Introduction & Objectives: Following the invention of high-throughput sequencing, cancer research was directed to investigate genetic/epigenetic alterations; this approach often inadvertently omitted the tumor heterogeneity. Cancer cell lines demonstrate considerable heterogeneity that is related to various aspects e.g. cellular signaling. This research was designed to limit the impact of heterogeneity on our previous findings for bladder cancer. We have recently considered it rational to investigate the biological effect of WWOX, AP-2α and AP-2γ which interact with each other, influencing cancer-related processes.
The purpose of this study was to determine the global gene expression profile in bladder cancer depending on different expression of WWOX, AP-2α and AP-2γ. It was intended to provide data on bladder cancer signaling independent of the specificity of a given cell line.
Materials & Methods: RT-112, HT-1376 and CAL-29 cell lines were used as biological replicates for workflow beginning with high-throughput sequencing method: CAGE-seq. Differential gene expression analysis was performed using limma-voom. Heatmaps were visualized using Heatmapper; the results were validated at the protein level using Western Blot. Both MSigDB and GeneRIF were used to determine the role of genes in biological processes. Principal component analysis was performed in R-language. Cellular variants with different levels of WWOX, AP-2α and AP-2γ were prepared so that overexpression involved one selected gene or both the WWOX gene and one of the AP-2 factors.
Results: AP-2α/γ transcription factor targets regulated in opposite directions by WWOX and AP-2 factor were identified. There were fewer genes in the comparisons related to AP-2α than in the equivalents for AP-2γ. Some target genes have been identified in two sets, i.e. CDH5, FBLN2, L1CAM, PRKCA. Observations for FGFR3 and STAT6 were verified at the protein level. Biological processes underlying carcinogenesis were also investigated; 173 genes implicated in these processes were identified. The gene set was subjected to principal component analysis which showed that variants differ regarding expression profile. Differences in signal transduction depending on WWOX/AP-2α/AP-2γ expression were also evaluated. Evident differences were noted for TGFBR2/MAP3K5, MAP3K7/TCF7L1 and HTR7/PLCE1 pathways, which respectively regulate the process of migration, metastasis and invasion.
Conclusions: These analyzes identify AP-2 target genes that are worth investigating in the context of broad spectrum of included biological processes. Some of these genes can be used in the treatment of this cancer. Differences in signal transduction indicate that WWOX inhibits the EMT process, AP-2γ enhances EMT, while AP-2α induces the opposite, i.e. MET. The study also confirmed earlier phenotypic observations, proving that the biological function of AP-2α is similar to that of WWOX, but not to AP-2γ. In view of the above, AP-2γ appears to 

The biological function of AP-2α is similar to that of WWOX, but not to AP-2γ

Introduction & Objectives: Sulfatase 2 (SULF2) can affect the occurrence and development of cancer by regulating HSPG-binding factors. In bladder cancer(BCa), the mechanism of SULF2 is unknown. Here, we clarify the mechanism that SULF2 affects the secretion of HSPG-binding factors (IL-8) and regulates the polarization of M2 macrophages in the BCa microenvironment.
Materials & Methods: The RNA sequencing of 90 patients with BCa was analyzed. SULF2 knockdown or overexpression cell lines, flow cytometry, CCK8, Transwell, Edu assay, Western Blot, qPCR, co-culture systems were used to analyze the effects of SULF2 on the biological functions of BCa in vitro. The mouse orthotopic BCa model, flow cytometry and IHC were used to analyze the changes of SULF2 on the tumor microenvironment of BCa in vivo.
Results: The high expression of SULF2 is closely related to poor prognosis. Knockdown or overexpression of SULF2 revealed that it promotes tumor proliferation and invasion through in vivo and in vitro. Furthermore, SULF2 affected the polarization of macrophages by using the mouse orthotopic BCa and flow cytometry analysis,. Mechanism studies clarify that SULF2 promotes the release of HSPG-binding factors--IL-8 to the microenvironment through β-catenin. Meanwhile, IL-8 activated the JAK2/STAT3 pathway of macrophages to promote the expression of CD163 and CD206, thereby regulating the polarization of macrophages to M2 macrophages.
Conclusions: These data indicate that SULF2 plays an important role in regulating the microenvironment of BCa. SULF2 promotes the polarization of macrophages to M2 by secreting IL-8, which further deepens the malignant progression of BCa.

Sulfatase2 affects the polarization of M2 macrophages through the IL-8/JAK2/STAT3 pathway in bladder cancer

Introduction & Objectives: Bladder cancer is one of the most common carcinomas and it brings about huge social economic burden. There is not a reliable way to predict the prognosis of bladder patients. We develop the nomogram to predict the prognosis of bladder cancer patients.
Materials & Methods: A total of 127 bladder cancer patients after radical cystectomy were studied retrospectively. Their clinicopathological data were collected for statistical analysis.
Results: The level of albumin/globulin ratio (AGR), C-reactive protein/albumin ratio (CAR), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) associated with pathological and hematological parameters like T stage and hemoglobin. Furthermore, the AGR was associated with overall survival (OS) and CAR, NLR, and PLR were associated with both OS and progression-free survival (PFS) (P<0.05). The multivariate analysis revealed that tobacco smoking, tumor T stage, M stage, NLR, CAR, and AGR were all independent predictors for OS of patients and tobacco smoking, tumor T stage, NLR, CAR, and AGR were independent predictors for PFS of patients. In addition, AGR, CAR, and NLR, as well as, the clinicopathological parameters in the development of nomograms with a C index of 0.901 (95% CI: 0.5051.269) for OS, and 0.807 (95% CI: 0.755–0.858) for PFS. The nomograms were able to provide a prognosis of the OS with the area under the curve (AUC) =0.86. Further, tests assessed the PFS with the AUC =0.84.
Conclusions: This study demonstrates that the nomograms of the inflammatory biomarkers were able to predict prognosis of bladder cancer patients after radical cystectomy.

Development of nomograms related to inﬂammatory biomarkers to estimate the prognosis of bladder cancer after radical cystectomy

Introduction & Objectives: Bladder cancer (BCa) is a common urologic malignancy characterized by poor prognosis. Abnormal metabolism and its key genes play a critical role in BCa progression. In this study, we report the role of phosphoglycerol dehydrogenase (PHGDH), a key molecule of serine metabolism, in regulating ferroptosis in BCa.
Materials & Methods: BCa tissues of 90 patients were analyzed by RNA-sequencing for differential pathways and genes. Western blot, qPCR and IHC were used to detect PHGDH expression in cell lines (in vitro) and patient tissues (in vivo). R software was used to analyze PHGDH expression, prognosis and PHGDH+SLC7A11 score. The biological functions of PHGDH were investigated through organoids, and in vitro and in vivo experiments. C11 probes, bioelectron microscopy and ferroptosis inhibitors/inducers were used to detect cellular ferroptosis levels. Protein profiling, co-IP and RIP assays were used to screen proteins that might bind to PHGDH. PHGDH-targeted inhibitor NCT-502 was used to evaluate its effect on BCa cells
Results: PHGDH was highly expressed in patients with BCa. Knock-down of PHGDH promoted ferroptosis, while decreased proliferation of BCa cells. Additionally, PHGDH knock-down downregulated the expression of SLC7A11. Co-IP and mass spectrometry experiments indicate that PHGDH binds to PCBP2, an RNA-binding protein, and inhibits its ubiquitination degradation. PCBP2 in turn stabilizes SLC7A11 mRNA and increases its expression. NCT-502, a PHGDH inhibitor, promotes ferroptosis and inhibits tumor progression in BCa. PHGDH+ SLC7A11 score was significantly correlated with patient prognosis.
Conclusions: In all, PHGDH via interaction with PCBP2, upregulates SLC7A11 expression. This inhibits ferroptosis and promotes malignant progression of BCA. We also preliminarily assessed that NCT-502 could serve as a therapeutic strategy for BCa

PHGDH inhibits ferroptosis and promotes malignant progression by upregulating SLC7A11 in bladder cancer

Introduction: Radiation cystitis is one of the late toxicities of pelvic radiation. Cervical cancer is the most common pelvic malignancy in India, and it is not uncommon to find the sequela after External Beam Radiotherapy and brachytherapy depositing over 60 to 65 Gy in bladder tissue. This sequela usually appears 6 months to 1 year after pelvic radiation and the risk remains till the patient is alive. We report a case of radiation cystitis 21 years after cervical cancer treatment. This is very rare in the sense that most patients present with this complication within few years of treatment.
Clinical findings: 62 year old woman was admitted to emergency department with history of bleeding in urine (Painless hematuria) and weakness for 10 days. She had no comorbidity and gave history of cervical cancer treatment in cobalt-60 machine followed by LDR brachytherapy in 2000. She had no records of her treatment; hence the dose of radiation and other details could not be ascertained. However roughly 80-85 Gy to high-risk Planning Target Volume (HR PTV) and over 65 Gy bladder dose is quite a possibility. Her vitals were normal except blood pressure, which was on lower side, 90/72 mm Hg and she was anemic. Abdominal and per vaginal examination were normal, except stenosed vagina.
Diagnosis & Treatment: Routine blood counts, liver function test and kidney function tests were normal except hemoglobin, 8.2 gms/ml. A contrast enhanced CT scan of abdomen and pelvis revealed a large clot/growth in urinary bladder. Urinary bladder malignancy could be a possibility at her age. After saline bladder irrigation, we performed a cystoscopy which showed a small clot in bladder and few areas of telangiectasis, definitive sign of radiation cystitis. Bladder irrigation, a course of antibiotics, ethamsylate and IV iron were administered along with two pints of whole blood. Within 5 days she gained strength and discharged with hemoglobin of 10.5 mg/ml and no active bleeding in urine She was advised to visit next month or early in case of bleeding.
Conclusions: Radiation cystitis is a late toxicity of pelvic radiation which can appear any time after 6 months of radiation treatment and the risk remains till the patient is alive. It can mimic a second primary cancer of urinary bladder and needs careful differentiation. Symptomatic and supportive care resolves most cases.

Radiation cystitis after 21 years of pelvic radiation

Introduction & Objectives: The effect of gender on the prognosis of bladder cancer (BCa) in different metastatic sites is insufficiently understood. We aimed to assess the impact and potential mechanisms of a combination of gender dimorphism and BCa metastasis sites on the risk of death.
Materials & Methods: Independent predictors of overall survival (OS) and cancer-specific survival (CSS) were analyzed after stratification by gender and metastasis sites from the SEER database. Furthermore, gender-differentially expressed genes (gDEGs) and function-enriched annotations for patients with lymph node metastasis (LNM) were identified from TCGA database. A gender-associated signature was constructed in TCGA and validated in the IMvigor210 trial, and the MRI-based radiomics signature was developed in our center to predict the gender-associated signature.
Results: In patients with metastatic BCa, the most common site of metastasis is bone in men and lung in women. Moreover, stratified by sex, LNM had a better prognosis in men than visceral metastasis, which was not observed in female. Similarly, stratified by the metastasis site, the prognosis of men in patients with LNM is better than that of women, which was not observed in visceral metastasis patients. Enrichment of DEGs between sexes in patients with LNM may be related to metastasis and tumor immunity, especially the role of neutrophils. Moreover, the gender-associated signature is related to the clinicopathological characteristics of patients, and patients in the high-risk group had worse survival outcomes, and higher susceptibility to cisplatin, docetaxel, camptothecin, and paclitaxel. A nomogram combined with the signature and clinical staging showed significant predictive power in survival prediction. Furthermore, patients with high radiomics scores had a strong tendency for high risk group.
Conclusions: These results may improve understanding of the differences in tumor biology between sexes and thus provide additional evidence for individualized treatment in BCa.

Gender dimorphism in survival of patients with lymph node metastasis of bladder cancer

Introduction & Objectives: Subsequent primary cancers (SPCs) are a serious complication for bladder cancer (BCa) survivors. Yet, the risk of BCa survivors developing or dying from SPCs remains unclear. Hence, this study aimed to investigate the risk of BCa survivors developing or dying from 15 specific-SPCs, and explore the differences in these risks in terms of patient age, time after diagnosis, and calendar year, in subgroups stratified by sex, race, and tumor stage. Materials & Methods: A total of 229,554 BCa survivors were identified from the Surveillance, Epidemiology, and End Results (SEER) 18 database from the period 2000–2018. Incidence and mortality per 10000 person-years, absolute excess risk (AER) per 10000 person-years, standardized incidence ratios (SIRs), and standardized mortality ratios (SMRs) were calculated. Results: Among BCa survivors, 38,207 developed SPCs and 17,546 died of SPCs. BCa survivors had a higher risk of developing or dying from SPCs than the general population for 10 and 7 of the 15 SPCs, respectively. Specifically, SPCs having a high risk of development or death from SPCs include ureter, kidney and renal pelvis, lung, cervix, liver, gastric, and pancreatic cancers. Whereas, SPCs that do not have a high risk include breast, endometrial, ovarian, melanoma, and lymphoma. SPCs that have a high risk of development but not death from SPCs include prostate, colorectal, and small intestine cancer. Furthermore, the risk of developing and dying from SPCs was significantly high for 10 and 6 of the 12 common SPCs in men, respectively, while for 6 and 5 of the 14 common SPCs in women, respectively. The SPCs with high risk of development in men were colorectal, breast, liver, and pancreatic cancer, and the ones with high risk of death were liver and pancreatic cancer; while women did not. Similarly, among the 15 specific-SPCs, 9 for whites, 4 for blacks, and 6 for other races had significantly high risk of developing SPCs, while 7 for whites, 6 for blacks, and 6 for other races had significantly high risk of dying from SPCs. The risk of development of liver, stomach, pancreas, and colorectal cancer were high in whites. The risk of prostate cancer death is high among blacks and other races. Moreover, SPCs with a high risk of development or death among young BCa survivors include ureter, kidney and renal pelvis, and lung cancer. Conclusions: Among BCa survivors, the risk of developing or dying from few SPCs is significantly high in different subgroups, especially in young patients and within 1 year of diagnosis. These findings may provide an important basis for clinical follow-up of BCa survivors.

Association between bladder cancer survivors and risk of subsequent primary cancers

Introduction & Objectives: Capecitabine, an oral 5-fluourouracil (5-FU) prodrug, could serve as a suitable alternative for 5-FU as a radiosensitizer in concurrent chemoradiotherapy (CCRT). Avoiding the necessity of indwelling central venous infusional devices, capecitabine is associated with increased convenience for both patients and healthcare professionals. Since large comparative studies are lacking, we aimed to compare toxicity, health-related quality of life (HRQoL) and survival after CCRT with 5-FU versus capecitabine.

Materials & Methods: Patients with non-metastatic urothelial MIBC (cT2-T4a, N0-2, M0), diagnosed between November 2017 and November 2019 and treated with CCRT with mitomycin C and either capecitabine or 5-FU were identified from the Netherlands Cancer Registry. Patient, tumor and treatment characteristics, and toxicity were compared between groups using ANOVA and Chi-square or Fisher-exact tests. HRQoL per treatment group was evaluated over time using the EORTC-QLQ-C30 questionnaire. Overall survival (OS) and disease-free survival (DFS) were evaluated using Kaplan Meier analyses with inverse probability treatment weights to adjust for baseline differences.

Results: Of the 266 patients included, 120 (45%) were treated with 5-FU and 146 (55%) with capecitabine. Compared to 5-FU, more patients in the capecitabine group completed a curative CCRT protocol according to treatment plan (60 vs 75%, p=0.01). Adverse events rates were equal in both groups (22 versus 18%, p=0.44). Two-year overall survival was significantly in favor of capecitabine (76% vs 62%, p=0.01). Two-year DFS was not significantly different (63% vs 51%, p=0.16). Reported HRQoL was similar for both treatment groups and showed a temporary decrease in several functioning or symptom scores at 6 or 12 months after diagnosis, but restored again to pre-treatment levels two years after diagnosis.

Conclusions: Concurrent chemoradiotherapy treatment with capecitabine and MMC is associated with a similar toxicity profile and health-related quality of life compared to 5-FU plus MMC. Also survival appears to be similar or even slightly better. As capecitabine is more patient-friendly compared to 5-FU, our data are in favor of replacement of 5-FU by capecitabine in CCRT of MIBC.

Concurrent chemoradiation for muscle-invasive bladder cancer using 5-fluorouracil versus capecitabine

Introduction & Objectives: Although recommended in international guidelines, the survival benefit of neoadjuvant chemotherapy (NAC) in muscle-invasive bladder cancer (MIBC) remains controversial. As a result, practice variation is expected. We evaluated guideline adherence and assessed practice variation between hospitals in NAC use and its effect on survival.

Materials & Methods: In this nationwide study based on the Netherlands Cancer Registry, we identified 1,025 patients newly diagnosed with non-metastatic MIBC between November 2017 and November 2019 who underwent radical cystectomy. Patients with ECOG performance status 0-1 and creatinine clearance ≥50 mL/min/1.73m2were considered NAC-eligible. Interhospital variation was assessed using case-mix adjusted multilevel analysis. The association between hospital-specific probabilities of NAC and survival was evaluated using a Cox proportional hazards model. All analyses were stratified by disease stage (cT2 versus cT3-4a).

Results: In total, 809 patients were considered NAC-eligible, but only 277 (34%) received NAC. Guideline adherence for NAC in cT2 was lower compared to T3-T4a disease (26% versus 55%) and interhospital variation was larger (7-57% versus 31-62%). For cT2-disease, adjusted two-year OS seems in favor of patients treated in hospitals with higher probability to administer NAC (HR 0.59, 95%CI 0.33-1.05) although not statistically significant. For cT3-4a, no significant effect was observed (HR 0.71, 95%CI 0.25-2.04).

Conclusions: Guideline adherence regarding NAC use is low and interhospital variation is large, especially for patients with cT2-disease. Our data suggest that hospitals more likely to give NAC in T2-disease perform slightly better concerning survival, although results should be interpreted with care as this was not statistically significant. Further research is warranted to elucidate the underlying mechanism. As literature is clear concerning the potential survival benefit of NAC in patients with cT3-4a disease, our data shows that guideline adherence could be improved.

Low guideline adherence to recommended use of neoadjuvant chemotherapy in patients with non-metastatic muscle-invasive bladder cancer

Introduction & Objectives: To compare the outcomes of high-risk non-muscle invasive bladder cancer (HR-NMIBC) patients treated with recirculant hyperthermic chemotherapy (HIVEC) with mitomycin C (MMC) vs bacillus Calmette-Guérin (BCG).
Materials & Methods: Phase II randomised clinical trial with HR-NMIBC patients, excluding carcinoma in situ. Participants were randomised 1:1 to receive either BCG for 1 year (SWOG schedule) or HIVEC with MMC 40 mg using the Combat BRS© system (1 weekly instillation for 6 weeks plus 1 monthly instillation for 6 months). Recirculating time for HIVEC was 60 minutes at a target temperature of 43°±0.5°C. The primary outcome was recurrence-free survival (RFS). Secondary outcomes included time to recurrence, progression-free survival (PFS), cancer-specific survival (CSS) and overall survival (OS), all of them at 24 months. Adverse events were routinely recorded.
Results: Fifty patients were included with a mean age of 73.5 years. With a median follow-up of 33.7 months, at 24 months RFS was 86.5% for HIVEC and 71.8% for BCG (p=0.184) in the intention-to-treat population (ITT) and 95.0% for HIVEC and 71.8% for BCG (p=0.064) in the per protocol analysis (PP). Time to recurrence was 21.5 and 16.1 months for HIVEC and BCG, respectively. PFS for HIVEC vs BCG was 95.7% vs 71.8% (p=0.043) in the ITT and 100% vs 75.1% (p=0.018) in the PP, respectively. CSS was 100% for both groups and OS was 91.5% for HIVEC vs 81.8% for BCG.
Conclusion: HIVEC shows an efficacy and safety profile similar to BCG and is a reasonable alternative to it in certain situations, such as shortages.

Final results of the HIVEC-HR randomised trial comparing hyperthermic MMC vs BCG in high-risk non-muscle invasive bladder cancer patients

Introduction:
MMC major side effects reported in the literature are really rare, being the most frequent ones irritative symptoms (10%) and allergic skin reactions (3%). However, although infrequent, we must monitor atypical symptoms and signs.

Clinical findings:
We present a 70-year-old male with personal history of former smoker, alcoholic cirrhosis and recurrent non-invasive bladder cancer (low-grade Ta): 2 TURB + inmediate postoperative and induction MMC in 2012 and 1 TURB + inmediate postoperative and induction MMC in 2020. During control cystoscopy after 2020 TURB, intravesical debri and adhered fibrin on the scar was found, suspecting a tumour recurrence, so a second TURB was performed. Diagnosis & Treatment: During that TURB, debri and fatty fluid was found, suspecting a bladder necrosis, which was confirmed with pathology. We decided to follow a conservative treatment keeping an indwelling catheter, antibiotic therapy and monitoring the evolution with cystographic control. After 9 weeks with the indwelling catheter, cystographic control showed absence of leakage, so it was removed. 3 weeks later another cystoscopy was performed, demonstrating persistence of the fistula, deciding to keep the indwelling catheter and perform a further study with MRI, which showed a fistula from the anterior bladder wall to the pubic and inguinal region. Since conservative treatment failed and he didn’t have any recurrence 2 years after TURB in 2020, laparoscopic fistula repair was performed.

Conclusion:
Atypical and uncommon side effects after MMC administration such as bladder necrosis and subsequent fistula have a challenging management due to lack of evidence in literature, being vital to individualize each case.

Management of bladder fistula secondary to bladder necrosis after adjuvant mitomycin: a case report

Introduction: Haematologic adverse events in immunotherapy are extremely uncommon, with neutropenia being the rarer, according with some authors. Specially when immunotherapy is used in monotherapy, as pembrolizumab in metastatic bladder carcinoma. The ideal approach, to these adverse events, are still unknown but corticosteroids appear to play a role.
Clinical findings: A 57-year-old woman, smoker, with no other relevant medical history, complained of 8-month history of haematuria and weight loss. She was diagnosed with a high-grade bladder carcinoma, pT2aN0M0, in March 2019, and then submitted to neoadjuvant chemotherapy with gemcitabine and cisplatin scheme. However, the disease progressed locally and with multiple lung metastasis. The treatment of the metastatic disease was then switched to pembrolizumab 200mg, 3/3 weeks, in October 2019. The treatment was carried until November 2020 without any complications.
Diagnosis & Treatment: On the 2nd of December 2020, the patient was observed in an urgent consultation because of gum discomfort and fever. The blood count revealed pancytopenia with severe neutropenia of 0.01x109/L and so she was admitted with a grade 4 severe febrile neutropenia. We started her on IV antibiotics, antifungals, granulocyte colony stimulation factor and methylprednisolone 2mg/kg/day for 16 days, slowly tapering the dose. There was a gradual clinical and analytic improvement, with regression of oropharyngeal lesions and neutropenia. The treatment with pembrolizumab was permanently suspended.
Conclusions: The optimal treatment of severe neutropenia secondary to immunotherapy is controversial because of the rarity of the events and the lack of guidelines on this subject. Nevertheless, the literature defends that a high dose of corticosteroids or another immunosuppressive drug might be helpful. Accordingly, to the literature the recovery time of neutropenia is longer than in chemotherapy, approximately 2 weeks, which was the case in this patient. To sum up, grade 4 toxicity requires immediate suspension of immunotherapy and rechallenge is controversial, leaving a gap in what treatment should follow.

A rare case of grade 4 febrile neutropenia with pembrolizumab in metastatic bladder carcinoma

Introduction: Approximately 5-10% of urothelial carcinomas originate in the renal pelvis or ureter. Systemic treatment with new targeted therapies has improved patient survival. Atezolizumab is a monoclonal antibody that blocks PD-L1 binding to PD-1 and B7.1 receptors and has been approved by the FDA (US Food and Drug Administration) in 2016 for the maintenance treatment of advanced urothelial carcinoma unresponsive to first-line chemotherapy, as documented in studies such as IMvigor 210 and 211. Clinical findings: We present the case of a 64-year-old male, hypertensive, smoker and with a history of ischemic heart disease. He was diagnosed in June 2020 with bilateral urothelial carcinoma during a study for hematuria and bilateral obstructive uropathy. Diagnosis & Treatment: The radiological diagnosis described a 5 cm repletion defect in the right distal ureter and a 3 cm defect in the left proximal ureter (image 1). It also found a pathological retroperitoneal lymphadenopathy. Urinary diversion was performed by percutaneous nephrostomy and a biopsy was taken at the same time (June 2020) by percutaneous access. The results showed up a high-grade urothelial carcinoma in left ureter and low-grade in right ureter, with a negative PD-L1 study IC 0. Patient was considered not candidate for cisplatin treatment, so it was decided to start first line neoadjuvant chemotherapy with carboplatin + gemcitabine (August-November 2020). 4 cycles were completed. He underwent laparoscopic right nephroureterectomy in January 2021. Final histopathological result was reported as low-grade invasive papillary urothelial carcinoma of 2 cm (pT2NxR0) and, subsequently in March 2021, left segmental urethreterectomy was performed with biopsy results compatible with high-grade invasive papillary urothelial carcinoma of 2 cm (pT1NxR0). A PET-CT scan was performed in May 2021, which showed persistent disease in the left ureter, so second-line treatment with Atezolizumab was approved. Diagnostic ureteroscopy was scheduled for November 2021 with cold biopsy findings of recurrence (urothelial proliferation of uncertain malignant potential). After 12 cycles of atezolizumab maintenance, a new PET-CT scan was performed in May 2022 without 18F-FDG avidity images indicating a complete metabolic response. In July 2022, a new diagnostic ureteroscopy was performed with multiple ureteral biopsy and cytology with negative inflammatory cells for malignancy. The patient is currently in the 14th cycle of atezolizumab maintenance, asymptomatic (ECOG 0) and without complications associated with treatment. He has a left double J catheter due to ureteral stricture after segmental ureterectomy.
Conclusions: In cases of upper urinary tract urothelial cell carcinoma with bilateral involvement and high risk of progression, it is necessary to establish a treatment adjusted to the individual characteristics of the patient and to assess the possibilities of adjuvant treatment with new targeted therapies 

Long time response in bilateral upper urinary tract urothelial cell carcinoma with atezolizumab: a case report

Introduction & Objectives: Many people affected by cancer are not getting the emotional or psychological support they need; the most deprived people are even less likely to have these needs met. Groups that are particularly vulnerable to lower health literacy include older adults, people with low-income earnings, digitally excluded people, people living in regional areas, people employed in manual labour, people at an educational disadvantage, and those with low socioeconomic status. Lower health literacy is associated with fewer doctor’s visits and worse health. Materials & Methods: Informed by a prior quantitative study of over 1,000 patients and carers and qualitative interviews of 17 healthcare professionals, ten carers, and 30 patients, we designed and distributed a follow-up survey to identify unmet needs. This survey asked about the satisfaction with currently available resources and examined new options for future services. Results: Based on the research conducted, the following solutions were designed to address the current challenges facing bladder cancer patients: Challenge Digitally excluded people unable to access online materials Solution We designed a suite of full-colour booklets that we post for free anywhere in the UK. These can be ordered online by healthcare professionals or patients or over the phone. Challenge Awareness of the symptoms of bladder cancer in people who have been employed in high-risk professions Solution We partnered with a workers’ union to send information to occupational health and safety officers and with NHS England to raise awareness of symptoms. We produced posters for toilet doors. Challenge People living in regional areas are unable to attend face-to-face support groups. Solution We host monthly online Zoom support groups; we also offer a Bladder Buddy system – where two people with similar diagnoses can have a telephone conversation. Challenge Lack of awareness of free support services Solution We produce nurse contact cards so that the nurse can give the patient their information and information about peer support services at the time of diagnosis. Challenge People at an educational disadvantage Solution Our website uses simple language, clear diagrams, and plenty of photos of actual patients. Challenge Lack of availability of healthcare professionals for follow-up questions Solution Our moderated private online forum of over 5,000 patients and carers offers 24-hour support, seven days a week. Challenge Feelings of isolation Solution We produce a free monthly newsletter, an annual magazine posted for free around the UK, awareness merchandise, and organise community Wee Walks every May. Conclusions: We developed strategies that allow us to improve the health literacy of deprived populations affected by bladder cancer. This improves their self-management skills and boosts their ability to engage in shared decision-making. This means they have better access to timely, patient-centred, value-based care 

Solutions for supporting deprived populations of patients and carers

Introduction & Objectives: Bladder cancer is the tenth most commonly diagnosed cancer in both genders. Bladder cancer is primarily a disease of older patients with age-incidence rates rising gradually around 50 years old. Malignant bladder tumours are rare among younger patients, with many benign conditions being confused with bladder tumours during cystoscopies in these patients.
Materials & Methods: Retrospective evaluation of all patients with 50 years old or younger who received transurethral resection of bladder (TUR-B) in our institution, from January 2011 until March 2022. Patients’ characteristics and pathological results were evaluated.
Results: During this period of time, over 2500 TUR-B were done in our institution. 64 patients had 50 years old or less at the time of surgery. The majority of patients were male (75%) and were in the fifth decade of life. 59,4% of patients looked for medical advise because of haematuria but some of them had less frequent manifestations of bladder tumours. Less than a quarter of the patients had a benign result after pathological evaluation. 18,8% had pT1 high grade tumours and 12,6% muscle-invasive tumours. There is no statistical significance between tobacco use and malignant pathology (p=0,60).
Conclusions: Although bladder tumours are much more frequent after 50 years old, we should be aware of typical complaints in younger patients and investigate them. A great part of our sample were smokers but we couldn’t demonstrate its effect on malignancy or benignity of their disease. A non-despicable sample had muscle-invasive and aggressive disease – 5 of 8 patients are already death and another one is already metastasized. Early recognition of the symptoms is the key to an early diagnosis and the better outcome possible for the patients.

Transurethral resection of bladder in patients 50 years old or younger: a tertiary single center analysis from 2011 to 2022

Introduction & Objectives: Bladder cancer (BC) is a complex disease associated with high morbidity and mortality rates if not optimally treated. Currently, the major challenges in the clinical management of bladder cancer are disease recurrence and progression in non-muscle invasive bladder cancer (NMIBC), and therapy failure and severe side effects in muscle invasive bladder cancer (MIBC). The aim of our study was to identify new molecular targetable biomarkers to improve BC patients’ stratification and the outcome of current immunotherapies.
Materials & Methods: In a prospective cohort of 70 BC patients and a series of BC cell lines that mimic the four stages of bladder oncogenesis, we assessed the genetic and molecular regulation of Telomerase Reverse Transcriptase (TERT) in maintaining telomeres’ length and explored the expression of immune checkpoint at the mRNA level. Furthermore, we investigated the dysregulation of two microRNAs in patient’s biopsies and in BC cell lines and their potential role in regulating the genes of interest.
Results: We found that TERT gene expression was undetectable in healthy bladder tissues but was upregulated in invasive stages and high tumour grade. The TERT expression was linked with the combined presence of C250T promoter mutation and THOR hypermethylation, resulting in progressing tumors and maintaining of telomere length.
In the same BC cohort, we showed that PD-L1 was highest among NMIBC specimens, while PD-L2 was significantly upregulated in MIBC. Similarly, in human bladder cancer cell lines, PD-L2 was expressed in NMIBC stage and increased according to the histological MIBC stage.
We also showed that miR-100-5p and 138-5p, potential regulators of TERT and PD1-Ligands, were highly expressed in healthy bladder specimens and cell lines, while expression decreased in the BC tissues and BC cell lines. In line with the binding prediction scores for these miRNAs on target genes, miRs 100-5p and 138-5p expression strongly inverse correlated with TERT, PD-L1, PD-L2 expression, but not PD1.
Conclusions: Our work highlight a new molecular loop involving TERT, PD1-Ligands and miR-138-5p in BC, that might represent not only a useful biomarker for improved diagnosis and patients’ stratification, but also as a promising axis that can be therapeutically targeted in situ.

Immune checkpoints and telomerase: novel targetable axis in bladder cancer’s management

Introduction & Objectives: The purpose of our study is to investigate to which extent patients with bladder cancer on endovesical installations altered their treatment and whether there are any factors that affected their decision during COVID.
Materials & Methods: We telephone-interviewed 300 consecutive patients and recorded the following parameters: age, sex, cohabitation, region of residence, level of education, employment status, disease duration, current treatment, and presence of co-morbidities. Specific questions with predefined answer options were asked: discontinuation of the medication received, reasons that led to discontinuation, whether advice was received from a clinician or other sources, symptomatology compatible with COVID-19 infection, and a questionnaire to detect nocebo behavior. Univariate and binary logistic regression analyses were performed using 'discontinuation of therapy due to fear of infections, 'discontinuation of therapy due to lack of resources/drug shortage', and 'consultation by a clinician' as dependent variables.
Results: We interviewed 300 patients (77.3% male, mean (+- SD), age 65.4+- 12.1 years, disease duration 4.5+- 3.6 years). 45% were on BCG, 33% on Mitomycin-C, and 22% on epirubicin instillations. Collectively, 5/300 discontinued endovesical instillations due to fear of immunosuppression; all but one were on BCG treatment. Fifteen patients stopped their treatment because of a lack of resources/shortage of drug; in total, 60 patients received advice about possible modifications to their treatment. All but two were guided by a clinician. Therapy withdrawal due to fear of immunosuppression was associated with underlying pulmonary disease in univariate analysis (p=0.022), and with unemployment (OR, 95%CI: 8.13, 1.30 to 65.3, p=0.03) and pulmonary disease (OR, 95%CI: 26.7, 4.16 to 215.3, p=0.003) in regression analysis. Treatment discontinuation due to lack of resources/drug shortage was not associated with any parameter tested. For most patients (68%) the disease remained stable without any recurrence or progression on follow-up cystoscopy. Treatment discontinuation was not associated with a disease exacerbation (p=0.323). Nocebo behavior was detected in 8.5% of the patients.
Conclusions: In conclusion, the discontinuation rate due to fear of immunosuppression in our cohort was low, mostly observed in patients on endovesical BCG instillations. Special consideration should be given to patients with certain social or clinical characteristics, such as unemployment and underlying pulmonary diseases.

Treatment adherence of patients with bladder cancer undergoing endovesical instillations 2 years post-COVID-19 pandemic

Introduction: Patients undergoing urinary diversions are at an increased risk(3-43%) of urolithiasis. Penile fractures are almost unheard of after cystectomy. Upper tract recurrence occurs in 5-10% of carcinoma bladder. Our index case underwent nerve sparing radical cystectomy, had recurrent stone formations, penile fracture repair and radical nephroureterectomy with conduit stone removal in the fifth year of follow-up. Clinical findings: A 40-year-old man underwent an uneventful nsRARC +IC 5 years ago. Bricker uretero-ileal anastomoses were performed. On follow-up, was found to have a lower ureteric calculus, for which he underwent flexible lithotripsy. After 2 years, he had a penile fracture with a 1 cm corporal defect with urethral involvement. After further 2 years, he had a recurrence in the left renal pelvis and 2cm stone in the ileal conduit, for which he underwent laparoscopic radical nephroureterectomy, ileal cuff excision and stone removal. Diagnosis & Treatment: Intraoperatively, laparoscopic nephroureterectomy was performed. Using a midline incision, challenging adhesiolysis was done to identify the conduit, dissect the left ureter, dismember the ureteroileal anastomosis with a cuff and remove the stone. The ileal defect was repaired in 2 layers. Right ureteric anastomosis left undisturbed. Total intraoperative time was 175 minutes. Patient is doing well 3 weeks post-operatively. Conclusions: A careful nsRARC can preserve potency, as evidenced by the penile fracture, a first to be reported to the best of our knowledge. A longer than usual length(30cm) of conduit can promote stone formation. Bricker ureteroileal anastomosis has the advantage over Wallace technique in such cases.

An eventful 5 year follow up of robotic radical cystectomy and ileal conduit involving recurrent stone surgeries, penile fracture repair with urethroplasty and laparoscopic assisted radical nephroureterectomy

Introduction: Urethral recurrence rates for transitional cell carcinoma have been shown to be 6.2% in patients post radical cystectomy. These are best managed with a total urethrectomy which are often challenging. We highlight the case of an elderly gentleman with urethral recurrence following radical cystoprostatectomy and the intraoperative challenges faced.
Clinical findings: A 76 year old male known case of hypertension, coronary artery disease (post CABG) presented 2 years back with chief complaints of storage LUTS and intermittent hematuria. On evaluation, he was diagnosed to have bladder mass for which he underwent a TURBT. Histopathology revealed high grade muscle invasive bladder carcinoma. Patient underwent open radical cystoprostatectomy with ideal conduit after 3 weeks, histopathology was consistent with a pT2N1 disease. Patient had an insignificant postoperative period. He received 6 cycles of Gemcitabine chemotherapy and was advised to start radiotherapy. Patient was lost to follow up for two years. Now he presented with urethral bleed, cytology revealing suspicion of high grade urothelial carcinoma. PET CT was normal. Patient underwent urethroscopy and biopsy was taken in view of multiple erythematous lesions which revealed invasive high grade urothelial carcinoma. He was thus diagnosed to have posterior urethral recurrence for which total urethrectomy was done.
Diagnosis & Treatment: A midline perineal incision was given and urethra defined. Urethra with corpus spongiosum was seperated from underlying corpora cavernosa after penile inversion. Challenges included dissecting the proximal bulbar end from the dense fibrosis present and coring out the distal end. Urethrectomy specimen was taken out in toto and histopathology revealed a pT1Nx rumor with GATA 3 positive cells. Patient had an uneventful postoperative period and is doing well.
Conclusion: Prostate involvement with urothelial carcinoma, tumor multifocality, node positivity and type of urinary diversion are significantly associated with Urethral recurrence following radical cystectomy. A positive urethral margin is considered an absolute indication for prophylactic urethrectomy. Total urethrectomy is the mainstay of management of secondary urethral cancers following RC. Challenges include prevention of a rectal injury while seperating the proximal end off the fibrosis and coring out the distal end off the glans.

Urethral recurrence following radical cystoprostatectomy: diagnosis and surgical management

Introduction: During the embryonic period, the urachus connects bladder to alantaoid. In the 34th week of pregnancy, this structure involute and forms the umbilical ligament. If partial involution of the urachus occurs, malignant transformation may develop. Urachal cancer accounts for less than 1% of all bladder cancers. It appears more frequently in adult males. The most frequent histological type is adenocarcinoma of mucinous subtype. The most frequent symptoms are hematuria, bacteriuria, mucinuria, pelvic pain or mass. The typical locations of this tumor are the bladder dome or the anterior wall of the bladder. It has an unfavorable prognosis due to the late onset of symptoms and the high risk of metastasis. We present a case of urachal adenocarcinoma diagnosed by histological study of a cystoprostatectomy indicated for invasive urothelial neoplasia. Clinical findings: 56-year-old male, former smoker, under study for first episode of monosymptomatic gross hematuria. We weren't found pathologic data on physical examination or ultrasound. However, urethrocystoscopy revealed a lesion of approximately 3.5 cm in bladder dome suspicious for malignancy. Diagnosis & Treatment: Due to the suspicion of neoplasia, transurethral resection (TUR) of the lesion was performed. Histological analysis was compatible with infiltrating urothelial carcinoma. The extension study didnt show distant involvement. Urological tumors committee decided to begin neoadjuvant treatment with 4 cycles of the MVAC scheme. (methotrexate, vincristine, adriamycin and cisplatin). The control CT scan showed an adenopathy in the left iliac bifurcation suspicious of tumor involvement. Subsequently, radical cystoprostatectomy was performed. The histological study was a mucinous urachal adenocarcinoma with presence of signet ring cells. Staging according to the Sheldon system was stage IV A due to iliac lymph node involvement. Conclusions: Urachal adenocarcinoma is a rare neoplasm with scare evidence about its management. The treatment of choice is cystoprostatectomy with wide urachal resection. Neoadjuvant or adjuvant chemotherapy and radiotherapy haven't demonstrated a survival benefit. It’s a tumor with a poor prognosis due to the high number of lymph node recurrences and distant metastases, so early diagnosis and management are essential.

Urachal mucinous adenocarcinoma: simulating muscle-invasive urothelial carcinoma

Introduction: Despite its macroscopic similarity to bladder cancer, nephrogenic adenoma is a rare lesion. However, the incidence has been on the rise in recent years. It is a urothelial metaplasia in the form of a polypoid or papillary lesion. The macroscopic appearance is difficult to distinguish from bladder cancer.
We present two cases of nephrogenic adenoma and a systematic review of the literature.
Clinical findings: Male, 84 years old and 75 years old, both with a history of prostate adenocarcinoma treated with radiotherapy (RT) and former smokers. Under follow-up for high grade T1 bladder carcinoma. Both urologically asymptomatic.
In the first case, in a control urethrocystoscopy 3 years after transurethral resection of the bladder, a polypoid lesion was observed in the left lateral wall.
In the second case, also at a follow-up urethrocystoscopy 6 years after transurethral resection of the bladder, a 2-cm flat lesion was observed in the trigone.
Diagnosis & Treatment: Due to the suspicion of bladder neoformation, transurethral resection of the described lesions was performed.
In the first case, the anatomopathological result of the lesion was nephrogenic adenoma and low grade non-invasive urothelial carcinoma. Subsequently, the patient suffered a recurrence in the form of invasive urothelial carcinoma.
In the second case, the histological result was compatible with nephrogenic adenoma. No recurrences of nephrogenic adenoma or urothelial cancer have been diagnosed in follow-up urethrocystoscopies.
Conclusions: Nephrogenic adenoma is a rare bladder lesion, with fewer than 70 cases published in the literature. It is usually diagnosed in adult males. They are often asymptomatic, although the most common form of presentation is voiding symptoms in the form of urgency and urinary frequency. Hematuria is less frequent than in bladder cancer.
Its incidence is higher in renal transplant patients. It has also been associated with other antecedents such as permanent bladder catheter, repeated infections, interstitial cystitis, previous bladder surgeries, intravesical instillations of BCG, urinary lithiasis, etc. In our case, both patients had received external RT for the treatment of prostate adenocarcinoma and bladder TUR for urothelial carcinoma prior to the appearance of the nephrogenic adenoma.
Published studies have failed to demonstrate malignant transformation of nephrogenic adenoma. In our case, one of the patients developed invasive urothelial carcinoma 3 years later.
There aren't generalized action protocols at present. Experts recommend complete transurethral resection of these lesions and periodic monitoring with urethrocystoscopy, since they are lesions with a risk of recurrence.

Nephrogenic adenoma: an unusual lesion of urothelium

Introduction: The most frequent clinical expression of ureteral tumors due to retroperitoneal masses is ureterohydronephrosis secondary to extrinsic compression. True ureteral metastasis are most rare and only happening in 0,3-8% of cases
Colorectal carcinoma is the third most frequent cancer. Urinary tract metastases are inusual. Fewer than 40 cases have been published in the literature.
Tumor dissemination is usually by hematogenous route and is usually asymptomatic. It is most often discovered by imaging tests.
We present a case of ureteral metastasis as a form of presentation of rectal adenocarcinoma.
Clinical findings: 67 years old female patient with a history of hematuria and right ureterohydronephrosis by ultrasound without objective cause.
Subsequently, the uro-CT scan showed grade III ureterohydronephrosis with dilatation of the right proximal ureter and change of caliber at the middle ureter with a focal image of solid density inside, suspicious of neoformation at that level.
Diagnosis & Treatment: After discussing the case, the urological tumors committee was decided to perform a diagnostic ureterorenoscopy that showed a neoformation in the right proximal uréter
With this diagnosis, a right nephroureterectomy was performed. The study of the piece was compatible with metastatic involvement of the renal sinus, perihilar fatty tissue and muscular layer of the right ureter due to intestinal carcinoma.
Later, colonoscopy showed a rectal polyp compatible with a well-differentiated and infiltrating rectal adenocacinoma.
The patient received treatment of primary tumor with radiotherapy and chemotherapy. Finally, the disease progressed with pulmonary metastases and patient died.
Conclusions: The diagnosis of urinary tract adenocarcinoma should be considered metastatic initially, as it is a rare disease.
Only this and one other case published in the literature have reported ureteral metastases as a form of initial presentation of colorectal adenocarcinoma.
Due to the small number of published cases, the therapeutic management of these patients isn't standardized. Experts opinion remains that chemotherapy should be the primary treatment.

Ureteral metastasis: an unusual presentation of rectal adenocarcinoma

Introduction: Urethra constitutes a place where other genitourinary malignancies frequently spread to. Primary urethral carcinoma (PUC) is a rare urinary tract tumour, comprising less than 1 % of malignancies that affect male patients. It is considered to be an aggressive tumour which is usually underdetected and also unsatisfactorily treated.
Primary urethral carcinoma (PUC) is a rare malignancy with a poor prognosis. Tumour site constitutes an important prognostic factor. Histology is also fundamental. Urothelial carcinoma is an infrequent subtype of PUC. Owing to its rare nature , histopathological study is so important. GATA3 has been explored as a marker for urothelial carcinoma. Therapeutic management also depends on the clinical stage and tumour site. Penile- preservative surgery can be an option in selected patients. Disease-free survival is variable, being able to reach up to 90% in those of distal location.
We´re presenting a case of a urothelial carcinoma in anterior urethra presented with a bleeding penis mass without any other urinary tract findings.
Clinical findings: An 82-year-old-male, smoker and with high blood pressure ‘s genital examination revealed a bleeding penis mass which affected distal urethra. It was first presented as urinary hesintacy. No local adenopathies were found. No other relevant findings were found either.
Diagnosis & Treatment: The urologist took a biopsy of the lesion. A detailed examination of the piece was performed by the Pathologist. Final histological result was reported as urothelial high grade carcinoma. CT didn’t reveal any other urinary tract tumours. Cystoscopy didn’t find any intravesical lesions either. The patient finally underwent surgery with a partial penectomy. Postoperative follow up was satisfactory. The patient was discharged from the hospital three days after surgery.
Primary urethral carcinoma (PUC) is a rare malignancy with a poor prognosis. Tumour site constitutes an important prognostic factor. Histology is also fundamental. Urothelial carcinoma is an infrequent subtype of PUC. Owing to its rare nature , histopathological study is so important. GATA3 has been explored as a marker for urothelial carcinoma (this technique was used in our case). Therapeutic management also depends on the clinical stage and tumour site.
Penile- preservative surgery can be an option in selected patients. Disease-free survival is variable, being able to reach up to 90% in those of distal location.
Conclusions: Primary urethral carcinoma is a rare condition that Urologists should bear in mind when they find suspicious urethral lesions. Phallus preservative surgery is an option that should be offered to selected patients.

Urothelial carcinoma in anterior urethra. An infrequent subtype of primary urethral carcinoma. A case report

Introduction & Objectives: Chemoradiotherapy is recommended for some patients with MIBC as a bladder-preserving treatment. Pembrolizumab has demonstrated clinical activity in metastatic bladder cancer, MIBC, and non-MIBC (NMIBC), and ongoing phase 2 trials of pembrolizumab plus chemoradiotherapy are promising. The randomized, double-blind, phase 3 KEYNOTE-992 trial (NCT04241185) will evaluate the safety and efficacy of pembrolizumab plus chemoradiotherapy compared with placebo plus chemoradiotherapy in patients with untreated MIBC who chose bladder preservation.
Materials & Methods: Patients eligible for enrollment will be aged ≥18 years, have histologically confirmed MIBC (T2-T4aN0M0) with predominant urothelial histology (≥50%) obtained via diagnostic or maximal transurethral resection of bladder tumor (TURBT) performed within 90 days before enrollment, have planned treatment with one of the radiosensitizing chemotherapy agents specified in the protocol, and have an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0‑2. Approximately 636 patients will be randomly assigned 1:1 to receive pembrolizumab 400 mg every 6 weeks (up to 9 doses) plus chemoradiotherapy or placebo every 6 weeks (up to 9 doses) plus chemoradiotherapy. Patients will be stratified by EOCG PS (0 and 1 vs 2), PD-L1 (combined positive score [CPS] <10 vs CPS ≥10), T stage (T2 vs T3 and T4), and geographic region (United States vs European Union vs rest of the world). The investigator’s choice of chemotherapy must be specified prior to random assignment. Allowed radiosensitizing chemotherapy regimens were cisplatin monotherapy (35 mg/m2 intravenously [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/m2IV twice weekly).Conventional radiotherapy consisting of 64 Gy at 2 Gy/fraction over 6.5 weeks (whole bladder with or without pelvic nodes) or hypofractionated radiotherapy consisting of 55 Gy at 2.75 Gy/fraction over 4 weeks (whole bladder only) are permitted based on local standards of care. Imaging via CT (chest) and CT urography or magnetic resonance urography (abdomen/pelvis/urinary tract) will be performed at 10 weeks after completion of chemoradiotherapy, every 12 weeks until the end of year 2, then every 24 weeks thereafter. Adverse events (AEs) will be monitored throughout the study and up to 30 days after cessation of treatment (90 days for serious AEs). The primary end point is bladder-intact event-free survival (time from random assignment to first documented occurrence of residual/recurrent MIBC, nodal or distant metastases, radical cystectomy, or death from any cause). Secondary end points are overall survival, metastasis-free survival, time to cystectomy, time to occurrence of NMIBC, and safety.
Results: KEYNOTE-992 is enrolling in Asia, Australia, Europe, North America, and South America.
Conclusions: Results of KEYNOTE-992 will provide further clarity on the e