Cisplatin, Bevacizumab, and Gemcitabine Followed by Surgery, Bevacizumab, and Paclitaxel in Treating Patients With Locally Advanced Nonmetastatic Bladder Cancer That Can Be Removed By Surgery

RATIONALE: Drugs used in chemotherapy, such as cisplatin, gemcitabine, and paclitaxel, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Monoclonal antibodies, such as bevacizumab, can block tumor growth in different ways. Some find tumor cells and kill them or carry tumor-killing substances to them. Others interfere with the ability of tumor cells to grow and spread. Bevacizumab may also stop the growth of tumor cells by blocking blood flow to the tumor. Giving combination chemotherapy together with bevacizumab before surgery may make the tumor smaller and reduce the amount of normal tissue that needs to be removed. Giving these treatments after surgery may kill any tumor cells that remain after surgery.

PURPOSE: This phase II trial is studying how well giving cisplatin, bevacizumab, and gemcitabine followed by surgery, bevacizumab, and paclitaxel works in treating patients with locally advanced nonmetastatic bladder cancer that can be removed by surgery.

OBJECTIVES:

Primary

• Determine the pT0 status (pathologic complete remission rate, no evidence of disease on cystectomy specimen) in patients with muscle-invasive, resectable, nonmetastatic transitional cell carcinoma (TCC) of the bladder treated with neoadjuvant cisplatin, bevacizumab, and gemcitabine hydrochloride followed by radical cystectomy and adjuvant bevacizumab and paclitaxel.

Secondary

• Determine if urinary survivin and urocytogenetics can predict responses in patients with muscle invasive, resectable, non-metastatic TCC of the bladder treated with neoadjuvant cisplatin and gemcitabine chemotherapy with bevacizumab.
• Evaluate the progression-free and median survival in patients treated with neo-adjuvant cisplatin and gemcitabine hydrochloride chemotherapy with bevacizumab followed by radical cystectomy.
• Determine the feasibility, tolerability and toxicity of neoadjuvant cisplatin and gemcitabine hydrochloride with bevacizumab in patients with muscle invasive, resectable, nonmetastatic transitional cell carcinoma (TCC) of the bladder.
• Correlate pT0 on cystoscopy with pT0 on radical cystectomy in patients treated with neoadjuvant cisplatin and gemcitabine hydrochloride chemotherapy with bevacizumab in patients with muscle invasive, resectable, nonmetastatic transitional cell carcinoma (TCC) of the bladder.
• Determine the influence of adjuvant paclitaxel plus bevacizumab (in pathologic non-complete responders) on progression-free and overall survival rates.
• Determine the safety of bevacizumab use in the adjuvant setting in therapy of locally advanced bladder cancer.
• Determine the rate of postoperative complications, following treatment with neoadjuvant therapy (cisplatin, gemcitabine hydrochloride, and bevacizumab) and radical cystectomy.

OUTLINE: This is a multicenter study.

• Neoadjuvant therapy: Patients receive cisplatin IV over 60 minutes and bevacizumab IV over 30-90 minutes on day 1 and gemcitabine hydrochloride IV over 30 minutes on days 1 and 8. Treatment repeats every 3 weeks for 4 courses in the absence of disease progression or unacceptable toxicity. Patients with nonmetastatic disease at 12 weeks proceed to surgery at least 30 days later.
• Surgery: Patients undergo radical cystectomy. Patients who achieve pT0 status (pathologic complete remission rate, no evidence of disease on cystectomy specimen) are observed off study. Patients with evidence of disease proceed to adjuvant therapy.
• Adjuvant therapy: Patients receive bevacizumab IV over 30-90 minutes and paclitaxel IV over 3 hours on day 1. Treatment repeats every 3 weeks for 3 courses in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed periodically for 6 years.

PROJECTED ACCRUAL: A total of 25 patients will be accrued for this study.

• Biological: bevacizumab
• Drug: cisplatin
• Drug: gemcitabine hydrochloride
• Drug: paclitaxel
• Procedure: adjuvant therapy
• Procedure: conventional surgery
• Procedure: neoadjuvant therapy

DISEASE CHARACTERISTICS:

• Histologically confirmed transitional cell cancer (TCC) of the bladder

  • Staged as follows:

    • Muscle invasive (T2-T4a)

    • Node negative (N0)

      • No histologically or cytologically proven lymph node metastases

    • Nonmetastatic (M0)

      • No evidence of distant metastases
• Resectable disease
• Able to begin protocol treatment within 6 weeks after transurethral resection and cystoscopic evaluation
• No central nervous system or brain metastases

PATIENT CHARACTERISTICS:

• ECOG performance status of 0-2
• Karnofsky 60-100%
• White blood cell count ≥ 3,000/mm^3
• Absolute neutrophil count ≥ 1,500/mm^3
• Platelet count ≥ 100,000/mm^3
• AST(SGOT) and ALT(SGPT) ≤ 2 times upper limit of normal
• Bilirubin ≤1.5 mg/dL
• Creatinine clearance ≥ 60 mL/min
• Urine protein/creatinine ratio < 1.0
• Blood pressure ≤150/100 mm Hg
• No prohibitive medical risks for chemotherapy
• No history of allergic reactions attributed to compounds of similar chemical or biologic composition to cisplatin, gemcitabine hydrochloride, or paclitaxel
• No unstable angina
• No history of myocardial infarction within the past 6 months
• No cardiac arrhythmias
• No New York Heart Association (NYHA) congestive heart failure ≥ grade 2
• No history of stroke within the past 6 months
• No clinically significant peripheral vascular disease
• No evidence of bleeding diathesis or coagulopathy
• No history of abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess within the past 6 months
• No serious nonhealing wound, ulcer, or bone fracture
• No psychiatric illness or other psychosocial situation that would limit ability to comply with study and/or follow-up procedures
• Not pregnant or nursing
• Negative pregnancy test
• Fertile patients must agree to use adequate contraception prior to study entry and for the duration of study participation
• No significant traumatic injury with in the past 28 days

PRIOR CONCURRENT THERAPY:

• No prior systemic chemotherapy
• No prior pelvic radiation therapy
• More than 4 weeks since prior participation in an experimental drug study other than a Genentech-sponsored bevacizumab cancer study
• No concurrent participation in an experimental drug study other than a Genentech-sponsored bevacizumab cancer study
• No major surgical procedure or open biopsy within the past 28 days
• No anticipation of need for major surgical procedure during the course of the study
• No minor surgical procedures, fine-needle aspirations, or core biopsies within the past 7 days

• No concurrent treatment with hormones or other chemotherapeutic agents except the following:

  • Steroids given for adrenal failure
  • Hormones administered for nondisease-related conditions (e.g., insulin for diabetes)
  • Intermittent use of dexamethasone as an antiemetic in solid tumor protocols
• No other concurrent investigational or commercial agents or therapies