Beyond conventional chemotherapy: Emerging molecular targeted and immunotherapy strategies in urothelial carcinoma

Cancer Treatment Reviews xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Cancer Treatment Reviews journal homepage: www.elsevierhealth.com/journals/ctrv

Anti-Tumour Treatment

Beyond conventional chemotherapy: Emerging molecular targeted and immunotherapy strategies in urothelial carcinoma Sadakatsu Ikeda a,⇑, Donna E. Hansel b, Razelle Kurzrock a a b

Department of Medicine, Division of Hematology/Oncology, and Center for Personalized Cancer Therapy, UC San Diego Moores Cancer Center, La Jolla, CA, USA Department of Pathology, Division of Anatomic Pathology, University of California, San Diego, La Jolla, CA, USA

a r t i c l e

i n f o

Article history: Received 14 May 2015 Accepted 17 June 2015 Available online xxxx Keywords: Urothelial carcinoma Targeted therapy Immune therapy Genetic aberrations

a b s t r a c t Advanced urothelial carcinoma is frequently lethal, and improvements in cytotoxic chemotherapy have plateaued. Recent technological advances allows for a comprehensive analysis of genomic alterations in a timely manner. The Cancer Genome Atlas (TCGA) study revealed that there are numerous genomic aberrations in muscle-invasive urothelial carcinoma, such as TP53, ARID1A, PIK3CA, ERCC2, FGFR3, and HER2. Molecular targeted therapies against similar genetic alterations are currently available for other malignancies, but their efficacy in urothelial carcinoma has not been established. This review describes the genomic landscape of malignant urothelial carcinomas, with an emphasis on the potential to prosecute these tumours by deploying novel targeted agents and immunotherapy in appropriately selected patient populations. Ó 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Urothelial carcinoma (transitional cell carcinoma) is estimated to cause 150,000 deaths (world-wide) per year [1]. This type of cancer affects the urinary system, including the renal pelvis, ureters, bladder, urethra, and urachus [2]. It is the most common type of bladder cancer [2]. Approximately 75–80% of cases of urothelial tumours present with non-muscle invasive disease; however, the remaining cases of advanced (muscle-invasive) disease can show progression to metastatic disease that is often fatal. Environmental carcinogens, such as tobacco, aromatic amines, phenacetin, and arsenic, as well as chronic infection with Schistosoma hematobium, and male gender, are known risk factors [3,4]. Despite advances in treatment over past decades, therapy for metastatic disease is still limited and often fails. Therefore, it is important to consider alternative therapeutics in urothelial malignancy. Currently, the most commonly used approach for the management of muscle-invasive urothelial carcinoma is multimodal therapy that combines surgery, radiation, and chemotherapy (Table 1) [5–12]. In muscle-invasive disease, neoadjuvant chemotherapy with standard-dose M-VAC (methotrexate, vinblastine, doxorubicin, and cisplatin) is the standard of care based on results from ⇑ Corresponding author at: UC San Diego Moores Cancer Center, 3855 Health Sciences Drive, #0658, La Jolla, CA 92093-0987, USA. Tel.: +1 (858) 822 5922; fax: +1 (858) 822 5884. E-mail address: [email protected] (S. Ikeda).

prospective randomised phase III trials [5,6,13]. In the U.S. intergroup trial (Table 1), the standard-dose M-VAC followed by radical cystectomy for patients with muscle-invasive resulted in an increase of 31 months in median overall survival (OS) compared to the group without neoadjuvant chemotherapy (median OS: 77 months vs 46 months, P = 0.06 by a two-sided stratified log-rank test) [5]. Another randomised phase III controlled trial showed that neoadjuvant CMV (cisplatin, methotrexate, vinblastine) plus local therapy (either radical cystectomy or radiation) yielded a 6% absolute 10-year OS benefit compared to local therapy alone (10-year OS, 36% vs 30%; HR 0.84; 95% confidence interval [CI], 0.72–0.99). Meta-analysis of platinum-based combination neoadjuvant chemotherapy therapy showed about 5% absolute OS benefit at five years [14–16]. These studies established cisplatin-based combination neoadjuvant therapy as the standard of care in patients with muscle-invasive urothelial cancer. Chemoradiation demonstrated survival benefit in patients who are not candidate for surgery [17]. Multiple regimens have also been developed to improve survival in patients with metastatic urothelial cancer. Phase I and phase II trials with standard-dose M-VAC showed an overall response rate (RR) of approximately 70%, including clinical complete response (CR) in 36% of patients [18,19]. Subsequently, a phase III trial was conducted to compare standard-dose M-VAC and cisplatin alone or CISCA (cisplatin, cyclophosphamide, and adriamycin). M-VAC was superior to either cisplatin alone or CISCA, and showed an absolute OS benefit of 3–4 months. [7,8] In studies of a dose-dense regimen with growth factor support,

http://dx.doi.org/10.1016/j.ctrv.2015.06.004 0305-7372/Ó 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Ikeda S et al. Beyond conventional chemotherapy: Emerging molecular targeted and immunotherapy strategies in urothelial carcinoma. Cancer Treat Rev (2015), http://dx.doi.org/10.1016/j.ctrv.2015.06.004

2

S. Ikeda et al. / Cancer Treatment Reviews xxx (2015) xxx–xxx

Table 1 Standard therapy for advanced urothelial carcinoma [5–12]. Stage

Therapy

Outcome

P value

Muscle-invasive disease

Standard dose-MVAC + radical cystectomy vs radical cystectomy only [5] Cisplatin, methotrexate, and vinblastine + local therapy vs local therapy only [6]

Median OS: 77 mo vs 46 mo

P = 0.06 (two-sided)

10 year OS: 36% vs 30%

HR 0.84 (95% CI, 0.72–0.99)

Median OS: 12.5 mo vs 8.2 mo Median OS: 12 mo vs 9 mo 5 year OS: 14% vs 22% Median OS: 14.8 mo vs 13.8 mo Median OS: 12.7 mo vs 15.8 mo

P = 0.002 N/A P = 0.042 P = 0.75 P = 0.75

Metastatic disease

Standard dose-MVAC vs cisplatin [7] Standard dose-MVAC vs CISCA [8] Standard dose-MVAC vs dose dense-MVAC [9,10] Standard dose-MVAC vs gemcitabine plus cisplatin [11] Gemcitabine plus cisplatin vs paclitaxel, gemcitabine, and cisplatin [12]

Abbreviations: CISCA = cisplatin, cyclophosphamide, and adriamycin; CMV = cisplatin, methotrexate, and VAC = methotrexate, vinblastine, adriamycin, and cisplatin; N/A = not available; OS = overall survival; vs = versus.

dose-dense M-VAC showed a superior CR rate (25% vs 11%, P = 0.009) and a superior RR (72% vs 58%, P = 0.016) compared to standard-dose M-VAC [9,10]. Median OS was slightly improved in the dose-dense regimen (15.1 months vs 14.9 months; HR 0.76, 95% CI: 0.58–0.99), and the 5-year survival rate was superior in the dose-dense arm (26.2% vs 13.5%; 95% CI, 0.15–0.29). Grade 3 and grade 4 toxicities were less common in the dose-dense regimen, especially in neutrophil counts. In another study, the combination of gemcitabine and cisplatin was compared to standard-dose M-VAC in a phase III setting with similar median progression free survival (PFS) (7.4 months vs 7.4 months) and median OS (13.8 months vs 14.8 months, P = 0.75), but with fewer toxicities [20]. Addition of paclitaxel to the combination of gemcitabine and cisplatin resulted in a higher RR (55.5% vs 43.6%, P = 0.0031), and higher toxicity but no OS benefit (median OS, 15.8 months vs 12.7 months, P = 0.75) [12]. These studies established the combination of gemcitabine and cisplatin or M-VAC as the standard of therapy in metastatic urothelial carcinoma. Although these results confirm that the combination chemotherapy improves outcomes, the overall benefit is modest, and alternative therapies are needed to significantly improve the prognosis of patients with metastatic urothelial carcinoma. Deployment of immunotherapy or matched targeted therapy approaches based on molecular profiles has resulted in significant benefits to patients with a variety of cancers ranging from chronic myelogenous leukaemia to lung cancer [21,22]. We therefore reviewed the molecular landscape of urothelial carcinoma and its implications for molecularly targeted and immunotherapeutic approaches.

vinblastine;

HR = hazard

ratio;

mo = months;

M-

gene (Table 2), making it the most commonly altered gene [25]. Heterozygosity at the 17p locus, with loss of function of the second allele, leads to a paradoxical stabilisation and overexpression of the defective protein in the nucleus of bladder cancer cells, leading to ready assessment of p53 status by immunohistochemistry in more than 90% of mutated cases [68,69]. Assessment of the TP53 gene by sequencing or immunohistochemistry lends itself to a unique targeted therapy approach using Wee-1 inhibitors such as MK-1775 [28,29], although its efficacy has not yet been studied in urothelial carcinoma. Wee1 is a tyrosine kinase that phosphorylates and inactivates CDC2 and is involved in G2 checkpoint signalling. Because p53 is a key regulator in the G1 checkpoint, p53-deficient tumours rely only on the G2 checkpoint after DNA damage. Hence, such tumours are selectively sensitised to DNA-damaging agents by Wee1 inhibition. In addition, recent retrospective data suggest that patients with TP53 mutations may benefit from anti-angiogenesis agents such as bevacizumab, perhaps because TP53 inhibits the transcription of VEGF-A (the target of bevacizumab), which may be upregulated in the presence of the mutation [30,70]. Bevacizumab demonstrated a RR in renal cell carcinoma of approximately 31% [71]. MLL2 The MLL2 gene (also called KMT2D) is a histone methyltransferase and a key regulator of histone H3 lysine 4 residue methylation [31]. Mutations in MLL2 are present in approximately 27% of urothelial carcinoma cases [25]. Menin-MLL inhibitor is a promising agent to target MLL2 aberrations and has demonstrated activity in a pre-clinical acute leukaemia model [32].

Genomic alterations in urothelial malignancy The advances in technology over recent decades have made it possible to capture genomic alterations in cancer. In urothelial carcinoma, whole genome sequencing studies have revealed both well-characterised and novel genomic alterations, with extensive work performed in more advanced disease [23–26]. The most commonly altered genes in muscle-invasive urothelial carcinoma are listed in Table 2 and Fig. 1 [27–65]. TP53 The p53 protein, encoded by the TP53 gene on chromosome 17p13.1, regulates DNA repair, apoptosis, senescence, growth arrest, and metabolic homeostasis [27]. P53 functions as a tumour suppressor through transcriptional activation of the p21 cyclin-dependent kinase inhibitor (CDKI) and subsequent inhibition of the G1-S cell cycle transition [66,67]. In the TCGA study data set, approximately 59% of patients had a genomic alteration in this

ARID1A The ARID1A gene is a DNA-binding subunit of SWI/SNF complexes and regulates gene expression through chromatin remodelling [33]. About 25% of urothelial carcinoma showed loss-of-function mutations of ARID1A [25]. Currently, no agent specifically targets the chromatin remodelling function of ARID1A. Recent data, however, suggest that ARID1A mutation can also sensitise cells to PI3K and AKT inhibitors, providing a venue for actionability [34]. KDM6A The KDM6A gene (also known as UTX) is a histone demethylase specific for histone H3 Lysin 27 and regulates gene transcription [35]. In approximately 24% of urothelial carcinoma, KDM6A is altered. There is no available targeted agent for KDM6A.

Please cite this article in press as: Ikeda S et al. Beyond conventional chemotherapy: Emerging molecular targeted and immunotherapy strategies in urothelial carcinoma. Cancer Treat Rev (2015), http://dx.doi.org/10.1016/j.ctrv.2015.06.004

Gene

Frequency

Pathway

Function

Examples of targeted agent

Comment

TP53

59%

p53 pathway

Tumour suppressor gene, regulates cell cycle, apoptosis, DNA repair, senescence, and metabolism [27]

MK-1775 (Wee-1 inhibitor)[28] Bevacizumab

Phase II in progress [29] Retrospective study in diverse tumours: 8 months PFS benefit [30]

MLL2

27%

Histone modification

Histone methyltransferase, regulates transcription via chromatin remodelling [31]

Menin-MLL inhibitor

Activity in pre-clinical model [32]

ARID1A

25%

SWI/SNF complexes

A member of SWI/SNF complex, has helicase and ATPase activities, regulates gene expression [33]

PI3K and AKT inhibitors

Activity in pre-clinical model [34]

KDM6A

24%

Histone modification

Histone demethylase, specific to Lys-27 of histone H3, regulates transcription [35]

Not available

PIK3CA

20%

PI3K pathway

Catalytic domain of PI3K, a serine-protein kinase, regulates cell proliferation, growth, migration, metabolism, and apoptosis [36]

Everolimus (mTOR inhibitor)[37]. Multiple PIK3CA and AKT inhibitors in development [38– 43]

Case report of complete response for 14 months in patient with mTOR mutation treated with everolimus and pazopanib [44]

EP300

15%

Histone modification

Functions as histone acetyltransferase, regulates transcription by chromatin remodelling [45]

Mocetinostat (HDAC inhibitor)

Currently in phase II study [46]

CDKN1A

14%

CDK/Rb pathway

Negative regulator of cell cycle [47]

PHA-848125AC (CDK2 inhibitor)

Currently in phase II for malignant thymoma [48]

RB1

13%

CDK/Rb pathway

Regulates G1-S phase progression, as well as transcription [49]

HLM006474 (E2F inhibitor)

Pre-clinical study showed activity [50]

ERCC2

12%

DNA repair

DNA helicase involved in DNA repair by nucleotide excision repair [51]

Platinum

Sensitises to platinum in urothelial carcinoma [52]

FGFR3

12%

Receptor tyrosine kinase

Receptor tyrosine kinase, regulates cell proliferation, differentiation, and apoptosis [53]

BGJ398

Phase I: 4 of 5 patients with urothelial cancer and FGFR mutations had regression [54] Phase I: partial response in a patient with urothelial cancer and FGFR abnormality [55] Phase I in progress [56] Phase I in progress [57] Activity in preclinical model [58] Phase III for other malignancies [59] Phase II for other malignancies [60] Phase II for other malignancies [61]

JNJ-42756493 BAY1163877 Lucitanib Ponatinib BIBF 1120 Brivanib Lenvatinib

STAG2

11%

Chromatin complex

A component of cohesin complex, a complex required in cell replication [62]

Not available

HER2/HER3

Mutation HER2: 0–9% HER3: 0–11% Amplification/ overexpression: HER2: 6–15%

Receptor tyrosine kinase

Regulates cell proliferation, growth, and migration [63]

Trastuzumab Lapatinib

S. Ikeda et al. / Cancer Treatment Reviews xxx (2015) xxx–xxx

A phase II study showed 70% RR in urothelial carcinoma [64] A phase I study showed 74% RR in urothelial carcinoma [65]

Abbreviations: IHC = immunohistochemistry; RR = response rate.

3

Please cite this article in press as: Ikeda S et al. Beyond conventional chemotherapy: Emerging molecular targeted and immunotherapy strategies in urothelial carcinoma. Cancer Treat Rev (2015), http://dx.doi.org/10.1016/j.ctrv.2015.06.004

Table 2 Commonly mutated genes in muscle-invasive urothelial carcinoma [27–65].

4

S. Ikeda et al. / Cancer Treatment Reviews xxx (2015) xxx–xxx

carcinoma for tumours that harbour mutations in CREBBP and/or EP300 [46]. CDKN1A

Fig. 1. Examples of important signalling pathways in urothelial carcinoma. Tyrosine kinase receptors such as EGFR, HER2, HER3, and FGFR3 activate the MAP kinase pathway (RAS-RAF-MEK) and the PI3K (PIK3CA-AKT-mTOR) pathways and lead to cell proliferation. Also, aberrations of cell cycle regulatory pathways (TP53, CDKN1A, CDKN2A, CCND1, CCNE1, RB1, and E2F3) increase cell proliferation. Lastly, abnormalities in histone modification factors (such as MLL2, ARID1A, and KDM6A) are observed in urothelial carcinoma. For common mutations, see Table 2. Genes frequently mutated/aberrant in urothelial tumours are in red.

PIK3CA The PIK3CA gene encodes one of the catalytic subunits of phosphoinositide-3 kinase (PI3K), and a protein complex regulates cell proliferation, cell growth, apoptosis, and metabolism [36]. Upstream activation of PI3K by receptor tyrosine kinase or G-protein coupled receptor activity results in conversion of phosphatidylinositol bisphosphate (PIP2) to phosphatidylinositol triphosphate (PIP3) and subsequent AKT and mammalian target of rapamycin (mTOR) activation [72,73]. Mutations of PIK3CA occur in approximately 20% of urothelial carcinoma [25], and often include gain-of-function mutations that involve the helical and kinase domain [74]. Multiple agents are available that can target PI3K and its major downstream effectors, AKT and mTOR. For example, everolimus (RAD001) binds to FKBP2 and exerts its effects primarily on the mTOR complex 1 (mTORC1) signalling complex; although used in a number of cancer types, phase II studies in metastatic urothelial cancer patients showed only a 4% response rate; protein expression did not correlate with response but mutations were not assessed [37]. In a different trial, one patient with urothelial carcinoma showed an extraordinary response to everolimus and pazopanib, a receptor tyrosine kinase inhibitor, and this correlated with an mTOR mutation [75]. Other PI3K pathway-targeted agents (buparlisib for PI3K; triciribine, MK-2206 for AKT; temsirolimus, sirolimus, and rapamycin for mTOR) are currently under investigation in urothelial carcinoma, although patients are not being selected on the basis of PI3K/Akt/mTOR pathway mutation status [38–43,76]. EP300 The EP300 gene is a histone acetyltransferase, that regulates gene transcription through chromatin remodelling in a manner similar to ARID1A [45]. The EP300 gene is mutated in approximately 15% of urothelial carcinomas [25]. Loss-of-function mutations of EP300 have been reported in lung, breast, ovarian, pancreatic, and colorectal cancer [45]. Currently, no targeted therapy is available for EP300 mutations. However, histone deacetylase inhibitors, such as vorinostat, have been associated with increased therapeutic response in lymphoma cell lines that contain EP300 and CREBBP mutations [77]. One histone deacetylase inhibitor, mocetinostat, is currently in a phase II study of advanced urothelial

The CDKN1A gene encodes p21, an inhibitor of CDK1 and CDK2 (but not CDK4 or CDK6) and upstream regulator of p53 function. p21 regulates the cell cycle, DNA repair, and apoptosis [47]. CDKN1A is mutated in approximately 14% of urothelial carcinoma within the TCGA dataset [25]. Loss of p21 expression (via alterations in the p21WAF1/CIP1 gene) may potentiate effects of TP53 mutation in bladder cancer and can itself serve as an independent predictor of progression in bladder cancer [78,79]. Although no direct inhibitor of p21 or its signalling pathway is currently under clinical trial for urothelial carcinoma, the use of the CDK2 inhibitor PHA-848125AC is currently being studied in a phase II setting for malignant thymoma [48]. Rb The retinoblastoma (Rb) gene, situated at chromosome 13q14, is a prominent tumour suppressor gene in urothelial carcinoma and is critical in regulating G1-S transition of the cell cycle [80]. Rb, once phosphorylated by cyclin dependent kinase (CDK) complexes, exerts its effects by release of the associated E2F transcription factor and initiation of the cell cycle [49]. The Rb gene is inactivated in many cancers [49], and it is mutated in approximately 13% of urothelial carcinoma [25]. Additional alterations of Rb in bladder cancer include deletions, hyperphosphorylation and loss of negative upstream regulation [78,81]. An E2F inhibitor is currently under development, with one preclinical study showing this inhibitor to reduce cell proliferation and increased apoptosis in a melanoma cell culture model [50]. ERCC2 Excision Repair Cross Complementation Group 2 (ERCC2) encodes a DNA helicase that can repair single-strand DNA damage by nucleotide excision repair [51]. Mutations of ERCC2 are observed in approximately 12% of urothelial carcinomas [25], and inactivating mutation is associated with increased response in platinum treatment in urothelial carcinoma [52]. The combination of single-strand damage repair and double-strand break repair may enhance cell death in a manner similar to that seen with BRCA mutations and response to PARP inhibitors and platinums [82]. FGFR3 Fibroblast growth factor receptor 3 (FGFR3) encodes a receptor tyrosine kinase that regulates cell proliferation, differentiation, and apoptosis [53]. FGFR3 signals through the RAS-MAP kinase and PI3K pathways and has been shown to be critical in low-grade non-invasive urothelial carcinomas, as well as in high-grade invasive disease [83,84]. In advanced urothelial carcinoma, FGFR3 is mutated in approximately 15–35% of cases [25,83]. In a recent phase I trial using a pan-FGFR inhibitor BGJ398, 4 out of 5 urothelial carcinoma patients with demonstrated FGFR3-activating mutation showed tumour regression [54]. In another study, a urothelial carcinoma patient with FGFR3-TACC3 fusion showed a partial response to the pan-FGFR inhibitor JNJ-42756493 [55]. Currently, expansion of the cohort is underway in the JNJ-42756493 phase I study, and an upcoming phase I trial for BAY1163877, another pan-FGFR inhibitor, is in process [56]. Additional studies that combine anti-angiogenic and FGFR targeted therapy have also been performed. In a phase II trial of advanced urothelial carcinoma with or without FGFR3 mutation,

Please cite this article in press as: Ikeda S et al. Beyond conventional chemotherapy: Emerging molecular targeted and immunotherapy strategies in urothelial carcinoma. Cancer Treat Rev (2015), http://dx.doi.org/10.1016/j.ctrv.2015.06.004

S. Ikeda et al. / Cancer Treatment Reviews xxx (2015) xxx–xxx

dovitinib (TKI258), an anti-angiogenic and FGFR inhibitor, demonstrated no clinical response in the FGFR3 mutated group and only 1 out of 31 partial responses in the non-mutated groups [85]. Lucitanib is a novel dual inhibitor for VEGFR and FGFR, and is currently under study in a phase I trial [57]. Ponatinib is a multitargeted tyrosine kinase inhibitor including FGFRs, and currently approved by the FDA for T315I-positive chromic myelogenous leukaemia or T315I-positive Philadelphia chromosome positive acute lymphoblastic leukaemia. Ponatinib inhibits tumour growth in an urothelial carcinoma xenograft model [58]. Other FGFR inhibitors, such as BIBF 1120, BMS-582664, and lenvatinib, are in phase II– III clinical trials, but to our knowledge, urothelial carcinoma is not included [59–61]. STAG2 Stromal antigen 2 (STAG2) encodes a subunit of the cohesion complex, and regulates chromatoid cohesion and segregation [62]. In the TCGA dataset, approximately 11% of urothelial carcinoma exhibited mutations [25]. The therapeutic implication of STAG2 alterations remains unclear.

5

approved by the FDA for melanoma [105]. Ipilimumab blocks the immune checkpoint receptor cytotoxic T lymphocyte antigen 4 (CTLA4), and activates cytotoxic T cells [106]. In the melanoma trial, ipilimumab prolonged overall survival and, more importantly, led to long-term durable response in a subset of patients [105]. In urothelial carcinoma, preoperative administration of ipilimumab showed the mobilisation of CD4+ICOShigh T-cells in resected specimens in 12 patients [96]. A a phase II study of ipilimumab with gemcitabine and cisplatin for advanced urothelial carcinoma as a first line treatment is currently in progress [97]. Approaches using anti-PD1 or anti-PD-L1 targeting, which block immune recognition of cancer cells, are also showing encouraging results. For example, MPDL3280A is an anti-PD-L1 monoclonal antibody that activates T-cells. A phase I study with MPDL3280A in pretreated metastatic urothelial carcinoma patients yielded an overall response rate of 50% in the PD-L1 positive group and 11% in the PD-L1 negative group [98,107]. Of interest, PD-L1 positivity may be a biomarker for response to anti-PD1 therapy in a variety of tumours, with response rates of about 0–17% for PD-L1 negative tumours and 36–100% in PD-L1-positive tumours by immunohistochemistry

HER2/neu (ErbB2) The ErbB family encompasses EGFR (ErbB1; HER1), HER2/neu (ErbB2), HER3 (ErbB3), and ErbB4, which represent tyrosine kinase receptors [86]. HER2 has been studied extensively in urothelial carcinoma, where it has been proposed to function as an oncogene [63,87]. HER2 forms a homodimer or a heterodimer with other ErbB family members, with resultant activation of downstream signalling pathways, such as MAP kinase, PI3 kinase, and MYC [63,87]. In urothelial carcinoma, mutations were observed in both HER3 (0–11%) and HER2 (0–9%) [88–90]. Overexpression or amplification in HER2 is seen in 6–15% of tumours [91,92]. Mutation of HER2 is associated with higher complete pathologic response in neoadjuvant chemotherapy [93]. HER2 gene alterations and resultant protein products can be targeted by HER2-directed therapy, such as trastuzumab, lapatinib, pertuzumab, and trastuzumab emtansine [63]. A single-arm phase II study with trastuzumab, paclitaxel, carboplatin, and gemcitabine for advanced urothelial carcinoma demonstrated an overall response rate of 70% in the HER2 positive population [64]. The efficacy of trastuzumab is currently being tested in a randomised phase II study [94]. Lapatinib is currently under evaluation in a phase II study of patients with urothelial carcinoma [95]. Immunotherapy Novel immunotherapy agents have shown promising activities in advanced urothelial carcinoma (Table 3) [96–104]. In 2011, ipilimumab became the first new-generation immunotherapy to be

Fig. 2. Proportion of molecular targeted therapy in current clinical trials for urothelial carcinoma. Only 12% of trials use a biomarker approach for selecting patients. A search in the clinicaltrial.gov web site (searched in https://clinicaltrials.gov; search term: [urothelial cancer OR bladder cancer]; study type: interventional studies; first received: 1/1/2012 and 1/1/2015), revealed that there were 223 interventional trials for urothelial carcinoma. After excluding intervention trials for life-style, diagnostic imaging, surgical procedure, or other malignancies, 96 trials remained. Among these trials, molecular targeted therapy was included in 37 trials (39%). Among molecular targeted therapy trials, only 11 trials (12% of total trials [N = 96]) sought to enroll patients based on identified biomarker alterations rather than including all patients with urothelial carcinoma. The remaining studies included cytotoxic chemotherapy in 35 trials (36%) and immunotherapy (including BCG) in 24 trials (25%).

Table 3 Emerging immunotherapy in urothelial carcinoma. Name

Company

Category

Comment

Ipilimumab

Bristol-Myers Squibb

CTLA-4 inhibitor

Mobilised T-cells in bladder cancer [96], currently in phase II trial [97]

MPDL3280A

Roche

PD-L1 inhibitor

Overall response rate 50% in PD-L1 positive pretreated advanced urothelial carcinoma [98]; currently in phase II trial [99]

MEDI4736

AstraZeneca

PD-L1 inhibitor

Currently in phase I trial [100,101]

Pembrolizumab

Merck

PD-1 inhibitor

Currently in phase III trial [102]

Nivolumab

Bristol-Myers Squibb

PD-1 inhibitor

Currently in phase II trial [103]

AMP-224

Amplimmune

PD-1 inhibitor

Completed phase I trial [104]

Please cite this article in press as: Ikeda S et al. Beyond conventional chemotherapy: Emerging molecular targeted and immunotherapy strategies in urothelial carcinoma. Cancer Treat Rev (2015), http://dx.doi.org/10.1016/j.ctrv.2015.06.004

6

S. Ikeda et al. / Cancer Treatment Reviews xxx (2015) xxx–xxx

[108]. A phase II study with MPDL34280A in advanced urothelial carcinoma is currently recruiting patients [99]. Other PD1 or PD-L1 inhibitors are under development (Table 3) [100–104]. Future direction Molecular and immunologically targeted therapy is revolutionising the field of oncology. For instance, trastuzumab has change the standard of care in HER2/neu positive breast cancer patients [109]. Discovery of the EGFR mutation and ALK rearrangement in non-small cell lung cancer have led to more effective, and less toxic targeted therapies [21]. However, despite the discovery of potentially targetable gene alterations in urothelial carcinoma, most current therapies were developed without patient selection strategies. There is currently no FDA-approved agent that can target urothelial carcinoma based on molecular or immunologic profiles. Indeed, in the list of currently registered clinical trials in clinicaltrials.gov (1/1/2012 and 1/1/2015), only 12% include targeted therapy application matched to the appropriate molecular/biologic alterations, indicating significant room for improvement (Fig. 2). So, where are we heading? It is conceivable that more improvement can be achieved through the pursuit of molecular targeted therapy similar to that for breast and lung cancer. However, it is challenging to design clinical trials of molecular targeted therapy, because of low mutation percentages and small populations. Perhaps a cooperative effort to design a ‘smart trial’, such as a basket trial or an umbrella trial, would work for subsets of genomic alterations [110], and could be expanded to include non-mutational alterations known to affect protein behaviour, including amplification, phosphorylation status, or other similar parameters. Finally, it is apparent that agents such as immunotherapy that targets PD1/PDL1 can have potent effects in urothelial malignancies, with response rates as high as 50% in individuals that harbour tumours overexpressing PDL1 [98,107]. In summary, there is an expanding knowledge base of immunological, mutational, and other genomic and proteomic alterations in urothelial carcinoma, as well as in other variants of bladder cancer. Interrogation of tumours for appropriate biomarkers and matching of patients to the right agents, as well as awareness of the complex genomic and proteomic milieu of bladder cancer, will be required in order to improve outcomes. Statement of author contributions All authors contributed to prepare, review, and write the manuscript. Conflict of interest Dr. Kurzrock has consultant fees from Sequenom and is a founder of RScueRx Inc. The other authors declare that they have no conflict of interest. Acknowledgments Funded in part by the Joan and Irwin Jacobs Fund and My Answer to Cancer philanthropic fund.

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14] [15]

[16]

[17]

[18]

[19]

[20]

[21] [22]

[23]

[24]

[25] [26]

References [1] Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011;61:69–90. [2] American Cancer Society. What is bladder cancer? . [3] Hinotsu S, Akaza H, Miki T, et al. Bladder cancer develops 6 years earlier in current smokers: analysis of bladder cancer registry data collected by the

[27] [28]

[29]

cancer registration committee of the Japanese Urological Association. Int J Urol 2009;16:64–9. Freedman ND, Silverman DT, Hollenbeck AR, et al. Association between smoking and risk of bladder cancer among men and women. JAMA 2011;306:737–45. Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med 2003;349:859–66. International phase III trial assessing neoadjuvant cisplatin, methotrexate, and vinblastine chemotherapy for muscle-invasive bladder cancer: long-term results of the BA06 30894 trial. J Clin Oncol 2011;29:2171–7. Loehrer Sr PJ, Einhorn LH, Elson PJ, et al. A randomized comparison of cisplatin alone or in combination with methotrexate, vinblastine, and doxorubicin in patients with metastatic urothelial carcinoma: a cooperative group study. J Clin Oncol 1992;10:1066–73. Logothetis CJ, Dexeus FH, Finn L, et al. A prospective randomized trial comparing MVAC and CISCA chemotherapy for patients with metastatic urothelial tumors. J Clin Oncol 1990;8:1050–5. Sternberg CN, de Mulder PH, Schornagel JH, et al. Randomized phase III trial of high-dose-intensity methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) chemotherapy and recombinant human granulocyte colonystimulating factor versus classic MVAC in advanced urothelial tract tumors: European Organization for Research and Treatment of Cancer Protocol No. 30924. J Clin Oncol 2001;19:2638–46. Sternberg CN, de Mulder P, Schornagel JH, et al. Seven year update of an EORTC phase III trial of high-dose intensity M-VAC chemotherapy and G-CSF versus classic M-VAC in advanced urothelial tract tumours. Eur J Cancer 2006;42:50–4. von der Maase H, Hansen SW, Roberts JT, et al. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: results of a large, randomized, multinational, multicenter, phase III study. J Clin Oncol 2000;18:3068–77. Bellmunt J, von der Maase H, Mead GM, et al. Randomized phase III study comparing paclitaxel/cisplatin/gemcitabine and gemcitabine/cisplatin in patients with locally advanced or metastatic urothelial cancer without prior systemic therapy: EORTC Intergroup Study 30987. J Clin Oncol 2012;30:1107–13. Neoadjuvant cisplatin, methotrexate, and vinblastine chemotherapy for muscle-invasive bladder cancer: a randomised controlled trial. International collaboration of trialists. Lancet 1999;354:533–40. Neoadjuvant chemotherapy in invasive bladder cancer: a systematic review and meta-analysis. Lancet 2003;361:1927–34. Winquist E, Kirchner TS, Segal R, et al. Neoadjuvant chemotherapy for transitional cell carcinoma of the bladder: a systematic review and metaanalysis. J Urol 2004;171:561–9. Neoadjuvant chemotherapy in invasive bladder cancer: update of a systematic review and meta-analysis of individual patient data advanced bladder cancer (ABC) meta-analysis collaboration. Eur Urol 2005;48:202–5 [discussion 205–206]. Rodel C, Weiss C. Organ-sparing multimodality treatment for muscleinvasive bladder cancer: can we continue to ignore the evidence? J Clin Oncol 2014;32:3787–8. Sternberg CN, Yagoda A, Scher HI, et al. Preliminary results of M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) for transitional cell carcinoma of the urothelium. J Urol 1985;133:403–7. Sternberg CN, Yagoda A, Scher HI, et al. Methotrexate, vinblastine, doxorubicin, and cisplatin for advanced transitional cell carcinoma of the urothelium. Efficacy and patterns of response and relapse. Cancer 1989;64:2448–58. Hvd Maase, Hansen SW, Roberts JT, et al. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: results of a large, randomized, multinational, multicenter, phase III study. J Clin Oncol 2000;18:3068–77. Camidge DR, Pao W, Sequist LV. Acquired resistance to TKIs in solid tumours: learning from lung cancer. Nat Rev Clin Oncol 2014;11:473–81. Weisberg E, Manley PW, Cowan-Jacob SW, et al. Second generation inhibitors of BCR-ABL for the treatment of imatinib-resistant chronic myeloid leukaemia. Nat Rev Cancer 2007;7:345–56. Iyer G, Al-Ahmadie H, Schultz N, et al. Prevalence and co-occurrence of actionable genomic alterations in high-grade bladder cancer. J Clin Oncol 2013;31:3133–40. Guo G, Sun X, Chen C, et al. Whole-genome and whole-exome sequencing of bladder cancer identifies frequent alterations in genes involved in sister chromatid cohesion and segregation. Nat Genet 2013;45:1459–63. Comprehensive molecular characterization of urothelial bladder carcinoma. Nature 2014;507:315–22. Ross JS, Wang K, Al-Rohil RN, et al. Advanced urothelial carcinoma: nextgeneration sequencing reveals diverse genomic alterations and targets of therapy. Mod Pathol 2014;27:271–80. Levine AJ, Oren M. The first 30 years of p53: growing ever more complex. Nat Rev Cancer 2009;9:749–58. Leijen S, Beijnen JH, Schellens JH. Abrogation of the G2 checkpoint by inhibition of Wee-1 kinase results in sensitization of p53-deficient tumor cells to DNA-damaging agents. Curr Clin Pharmacol 2010;5:186–91. NCI-MPACT: molecular profiling-based assignment of cancer therapy for patients with advanced solid tumors. Clinicaltrials.gov. NCT01827384.

Please cite this article in press as: Ikeda S et al. Beyond conventional chemotherapy: Emerging molecular targeted and immunotherapy strategies in urothelial carcinoma. Cancer Treat Rev (2015), http://dx.doi.org/10.1016/j.ctrv.2015.06.004

S. Ikeda et al. / Cancer Treatment Reviews xxx (2015) xxx–xxx [30] Said R, Hong DS, Warneke CL, et al. P53 mutations in advanced cancers: clinical characteristics, outcomes, and correlation between progression-free survival and bevacizumab-containing therapy. Oncotarget 2013;4:705–14. [31] Ng SB, Bigham AW, Buckingham KJ, et al. Exome sequencing identifies MLL2 mutations as a cause of Kabuki syndrome. Nat Genet 2010;42:790–3. [32] Grembecka J, He S, Shi A, et al. Menin-MLL inhibitors reverse oncogenic activity of MLL fusion proteins in leukemia. Nat Chem Biol 2012;8:277–84. [33] Wilson BG, Roberts CW. SWI/SNF nucleosome remodellers and cancer. Nat Rev Cancer 2011;11:481–92. [34] Samartzis EP, Gutsche K, Dedes KJ, et al. Loss of ARID1A expression sensitizes cancer cells to PI3K- and AKT-inhibition. Oncotarget 2014;5:5295–303. [35] Chi P, Allis CD, Wang GG. Covalent histone modifications – miswritten, misinterpreted and mis-erased in human cancers. Nat Rev Cancer 2010;10:457–69. [36] Engelman JA. Targeting PI3K signalling in cancer: opportunities, challenges and limitations. Nat Rev Cancer 2009;9:550–62. [37] Milowsky MI, Iyer G, Regazzi AM, et al. Phase II study of everolimus in metastatic urothelial cancer. BJU Int. 2013;112:462–70. [38] Phase II evaluating efficacy of temsirolimus in 2 line therapy for patients with advanced bladder cancer (VESTOR). Clinicaltrials.gov. NCT01827943. [39] Sirolimus, cisplatin, and gemcitabine hydrochloride in treating patients with bladder cancer. Clinicaltrials.gov. NCT01938573. [40] Neoadjuvant rapamycin in patients undergoing radical cystectomy. Clinicaltrials.gov. NCT01827618. [41] Buparlisib in metastatic transitional cell carcinoma of the urothelium. Clinicaltrials.gov. NCT01551030. [42] Phase I study of triciribine phosphate monohydrate (TCN-PM, VD-0002) in adult subjects with metastatic cancer. Clinicaltrials.gov. NCT00363454. [43] MK2206 and paclitaxel in treating patients with locally advanced or metastatic solid tumors or metastatic breast cancer. Clinicaltrials.gov. NCT01263145. [44] Wagle N, Grabiner BC, Van Allen EM, et al. Activating mTOR mutations in a patient with an extraordinary response on a phase I trial of everolimus and pazopanib. Cancer Discov 2014;4:546–53. [45] Gayther SA, Batley SJ, Linger L, et al. Mutations truncating the EP300 acetylase in human cancers. Nat Genet 2000;24:300–3. [46] Phase 2 study of mocetinostat in patients with urothelial carcinoma having inactivating alterations of specific genes. Clinicaltrials.gov. NCT02236195. [47] Abbas T, Dutta A. P21 in cancer: intricate networks and multiple activities. Nat Rev Cancer 2009;9:400–14. [48] Study of oral PHA-848125AC in patients with malignant thymoma previously treated with multiple lines of chemotherapy. Clinicaltrials.gov. NCT01301391. [49] Knudsen ES, Knudsen KE. Tailoring to RB: tumour suppressor status and therapeutic response. Nat Rev Cancer 2008;8:714–24. [50] Ma Y, Kurtyka CA, Boyapalle S, et al. A small-molecule E2F inhibitor blocks growth in a melanoma culture model. Cancer Res 2008;68:6292–9. [51] Compe E, Egly JM. TFIIH: when transcription met DNA repair. Nat Rev Mol Cell Biol 2012;13:343–54. [52] Van Allen EM, Mouw KW, Kim P, et al. Somatic ERCC2 mutations correlate with cisplatin sensitivity in muscle-invasive urothelial carcinoma. Cancer Discov 2014;4:1140–53. [53] Turner N, Grose R. Fibroblast growth factor signalling: from development to cancer. Nat Rev Cancer 2010;10:116–29. [54] Lecia V, Sequist PC, Andrea V, Josep T, Jan HMS, Jean-Pierre D, Patricia LoRuss7, Ross Camidge D, Manuel Hidalgo Medin9, Martin S, Mario C, Gary Tian G, Steven W, Jesus C. Phase I study of BGJ398, a selective pan-FGFR inhibitor in genetically preselected advanced solid tumors. Available at: [accessed on 13.05.15]. [55] Rodrigo Dienstmann RB, Barbara A, Jordi R, Andrea V, Anas G, Suso P, Hans S, Timothy P, Bob Z, Kim S, Yusri E, Chris T, Vijay Peddareddigar4, Josep T, Feng Roger Lu4, Jean-Charles S. First in human study of JNJ-42756493, a potent pan fibroblast growth factor receptor (FGFR) inhibitor in patients with advanced solid tumors. Available at: [accessed on 13.05.15]. [56] Phase I dose escalation pan-FGFR (fibroblast growth factor receptor) inhibitor. Clinicaltrials.gov. NCT01976741. [57] Study of oral lucitanib (E-3810), a dual VEGFR-FGFR tyrosine kinase inhibitor, in patients with solid tumors. Clinicaltrials.gov. NCT01283945. [58] Gozgit JM, Wong MJ, Moran L, et al. Ponatinib (AP24534), a multitargeted pan-FGFR inhibitor with activity in multiple FGFR-amplified or mutated cancer models. Mol Cancer Ther 2012;11:690–9. [59] Okamoto I, Kaneda H, Satoh T, et al. Phase I safety, pharmacokinetic, and biomarker study of BIBF 1120, an oral triple tyrosine kinase inhibitor in patients with advanced solid tumors. Mol Cancer Ther 2010;9:2825–33. [60] Jonker DJ, Rosen LS, Sawyer MB, et al. A phase I study to determine the safety, pharmacokinetics and pharmacodynamics of a dual VEGFR and FGFR inhibitor, brivanib, in patients with advanced or metastatic solid tumors. Ann Oncol 2011;22:1413–9. [61] Yamamoto Y, Matsui J, Matsushima T, et al. Lenvatinib, an angiogenesis inhibitor targeting VEGFR/FGFR, shows broad antitumor activity in human

[62] [63]

[64]

[65]

[66] [67] [68] [69]

[70] [71]

[72]

[73]

[74]

[75]

[76]

[77]

[78] [79] [80]

[81]

[82] [83] [84]

[85]

[86] [87] [88]

[89] [90] [91]

[92]

7

tumor xenograft models associated with microvessel density and pericyte coverage. Vasc Cell 2014;6:18. Solomon DA, Kim JS, Bondaruk J, et al. Frequent truncating mutations of STAG2 in bladder cancer. Nat Genet 2013;45:1428–30. Arteaga CL, Sliwkowski MX, Osborne CK, et al. Treatment of HER2-positive breast cancer: current status and future perspectives. Nat Rev Clin Oncol 2012;9:16–32. Hussain MH, MacVicar GR, Petrylak DP, et al. Trastuzumab, paclitaxel, carboplatin, and gemcitabine in advanced human epidermal growth factor receptor-2/neu-positive urothelial carcinoma: results of a multicenter phase II National Cancer Institute trial. J Clin Oncol 2007;25:2218–24. Daugaard G, Sengelov L, Agerbaek M, et al. Phase I results from a study of lapatinib with gemcitabine and cisplatin (GC) in advanced/metastatic bladder cancer. ASCO Meeting Abstracts 2013;31:252. Finlay CA, Hinds PW, Levine AJ. The p53 proto-oncogene can act as a suppressor of transformation. Cell 1989;57:1083–93. Mitra AP, Lin H, Datar RH, Cote RJ. Molecular biology of bladder cancer: prognostic and clinical implications. Clin Genitourin Cancer 2006;5:67–77. Keegan PE, Lunec J, Neal DE. P53 and p53-regulated genes in bladder cancer. Br J Urol 1998;82:710–20. Baas IO, Mulder JW, Offerhaus GJ, et al. An evaluation of six antibodies for immunohistochemistry of mutant p53 gene product in archival colorectal neoplasms. J Pathol 1994;172:5–12. Farhang Ghahremani M, Goossens S, Haigh JJ. The p53 family and VEGF regulation: ‘‘it’s complicated’’. Cell Cycle 2013;12:1331–2. Escudier B, Pluzanska A, Koralewski P, et al. Bevacizumab plus interferon alfa2a for treatment of metastatic renal cell carcinoma: a randomised, doubleblind phase III trial. Lancet 2007;370:2103–11. Katso R, Okkenhaug K, Ahmadi K, et al. Cellular function of phosphoinositide 3-kinases: implications for development, homeostasis, and cancer. Annu Rev Cell Dev Biol 2001;17:615–75. Currie RA, Walker KS, Gray A, et al. Role of phosphatidylinositol 3,4,5trisphosphate in regulating the activity and localization of 3phosphoinositide-dependent protein kinase-1. Biochem J 1999;337(Pt 3):575–83. Platt FM, Hurst CD, Taylor CF, et al. Spectrum of phosphatidylinositol 3-kinase pathway gene alterations in bladder cancer. Clin Cancer Res 2009;15:6008–17. Wagle N, Grabiner BC, Van Allen EM, et al. Activating mTOR mutations in a patient with an extraordinary response on a phase I trial of everolimus and pazopanib. Cancer Discov 2014;4:546–53. Ma CX, Gao F, Naughton M, et al. A phase I study of the AKT inhibitor MK2206 plus hormonal therapy in postmenopausal women with estrogen receptor positive (ER+) metastatic breast cancer (MBC). ASCO Meeting Abstracts 2014;32:553. Andersen CL, Asmar F, Klausen T, et al. Somatic mutations of the CREBBP and EP300 genes affect response to histone deacetylase inhibition in malignant DLBCL clones. Leuk Res Rep 2012;2:1–3. Mitra AP, Birkhahn M, Cote RJ. P53 and retinoblastoma pathways in bladder cancer. World J Urol 2007;25:563–71. Stein JP, Ginsberg DA, Grossfeld GD, et al. Effect of p21WAF1/CIP1 expression on tumor progression in bladder cancer. J Natl Cancer Inst 1998;90:1072–9. Horowitz JM, Park SH, Bogenmann E, et al. Frequent inactivation of the retinoblastoma anti-oncogene is restricted to a subset of human tumor cells. Proc Natl Acad Sci USA 1990;87:2775–9. Chatterjee SJ, George B, Goebell PJ, et al. Hyperphosphorylation of pRb: a mechanism for RB tumour suppressor pathway inactivation in bladder cancer. J Pathol 2004;203:762–70. Polyak K, Garber J. Targeting the missing links for cancer therapy. Nat Med 2011;17:283–4. Cappellen D, De Oliveira C, Ricol D, et al. Frequent activating mutations of FGFR3 in human bladder and cervix carcinomas. Nat Genet 1999;23:18–20. Murgue B, Tsunekawa S, Rosenberg I, et al. Identification of a novel variant form of fibroblast growth factor receptor 3 (FGFR3 IIIb) in human colonic epithelium. Cancer Res 1994;54:5206–11. Matthew I, Milowsky CD, Ignacio DM, Satinder J, Frederick EM, Christopher S, et al. Final results of a multicenter, open-label phase II trial of dovitinib (TKI258) in patients with advanced urothelial carcinoma with either mutated or nonmutated FGFR3. J Clin Oncol 2013;31(Suppl. 6):2013 [abstr 255]. Sharma SV, Bell DW, Settleman J, Haber DA. Epidermal growth factor receptor mutations in lung cancer. Nat Rev Cancer 2007;7:169–81. Nahta R. Molecular mechanisms of trastuzumab-based treatment in HER2overexpressing breast cancer. ISRN Oncol 2012;2012:428062. Cerami E, Gao J, Dogrusoz U, et al. The cBio cancer genomics portal: an open platform for exploring multidimensional cancer genomics data. Cancer Discov 2012;2:401–4. Gao J, Aksoy BA, Dogrusoz U, et al. Integrative analysis of complex cancer genomics and clinical profiles using the cBioPortal. Sci Signal 2013;6:pl1. Network CGAR. Comprehensive molecular characterization of urothelial bladder carcinoma. Nature 2014;507:315–22. Hansel DE, Swain E, Dreicer R, Tubbs RR. HER2 overexpression and amplification in urothelial carcinoma of the bladder is associated with MYC coamplification in a subset of cases. Am J Clin Pathol 2008;130:274–81. Yan M, Parker BA, Schwab R, Kurzrock R. HER2 aberrations in cancer: implications for therapy. Cancer Treat Rev 2014;40:770–80.

Please cite this article in press as: Ikeda S et al. Beyond conventional chemotherapy: Emerging molecular targeted and immunotherapy strategies in urothelial carcinoma. Cancer Treat Rev (2015), http://dx.doi.org/10.1016/j.ctrv.2015.06.004

8

S. Ikeda et al. / Cancer Treatment Reviews xxx (2015) xxx–xxx

[93] Groenendijk FH, de Jong J, Fransen van de Putte EE, et al. ERBB2 mutations characterize a subgroup of muscle-invasive bladder cancers with excellent response to neoadjuvant chemotherapy. Eur Urol 2015. [94] Efficacy of combination of trastuzumab to gemcitabine – platinum advanced or metastatic urothelial carcinoma (CVH-CT02). Clinicaltrials.gov. NCT01828736. [95] A double blind randomised study of lapatinib and placebo in metastatic TCC of the urothelium (LaMB). Clinicaltrials.gov. NCT00949455. [96] Carthon BC, Wolchok JD, Yuan J, et al. Preoperative CTLA-4 blockade: tolerability and immune monitoring in the setting of a presurgical clinical trial. Clin Cancer Res 2010;16:2861–71. [97] First-line gemcitabine, cisplatin + ipilimumab for metastatic urothelial carcinoma. Clinicaltrials.gov. NCT01524991. [98] Powles T, Vogelzang NJ, Fine GD, et al. Inhibition of PD-L1 by MPDL3280A and clinical activity in pts with metastatic urothelial bladder cancer (UBC). ASCO Meeting Abstracts 2014;32:5011. [99] A study of MPDL3280A in patients with locally advanced or metastatic urothelial bladder cancer. Clinicaltrials.gov. NCT02108652. [100] Lutzky J, Antonia SJ, Blake-Haskins A, et al. A phase 1 study of MEDI4736, an anti-PD-L1 antibody, in patients with advanced solid tumors. ASCO Meeting Abstracts 2014;32:3001. [101] Segal NH, Antonia SJ, Brahmer JR, et al. Preliminary data from a multi-arm expansion study of MEDI4736, an anti-PD-L1 antibody. ASCO Meeting Abstracts 2014;32:3002.

[102] A study of pembrolizumab (MK-3475) versus paclitaxel, docetaxel, or vinflunine for participants with advanced urothelial cancer (MK-3475-045/ KEYNOTE-045). Clinicaltrials.gov. NCT02256436. [103] A phase 1/2, open-label study of nivolumab monotherapy or nivolumab combined with ipilimumab in subjects with advanced or metastatic solid tumors. Clinicaltrials.gov. NCT01928394. [104] Study to assess the safety, tolerability, and pharmacokinetics of AMP-224 in patients with advanced cancer. Clinicaltrials.gov. NCT01352884. [105] Hodi FS, O’Day SJ, McDermott DF, et al. Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J Med 2010;363:711–23. [106] Mullard A. New checkpoint inhibitors ride the immunotherapy tsunami. Nat Rev Drug Discov 2013;12:489–92. [107] Powles T, Eder JP, Fine GD, et al. MPDL3280A (anti-PD-L1) treatment leads to clinical activity in metastatic bladder cancer. Nature 2014;515:558–62. [108] Patel SP, Kurzrock R. PD-L1 expression as a predictive biomarker in cancer immunotherapy. Mol Cancer Ther 2015;14:847–56. [109] Nahta R, Esteva FJ. Trastuzumab: triumphs and tribulations. Oncogene 2007;26:3637–43. [110] Menis J, Hasan B, Besse B. New clinical research strategies in thoracic oncology: clinical trial design, adaptive, basket and umbrella trials, new end-points and new evaluations of response. Eur Respir Rev 2014;23:367–78.

Please cite this article in press as: Ikeda S et al. Beyond conventional chemotherapy: Emerging molecular targeted and immunotherapy strategies in urothelial carcinoma. Cancer Treat Rev (2015), http://dx.doi.org/10.1016/j.ctrv.2015.06.004