Global Congress on Bladder Cancer 2020: abstract booklet by mirrorsofmedicine

5th edition

Abstract book VIRTUAL MEETING

10 & 15 October 2020

Live 15 October bladdr.org

All abstracts are available online • Browse published posters • Contact authors directly You can find an overview of all accepted abstracts on prosca.org/abstracts.

ORGANISING COMMITTEE OF THE CONGRESS Piotr Chlosta, Jagiellonian University, Krakow, Poland Ananya Choudhury, Christie NHS Foundation Trust, Manchester, UK Maria De Santis, Charité Medical University Hospital, Berlin, Germany Piotr Milecki, Wielkopolskie Oncology Centre, Poznan, Poland Badrinath Konety, University of Minnesota, Minneapolis, USA Iwona Skoneczna, Saint Elizabeth’s Hospital, Warsaw, Poland Piotr Wysocki, Jagiellonian University, Krakow, Poland

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ABSTRACTS OF THE GLOBAL CONGRESS ON BLADDR CANCER, 5TH EDITION VIRTUAL MEETING, 10 TO 15 OCTOBER 2020

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OPDIVO® (nivolumab) as monotherapy is indicated for the treatment of locally advanced unresectable or metastatic urothelial carcinoma in adults after failure of prior platinum-containing therapy.1

OPDIVO® demonstrated efficacy in urothelial carcinoma patients after failure of prior platinum-containing therapy 1-3 In the Phase II CheckMate 275 study,* OPDIVO® demonstrated:

20.7% ORR 20.7% objective response rate (95% CI: 16.1–26.1, n=56/270)2

8.6

months 8.6 months median OS (95% CI: 6.1–11.3)2

Consistent safety profile with that established across tumour types for OPDIVO® monotherapy1-3

This material has been produced to ensure compliance with the EFPIA and local Belgian regulations. The indication is according to European Commission licensing. Prescribing information may vary depending on local approval in each country or region. Therefore, before prescribing any product, always refer to local materials such as the prescribing information and/or the Summary of Product Characteristics (SPC). For Belgian abbreviated prescribing information, please click here. 6

OPDIVO® demonstrated an ORR of 20.7%2 CheckMate 275 – ORR (33.7-month minimum follow-up)2

20.7% ORR (56/270)

95% CI: 16.1–26.1 PR: 14.1% (n=38) CR: 6.7% (n=18) ORR by PD-L1 Expression Status

Adapted from Galsky MD, et al. Clin Cancer Res 2020.

≥1% (124/270) 25.8% ORR

<1% (146/270) 16.4% ORR

(95% CI: 18.4–34.4)

(95% CI: 10.8–23.5)

• 20.7% of patients (56/270) experienced stable disease Primary analysis (median follow-up of 11.5 months)1 • ORR in ITT population: 20.0% (95% CI: 15.4–25.3), (PR=17.0%, CR=3.0%) • ORR in PD-L1 ≥1%: 25% (95% CI: 17.7–33.6) • ORR in PD-L1 <1%: 16% (95% CI: 10.3–22.7)

OPDIVO® has a safety profile in urothelial carcinoma consistent with that established across its use across other tumour types1-3 In CheckMate 275 (33.7-month follow-up):2 • Grade 3/4 TRAEs occurred in 24.8% of patients (n=67) – Three patients (1%) died from TRAEs† • No new safety signals were identified * Phase II, single-arm study of OPDIVO® in 270 patients with metastatic or unresectable urothelial carcinoma who have progressed or recurred following treatment with a platinum agent. Patients received OPDIVO® 3 mg/kg intravenously every 2 weeks, with treatment continuing until progression, unacceptable toxicity or other protocol-defined reasons. The primary endpoint was objective response rate per blinded independent review committee (BIRC).1-3 † One instance each of pneumonitis, respiratory failure and circulatory collapse.2 AE – adverse event; CI – confidence interval; CR – complete response; ITT – intention-to-treat; ORR – objective response rate; OS – overall survival; PD-L1 – programmed death-ligand 1; PR – partial response; TRAE – treatment-related adverse event References: 1. OPDIVO® Summary of Product Characteristics. Available at: https://www.ema.europa.eu/en/documents/product-information/opdivo-epar-product-information_en.pdf [Accessed August 2020]. 2. Galsky MD, Saci A, Szabo PM et al. Nivolumab in Patients with Advanced Platinum-resistant Urothelial Carcinoma: Efficacy, Safety, and Biomarker Analyses with Extended Follow-up from CheckMate 275. Clin Cancer Res 2020; published online. DOI:10.1158/1078-0432.CCR-19-4162. 3. Sharma P, Retz M, Siefker-Radtke A et al. Nivolumab in metastatic urothelial carcinoma after platinum therapy (CheckMate 275): a multicentre, single-arm, phase 2 trial. Lancet Oncol 2017;18(3):312-322. © 2020 Bristol-Myers Squibb Company. All rights reserved. OPDIVO® and the related logos are trademarks of Bristol-Myers Squibb Company. 1506BE2006481-01 Date of preparation: September 2020

Introduction & objectives: PD-L1 expression, tumor mutational burden (TMB), T-effector gene expression and a fibroblast TGF-β– response signature (F-TBRS) have been shown to be associated with clinical outcomes with atezolizumab monotherapy in locally advanced or metastatic urothelial carcinoma (mUC; Mariathasan, Nature. 2018). In this analysis from IMvigor130, we report the potential predictive role of these biomarkers for atezolizumab ± platinum/gemcitabine (plt/gem) in patients with mUC.

IMVIGOR130: TUMOR MICROENVIRONMENT BIOMARKERS ASSOCIATED WITH OVERALL SURVIVAL FROM A RANDOMIZED, PHASE III STUDY IN LOCALLY ADVANCED OR METASTATIC UROTHELIAL CANCER

Material & Methods: Patients with first-line mUC were randomized 1:1:1 to Arms A (atezolizumab + plt/gem), B (atezolizumab monotherapy) or C (placebo + plt/gem). Coprimary efficacy endpoints were progression-free survival (PFS) and overall survival (OS; hierarchical approach). Exploratory biomarker analyses included clinical outcomes by PD-L1 status, TMB (FoundationOne), APOBEC mutation analysis and T-effector and TGF-β-response gene response signatures (TBRS; by RNA-seq).

Maria De Santis, Uro-Oncology, Charité Universitätsmedizin, Berlin, Germany Matthew Galsky, Hematology - Oncology, Icahn School of Medicine at Mount Sinai, United States Romain Banchereau Habib Hamidi Ning Leng Will Harris Peter H. O'Donnell Edward E. Kadel III Kobe Yuen Dexter Jin Hartmut Koeppen Darren Tayama Enrique Grande Jose Angel Arranz Arija, Department of Urology, Hospital General Universitario Gregorio Marañón, Spain Ian D. Davis Eiji Kikuchi Xiaodong Shen Aristotelis Bamias Sanjeev Mariathasan

Results: Biomarker-evaluable patients (BEP; n = 851) were representative of the ITT population (N = 1200). Biomarker results are shown in Table. Improved OS with atezolizumab monotherapy was observed in patients with high TMB tumors (> 10 muts/Mb) or PD-L1 IC2/3 status. Favorable outcomes with atezolizumab monotherapy were also identified for a subset of patients whose tumors had both high PD-L1 and high TMB (≈ 14% of BEP); however, similar results were not seen with atezolizumab + plt/gem vs placebo+ plt/gem. APOBEC mutagenesis was associated with improved OS with atezolizumab-containing regimens, whereas high F-TBRS conferred resistance to atezolizumab monotherapy. Conclusions: These results from IMvigor130 reinforce the predictive nature of biomarkers associated with response and resistance to atezolizumab monotherapy and highlight potentially distinct biology underlying benefit with atezolizumab ± plt/gem. Further prospective validation of a possible biomarker-directed approach to 1L mUC treatment is warranted.

MUSCLE INVASIVE BLADDER CANCER - ARE THERE ANY SURVIVAL PROGNOSTIC PREDICTORS?

CAN CHECKPOINT INHIBITOR IMMUNE-RELATED ADVERSE EVENTS BE A PROGNOSIS FACTOR IN UROTHELIAL CANCER?

Gil Falcao, urology, centro hospitalar universitario lisboa central, Portugal Rui Bernardino Thiago Guimar達es Mariana Medeiros Vanessa Andrade Jo達o Guerra Miguel Gil Cabrita Carneiro Luis Campos Pinheiro

Introduction & objectives: Urothelial carcinoma of the bladder (UCB) is the second most common genitourinary malignancy and is associated with a heterogeneous clinical outcome. Radical cystectomy (RC) with bilateral pelvic lymph node dissection (PLND) is currently the gold standard treatment for muscle-invasive UCB. Despite that, a significant proportion of patients develop disease recurrence. Several studies have evaluated the risk factors for survival after cystectomy. The implication of such factors will help in modification of treatment strategies to improve the prognosis of bladder cancer patients. Our aim is to evaluate the influence of clinical and histopathological parameters on outcomes of patients with urothelial carcinoma of the bladder (UCB).

Introduction & objectives: Imunnotherapy has gained a high value in the oncology environment, with benefits for the patients (pts) that are eligible for it. However, these drugs are not completely harmless, and immune related adverse events (IRae) have been reported. There have been reports showing clinical benefit in patients that report IRae. Our mains goal is to show if our study matches the recent literature. Material & methods: In our study, we did a retrospective analyses in pts who were treated with checkpoint inhibitors for urotelial cancer in our center, between January 2015 and December 2019. Every patient must have had ECOG performance status of 0-2 and were treated with anti PD-1 or anti PD-L1. for advanced muscle invasive urothelial cancer. Progression free survival (PFS) and overall survival (OS) were evaluated starting from the time of the begining of imunnotherapy. Disease control rate was evaluated [Stable disease (SD) + Partial response (PR) + Complete response (CR)]. Results were compared with pts that developed IRae. Demographic and clinical data were collected and the information was cross-checked with that of the pharmaceutical services. A multivariate logistic regression was used to evaluated significance. Significance (p) of less than 0.05 was considered statistically significant. Statistical analysis was performed in stata.

Materials and Methods: A retrospective analysis was performed through the electronic process of all patients undergoing radical cystectomy between January 2014 and January 2020 (6 years). Demographic and clinical data were collected and the information was cross-checked with that of the anatomopathological and pharmaceutical services. Significance (p) of less than 0.05 was considered statistically significant. Statistical analysis was performed in Stata. Results: 93 patients with a mean age of 72 years were analyzed. About 92% of the patients were male. The following factors were evaluated: age, gender, smoking habits, comorbidities (Charlson Index), tumor stage, tumor differentiation, histological variant, necrosis, lymphovascular/perineural invasion (LVI/PNI), concomitant carcinoma in situ (CIS), presence of lymph node metastasis, disease recurrence and performance of neoadjuvant chemotherapy. Of all the factors evaluated, a statistically significant relationship was observed between OS and tumor stage, presence of lymph node metastasis and disease recurrence.

Results: A total of 30 pts were included in this study. The median age was 69 (63-88). 22 (74%) were male and 8 (26%) were female. 17 (57%) pts were treated with pembrolizumab, 7 (23%) nivolumab and 6 (20%) atezolizumab. 6 pts had 1st line treatment, 20 pts 2nd line and 4 had 3rd line treatment. 18 (61%) had cisplatin based treatment. 25 (83%) had ECOG PS 0-1. 7pts developed IRae. Every IRae were grade 2 or lower. The most common IRae was hypothyroidism (6pts). 1 pt had pneumonitis and 1 had skin related IRae. Median follow up time was 15 months ( 3.27 - 24.40). Median PFS was 6.3 months (2.1-19.5). Median OS was 13.6 months (7.6not reached). Disease control rate was higher in the group that developed IRae, 85%(n=7) vs 56% (n=23). However, there was no statistical significance (p=0.19). Median PFS were higher in the IRae group (9.4m vs 5.6m) (p=0.13). Median OS was higher in the IRae group (17.6m vs 12.1m) (p=0.2)

Conclusions: Invasive muscle tumors of the bladder and cystectomy are associated with high morbidity and mortality, and it is important to identify risk factors for a better treatment of this population. In this series of patients only presence of lymph node metastasis, disease recurrence and tumor stage were associated with higher mortality. The small sample size may justify the nonassociation of other risk factors as predictive of survival.

Conclusions: There seems to be a trend towards clinical benefit in patients that develop IRae with imunne checkpoint inhibition in advanced urothelial cancer. However, due to limitation of the low sample of patients no statistical significance could be established. Prospective trials with higher samples could be evaluated to adress this hipo

Events v4.0 will be monitored from randomization through 30 days after last dose of study drug (90 days for serious AEs).

PERIOPERATIVE PEMBROLIZUMAB OR PEMBROLIZUMAB PLUS ENFORTUMAB VEDOTIN (EV) AND CYSTECTOMY COMPARED TO CYSTECTOMY ALONE IN PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER (MIBC) WHO ARE CISPLATIN-INELIGIBLE (KEYNOTE-905/EV-303)

Results: KEYNOTE-905 study is ongoing or planned in 25 countries across Asia, Australia, Europe, and North America. Conclusions: KEYNOTE-905 will provide further clarity on efficacy of perioperative pembrolizumab with or without EV in cisplatinineligible MIBC.

Matthew Galsky, Hematology - Oncology, Icahn School of Medicine at Mount Sinai, United States Andrea Necchi Neal D. Shore Elizabeth Plimack Calvin Jia Eric Sbar Blanca Homet Moreno Fred Witjes Introduction & objectives: Patients with MIBC who are ineligible for neoadjuvant cisplatin-based chemotherapy receive the standard of care treatment of radical cystectomy (RC) and pelvic lymph node dissection (PLND). This therapy alone is associated with high rates of recurrence and relatively poor overall survival (OS); novel perioperative systemic therapy regimens are needed. The PURE-01 single-arm study (NCT02736266) found that the PD-1 inhibitor pembrolizumab as single-agent neoadjuvant therapy in patients with MIBC had antitumor activity. The study also found that high PD-L1 expression was associated with a higher pathologic complete response rate (pCR). Materials & Methods: The KEYNOTE-905 (NCT03924895) randomized, multinational phase 3 study will assess efficacy and safety of perioperative pembrolizumab plus RC and perioperative EV with pembrolizumab plus RC vs RC alone for patients with MIBC. The patient population will comprise adults with histologically confirmed MIBC (T2-T4aN0M0 or T1-T4aN1M0) with predominant (≥50%) urothelial histology, confirmed by blinded independent central review. These patients must also be previously untreated with systemic therapies for MIBC, be cisplatin-ineligible, have Eastern Cooperative Oncology Group performance status of 0-2, and have tumor tissue for histology and PD-L1 analysis. Approximately 836 patients will be randomized 1:1:1 to 3 cycles of neoadjuvant pembrolizumab followed by RC plus PLND and 14 cycles of adjuvant pembrolizumab or 3 cycles of neoadjuvant EV and pembrolizumab followed by RC plus PLND and 6 cycles of adjuvant EV and 14 cycles of adjuvant pembrolizumab or RC plus PLND alone. Neoadjuvant or adjuvant pembrolizumab 200 mg will be administered intravenously every 3 weeks (Q3W). Neoadjuvant or adjuvant EV 1.25 mg/kg will be administered on days 1 and 8 Q3W. Stratification factors will be PD-L1 status (combined positive score [CPS] ≥10 vs <10), disease stage (T2N0 vs T3/T4N0 vs T1T4aN1), and region (United States vs European Union vs Most of the World). Imaging (CT or MRI) will be performed 5 weeks or fewer precystectomy and at 6 weeks postcystectomy. Scans will then be performed Q12W up to week 96 postcystectomy and at discontinuation. Thereafter (ie, year 3 and beyond) imaging will be Q24W. The coprimary endpoints are pCR and event-free survival (EFS) (expressing PD-L1 [CPS ≥10] and all patients regardless of CPS). Secondary endpoints are OS, disease-free survival, and pathologic downstaging in populations described for pCR and EFS safety, and patient-reported outcomes. Adverse events (AEs) graded according to Common Terminology Criteria for Adverse

REAL-LIFE EXPERIENCE IN MULTIMODAL BLADDER PRESERVING TREATMENT FOR MUSCLE-INVASIVE BLADDER CANCER

WWOX–AP-2α INTERACTION AFFECTS BIOLOGY OF BLADDER CANCER AND DEMONSTRATES USEFULNESS IN ITS CLINICAL FEATURES’ DISCRIMINATION

Luísa Jerónimo Alves, Urology, Hospital Beatriz Ângelo, Portugal João de Brito Ascensão Catarina Diogo Gameiro Sofia Margarida Pinheiro Lopes João Pádua Marcelino

Damian Kołat, Department of Molecular Carcinogenesis, Medical University of Lodz, Poland Żaneta Kałuzińska Elzbieta Pluciennik, Molecular Carcinogenesis, Medical University of Lodz Poland, Poland Introduction & objectives: The WW Domain Containing Oxidoreductase (WWOX) tumor suppressor gene is located in direct proximity to chromosomal locus 16q24 that is related to tumor progression of 20-45% bladder cancers. It encodes protein containing two WW domains, the first of which recognizes prolinerich motifs of proteins such as Activating Enhancer-Binding Protein 2 Alpha (AP-2α) transcription factor (encoded by TFAP2A gene). The literature data indicate that WWOX sequestrates AP-2α outside nucleus, which suppresses its transcriptional transactivation functions. The purpose of this research was to examine diverse properties of bladder cancer with various WWOX and TFAP2A expression levels in CAL-29 cell line (grade IV) and determine their effect on useful clinical features in patients.

Introduction & objectives: Radical cystectomy is the standard of care for muscle-invasive bladder cancer (MIBC). Multimodal bladder preserving treatment (MMT), which combines transurethral resection of the bladder (TURB), chemotherapy and radiotherapy (RT), may be an option for well-informed patients who refuse radical surgery or for those unfit for cystectomy. The aim of our study is to evaluate the oncological outcomes of patients treated with MMT in our institution. Material and Methods: Retrospective evaluation of the electronic medical records of all pts diagnosed with MIBC who underwent MMT in Hospital Beatriz Ângelo, from 2012 to 2019. Statistical analysis was performed with the use of SPSS version 24. Results: A total of 16 patients (pts) were included, with a median age of 76 [59;85] years-old (yo), 94% being males. Fourteen pts were initially diagnosed with MIBC and two progressed from nonmuscle invasive disease. Six patients were unfit for platinum-based chemotherapy regimens, and were treated with 5-fluorouracil plus mitomycin. Four patients discontinued chemotherapy due to hematological toxicity. After a median follow-up of 36,7 months [10,2;82], there were 8 deaths, 4 of which disease-related. Two pts developed metastatic disease. The median overall survival (OS) was 68,3 months [95%CI: 10,7 – 125,9].

Materials & Methods: Using two lentiviral systems we created in vitro models with various WWOX and TFAP2A expression on which the cell viability, adhesion, proliferation and 3D culture growth assays were performed. Bioinformatic analyzes were conducted on bladder cancer data acquired from The Cancer Genome Atlas (TCGA) using Weighted Gene Correlation Network Analysis (WGCNA) and NETworkbased Gene Enrichment (NET-GE) tool with Molecular Signatures Database (MSigDB) used to assign the role of a particular gene to the biological process.

Conclusion: As tends to occur in most centers, all our patients selected for MMT were unfit for radical surgery. In spite of being a small cohort of patients, we found encouraging results, with only four disease related deaths over a median period of 36,7 months. Evaluating real-life outcomes may contribute to a better selection of patients for bladder sparing treatments, eventually allowing us to expand its indications for frail patients with a small burden of disease.

Results: In variant with ↑WWOX/↑TFAP2A expression we observed reduced mitochondrial redox potential, decrease in the number and size of spatial colonies and lowered adhesion to fibronectin, collagen I and collagen IV in comparison to cells with ↑WWOX expression and native TFAP2A expression. Similar tendencies were noticed in variant with ↑TFAP2A overexpression and native WWOX expression compared to control cells although with additional demonstration of lower proliferative potential. Decreased size of 3D colonies was also observed in cells with ↑WWOX expression and native TFAP2A, compared to its control. To further investigate WWOX role, in silico analyzes (WGCNA, NETGE) have been conducted on TCGA data of patients having ↑TFAP2A but various WWOX expression. Using WGCNA, we extracted cluster of 530 genes that noticeably differentiated samples in terms of bladder cancer papillary and non-papillary subtypes. Subsequently, ontological analysis of these genes indicated that these genes are primarily implicated in adhesion and proliferation but also in apoptosis, cell cycle or several signaling pathways (e.g. JAK-STAT, MAPK, Wnt, NFkB). Conclusions: Taken together, our study indicates that WWOX interplays with AP-2α in regulation of bladder cancer spatial colonies growth. However, the effect on tumor cell viability, proliferation and adhesion appears to be dependent on the AP2α level. Thus, subsequent in silico analyzes were focused on characterizing the dissimilarities of groups differing in WWOX gene expression level. Ultimately, these tools revealed valuable data concerning correlation of clinical traits with expression profile that once examined through gene ontology, disclosed influence on crucial biological processes or signaling pathways. This work was supported by NCN Poland grant number 2016/21/B/NZ2/01823.

Figure 1. Diﬀerences of adhesion ability to selected extracellular matrix proteins between CAL-29 variants. (A) Collagen IV. (B) Fibronectin. (C) Collagen I. (D) BSA.

Figure 2. Diﬀerences in proliferation potential between CAL-29 variants. p<0.01 (**).

p<0.001 (***), p<0.0001 (****).

Figure 3. Comparison of the growth of C in the 3D matrix. (A) Contr/contr variant (C) WWOX/contr variant. (D) WWOX/A v

Figure 1. Differences of adhesion ability to Figure 2. Differences proliferation potential between Figure 3. Comparison of the growth of CAL-29 cell line variants es in proliferation potential between Figure 3. Comparison ofselected the growth of CAL-29 cell line variants in Figure 4. Differences in mitochondrial redox potential between extracellular matrixinproteins between(A) CAL-29 variants. (**). in the 3D matrix. (A) Contr/contr variant. (B) Contr/A variant. <0.01 (**). the 3D matrix. Contr/contr variant. (B) CAL-29 Contr/Avariants. variant. p<0.01 CAL-29 variants. p<0.05 (*), p<0.01 (**), p<0.001 (***), p<0.0001 (****). (A) Collagen IV. (B)(C) Fibronectin. (C) Collagen (D) BSA. (C) WWOX/contr variant. (D) WWOX/A variant. WWOX/contr variant. I. (D) WWOX/A variant.

between

p<0.001 (***), p<0.0001 (****).

Figure 6. Heatmap with the highest module-trait relationship for histologic grade.

Figure 5. Module-trait relationship presenting the most valuable correlations between clinical trait and expression proﬁle.

Figure 7. Heatmap with the highest module-trait relationship for bladder cancer subtyp Figure 3. Comparison of the growth of CAL-29 cell line variants in the 3D matrix. (A) Contr/contr variant. (B) Contr/A variant. (C) WWOX/contr variant. (D) WWOX/A variant.

igure 6. Heatmap with the highest module-trait relationship for histologic grade.

Figure 4. Diﬀerences in mitochondrial redox potential between CAL-29 variants. p<0.05 (*), p<0.01 (**), p<0.001 (***), p<0.0001 (****).

Figure 6. Heatmap with the highest module-trait relationship for histologic grade.

Figure 5. Module-trait relationship presenting the most valuable correlations between clinical trait and expression proﬁle. Figure 8. Visualization of gene ontology analysis with the use of 530 genes Figuresamples 7. Heatmap with the highest module-trait for bladder cancer subtype. distinguishing of bladder cancer non-papillary and relationship papillary subtypes. ure 7. Heatmap with the highest module-trait relationship for bladder cancer subtype.

ighest module-trait relationship for histologic grade.

est module-trait relationship for bladder cancer subtype.

Figure 8. Visualization of gene ontology analysis with the use of 530 genes distinguishing samples of bladder cancer non-papillary and papillary subtypes.

Figure 8. Vi distinguishin

Andreas Luebke, Department of Pathology, University Medical Center Hamburg-Eppendorf, Germany

Ashley Mehmi, Urology, North Bristol Trust, Bristol, United Kingdom Emily Cooper Kate Warren Helena Burden

COVID-19 LOCKDOWN REDUCES SCREENING AND FOLLOW-UP IN URINARY CYTOLOGY

G2TA BLADDER CANCER WITHOUT DETRUSOR, DO WE NEED TO RESTAGE AT 6 WEEKS?

Introduction & objectives: The national lockdown due to coronavirus disease 2019 (COVID-19) wholly altered the daily practice in our cytology lab. We wanted to know how COVID-19 changed the number and composition of urinary specimens as a classic example of a cytological screening and follow-up procedure.

Introduction & objectives: NICE bladder cancer guidelines currently recommend that patients with a pathological grading of G2ta bladder Transitional Cell Carcinoma (TCC) at first diagnosis Trans-Urethral Resection of Bladder Tumour (TURBT) without muscle in the specimen, should undergo a restaging TURBT within 6 weeks. We investigated our population of G2ta bladder TCC patients, to compare outcomes in patients with and without detrusor muscle in the initial specimen. The study aimed to ascertain whether a restaging TURBT was necessary in this group.

Methods: The overall numbers and percentages of urinary cytology (voided urine, bladder washings, washings from the upper urinary tract) were processed at the University Medical Center Hamburg-Eppendorf during the first four weeks of Germany's national lockdown were compared with those of the equivalent period in 2019. All urinary specimens were classified according to the Paris System for Reporting Urinary Cytopathology.

Methods: Patients with a diagnosis of G2ta bladder TCC were identified from a bladder cancer database (diagnosed 2012 -2019). Retrospective data was collected from the Somerset Cancer Registry.

Results: During the lockdown, the proportion of urinary specimens significantly dropped from 460 (29,5%) of 1559 total specimen in 2019 to 221 (23,8%) of 928 total specimens (X2p= .0020). In 2019 of all 460 samples, 385 (83,7%) were voided urine, 56 (12,1%) were bladder washings, and 19 (4,1%) samples were from the upper urinary tract. In 2020 of all 221 samples, 198 (89,6%) were voided urine, 13 (5,9%) were bladder washings, and 10 (4,5%) were washings from the upper urinary tract. The malignancy rate significantly lowered from 14 (3%) of 460 total samples in 2019 to 1 (0,0045%) of 221 whole urine samples in 2020 (Fisher exact test p=0.0463).

Results: A total of 143 patients were identified for inclusion, based on a first diagnosis of G2ta bladder TCC from 2012 – 2019. N=98 (69%) patients had muscle in their first specimen, n=45 (31%) patients did not have muscle in the initial diagnostic specimen. Of these patients with no muscle in their specimen, an MDT decision was made to perform a restaging TURBT in 13 patients (29%). Of these 13 patients, only one patient was upgraded to G3T1 TCC. Of the 45 patients who did not have muscle present in their initial specimen, the recurrence rate at 1 year was 35% (n=16). In the 98 patients who had muscle present in their initial specimen, the recurrence rate at 1 year was 31% (n=31). No significant difference was detected between the recurrence rates in each group (p=0.7, Fisher’s exact test). The number of patients upgraded within the year was 8% (n=4/45) and 6% (n=6/98), in the groups with no muscle present and muscle present, respectively. No significant difference was detected in high-grade recurrence between the groups (p=0.7, Fisher’s exact test).

Conclusions: The COVID-19 lockdown reduced the overall case numbers in urinary cytology. The proportions of urine specimens and the malignancy rates in urinary cytology decreased significantly, indicating that bladder cancer screening and followup were reduced in the covid19 lockdown.

Conclusion: Our data shows that there is no difference in the recurrence or upgrade rate at 1 year in patients with initial G2ta bladder TCC, whether muscle is present in the specimen or not. This suggests that it is unnecessary to perform a restaging TURBT at 6 weeks in these patients, even if there is no detrusor muscle present in the initial resection specimen.

DIFFERENTIAL DIAGNOSIS OF MUSCLE-INVASIVE AND MUSCLENON-INVASIVE BLADDER CANCER USING RAMAN SPECTROSCOPY (RAMAN SPECTROSCOPY)

PERIOPERATIVE PEMBROLIZUMAB OR PLACEBO AND NEOADJUVANT CHEMOTHERAPY IN PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER (MIBC) WHO ARE ELIGIBLE FOR CISPLATIN (KEYNOTE-866 PHASE 3 STUDY)

Gilmanova Rita Flaridovna, oncology, Federal State Budgetary Educational Institution of Higher Education "Bashkir State Medical University" of the Ministry of Healthcare of the Russian Federation, Ufa, Russia

Arlene Siefker-Radtke, Genitourinary Medical Oncology, The University of Texas MD Anderson Center, United States Gary Steinberg Jens Bedke Hiroyuki Nishiyama Xiao Fang Ritesh Kataria Blanca Homet Moreno Christopher J Hoimes, Medical Oncology, Duke University, United States

Introduction & objectives: According to global statistics, bladder cancer is a common nosology, ranking 9th in the overall structure of cancer incidence and tending to a constant progressive growth. The fact of tumor invasion into the muscle layer of the bladder fundamentally divides all patients according to the tactics of further observation and treatment into 2 groups - with non-muscleinvasive bladder cancer (MNIRMP) (stages Tis, Ta-T1) and muscleinvasive cancer (MIBC) (stage T2, T3, T4) Therefore, it is imperative to develop an inexpensive, fast and automated diagnostic method with high sensitivity.

Introduction & objectives: Despite aggressive local and systemic therapy, MIBC outcomes remain dismal, with high recurrence rates and poor survival outcomes. Standard-of-care therapy of neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy results in a modest 5-year survival benefit. A phase 2 trial of neoadjuvant chemotherapy plus pembrolizumab had promising antitumor activity in cisplatin-eligible patients with MIBC (HCRN GU14-188; NCT02365766). In this trial, the estimated 36-month overall survival (OS), relapse-free survival, and disease-specific survival rates were 82%, 63%, and 87%, respectively, and toxicity was manageable, thus warranting further study of perioperative pembrolizumab plus neoadjuvant chemotherapy in MIBC.

Purpose of the study: Carry out a comparative spectroscopic characterization of MNIRMP and MIRMP. Research methods: We studied the material obtained from 75 patients diagnosed with bladder cancer (male – 57, female – 18), who were examined and treated at the oncology department of the BSMU Clinic. Tumor tissues of the urinary bladder removed during TUR of the bladder and radical cystoprostatvesiculectomy were examined. Tumor tissue sample: without sample preparation. The study of the samples was carried out on a Horiba Scientific apparatus. Configuration: wavelength 785 nm, grating 1200 gr/mm, filter 100%, confocal aperture 300 μm. Integration time 50 s. Spectral data analysis was carried out using Spectragryph software.

Materials & Methods: The KEYNOTE-866 (NCT03924856) randomized, multinational, phase 3 study will assess efficacy and safety of perioperative pembrolizumab plus chemotherapy (gemcitabine plus cisplatin) versus perioperative placebo plus chemotherapy for patients with MIBC. Enrolled patients are adults with histologically confirmed MIBC (T2-T4aN0M0) with predominant (≥50%) urothelial histology confirmed by blinded independent central pathology and imaging review. Patients must also be previously untreated, be cisplatin-eligible, have Eastern Community Oncology Group (ECOG) performance status 0 or 1, and have tumor tissue for histology and PDL1 analysis. Approximately 790 patients will be randomly assigned in a 1:1 ratio to 4 cycles of neoadjuvant pembrolizumab or placebo plus chemotherapy followed by 13 cycles of adjuvant pembrolizumab or placebo after radical cystectomy plus pelvic lymph node dissection. Neoadjuvant or adjuvant pembrolizumab 200 mg or placebo will be administered intravenously every 3 weeks (Q3W); neoadjuvant chemotherapy consists of 4 cycles of gemcitabine 1000 mg/m2 plus cisplatin 70 mg/m2 Q3W. Stratification factors will be PD-L1 status (combined positive score [CPS] ≥10 vs <10), disease stage (T2 vs T3/4), and region (United States vs Europe vs rest of world). Imaging (CT or MRI) will be performed 5 weeks or less prior to cystectomy and at 6 weeks postcystectomy. Imaging will then be performed Q12W up to week 96 postcystectomy and at discontinuation. Thereafter—year 3 and beyond—imaging will be Q24W. The dual primary end points are pathologic complete response (pCR) and event-free survival (EFS) evaluated in patients whose tumors express PD-L1 (CPS ≥10) and in all patients irrespective of CPS score. Secondary end points are OS, disease-free survival, and pathologic downstaging in patients with CPS≥10 and in all patients irrespective of CPS score, as well as safety, and patient-reported outcomes. Adverse events (AEs) graded per Common Terminology Criteria for Adverse Events, version 4.0, will be monitored from randomization through 30 days after last dose of study drug (90 days for serious AEs).

Results: It was found that the Raman fluorescence spectra of bladder cancer samples contain pronounced peaks in the range of 500–2500 cm 1. It should be noted that the high intensity of peaks 750 cm 1 (thymine), 1000 cm 1 (phenylalanine), 1100 cm 1 (complex of fatty acids In addition, there is a significant increase in the intensity of peaks in the region of 850 cm - 1, 1250 cm - 1 (the C - NH2 bond in adenine, guanine, and cytosine molecules), as well as 1660 cm - 1 (the bond of amides I: C = O proteins, α - helical conformation, C = C-bond of lipids). Comparison of the obtained data showed that the intensity of the peaks in tissue samples with MIBC is significantly higher than in samples with MIBC. In this case, a particularly striking difference is observed in the region 1000 cm1.1250 cm-1, 1660 cm-1. Conclusions: The results of the study indicate the possibility of using the Raman spectroscopy method in the diagnostic algorithm for bladder tumors.

Results: The KEYNOTE-866 study is underway in 22 countries across Asia, Australia, Europe, and North America. Conclusions: KEYNOTE-866 will provide further clarity on the efficacy of perioperative pembrolizumab plus chemotherapy in MIBC. 14

A NEW PROTEOMIC BIOMARKER PANEL FOR BLADDER CANCER STAGE DIFFERENTIATION BY LABEL-FREE QUANTITATIVE HIGH-RESOLUTION MASS SPECTROMETRY Mariana Silva Medeiros, Urology, Centro Hospitalar e Universitário Lisboa Central, Portugal João Guerra Miguel Gil Vanessa Andrade, Urology, Centro Hospitalar Lisboa Central, Portugal Thiago Guimarães Rui Bernardino, Urologia, Centro Hospitalar Lisboa Central, Portugal Frederico Ferronha Luís Campos Pinheiro Introduction & objectives: Bladder cancer (BC) is the seventh most commonly diagnosed cancer in the male. After tumor resection (TURB), clinical staging is fundamental for prognosis and for treatment decision as non-muscle invasive (Ta and T1) and invasive (T2+) are treated with a completely different procedure. To this day, a large proportion of T1 cases and some of Ta cases are under-staged, hence some T1 cases should be re-operated to a better staging. Noninvasive methods capable of differentiating bladder cancer stages (mainly differentiating T1 and T2) would be essential for diagnosis of under staged T2 cases. On a previous pilot study, we had identified a panel of 83 candidate biomarkers for bladder cancer (BC) diagnostics and staging (Ta n=6, T1 n=6, T2+ n=6) with two control groups (LUTS n=6 and non-urinary condition patients n=6). Despite this breakthrough, the number of samples used in the pilot study was low. Our aim is to increase the accuracy of the biomarker panel for BC stage differentiation using a greater amount of patients. We also intend to identify proteins that could measure bladder cancer progression. Methods: Briefly, 50 urine samples were collected from volunteers of the following groups: 1) 20 patients with bladder cancer stage Ta; 2) 19 patients with BC stage T1 and 3) 11 patients with BC stage T2+. The urinary proteome was cleaned and digested using the FilterAided Sample Preparation methodology and analysed by liquid chromatography-mass spectrometry. For protein identification and label-free quantification we usedMaxQuant and the data was further interrogated with the bioinformatics platform Perseus. Results: A more significant and robust biomarker panel can be seen in figure 1 which consists of 103 proteins that were up or down-regulated between the three different BCa stages evaluated. In comparison with the previous pilot study, we encounter new biomarkers and further validated 62% of the previously proposed protein biomarkers. Furthermore, ceruloplasmin, hemopexin and retinol-binding protein 4 were the proteins with higher levels of significance that can distinguish the different BCa stages. Ceruloplasmin and hemopexin can differentiate an early BCa (Ta) stage from more advanced stages (T1 and T2+) and retinol-binding protein 4 abundance consistently increases from Ta to T1 and to T2+. Conclusion: Our results showed a proteomic biomarker panel capable to differentiate bladder cancer stages. Besides, ceruloplasmin and hemopexin can differentiateTa stage from stages T1 and T2+ and retinol-binding protein 4 can be a candidate biomarker predictor of progression.

INTRACORPOREAL VERSUS EXTRACORPOREAL URINARY DIVERSION FOLLOWING ROBOTASSISTED RADICAL CYSTECTOMY: A META-ANALYSIS, CUMULATIVE ANALYSIS AND SYSTEMATIC REVIEW Karthik Tanneru, Urology, University of Florida, United States Jatinder Kumar Muhammad Umar Alam, Urology, University of Florida, United States Daniel Norez Soroush Bazargani Seyed Behzad Jazayeri Hariharan Ganapathi Palayapalayam Mark Bandyk Robert Marino Shiva Gautam Shahriar Koochekpour K.C.Balaji Joseph Costa Introduction & objectives: Over the last decade, the increased utilization of robot-assisted radical cystectomy (RARC) in the surgical treatment of muscle-invasive bladder cancer has led to an uptrend in intracorporeal urinary diversions (ICUD). However, the operative results comparing ICUD to extracorporeal urinary diversion (ECUD) have varied widely. We performed a metaanalysis to analyze peri-operative outcomes and complications of ICUD compared to ECUD following RARC. Methods: This study is registered at International Prospective Register of Systematic Reviews (PROSPERO) CRD42020164074. We performed a critical search of PubMed, EMBASE, and Cochrane databases in August 2019. A total of 6 studies comparing ICUD vs ECUD were identified and meta-analysis was conducted on these studies. In addition, a cumulative analysis was also performed on 83 studies that reported perioperative outcomes after RARC and ICUD or ECUD. Results: The Weighted Mean Difference (WMD) of operative time and blood loss between ICUD and ECUD group was (16; 95% confidence interval -34 to 66) and (-86; 95% confidence interval -124 to -48) respectively. ICUD and ECUD had comparable early (30-day) and mid-term (30-90 day) complication rate (RR 1.19; 95% confidence interval 0.71-2.0; p = 0.5) and (RR 0.91; 95% confidence interval 0.71-1.15 p = 0.4) respectively. In the 83 studies that were included in the cumulative analysis, the mean operative time for ileal conduit and neobladders by ICUD were 307 and 428 minutes respectively compared to ECUD 428 and 426 minutes respectively. Conclusion: ICUD and ECUD have comparable short and midterm complication rate. The ICUD group has lower blood loss and a lower rate of blood transfusion compared to ECUD.

PHASE 3 KEYNOTE-992 STUDY: PEMBROLIZUMAB PLUS CHEMORADIOTHERAPY (CRT) VERSUS PLACEBO PLUS CRT FOR PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER (MIBC)

VERY LOW RISK OF SEVERE COMPLICATIONS AFTER A SINGLE, POST-OPERATIVE INSTILLATION OF INTRAVESICAL CHEMOTHERAPY IN PATIENTS WITH LOW- OR INTERMEDIATE RISK UROTHELIAL CARCINOMA OF THE BLADDER

Michiel Van Der Heijden, Molecular Carcinogenesis, Netherlands Cancer Institute, Netherlands Andrew James Weickhardt Arjun Vasant Balar Shahrokh F. Shariat Neal Shore Xiao Fang James Luke Godwin Ekta Kapadia Jeff Michalski, Radiation Oncology, Washington University, Saint Louis, United States Nicholas D. James

L.M.C. van Hoogstraten, Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Netherlands Fred Witjes Theodora Maria Ripping, Research and Development, Netherlands Comprehensive Cancer Organisation, Netherlands BlaZIB study group R.I. Nooter L.A. Kiemeney Katja Aben, Research & Development, Netherlands Comprehensive Cancer Organisation, Netherlands

Introduction & objectives: Standard of care for bladderpreserving treatment with MIBC is CRT. Pembrolizumab has clinical activity across many stages of bladder cancer, including metastatic bladder cancer, MIBC, and non–muscle-invasive bladder cancer (NMIBC). Two phase 2 studies (NCT02662062 and NCT02621151) to test pembrolizumab plus CRT for MIBC are ongoing, and initial data are promising. KEYNOTE-992 (NCT04241185) will further investigate the safety and efficacy of pembrolizumab plus CRT in patients with MIBC who opt for bladder preservation.

Introduction & objectives: EAU guidelines recommend a single, post-operative instillation (SPI) of intravesical chemotherapy within 24 hours after transurethral resection of a bladder tumor (TURBT) in patients with a low- to intermediate risk non-muscle invasive bladder cancer (NMIBC). However, remarkable variation exists in the use of SPI. Fear for severe and potential deadly complications is likely to contribute to this variation but evidence is limited. Therefore we investigated the risk of severe complications and mortality after SPI in patients with low- and intermediate risk NMIBC.

Materials & Methods: KEYNOTE-992 is an ongoing, multicenter, double-blind, placebo-controlled, randomized, phase 3 trial to evaluate the efficacy and safety of first-line pembrolizumab versus placebo—both added to CRT—in patients with MIBC. Adults with confirmed cT2-T4a, nonmetastatic (N0M0) MIBC who opt to undergo bladder-preserving therapy will be eligible for enrollment. Approximately 636 patients will be randomly assigned 1:1 to receive CRT plus either pembrolizumab 400 mg IV Q6W or placebo. The study drug—ie, pembrolizumab or placebo—will be discontinued after 9 doses. The investigator must choose 1 of the following radiotherapy (RT) plans before study begins: conventional RT consisting of 64 Gy at 2 Gy/fraction over 6.5 weeks (whole bladder with or without pelvic nodes) or hypofractionated RT consisting of 55 Gy at 2.75 Gy/ fraction over 4 weeks (whole bladder). Investigators must likewise choose 1 of the following radiosensitizing chemotherapy regimens: cisplatin monotherapy (35 mg/m2 IV weekly), 5-fluorouracil (500 mg/m2 on days 1-5 and days 22-26) plus mitomycin C (12 mg/m2 on day 1), and gemcitabine monotherapy (27 mg/m2 IV twice weekly). Efficacy will be assessed by cystoscopy (± biopsy); imaging (CT or MRI) with blinded independent central review; and urine cytology at 10 weeks after CRT, then Q12W until the end of year 2, and every 24 weeks thereafter. Enrollment will be stratified by ECOG PS (PS 0 or 1 vs 2), PD-L1 combined positive score (<10 vs ≥10), T stage (T2 vs T3 or T4), and geographic region (US vs Europe vs rest of world). Primary end point is bladder-intact event-free survival, defined as the time from randomization to first occurrence of the following: residual/ recurrent MIBC, nodal or distant metastases, radical cystectomy, or death from any cause. Key secondary end point is overall survival. Other secondary end points include metastasis-free survival, time to any NMIBC, time to cystectomy, and safety. Adverse events (AEs) will be monitored from randomization through 30 days after last dose of study drug (90 days for serious AEs).

Materials and methods: Patients diagnosed with TaG1G2 urothelial bladder carcinoma between 2009 and 2018 who underwent TURBT were identified in the Netherlands Cancer Registry. Data were supplemented with information on cause of death and severe complications after cancer treatment by reexamining the electronic health records. Severe complications were defined as complications possibly related to SPI which required a prolonged hospital stay of at least 3 days after TURBT or readmission within 14 days. Based on these data the 14-day complication risk and the 30-day mortality risk were evaluated. To assess the reasons for not administering SPI, a telephone survey was performed among a subset of Dutch urologists (n=10). Results: In the Netherlands, large variation in the use of SPI is observed. In recent years, the proportion of patients with SPI ranged from 0% to over 80% between hospitals, with a median of 53%. Of the 14,177 patients who received SPI, 18 patients died within 30 days. Three deaths could possibly be attributed to the SPI, resulting in a 30-day mortality risk of 0.02% (3 of 14,177 patients). Of 2,634 patients who had SPI in 2017 and 2018, 47 patients experienced complications which might be linked to SPI, resulting in a 14-day complication risk of 1.78% (47 of 2,634 patients). Complications possibly related to SPI included voiding dysfunction (n=22, 0.84%), pain (n=18, 0.68%) and irritative complaints (n=2, 0.08%). The telephone survey revealed that the most important reasons not to administer SPI include both the fear of severe complications and non-belief in the efficacy of SPI. Conclusion: In the worst case scenario, the risk of possibly SPI related mortality (0.02%) and severe complications (1.78%) is very low after a TURBT in TaG1G2 bladder tumours followed by SPI of intravesical chemotherapy. Given these data, SPI can be considered a safe treatment in patients with low- or intermediate risk NMIBC who underwent TURBT without (suspected) perforation. As fear of complications and non-belief in the effect of SPI is still present in current practice and considering the substantial variation in use of SPI, our findings suggest that at least a part of patients is wrongly withheld an effective treatment.

Results: KEYNOTE-992 is enrolling at sites in Czech Republic, Denmark, Estonia, Guatemala, Italy, Israel, Republic of Korea, Latvia, Malaysia, Netherlands, Spain, Taiwan, Turkey, Ukraine, and the United States of America. Conclusions: KEYNOTE-992 will provide further clarity on the efficacy of pembrolizumab plus CRT in previously untreated MIBC.

TARGETING ANTISENSE MITOCHONDRIAL NONCODING RNAS INDUCES BLADDER CANCER CELL DEATH AND INHIBITION OF TUMOR GROWTH THROUGH REDUCTION OF SURVIVAL AND INVASION FACTORS

FLEXIBLE BLUE LIGHT CYSTOSCOPY PROVIDES INCREASED EFFICACY TO MANAGE NON-MUSCLE INVASIVE BLADDER CANCER IN THE OUTPATIENT CLINIC Kristine Young-Halvorsen, Medical Affairs, Photocure ASA, Oslo, Norway Kari Myren, Medical, Photocure ASA, Oslo, Norway Per-Uno Malmström

Jaime Villegas Olavarría, Centro de Medicina Veterinaria, Universidad Andres Bello - Fundación Ciencia & Vida, Chile Vincenzo Borgna Lorena Lobos-Gonzales Francisca Guevara Claudio Villota Veronica Burzio Luis O Burzio

Introduction & objectives: Non-muscle invasive bladder cancer (NMIBC) is one of the most prevalent cancers, associated with a high recurrence-, but low mortality rate. Numerous surgical procedures through the life-time of those affected makes NMIBC an expensive cancer to treat, with significant impact on quality of life. Rigid Blue light cystoscopy (BLC) is routinely used in the operating room to allow improved detection of malignant tumors, leading to more complete tumor resection and reduced recurrence rates. Flexible BLC in the out-patient (OP) setting can assist diagnosis and treatment of NMIBC and could improve patient care by reducing therapeutic burden in addition to saving time and cost. The aim of the current study is to evaluate how OP BLC can improve patient management.

Introduction & objectives: Bladder cancer (BCa) is the most common malignant tumor of the urinary tract, corresponding to the seventh most common cancer worldwide, with over 420,000 new cases every year and accounting for over 160,000 deaths. We have reported that the ASncmtRNAs (antisense non-coding mitochondrial RNAs) are promising targets to inhibit tumor growth in pre-clinical models. ASncmtRNAs knock down (ASK for short) with antisense oligonucleotides (Andes-1537) induces strong inhibition of the aggressive murine melanoma tumors of B16F10 cells. Similarly, ASK induces also strong inhibition of tumor growth in a pre-clinical model of renal cell carcinoma using Renca cells. ASK of the antisense noncoding mitochondrial RNAs (ASncmtRNAs) induces apoptotic death of several human tumor cell lines, but not normal cells, supporting a selective therapy against different types of cancer. In this work, we evaluated the effects of knockdown of ASncmtRNAs on bladder cancer (BCa) in vitro and preclinical models.

Materials & methods: The Nordic Flexible BLC registry is an ongoing prospective multicenter study initiated to observe the clinical use and explore possible benefits of OP BLC. Data recorded include NMIBC history, cystoscopy findings, treatment performed and further management. The role of OP BLC in follow-up of NMIBC with focus on number of cases that required no further work-up is presented. Results: To date, a total of 354 patients in follow-up of NMIBC have been included in the study from five participating sites. Patients are predominantly of high (67%) and intermediate (29%) risk categories, according to the EAU risk classification. In these patients, 462 procedures were performed during follow-up, 370 cases showing suspicious lesions. A total of 737 lesions were observed, of which 409 (55%) were fulgurated on-site by laser (42%) or diathermia (57%). Biopsies of 319 suspicious lesions confirmed malignancy in 166 lesions, of which 24% were only visible with BLC. In 88% of cases with suspicious lesions, the patient could be spared from a TURBT, of which 32% received intravesical therapy.

Material & Methods: We transfected the BCa cell lines UMUC-3, RT4 and T24 with the specific antisense oligonucleotide Andes1537S, targeted to the human ASncmtRNAs. The effect over cell proliferation, death cell and apoptosis was evaluated by tripan blue assay, flow cytometry and TUNEL assay. Xenograft studies of BCa using UMUC-3 cell line was performed injecting subcutaneously 5x10exp5 cells in 100 μl of sterile saline into the left flanks of 10 NOD/SID mice and tumor growth was monitored every three days with an electronic caliper. When tumors reached a volume of about 100 mm3, mice were randomized into two groups of 5 mice each. For treatment, mice were injected intraperitoneally (ip) every other day with 200 µl, either alone or containing 100 µg Andes-1537. For patient-derived xenograft (PDX) model a tumor specimen was obtained from a patient diagnosis with BCa, subjected to radical bladder resection at the Urology Department of Hospital Barros Luco-Trudeau, Santiago, Chile.

Conclusions: In follow-up of high and intermediate-risk patients, flexible OP BLC helped resolve a substantial amount of cases by complete fulguration on-site or direct referral to intravesical instillation treatment, providing increased efficacy to manage NMIBC and a reduction in surgical burden.

Results: Knockdown induced a strong inhibition of cell proliferation and increase in cell death in all three cell lines. As observed in UMUC-3 cells, the treatment triggered apoptosis, evidenced by loss of mitochondrial membrane potential and Annexin V staining, along with activation of procaspase-3 and downregulation of the anti-apoptotic factors survivin and Bcl-xL. Treatment also inhibited cell invasion and spheroid formation together with inhibition of N-cadherin and MMP 11. In vivo treatment of subcutaneous xenograft UMUC-3 tumors in NOD/SCID mice with Andes-1537S induced inhibition of tumor growth as compared to saline control. Similarly, treatment of a high-grade bladder cancer PDX with Andes1537S resulted in a strong inhibition of tumor growth. Conclusion: Our results suggest that ASncmtRNAs could be potent targets for bladder cancer as adjuvant therapy. Grant: Proyecto Basal AFB 170004. ANID. Chile.

CASE REPORTS 17

A RARE CASE OF RECURRENT PARAGANGLIOMA OF URINARY BLADDER

LATE RECURRENCE FOLLOWING RADICAL CYSTECTOMY WITH ORTHOTOPIC ILEAL NEOBLADDER IN NMIBC: A CASE REPORT

Arunkumar Annamalai, Urology, Nizam's Institute of Medical Sciences, India Yogesh Torkadi

Arunkumar Annamalai, Urology, Nizam's Institute of Medical Sciences, India

Introduction: Pheochromocytomas are tumors of chromaffin cells, derived from the embryonic neural crest, usually originate from the adrenal medulla. 10% of these tumors occur at extraadrenal sites and are known as paragangliomas. Paraganglioma is rare account for <0.06% of all urinary bladder tumors and 6% of all extra-adrenal pheochromocytomas. It arises from chromaffin tissue of the sympathetic nervous system within the layers of the bladder wall. Most common site is the dome or the trigone of the bladder. Bladder paraganglioma is an extremely rare tumor with a high recurrence rate.

Introduction: Bladder cancer is the most common cancer of the urinary tract with a peak incidence seen in 6th to 7th decade of life. The incidence is more common in males, nearly three-quarters of total bladder cancer occurs in men. Non muscle invasive bladder cancer (NMIBC) is the malignant urothelial tumor that is not involving the detrusor muscle. Approximately 70-80% of bladder tumors at presentation are NMIBC with 60-70% as Ta, 20-30% as T1 and 10% as CIS. Radical cystectomy is the gold standard treatment for muscle invasive bladder cancers, but should be considered in NMIBC with high risk for progression.

Case report: A 20 year old female patient presented with complaints of burning sensation during micturation and intermittent hematuria since 1 month. she had a history of similar complaint in the past and found to have bladder growth, for which she underwent TURBT 6 months back. The histopathology report was suggestive of bladder Paraganglioma.

Case report: A 51 years old male patient, who is known case of bladder cancer (Low grade papillary urothelial carcinoma- pT1, N0) underwent radical cystectomy with orthotopic ileal neobladder 5 years ago on regular follow up, complained of right groin swelling for 2 weeks. On examination there was multiple right inguinal lymph nodes of largest of 2x2 cm size. In CECT abdomen and pelvis there was few necrotic inguinal lymphnodes without any significant abnormality in the neobladder or in rest of the abdominal organs. Urine cytology showed features suspicious of malignancy and the patient underwent cystoscopy which showed a small papillary growth at urethral anastamotic site. USG guided right inguinal lymphnode biopsy showed metastatic urothelial carcinoma and the wholebody PET-CT scan revealed increased FDG uptake in right iliac and right inguinal lymphnodes.

On examination general condition and vitals were stables; abdomen was soft, nontender and no lump palpable. Serum Chromogranin A level was 184 ng/ml (<108) with raised 24 hour Urine Metanephrine - 1760 (600-1600). Ultrasonography of abdomen & pelvis showed a 4.4.x 1.9 cm lesion in region of trigone on left side of bladder with increased vascularity. CECT abdomen & pelvis showed a pedunculated heterogenously enhancing lesion arising from posterolateral wall of Urinary bladder on left side of size 2.5 x 2.5 x 1.3 cm without extravesical spread.

Diagnosis & treatment: The patient was diagnosed as Anastamotic site recurrence with metastasis and planned for chemotherapy. 4 cycles of cisplatin and gemcitabine was given following which the whole body PET-CT showed metabolic and morphologic regression of the right iliac and right inguinal lymph nodes. He subsequently underwent excision of the orthotopic ileal neobladder with urethrectomy and conversion to ileal conduit. The enlarged iliac lymphnodes were removed with right inguinal lymphnode dissection. Histoplathological report showed unremarkable ileal neobladder with negative ureteral margin and urethral dysplasia; the iliac lymphnodes showed high grade urothelial carcinoma.

Diagnosis & treatment: Based on past history, laboratory and imaging investigation recurrent paraganglioma was diagnosed and the patient underwent partial cystectomy. Histopathological findings were compatible with the diagnosis, on gross examination the tumor showed 2.2x2x1.3 cm submucosal lesion. On microscopy the specimen showed presence of round to polygonal cells arranged in small nests or “zellballen” pattern, separated by highly vascularized fibrous septa; on immunohistochemistry staining was strongly positve for synaptophysin and chromogranin. S-100 staining shows diffuse positivity. Discussion: Paraganglioma of bladder are generally solitary and submucosal in nature. Most commonly seen in women of 2 to 3 decade of life. 15-20% of these tumour are malignant, 80-85 % of it are hormonally active. Both CT scanning and MRI are useful in the localisation of both the primary tumour and any metastases however Scanning with 131 Iodine metaiodinebenzylguinidine (MIBG) has been shown to have a very high sensitivity and specificity for phaeochromocytoma detection.

Conclusion: Recurrence and survival following radical cystectomy depends on the final pathological stage and lymphnode metastasis. The 5 year cancer specific survival following radical cystectomy is approximately 90 % for those with non-invasive disease on the final pathological examination. The risk of urethral recurrence following cystectomy range from 4-8% in men; risk factors are non-muscle invasive disease in the final pathology and prostatic urethral involvement. Longterm follow up is essential for timely diagnosis and management of late recurrences following radical cystectomy.

Conclusion: Paraganglioma of urinary bladder have a characteristic histological and immunochemistry feature and it’s a cornerstone for diagnosis, it is found that metastatic dissemination is the only real proof of malignancy. Surgery is the mainstay of the treatment that requires total excision. Bladder paragangliomas tends to recur and metastasis, so lifelong followup is required.

BLADDER DIVERTICULUM CANCER

GIANT INFLAMMATORY MYOFIBROBLASTIC TUMOR OF URINARY BLADDER

Angela Pascual Fernandez, Urology, Complejo asistencial universitario de Palencia, Spain Introduction: Carcinoma arising in a bladder diverticulum is uncommon, and data on treatment and outcome are sparse. Our objective is to analyze clinicopathological features of diverticulum bladder cancer and difficulties on diagnosis.

Angela Pascual Fernandez, Urology, Complejo asistencial universitario de Palencia, Spain Introduction: Inflammatory myofibroblastic tumor (IMT) is an unusual intermediate soft tissue tumor, rarely occurring in the urinary bladder. IMT has a relatively good prognosis and is considered to be a tumor with intermediate biologic potential because of its low risk of distant metastases.

Clinical findings: A 61-year old man healthy, never smoked, presented with frank hematuria and relapsing urinary lower tract infections with positive urine cultures to E. Coli. The clinic started a few months ago.

Clinical findings: A 42-year old man with factor VII deficiency, non smoker, was evaluated by Internal Medicine because of microhematuria, severe anemia, frequency–dysuria syndrome and bladder outlet obstruction.

Diagnosis and treatment: Uroflowmetry was obstructive and urinary ultrasound revealed a small prostate with a large bladder diverticulum and a single stone within the diverticulum. Patient underwent cystoscopy under anesthesia. A large diverticulum on the right lateral wall was identified, without a real lithiasis, but a single calcified bladder tumour inside diverticulum. Neoplasm transurethral resection was incompletely performed because of obturator kicking and an elevated uncontrolled bleeding risk due to highly vascularized tumour bed. Pathology report revealed a high grade papillary urothelial carcinoma with extensively squamous differentiation with no muscularis propria or muscle staged as cT1R2. Random bladder biopsies and prostatic urethral biopsy were both negative. A multiphasic computed tomography scan showed a large diverticulum with narrow diverticular neck and residual tumour (2*3 cm) with doubt of perivesical tissues infiltration or inflammation post resection. No enlarged lymph nodes or other metastasis were detected (Fig. 1).

Diagnosis and treatment: The patient was referred to urological evaluation for the finding of a large bladder mass of 8 centimeters, without distant metastases on CT-scan. Abdominal MRI scan was performed, finding no evidence of extravesical mass and a tumor bed on left lateral bladder wall about 3 centimeters (Figure 1).

Figure 1. Abdominal MRI scan showed a single giant bladder mass, with no signs of extravesical mass. Patient underwent to transurethral resection, that was incompletely performed, requiring the use of NovoSeven®, a recombinant human coagulation Factor VIIa (rFVIIa) and several units of red blood cells. Three weeks later, an additional “second – look” was performed, likewise incomplete. Pathology report revealed an inflammatory myofibroblastic tumor. Histological examination (hematoxylineosin staining) showed spindle cell proliferation with inflammatory cells on a myxoid stroma. The results of immunohistochemistry examination showed: Vimentin (+), CD68 (+), Desmin (+), Caldesmon (+) and ALK (+), AE1/AE3 (-), CK34β12 (-), actin (-), Myogenin (-), p53 (-), S-100 (-), EMA (-), BCL2 (-), DOG1 (-) and CD117 (-). After discussing the treatment plan with the patient and his family, a decision to do a conservative management with a partial laparoscopic cystectomy was made. Final pathology report was an inflammatory myofibroblastic bladder tumor with muscle layer infiltration (pT2b).

Figure 1. Large diverticulum with residual tumour on CT scan. After discussing the treatment plan with the patient and his family and, with the difficulty to reliably predict tumour stage, a decision to do a laparoscopic radical cystectomy with standard lymph node dissection and orthotopic neobladder substitution was made. The pathology revealed a high-grade urothelial carcinoma with squamous differentiation with microscopically perivesical tissue infiltration and negative lymph nodes (on 29/29 identified lymph nodes) staged as pT3aN0. After 6 months, patient was free of tumour recurrence and recovered completely daytime continence in 3 months.

Conclusions: Also called inflammatory pseudotumor, first case report of an inflammatory myofibroblastic tumor of the urinary bladder was made in 1980. Most patients are young (mean age of 38.9). Hematuria is the commonest clinical manifestation. It is characterized by atypical spindle cell proliferation and inflammatory cell infiltrates primarily involving lymphocytes and plasma cells. Most frequently found on lung. IMT in the urinary bladder is unusual. Recent reports have indicated that ALK (anaplastic lymphoma kinase) was overexpressed in a substantial proportion of IMT. A positive finding of ALK in up to 87.5% of IMT can be useful for the differentiation of IMT from other spindle cell tumors. Surgical resection is the treatment of choice. Most patients goes to TURB, but partial and radical cystectomy can be considered. IMT of the bladder have a local tumor recurrence rate after surgery of 4%. Complete surgical resection is the most important factor to avoid local recurrence. IMT tumors are classified as intermediate (rarely metastasizing) tumors according to the WHO classification of soft tissue tumors.

Conclusions: Neoplasms of urinary bladder diverticulum are uncommon, but not rare. Most malignant tumours in bladder diverticulum are transitional type, followed by squamous cell carcinoma. Bladder tumours arising in a diverticulum are difficult to diagnose because filling defects are not always visualized or they can be confused with stones due to calcified tumours. Bladder diverticulum neoplasms are characterized by early transmural invasion due to lack of muscular fibers thus, prompt diagnosis and treatment are crucial. Complete transurethral resection of diverticulum bladder tumours is often difficult considering the risk of bladder bleeding or perforation. Preoperative local staging remains a diagnostic challenge.

UROTHELIAL CANCER. NEW THERAPIES, NEW TOXICITIES: MYASTHENIA GRAVIS

METASTASIS TO THE PENIS FROM A BLADDER CARCINOMA INVADING ONLY THE LAMINA PROPRIA: CASE REPORT. REVIEW OF THE LITERATURE AND DESCRIPTION OF THE METASTATIC PATHWAYS

Alba Rosa Díaz, Oncología Médica, Hospital Universitario de Canarias, Spain Ignacio Durán, Medical Oncology, Hospital Marqués de Valdecilla, Santander, Spain Lucía Andrea Alonso Buznego Introduction: The increased use of inmune checkpoint inhibitors has shown a new spectrum of toxicities. Inmunerelated adverse events (irAEs) are diverse. Neurologic toxicity is uncommon, representing 1-14% of all irAEs. We report a case of immunotherapy-induced myasthenia gravis in a patient under treatment for urothelial cancer.

Marius Stanimir, Urology, CHU UCL Namur Site Mont-Godinne, Belgium Marcelo Di Gregorio Francis Lorge Marie-Cécile Nollevaux Lionel D'Hondt

Case: clinical findings, diagnosis and treatment: A 67-yearold male diagnosed with stage IV upper tract urothelial cancer completed four cycles of cisplatin-gemcitabine along with anti-CTLA4 and anti-PDL1. Subsequently the patient continued with anti-PDL1 single-agent maintenance. Around the start of monotherapy, the patient referred progressive fatigue being ruled out metabolic and analytic causes. Following, muscle weakness and eyelid dropped appeared. Upon a myasthenic syndrome suspicion treatment was interrupted and patient referred to neurology where the diagnosis was confirmed [positive acetylcholine receptor antibodies] and treatment started accordingly requiring pyridostigmine, steroids and finally immunoglobulins to control.

Introduction: Penile cancer is uncommon in industrialized countries with a low incidence of the disease of about 1/100.000 men in Europe and USA. Despite its rich venous and lymphatic vascularization, secondary metastasis to the penis are rare. Case presentation: We present the case of a 70 years old male, who was initially referred for gross hematuria in May 2018. After meticulous anamnesis, a cystoscopy was performed under local anesthesia, which detected a bladder lesion situated at the dome of the bladder that seemed to be muscular invasive bladder tumor. The histological exam after a transurethral resection of the tumor, revealed an invasive high-grade papillary transitional carcinoma of the bladder with lamina propria invasion (pT1 HG). The secondlook transurethral resection was performed at the site of the anterior resection and the histological examination of the tissue revealed the same high-grade papillary transitional carcinoma of the bladder with lamina propria invasion but no muscular invasion (pT1 HG). During the follow-up, a thoraco-abdominal CT scan was performed and a nodule in the upper right lobe of the lung was discovered which was resected (lung acinar adenocarcinoma - pT1cN0). At 7 months from the diagnosis, an abdominal CT scan was performed finding a tumor at the anterior bladder wall measured at about 78x77x78 mm and staging of cT4. Following these findings, a MVAC chemotherapy (Methotrexate, Vinblastine, Doxorubicin and Cisplatin) was admistrated and a cystoprostatectomy was performed with an histological result of fibrosis and ypT0pN0 classification. About eight months after the cystoprostatectomy, the patient complained of having pain and swelling of the right side cavernous body. An MRI of the pelvis was performed and a lesion of about 30x20x20 mm was observed at the base of the penis. A total penectomy with perineal urethrostomy was performed and the result of the histological examination of the tumor revealed a transitional carcinoma suggesting a metastasis of the urothelial carcinoma of the bladder, pM1bR2. A PET/CT had been performed 3 months after the penectomy and it showed multiple retroperitoneal, right external iliac and bilateral inguinal positives lymph nodes. Metastasis of the obturator foramen and of the right peritoneal flank were also observed. Giving the mentioned results of the PET/CT, we started a treatment based on Pembrolizumab. At the time of publishing, the patient is following the immunotherapy treatment and he has no progression of the disease.

Conclusions: IrAE physiopathology is not fully understood and seems to follow a stochastic pattern. Promoting a pro-inflammatory environment with T-cells and cytokines stimulates auto-antibodies production and/or auto-reactive T-cells. Similarities among tissueantigens and neo-antigens produced by the tumor could induce a crossed-reaction. Clinical identification of “high risk” patients is still a challenge with no established predictive factors. The incidence of neurologic irAEs has been estimated in 3.8% with single agent anti-CTLA4, 6.1% with anti-PD1 and 12% with the combination. Myasthenia gravis (MG) has been described both in association with monotherapy and combinations. It can present as a new diagnosis (72.7%) or an exacerbation of a previous known MG (18.2%) or a subclinical MG (9.1%). Myasthenia gravis is usually associated with myositis. Most frequent clinical presentation includes weakness of ocular, bulbar and respiratory muscles. Half of the patients developed fast crisis and required ventilator support. Abnormal results in neurophysiology studies were only observed in half of the patients, which could be related to the co-existence of myositis. Acetylcholine receptor antibody resulted positive in 57-83% of cases, lower index than in conventional myasthenia. Interrupting immunotherapy and corticosteroids (1-1.5 mg/Kg) is the main treatment. Pyridostigmine, inmunoglobulins and plasmapheresis are other measures to be considered according to severity and response to treatment. In conclusion, neurologic IrAEs are infrequent but can be potentially severe. It is critical to be familiar with their presentation and management. A prompt identification might lead to an early intervention and increase treatment success.

Conclusion: Although the metastasis to the penis is a rare condition, the differential diagnosis is essential for deciding on the right treatment for the patient. Even though most of the patients could benefit from a multi modal treatment, the overall survival period for most of the patients is about 9 months after the diagnosis of the penile metastasis.

Conclusion: Atezolizumab-induced myasthenia gravis has been documented to have poor outcomes whether as an exacerbation of pre-existing disease[5] or de novo presentation[6]. Our case illustrates the need for high suspicion of non-specific neurological symptoms to enable early detection and referral to specialist Neurology services. Diagnosis can be aided by measurement of anti-AChR and anti-MUSK antibodies depending on clinician suspicion.

ATEZOLIZUMAB-INDUCED MYASTHENIA GRAVIS IN A PATIENT WITH METASTATIC UROTHELIAL CARCINOMA Boris Tocco, Clinical Oncology, Royal Marsden Hospital, United Kingdom Adham Hijab Robert Huddart Shaista Hafeez Introduction: The increasing use of immune checkpoint blockade in metastatic cancer has resulted in greater prevalence of immune-related adverse events (irAEs). The anti-CTLA-4 and anti-PD-1 action resulting in T-cell mobilisation causes a surge in tumoural immune response but is also well documented to result in autoimmune toxicities[1]. The use of atezolizumab in cisplatin-ineligible metastatic bladder cancer was approved in the UK based on the IMvigor trial[2]. The toxicities arising from its use more commonly affect bowel, liver, lung and endocrine tissue[1]. The development of immunotherapyinduced myasthenia gravis has been reported with other checkpoint inhibitors[4] but rarely related to atezolizumab â&#x20AC;&#x201C; this report describes a case of atezolizumab-induced myasthenia gravis in the context of metastatic bladder cancer. Clinical history: A 77 year old gentleman, with a history of hypercholesterolemia, underwent a primary radical cystectomy and bilateral pelvic lymph node dissection for pT3bN2 transitional cell carcinoma of the bladder. He was ineligible for neoadjuvant cisplatin-based chemotherapy due to hearing loss and declined adjuvant treatment. Immunohistochemistry of operative tissue sample revealed a PD-L1 expression of 5-10%. He suffered a nodal relapse 4 months post-operatively. He was surveyed with interval CT scans which found slowlyprogressive disease and, 8 months later, started palliative systemic therapy with 3-weekly intravenous atezolizumab at 1200mg. After his 2nd cycle of treatment, he presented with double vision and head drop. On examination, he was diplopic with MRC grade 4/5 power of neck extension and proximal muscles groups. There was no fatigability. Imaging with MRI head with contrast did not find any abnormality. Blood tests for pituitary, thyroid, and adrenal function were normal. Creatine kinase was elevated at 337 U/L (normal range 55-175 U/L). He was started on dexamethasone 4mg once daily for presumed immunotherapy-induced myopathy and reviewed by the local Neurology team who requested an electromyograph which demonstrated myopathic potentials in proximal muscles with sparing of distal muscles suggestive of proximal myopathy or myasthenia gravis. Serology test was positive for anti-acetylcholine receptor antibodies confirming a diagnosis of immunotherapy-induced myasthenia gravis. Anti-MUSK antibodies were negative. Initiation of pyridostigmine 60mg three times daily with prednisolone 30mg once daily resulted in a complete remission of his symptoms. Off-treatment surveillance suggested an initial favourable response which was maintained on subsequent imaging until the patient died due to a bronchopneumonia 9 months after stopping atezolizumab. He had continued long-term steroids until the time of his death.

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