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.

The Impact of Travel Time on Trimodal Therapy Compared to Cystectomy for Bladder Cancer

PURPOSE/OBJECTIVE(S)

Neoadjuvant chemotherapy followed by radical cystectomy (RC) and Transurethral Resection of Bladder Tumor (TURBT) followed by concurrent chemoradiation therapy (trimodal therapy, TMT) are both evidence-based approaches to the management of muscle-invasive bladder cancer, and no randomized evidence conclusively supports the use of one treatment over another. Literature suggests that increasing distance to radiation therapy (RT) facilities reduces the likelihood that patients will receive RT, though this has not been evaluated in bladder cancer. We hypothesize that greater travel time between a patient's home and their closest RT facility is associated with a lower likelihood of undergoing TMT.

MATERIALS/METHODS

Clinical data and the locations of patient residences and surgical facilities performing RC were obtained from the California Cancer Registry. RT facility locations were compiled from state regulatory databases and dosimetric accrediting bodies. Travel time was identified using the Google Distance Matrix API. California patients diagnosed with T2-4N0 bladder cancer in 2018-2019 who underwent TMT (> = 55Gy) or RC were included in this analysis. Chi-square tests, Kruskal-Wallis tests, and univariate and multivariate logistic regressions were performed to assess factors associated with an increased likelihood of receipt of TMT, and to compare travel times for patients receiving TMT vs RC.

RESULTS

A total of 536 patients met inclusion criteria, and 27.1% underwent TMT. Patients receiving TMT were more likely to be older, White, male, and live further from their nearest RT facility. After adjusting for age, sex, and race/ethnicity, patients undergoing TMT were more likely than RC patients to live more than 30 minutes away from the nearest RT facility (OR 1.53, p = 0.21, ref<15 minutes). On multivariate analysis, patients receiving TMT were less likely than surgical patients to live 30-60 minutes or >60 minutes from their treatment facility ((OR 0.5, p-value<0.01, and OR 0.23, p-value <.001), ref: <30 minutes). Only 26.2% of patients who received TMT were treated at their nearest RT facility, while 13.3% of patients undergoing RC were treated at their nearest surgical facility.

CONCLUSION

In a modern cohort of bladder cancer patients in California, about a quarter of T2-4N0 patients are undergoing bladder preservation. Patients undergoing TMT lived further from their nearest RT facility than patients undergoing surgery. Surgical patients were more likely to live >30 minutes from their treating facility than TMT patients. A minority of patients underwent treatment at the facility nearest to them, regardless of treatment modality chosen. Taken together, this suggests that proximity to the nearest RT facility may not be associated with a higher likelihood of undergoing TMT. Examination of actual treatment facilities (as opposed to the closest facility) shows that patients are traveling further for surgical care than TMT.

Impact of perioperative chemotherapy on survival in patients with advanced primary urethral cancer: results of the international collaboration on primary urethral carcinoma

BACKGROUND

To investigate the impact of perioperative chemo(radio)therapy in advanced primary urethral carcinoma (PUC).

PATIENTS AND METHODS

A series of 124 patients (86 men, 38 women) were diagnosed with and underwent surgery for PUC in 10 referral centers between 1993 and 2012. Kaplan-Meier analysis with log-rank testing was used to investigate the impact of perioperative chemo(radio)therapy on overall survival (OS). The median follow-up was 21 months (mean: 32 months; interquartile range: 5-48).

RESULTS

Neoadjuvant chemotherapy (NAC), neoadjuvant chemoradiotherapy (N-CRT) plus adjuvant chemotherapy (ACH), and ACH was delivered in 12 (31%), 6 (15%) and 21 (54%) of these patients, respectively. Receipt of NAC/N-CRT was associated with clinically node-positive disease (cN+; P = 0.033) and lower utilization of cystectomy at surgery (P = 0.015). The objective response rate to NAC and N-CRT was 25% and 33%, respectively. The 3-year OS for patients with objective response to neoadjuvant treatment (complete/partial response) was 100% and 58.3% for those with stable or progressive disease (P = 0.30). Of the 26 patients staged ≥cT3 and/or cN+ disease, 16 (62%) received perioperative chemo(radio)therapy and 10 upfront surgery without perioperative chemotherapy (38%). The 3-year OS for this locally advanced subset of patients (≥cT3 and/or cN+) who received NAC (N = 5), N-CRT (N = 3), surgery-only (N = 10) and surgery plus ACH (N = 8) was 100%, 100%, 50% and 20%, respectively (P = 0.016). Among these 26 patients, receipt of neoadjuvant treatment was significantly associated with improved 3-year relapse-free survival (RFS) (P = 0.022) and OS (P = 0.022). Proximal tumor location correlated with inferior 3-year RFS and OS (P = 0.056/0.005).

CONCLUSION

In this series, patients who received NAC/N-CRT for cT3 and/or cN+ PUC appeared to demonstrate improved survival compared with those who underwent upfront surgery with or without ACH.

Risk stratification of pT1-3N0 patients after radical cystectomy for adjuvant chemotherapy counselling

BACKGROUND

In pT1-T3N0 urothelial carcinoma of the bladder (UCB) patients, multi-modal therapy is inconsistently recommended. The aim of the study was to develop a prognostic tool to help decision-making regarding adjuvant therapy.

METHODS

We included 2145 patients with pT1-3N0 UCB after radical cystectomy (RC), naive of neoadjuvant or adjuvant therapy. The cohort was randomly split into development cohort based on the US patients (n=1067) and validation cohort based on the Europe patients (n=1078). Predictive accuracy was quantified using the concordance index.

RESULTS

With a median follow-up of 45 months, 5-year recurrence-free and cancer-specific survival estimates were 68% and 73%, respectively. pT-stage, ge, lymphovascular invasion, and positive margin were significantly associated with both disease recurrence and cancer-specific mortality (P-values ≤ 0.005). The accuracies of the multivariable models at 2, 5, and 7 years for predicting disease recurrence were 67.4%, 65%, and 64.4%, respectively. Accuracies at 2, 5, and 7 years for predicting cancer-specific mortality were 69.3%, 66.4%, and 65.5%, respectively. We developed competing-risk, conditional probability nomograms. External validation revealed minor overestimation.

CONCLUSION

Despite RC, a significant number of patients with pT1-3N0 UCB experience disease recurrence and ultimately die of UCB. We developed and externally validated competing-risk, conditional probability post-RC nomograms for prediction of disease recurrence and cancer-specific mortality.

The role of pelvic lymphadenectomy for prostate cancer--therapeutic?

PURPOSE

The incidence of metastatic lymph node involvement in prostate cancer has decreased with the advent of prostate specific antigen testing. Various algorithms have been designed to assess the probability of lymphatic involvement, resulting in the omission of lymph node dissection in many cases. However, recent reports suggest an underestimation of lymph node involvement. Meticulous lymph node dissection may provide a survival benefit by addressing micrometastatic disease. We analyzed the current literature on extended pelvic lymphadenectomy in prostate cancer.

MATERIAL AND METHODS

The pelvic lymphadenectomy literature was reviewed using a MEDLINE search, focusing on the prevalence of positive nodes, staging vs extended lymphadenectomy and therapeutic benefits.

RESULTS

Staging pelvic lymphadenectomy provides valuable prognostic data and it may be therapeutic. Extended lymph node dissection increases the detection of positive nodes. The number of positive or negative nodes resected may increase survival. The observed survival benefits may be due to the elimination of micrometastatic disease.

CONCLUSIONS

The role, indications and extent of lymphadenectomy remain controversial. Extended lymph node dissection should be performed in all patients at high risk to increase staging accuracy and provide a potential survival benefit. Detailed, meticulous dissection of the internal iliac lymph tissue is required. The benefit of extended lymph node dissection in patients at low risk remains to be determined.

Outcomes of surveillance in unselected patients with clinical stage I testicular germ cell tumors: Results of a modern single institution series

5085

Background: Orchiectomy is curative in 50–80% of patients (pts) with clinical stage I testicular germ cell cancer (CSITC) and modern chemotherapy at the time of relapse is nearly always curative. Traditional management in the US and Europe, which includes retroperitoneal lymph node dissection (RPLND) or adjuvant radiation or chemotherapy, imposes a significant treatment burden on all patients with CSITC. This study investigated outcomes of active surveillance in all pts with CSITC, with additional post-orchiectomy therapy reserved for only those pts who recur. Methods: Since 1998, Oregon Health & Science University’s institutional policy has been to recommend active surveillance alone to all CSITC pts after orchiectomy, independent of known risk factors. We retrospectively identified and reviewed the charts of 90 pts with CSITC treated between 1998 and 2006. Prognostic factors for relapse, time to relapse, post-orchiectomy treatment required, and overall survival rates were tabulated. Results: Of the 53 pts with CSI nonseminoma, complete data are currently available for 36. 12 (33%) relapsed at a median of 6 months (range 3–48) and all received 3 cycles of bleomycin, etoposide, and cisplatin (BEP). 2 pts (5.5% of total population) required RPLND post-chemotherapy for residual teratoma. No additional relapses have been seen, and all 36 pts are alive at a median follow-up of 51 months. Of 37 pts with CSI seminoma, complete data are available for 28. Seven pts (25%) experienced abdominal relapse, at a median of 10 months (range 3–14 months) after orchiectomy. All 7 pts were treated with abdominal radiation. Two pts subsequently relapsed and were cured with chemotherapy. All CSITC pts are alive without disease at a median follow-up of 60 months. Complete data on all 90 pts will be available this spring. Conclusion: This, the largest modern US series of surveillance alone after orchiectomy, resulted in uniformly excellent outcomes suggesting that primary active surveillance reduces the global burden of treatment for pts with CSITC and is appropriate for all pts with clinical stage I disease, independent of clinical risk factors or pathological subtype.

No significant financial relationships to disclose.

Targeted mid-trimester ultrasound examination: how does fetal anatomic visualization depend upon the duration of the scan?

OBJECTIVE

To determine the relationship between visualization of key fetal anatomic structures during mid-trimester ultrasound examination with gestational age and duration of examination.

METHODS

One hundred ultrasound examinations at 16-22 weeks' gestation were reviewed to determine the times at which key fetal anatomic features were seen. Scans were terminated at 30 min or when a comprehensive anatomic survey was complete. Exclusion criteria included multiple gestation, maternal weight>77 kg, abdominal wall scarring, and suspected fetal anomalies.

RESULTS

Visualization of cranial anatomy including lips, face, midline, ventricles, choroid plexus, and cerebellum was achieved in 98% of patients within 30 min. The corresponding figures for spine, cardiac screening (four-chamber, aortic, and pulmonary outflow views) and for abdominal anatomy (stomach, kidneys, bladder, ventral wall, and three-vessel cord) were 91%, 91%, and 99%, respectively. A complete anatomic survey including each of the above elements was obtained by 10, 15, 20, 25, and 30 min in 8%, 31%, 53%, 72% and 81% of the subjects. Rates of complete anatomic surveys within 30 min improved by gestational age interval, from 20/30 (67%) at 16-18 weeks, to 36/44 (82%) at 18-20 weeks, and 25/26 (96%) at 20-22 weeks; this rise was primarily due to improvements in visualization of the spine and heart.

CONCLUSIONS

A comprehensive anatomical survey can be completed in 10 min or less in a minority of patients. For each 5-min time increment up to 30 min, the rate of complete surveys improves. Rates of completed anatomic surveys rise with gestational age.

Molecular prognostication in bladder cancer--a current perspective

The optimal management of bladder cancer depends on the accurate assessment of the tumour's biological potential. Advances in molecular biology and cytogenetics have spurred intense research in identifying and characterising prognostic markers for patients with transitional cell carcinoma (TCC) of the bladder. The molecular changes that occur can be categorised into (1) chromosomal alterations leading to carcinogenesis, (2) cellular proliferation as a result of dysregulation of cell cycle control, and (3) growth control processes such as angiogenesis leading to metastasis. The accumulation of these changes ultimately determines a tumour's clinical behaviour and response to therapy. As the understanding of bladder cancer evolves, novel molecular markers for prognostication will make their way from the research laboratory to the clinical setting with the promise to improve patient care and outcomes.

Placental pathology casebook. Complete hydatidiform mole with coexistent term twin pregnancy

A case of twin pregnancy consisting of a complete hydatidiform mole with a coexistent, viable fetus is presented. The case is distinctive for its presentation on ultrasound, its unusually low levels of serum hCG, its remarkable histology, and its term delivery.