Adjuvant chemotherapy of superficial transitional cell bladder carcinoma: preliminary results of a European organization for research on treatment of cancer. Randomized trial comparing doxorubicin hydrochloride, ethoglucid and transurethral resection alone

Phase I and pharmacology study of intravesical mitoxantrone for recurrent superficial bladder tumors

A phase 1 study of intravesical mitoxantrone was done in patients with superficial bladder tumors recurrent after previous intravesical therapy. Mitoxantrone (5 to 10.5 mg.) was instilled in the bladder via catheter and was left in situ for 2 hours. Each patient received 6 treatments at 1-week intervals. Pharmacology studies were conducted in a subset of consenting patients. Dysuria, urinary frequency and hematuria were dose-limiting at 10 to 10.5 mg., the dose recommended for our phase 2 studies. One patient treated with 7.5 mg. mitoxantrone had bladder contracture after severe bladder injury caused by the drug. The interval free of recurrence increased in 5 of 8 patients treated with 10 to 10.5 mg. mitoxantrone and in 6 of 19 treated at lower dose levels. One patient who had residual evaluable tumor in the bladder at treatment experienced a complete remission for 16 months. Only 1 of 18 patients who underwent pharmacology studies had any mitoxantrone detectable in the blood after intravesical administration. This patient had severe irritative symptoms at treatment. No systemic toxicity was noted in any patient. Of the mitoxantrone instilled into the bladder 33 to 100% (mean 75%) was recovered in the specimen voided at the end of treatment. In summary, intravesical mitoxantrone is reasonably well tolerated and should be studied further at a dose of 10 mg. per week for 6 weeks. Caution should be exercised, since bladder contracture was seen in 1 patient. Systemic absorption and toxicity are negligible.

Bacillus Calmette-Guerin versus doxorubicin versus thiotepa: a randomized prospective study in 202 patients with superficial bladder cancer

We report the second interim analysis of data from a randomized prospective trial comparing the prophylactic effect of 15 courses of 50 mg. doxorubicin, 50 mg. thiotepa or 150 mg. bacillus Calmette-Guerin instilled intravesically against recurrences and progression of superficial transitional cell bladder cancer. Of 202 enrolled patients 176 currently are evaluable with a mean follow-up of 3 years (range 3 to 97 months). The number of patients with recurrences was significantly lower in the bacillus Calmette-Guerin arm (9 of 67) compared to the doxorubicin (23 of 53, p equals 0.002) and thiotepa (20 of 56, p equals 0.003) arms. The over-all recurrence index per 100 patient-months also was lower for the bacillus Calmette-Guerin versus the thiotepa and doxorubicin groups (0.53 versus 1.55 and 1.7, respectively). Bacillus Calmette-Guerin also was superior in preventing recurrences and progression of high risk tumors, that is stage T1, grade 3 or multiple growths, associated or not with carcinoma in situ. In the stage T1 category 19 of 32 (60%) tumors recurred under treatment with doxorubicin, 11 of 33 (33%) with thiotepa and 6 of 49 (12%) with bacillus Calmette-Guerin. Toxicity to intravesical bacillus Calmette-Guerin was higher compared to the other drugs but it was not limiting: bladder irritability and malaise occurred in 42% of the patients, granulomatous cystitis in 16.4% and bladder contraction in 1.4% (1 of 64). The latter complication occurred in a patient whose stage T1m grade 2 tumors had recurred 3 times, who underwent 3 transurethral bladder resections within 15 months and who had received thiotepa for 4 months after having been removed from the study 11 months after entry. Three patients in the doxorubicin group (5.6%) underwent radical cystectomy for local urothelial progression. One patient (1.8%) in the same group died of distant progression. Our preliminary results suggest that at the dose, periodicity and duration used in the study bacillus Calmette-Guerin is significantly superior to the chemotherapeutic agents doxorubicin and thiotepa for the prophylaxis of recurrence and retardation of progression in superficial transitional cell bladder tumors.

Intravesical mitomycin C instillation as a prophylactic treatment of superficial bladder tumor

A study was performed to determine the prophylactic efficacy of intravesical mitomycin C instillation in 43 patients with recurrent (more than 3), multiple (more than 3) or large (more than 3 cm.) superficial bladder tumors (stage Ta or T1). Of the patients 21 were treated with 8 weekly intravesical instillations of 40 mg. mitomycin C after transurethral resection and 22 were followed conventionally. The recurrence rate was 42.9 per cent in the mitomycin C group and 40.9 per cent in the controls during the first 3 months, and it was 81.0 and 77.3 per cent, respectively during 24 months. Recurrences per 100 patient-months were 8.7 and 8.9, respectively. Two patients in the mitomycin C group and 4 controls had recurrent tumors with progression in stage. We conclude tentatively from these observations that intravesical mitomycin C instillation is not effective in the prophylaxis of tumor recurrence in patients at high risk. This finding is contrary to other reports indicating a marked decrease in recurrence with mitomycin C.

Intravesical thiotepa versus mitomycin C in patients with Ta, T1 and TIS transitional cell carcinoma of the bladder: a phase III prospective randomized study

A prospective randomized clinical trial was conducted by the National Bladder Cancer Group to compare thiotepa and mitomycin C in ablating residual Ta, T1 and TIS transitional cell carcinoma of the bladder. Eight weekly instillations were given followed by cystoscopy 4 weeks after the treatment was stopped. The over-all complete response rate based on cystoscopy and either biopsy or cytology was 26 per cent for thiotepa versus 39 per cent for mitomycin C (p equals 0.08). The greatest efficacy was seen in the Ta group with mitomycin C demonstrating superiority over thiotepa. Patients with negative cystoscopy and biopsy but who had positive cytology were considered to be partial responders. When partial and complete responders were combined the over-all response rate was 53 per cent for thiotepa and 63 per cent for mitomycin C (p equals 0.23). Patients with TIS appeared to respond equally to thiotepa and mitomycin C. Toxicity included urinary frequency in 22 of the 73 patients in the thiotepa arm and 31 of the 76 patients receiving mitomycin C. A rash was observed in 2 of the thiotepa group versus 14 of the mitomycin C group. Bone marrow depression occurred in 15 patients receiving thiotepa and in 12 receiving mitomycin C.

Natural history and treatment of low and high risk superficial bladder tumors

Since 1979 a prospective randomized trial was done to examine the efficacy of intravesical doxorubicin as prophylaxis against recurrence. After complete transurethral resection of the tumor, patients were divided into 3 groups at random: group 1-no further treatment after transurethral resection, group 2-doxorubicin twice weekly for 6 weeks and group 3-doxorubicin for 1 year. A total of 268 patients entered the study. Neither frequency of recurrences, tumor progression nor survival rate was improved significantly by the adjuvant treatment, so that only a limited number of patients will profit by instillation therapy. Analysis of previously reported data suggests that patients with superficial bladder tumors can be stratified into groups with appreciable differences in risk of progression. With regard to these results a differentiated use of a "wait and see" adjuvant intravesical therapy and more aggressive treatment after transurethral resection of superficial bladder tumors seems to be indicated rather than a general practice of chemoprophylaxis.

Selecting initial therapy for bladder cancer

Progress has been made at both ends of the spectrum of bladder cancer. The introduction and increasing use of effective intravesical agents for both treatment and prophylaxis of tumors limited to the mucosa or lamina propria has reduced the incidence and frequency of subsequent tumors. At the other end of the spectrum--patients with locally extensive bladder cancer--neoadjuvant or initial chemotherapy is producing complete and partial responses. Hopefully this will translate into an improvement in the cure rate. In arriving at a decision regarding treatment for a patient with bladder cancer the urologist integrates information derived from a thorough endoscopic examination of the lower urinary tract (bladder and urethra), complete grading and staging of resected tumor including results of mucosal biopsies from suspicious and normal appearing urothelium, and cytology obtained by bladder irrigation. Treatment also may be influenced by such factors as prior history and treatment of bladder cancer and the patient's age and medical status. Assuming no prior bladder tumor history, endoscopic resection/fulguration followed by intravesical therapy will be used for tumors confined to the mucosa (Ta or Tcis) or lamina propria (TI). Optimally the urologist should resect all evident tumor and incorporate the intravesical agent as prophylaxis. Cytology and endoscopy will monitor the success of this approach. If the patient develops another superficial tumor while receiving prophylaxis another intravesical agent can be delivered, possibly using an intensive treatment schedule. Several agents have demonstrated effectiveness both for treatment and prophylaxis. They include mitomycin C, thiotepa, Adriamycin (doxorubicin), and bacillus Calmette-Guerin. The indications for radical cystectomy are invasion into the bladder muscle, tumor extension into the prostatic ducts or prostatic substance, or persistent tumor after an adequate trial of one or more intravesical agents used in conjunction with endoscopic resection. The escalating complete and partial response rates associated with combination chemotherapy of metastatic bladder cancer has led to the use of these regimens before considering cystectomy for patients with locally extensive bladder cancer, e.g., T3, T4, and N1-2. Downstaging with chemotherapy in this group of poor-risk patients may be preferable to the traditional approach of proceeding with exenterative surgery or full-dose radiation and considering chemotherapy later when metastases are evident.

The role of adjunctive immunotherapy in superficial bladder cancer

Seventy-eight patients with superficial bladder cancer were entered into a randomized study. A streptococcal preparation, OK-432, was injected into bladder cancers before transurethral resection and instilled into the bladder for 6 months after resection to reduce the recurrence. The control group were only transurethrally resected, as usual. The recurrence rate for patients with primary disease was 3.6 in 100 months for the OK-432 group and 9.1 in 100 months for the control group (P less than 0.05). In the control group, multiple, large, sessile, and high-grade tumors had high recurrence rates. But in the OK-432 group, overall recurrence rates were low in both high-risk and low-risk patients. Supplementary immunotherapy is especially effective and is recommended in high-risk patients.

Absorption of epi-doxorubicin after intravesical administration in patients with in situ transitional cell carcinoma of the bladder

Nine patients with in situ bladder cancer (TIS) were treated by intravesical instillation of epi-doxorubicin (epi-DOX). The amount of anthracycline in 1 ml plasma was in the nanogram range. 78.9 +/- 12.0% and 84.2 +/- 10.6% of the administered dose (30 and 50 mg, respectively) could be recovered.

Stage T1, grade 3 transitional cell carcinoma of the bladder: an unfavorable tumor?

Transurethral resection only was performed in 172 patients with initial stage Ta, T1 transitional cell carcinoma of the bladder. Additional treatment during the course of disease was given to 9 patients with carcinoma in situ and to 8 patients with tumor progression. The mean followup was 106 months. The 10-year survival rates were 95 per cent for patients with stage Ta, grade 1 disease, 89 per cent for stage Ta, grade 2, 84 per cent for stage Ta, grade 3, 78 per cent for stage T1, grade 2 and 50 per cent for stage T1, grade 3. The percentage of first tumor recurrence at the same site increased with tumor grade (stage T1, grade 3 was 74 per cent). The recurrence rate in stage T1, grade 3 tumors (4.08) differed significantly from the other groups of superficial tumors. The tumor progression rate for stage T1, grade 3 tumors (32.5 per cent) was significantly higher as well. The characteristics of stage T1, grade 3 tumors with and without progression were different in regard to multiplicity, recurrence rate, mean interval to recurrence and type of tumor invasion. Of the 13 patients who died of progressive neoplastic disease 11 presented initially with stage T1, grade 3 tumors. When these results are considered it is obvious that a patient with a stage T1, grade 3 tumor deserves additional therapy, such as chemotherapy, immunotherapy or phototherapy.

Prognostic factors in superficial bladder cancer

A retrospective analysis of 91 patients with superficial transitional cell carcinoma (stages Ta and T1) is reported. In all of the patients transurethral resection was the treatment of choice. With the recurrence rate as the primary endpoint of interest it appeared that the number of tumours at presentation, invasion of the lamina propria, and histological grade were to be of prognostic importance. The frequency of tumour progression in our group was found to be 10 per cent. All of the patients who developed muscle invasion had lamina propria invasion at presentation.

Verapamil enhanced in vitro chemosensitivity of a murine bladder carcinoma, FCB

The in vitro enhancement of chemotherapeutic efficacy by verapamil, a calcium antagonist, was assessed using FCB, a transplantable murine transitional cell carcinoma. Exponentially growing FCB cells were partially resistant to treatment with both thiotepa (10(-4) M) and Adriamycin (10(-5) M), however, there was a significant reduction in cell growth when either agent was administered in combination with verapamil (10(-5) M); the effect was evident over a wide range of drug concentrations (10(-4) - 10(-9) M). There was also a pronounced inhibition of DNA precursor incorporation when verapamil was used in combination with either agent. Fluorometric analysis of Adriamycin uptake indicated that verapamil caused an increase in the intracellular concentration of the agent. The data presented are consistent with the postulate that verapamil enhances chemotherapeutic efficacy by altering cellular permeability to the cytotoxic agents. Our study indicates that the use of verapamil in combination with cytotoxic agents for intravesical chemotherapy of bladder tumors may prove to be beneficial in human patients.

Chemical pericystitis: a rare complication of intravesical doxorubicin

We report a rare instance of chemical pericystitis in a 60-year-old man who had undergone transurethral resection of a bladder tumor and subsequent intravesical instillation of doxorubicin. The patient had a high fever lasting for 18 days, lower abdominal pain and mild hydronephrosis. Extravasation of doxorubicin through the resected and thinned region of the bladder wall seemed to be responsible for this complication. The lesion improved spontaneously without any sequela.

Factors influencing the prognosis in bladder cancer

In the categories T1, T2 and T3NxM0 bladder cancer, diameter not exceeding 5 cm, the treatment in the Rotterdam Radio-Therapy Institute consists of interstitial irradiation with needles containing radioactive material. The results of treatment and the role of additional external irradiation are discussed. Category T3NxM0 tumors diameter exceeding 5 cm are treated by external irradiation followed by cystectomy; the results are presented here. Factors influencing prognosis appeared to be degree of differentiation, number of transurethral resections (TURs) prior to definitive treatment, intravenous pyelography (IVP), vascular invasion, T category after preoperative irradiation, and postsurgical histopathologically-assessed T category (pT).