Effect of Immunotherapy on Local Treatment of Genitourinary Malignancies

Context: Management of metastatic genitourinary malignancies has recently been transformed through the use of immune checkpoint inhibitors. The best way to integrate them into local treatment paradigms is still under investigation. Objective: To systematically evaluate evidence regarding the use of immunotherapy in the treatment of local disease, in both the perioperative and the metastatic setting. Evidence acquisition: We performed a critical review of PubMed and ClinicalTrials.gov according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement. Prospective and retrospective studies between 2011 and 2018 were included. Twenty-four publications were selected for inclusion, including 10 on urothelial carcinoma, seven on renal cell carcinoma, six on prostate cancer, and one on germ-cell cancer. Evidence synthesis: Prospective early-phase trials investigating neoadjuvant immunotherapy prior to cystectomy in urothelial carcinoma suggest a high rate of pathological complete response, from 29% with atezolizumab to 39.5% with pembrolizumab. Several neoadjuvant and adjuvant trials are still ongoing in bladder, renal, and prostate cancers, before or after surgery. The combination of immunotherapy and radiotherapy is being explored and could offer an interesting strategy for definitive treatment modality with curative intent. Finally, in metastatic disease, delayed local treatment could be discussed after immunotherapy in selected patients with an excellent radiographic response. Conclusions: Little evidence exists on the oncological impact of immunotherapy on the local treatment of genitourinary malignancies, but preliminary results are encouraging and many prospective trials are ongoing. Patient summary: In this study, we review recent advances in immunotherapy and its role in local treatment. Immunotherapy is evaluated before or after surgery, or in combination with radiotherapy for localized disease. Ongoing trials will bring clarity on the local downstaging effect of immunotherapy and its association with oncological and functional outcomes.