[French ccAFU guidelines - update 2020-2022: upper urinary tract urothelial carcinoma]

INTRODUCTION

-The purpose was to propose an update of the French guidelines from the national committee ccAFU on upper tract urothelial carcinomas (UTUC).

METHODS

- A systematic Medline search was performed between 2018 and 2020, as regards diagnosis, options of treatment and follow-up of UTUC, to evaluate different references with levels of evidence.

RESULTS

- The diagnosis of this rare pathology is based on CT-scan acquisition during excretion and ureteroscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment, nevertheless a conservative endoscopic approach can be proposed for low risk lesion: unifocal tumor, possible complete resection and low grade and absence of invasion on CT-scan. Close monitoring with endoscopic follow-up (flexible ureteroscopy) in compliant patients is therefore necessary. After RNU, bladder instillation of chemotherapy is recommended to reduce risk of bladder recurrence. A systemic chemotherapy is recommended after RNU in pT2-T4 N0-3 M0 disease.

CONCLUSION

- These updated guidelines will contribute to increase the level of urological care for diagnosis and treatment for UTUC.

[French ccAFU guidelines - update 2020-2022: bladder cancer]

OBJECTIVE

- To update French guidelines for the management of bladder cancer specifically non-muscle invasive (NMIBC) and muscle-invasive bladder cancers (MIBC).

METHODS

- A Medline search was achieved between 2018 and 2020, notably regarding diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

RESULTS

- Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS <1) and renal function (creatinine clearance >60 mL/min) allow it (only in 50% of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

CONCLUSION

- These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment of patients diagnosed with NMIBC and MIBC.

French ccAFU guidelines – Update 2018–2020: Bladder cancer

Objective

To propose updated French guidelines for non-muscle invasive (NMIBC) and muscle-invasive (MIBC) bladder cancers.

Methods

A Medline search was achieved between 2015 and 2018, as regards diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

Results

Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS < 1) and renal function (creatinine clearance > 60 mL/min) allow it (only in 50 % of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

Conclusion

These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment for NMIBC and MIBC.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la vessie French ccAFU guidelines — Update 2018—2020: Bladder cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.006. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.006. That newer version of the text should be used when citing the article.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la voie excrétrice supérieure French ccAFU guidelines — Update 2018—2020: Upper tract urothelial carcinoma

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.005. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.005. That newer version of the text should be used when citing the article.

[CCAFU french national guidelines 2016-2018 on upper tract tumors]

INTRODUCTION

The purpose was to propose an update of the french guidelines from the national committee CCAFU on upper tract urothelial carcinomas (UTUC).

METHODS

A systematic Medline search was performed between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of UTUC, to evaluate different references with levels of evidence.

RESULTS

The diagnosis of this rare pathology is based on CT-scan acquisition during excretion and ureteroscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment, nevertheless a conservative endoscopic approach can be proposed for low risk lesion: unifocal tumour, possible complete resection and low grade and absence of invasion on CT-scan. Close monitoring with endoscopic follow-up (flexible ureteroscope) in compliant patients is therefore necessary. After RNU, bladder instillation of chemotherapy is recommended to reduced risk of baldder recurrence. The place of systemic therapy (adjuvant and neoadjuvant chemotherapy) remains to define.

CONCLUSION

These updated guidelines will contribute to increase the level of urological care for diagnosis and treatment for UTUC. © 2016 Elsevier Masson SAS. All rights reserved.

Epicure: a European epidemiological study of patients with an advanced or metastatic Urothelial Carcinoma (UC) having progressed to a platinum-based chemotherapy

Background

Platinum-based systemic chemotherapy is considered the backbone for management of advanced urothelial carcinomas. However there is a lack of real world data on the use of such chemotherapy regimens, on patient profiles and on management after treatment failure.

Methods

Fifty-one randomly selected physicians from 4 European countries registered 218 consecutive patients in progression or relapse following a first platinum-based chemotherapy. Patient characteristics, tumor history and treatment regimens, as well as the considerations of physicians on the management of urothelial carcinoma were recorded.

Results

A systemic platinum-based regimen had been administered as the initial chemotherapy in 216 patients: 15 in the neoadjuvant setting, 61 in adjuvant therapy conditions, 137 in first-line advanced setting and 3 in other conditions. Of these patients, 76 (35 %) were initially considered as cisplatin-unfit, mainly because of renal impairment (52 patients). After platinum failure, renal impairment was observed in 44 % of patients, ECOG Performance Status ≥ 2 in 17 %, hemoglobinemia < 10 g/dL in 16 %, hepatic metastases in 13 %. 80 % of these patients received further anticancer therapy. Immediately after failure of adjuvant/neoadjuvant chemotherapy, most subsequent anticancer treatments were chemotherapy doublets (35/58), whereas after therapy failure in the advanced setting most patients receiving further anticancer drugs were treated with a single agent (80/114). After first progression to chemotherapy, treatment decisions were mainly driven by Performance Status and prior response to chemotherapy (>30 % patients). The most frequent all-settings second anticancer therapy regimen was vinflunine (70 % of single-agent and 42 % of all subsequent treatments), the main reasons evoked by physicians (>1 out of 4) being survival benefit, safety and phase III evidence.

Conclusion

In this daily practice experience, a majority of patients with urothelial carcinoma previously treated with a platinum-based therapy received a second chemotherapy regimen, most often a single agent after an initial chemotherapy in the advanced setting and preferably a cytotoxic combination after a neoadjuvant or adjuvant chemotherapy. Performance Status and prior response to chemotherapy were the main drivers of further treatment decisions.

Tumor heterogeneity of fibroblast growth factor receptor 3 (FGFR3) mutations in invasive bladder cancer: implications for perioperative anti-FGFR3 treatment

BACKGROUND

Fibroblast growth factor receptor 3 (FGFR3) is an actionable target in bladder cancer. Preclinical studies show that anti-FGFR3 treatment slows down tumor growth, suggesting that this tyrosine kinase receptor is a candidate for personalized bladder cancer treatment, particularly in patients with mutated FGFR3. We addressed tumor heterogeneity in a large multicenter, multi-laboratory study, as this may have significant impact on therapeutic response.

PATIENTS AND METHODS

We evaluated possible FGFR3 heterogeneity by the PCR-SNaPshot method in the superficial and deep compartments of tumors obtained by transurethral resection (TUR, n = 61) and in radical cystectomy (RC, n = 614) specimens and corresponding cancer-positive lymph nodes (LN+, n = 201).

RESULTS

We found FGFR3 mutations in 13/34 (38%) T1 and 8/27 (30%) ≥T2-TUR samples, with 100% concordance between superficial and deeper parts in T1-TUR samples. Of eight FGFR3 mutant ≥T2-TUR samples, only 4 (50%) displayed the mutation in the deeper part. We found 67/614 (11%) FGFR3 mutations in RC specimens. FGFR3 mutation was associated with pN0 (P < 0.001) at RC. In 10/201 (5%) LN+, an FGFR3 mutation was found, all concordant with the corresponding RC specimen. In the remaining 191 cases, RC and LN+ were both wild type.

CONCLUSIONS

FGFR3 mutation status seems promising to guide decision-making on adjuvant anti-FGFR3 therapy as it appeared homogeneous in RC and LN+. Based on the results of TUR, the deep part of the tumor needs to be assessed if neoadjuvant anti-FGFR3 treatment is considered. We conclude that studies on the heterogeneity of actionable molecular targets should precede clinical trials with these drugs in the perioperative setting.

[Tasquinimod: How to act on microenvironment in metastatic prostate cancer]

Despite the recent introduction of new drugs, castration-resistant metastatic prostate cancer, (mCRPC) remains a poor prognosis disease, with a crucial need for new therapeutic approaches. Tasquinimod is a newly developed molecule, orally administered, currently evaluated in phase III studies. Tasquinimod targets the tumor microenvironment, focusing on the angiogenic and immune components. Its specific action on the S100A9 protein restores immunity and reduces angiogenesis. A phase II double-blind randomized study against placebo showed an improvement of more than 50% of progression free survival in the group of mCRPC patients treated with tasquinimod, as compared to the placebo group. At a dose of 1mg/day, the tolerance of tasquinimod appeared acceptable. This review presents the available preclinical and clinical results of tasquinimod, with a particular focus on the originality of its mode of action.

[Chemotherapy in perioperative setting for infiltrative bladder cancer]

INTRODUCTION

Despite an aggressive initial treatment, only 60% of patients with T2-staged bladder tumours, 50% with T3a and 15% with T3b staged-tumours will be alive at 5 years. The purpose of this review is to clarify the potential role of chemotherapy in localised urothelial tumours, which has not been clearly defined.

MATERIALS AND METHODS

To address this question, we reviewed published randomized trials of chemotherapy in urothelial tumours of the bladder in both neoadjuvant and adjuvant settings from 1980 and 2010 and corresponding meta-analyses in PubMed.

RESULTS

In the neoadjuvant setting, a meta-analysis of individual data from 3005 patients demonstrated an absolute survival benefit of 5.5% at 5 years. Despite these results, neoadjuvant chemotherapy is very rarely proposed in this indication. Comparative trials performed in the adjuvant setting have been limited by major methodological weaknesses, preventing definitive conclusions. In a meta-analysis based on individual data from 491 patients, a 25% reduction in death risk was observed for an absolute gain of 9% at 3 years.

CONCLUSION

In light of these data, chemotherapy should be offered early and proposed as a reasonable option for patients for tumours with extravesical extension or with nodal involvement detected postoperatively, neoadjuvant chemotherapy is the standard of care.

[The role and method of fluorescence-guided cystoscopy in 2011 for management of bladder cancer: Review of the Oncology Committee of the French Urology Association]

AIM

Fluorescence-guided cystoscopy is a useful tool for bladder tumour detection in association with white-light cystoscopy and decreases the residual tumour rate. The aim of the study was to provide an overview of the pertinent literature on this subject.

MATERIALS AND METHODS

The data were provide from a Medline(®) research by using the follow keywords: urinary bladder neoplasms; cystoscopy; fluorescence; prognosis; intraepithelial neoplasm.

RESULTS

No evidence 1 level data was available. The fluorescence-guided cystoscopy improves the bladder cancer detection rate, especially the flat lesions, and improve the recurrence-free survival by decreasing the residual tumour rate. The specific indications for fluorescence-guided cystoscopy in the diagnosis and management of non-muscle invasive bladder cancer (NMIBC) should benefit the patients.

CONCLUSION

The fluorescence-guided cystoscopy is a benefical tool in association with white-light cystoscopy in NMIBC diagnosis. It has been shown to have a positive impact on recurrence-free survival but not on progression-free survival. More investigations with significant follow-up should be lead in the future to accurately assess its therapeutic impact on patients.

[Physiopathology and new therapeutic strategies in the management of bone metastases of prostate cancer]

Prostate cancer (PCa) is one of the most common human malignancies that have a strong propensity to spread in the bones. Despite the progress in the diagnosis and the treatment of prostate cancer, bone metastases are present in nearly 95% of men with metastatic PCa at autopsy. Bone metastases are a major cause of skeletal complications which may negatively affect the quality of life and increase morbidity and mortality in men with advanced PCa. Bisphosphonates are potent inhibitors of bone resorption that have demonstrated clinical benefit for the treatment of bone metastases. They are standard of care for the prevention of skeletal complications such as pain and pathological fractures in patients with bone metastases from PCa. More recently, the discovery of the OPG/RANK/RANKL system has permitted to better understand the role of OPG and RANKL as key regulators of osteoclast-mediate bone destruction in both normal bone remodelling and pathologic conditions. RANKL has been shown to contribute to the vicious cycle of bone destruction and tumour growth in PCa. Therefore, the development of new emerging treatment that inhibits RANKL using RANKL antibodies, as denosumab, resulted in a better control and treatment of skeletal complications, with the hope in a near future to prevent bone metastases.

[Postoperative radiotherapy of prostate cancer]

After radical prostatectomy, the risk of biological recurrence at 5 years varies from 10 to 40 % and this natural evolution of the disease has led radiation therapy being proposed as a supplement to surgery. When the recurrence risk is essentially local, supplementary radiotherapy is justified in the aim of improving biological recurrence-free survival, local control, metastasis-free survival and specific and global survival, while respecting patient quality of life. Three recent studies, EORTC 22911, ARO 9602 and SWOG 8794 found a similar advantage for biological recurrence-free survival without higher major additional toxicity. However, only the SWOG 8794 study found a significant improvement for metastasis-free survival and global survival. In an adjuvant setting, the optimal moment to propose this postoperative radiotherapy remains uncertain: should it be proposed systematically to all pT3 R1 patients, running the risk of pointlessly treating patients who will never recur, or should it only be proposed at recurrence? The GETUG AFU 17 trial will provide answers to the question of the optimal moment for postoperative radiotherapy for pT3-4 R1 pN0 Nx patients with the objective of comparing an immediate treatment to a differed early treatment initiated at biological recurrence.

Irofulven (IROF) combined with oxaliplatin (OXA) in advanced hepatocellular carcinoma (HCC) patients (pts): Phase I study (preliminary results)

14082

Background: IROF, a semisynthetic derivative of the natural product illudin S, is a novel DNA binding agent that has demonstrated antitumor activity in pts with a variety of chemoresistant tumors. Currently available systemic chemotherapy offers limited benefit to HCC pts. Evidence of IROF activity in HCC was seen with IROF 11 mg/m2 daily x4 every 28 days (Stuart et al, ASCO 2003), and every other week dosing schedules (Falcon et al, ASCO 2004). Preclinically, IROF exhibits additive and synergistic antitumor activity in combination with OXA. Methods: Dose escalation was performed in pts with HCC and other advanced malignancies in this Phase I study. Dose levels (DL) were OXA (mg/m2)/IROF (mg/kg): DLI: 40/0.3; DLII: 40/0.4; DLIII: 50/0.4; DLIV: 60/0.4; DLV: 70/0.4; DLVI: 80/0.4. OXA (2-hour infusion) was followed by IROF (30-min infusion) on Days 1 and 15 every 28 days. Results: Of the 41 pts treated, 8 had HCC, 2 treated at DLI and 6 at DLVI. Median age of these 8 pts was 48 years; PS (ECOG) 0/1: 1/7; median AFP 1253 ug/L (range 16–39760); 3 pts had a history of hepatitis (B/C : 2/1) and 2 of cirrhosis; 3 had prior chemotherapy and 3 chemoembolization; all but one had metastatic disease. Safety: A median of 3 cycles was given (range 1+ to 5+). One pt experienced grade (G) 3 vomiting, 5 pts G1–2 asthenia and nausea, 4 G3 thrombocytopenia and 3 G3 neutropenia. Efficacy: Activity was seen in 6 of the 8 HCC pts, (DLI: 1; DLVI: 5); 1 confirmed PR with AFP decrease from 1250 to 1.9 (99.8%; DLVI) and PFS of 3.5+ months; 1 PR, non-confirmed (42% AFP decrease, 20741 to 11974; DLVI) with PFS of 3.6 months, and 4 SD (DLI: 1; DLVI: 3) were observed with a median duration of 3.6 months (3.2–6.0 +); 3 SD pts (3.8, 3.9 and 3.2+ month duration) had 12%, 52% and 36% AFP decrease respectively. Based on activity in the whole cohort and in the absence of an MTD, DLVI (80/0.4) was selected as the recommended dose. Conclusions: Combined IROF/OXA shows substantial activity and is well tolerated in advanced HCC pts. Additional HCC patients will be included at the RD to evaluate the efficacy of IROF/OXA in this indication.

[Table: see text]

A three schedule phase I trial of CP-4055, weekly and q2 weeks in patients with advanced or metastatic solid tumors

2067

Background: CP-4055 (ELACYT, ara-C 5’-elaidic acid ester) is a novel cytotoxic agent with broad preclinical antitumor activity in solid tumors. CP-4055 is based on Lipid Vector Technology and has a different cellular uptake compared to ara-C. An initial phase I trial of a day 1–5 q4 weeks (w) schedule (sch) determined a recommended dose of 200 mg/m2/day and showed clinical activity (Aamdal et al, AACR 2005). We report a multiple sch, parallel, dose intensity-guided dose escalation phase I trial, with pharmacokinetic (PK) assessment, intended to determine Maximum Tolerated Dose (MTD). Methods: Patients (pts) with refractory solid tumors received i.v. CP-4055 over 2 hours according to 3 sch: days 1, 8 q3w (Sch 1); days 1, 15 q4w (Sch 2); days 1, 8, 15 q4w (Sch 3). Dose escalation: dose level (DL) 1: 80 mg/m2/w, DL2: 160; DL3: 240; DL4: 320; DL5: 400; DL6: 440; DL7: 520, with standard definitions of dose limiting toxicity (DLT). Results: Since June 2004, 45 pts have been treated in 4 European centers; 3 are still ongoing, 37 discontinued for progressive disease, 3 for refusal, 2 for AE (1 treatment-related grade [gr] 3 paresthesia), trial is ongoing. Demographics: male/female: 27/18; median age 54 (range 35–79); ECOG PS 0/1/2: 19/24/2. Main tumor types: colorectal 6, breast 5, head & neck 5; median 3 lines prior chemotherapy (range 0–5). Exposure: 128 cycles administered, including 5 pts with ≥ 6 cycles. MTD: No DLT has been observed and dose escalation is ongoing. Safety (NCI-CTCAE v3): 45 pts assessable. Principal toxicities by pt (gr 1–2/3): anemia 34/1; nausea and vomiting 29/3; asthenia 24/1; neutropenia 12/2; headache 8/0; thrombocytopenia 3/0. No clear association with sch or DL was observed for this mild/moderate toxicity. There were no dose reductions. PK: ara-U/ara-C AUC ratio exceeds by 3-fold the standard ara-U/ara-C AUC ratio. Efficacy: 41 pts were assessable, 10 pts had stable disease (lasting > 6 months in 4 pts: 2 NSCLC, 1 colorectal, 1 kidney). Conclusions: CP-4055 shows preliminary evidence of activity and is well tolerated up to a dose of 440 mg/m2/w. PK results indicate that a majority of ara-U in plasma originates from intracellular deamination of ara-C from CP-4055, confirming intracellular retention of CP-4055. Accrual is ongoing at the DI of 520 mg/m2/w.

[Table: see text]