Evaluating the impact of 18F-FDG-PET-CT on risk stratification and treatment adaptation for patients with muscle-invasive bladder cancer (EFFORT-MIBC): a phase II prospective trial

Flor Verghote, Lindsay Poppe, Sofie Verbeke, Piet Dirix, Maarten Albersen, Gert De Meerleer, Charlien Berghen, Piet Ost, Geert Villeirs, Pieter De Visschere, Kathia De Man, Daan De Maeseneer, Sylvie Rottey, Charles Van Praet, Karel Decaestecker, Valérie Fonteyne, Flor Verghote, Lindsay Poppe, Sofie Verbeke, Piet Dirix, Maarten Albersen, Gert De Meerleer, Charlien Berghen, Piet Ost, Geert Villeirs, Pieter De Visschere, Kathia De Man, Daan De Maeseneer, Sylvie Rottey, Charles Van Praet, Karel Decaestecker, Valérie Fonteyne

Abstract

Background: The outcome of patients with muscle-invasive bladder cancer (MIBC) remains poor, despite aggressive treatments. Inadequate primary staging, classically performed by computed tomography (CT)-imaging, could lead to inappropriate treatment and might contribute to these poor results. Although not (yet) adapted by international guidelines, several reports have indicated the superiority of 18F-fluorodeoxyglucose-positron emission tomography-CT (18F-FDG-PET-CT) compared to CT in the detection of lymph node and distant metastases. Thereby the presence of extra-vesical disease on 18F-FDG-PET-CT has been correlated with a worse overall survival. This supports the hypothesis that 18F-FDG-PET-CT is useful in stratifying MIBC patients and that adapting the treatment plan accordingly might result in improved outcome.

Methods: EFFORT-MIBC is a multicentric prospective phase II trial aiming to include 156 patients. Eligible patients are patients with histopathology-proven MIBC or ≥ T3 on conventional imaging treated with MIBC radical treatment, without extra-pelvic metastases on conventional imaging (thoracic CT and abdominopelvic CT/ magnetic resonance imaging (MRI)). All patients will undergo radical local therapy and if eligible neo-adjuvant chemotherapy. An 18F-FDG-PET-CT will be performed in addition to and at the timing of the conventional imaging. In case of presence of extra-pelvic metastasis on 18F-FDG-PET-CT, appropriate intensification of treatment with metastasis-directed therapy (MDT) (in case of ≤3 metastases) or systemic immunotherapy (> 3 metastases) will be provided. The primary outcome is the 2-year overall survival rate. Secondary endpoints are progression-free survival, distant metastasis-free survival, disease-specific survival and quality of life. Furthermore, the added diagnostic value of 18F-FDG-PET-CT compared to conventional imaging will be evaluated and biomarkers in tumor specimen, urine and blood will be correlated with primary and secondary endpoints.

Discussion: This is a prospective phase II trial evaluating the impact of 18F-FDG-PET-CT in stratifying patients with primary MIBC and tailoring the treatment accordingly. We hypothesize that the information on the pelvic nodes can be used to guide local treatment and that the presence of extra-pelvic metastases enables MDT or necessitates the early initiation of immunotherapy leading to an improved outcome.

Trial registration: The Ethics Committee of the Ghent University Hospital (BC-07456) approved this study on 11/5/2020. The trial was registered on ClinicalTrials.gov (NCT04724928) on 21/1/2021.

Keywords: 18F-FDG-PET-CT; Distant metastasis; Immunotherapy; Metastasis-directed therapy; Muscle-invasive bladder cancer; Neo-adjuvant chemotherapy; Oligometastasis; Overall survival; Primary staging; Stereotactic body radiation therapy.

Conflict of interest statement

VF has received grant funding from Ipsen and has consulted for Ipsen and Janssen, all unrelated to this research project. PO has received grants from Ferring Pharmaceuticals, Merck, Varian and Bayer, has consulted for Ferring Pharmaceuticals, Bayer, Janssen, Curium and Novartis, all unrelated to this research project. VPC has consulted for Astellas, unrelated to this project. The other authors declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Overview of the EFFORT-MIBC study design. (1) Inclusion and exclusion criteria need to be fulfilled to be included in the study. (2) Stratification into treatment arms is based on the 18F-FDG-PET-CT result. In case of neo-adjuvant chemotherapy, stratification is based on the results of both 18F-FDG-PET-CT’s (e.g. prior to and after neo-adjuvant chemotherapy). Abbreviations: MIBC: muscle-invasive bladder cancer; CT: computed tomography; MRI: magnetic resonance imaging; 18F-FDG-PET-CT: 18F-fluorodeoxyglucose-positron emission tomography-computed tomography; MDT: metastasis-directed therapy
Fig. 2
Fig. 2
Schedule of the follow-up moments and associated assessments and investigations. (1) Follow-up specific for patients receiving neo-adjuvant chemotherapy. (2) Follow-up specific for patients in treatment arm 2. (3) At predefined follow-up visits a standard blood control (including erythrocytes, leucocytes (including formula), thrombocytes, sedimentation, creatinine, electrolytes, liver/renal and inflammatory parameters) is performed. Abbreviations: QOL: quality of life; CT: computed tomography; MRI: magnetic resonance imaging; 18F-FDG-PET-CT: 18F-fluorodeoxyglucose-positron emission tomography-computed tomography; RC: radical cystectomy; TMT: trimodality treatment; MDT: metastasis-directed therapy; M: month(s); FU: follow-up

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