Muscle-invasive Urothelial Cancer Research Articles

Abstract 5219: Loss of chromosome Y is unrelated to the composition of the tumor microenvironment and patient prognosis in muscle-invasive urothelial bladder cancers

Abstract Background: Loss of chromosome Y (LOY) occurs commonly in cancers of male patients. It was recently proposed to be associated with cancer aggressiveness and altered T-cell function in bladder cancer and it was found to be linked to poor prognosis in a TCGA bladder cancer patient cohort of 300 patients based on a combined analysis of RNAs from Y-chromosome genes. In this study, we aimed to clarify the clinical relevance of LOY in a large cohort of urothelial bladder cancer patients by using fluorescence in-situ hybridization (FISH). Design: X and Y chromosomes were analyzed by FISH on a tissue microarray (TMA) containing 1,819 urothelial carcinomas of the urinary bladder from male patients including 487 patients who had undergone cystectomy for muscle-invasive disease and for which follow-up data were available. Data of tumor microenvironment parameters were obtained in a previous study. Results: LOY was found in 26.0% of 1,479 analyzable cancers. In the subset of non-invasive cancers, the frequency of LOY increased from pTaG2 (14.5%) to pTG3 (28.6%) but these differences were not significant (p=0.1015). In muscle-invasive cancers, the frequency of LOY increased slightly from pT2 (25.4%) to pT4 cancers (32.8%) but this association was again not significant (p=0.1868). Within pT2-4 cancers, LOY was associated with venous invasion (p=0.0010) but unrelated to pT, pN, and L-status, as well as to overall, recurrence-free, and cancer-specific survival. Muscle-invasive urothelial carcinomas with and without LOY did not show significant differences in the number of CD8 positive lymphocytes, the fraction of CD8 positive intraepithelial lymphocytes, the number of macrophages and dendritic cells, as well as the fraction of t helper and t regulatory cells. Conclusion: FISH is the gold standard for determining LOY. That LOY was neither associated with histopathological parameters of cancer aggressiveness and patient prognosis nor with any parameters describing the tumor microenvironment strongly argues against a driving role of LOY for bladder cancer progression and cancer associated immune reaction. The slight increase of LOY from pTaG2 to pT4 cancers is consistent with a continuous (but clinically irrelevant) loss of the dispensable Y chromosomes during tumor evolution over time. Citation Format: Martina Kluth, Henning Plage, Sebastian Hofbauer, Kira Furlano, Sarah Weinberg, Antonia Franz, Annika Fendler, Florian Roßner, Simon Schallenberg, Sefer Elezkurtaj, Niclas C. Blessin, Maximilian Lennartz, Andreas H. Marx, Henrik Samtleben, Margit Fisch, Michael Rink, Marcin Slojewski, Krystian Kaczmarek, Thorsten Ecke, Stefan Koch, Nico Adamini, Ronald Simon, Guido Sauter, Joachim Weischenfeldt, Tobias Klatte, Sarah Minner, David Horst, Thorsten Schlomm, Dr. med Henrik Zecha Zecha. Loss of chromosome Y is unrelated to the composition of the tumor microenvironment and patient prognosis in muscle-invasive urothelial bladder cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5219.

The Effect of Retinoic Acid on Arsenite-Transformed Malignant UROtsa Bladder Cancer Cells: In Vitro Model of Basal Muscle-Invasive Bladder Cancer.

Bladder cancer (BC) is the eighth most common cause of cancer death in the United States of America. BC is classified into non-muscle-invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC). Genetically, MIBCs are categorized into the more aggressive basal subtype or less aggressive luminal subtype. All-trans retinoic acid (tretinoin), the ligand for the RAR-RXR retinoic acid receptor, is clinically used as a differentiation therapy in hematological malignancies. This study aims to determine the effects of retinoic acid on arsenite-transformed malignant urothelial cells (UROtsa As), serving as a model for basal muscle-invasive bladder cancer. We treated three independent isolates of arsenite-transformed malignant human urothelial UROtsa cells (UROtsa As) with tretinoin for 48 h. Cell viability, proliferation, and apoptosis were analyzed using crystal violet staining and flow cytometry. mRNA and protein level analyses were performed using RT-qPCR and the Simple Western™ platform, respectively. Tretinoin was found to reduce cell proliferation and urosphere formation, as well as decrease the expression of basal markers (KRT1, KRT5, KRT6, EGFR) and increase the expression of luminal differentiation markers (GATA3, FOXA1). Mechanistically, the antiproliferative effect of tretinoin was attributed to the downregulation of c-myc. Our results suggest that targeting the retinoic acid pathway can diminish the aggressive behavior of basal muscle-invasive urothelial cancer and may enhance patient survival.

Predictive value of dynamic changes in ctDNA and baseline biomarkers with neoadjuvant atezolizumab in operable urothelial carcinoma in the ABACUS trial.

534 Background: Circulating tumour DNA (ctDNA) is being explored in the neoadjuvant setting in multiple prospective trials. Dynamic changes may be a surrogate marker of pathological complete response. ABACUS was a multi-centre, single-arm phase II trial investigating two cycles of atezolizumab before cystectomy in patients with muscle-invasive urothelial cancer who were ineligible for or refused neoadjuvant cisplatin-based chemotherapy (NCT02662309). Results of primary and secondary endpoints have been previously published. Here we perform exploratory biomarker analysis using different definitions of ctDNA response and assess correlation with tissue response at time of cystectomy in the ABACUS trial. We also assess how these definitions of response correlate with baseline biomarker expression. Methods: Patients with baseline PDL-1, CD8, TMB and sequential ctDNA measurements (baseline and at cystectomy) were included. ctDNA analysis was performed using the Signatera assay, PD-L1 positivity was defined as ≥5% of immune cell staining, TMB was assessed using the FoundationOne CDx assay and CD8 measurement was performed via immunohistochemistry analyses. Two definitions of ctDNA response were used—ctDNA clearance and a 50% reduction (or greater) in ctDNA variant allele frequency (VAF). Results were correlated with pathological complete response (pCR) rate at time of cystectomy and relapse-free survival. Results: The 2-yr DFS and OS rates in ABACUS were 68% and 77%, respectively (N=95). 40 patients had sequential DNA analysis. 43% (17/40) had pathological complete response and 20% (8/40) experienced relapse. 63% (25/40) patients were ctDNA+ at baseline, with 40% (10/25) having ctDNA response of 50% VAF reduction and 8% (3/40) achieving ctDNA clearance. 30% (3/10) of patients who had VAF reduction experienced relapse and 40% (4/10) achieved pCR. All patients with ctDNA clearance achieved pCR none relapsed. There was no association between VAF reduction of 50% and tissue response (pCR) (p=0.24). Additional analysis showed no association between a ctDNA reduction of 75% (rather than 50%) and pCR (p=0.24). Baseline PDL-1, TMB and not predictive of pathological complete response (p=0.18, p=0.77, p=0.10, respectively) or ctDNA response (p=0.54, p=0.77, p=0.74) to neoadjuvant atezolizumab. There was no difference in relapse rates between ctDNA/PD-L1+ve vs ctDNA+ve/PD-L1-ve patients (16% vs 16%, respectively). Conclusions: ctDNA clearance is rare but appears more accurate than 50% reduction in VAF to predict response/relapse. This is relevant for ongoing neoadjuvant trials planning to use this as an endpoint. Combining immune tissue based biomarkers with ctDNA does not appear to improve biomarker accuracy.

Molecular residual disease detection in resected, muscle-invasive urothelial cancer with a tissue-based comprehensive genomic profiling-informed personalized monitoring assay.

Circulating tumor DNA (ctDNA) detection postoperatively may identify patients with urothelial cancer at a high risk of relapse. Pragmatic tools building off clinical tumor next-generation sequencing (NGS) platforms could have the potential to increase assay accessibility. We evaluated the widely available Foundation Medicine comprehensive genomic profiling (CGP) platform as a source of variants for tracking of ctDNA when analyzing residual samples from IMvigor010 (ClinicalTrials.gov identifier NCT02450331), a randomized adjuvant study comparing atezolizumab with observation after bladder cancer surgery. Current methods often involve germline sampling, which is not always feasible or practical. Rather than performing white blood cell sequencing to filter germline and clonal hematopoiesis (CH) variants, we applied a bioinformatic approach to select tumor (non-germline/CH) variants for molecular residual disease detection. Tissue-informed personalized multiplex polymerase chain reaction-NGS assay was used to detect ctDNA postsurgically (Natera). Across 396 analyzed patients, prevalence of potentially actionable alterations was comparable with the expected prevalence in advanced disease (13% FGFR2/3, 20% PIK3CA, 13% ERBB2, and 37% with elevated tumor mutational burden ≥10 mutations/megabase). In the observation arm, 66 of the 184 (36%) ctDNA-positive patients had shorter disease-free survival [DFS; hazard ratio (HR) = 5.77; 95% confidence interval (CI), 3.84-8.67; P < 0.0001] and overall survival (OS; HR = 5.81; 95% CI, 3.41-9.91; P < 0.0001) compared with ctDNA-negative patients. ctDNA-positive patients had improved DFS and OS with atezolizumab compared with those in observation (DFS HR = 0.56; 95% CI, 0.38-0.83; P = 0.003; OS HR = 0.66; 95% CI, 0.42-1.05). Clinical sensitivity and specificity for detection of postsurgical recurrence were 58% (60/103) and 93% (75/81), respectively. We present a personalized ctDNA monitoring assay utilizing tissue-based FoundationOne® CDx CGP, which is a pragmatic and potentially clinically scalable method that can detect low levels of residual ctDNA in patients with resected, muscle-invasive bladder cancer without germline sampling.

Integrated multiomics analysis and machine learning refine molecular subtypes and prognosis for muscle-invasive urothelial cancer

Muscle-invasive urothelial cancer (MUC), characterized by high aggressiveness and significant heterogeneity, is currently lacking highly precise individualized treatment options. We used a computational pipeline to synthesize multiomics data from MUC patients using 10 clustering algorithms, which were then combined with 10 machine learning algorithms toidentify molecular subgroups of high resolution and develop a robust consensus machine learning-driven signature (CMLS). Through multiomics clustering, we identified three cancer subtypes (CSs) that are related to prognosis, with CS2 exhibiting the most favorable prognostic outcome. Subsequent screening enabled identification of 12 hub genes that constitute a CMLS with robust predictive power for prognosis. The low-CMLS group exhibited a more favorable prognosis and greater responsiveness to immunotherapy and was more likely to exhibit the "hot tumor" phenotype. The high-CMLS group had a poor prognosis and lower likelihood of benefitting from immunotherapy, but dasatinib and romidepsin may serve as promising treatments for them. Comprehensive analysis of multiomics data can offer important insights and further refine the molecular classification of MUC. Identification of CMLS represents a valuable tool for early prediction of patient prognosis and for screening potential candidates likely to benefit from immunotherapy, with broad implications for clinical practice.

AI-based identification of FGFR3 mutation status from routine histology slides of muscle-invasive bladder cancer.

e16580 Background: Gain of function mutations of the FGFR3 gene have been reported to be important driver mutations in a subset of muscle-invasive bladder urothelial cancer (MIBC). Subsequently, gene specific kinase inhibitors (e.g., erdafitinib) have been developed to target FGFR3 mutant metastasized MIBC with promising clinical activity. FGFR3 mutational status testing is required for erdafitinib treatment, but FGFR3 mutations are rare in metastatic MIBC (10-15%). Thus, cheap and fast pre-screening tools such as artificial intelligence (AI) based image classifiers could help to reduce turnover times of FGFR3 mutational testing and save costs arising from universal mutational testing. Herein, we propose an AI-based approach to identify MIBC FGFR3 mutated patients on routine histological slides. Methods: Slides from 612 patients with MIBC from two different sources (CCC-EMN Erlangen cohort n = 239, mutant = 20; TCGA-BLCA n = 373, mutant = 50) were used. The CCC-EMN cohort was used as a discovery set while TCGA-BLCA was used as an independent validation set. A two-step AI model was used to 1) extract features from each slide and 2) predict FGFR3 status from these features. The AUC, sensitivity and specificity were used as metrics to assess the performance of our model. Most predictive regions of FGFR3 mutation were reviewed by an expert pathologist. Results: The model reached an AUC/Sensitivity/Specificity of 0.82 [0.76-0.87] / 0.90 [0.82-0.97] / 0.57 [0.53-0.62] on TCGA-BLCA, substantially improving upon results previously reported on the same cohort (Loeffler et al. 2021: AUC = 0.70). Most predictive regions of FGFR3 mutation revealed monomorphous conventional urothelial tumor morphology and low desmoplastic tumor stroma content, while least predictive regions contained pleomorphic tumor morphology and high amounts of desmoplastic tumor content. Conclusions: By ruling out 57% of MIBC FGFR3 wild type tumors with high sensitivity, our model is the first to reach valuable performance for clinical use. Consequently, this study paves the way for the development of FGFR3 pre-screening tools to ease the management of patients with MIBC.

Final analysis results from a multicenter clinical study of tislelizumab combined with gemcitabine and cisplatin as neoadjuvant therapy in patients with cT2-T4aN0M0 MIBC.

4585 Background: To evaluate the efficacy and safety of tislelizumab combined with gemcitabine and cisplatin as neoadjuvant therapy for patients (pts) with clinical T2-T4aN0M0 (cT2-T4aN0M0) muscle-invasive bladder urothelial cancer (MIBC). At predefined interim analysis, the study has met the first stage aim. Here reported the results of the predefined final analysis. Methods: This phase II study enrolled pts tolerated with the cisplatin therapy. Eligible pts received tislelizumab 200 mg in day 1 (D1), cisplatin 70 mg/m2 D2, and gemcitabine 1000 mg/m2 D1 and D8 every 21 days for four cycles. Radical cystectomy (RC) was performed within 6 weeks after last dose treatment. The primary end point was pathologic complete response (pCR, pT0N0M0). Secondary end points were pathologic downstaging (≤pT1N0M0) (pDS), EFS, OS and safety. Simon two-stage design was used. If &gt;5 pts achieved pCR in the first stage (n=22), study would proceed to the second stage and enroll 33 additional pts. If &gt;18 of 55 pts achieved pCR, we would deem the study to have met the primary endpoint. Results: At the data cut off time of 14th Dec 2022, 63 pts (38 cT2, 19 cT3, and 6 cT4a) have completed neoadjuvant therapy, with median age of 64 (48-75) years. The median relative dose intensity of tislelizumab, cisplatin and gemcitabine were 92.3%, 85.7% and 85.6%, respectively. At this time, 55 pts underwent RC and completed 30 days post-surgery follow-up. The median time from last dose to RC was 4.4 (range: 0.6-13.3) weeks. Eight pts refused RC. Among 55 efficacy evaluable pts, 27 (49.1% [90% CI, 37.4-60.9]) pts achieved pCR, while 41 (74.5% [95% CI, 61.0-85.3]) pDS. Pts with cT2 achieved 55.6% (20/36) pCR and 86.1% (31/36) pDS. Among 14 non-responders, 3 of them (1 cT2, 2 cT3) achieved pT0, but with pathologic N1. Clavien-Dindo grade ≥3 postoperative complications occurred in 7.9% pts. Most common neoadjuvant therapy related AEs of any grade were hematologic toxicities (88.9%), nausea (77.8%), and vomiting (50.8%). Grade ≥3 neoadjuvant therapy related AEs occurred in 60.3% pts, which were hematologic toxicities (58.7%) in most. The frequently occurring immune-related AEs (irAEs) (&gt;5%) included dizziness (14.3%), fatigue (12.7%), ASL/ALT increased (7.9%), rash (7.9%), pruritus (7.9%), and GGT increased (6.3%). Grade ≥3 irAEs occurred in 2 pts (pneumonia, n=1; cardiomyopathy, n=1). Conclusions: The study met its primary endpoint. Neoadjuvant tislelizumab combined with gemcitabine and cisplatin showed promising anti-tumor activity with high pCR and well tolerance in MIBC pts. Clinical trial information: ChiCTR2000037670 .

SWOG S1011: A phase III surgical trial to evaluate the benefit of a standard versus an extended lymphadenectomy performed at time of radical cystectomy for muscle invasive urothelial cancer.

4508 Background: S1011 tested the hypothesis that an extended lymphadenectomy (ELND) is associated with improved disease-free and overall survival (DFS, OS) compared to standard (S) LND in patients with localized muscle invasive bladder cancer (MIBC) undergoing radical cystectomy (RC)(NCT01224665). Methods: Eligible patients with cT2-4a N0-2 were stratified by receipt and type of neoadjuvant chemotherapy (NAC), T2 vs T3-4a and PS 0-1 vs 2. Patients were randomized 1:1 after intraoperative exploration determined they did not have disease outside the pelvis. All patients then underwent a standard bilateral pelvic LND including external and internal iliac and obturator LNs. If randomized to the experimental arm additional ELND up to at least the aortic bifurcation including common iliac (CI), pre-sciatic, and pre-sacral nodes was performed. We hypothesized that patients in the ELND arm would have a 10% improvement in 3-year DFS compared to an estimated 55% for patients in the SLND arm (HR = 0.72). Assuming a 1-sided a=0.025 and 85% power, 564 eligible randomized patients were required. Final analysis was to occur at 184 DFS events in the SLND arm or after max follow-up (6 yrs) using a stratified logrank(LR) test with a=0.022 to account for interim testing. Hazard ratios from Cox model are adjusted for strat factors. Secondary endpoints included OS and safety. Results: 36 surgeons at 27 sites in US and Canada were credentialed prior to enrolling patients, 658 were registered from 8/11-2/17, and 618 eligible patients were randomized to ELND (n=292) or SLND (n=300). Median f/up was 6.1 years in both arms. Median age was 69, 21% female, and 9% non-White. Clinical stage was balanced in both arms: T2 (71%) and T3-4a (29%). NAC was given to 57% in both. Pathologic T stage was &lt;T2 in 39% in S and 37% in E and ³ T2 in 61% and 63%, respectively. Median lymph nodes removed was higher in ELND compared to SLND (41 vs 25), but there was no difference in node metastasis with 26% vs 24%, respectively. More ELND patients had N2 or N3 disease. ELND was associated with increased G3-4 AEs compared to SLND: 16% vs 8%. Deaths within 90 days of RC occurred in 26 (4.4%) patients, including 16 in ELND vs 9 in SLND. There was no difference in DFS between E vs S arms (HR 1.10; 95% CI 0.87, 1.42), 1-sided LR p=0.82. OS results were similar (HR 1.15 95% CI 0.89, 1.48), 1-sided LR p=0.87. Conclusions: Patients with MIBC undergoing RC and ELND had increased node yield and higher pathologic N stage, but no significant DFS or OS benefit compared to patients undergoing SLND. ELND was also associated with greater morbidity and higher peri-operative mortality. Clinical trial information: NCT01224665 . [Table: see text]

KI-67 LABELLING INDEX IN UROTHELIAL NEOPLASM

Urothelial neoplasms can be classified as non-invasive &amp; invasive lesions. The major prognostic factors are degree of differentiation and depth of invasion in urothelial tumors. Ki-67 is a non- histone nuclear protein marker of cell proliferation which is encoded by MKi-67 gene in humans. This study evaluates and correlate immunohistochemical Ki-67 expression in Non-invasive &amp; Invasive urothelial neoplasm. This retrospective study is done in the Department of Pathology of L.N. Medical College and J.K. Hospital, Bhopal. Urothelial Neoplasm cases diagnosed from January 2019 to January 2022 were included, &amp; relevant clinico-pathological data and their Ki-67 Labelling Index was evaluated &amp; correlated. Total 60 cases were studied, 30 had invasive carcinoma whereas, 30 had non-invasive neoplasm. Ki-67 expression (&gt;13%) was seen maximum in invasive cancers i.e 40% cases, whereas (&lt;13%) was seen maximum in non-invasive neoplasms i.e 38.3%. A statistically significant expression of Mean Ki-67 Labelling Index was observed that increased from papilloma to PUNLMP, Non- Invasive urothelial neoplasm Low grade &amp; High grade in non-invasive urothelial neoplasm (p&lt;0.001), and from lamina propria invasive to muscle invasive urothelial cancers (p=0.013). A Higher tumor proliferation of greater than 13% was significantly related to greater tumor size (p=0.04). Ki-67 labelling index being a measure of tumor proliferation is related to tumor histological grade. Large urothelial tumor size was associated to high Ki-67 LI and was not strongly associated with age and gender. Therefore Ki-67 expression can be used as Diagnostic &amp; Prognostic marker in urothelial tumors.

Long-term outcomes of pembrolizumab (pembro) in combination with gemcitabine (gem) and concurrent hypofractionated radiation therapy (RT) as bladder sparing treatment for muscle-invasive urothelial cancer of the bladder (MIUC): A multicenter phase 2 trial.

4509 Background: Trimodality therapy (TMT) is a standard treatment option for MIUC. We previously reported an early analysis of a phase II study of pembro added to standard TMT with maximal transurethral resection of bladder tumor (TURBT), hypofractionated RT and twice weekly gem (ASCO 2021). Herein we present updated follow up safety and efficacy results. Methods: In this multicenter phase 2 trial, patients (pts) with clinical T2-T4aN0M0 MIUC who were ineligible fpr or declined radical cystectomy, had ECOG PS 0/1 and eGFR≥30 cc/min were enrolled. Pts received pembro 200 mg IV x 1 followed by maximal TURBT and then whole bladder RT (52 Gy/20 fx) with twice weekly gem 27 mg/m2 and pembro Q3 wks x 3 treatments. Response was assessed every 12 weeks post-RT with CT/MRI, tumor bed biopsy and cytology. The primary endpoint was 2-yr bladder-intact disease-free survival (BIDFS; first of MIUC, regional or distant metastases, cystectomy or death). Our study had 85% power to detect a 20% absolute improvement in 2-yr BIDFS rate over 60% historical rate (Mak JCO 2014). Key secondary endpoints included safety, 12-week pathologic complete response (CR) rate, metastases-free survival (MFS) and overall survival (OS). Results: Between 5/2016 and 6/2022, 54 pts (median age 74 years, 72% male, 83% Caucasian; clinical stage: 74% T2, 22% T3 and 4% T4) were enrolled at 5 institutions. PD-L1 status was available in 43 pts, and 21 pts (49%) had modified proportion score≥10. Forty-six (88%) pts completed all therapy. 1/54 (2%), 3/54 (6%), and 4/54 (7%) discontinued RT/Gem, Gem or Pembro, respectively, most commonly due to toxicity. 6 pts (11%) underwent salvage cystectomies. As of 6/2022, with a median FU of 23 months (1.6- 62.7) there were 12 (22%) tumor recurrences (3 MIUC, 5 locoregional, 4 distant). 4 pts (7%) had non-muscle invasive only recurrences. The efficacy outcomes are shown. 10 pts died during the study period (18%; 3 from disease progression, 1 from treatment toxicity and 6 from unrelated/unknown causes). There were no new safety signals in our updated analysis: 13 pts (24%) experienced 17 AEs that were Grade 3 or greater (cytopenias [n=7], colitis [n=5], cystitis [n=2], polyneuropathy, fatigue, hypokalemia [n=1, each]). Grade 3 or greater immune-related AEs included 2 pts with colitis, 1 pt with polyneuropathy and 1 pt with Grade 5 colonic perforation. Conclusions: TMT combined with pembro was well tolerated and continues to show promising early outcomes data. A large phase 3 trial is underway to further explore this treatment. Clinical trial information: NCT02621151 . [Table: see text]

Presence of CD8+ cytotoxic T-cells in proximity to tumor cells, TIM3, CTLA-4 and prognostic implications for muscle-invasive urothelial cancer.

4582 Background: Although it is well known that the quantity of specific immune cell types can provide prognostic information in bladder cancer, only little is known about the prognostic relevance of the localization of immune cells within the tumor microenvironment. Methods: To study the spatial interplay of different immune cell subpopulations and its prognostic role in bladder cancer, 2463 urothelial bladder carcinomas were immunostained with 21 antibodies (i.e., TIM-3, PD-L1, PD-1, CTLA4, CD3, CD8, CD4, FOXP3, CD20, CD68, CD163, CD11c, panCK, Ki67, CD31, Vimentin, HLA-DRa, Myosin-11, Desmoglein 3, PAX-8, and CDH16) using BLEACH&amp;STAIN multiplex fluorescence immunohistochemistry in a tissue microarray format and analyzed using a framework of neuronal networks for image analysis. Thus, Spatial immune parameters were compared with histopathological parameters and overall survival data. Results: The identification of more than 300 different immune cell subpopulations and the characterization of their spatial relationship resulted in numerous spatial interaction patterns. 32 immune parameters showed prognostic significance in univariate analyses of which 16 were independent from pT, pN, and histologic grade in muscle-invasive bladder cancer. The strongest association to clinical outcome was identified for intraepithelial CD8+ cytotoxic T-cells (AUC: 0.70) while stromal CD8+ cells were less relevant (AUC: 0.64, p=0.016). A favorable prognosis of inflamed cancers with high levels of “exhaustion markers” suggests that TIM3, PD-L1, PD-1, and CTLA-4 on inflammatory cells do not hinder anti-tumoral immune response in tumors rich of tumor infiltrating tumor cells. Conclusions: The density of intraepithelial CD8+ T-cells was the strongest prognostic feature in muscle-invasive bladder cancer. Given that tumor cell killing by CD8+ cytotoxic T-lymphocytes through direct cell-to-cell-contacts represents the “terminal end route” of anti-tumor immunity, the quantity of “tumor-cell adjacent CD8+ T-cells” may constitute a surrogate for the efficiency of cancer recognition by the immune system that can be measured straightaway using conventional brightfield IHC in routine pathology as the CD8 labelling index.

Real-world retrospective study of immune checkpoint inhibitors in combination with radiotherapy or chemoradiotherapy as a bladder-sparing treatment strategy for muscle-invasive bladder urothelial cancer.

Recent developments in MIBC treatment suggest good efficacy of bladder sparing treatment combined with immune checkpoint inhibitor. However, there is no standard treatment mode. A retrospective analysis was conducted to reveal the efficacy and safety of PD-1 inhibitor in combination with radiotherapy or chemoradiotherapy. We retrospectively analyzed 25 patients with MIBC T2-T3N0M0 disease who were unfit or unwilling to undergo RC. These patients underwent the maximum TURBT followed by PD-1 inhibitor (Tislelizumab or Toripalimab) in combination with radiotherapy or chemoradiotherapy (gemcitabine plus cisplatin) between April 2020 and May 2022. The primary outcome was clinical complete response (cCR) rate. The secondary outcomes were disease free survival (DFS) and overall survival (OS). Revised: Of 25 patients, 22 were T2 (88%), while 3 were T3 (12%). The median age is 65 years (51-80). Twenty-one patients had programmed cell death ligand 1 (PD-L1) combined positive score (CPS) of 1 or more, and 4 patients had CPS<1 or unknown. Sixteen patients received chemoradiotherapy. Tislelizumab and Toripalimab were administered to 19 and 6 patients, respectively. The median number of cycles of immunotherapy was 8. Twenty-three patients (92%) achieved cCR. Following a median of 13 months of follow-up (range, 5-34 months), 1-year DFS and OS rate were 92% and 96%, respectively. In the univariate analysis, T stage significantly influenced OS and ORR, and efficacy evaluation significantly influenced OS, DFS, and ORR. The expression of PD-L1 and chemotherapy had no effect on prognosis. In the multivariate analysis, no independent prognostic factors were found. Grade 3 or 4 adverse events (AE) were reported in 35.7% patients. Bladder sparing therapy with PD-1 inhibitor in combination with radiotherapy or chemoradiotherapy is feasible, safe, and highly effective for patients who were unfit or unwilling to undergo RC.

(388) Primary Penile Squamouse Cell Cancer Related Malignant Priapism In A Cystectomized Patient: A Case Report

Abstract Introduction Priapism is a prolonged (&amp;gt; 4 hours) and unintended erection without sexual stimulation or sexual desire. Priapism due to neoplasms is called malignant priapism, which is a rare condition that tends to occur with corporeal metastasis of other pelvic area malignancies. Priapism due to primary penile malignancies is extremely rare. Objective In this article, we present the case of a patient who underwent total penectomy and bilateral inguinal lymphadenectomy due to malignant priapism related to primary penile squamous cell cancer (SCC), and who also underwent radical cystectomy (RC) and total urethrectomy due to urothelial carcinoma 19 and 2 years prior, respectively. Methods We prepared the patient's information to present. Results An 82-year-old male patient presented to an outpatient clinic with unintended erection and penile pain of about 48 hours’ duration and was on follow-up in our clinic because of urothelial carcinoma history. The patient’s history indicated that he underwent RC and orthotopic neobladder due to muscle-invasive urothelial cancer (UC) in the bladder. No tumor was observed in the final cystectomy pathology; therefore, no adjuvant therapy was given. Seventeen years after the RC operation, he presented with hematuria and a papillary lesion detected in the mid-urethra during cystourethroscopy. Since the biopsy result from this region was compatible with high-grade UC, he underwent total urethrectomy, neobladder resection, and ileal conduit. Urethrectomy pathology results were reported as UC invading the subepithelial stroma and lymphovascular area. Adjuvant MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) chemotherapy was administered. On follow-up 2 years after the urethrectomy operation, he presented with prolonged priapism. On examination, a cold and erect penis with a 1 cm diameter ulcerated lesion on the glans penis were observed. Hypoxia and hypercarbia were observed on the cavernosal blood gas examination, which was compatible with ischemic priapism. The hemogram was normal. On the emergent penile duplex Doppler ultrasound showed decreased blood flow and a mass on the proximal part of the penis. Subsequently, pelvic magnetic resonance imaging was performed and a mass was observed that was fully destructive to the cavernosal bodies and had irregularly circumscribed borders (Figure 1). Afterward, the patient underwent a total penectomy and bilateral inguinal lymphadenectomy. The pathology report from the penectomy material suggested that the tumor was compatible with moderately differentiated SCC. No sign of metastasis was observed in the lymph nodes. Extensive sampling of the tumor did not reveal any UC in situ, nor SCC in situ. The penis shaft was fully infiltrated by the tumor, with SCC morphology starting from the surgical margin and damaging all the structures of the penile body (Figure 2). The patient was transferred to the oncology clinic for additional treatment planning. Conclusions Despite being the most common primary malignancy of the penis, to the best of our knowledge priapism due to primary penile SCC has been reported only once in the literature. Although metastatic disease is typically thought to be the cause, when a patient with a history of pelvic malignancy presents with malignant priapism, it should be kept in mind that primary malignancies of the penis may also cause this condition. Disclosure No

MP14-19 ALTERATIONS OF INSULIN SIGNALING AND TUMOR BIOLOGY IN UROTHELIAL CARCINOMA OF DIABETIC AND NON-DIABETIC PATIENTS

You have accessJournal of UrologyCME1 Apr 2023MP14-19 ALTERATIONS OF INSULIN SIGNALING AND TUMOR BIOLOGY IN UROTHELIAL CARCINOMA OF DIABETIC AND NON-DIABETIC PATIENTS Simon Walz, Martin Heni, Carmen Wandel, Sven Walter, Marcus Scharpf, Arnulf Stenzl, Lisanne Exner, Jörg Hennenlotter, and Steffen Rausch Simon WalzSimon Walz More articles by this author , Martin HeniMartin Heni More articles by this author , Carmen WandelCarmen Wandel More articles by this author , Sven WalterSven Walter More articles by this author , Marcus ScharpfMarcus Scharpf More articles by this author , Arnulf StenzlArnulf Stenzl More articles by this author , Lisanne ExnerLisanne Exner More articles by this author , Jörg HennenlotterJörg Hennenlotter More articles by this author , and Steffen RauschSteffen Rausch More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003234.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Differential insulin receptor (IR) expression and altered ratios of IR substrate (IRS) isoforms 1 and 2 in malignant tissues suggest a potential involvement of this cascade in urothelial cancer (UC) tumor biology and pathogenesis. Patients suffering from diabetes mellitus (DM) show an increased risk of developing UC and present with impaired prognosis. As the cellular link in pathogenesis is still unclear for UC and DM, we investigated IRß, IRS1, 2 and their ratio (%IRS1/2) in muscle-invasive UC compared to normal urothelial tissue and their influence on the pro-oncogenic PI3K-AKT-mTOR signaling pathway. METHODS: In 103 muscle-invasive UC patients (n=31 pT2, n=72 >pT2; n=25 G2, n=78 >G2; n=23 DM) after radical cystectomy, tumor tissue was constructed to a tissue microarray and protein expression levels of IRß and of IRS1, 2 were evaluated by immunohistochemistry and scored. Subsequently, expression results of these cascade proteins including their ratios were compared to expression levels of protein kinase B (AKT), each in the cytoplasm (CP) and nuclear (Nuc) compartment of UC and benign urothelium (n=42), respectively. RESULTS: All variables IRß, %IRS1/2-CP as well as -Nuc showed significantly lower expression levels in UC, with strongly decreased IRS1 expression (all p<0.02). UC tissue from patients with DM showed significantly lower IRS2-Nuc expressions (<0.03). Expression of IRß, IRS1,2-CP as well as -Nuc correlated with AKT in univariate analysis (all <0.0001). In multivariate analysis, IRß, IRS1-CP and IRS2-Nuc remained independently associated with AKT signaling. DM hereby modifies the relationship between IRS1-CP and AKT in UC: In patients suffering from DM, their linear association is less pronounced (m=0.01) as compared to UC patients without DM (m=0.003, interaction term p=0.039). CONCLUSIONS: The study shows significant alterations of insulin signaling in UC. The interactions of the IR cascade and protein kinase B appear individually associated with DM-associated metabolic alterations which may confer to distinct UC biology. Source of Funding: Funded by the Eberhard-Karls-University of Tuebingen and the University Hospital Tuebingen © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e190 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Simon Walz More articles by this author Martin Heni More articles by this author Carmen Wandel More articles by this author Sven Walter More articles by this author Marcus Scharpf More articles by this author Arnulf Stenzl More articles by this author Lisanne Exner More articles by this author Jörg Hennenlotter More articles by this author Steffen Rausch More articles by this author Expand All Advertisement PDF downloadLoading ...

Treatment of muscle-invasive urothelial cancer with nivolumab (CheckMate 274 study): a plain language summary

This is a summary of a paper published in a medical journal that describes the results of a study called CheckMate 274. This study looked at a new treatment for muscle-invasive urothelial cancer, a type of cancer found in the urinary tract that has spread from the inner lining of the urinary tract or bladder and into the surrounding muscle wall where it can then spread to other parts of the body. The standard treatment for muscle-invasive urothelial cancer is surgery to remove affected parts of the urinary tract. However, cancer returns in more than half of people after this surgery. Adjuvant therapy is given to people after surgery with muscle-invasive urothelial cancer with a goal to reduce the risk of the cancer coming back; however, at the time this study started, there was no standard adjuvant treatment. In the CheckMate 274 study, researchers compared nivolumab with a placebo as an adjuvant treatment for people with muscle-invasive urothelial cancer. The aim of the study was to understand how well nivolumab worked to reduce the chance of the cancer returning after surgery. The study also looked at what side effects (unwanted or unexpected results or conditions that are possibly related to the use of a medication) people had with treatment. The results showed that people who received nivolumab versus placebo: Survived longer before the cancer was detected again, including people who had programmed death ligand-1 (shortened to PD-L1) on their cancer cells. Survived longer before a secondary cancer outside of the urinary tract was detected. Experienced no differences in health-related quality of life (the impact of the treatment on a person's mental and physical health). Had similar side effects to the people who received nivolumab in other studies. Clinical Trial Registration: NCT02632409 (ClinicalTrials.gov).

217P Characterization of immune cells in the tumor microenvironment of advanced bladder cancer

Cisplatin-based combination chemotherapy (CHT) improves survival in patients with muscle-invasive (MIBC) and metastatic urothelial cancer (mUC). Here we map the cellular landscape in MIBC and mUC and explore its associations to outcome.

Atezolizumab for the treatment of advanced recurrent basal cell carcinoma and urothelial carcinoma of bladder: a case report

BackgroundThe use of checkpoint inhibitors has become increasingly important in the treatment of different cancers, including advanced muscle-invasive urothelial cancer and even in basal cell carcinoma. We present the case of a patient with advanced basal cell carcinoma and metastatic muscle-invasive urothelial cancer, who was treated with the programmed death-ligand 1 inhibitor, atezolizumab for both cancers.Case presentationA 72-year-old Caucasian female patient, with a history of smoking without any comorbidities developed periocular basal cell carcinoma, which was surgically removed but relapsed 4 years later. Surgical excision was carried out twice, but with positive margins, therefore definitive radiotherapy was given. Subsequently, the patient developed non-muscle-invasive papillary urothelial carcinoma, which was removed by transurethral resection. Follow-up was irregular owing to the patient’s inadequate compliance, and within 2 years, the patient’s cancer relapsed and histology confirmed muscle-invasive urothelial carcinoma. Definitive radiochemotherapy was not accepted by the patient. Meanwhile, the patient’s basal cell carcinoma had also progressed, despite receiving vismodegib therapy. Therefore, the patient was administered epirubicin-cisplatin. Having reached the maximum cumulative dose of epirubicin, treatment with this chemotherapeutic agent could not be continued. The patient developed bladder cancer metastasis in her left suprainguinal lymph nodes. Owing to the presence of both types of tumors, programmed death-ligand 1 inhibitor atezolizumab treatment was chosen. In just over 1 year, the patient received 17 cycles of atezolizumab altogether, which was tolerated well without any adverse or side effects. Follow-up imaging scans indicated complete remission of the metastatic bladder cancer and stable disease of the basal cell carcinoma. The patient subsequently passed away in hospital due to a complication of COVID-19 infection.ConclusionsOur patient attained stable disease in advanced basal cell carcinoma and complete remission in metastatic muscle-invasive urothelial cancer after receiving programmed death-ligand 1 inhibitor, atezolizumab, therapy. To our knowledge, this is the first paper to report the use of programmed death-ligand 1 inhibitor, atezolizumab, as treatment for advanced basal cell carcinoma. This case may also be of interest for clinicians when treating patients with two synchronous cancers.

Stellenwert der Immuntherapie in der perioperativen Behandlung des lokalisierten muskelinvasiven Urothelkarzinoms

BackgroundImmune checkpoint inhibitors are the standard of care in the first-line and second-line treatment of metastatic and locally advanced urothelial cancer. The use of immunotherapy in perioperative treatment is a new focus in the uro-oncological landscape. Current studies are investigating immune checkpoint inhibitors as monotherapy and in combination with chemotherapy or irradiation in the perioperative setting.ObjectiveOverview of the currently published data, overview of new study concepts and an outlook on future developments in perioperative immunotherapy.ConclusionNeoadjuvant monotherapy with immune checkpoint inhibitors has failed to show sufficient response rates in muscle-invasive bladder cancer. In contrast, higher response rates have been observed for combinations of immunotherapy and established chemotherapy regimens, so that current phase III trials are now investigating this approach. Among others, sandwich regimens consisting of neoadjuvant immunochemotherapy and adjuvant immunotherapy following radical cystectomy are currently being investigated. Immune checkpoint inhibitors were investigated as adjuvant treatment in patients with high risk of recurrence in muscle-invasive urothelial cancer following radical resection. In this group a significant advantage with respect to disease-free survival (DFS) was observed for adjuvant immunotherapy with nivolumab. The effect was particularly pronounced in patients with a tumor status positive for programmed cell death 1 ligand 1 (PD-L1), so that the European Medicines Agency (EMA) has approved adjuvant immunotherapy with nivolumab for this subgroup as a new uro-oncological treatment indication.

Neoadjuvant Chemotherapy with Accelerated Methotrexate, Vinblastine, Doxorubicin, and Cisplatin in Patients with Muscle-invasive Bladder Cancer: A Retrospective Age-stratified Analysis on Safety and Efficacy

BackgroundThe standard of care (SOC) for muscle-invasive bladder cancer (MIBC) includes cisplatin-based combination chemotherapy in the neoadjuvant setting followed by radical cystectomy. Older patients often do not receive SOC due to perceived toxicity concerns despite guideline-directed recommendations. ObjectiveTo characterize the safety and efficacy of neoadjuvant accelerated methotrexate, vinblastine, adriamycin, and cisplatin (aMVAC) in MIBC patients as a function of age. Design, setting, and participantsA retrospective analysis was conducted in 186 MIBC patients treated at Fox Chase Cancer Center between January 1, 2002 and December 31, 2018. Adults with histologically proven muscle-invasive urothelial cancer were eligible. The exclusion criteria included nonurothelial histology, lack of muscularis propria invasion, and primary upper tract or metastatic disease. InterventionNeoadjuvant chemotherapy with aMVAC. Outcome measurements and statistical analysisPatients were stratified by age (<65, 65–74, and >75 yr old). Renal function was assessed at baseline and at time points after treatment. Clinicopathologic variables were compared between age groups to determine efficacy. Results and limitationsThere were no statistically significant differences in dose reductions, treatment interruptions, time to surgery, or adverse events when patients were stratified by age in univariate and multivariate analyses. Full safety data were not available due to the retrospective nature of the study. Baseline renal function was significantly worse among older patients, and the percent decline in creatinine clearance was greater with older age. We found comparable efficacy of aMVAC regardless of age. ConclusionsAccelerated MVAC was safe and demonstrated efficacy in MIBC irrespective of age in this single-center, retrospective study. Careful selection based on clinical variables, and not age, should identify patients able to receive neoadjuvant chemotherapy. Patient summaryWe examined the feasibility of the standard cisplatin-based chemotherapy regimen given prior to surgery in patients with muscle-invasive bladder cancer. Elderly patients experienced a greater decline in kidney function with treatment but not more complications than younger patients and tolerated therapy with minimal dose changes, resulting in benefit regardless of age.

Interim results from a multicenter clinical study of tislelizumab combined with gemcitabine and cisplatin as neoadjuvant therapy for patients with cT2-T4aN0M0 MIBC.

4580 Background: To evaluate the efficacy and safety of tislelizumab combined with gemcitabine and cisplatin as neoadjuvant therapy for patients (pts) with clinical T2-T4aN0M0 (cT2-T4aN0M0) muscle-invasive bladder urothelial cancer (MIBC). Methods: This multicenter, open-label, single arm phase II study enrolled pts tolerated with the cisplatin therapy. Eligible pts received tislelizumab 200 mg in day 1 (D1), cisplatin 70 mg/m2 D2, and gemcitabine 1000 mg/m2 D1 and D8 every 21 days for four cycles. Radical cystectomy (RC) was performed within 6 weeks after last dose treatment. The primary end point was pathologic complete response (pCR, pT0N0M0). Secondary end points were pathologic downstaging (≤pT1N0M0), EFS, OS and safety. Simon two-stage design was used. If &gt; 5 pts achieved pCR in the first stage (n = 22), study would proceed to the second stage and enroll 33 additional pts. If &gt; 18 of 55 pts achieved pCR, we would deem the study to have met the primary endpoint. Results: We reported the results in the first stage. By Oct 2021, 23 eligible pts were enrolled. Eighteen pts have completed neoadjuvant therapy, with median age of 62 (48-72) years and 8 (44.4%) pts of PD-L1 positive, among whom 17 pts underwent RC and one declined RC. At the data cut off time of 14th Jan 2022, among 17 evaluable pts (12 cT2, 3 cT3, and 2 cT4a), 10 (58.8% [95% CI, 32.9-81.6]) pts achieved pCR and 13 (76.5% [95% CI, 50.1-93.2]) achieved pathologic downstaging. No significant differences were found in pCR (62.5% vs. 55.6%) and downstaging (75.0% vs. 77.8%) rates between pts with PD-L1 positive versus PD-L1 negative. Eighteen pts completed 71/72 cycles of tislelizumab, 68/72 cycles of cisplatin and 135/144 cycles of gemcitabine therapy. The rate of dose reduction (all due to AEs) of cisplatin and gemcitabine therapy was 25.0% (17/68 cycles) and 23.7% (32/135 cycles), respectively. The relative dose intensity of tislelizumab, cisplatin and gemcitabine were 93.6%, 84.5% and 85.9%, respectively. Most common neoadjuvant therapy related AEs of any grade were hematologic toxicities (94.4%), nausea (72.2%), vomiting (61.1%), decreased appetite (55.6%), fatigue (27.8%), pruritus (22.2%) and ALT/AST increased (22.2%). Grade ≥3 neoadjuvant therapy related AEs were neutropenia (n = 6), thrombocytopenia (n = 4), anemia (n = 2) and lymphocyte count decreased (n = 1). Eight pts experienced grade 1-2 immune related AEs, including pruritus (n = 4), rash (n = 2), ALT/AST increased (n = 4), GGT increased (n = 2), CPK increased (n = 1), hyperthyroidism (n = 1), hypothyroidism (n = 1). Conclusions: Neoadjuvant tislelizumab combined with gemcitabine and cisplatin showed promising anti-tumor activity with high pCR and well tolerance in MIBC pts. The target of first stage has been achieved, and enrollment is ongoing. At the data cut off 14th Jan 2022, 34 pts have been enrolled. Clinical trial information: ChiCTR2000037670.