International Journal of Urology (2015) 22, 612--613
Urological Notes
Chemotherapeutic effects on circulating tumor cells in bladder cancer Brian Winters M.D.,1 Andrew James M.D.,2 Jean Lee M.D.,3 Jennilee Kho B.S.,1 Colm Morrissey Ph.D.1 and Jonathan Wright M.D., M.S.1,4
Abbreviations & Acronyms CTC = circulating tumor cells RC = radical cystectomy RECIST = Response Evaluation Criteria in Solid Tumors UC = urothelial carcinoma
Departments of 1Urology, and Radiology, University of Washington School of Medicine, 4Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, and 2 Division of Urology, University of Kentucky College of Medicine, Lexington, KY, USA [email protected] 3
DOI: 10.1111/iju.12758
UC is the sixth most common malignancy in the USA, with an estimated 74 000 new diagnoses and 15 000 deaths predicted in 2014 (2.7% of all cancer deaths).1 Approximately 30% of UC patients will present with muscle-invasive disease, for which RC is the standard of care.2 Another ~5% of patients will present with metastatic disease, and 50% of those treated with cystectomy will develop metastasis by 5 years, requiring chemotherapy.3 Neoadjuvant chemotherapy is commonly used in muscle-invasive UC treatment, providing a complete response rate of ~25–30%,3,4 and overall survival benefit of ~5%.5 The response to chemotherapy in either setting is monitored with imaging, which is clearly limited by the inability to detect micrometastatic disease. As there are no current serum markers to help assess chemotherapeutic response, novel biomarkers could greatly improve clinical care in regards to RC timing or changes in chemotherapy regimen. CTC could have the potential to be this sensitive biomarker. A meta-analysis of 21 UC studies (869 patients) found that patients with detectable CTC were fivefold more likely to have advanced stage (T3 or greater) disease (OR 5.1, 95% CI 2.49–10.26) compared with controls.6 Several of these studies used the CellSearch system (Veridex, Raritan, NJ, USA) for CTC enumeration suggesting the utility in this technique. For the current study, we carried out a prospective trial examining CTC in UC patients undergoing cisplatin-based chemotherapy using CellSearch with the hypothesis that a decline in CTC will correlate with a clinical response to chemotherapy. Patients with cT2–4, N±, M ± UC undergoing cisplatin-based chemotherapy were identified and asked to participate in this institutional review board-approved study (#7823). Clinical and pathological data, including age, race, sex, date of diagnosis, date of surgery, clinical stage, type of chemotherapy delivered, percentage of chemotherapy received and pathological stage at RC were collected. Peripheral blood samples were drawn in duplicate from each eligible patient to ensure no Merkel cell contamination. Initial draw was carried out before the start of chemotherapy. For patients with more than five CTC found on initial draw, a subsequent draw at the conclusion of chemotherapy was carried out. CTC were isolated using CellSearch technology (Veridex), which included enrichment and semi-automatic microscopy to detect EpCAM (CD326) expressing UC cells through anti-EpCAM antibodies as previously described.7 A total of 31 patients participated in the present study. Five patients were excluded for the following reasons: inadequate sample (two patients); instrument failure (one patient); outside sample processed incorrectly (one patient); and no pretreatment sample available (one patient). Adequate samples were obtained in 26 patients (21 male, five female; Table S1). In those with cT2–4 N0–2 M0 UC (n = 16), CTC were detected in three patients (19%), and in each case, only a single CTC was detected. A total of 10 patients presented with metastatic or clinical N3 disease (common iliac nodal involvement) and five (50%) had CTC present. Of these, four patients had more than five CTC detected before cisplatin-based treatment. These four patients all experienced a decline in CTC post-chemotherapy (median decline of 17 CTC, mean percentage decline of 86),
Table 1 CTC change relative to cisplatin-based chemotherapy Patients with >5 CTC (stage)
Pretreatment CTC
Post-treatment CTC
Patient Patient Patient Patient
7 16 18 70
2 1 0 16
#1 #2 #3 #4
(cT2aN3) (pTaN0; recurrent M1) (cT3N1M1) (cT2M1)
Change 5 15 18 54
% Decline
RECIST
71 94 100 77
Complete response Partial response Partial response Stable disease
Four patients had more than five CTC at presentation and subsequent blood draw was carried out. Numbers shown represent CTC before and after cisplatin-based chemotherapy as well as percentage overall decline for each patient. CTC decline correlated with clinical response to treatment. TNM staging classification based on American Joint Committee on Cancer (Chicago, IL, USA), 7th edition.
612
© 2015 The Japanese Urological Association
Urological Notes
and three of four patients stabilized (1) or showed radiological improvement (2) based on imaging (see RECIST criteria; Table 1). In these patients, three (75%) ultimately progressed and had died at ~1 year post-treatment (one with unknown cause of death, two because of disease progression). The remaining patient (#4, Table 1) experienced the largest percentage CTC decline and was doing well 14 months post-chemotherapy with minimal progression. Overall, we found a low percentage (19%) of patients with non-metastatic UC to have detectable CTC. This is lower than the reported sensitivity of 35% from the literature (95% CI 32–38%).6 These patients had undergone endoscopic resection of their bladder tumor, which could have effectively “debulked” the tumor, and resulted in lower tumor bulk and CTC burden. In fact, in each non-metastatic patient who had CTC present, only one CTC was detected. A high percentage (50%) of patients with disease beyond the pelvis had CTC present, and a corresponding decline in CTC with chemotherapy treatment was observed. Future efforts of CTC enumeration and response to therapy will need to be undertaken as part of larger metastatic trials to confirm these findings.
References 1. Howlader N, Noone AM, Krapcho M et al. (eds). SEER Cancer Statistics Review, 1975-2011. National Cancer Institute, Bethesda, MD, USA [Cited September 2014.] Available from URL: http://seer.cancer.gov/csr/1975_2011/ 2. Kaufman DS, Shipley WU, Feldman AS. Bladder cancer. Lancet 2009; 374: 239–49. 3. Dash A, Pettus JA 4th, Herr HW et al. A role for neoadjuvant gemcitabine plus cisplatin in muscle-invasive urothelial carcinoma of the bladder: a retrospective experience. Cancer 2008; 113: 2471–7. 4. Yeshchina O, Badalato GM, Wosnitzer MS et al. Relative efficacy of perioperative gemcitabine and cisplatin versus methotrexate, vinblastine, adriamycin, and cisplatin in the management of locally advanced urothelial carcinoma of the bladder. Urology 2012; 79: 384–90. 5. Advanced Bladder Cancer Overview Collaboration. Neoadjuvant chemotherapy for invasive bladder cancer. Cochrane Database Syst. Rev. 2005; (2): CD005246. 6. Msaouel P, Koutsilieris M. Diagnostic value of circulating tumor cell detection in bladder and urothelial cancer: systematic review and meta-analysis. BMC Cancer 2011; 11: 336–50. 7. Rink M, Chun FK, Minner S et al. Detection of circulating tumour cells in peripheral blood of patients with advanced non-metastatic bladder cancer. BJU Int. 2011; 107: 1668–75.
Supporting information Additional supporting information may be found in the online version of this article at the publisher’s web-site:
Acknowledgment This work was supported by the Royalty Research Fund grant 65-6275, University of Washington.
Conflict of interest None declared.
© 2015 The Japanese Urological Association
Table S1 Patient characteristics of all patients enrolled in the CTC study are shown in this supporting table. Initial blood draw carried out before the start of neoadjuvant chemotherapy. Subsequent CTC draw was only carried out for patients with more than five CTC on initial draw (n = 4). TNM staging classification is based on American Joint Committee on Cancer (Chicago, IL, USA), 7th edition. Abbreviations are outlined in the table legend.
613
Urological Notes
Chemotherapeutic effects on circulating tumor cells in bladder cancer Brian Winters M.D.,1 Andrew James M.D.,2 Jean Lee M.D.,3 Jennilee Kho B.S.,1 Colm Morrissey Ph.D.1 and Jonathan Wright M.D., M.S.1,4
Abbreviations & Acronyms CTC = circulating tumor cells RC = radical cystectomy RECIST = Response Evaluation Criteria in Solid Tumors UC = urothelial carcinoma
Departments of 1Urology, and Radiology, University of Washington School of Medicine, 4Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, and 2 Division of Urology, University of Kentucky College of Medicine, Lexington, KY, USA [email protected] 3
DOI: 10.1111/iju.12758
UC is the sixth most common malignancy in the USA, with an estimated 74 000 new diagnoses and 15 000 deaths predicted in 2014 (2.7% of all cancer deaths).1 Approximately 30% of UC patients will present with muscle-invasive disease, for which RC is the standard of care.2 Another ~5% of patients will present with metastatic disease, and 50% of those treated with cystectomy will develop metastasis by 5 years, requiring chemotherapy.3 Neoadjuvant chemotherapy is commonly used in muscle-invasive UC treatment, providing a complete response rate of ~25–30%,3,4 and overall survival benefit of ~5%.5 The response to chemotherapy in either setting is monitored with imaging, which is clearly limited by the inability to detect micrometastatic disease. As there are no current serum markers to help assess chemotherapeutic response, novel biomarkers could greatly improve clinical care in regards to RC timing or changes in chemotherapy regimen. CTC could have the potential to be this sensitive biomarker. A meta-analysis of 21 UC studies (869 patients) found that patients with detectable CTC were fivefold more likely to have advanced stage (T3 or greater) disease (OR 5.1, 95% CI 2.49–10.26) compared with controls.6 Several of these studies used the CellSearch system (Veridex, Raritan, NJ, USA) for CTC enumeration suggesting the utility in this technique. For the current study, we carried out a prospective trial examining CTC in UC patients undergoing cisplatin-based chemotherapy using CellSearch with the hypothesis that a decline in CTC will correlate with a clinical response to chemotherapy. Patients with cT2–4, N±, M ± UC undergoing cisplatin-based chemotherapy were identified and asked to participate in this institutional review board-approved study (#7823). Clinical and pathological data, including age, race, sex, date of diagnosis, date of surgery, clinical stage, type of chemotherapy delivered, percentage of chemotherapy received and pathological stage at RC were collected. Peripheral blood samples were drawn in duplicate from each eligible patient to ensure no Merkel cell contamination. Initial draw was carried out before the start of chemotherapy. For patients with more than five CTC found on initial draw, a subsequent draw at the conclusion of chemotherapy was carried out. CTC were isolated using CellSearch technology (Veridex), which included enrichment and semi-automatic microscopy to detect EpCAM (CD326) expressing UC cells through anti-EpCAM antibodies as previously described.7 A total of 31 patients participated in the present study. Five patients were excluded for the following reasons: inadequate sample (two patients); instrument failure (one patient); outside sample processed incorrectly (one patient); and no pretreatment sample available (one patient). Adequate samples were obtained in 26 patients (21 male, five female; Table S1). In those with cT2–4 N0–2 M0 UC (n = 16), CTC were detected in three patients (19%), and in each case, only a single CTC was detected. A total of 10 patients presented with metastatic or clinical N3 disease (common iliac nodal involvement) and five (50%) had CTC present. Of these, four patients had more than five CTC detected before cisplatin-based treatment. These four patients all experienced a decline in CTC post-chemotherapy (median decline of 17 CTC, mean percentage decline of 86),
Table 1 CTC change relative to cisplatin-based chemotherapy Patients with >5 CTC (stage)
Pretreatment CTC
Post-treatment CTC
Patient Patient Patient Patient
7 16 18 70
2 1 0 16
#1 #2 #3 #4
(cT2aN3) (pTaN0; recurrent M1) (cT3N1M1) (cT2M1)
Change 5 15 18 54
% Decline
RECIST
71 94 100 77
Complete response Partial response Partial response Stable disease
Four patients had more than five CTC at presentation and subsequent blood draw was carried out. Numbers shown represent CTC before and after cisplatin-based chemotherapy as well as percentage overall decline for each patient. CTC decline correlated with clinical response to treatment. TNM staging classification based on American Joint Committee on Cancer (Chicago, IL, USA), 7th edition.
612
© 2015 The Japanese Urological Association
Urological Notes
and three of four patients stabilized (1) or showed radiological improvement (2) based on imaging (see RECIST criteria; Table 1). In these patients, three (75%) ultimately progressed and had died at ~1 year post-treatment (one with unknown cause of death, two because of disease progression). The remaining patient (#4, Table 1) experienced the largest percentage CTC decline and was doing well 14 months post-chemotherapy with minimal progression. Overall, we found a low percentage (19%) of patients with non-metastatic UC to have detectable CTC. This is lower than the reported sensitivity of 35% from the literature (95% CI 32–38%).6 These patients had undergone endoscopic resection of their bladder tumor, which could have effectively “debulked” the tumor, and resulted in lower tumor bulk and CTC burden. In fact, in each non-metastatic patient who had CTC present, only one CTC was detected. A high percentage (50%) of patients with disease beyond the pelvis had CTC present, and a corresponding decline in CTC with chemotherapy treatment was observed. Future efforts of CTC enumeration and response to therapy will need to be undertaken as part of larger metastatic trials to confirm these findings.
References 1. Howlader N, Noone AM, Krapcho M et al. (eds). SEER Cancer Statistics Review, 1975-2011. National Cancer Institute, Bethesda, MD, USA [Cited September 2014.] Available from URL: http://seer.cancer.gov/csr/1975_2011/ 2. Kaufman DS, Shipley WU, Feldman AS. Bladder cancer. Lancet 2009; 374: 239–49. 3. Dash A, Pettus JA 4th, Herr HW et al. A role for neoadjuvant gemcitabine plus cisplatin in muscle-invasive urothelial carcinoma of the bladder: a retrospective experience. Cancer 2008; 113: 2471–7. 4. Yeshchina O, Badalato GM, Wosnitzer MS et al. Relative efficacy of perioperative gemcitabine and cisplatin versus methotrexate, vinblastine, adriamycin, and cisplatin in the management of locally advanced urothelial carcinoma of the bladder. Urology 2012; 79: 384–90. 5. Advanced Bladder Cancer Overview Collaboration. Neoadjuvant chemotherapy for invasive bladder cancer. Cochrane Database Syst. Rev. 2005; (2): CD005246. 6. Msaouel P, Koutsilieris M. Diagnostic value of circulating tumor cell detection in bladder and urothelial cancer: systematic review and meta-analysis. BMC Cancer 2011; 11: 336–50. 7. Rink M, Chun FK, Minner S et al. Detection of circulating tumour cells in peripheral blood of patients with advanced non-metastatic bladder cancer. BJU Int. 2011; 107: 1668–75.
Supporting information Additional supporting information may be found in the online version of this article at the publisher’s web-site:
Acknowledgment This work was supported by the Royalty Research Fund grant 65-6275, University of Washington.
Conflict of interest None declared.
© 2015 The Japanese Urological Association
Table S1 Patient characteristics of all patients enrolled in the CTC study are shown in this supporting table. Initial blood draw carried out before the start of neoadjuvant chemotherapy. Subsequent CTC draw was only carried out for patients with more than five CTC on initial draw (n = 4). TNM staging classification is based on American Joint Committee on Cancer (Chicago, IL, USA), 7th edition. Abbreviations are outlined in the table legend.
613
