Gemcitabine for the Prevention of Intravesical Recurrence of Urothelial Cancer in Patients With Upper Urinary Tract Urothelial Cancer Undergoing Radical Nephroureterectomy, GEMINI Study

GEMINI: An Open-Label, Single-Arm, Phase II Study of Intraoperative Gemcitabine Intravesical Instillation in Patients Undergoing Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma

This phase II trial studies how well gemcitabine works in preventing urothelial cancer from coming back within the bladder (intravesical recurrence) in patients with upper urinary tract urothelial cancer undergoing radical nephroureterectomy. Drugs used in chemotherapy, such as gemcitabine, 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. Instilling gemcitabine into the bladder during surgery, may reduce the chance of recurrence of upper urinary tract urothelial cancer.

PRIMARY OBJECTIVE:

I. To determine the efficacy of a single intraoperative intravesical instillation of gemcitabine hydrochloride (gemcitabine) at time of radical nephroureterectomy (RNU) for clinically localized upper tract urothelial carcinoma (UTUC) in preventing intravesical recurrence of urothelial cancer (UC) at one year.

SECONDARY OBJECTIVES:

I. To assess time to recurrence for entire duration of follow-up. II. To assess the qualitative and quantitative toxicities.

EXPLORATORY OBJECTIVES:

I. To stratify intravesical UC recurrence free survival by tumor grade, neoadjuvant chemotherapy, tumor stage, ureteral tumor location, and history of bladder cancer.

II. To assess incidence and time to development of muscle-invasive bladder cancer (MIBC).

OUTLINE:

Patients receive gemcitabine hydrochloride intravesically for at least 1 hour at the time of RNU.

After completion of study, patients are followed up at 2 weeks, and 3, 6, 12, 18, and 24 months.

Inclusion Criteria:

• Clinical diagnosis of localized (clinical American Joint Committee on Cancer [AJCC] stage Ta-T4N0M0) low- and high-grade UC of the renal pelvis and/or ureter
• Plan to undergo RNU
• Creatinine < 2.2 mg/dL (194 mmol/L)
• Hemoglobin > 9 g/dL
• White blood cell count >= 3000/uL
• Platelet count > 75,000/uL and < 500,000/uL
• Serum bilirubin levels below 2 times the institution's upper limits of normal
• Alkaline phosphatase levels below 2 times the institution's upper limits of normal
• Aspartate aminotransferase levels below 2 times the institution's upper limits of normal
• Alanine aminotransferase levels below 2 times the institution's upper limits of normal
• Eastern Cooperative Oncology Group (ECOG) performance status score 0 - 2
• Suitable candidate for surgery at the discretion of the investigator
• Patient must be capable of giving appropriate approved informed consent or have an appropriate representative available to do
• Patient with a prior malignancy allowed if adequately treated > 3 years ago with no current evidence of disease
• Women of childbearing potential (WOCBP) must have a negative pregnancy urine test within 28 days of registration, and be using an adequate method of contraception to avoid pregnancy prior to and for at least 6 months after gemcitabine instillation to minimize the risk of pregnancy
• Male patient who has a partner that is a WOCBP must agree to use physician-approved contraceptive methods (e.g., abstinence, condoms, vasectomy) and should avoid conceiving children prior to and for 6 months following gemcitabine instillation

Exclusion Criteria:

• Pure non-urothelial histology; urothelial carcinoma with differentiation allowed
• Evidence of nodal or distant metastases; enlarged retroperitoneal lymph nodes > 2 cm or histologically positive lymph nodes
• History of UC of the bladder within 12 months preceding RNU, or receipt of intravesical therapy within 6 months
• History of or current prostatic urethral, urethral, or contralateral upper tract UC
• Planned radical cystectomy at time of RNU
• Symptomatic urinary tract infection of bacterial cystitis (once satisfactorily treated, patients can enter the study)
• Patient with any current malignancy except for basal or squamous cell skin cancers, noninvasive cancer of the cervix, or any other cancer deemed to be of low-risk for progression or patient morbidity during the trial period (i.e. Gleason 6 prostate cancer, renal mass < 3 cm)
• Women who are pregnant or breastfeeding
• Prisoners or subjects who are involuntarily incarcerated
• Inability for adequate follow-up, including concerns for patient compliance or geographic proximity