Prediction of neo-adjuvant chemotherapy response in bladder cancer: the impact of clinical parameters and routine biomarkers

Figures & data

Figure 1. Inclusion of patients for analysis.

Figure 2. OS (a and c) and CSS (b and d) in months from TURBT of urothelial MIBC patients treated with NAC and radical cystectomy in Helsinki and Turku University Hospitals between 2008 and 2013 (n = 59). The whole patient cohort (a and b), according to treatment response (c and d). TURBT, Transurethral resection of bladder tumour; MIBC, Muscle invasive bladder cancer; NAC, Neo-adjuvant chemotherapy; Complete response, pT0N0; Partial response, < pT2N0; No response, ≥ pT2 and/or N+.

Table 1. Urothelial MIBC patients treated with NAC and radical cystectomy in Helsinki and Turku University Hospitals between 2008 and 2013 (n = 59).

Age	Years, mean/median (range)	64/65 (47–76)
Gender	Male, n (%)	49 (83)
Smoking status known (n = 53)	active or stopped	45 (76)
Center	Turku University Hospital	29 (49)
	Helsinki University Hospital	30 (51)
Grade (WHO 1973)	1	1 (2)
(TURBT)	2	15 (25)
	3	43 (73)
LVI	Yes	16 (27)
(TURBT)	No	43 (73)
pT-category	pT0	26 (44)
(Cystectomy)	pTa-T1, Tis	10 (17)
	pT2	11 (19)
	pT3	10 (17)
	pT4	2 (3)
pN-category	pN0	52 (88)
(Cystectomy)	pN+	6 (10)
	data missing	1 (2)
Response to NAC	Complete Response (T0N0)	26 (44)
	Partial Response (Ta-T1, Tis, N0)	10 (17)
	No Response (≥T2 and/or N+)	23 (39)
NAC regimen	Cisplatin-Gemcitabine	56 (95)
	Carboplatin-Gemcitabine	3 (5)
Cycles of NAC	2	7 (12)
	3	22 (37)
	4	29 (49)
	6	1 (2)
Follow-up	months, mean/median (range)	49/49 (3–93)
Patient status	Alive, no evidence of disease	46 (78)
	Dead do to MIBC	8 (14)
	Dead do to other reason	5 (8)
MIBC	Muscle invasive bladder cancer
NAC	Neo-adjuvant chemotherapy
TURBT	Trans-urethral resection of bladder tumour
LVI	Lympho-vascular invasion

Table 2. Immuno-histochemical markers selected to stain the cancer samples from TURBT sections and their distribution according to expression.

Marker		n (%)
p53	≤10% expression	31 (53)
(n = 59)	>10% expression	28 (47)
Ki-67	Low expression	29 (49)
(n = 59)	High expression	30 (51)
Her-2	No expression	16 (28)
(n = 58)	Any expression	42 (72)
EGFR	No expression	45 (76)
(n = 59)	Any expression	14 (24)

Ki-67 was dichotomized by the mean value (62.8).

Table 3. Correlation between marker status with both WHO Grade and Lympho-vascular invasion (LVI) from TURBT sections.

Marker		Grade (WHO 1973)			LVI
		1-Feb	3	p-value	No	Yes	p-value
p53	≤10% expression	14 (45)	17 (56)		26 (84)	5 (16)
(n = 59)	>10% expression	2 (7)	26 (93)	0.001*	17 (61)	11 (39)	0.077
Ki-67	Low expression	11 (38)	18 (62)		21 (72)	8 (28)
(n = 59)	High expression	5 (17)	25 (83)	0.084	22 (73)	8 (27)	1.000
Her-2	No expression	3 (19)	13 (81)		12 (75)	4 (25)
(n = 58)	Any expression	13 (31)	29 (69)	0.514	31 (74)	11 (26)	1.000
EGFR	No expression	14 (31)	31 (69)		34 (76)	11 (24)
(n = 59)	Any expression	2 (14)	12 (86)	0.310	9 (64)	5 (36)	0.485

Pearson Chi-square test was used to calculate the correlation between marker status and Grade or Lympho-vascular invasion.

Fisher’s exact test was used if less than five units were available.

Ki-67 was dichotomized by the mean value (62.8).

*Significant p-value.

Table 4. Binary logistic regression analysis evaluating associations of variables with chemotherapy response in cystectomy specimen.

	Complete response (vs partial and No response)		Complete and partial response (vs No response)
	OR	95 % CI	OR	95 % CI
Age	1.029	0.958–1.105	1.027	0.955–1.103
Gender
Male	Reference		Reference
Female	0.818	0.25–3.268	0.354	0.088–1.429
Smoking (data available n = 53)
Active/Stopped	Reference		Reference
Never	2.281	0.485–10.732	1.111	0.236–5.238
WHO Grade (TURBT)
1 or 2	Reference		Reference
3	2.100	0.623–7.074	0.918	0.281–2.994
LVI (TURBT)
Yes	Reference		Reference
No	1.018	0.320–3.236	0.918	0.281–2.994
Cycles of chemotherapy
2 or 3	Reference		Reference
4 or 6	2.171	0.760–6.200	4.044	1.321–12.377
p53
≤10%	Reference		Reference
>10%	1.200	0.428–3.361	0.733	0.257–2.095
Ki-67
Low	Reference		Reference
High	1.636	0.580–4.615	0.514	0.177–1.491
Her-2 (n = 58)
No expression	Reference		Reference
Any expression	3.300	0.914–11.910	2.000	0.620–6.452
EGFR
No expression	Reference		Reference
Any expression	1.368	0.411–4.558	1.827	0.497–6.715

Complete response pT0N0; Partial response < pT2N0; No response pT2 and/or N+. Ki-67 was dichotomized according to mean value (62.8).

Table 5. Univariate Cox regression analysis (OS and CSS) evaluating association of variables for survival.

	OS		CSS
	HR	95% CI	HR	95% CI
Age	1.057	0.974–1.148	1.007	0.915–1.108
Gender
Male	Reference	–	Reference	–
Female	2.978	0.907–9.781	6.019	1.497–24.200
Smoking (n = 53)
Active/Stopped	Reference	–	Reference	–
Never	1.244	0.267–5.800	3.145	0.575–17.196
Grade (TURBT)
1 or 2	Reference	–	Reference	–
3	2.044	0.450–9.280	2.044	0.450–9.280
LVI (TURBT)
No	Reference	–	Reference	–
Yes	1.846	0.603–5.657	2.954	0.736–11.851
Chemocycles
2 or 3	Reference	–	Reference	–
4 or 6	0.924	0.281–3.033	0.935	0.234–3.741
NAC
Cis-Gem	Reference	–	Reference	–
Regimen
Car-Gem	1.388	0.180–10.707	2.441	0.300–19.851
pT
T0	Reference	–	Reference	–
Ta-T4	2.010	0.617–6.546	5.990	0.736–48.730
T0, Ta, T1, Tis	Reference	–	Reference	–
T2–T4	2.299	0.767–6.888	5.610	1.128–27.909
pN
N0	Reference	–	Reference	–
N+	6.188	1.801–21.261	6.430	1.526–27.092
p53
	Reference	–	Reference	–
	1.238	0.414–3.701	3.375	0.681–16.723
Ki-67
Low	Reference	–	Reference	–
High	0.781	0.262–2.326	0.546	0.130–2.287
Her-2
No expression	Reference	–	Reference	–
Any expression	0.700	0.225–2.177	2.633	0.324–21.406
EGRF
No expression	Reference	–	Reference	–
Any expression	0.509	0.112–2.323	0.459	0.056–3.728

Ki-67 was dichotomized according to the mean value (62.8).

Table

Antigen	Antibody clone and vendor	Antibody dilution	Primary antibody incubation time
Ki-67	MIB-1, DAKO	1:100	32 min
p53	DO-7, DAKO	1:500	24 min
c-erbB2 (HER-2)	4B5, Roche	1:166*	48 min
EGFR	31G7, Invitrogen	1:25	30 min

*Ready-to-use solution with an antibody concentration of approximately 6 µg/mL.