The aim of this study is to evaluate a risk-adapted approach to the treatment of muscle invasive bladder cancer. Each baseline transuretheral resection of bladder tumor (TURBT) sample will be sequenced while proceeding with neoadjuvant accelerated methotrexate, vinblastine, doxorubicin, and cisplatin (AMVAC) chemotherapy. Based on the mutational profile and the post AMVAC TURBT findings, patients will be treated with active surveillance (experimental arm), or standard of care intravesicle therapy, chemoradiation or surgery. We hypothesize that this approach will lead to non-inferior metastasis-free survival at 2 years, while preserving the bladder and thus quality-of-life for a proportion of patients.
This phase II trial studies how well maximal transurethral surgery (surgery performed with a
special instrument inserted through the urethra) followed by accelerated methotrexate,
vinblastine, doxorubicin hydrochloride, cisplatin, and radiation therapy work in treating
patients with bladder cancer that has spread to the muscle. Drugs used in chemotherapy, such
as methotrexate, vinblastine sulfate, doxorubicin hydrochloride, and cisplatin work in
different ways to stop the growth of tumor cells, either by killing the cells, by stopping
them from dividing, or by stopping them from spreading. Radiation therapy uses high-energy
x-rays to kill tumor cells and shrink tumors. Giving chemotherapy with radiation therapy may
kill more tumor cells. Giving combination chemotherapy and radiation therapy before surgery
may make the tumor smaller and reduce the amount of normal tissue that needs to be removed.
|Overal Status||Start Date||Phase||Study Type|
|Recruiting||February 24, 2016||Phase 2||Interventional|
Primary Outcome 1 - Measure: Metastasis-free survival (MFS) at 2 years.
Primary Outcome 1 - Time Frame: 24 months
- Male or female patients ≥18 years.
- Primary urothelial or predominantly urothelial carcinoma of the bladder.
- Histologic evidence of muscularis propria invasion.
- AJCC27 clinical stage T2-T4a .
- No radiographic evidence of lymph node positivity (N0) or metastatic disease (M0).
Clinical lymphadenopathy on staging CT greater than 1.5 cm in short axis must be
biopsy proven negative.
- ECOG performance status 0, 1, or 2.
- Left ventricular ejection fraction ≥ 50% by MUGA or ECHO within 6 months of study
- Normal organ and bone marrow function as defined:
Leukocytes ≥ 3,000/mcL Absolute neutrophil count ≥ 1,500/mcL Platelets ≥ 100,000/mcL Total
bilirubin ≤ institutional upper limit of normal (ULN) AST(SGOT)/ALT(SGPT) ≤ 2.5 X
institutional ULN Creatinine Creatinine Clearance ≥ 50 mL/min (calculated using the
Cockroft-Gault formula or measured with 24 hour urine collection)
- Any component of small cell histology.
- Prior pelvic radiation therapy or patients who have undergone prior radiation to
greater than or equal to 25% of the bone marrow within the past year are excluded due
to risk of life threatening myelosuppression
- Prior systemic chemotherapy; patients who have received any previous systemic
chemotherapy or radiation therapy for urothelial carcinoma or cytotoxic chemotherapy
for another malignancy within 1 year of study entry are ineligible.
- Prior or concurrent malignancy of any other site except for non-melanoma skin cancer,
unless disease free interval ≥ 5 years.
- Patients who have received experimental agents within 4 weeks of study entry.
- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to Methotrexate, Vinblastine, Adriamycin or Cisplatin or other agents used
in the study
- Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection (defined by current oral or intravenous antibiotic therapy), symptomatic
congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric
illness/social situations that would limit compliance with study requirements.
- Pregnant women are excluded from this study due to the potential for teratogenic or
abortifacient effects of cytotoxic chemotherapy.
- Known HIV-positive patients on combination antiretroviral therapy are ineligible
because of the potential for pharmacokinetic interactions with cytotoxic chemotherapy.
In addition, these patients are at increased risk of lethal infections when treated
with marrow-suppressive therapy.
- Patients with hydronephrosis that has not been addressed with an intervention such as
placement of a stent.
- Pregnancy & Women of Childbearing Potential
Minimum Age: 18 Years
Maximum Age: N/A
Healthy Volunteers: No
Name: Daniel Geynisman, MD
|Washington Cancer Institute at MedStar Washington Hospital Center
Washington, District of Columbia 20010
Lambros Stamatakis, MD
Baltimore, Maryland 21287
Jean Hoffman-Censits, MD
|Sidney kimmel Cancer Center
Philadelphia, Pennsylvania 19107
James Mark, MD
|Fox Chase Cancer Center
Philadelphia, Pennsylvania 19111
Daniel Geynisman, MD