0.051). Comparing the predictive value for death, early post-treatment CTC counts at q1 demonstrated significant accuracy with an area under the curve of 79.5 % (p = 0.004) similar to CTC counts at q4 (76.7 %; p = 0.009). Radiologic and clinical response at q4 displayed accuracy similar to early CTC counts at q1 (72.2 %; p = 0.03 and 75.0 %; p = 0.02) despite low sensitivities.

CONCLUSIONS

CTC counts appear to be an earlier and more sensitive predictor for survival and treatment response than current OR approaches and may provide complementary information toward individualized treatment strategies.

[Sexuality after radical prostatectomy: Evaluation of erectile function and patient counseling regarding their sex life]

BACKGROUND

Patient counseling by using the IIEF to assess erectile function (EF) before and after radical prostatectomy (RPX) is only possible under limited circumstances. The aim of this study was to evaluate if the Erection Hardness Score (EHS) could be used in addition to the IIEF for the assessment of EF and patient preference regarding counseling for their sex life.

MATERIAL AND METHODS

EF was evaluated in 307 patients 3-60 months after RPX using the IIEF-EF and EHS. Questionnaires assessed sexual activity/intercourse as well as satisfaction with sex life irrespective of EF (10-point Likert scale). Patients were further asked concerning development of new sexual methods independent of erection firm enough for penetration and further wishes regarding counseling for their sex life.

RESULTS

Of 272 patients, 82.0% underwent bilateral nerve-sparing prostatectomy, 30.5% (n=83; mean age: 68.1 years) had sexual intercourse and 41.9% (n=114) were sexually active. EH Scores 1-2 and 4 coincided with compatible IIEF-EF Scores 1-21, and ≥ 26, respectively. Of the patients with an EHS of 3, 55.9% had an IIEF-EF score that was notably lower. Of patients with sexual intercourse, 65.8% were satisfied with their sex life; 53.2% of sexually active patients were satisfied without sexual intercourse. Alternative methods were manual/oral stimulation, cuddling, and the use of vibrators. Patients request individually tailored, realistic counseling.

CONCLUSION

The advantage of the EHS compared to the IIEF is that the erectile function can be assessed irrespective of sexual intercourse and sexual partner. Counseling should assist patients towards the attainment of a satisfying sex life-even without an erection.

[Hands-on teaching for students in urology: the use of peer teaching and simulators]

BACKGROUND

Hands-on training in urology for medical students is characterized by several challenges. We tried to improve our practical training day using peer teaching/peer-assisted learning and simulators.

MATERIAL AND METHODS

An average of 116 students participated in our practical training day every semester between 2007/2008 and summer semester 2011. We evaluated students' satisfaction, human resources, and student to teacher ratio before and after the restructuring.

RESULTS

After the restructuring in 2008/2009, all categories showed improvement (1=best; 6=worst). The general rating rose from 2.2 (2008) to 1.45 (2011); practical training improved from 2.85 (2008) to 1.55 (2011).

DISCUSSION

Peer teaching and simulators are reasonable tools in medical education in urology. They increase individual coaching of students and lead to improved satisfaction and subjective learning success. Interprofessional education with the selective use of nursing staff as teachers was widely accepted. With these tools essential hands-on skills in urology can be acquired by all medical students.

Mutant PIK3CA controls DUSP1-dependent ERK 1/2 activity to confer response to AKT target therapy

Background:

Alterations in the phosphoinositide 3-kinase/AKT/mammalian target of rapamycin (PI3K/AKT/mTOR) signalling pathway are frequent in urothelial bladder cancer (BLCA) and thus provide a potential target for novel therapeutic strategies. We investigated the efficacy of the AKT inhibitor MK-2206 in BLCA and the molecular determinants that predict therapy response.

Methods:

Biochemical and functional effects of the AKT inhibitor MK-2206 were analysed on a panel of 11 BLCA cell lines possessing different genetic alterations. Cell viability (CellTiter-Blue, cell counts), apoptosis (caspase 3/7 activity) and cell cycle progression (EdU incorporation) were analysed to determine effects on cell growth and proliferation. cDNA or siRNA transfections were used to manipulate the expression of specific proteins such as wild-type or mutant PIK3CA, DUSP1 or CREB. For in vivo analysis, the chicken chorioallantoic membrane model was utilised and tumours were characterised by weight and biochemically for the expression of Ki-67 and AKT phosphorylation.

Results:

Treatment with MK-2206 suppressed AKT and S6K1 but not 4E-BP1 phosphorylation in all cell lines. Functionally, only cell lines bearing mutations in the hotspot helical domain of PIK3CA were sensitive to the drug, independent of other genetic alterations in the PI3K or MAPK signalling pathway. Following MK-2206 treatment, the presence of mutant PIK3CA resulted in an increase in DUSP1 expression that induced a decrease in ERK 1/2 phosphorylation. Manipulating the expression of mutant or wild-type PIK3CA or DUSP1 confirmed that this mechanism is responsible for the induction of apoptosis and the inhibition of tumour proliferation in vitro and in vivo, to sensitise cells to AKT target therapy.

Conclusion or interpretation:

PIK3CA mutations confer sensitivity to AKT target therapy in BLCA by regulating DUSP1 expression and subsequent ERK1/2 dephosphorylation and can potentially serve as a stratifying biomarker for treatment.

[Pharmaceutical treatment of advanced urinary bladder cancer: new developments in 2014]

The perioperative treatment of muscle-invasive bladder cancer has become a standard procedure in recent years. New agents, such as programmed cell death protein 1 (PD1) and PD1-ligand 1 (PD1-L1) inhibitors have opened up the door for immunomodulation therapy of metastasized bladder cancer. This article focuses on data which have changed or have the potential to change the pharmaceutical treatment of advanced bladder cancer with a review of the literature in Medline PubMed and proceedings of major meetings, e.g. the European Association of Urology (EAU), the American Society of Clinical Oncology (ASCO), the ASCO Genitourinary Cancers Symposium (ASCO GU) and the American Urological Association (AUA).

[Functional imaging in bladder cancer]

Computed tomography (CT) represents the current standard imaging modality in muscle invasive bladder cancer; however, local tumor and lymph node staging is often impaired. Magnetic resonance imaging (MRI) with diffusion-weighted sequences, determination of apparent diffusion coefficient (ADC) values or utilization of supraparamagnetic iron nanoparticles potentially exhibits advantages in the assessment of local tumor and lymph node involvement and therefore might play a role in the staging of bladder tumor in the future. Likewise, positron emission tomography (PET) with the currently used tracers (18)F fluorodeoxyglucose ((18)F-FDG), (11)C-choline and (11)C-acetate is being investigated in bladder cancer patients, mostly in combination with diagnostic CT. Although promising results could be obtained for PET/CT investigations to some extent, the true value cannot be determined at present.

[Compassionate use of abiraterone and cabazitaxel: first experiences in docetaxel-pretreated castration-resistant prostate cancer patients]

OBJECTIVE

First clinical experiences with abiraterone and cabazitaxel for the treatment of metastatic castration-resistant prostate cancer patients following docetaxel chemotherapy are reported.

PATIENTS AND METHODS

We describe PSA response rates and disease control rates determined by imaging studies at 3 months as well as side effects in the daily routine. All patients were treated within the"compassionate use" programs of cabazitaxel and abiraterone or treated according to their inclusion and exclusion criteria at the "Technische Universität München".

RESULTS

Of 54 patients, 15 were treated with cabazitaxel and 39 with abiraterone. In patients treated with cabazitaxel, after 3 months of therapy the PSA reduction rate > 50% was 46.2%, the PSA progression rate was 15.4%, and the disease control rate was 83.3%. Main grade 3/4 hematotoxicities were neutropenia (40%) and anemia (20%). Febrile neutropenia was observed in 2 of 15 (13.3%) patients. Main non-hematological grade 3/4 toxicities were diarrhea (13.3%) and polyneuropathy (13.3%). In patients treated with abiraterone, after 3 months of therapy the PSA reduction rate >50% was 35.1%, the PSA progression rate was 46.0%, and the disease control rate was 47.1%. Main grade 3/4 hematotoxicities were anemia (5.1%) and thrombocytopenia (5.1%). Main non-hematological toxicities were fatigue (20.5%), sweating (17.9%), and constipation (10.3%).

CONCLUSION

Utilization of cabazitaxel and abiraterone in the daily routine show response rates comparable to their approval studies with acceptable side effects.

[Lichen sclerosus in the genitourinary region]

Lichen sclerosus (LS) is a chronic inflammatory disorder of the skin and mucosa, presenting to genitourinary physicians, pediatricians, and dermatologists. It affects both sexes with a lower incidence in men than in women. Autoimmune factors, infections, and genetic disposition are implicated in its pathogenesis. The classic clinical picture is of atrophic white plaques in the anogenital region. Pruritus, soreness, difficulty retracting the foreskin, and obstructive urinary symptoms are frequent complaints. Early histological confirmation by biopsy is recommended. The disorder is usually highly responsive to ultrapotent topical steroids. This may help arrest or delay the progressive nature of this disorder. Surgical treatment may be needed in cases of disease progression despite medical therapy. Circumcision is a successful treatment, if LS is limited to the glans and foreskin. In cases of meatal stenosis meatoplasty and in cases of urethral involvement one- or two-stage oral graft urethroplasty is necessary.

[Oncological pelvic surgery under urological aspects: bladder carcinoma]

The aim of the treatment of invasive bladder cancer with radical cystectomy and subsequent urinary diversion is to combine a safe oncological procedure with a satisfactory quality of life. Radical cystectomy is the treatment of choice for all patients with recurrent or multifocal high grade T1 bladder cancer, T1 tumors with high risk of progression, failure of Bacillus Calmette-Guérin treatment and muscle-invasive bladder cancer. Radical cystectomy offers excellent recurrence-free and cancer-specific survival rates as well as local tumor control in patients with organ-confined and node-negative diseases. Tumor control in non-organ-confined tumors is still satisfactory with long term recurrence-free survival (RFS) rates of about 50%. Nerve-sparing cystectomy is of importance for lower urinary tract function, including continence rates after orthotopic urinary diversion and for sexual function in males and females. Orthotopic urinary reconstruction using a neobladder achieves good continence rates. Overall quality of life after radical cystectomy remains good in most patients irrespective of the type of urinary diversion.

CD147 silencing inhibits lactate transport and reduces malignant potential of pancreatic cancer cells in in vivo and in vitro models

BACKGROUND

CD147 (basigin, EMMPRIN) is a multifunctional, highly conserved glycoprotein enriched in pancreatic ductal adenocarcinomas (PDACs) which is associated with poor prognosis in many malignancies. The role of CD147 in pancreatic cancer, however, remains elusive.

METHODS AND RESULTS

Silencing of CD147 by RNA interference (RNAi) reduced the proliferation rate of MiaPaCa2 and Panc1 cells. CD147 is required for the function and expression of the monocarboxylate transporters MCT1 and MCT4 that are expressed in human PDAC cells as demonstrated by real-time reverse transcription-PCR (RT-PCR) as well as immunohistology. MCT1 and MCT4 are the natural transporters of lactate, and MiaPaCa2 cells exhibited a high rate of lactate production, which is characteristic for the Warburg effect, an early hallmark of cancer that confers a significant growth advantage. Further induction of lactate production by sodium azide in MiaPaCa2 cells increased MCT1 as well as MCT4 expression. CD147 silencing inhibited the expression and function of MCT1 and MCT4 and resulted in an increased intracellular lactate concentration. Addition of exogenous lactate inhibited cancer cell growth in a dose-dependent fashion. In vivo, knock-down of CD147 in MiaPaCa2 cells by inducible short hairpin RNA (shRNA)-mediated CD147 silencing reduced invasiveness through the chorioallantoic membrane of chick embryos (CAM assay) and inhibited tumourigenicity in a xenograft model in nude mice.

CONCLUSION

The function of CD147 as an ancillary protein that is required to sustain the expression and function of MCT1 and MCT4 is involved in the association of CD147 expression with the malignant potential of pancreatic cancer cells exhibiting the Warburg effect.

[Systemic chemotherapy for bladder cancer: news in 2009]

This review summarizes the results of first-line and second-line systemic chemotherapy for advanced urothelial carcinoma as well as data from adjuvant and neoadjuvant trials for locally advanced bladder cancer. Whereas conventional systemic chemotherapy prevailed for over two decades, targeted therapeutics have been introduced to treat urothelial cancer during recent years. As in other tumor entities, molecular profiling will presumably emerge in the future as a means to tailor individual therapy.

[EMMPRIN (CD147). A new key protein during tumor progression in bladder cancer]

EMMPRIN (CD147) is a cell surface protein that is highly expressed on tumor cells. Elevated EMMPRIN levels have been detected in a variety of malignant tumors and have been associated with tumor progression in experimental and clinical conditions. Recent studies have shown that EMMPRIN is an independent prognostic factor for overall survival in bladder cancer patients. In a multicenter phase II trial, antibodies against EMMPRIN were shown to be successful in hepatocellular cancer therapy. We are characterizing the functional importance of EMMPRIN in bladder cancer in order to evaluate this protein as a new target molecule for therapy.

[Is there an indication for adjuvant or neoadjuvant systemic chemotherapy in bladder cancer?]

Two recent meta-analyses demonstrated a significant influence of adjuvant as well as neoadjuvant cisplatin-based chemotherapy regimens on survival of patients undergoing radical cystectomy for bladder cancer. Therefore, the introductory question can be answered with "yes". However, while providing the best evidence available to date on the subject, both analyses are based on clinical trials of dubious quality. Thus, the question today is not whether perioperative chemotherapy is advantageous in some patients undergoing radical cystectomy, but rather which subgroups will actually benefit from additional systemic treatment. Instead of a detailed literature overview, this article discusses potential advantages and disadvantages of perioperative chemotherapy and outlines basic principles for the design of future studies investigating both strategies in bladder cancer.

[The latest news on bladder cancer]

A review of the current literature provides new scientific insights into the diagnosis, prognosis and novel molecular targets for bladder cancer. The new WHO classification refines our staging system and influences treatment options. International clinical databases provide new tools for calculating the individual risk for bladder cancer recurrence and progression. Systematic gene cluster analysis defines multimarker panels that can serve as robust predictors of outcome. Discoveries of new signaling pathways in bladder cancer are leading to novel molecular targets for innovative therapies.

Palliative und supportive Therapie bei Patienten mit fortgeschrittenem Prostatakarzinom

In patients with advanced prostate cancer, quality of life and prevention of complications come to the fore. Besides handling local complications such as obstruction, hematuria and lymphedema, treatment of bone metastases and their complications is of great importance. Analgesic measures, bisphosphonates, radiation therapy, radionuclide therapy and neurosurgical procedures are available. Spinal cord compression with acute motor and sensory deficiency requires immediate neurosurgical and/or radiation therapy. Tumor anemia should be treated appropriately.

Assoziation von familiärem Status mit Histologie und klinischem Verlauf beim frühen Prostatakarzinom

BACKGROUND

In a large number of studies a positive family history is documented as one of the main risk factors for the development of prostate cancer. In a US population an association between early-onset prostate cancer among familial patients and a more differentiated tumour was shown. The aim of this study was to compare clinical parameters between sporadic and familial or hereditary patients with an age at diagnosis < or =55 years.

MATERIAL AND METHODS

The clinical data of prostate cancer patients with an age at diagnosis < or =55 years and who were recruited between July 1999 and the end of June 2004 to the database "familial prostate cancer in Germany" were analysed. The following data were documented for all patients: PSA at diagnosis, histopathological stage, grading, Gleason score and progression-free survival.

RESULTS

The clinical data of 685 patients could be completed: 222 (32.4%) had one first-degree relative with prostate cancer, 48 of whom (7.0%) were hereditary; 463 (67.6%) were sporadic. The median age at diagnosis in the hereditary patients was 51.6 (41-55) years, in the familial patients 51.1 (35-55) years and in the sporadic patients 52.0 (38-55) years. The median follow-up was 24 months in hereditary, 36 months in familial and 35 months in sporadic patients. An initial curative therapy with radical prostatectomy or radiotherapy/brachytherapy was planned in 657/685 (95.9%) of the patients. There were no clear differences regarding PSA at diagnosis, the postoperative parameters (organ-confined disease, lymph node involvement, Gleason score, grading) and the progression-free survival in sporadic and familial or hereditary patients.

CONCLUSIONS

Patients with an age at diagnosis < or =55 years have a positive family history more often than all prostate cancer patients in Germany. No association could be shown between pathohistological stage or clinical course and a positive family history in patients with an age at diagnosis < or =55 years.

Neobladder Emptying Failure in Males: Incidence, Etiology and Therapeutic Options

PURPOSE

Neobladder reconstruction is considered the best option for patients requiring cystectomy. Limited information is available about incidence, etiology and therapeutic options for neobladder emptying failure in males.

MATERIALS AND METHODS

In a retrospective study we analyzed the data of a consecutive series of 655 male patients (age range 23 to 82 years, median 63; followup range 0 to 208 months, median 36.5) who received an ileal neobladder following radical cystectomy at our institution. All patients had a complete followup until death or until December 2003. Data on all diagnostic and therapeutic procedures performed for neobladder emptying failure were collected.

RESULTS

Of 655 patients 75 (11.5%) had at least 1 episode of failure emptying the neobladder requiring some form of therapy during followup. Failure was due to dysfunctional voiding in 23 patients (3.5%) and mechanical obstruction in 52 patients (8%). Causes of mechanical obstruction were benign strictures of the neovesicourethral anastomosis (23 patients, 3.5%) or the anterior urethra (11 patients, 1.7%), neoplastic obstruction by local tumor recurrence (13 patients, 2.0%) or a nonurological malignancy (1 patient, 0.2%), and obstruction by mucosal valves (3 patients, 0.5%) or a foreign body (1 patient, 0.2%). In 38 of 52 patients with mechanical obstruction of the neobladder outlet emptying was fully restored with endourological procedures, while in 14 of 52 patients long-term catheterization was necessary. Catheterization was the therapy of choice for all patients with dysfunctional voiding.

CONCLUSIONS

Neobladder emptying failure is of major concern but is not an argument against orthotopic diversion. The overall rate of transient or permanent neobladder emptying failure in males is high but most of the mechanical causes can be managed endoscopically, while the rate of patients with long-term catheterization for dysfunctional voiding is relatively low.

[Prospective evaluation of prostate cancer screening in men with a family history of the disease]

BACKGROUND

Family history is one of the strongest risk factors for prostate cancer. In this prospective study we evaluated the results of prostate cancer screening performed in healthy brothers of prostate cancer patients. The detection rate of prostate cancer and the positive predictive value of the examinations were determined.

MATERIAL AND METHODS

The study population comprised 513 healthy men who were 38-75 years of age (median 62.0 years). Of these men, 268 having only one affected brother with prostate cancer were assigned to the sporadic group, and 245 probands having 2-10 affected relatives were assigned to the familial group. An abnormal PSA and/or a pathological digital rectal examination (DRE) was noted in 17.5% of familial (43/245) and 15.8% of sporadic probands (35/268). A biopsy of the prostate was performed in 60.5% of familial (26/43) and 71.4% of sporadic (25/35) men with pathological findings.

RESULTS

Prostate cancer was found in 15 of 26 familial (57.7%) and 16 of 25 sporadic (64.0%) probands by prostate biopsy. The overall detection rate was 6.0% (31/513).

CONCLUSION

Due to an increased prevalence the detection rate of prostate cancer and the positive predictive value of PSA and/or DRE are higher in men with a family history as expected in an unselected population. Our data suggest that in predisposed men prostate cancer screening should be recommended early. Furthermore an early indication for prostate biopsy is necessary. This recommendation should also be applied if only one first-degree relative has prostate cancer.

Systemische Therapie des metastasierten Nierenzellkarzinoms

Cytokine-based immunotherapy was the only viable option in metastatic, nonresectable renal cell carcinoma (RCC) for many years. Systemic immunotherapy has become increasingly established as a standard therapy during the last 15 years. In this context, interleukin-2 (IL-2) and interferon-alpha (IFN-alpha) turned out to be the most effective single agents in RCC. Subsequently, the approved subcutaneous application of these compounds was the preferred administration route in Germany. Response rates with cytokine combination therapy were almost similar to those of more aggressive concepts using additional chemotherapeutic agents.Currently, new compounds targeting specific signaling pathways are readily available and have passed clinical testing. Such small molecules like tyrosine kinase inhibitors, monoclonal antibodies, or the mTOR inhibitor CCI-779 may dramatically change the established concepts of systemic RCC treatment. This paper gives an overview of established, current, and evolving concepts of systemic therapy in RCC.

Keine synergistische Wirkung der Kombination von ∆9-Tetrahydrocannabinol und Piritramid bei postoperativen Schmerzen

BACKGROUND

It is concluded from animal experiments that cannabinoid receptor and mu-opioid receptor agonists act synergistically with respect to antinociception. In order to demonstrate this effect under clinical conditions, we conducted a randomized double blind trial with patients after radical prostatectomy.

PATIENTS AND METHODS

From the evening before the operation until the morning of the second postoperative day, all patients received eight oral doses of either placebo or 5 mg Delta(9)-tetrahydrocannabinol (dronabinol). Postoperatively patients had access to patient-controlled analgesia with the micro-opioid agonist piritramide for 48 h. We expected patients receiving dronabinol to require significantly less piritramide compared to patients on placebo.

RESULTS

The consumption of piritramide was recorded in 100 patients after radical retropubic prostatectomy with regional lymphadenectomy. Patients in the placebo group consumed 74 mg (median), interquartile range (IQR) 44-90 mg, patients in the verum group consumed 54 mg (median) IQR 46-88 mg. The difference between groups was not statistically significant. Plasma concentrations of Delta(9)-THC were measurable in all patients in the verum group. The levels (median) were 1.5 ng/ml (IQR 0.6-2.3), 1.3 ng/ml (IQR 0.5-2.2) and 1.9 ng/ml (IQR 0.8-2.7) on the day of operation, the first and second postoperative day, respectively.

CONCLUSION

We found neither a synergistic nor even an additive antinociceptive interaction between Delta(9)-tetrahydrocannabinol and the micro-opioid agonist piritramide in a setting of acute postoperative pain.