Advanced Muscle-invasive Bladder Cancer Research Articles

Clinical practice guideline on bladder cancer (Part III)

AbstractBladder cancer (BC) has become a significantly prevalent disease in China, with an incidence rate of 5.80 per 100 000 in 2015, ranking it as the thirteenth most common type of cancer within the nation. This illness presents a serious public health concern, highlighting the imperative need to unify the standards for diagnosis and treatment to improve patient outcomes. The section of the clinical practice guideline in question is dedicated to addressing muscle‐invasive bladder cancer (MIBC) and metastatic BC. The primary treatment strategies for MIBC are well‐defined: preoperative (neoadjuvant) chemotherapy combined with radical cystectomy stands as the conventional treatment protocol. For patients with locally advanced MIBC, integrating systemic and local therapies is advocated to enhance treatment effectiveness. In cases of metastatic BC, the focus shifts to systemic treatment supplemented by supportive care measures. The guideline also succinctly presents the pros and cons of various urinary diversion surgeries, which are critical considerations following radical cystectomy. It provides an in‐depth exploration of the treatment modalities for metastatic urothelial carcinoma of the bladder. Additionally, this part delves into the integrated approach to treatment and the use of radiotherapy in bladder preservation for localized disease. Moreover, it offers a concise overview of the classification, diagnosis, and therapeutic approaches for nonurothelial carcinoma of the bladder. Lastly, this part emphasizes the importance of recommended posttreatment follow‐up for MIBC patients to ensure comprehensive and ongoing care management.

Analysis of transferrin in urine in patients with bladder cancer using nanobodies

It is known that the saturation ratio of transferrin (Tf) with iron in human blood is an important clinical parameter. Specific antibodies can be used to analyze subtle changes in the relative abundance of different forms of transferrin potentially associated with a pathological process. Recently, the authors of this study were able to obtain and characterize highly specific single-domain antibodies (nanobodies) that predominantly recognize the iron-saturated (holo-Tf) or iron-unsaturated (apo-Tf) form of transferrin. In this work, under conditions closer to physiological than in previous experiments, we further demonstrated that these unique nanobodies have extremely high differential binding specificity for different forms of Tf in different human biological fluids. Using these nanobodies, we were able to analyze for the first time the relative abundance of transferrin forms in urine samples from patients with bladder cancer (BC). We have shown that an increase in the concentration of total Tf in urine samples normalized for creatinine is associated with the degree of progress and growth of malignancy of BC. In the samples of healthy donors and in the early stages of BC (G1), Tf is detected in much smaller amounts (compared to later stages) and only with additional concentration of the studied samples. For most of the studied urine samples from BC patients, it is expected (as previously shown in the case of Tf in the blood of terminal ovarian cancer patients) that the concentration of apo-Tf is clearly higher than holo-Tf, especially in the case of the most advanced muscle-invasive BC. It was a surprise for us that approximately equal amounts of apo-Tf and “holo-Tf” were found in the urine samples of some patients with BC. We hypothesized that the “holo-Tf” fraction in this case can be largely represented by “secondary complexes” formed by apo-Tf in combination with ions other than Fe3+, which accumulate in the urine of some cancer patients and are able to bind to apo-Tf, changing its conformation towards holo-Tf. Using inductively coupled plasma ionization mass spectroscopy (ICP-MS), we obtained the first results confirming our hypothesis. The “holo-Tf” preparation in these urine samples was found to be highly enriched in zinc and nickel. Also in this preparation, a relative enrichment in cadmium is observed, but it is present in much lower concentrations. The data obtained indicate that the nanobody used, recognizing predominantly the iron-saturated form of transferrin (holo-Tf), is also capable of binding transferrin in association with other metal ions that are different from iron. This ability could potentially open up new possibilities in studies of the relative abundance of various metal ions in association with transferrin in human biological fluids in normal and pathological conditions.

Effectiveness of perioperative chemotherapy and radical cystectomy in treating bladder cancer

BackgroundDespite abundant evidence supporting the use of perioperative chemotherapy from clinical trials, no study to date has comprehensively evaluated its use in the treatment of muscle-invasive bladder cancer (MIBC) in the real-world setting. Little is known regarding the impact of pretreatment disease stage and real-world factors such as patient comorbidities preventing timely completion of therapy on its effectiveness. This study aims to assess the usage of perioperative chemotherapy and examines its impact on pathologic downstaging rates and recurrence free survival in patients undergoing radical cystectomy. MethodsA retrospective review was conducted in 805 patients with muscle invasive bladder cancer undergoing radical cystectomy with no perioperative chemotherapy, 761 with presurgical chemotherapy followed by radical cystectomy, and 134 radical cystectomy followed by adjuvant chemotherapy. Relevant clinicopathologic features were reviewed. Recurrence-free survival and Overall Survival probability estimates were calculated using the Kaplan–Meier method and compared using the Log-rank or Gehan-Breslow tests. The prognostic effects of presurgical chemotherapy and adjuvant chemotherapy regimens were evaluated by estimating hazard ratio and 95% confidence interval from an adjusted Cox proportional hazards model. Statistical tests were 2-sided, and significance was defined as P-value < 0.05. ResultsIn this contemporary, real-world cohort, 5-yr RFS was found to be 65.6% in pT0, 59.1%in <pT2, 35.4% in pT2, 15.3% in >pT2, and 10.8% in pN+ patients. Presurgical chemotherapy increased pathologic downstaging rates from 27.5% to 41.1% in patients with ≥cT2 BCa. Stratified by clinical T-stage, only cT2 patients derived recurrence-free survival (Median 45.3 months vs. 29.0 months, P < 0.01) and overall survival (Median 62.3 months vs. 41.9 months, P < 0.001) benefits. In patients with adverse pathologic features (≥pT3 or pN+), adjuvant chemotherapy improved recurrence-free survival (Median 22.8 months vs. 10.0 months, P < 0.0001) and overall survival (Median OS 32.4 months vs. 16.3 months, P < 0.0001). ConclusionsWe report real-world outcomes from a large cohort of muscle-invasive bladder cancer patients undergoing surgical treatment with/out perioperative chemotherapy. Pathologic response rates to pre-surgical chemotherapy were modest and led to clinical benefit only in cT2 patients. Adjuvant chemotherapy provided survival benefit for pathologically advanced MIBC patients irrespective of pT/N staging.

Analysis of Transferrin in the Urine of Patients with Bladder Cancer Using Nanobodies.

It is known that the saturation ratio of transferrin (Tf) with iron in human blood is an important clinical parameter. Specific antibodies can be used to analyze subtle changes in the relative abundance of different forms of transferrin potentially associated with a pathological process. Recently, the authors of this study were able to obtain and characterize highly specific single-domain antibodies (nanobodies) that predominantly recognize the iron-saturated (holo-Tf) or iron-unsaturated (apo-Tf) form of transferrin. In this work, under conditions closer to physiological than in the previous experiments, we further demonstrated that these unique nanobodies have extremely high differential binding specificity for different forms of Tf in different human biological fluids. Using these nanobodies, we were able to analyze for the first time relative abundance of the transferrin forms in urine samples from the patients with bladder cancer (BC). We have shown that increase in the concentration of total Tf in the urine samples normalized for creatinine is associated with the degree of progress and growth of malignancy of BC. In the samples of healthy donors and in the early stages of BC (G1), Tf is detected in much smaller amounts (compared to the later stages) and only with additional concentration of the studied samples. For most of the studied urine samples from the BC patients, it is expected (as previously shown in the case of Tf in the blood of terminal ovarian cancer patients) that the concentration of apo-Tf is clearly higher than holo-Tf, especially in the case of the most advanced muscle-invasive BC. It was a surprise for us that approximately equal amounts of apo-Tf and holo-Tf were found in the urine samples of some patients with BC. We hypothesized that the holo-Tf fraction in this case could be largely represented by the "secondary complexes" formed by apo-Tf in combination with ions other than Fe3+, which accumulate in the urine of some cancer patients and are able to bind to apo-Tf, changing its conformation towards holo-Tf. By using inductively coupled plasma mass spectroscopy (ICP-MS), we obtained first results confirming our hypothesis. Preparation of the holo-Tf in these urine samples was found to be highly enriched in zinc and nickel. Also, relative enrichment in cadmium has been observed in this preparation, but at much lower concentrations. The obtained data indicate that the used nanobody, while recognizing predominantly the iron-saturated form of transferrin (holo-Tf), is also capable of binding transferrin in association with other metal ions that are different from iron. This ability could potentially open up new possibilities for investigation of relative abundance of various metal ions in association with transferrin in human biological fluids in normal and pathological conditions.

A phase 2, open-label study of neoadjuvant chemotherapy plus tislelizumab followed by radiotherapy-based, bladder-preserving treatment for high risk/locally advanced muscle invasive urothelial bladder cancer (HOPE-02).

516 Background: Tri-modality therapy (TMT) is an alternative to radical cystectomy for selected muscle-invasive bladder cancer (MIBC) patients with bladder-preserving will. Neoadjuvant treatment makes chance for imperfect patients to turn into ideal bladder-sparing patients. This phase 2 study aimed to explore the efficacy of neoadjuvant chemotherapy plus tislelizumab followed by radiotherapy as a strategy of bladder-sparing therapy for high risk/locally advanced MIBC (Trial registration number: ChiCTR2100045213). Methods: Pathological and imaging diagnosed cT2-4bN0-3M0-1a MIBC received 3-4 cycles of neoadjuvant chemotherapy (gemcitabine and cisplatin or carboplatin) plus tislelizumab (200mg every three weeks for one year). Radiotherapy (60.4-64.4 Gy /1.8Gy/33-35f to bladder with 50.4 Gy/1.8Gy/28f to pelvic) were given to patients with non- progressed disease (PD) after neoadjuvant therapy. The primary endpoint was complete response rate (CR, including T0/Ta/Tis), and the secondary endpoints were progression-free survival (PFS), bladder-intact disease free survival (BI-DFS), overall survival (OS) and toxicity. Results: The simple size is 43 participants. Until now, 28 patients were included, of which 23 patients received radiotherapy and 16 patients finished efficacy evaluation with imaging and cystoscopic biopsy after radiotherapy. Median follow-up time was 14.2 (1.5-17.4) months (m). Two of the 16 patients were Tis and 14 were T0 after radiotherapy, indicating the primary CR rate were 100%. For the 2 patients with Tis received BCG vaccine intravesical perfusion, and T0 was achieved when the second therapy evaluation. No patient died and only one patient had distant metastasis. The one-year PFS rate, one-year BI-DFS and one-year OS were 100%. Grade 3 and 4 hematological system adverse events were 23.3% and 2.3%. One patient had reduced bladder capacity (100-200 mL) with 2-h intervals of micturition, and 3 patients had frequency with urgency, nocturia and dysuria. Three patients had grade1 immunotherapy related abnormality of thyroidal function and 3 patients suffered from grade 2 myositis. The current bladder-preserving therapies research were well-tolerated with acceptable and manageable toxicities. Conclusions: Neoadjuvant chemotherapy plus tislelizumab followed by radiotherapy showed perfect efficacy and acceptable toxicities, which maybe an optimal strategy for high risk/locally advanced MIBC patients with bladder-preserving willingness. Clinical trial information: ChiCTR2100045213 .

Tumor and Stromal Cell Targeting with Nintedanib and Alpelisib Overcomes Intrinsic Bladder Cancer Resistance.

Bladder cancer is a highly prevalent tumor, requiring the urgent development of novel therapies, especially for locally advanced and metastatic disease. Nintedanib is a potent antifibrotic angio-kinase inhibitor, which has shown clinical efficacy in combination with chemotherapy in patients with locally advanced muscle-invasive bladder cancer. Nintedanib inhibits fibroblast growth factor receptors (FGFRs), validated targets in patients with bladder cancer harboring FGFR3/2 genetic alterations. Here, we aimed at studying its mechanisms of action to understand therapy resistance, identify markers predictive of response, and improve the design of future clinical trials. We have used a panel of genetically well-characterized human bladder cancer cells to identify the molecular and transcriptomic changes induced upon treatment with nintedanib, in vitro and in vivo, at the tumor and stroma cell levels. We showed that bladder cancer cells display an intrinsic resistance to nintedanib treatment in vitro, independently of their FGFR3 status. However, nintedanib has higher antitumor activity on mouse xenografts. We have identified PI3K activation as a resistance mechanism against nintedanib in bladder cancer and evidenced that the combination of nintedanib with the PI3K inhibitor alpelisib has synergistic antitumor activity. Treatment with this combination is associated with cell-cycle inhibition at the tumoral and stromal levels and potent nontumor cell autonomous effects on α-smooth muscle actin-positive tumor infiltrating cells and tumor vasculature. The combination of nintedanib with PI3K inhibitors not only reversed bladder cancer resistance to nintedanib but also enhanced its antiangiogenic effects.

Bladder cancer in young adults: Disease and treatment characteristics of patients treated at a tertiary cancer center.

The incidence of bladder cancer in the Middle East is increasing. Nevertheless, data on the young population with urothelial carcinoma (UC) of the urinary bladder in this region is scarce. Therefore, we evaluated clinical and tumor characteristics, in addition to treatment details in patients younger than 45 years old. We reviewed all patients presenting with UC of the urinary bladder from July 2006 to December 2019. Clinical characteristics including demographics, stage at presentation, and treatment outcomes were extracted. Out of 1272 new cases of bladder cancer, a total of 112 (8.8%) patients were ≤45 years old. Seven patients (6%) had nonurothelial histology and were excluded from the study. The remaining 105 eligible patients with UC had a median age at presentation of 41 years (35-43). Ninety-three patients (88.6%) were males. Tumor stage at presentation: nonmuscle invasive disease (Ta-T1), locally advanced muscle-invasive bladder cancer (MIBC) (T2-3), and metastatic disease were 84.7%, 2.8%, and 12.5%, respectively. All patients with MIBC received neoadjuvant cisplatin-based chemotherapy. Radical cystectomy was performed in 8 (7.6%) cases; three patients with MIBC and five with high-volume non-MIBC. Neobladder reconstruction was done in six patients. A total of 13 patients with metastatic disease (93%) received palliative chemotherapy (gemcitabine/cisplatin), and one (7%) was a candidate for best supportive care only. Bladder cancer is relatively rare in the young population, although the incidence at our region is higher than other reports in the literature. Most patients present with early disease. Early diagnosis and multidisciplinary approach are paramount for the management of these patients.

135O A multi-center phase Ib/II study of RC48-ADC combined with tislelizumab as neoadjuvant treatment in patients with HER2 positive locally advanced MIBC

Bladder cancer with HER2 high expression is related to pathological malignancy and poor prognosis. The standard care for muscle-invasive bladder cancer (MIBC) is neoadjuvant chemotherapy (NAC) followed by radical cystectomy. For HER2 positive MIBC, the efficacy of cisplatin- based NAC are unsatisfied. This study aims to evaluate the safety and efficacy of RC48-ADC, an anti-HER2 antibody conjugation, and tislelizumab as a novel neoadjuvant treatment in this population.

Predictive value of molecular subtypes and APOBEC3G for adjuvant chemotherapy in urothelial bladder cancer.

Although targeted approaches have become available in second- and third-line settings, platinum-based chemotherapy remains the standard first-line treatment for advanced muscle-invasive bladder cancer (MIBC). Therefore, the prediction of platinum resistance is of utmost clinical importance. In this study, we established a routine compatible method for the molecular classification of MIBC samples according to various classification systems and applied this method to evaluate the impact of subtypes on survival after adjuvant chemotherapy. This retrospective study included 191 patients with advanced MIBC (pT≥3 or pN+) who underwent radical cystectomy, with or without adjuvant chemotherapy. A 48-gene panel and classifier rule set were established to determine molecular subtypes according to TCGA, MDA, LundTax, and Consensus classifications. Additionally, 12 single platinum-predictive candidate genes were assessed. The results were correlated with patients' clinicopathological and follow-up data and were validated using independent data sets. Our final evaluation of 159 patients demonstrated better survival in the luminal groups for those who received chemotherapy compared with those who did not. In contrast, no such differences were observed in basal subtypes. The use of chemotherapy was associated with better survival in patients with high APOBEC3G expression (p < 0.002). This association was confirmed using an independent data set of patients who received neoadjuvant platinum therapy. The proposed method robustly replicates the most commonly used transcriptome-based subtype classifications from paraffin-embedded tissue samples. The luminal, but not basal, molecular subtypes had the greatest benefit from adjuvant platinum therapy. We identified and validated APOBEC3G as a novel predictive marker for platinum-treated patients.

The increasing indications of FDG-PET/CT in the staging and management of Invasive Bladder Cancer.

The management of locally advanced muscle invasive bladder cancer (MIBC) often necessitates neo-adjuvant chemotherapy (NAC) to eliminate any micro-metastatic disease prior to definitive radical cystectomy (RC) and pelvic lymph node dissection (PLND). The most common imaging techniques traditionally used during this process are computerised tomography (CT) and magnetic resonance imaging (MRI), both of which lack a high sensitivity for nodal staging. In this paper, we attempt to review the evolving indications of F-fluoro-2-deoxy-D-glucose positron emission tomography/computerised tomography (FDG-PET/CT) imaging, in the pre-clinical and post-treatment staging of bladder cancer, with a focus on its ability to evaluate response to NAC. We concluded that use of FDG-PET/CT allows for improved nodal staging and metastatic disease detection, compared to traditional imaging modalities. This enabled earlier detection of tumour response to NAC and/or residual disease, impacting factors such as duration of chemotherapy, with its associated adverse effects, and timing of surgical intervention. However, further studies are required to reliably assess its impact on both overall and disease-free survival.

Classification of Muscle Invasive Bladder Cancer to Predict Prognosis of Patients Treated with Immunotherapy.

Background Recently, immunotherapies have been approved for advanced muscle invasive bladder cancer (MIBC) treatment, but only a small fraction of MIBC patients could achieve a durable drug response. Our study is aimed at identifying tumor microenvironment (TME) subtypes that have different immunotherapy response rates. Methods The mRNA expression profiles of MIBC samples from seven discovery datasets (GSE13507, GSE31684, GSE32548, GSE32894, GSE48075, GSE48276, and GSE69795) were analyzed to identify TME subtypes. The identified TME subtypes were then validated by an independent dataset (TCGA-MIBC). The subtype-related biomarkers were discovered using computational analyses and then utilized to establish a random forest predictive model. The associations of TME subtypes with immunotherapy therapeutic responses were investigated in a group of patients who had been treated with immunotherapy. A prognostic index model was constructed using the subtype-related biomarkers. Two nomograms were built by the subtype-related biomarkers or the clinical parameters. Results Two TME subtypes, including ECM-enriched class (EC) and immune-enriched class (IC), were found. EC was associated with greater extracellular matrix (ECM) pathways, and IC was correlated with immune pathways, respectively. Overall survival was significantly greater for tumors classified as IC, whereas the EC subtype had a worse prognosis. A total of nine genes (AKAP12, APOL3, CXCL13, CXCL9, GBP4, LRIG1, PEG3, PODN, and PTPRD) were selected by computational analyses to construct the random forest model. The area under the curve (AUC) values for this model were 0.827 and 0.767 in the testing and external validation datasets, respectively. Therapeutic response rates were greater in IC patients than in EC patients (28 percent vs. 18 percent). Patients with a high prognostic index had a poorer prognosis than those with a low prognostic index. The nomogram constructed from nine genes and stage achieved a C-index of 0.71. Conclusion The present investigation defined two distinct TME subtypes and developed models to assess immunotherapeutic treatment outcomes.

Real-world study of chemotherapy plus immunotherapy versus chemotherapy alone as neoadjuvant treatment guided bladder-sparing therapy for localized muscle-invasive bladder cancer.

499 Background: Bladder-preserving combined-modality therapy has been a popular research field as an alternative to radical cystectomy for selected patients with localized muscle-invasive bladder cancer (MIBC). This real-world study aimed to compare the efficacy of neoadjuvant chemotherapy plus immunotherapy versus chemotherapy alone as one of bladder-sparing therapies for localized MIBC. Methods: Patients with cT2-4bN0-3M0-1a pathological and imaging diagnosed MIBC were included in the study. Either chemotherapy (gemcitabine and cisplatin/carboplatin) plus immunotherapy (PD-1 checkpoint inhibitor, including pembrolizumab，tislelizumab and toripalimab) or chemotherapy alone were given as patients’ wish. The primary endpoint was complete response rate (CR, T0/Ta/Tis), and the secondary endpoints were disease control rate (DCR), progression-free survival (PFS), bladder-intact disease-free survival (BI-DFS) and toxicity. Results: In total, 41 patients were included, 25 in combination group and 16 in chemotherapy group respectively. The baseline characteristics were well balanced in two groups. Median follow-up time was 15.3 ±4.4 months(m). No patient died. The efficacy evaluable population was consisted of 34 pts (22 in combination group; 12 in chemotherapy alone group). The CR rate for combination group was 50.0% and 0 for chemotherapy alone group. One patient suffered from disease progression in combination group and three in chemotherapy group. The DCRs for combination group and chemotherapy group were 95.5% and 66.7%, respectively ( p= 0.003). Twelve patients had radiotherapy and six patients had radical cystectomy followed by neoadjuvant treatments in combination group. And two patients had radiotherapy and three patients had radical cystectomy in chemotherapy group. The one-year PFS rates were 95.5% and 62.5% for combination group and chemotherapy group( p= 0.010), and the one-year BI-DFS were 66.1% versus 27.5% respectively( p= 0.159). The bladder-preserving combined-modality therapies used were well-tolerated with acceptable and manageable toxicities. Grade ¾ hematological system adverse events were 15.9% and 6.4% in combination group and chemotherapy group, respectively ( p= 0.021). Conclusions: Neoadjuvant chemotherapy plus immunotherapy showed better efficacy compared with chemotherapy alone as an important bladder-sparing therapy for locally advanced MIBC with acceptable and manageable toxicities.

Potential therapeutic effects of adjuvant chemotherapy after neoadjuvant chemotherapy for locally advanced muscle-invasive bladder cancer.

Although the administration of neoadjuvant chemotherapy has been associated with improved prognosis in patients with muscle-invasive bladder cancer, the therapeutic effects of adjuvant chemotherapy remain unknown in real-world settings. Therefore, we herein evaluated the clinical outcomes of adjuvant chemotherapy in pT3/4 muscle-invasive bladder cancer patients. Among 587 bladder cancer patients who underwent radical cystectomy, 200 with a pathological T3 or higher muscle-invasive bladder cancer were included in the present analysis. Recurrence-free survival and cancer-specific survival were assessed by multivariate Cox regression analysis. Median age was 73years, and the median follow-up duration was 17months. The 5-year cancer-specific survival rate was 53.6% in 66 patients treated with adjuvant chemotherapy, which was significantly higher than that in those without adjuvant chemotherapy (34.0%, P=0.025). The absence of adjuvant chemotherapy (hazard ratio=2.114, P=0.004) and lymphovascular invasion (hazard ratio=2.203, P=0.011) was identified as independent prognostic indicators for cancer-specific death. In patients treated without neoadjuvant chemotherapy (n=143), the absence of adjuvant chemotherapy (hazard ratio:1.887, P=0.030) remained an independent indicator for cancer-specific death. For those treated with adjuvant chemotherapy without neoadjuvant chemotherapy, three or more adjuvant chemotherapy cycles were independently associated with favourable outcome (hazard ratio=0.240, P=0.009). In contrast, for neoadjuvant chemotherapy-treated patients (N=57), adjuvant chemotherapy was not independently associated with disease recurrence or cancer-specific death. Adjuvant chemotherapy was associated with improvements in the prognosis of patients, even in those with pT3 or higher muscle-invasive bladder cancer. Although three or more cycles of adjuvant chemotherapy were effective for muscle-invasive bladder cancer patients treated without neoadjuvant chemotherapy, no therapeutic advantages were observed with additional adjuvant chemotherapy in patients treated with neoadjuvant chemotherapy.

Targeting WD repeat domain 5 enhances chemosensitivity and inhibits proliferation and programmed death-ligand 1 expression in bladder cancer

BackgroundChemotherapy and/or immunotherapy are first-line treatments for advanced muscle-invasive bladder cancer (BCa), but the unsatisfactory objective response rate to these treatments yields poor 5-year patient survival. Discovery of therapeutic targets essential for BCa maintenance is critical to improve therapy response in clinic. This study evaluated the role of targeting WD repeat domain 5 (WDR5) with the small molecule compound OICR-9429 and whether it could be used to treat bladder cancer.MethodsWe analysed the expression and clinical prognosis of WDR5 in a TCGA cohort. The pharmacological role of OICR-9429 was further investigated in vitro and in vivo. RNA sequencing, western blot, and chromatin immunoprecipitation (ChIP) were utilized to explored the mechanism underlying OICR-9429-induced WDR5 inhibition.ResultsFirst, we found that WDR5 expression was upregulated in BCa and was associated with histologic grade, metastasis status, histologic subtype, and molecular subtype. High WDR5 expression level was also correlated with shorter overall survival (OS) in BCa. The WDR5 inhibitor OICR-9429 reduced cell viability by decreasing H3K4me3 levels but not WDR5 levels in T24, UM-UC-3, and TCCSUP BCa cells. OICR-9429 suppressed the proliferation of BCa cells by blocking the G1/S phase transition. Next, OICR-9429 enhanced apoptosis and chemosensitivity to cisplatin in BCa cells. In addition, OICR-9429 independently inhibited the motility and metastatic behaviour of BCa cells. In vivo experiments further revealed that OICR-9429 suppressed tumour growth, enhanced chemosensitivity, and reduced the toxicity of cisplatin in BCa. Notably, WDR5 was positively correlated with programmed death-ligand 1 (PD-L1) expression, and OICR-9429 suppressed immune evasion by blocking PD-L1 induced by IFN-γ. Mechanistically, some cell cycle-, antiapoptosis-, DNA repair-, metastasis-, and immune evasion-related genes, including BIRC5, XRCC2, CCNB1, CCNE2, PLK1, AURKA, FOXM1, and PD-L1 were identified to be directly regulated by OICR-9429 in a H3K4me3-dependent manner.ConclusionsOur novel finding is that the WDR5 inhibitor, OICR-9429, suppressed proliferation, metastasis and PD-L1-based immune evasion while enhancing apoptosis and chemosensitivity to cisplatin in BCa by blocking the WDR5-MLL complex mediating H3K4me3 in target genes. Hence, our findings offer insight into a multipotential anticancer compound, OICR-9429, which enhances the antitumour effect of cisplatin or immunotherapy in BCa.

Bladder cancer in young adults: Disease and treatment characteristics of patients treated at tertiary cancer center.

e16521 Background: The incidence of bladder cancer in the Middle East is increasing. The data on young population with urothelial carcinoma (UC) of urinary bladder in the region is scarce. We evaluated clinical and tumor characteristics, in addition to management details in patients younger than 45 years old. Methods: We reviewed of all patients presenting with UC of the urinary bladder from July 2006 to December 2019. Clinical characteristics including demographics, stage at presentation, and treatment outcomes were described. Results: Out of 1,272 new cases of bladder cancer, a total of 112 patients (8.8%) were ≤45 years old. Seven patients (6%) had non-urothelial histology and were excluded. The remaining 105 eligible patients with UC had a median age at presentation was 41 years (35-43). Ninety three patients (88.6%) were males. Tumor stage at presentation: non-muscle invasive disease (Ta-T1), locally advanced muscle invasive bladder cancer (MIBC) (T2-3), and metastatic disease were 14 cases (84.7%), 2.8%, and 12.5%, respectively. All patients with MIBC received neoadjuvant cisplatin-based chemotherapy. Radical cystectomy was performed in 8 cases (7.6%); 3 patients with MIBC and 5 with high volume non-MIBC. Neobladder reconstruction was done in 6 patients. A total of 13 patients with metastatic disease (93%) received palliative chemotherapy (Gemcitabine/Cisplatin), and one (7%) was candidate of best supportive care only. Conclusions: Bladder cancer is relatively rare in young population, though the incidence at our region is higher than other reports in the literature. Most of patients present with early disease. Early diagnosis and multidisciplinary approach are paramount for management of these patients.

Adjuvant Systemic Therapy for High-risk Muscle-invasive Bladder Cancer After Radical Cystectomy: Current Options and Future Opportunities

We describe the case of a 71-yr-old woman with locally advanced muscle-invasive bladder cancer and stage III chronic kidney disease due to an obstructed nonfunctional left kidney. She was started on neoadjuvant immunotherapy, but had to stop treatment because of acute worsening of renal function. Radical cystectomy was then performed uneventfully, revealing pT3aN1 urothelial carcinoma of the bladder. Adjuvant chemotherapy in high-risk locally advanced bladder cancer after radical cystectomy currently poses several challenges, especially for cisplatin-ineligible candidates. Recent data on adjuvant immunotherapy trials suggest a disease-free survival advantage for this subgroup of patients. The current and future role of immuno-oncology agents in this setting is discussed. Patient summaryPatients with advanced bladder cancer might benefit from further chemotherapy or immunotherapy following bladder removal, but it is still unclear which patients benefit the most from this strategy. Measurement of biomarkers and scans to show urinary function will probably help in optimising patient selection for this treatment in the near future.

The role of palliative radiotherapy in the management of elderly and frail patients with advanced bladder cancer: A survey by the AIROuro-group.

Radiotherapy (RT) is rarely used in the palliative management of muscle-invasive bladder cancer (MIBC). This survey aims to explore current care patterns within the Italian Radiation Oncologist community on this topic. In 2020, the uro-oncological study group of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) conducted a survey evaluating the RT role in advanced MIBC. An electronic questionnaire was administered online to the society members asking for: general considerations, patients' selection, and aim of the treatment, RT schedule and practical consideration, past and future perspective. Sixty-one questionnaires were returned (33% response rate). Most responders (62.30%) declared to work in a Center with a multidisciplinary uro-oncological team, and 8.20% to evaluate more than 20 patients with MIBC/year for palliative RT. Elderly patients were the most frequently evaluated (46.7%) and life expectancy was the most common selection criteria (44.60%). Thirty Gy in 10 fractions (58.9%), whole bladder as GTV (62.5%), PTV isotropic margins of 1.5-2cm (44.6%) and IMRT/VMAT technique (58.14%) were the most common treatment choices. Patients amenable for bladder palliative RT were most commonly referred by the urologist (43.86%) or the multidisciplinary team (38%). The reported main reasons for the low involvement of radiation oncologist in the management of MIBC patients were low attention to the palliative setting in bladder cancer (37.5%); radiation oncologist not involved in the management of these patients (32.1%); cases not discussed in the multidisciplinary board (26.8%). This survey illustrated the current use of palliative RT for patients with advanced MIBC in Italy and suggested the need for a greater involvement of radiation oncologists in their management.

Molecular characterization of advanced muscle invasive bladder cancer (MIBC): Comparison of low-input targeted RNA sequencing (RNAseq) strategies.

564 Background: 5-year survival for advanced MIBC is poor (~5%), but newer targeted agents (e.g., PD-1/PD-L1 or FGFR) have improved survival over traditional chemotherapy. To better select patients suited for targeted therapies, molecular characterization is more important than ever. The following study compares RNAseq using two low-RNA-input methods (SureSelect hybridization-capture and AmpliSeq PCR amplification, using 200 ng and 10 ng extracted RNA, respectively), as part of a retrospective study of advanced MIBC patients treated with anti-PD-1/PD-L1 therapy (Mayhew et al, 2019 ASCO). RNAseq results, including correlation between methods and molecular subtype agreement are presented herein. Methods: RNA extracts from 24 representative FFPE MIBC tumor samples were analyzed using SureSelect XT RNA (Agilent) and AmpliSeq transcriptome (Illumina) by NovaSeq6000 paired end sequencing. Samples were split between 4 molecular subtypes using the GeneCentric 60-gene MIBC nearest centroid subtyper (n = 6/subtype; luminal, luminal infiltrated, basal, basal infiltrated) (Mayhew et al, 2019 ASCO). Pearson correlation analysis was performed for all genes, as well as the 60 suptyper genes. Expression subtype calls were compared using RNAseq data obtained from both sequencing methods. Results: Of 58,000 genes queried (GrCH38.v22), 27,671 (55%) were found using both methods and 13,992 (28%) were not found using either method. 15,575 unique genes were found using SureSelect and 1,149 unique genes were found using AmpliSeq. The two methods were well correlated: median of 0.87 (0.73-0.89) overall and 0.80 (0.54-0.86) for the 60 subtyper genes. 22 of the 24 samples (92%) had congruent subtype calls using the 60-gene MIBC subtyper; one luminal-infiltrated called basal and one basal called basal-infiltrated. Conclusions: This study demonstrated comparable RNAseq analysis using two low-input FFPE-compatible methods. Using AmpliSeq, MIBC tumors were able to be molecularly characterized, including subtype analysis, with only 1/20th of the extracted RNA needed for SureSelect. Further validation of AmpliSeq methodology in MIBC and other tumor types is warranted.

Phase II randomized placebo-controlled neoadjuvant trial of nintedanib or placebo with gemcitabine and cisplatin in locally advanced muscle invasive bladder cancer (NEO-BLADE).

438 Background: Neo-adjuvant chemotherapy Improves overall survival in patients with MIBC. Nintedanib is an orally available, potent, small molecule, triple kinase inhibitor with the potential to further benefit patient prognosis. Methods: NEO-BLADE was designed as a randomised, placebo controlled phase II study (n=120) to compare the addition of nintedanib (N) (150mg/200mg BD) to a combination of Gemcitabine (G) and Cisplatin (C). The study was powered (80%, alpha=15% [one sided]) to detect an improvement in the histological complete response rate of 20% (OR = 2.37). Results: 120 patients were recruited from 15 sites between 04/Dec/2014 and 03/Sep/2018 (22% Female) with 109 patients evaluable. Complete response (CR) rates ( by ITT) were 22/57 (38.6%) and 25/63 (39.7%) for patients treated with/without N. Pathological CR on ITT was 21/57 (36.8%) and 20/63 (31.74%); For pathological evaluable patients it was 21/41 (51. 22% ) and 20/45 ( 44.44%) respectively. Patients treated with N showed a benefit in terms of PFS and OS with 12 month PFS rates of 89.0% and 74.1% in the Nintedanib and Placebo group respectively. P= 0.038 and HR (CI) 0.479 (0.236, 0.976). OS at 12/24 months N 96.26%/ 88.87% while in Placebo group 82.83%,/69.36%. P=0.022, HR (CI) 0.389 (0.168, 0.902). Toxicity was reported in terms of grade 3 adverse events [12/63 (19%) Placebo, 23/57 (40%) N] and Serious Adverse Events [35/63 (56%) Placebo, 34/57 (53%) N]. In terms of thromboembolic events, this was observed in 16/57 (28%) of patients treated with N and 13/63 (21%) without N (P=0.461). Conclusions: The study failed to reach its primary endpoint in demonstrating an improvement in pathological response rate between N and Placebo when given alongside G and C. The trial met its secondary end point in improvement of progression free survival and over all survival at 12 months and 24 months. Safety data from this placebo -controlled study confirms triplets can be given safely. There are efficacy signals with improvement in PFS and OS and the regimen warrants further investigation in randomised phase III trial. Translational studies to assess bio markers of response are planned. Clinical trial information: 11977.

Frailty has significant impact on treatment selection in patients with muscle-invasive bladder cancer.

429 Background: Although measuring frailty is important to estimate risks and to aid shared decision making, the impact of frailty on surgical indication in muscle-invasive bladder cancer (MIBC) remain unclear. We aimed to investigate the impact of frailty on treatment modality selection in patients with MIBC. Methods: Between October 2013 and September 2019, we underwent frailty evaluation in 149 patients with localized or locally advanced MIBC (T2-4N0-1M0). Frailty evaluation included modified Frailty index (mFI), Fried phenotype (FP), and frailty discriminant score (FDS). Primary purpose was comparison of frailty between the patients who underwent radical cystectomy (RC group) and trimodal therapy for bladder preservation (TMT group). Optimal cutoff values of frailty between the RC and non-RC groups was defined by receiver operating characteristic curve. Secondary purpose included overall survival (OS) comparison between in patients with frail and non-frail. Overall survival (OS) was compared using Kaplan-Meier method and Cox regression analysis. Results: Of 149, 88 and 61 patients were classified to RC and TMT group, respectively. The median age in the TMT group was significantly older than that in the RC group (80 vs. 68 years). A significantly higher prevalence of frailty was observed in the TMT group than that of the RC group in FP ≥3 (5.7% vs. 61%, P &lt; 0.001), mFI ≥2 (22% vs. 61%, P &lt; 0.001), and FDS ≥2.30 (40% vs. 72%, P &lt; 0.001). Univariate logistic regression analysis showed that frailty was significantly associated with TMT. Frailty was significantly associated with overall survival between the RC and TMT groups in the FP and FDS, whereas it was not the case in mFI. Conclusions: Frailty was significantly associated with indication of RC in patients with MIBC. Measuring frailty is important to estimate risks and to aid shared decision making.