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Neoadjuvant Systemic Therapy in Kidney and Bladder Cancer: Current Evidence and Emerging Paradigms.

Rana R McKay1, Asha Tipirneni2, Rick Bangs3

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Neoadjuvant therapy shows promise for bladder cancer and renal cell carcinoma, with pathologic complete response (pCR) as a key outcome. Artificial intelligence may enhance diagnosis and treatment prediction in genitourinary cancers.

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Area of Science:

  • Genitourinary oncology
  • Neoadjuvant systemic therapy
  • Pathologic response assessment

Background:

  • Neoadjuvant therapy improves outcomes in high-risk localized genitourinary malignancies.
  • Cisplatin-based chemotherapy is standard for bladder cancer; neoadjuvant treatment for renal cell carcinoma is investigational.
  • Pathologic complete response (pCR) is a validated surrogate for survival in bladder cancer.

Purpose of the Study:

  • To examine neoadjuvant therapy and pathologic response in renal cell carcinoma (RCC) and bladder cancer.
  • To explore pathologic biomarker development, including AI applications.
  • To highlight future directions for optimizing therapeutic sequencing and outcomes.

Main Methods:

  • Review of neoadjuvant systemic therapy strategies in bladder cancer and RCC.
  • Evaluation of pathologic response assessment and biomarker development.
  • Exploration of emerging technologies like AI-driven digital pathology.

Main Results:

  • Neoadjuvant chemotherapy with or without immunotherapy is standard in bladder cancer, with pCR as a surrogate.
  • Immune checkpoint inhibitor combinations show promise in RCC, inducing pathologic responses.
  • Gaps remain in standardized criteria, surrogacy, and optimal post-pCR management.

Conclusions:

  • Neoadjuvant therapy is evolving in genitourinary cancers, with pCR as a critical endpoint.
  • AI-driven digital pathology offers potential for improved diagnosis and treatment prediction.
  • Further research is needed to optimize neoadjuvant strategies and integrate novel agents.