A low dose bacillus Calmette-Guerin regimen in superficial bladder cancer therapy: is it effective?

BCG versus epirubicin in the prophylaxis of multiple superficial bladder tumours: results of a prospective randomized study using modified treatment schemes

A prospective randomized trial on 94 eligible patients evaluated and compared the efficacy of adjuvant intravesical epirubicin and bacillus Calmette-Guérin (BCG) after complete resection of multifocal superficial bladder cancer. BCG treatment schedule consisted of an induction 6-week course of instillations (150 mg Pasteur BCG per instillation) and single maintenance doses to patients who remained free of recurrences at follow-up examinations for a total treatment period of 2 years. These initial responders received additionally a separate 4-week course of therapy 6 months after the start of treatment. Chemoprophylaxis included an early (on the second postoperative day) instillation followed by 4 weekly treatments with epirubicin (50 mg per instillation) and then by 10 monthly treatments for the initial responders during the first year of follow-up and at every follow-up examination for a total treatment period of 2 years. The overall treatment results did not differ significantly between the 2 arms (54% of patients of the epirubicin group remained free of recurrences compared to 65% of those treated with BCG) for an identical mean follow-up of 35.1 months. However, a significant benefit in favour of BCG when compared with epirubicin was shown in patients who had stage T1 and grade 3 tumours and in terms of relative risk of recurrences, disease-free interval and recurrence rate per 100 patient-months. Both drugs were proved to be safe with manageable toxicity.

Evaluation of a low-dose intravesical bacillus Calmette-Guérin (Tokyo strain) therapy for superficial bladder cancer

To examine whether intravesical instillation of low-dose bacillus Calmette-Guérin (BCG) therapy is effective with low toxicity, we reviewed data for 111 patients with superficial bladder cancer (stages Ta and T1). Among them, 74 received the BCG treatment for prophylaxis of intravesical recurrence after transurethral resection, and the remaining 37 therapeutically for Ta or T1 tumours. The patients were divided into two groups by instillation dose of BCG (Tokyo 172 strain): 40 mg (n = 55) and 80 mg (n = 56), and statistically compared for recurrence, antitumour effect and toxicity. The mean instillations were done 8.4 times in the 40 mg dose group and 8.6 times in the 80 mg dose group. Among the 74 patients with BCG therapy for prophylaxis those with a previous episode of bladder cancer treatment (n = 47) experienced a significantly (p = 0.006) shorter recurrence-free interval than those with no episode (n = 27). Among 47 patients with a previous treatment episode, those receiving the 80 mg dose demonstrated a significantly longer recurrence-free interval than those given the 40 mg dose (p = 0.03). Among the 27 patients without previous treatment no significant difference in recurrence-free intervals was found between the two dose groups. Univariate and multivariate analyses using Cox's proportional hazards model confirmed the above findings. The recurrence index was also significantly reduced after BCG therapy in the 80 mg and 40 mg groups and similar antitumour effects for Ta or T1 tumours were observed in the two dose groups. The degree of toxicity due to BCG therapy was significantly (p = 0.02) lower with the 40 mg dose. The present study suggests that (1) a 40 mg BCG low-dose (Tokyo 172 strain) regimen is useful for preventing recurrence, with sufficient therapeutic efficacy and low frequency of toxicity, among patients without a previous treatment, and (2) prophylactic effects with the 80 mg dose regimen are much superior for previous treatment cases.

Il BCG nei tumori superficiali della vescica

The Authors’ aim is to report on their experience in treating superficial bladder cancer with Bacillus Calmette-Guerin, comparing the results with other kinds of therapy.

Five-year results of a phase II study with low-dose bacille Calmette-Guerin therapy in high-risk superficial bladder cancer

OBJECTIVES

Numerous studies have shown bacille Calmette-Guérin (BCG) to be an effective prophylactic and therapeutic agent for superficial transitional cell carcinoma of the bladder. The high-grade T1 lesion treated by transurethral resection alone is reported to progress to muscle invasion in 30% to 50% of the patients. Until now, optimal treatment schedule and optimal dose have not been defined. As suggested by Pagano's group, we used BCG in a lower dose than hitherto usual in our high-risk cancer patients.

METHODS

Five years ago, we treated 32 Stage T1 cancer patients who were described as at high risk based on the criteria of histologic grade 3 in 21 patients, grade 2, but multiple in 11 patients, and with carcinoma in situ in 17 patients. Follow-up ranged from 51 to 63 months, with a mean of 57 months. We used BCG strain Pasteur Paris 75 mg weekly for 6 weeks and then maintenance therapy monthly for the first year and every 3 months for the second year. Complete remission was defined as negative cystoscopy, biopsy, and cytology.

RESULTS

After a single 6-week course of BCG, 25 patients had negative cytology and biopsy findings after 3 months; 2 other patients needed a second 6-week cycle of BCG, for an overall response rate of 80%. Five patients underwent cystectomy because of multiple recurrences and tumor progression. After 2 years of follow-up, but under continuing maintenance therapy, 3 additional patients had tumor recurrences and also underwent cystectomy. Now, after 5 years' follow-up, the overall progression rate to cystectomy was 25% (8 of 32 patients), but none of the patients had progression to metastasis. Treatment-related toxicity did not appear to be lower at a lower dose of BCG.

CONCLUSIONS

Low-dose BCG therapy is also an effective treatment in high-risk T1 bladder cancer (especially with maintenance therapy and short-term evaluations of the patients always by the same controlling physician) to prevent progression and recurrence and to preserve bladder function.

Interaction between fibronectin-bearing surfaces and Bacillus Calmette-Guérin (BCG) or gelatin microparticles

Gelatin, prepared commercially by degradation of animal collagen, was studied to see whether it had an affinity for fibronectin, which has a known affinity for collagen, and whether gelatin-based drugs could be used to target fibronectin-excreting tumours. Bacillus Calmette-Guérin (BCG) vaccine, an attenuated strain of Mycobacterium bovis, is currently the most effective treatment for superficial transitional cell carcinoma of the bladder. The living cells of the BCG vaccine associate with the fibronectin-bearing surfaces of the tumour. Using a multi-well culture plate technique, gelatin microparticles were shown to be adsorbed onto murine S180 sarcoma cells and this reaction was substantially inhibited by the addition of human plasma fibronectin. The avidities of various BCG substrains and gelatin microparticles for glass-bound fibronectin were measured and the association constants determined. The gelatin microparticles associated with the fibronectin with equal avidity as the BCG cells. The results suggest that this model system may allow the investigation of gelatin-based drug delivery devices capable of targeting fibronectin-bearing surfaces associated with some tumours.

Low-dose bacille Calmette-Guérin (BCG) therapy in superficial high-risk bladder cancer: a phase II study with the BCG strain Connaught Canada

OBJECTIVE

To evaluate low-dose bacille Calmette-Guérin (BCG) therapy, with the Connaught Canada strain, in patients with superficial transitional cell carcinoma (STCC) of the urinary bladder.

PATIENTS AND METHODS

Between September 1990 and December 1992 25 patients were entered into a phase II study to evaluate the feasibility, response and toxicity of BCG immunotherapy for patients with high-risk STCC. Therapy consisted of six, weekly instillations of 27 mg (3 x 10(8) colony-forming units) of the BCG strain Connaught Canada. Maintenance therapy was administered monthly for 1 year with the same dosage.

RESULTS

Of 25 eligible patients, 84% had complete responses after the initial cycle with low-dose BCG and had stable disease. Four patients had no response, three of whom subsequently underwent radical cystectomy. The mean length of follow-up was 30.8 months (25-36). Toxicity included profound local reactions such as severe dysuria, frequency and gross haematuria. No systemic infections, except fever, were seen; none of the patients needed isoniazid. All reactions were treated symptomatically.

CONCLUSIONS

The results of this study suggest that low-dose BCG with the strain Connaught Canada can be successfully used in the treatment of patients with high-risk STCC. Toxicity was not reduced substantially by the lower dosage of BCG used.

Bacillus Calmette-Guérin treatment of existing papillary bladder cancer and carcinoma in situ of the bladder. Four-year results. The Bladder Cancer BCG Study Group

BACKGROUND

Intravesical instillation therapy of Bacillus Calmette-Guérin (BCG) has become a standard treatment for carcinoma in situ (CIS) of the urinary bladder. However, there have been few reports concerning the direct effect of BCG on existing tumors classified as Ta or T1. In the first stage of this clinical study, 157 patients were treated with BCG intravesical instillation (Tokyo 172 strain [BCG Co. Ltd., Tokyo, Japan]; 80 mg weekly for eight times) by our Study Group. The efficacy on existing tumors was a complete response (CR) rate of 84.4% and 66.4% and a partial response (PR) of 6.3% and 20.8% for 32 cases of CIS and 125 cases of Ta or T1 tumors, respectively.

METHODS

In the second stage of this study, the authors investigated the outcome of the 138 patients who had achieved CR or PR in the first stage. One hundred twenty (87.0%) of the patients were followed fully. Of those patients, 52 were randomized to receive prophylactic (maintenance) therapy consisting of BCG of 40 mg monthly for 12 times (Group A), whereas 55 were randomized to an untreated control group (Group B). Thirteen other patients refused to be randomized and were followed without prophylactic instillation.

RESULTS

The median follow-up period was 48 months for Group A and 42 months for Group B. In Groups A and B, the beneficial effect of the BCG therapeutic instillation persisted for a long time, and the 3-year nonrecurrence rate was 77.6% in Group A and 74.2% in Group B. Disease progression was observed rarely.

CONCLUSION

For patients in whom transurethral resection of tumors of the bladder (TUR-Bt) alone is unlikely to eliminate the tumor, intravesical BCG is potentially the treatment of choice.

Intravesical bacillus Calmette-Guerin for superficial bladder cancer: experience with Danish 1331 strain

A total of 95 patients with stage Ta/T1 superficial bladder cancer was eligible for intravesical bacillus Calmette-Guerin (BCG) immunoprophylaxis according to the standard high risk criteria for tumor recurrence and progression. Of these patients 50 agreed to undergo treatment while the remaining 45 refused any intravesical therapy and served as concurrent nonrandomized controls. The patient and tumor characteristics in the 2 groups of patients were identical. All patients underwent complete transurethral resection of the bladder tumor. Therapy consisted of 120 mg. weekly instillations of BCG (Danish 1331 strain) for 6 weeks. Among the 50 patients 33 received BCG initially while 17 received it after failure of intravesical chemotherapy. Responses were evaluated according to standard criteria. Recurrence was noted in 24 patients (48%) in the BCG group compared to 38 (84.4%) in the control group. The recurrence rates per year and per 100 patient-months were significantly reduced in the BCG arm compared to the control arm. The mean interval to first recurrence and the mean recurrence interval were significantly increased in the BCG arm compared to the control arm. The relative risk of recurrence in the BCG group was 0.62 versus 1.63 in the control group. Subgroup analysis showed significant benefit of BCG for patients with single as well as multiple, stages Ta and T1, and grades II and III tumors. Comparison with pretreatment controls in the BCG group revealed a significant reduction in the recurrence rate in those patients after treatment with BCG, which was not seen in the control group. The benefit of BCG was seen in those who received BCG initially as well as in those who received it after failure of intravesical chemotherapy. Multivariate analysis of prognostic factors showed that this benefit in the BCG group was related only to the treatment, while other prognostic parameters, such as tumor stage, grade, number and so forth were not independent prognostic variables. The rate of progression to muscle invasion was not significantly different in the 2 treatment groups. The relapse-free survival in the BCG group was 35.4% at 60 months compared to 11.2% in the control group (p < 0.001). The side effects of BCG therapy were mild, brief and easily controlled with conservative measures.

Immunotherapy with bacille Calmette-Guérin in patients with superficial transitional cell carcinoma of the bladder associated with bilharziasis

OBJECTIVE

To test the effectiveness and possible side-effects that may result from intravesical immunotherapy with bacillus Calmette-Guérin (BCG) for superficial bladder cancer associated with bilharziasis.

PATIENTS AND METHODS

Intravesical instillation of the Pasteur strain of BCG was carried out in 13 patients after transurethral resection of superficial transitional cell carcinoma (TCC) associated with bilharziasis. The recurrence rate in these patients was compared retrospectively with that of 17 patients with superficial TCC associated with bilharziasis in whom a recurrence had occurred previously and who had not received immunotherapy.

RESULTS

There was a statistically significant decrease in the recurrence of tumours after intravesical BCG therapy. The tumour-free period after BCG treatment was 15.7 months compared with 6.7 months in the control group.

CONCLUSION

The presence of bilharziasis does not appear to influence the effectiveness of immunotherapy with BCG for superficial bladder cancer.

Dosaggio dell'interleuchina urinaria nel monitoraggio della terapia con BCG endocavitario nel carcinoma superficiale della vescica

To study the local immunological effects of BCG therapy in superficial bladder cancer patients, the Authors have investigated the production of interleukin-2 in the urine. Urine specimens were collected before and halfway through the six-week BCG instillation cycle. The Authors have analysed the correlation between the presence of IL-2 in the urine and the clinical response to BCG therapy.

Total cystectomy after intravesical bacillus Calmette-Guérin (Tokyo strain) therapy for superficial bladder cancer: experience in Japan

To clarify which patients might most require total cystectomy after intravesical bacillus Calmette-Guérin (BCG) therapy, we reviewed data for 111 individuals with superficial bladder cancer. Of the 111 patients, 73 received the BCG treatment for prophylaxis of intravesical recurrence after transurethral resection (group 1), 24 therapeutically for Ta or T1 tumours (group 2), and 14 for eradicating carcinomas in situ (CIS, group 3). Although the BCG therapy significantly reduced frequencies of recurrence in group 1, 27 patients (37%) did develop tumours again. Tumours disappeared in 18 of 24 patients (75%) in group 2, and in 11 of 14 (79%) in group 3. The rate of disease progression was 6% for all 111 patients: 3% (2/73) for group 1, 17% (4/24) for group 2, and 7% (1/14) for group 3. A total of 16 of the 111 patients (14%) underwent total cystectomy, the respective figures being 7% in group 1, 29% in group 2, and 29% in group 3. Indications for total cystectomy were progression in 7, recurrent multiple tumours in 5, persistent CIS in 2, a contracted bladder in 1, and occurrence of bilateral renal pelvic cancer in 1. Thus, 4 of 6 patients (67%) who had tumours unresponsive to BCG therapy in group 2 demonstrated progression and necessitated total cystectomy. Because tumours persisting after BCG therapy are frequently of the muscle-invasive type, such cases should be regarded as candidates for immediate total cystectomy.

A randomized trial of early intravesical instillation of epirubicin in superficial bladder cancer. The Nagoya University Urological Oncology Group

A total of 135 patients with superficial bladder cancer diagnosed as totally resectable were entered into a randomized multicenter trial to investigate the efficacy of early intravesical epirubicin instillation after resection in comparison with transurethral resection (TUR) alone. Epirubicin (40 mg/40 ml saline) was given within 24 h of TUR and once during the 1st week, weekly for 4 weeks and then monthly for 11 months. In all, 122 patients (90.4%) were eligible and 119 (88.1%) were evaluable. The interval to initial recurrence was significantly longer (P = 0.02) in the epirubicin group (36 months; 95% confidence interval, 32-40 months) than in the group receiving TUR alone (28 months; 95% confidence interval, 24-32 months). The recurrence rate per year in the epirubicin group was less than that in the TUR-alone group (0.13 versus 0.29 annual recurrences). Disease progression was observed in only one patient in the epirubicin-instillation group. The main toxicity encountered was bladder irritation (13.8%). These results demonstrate that early intravesical epirubicin instillation is efficacious in preventing local recurrence.

Immunotherapy of murine bladder cancer with keyhole limpet hemocyanin (KLH)

Keyhole limpet hemocyanin (KLH) is a potent immunogen that is being evaluated as an immunotherapeutic alternative to BCG in the treatment of bladder cancer. In the mouse bladder tumor model (MBT2) intralesional KLH significantly reduced tumor incidence, growth rate, and mortality and exhibited antitumor activity similar to that achievable with BCG. Endotoxin contamination of KLH was not responsible for the antitumor activity, although endotoxin alone was shown to have anti-tumor activity in this animal model. Keyhole limpet hemocyanin is both safe and effective in the MBT2 model, and is an immunomodulator to consider for clinical trials.

Clinical value of pathologic changes after intravesical BCG therapy of superficial bladder cancer

Bladder pathologic features related to intravesical bacillus Calmette-Guerin (BCG) therapy in superficial bladder cancer (Ta, T1, Tis) were evaluated and related to clinical outcome. A total of 105 patients were treated with 75 mg Pasteur BCG weekly for six consecutive weeks. When tumor was not demonstrated a maintenance course was given. An additional six-week course was given when tumor recurrence or persistence, without progression, was observed after the induction course. An inflammatory change in the bladder was the most common pathologic finding. Granuloma was the only specific BCG-related feature and did not appear to be a prognostic factor because of low incidence (24%) and lack of correlation with clinical course. Dysplasia occurred more frequently (57%) in nonresponder patients and (26%) in responder patients, often heralding recurrence of tumor. All patients showing concurrent squamous and/or glandular metaplasia were unresponsive to BCG therapy. Histology and cytology did not correlate perfectly: cytology was ineffective in low-grade tumors and improved diagnostic accuracy, particularly when dysplasia was histologically evident.

Dose-response of bacillus Calmette-Guerin in the treatment of superficial bladder cancer

Although bacillus Calmette-Guerin (BCG) has been recognized as an effective therapy for superficial bladder cancer, dose-response studies are not available. Such studies are important because the administration of the vaccine is not devoid of significant side effects when the standard dose of 120 mg. is used. It has been speculated that smaller doses may be equally effective but carry fewer side effects. A controlled study comparing 2 doses of BCG was conducted as an initial step to explore this possibility. A total of 97 patients with a diagnosis of superficial (stages TIS, Ta and T1) bladder cancer was assigned to receive either 60 or 120 mg. BCG intravesically weekly for 6 weeks. The higher dose resulted in a better response for stages TIS, Ta (for prophylaxis of recurrence) and T1. However, the differences were not statistically significant. When stage TIS and Ta tumors coexisted, a significantly better response was recorded for the high dose. The overall success for the 2 treatments was 67% and 37% for the high and low doses, respectively. These differences reached statistical significance (p less than 0.02). Side effects were significantly less in number and severity in patients receiving the smaller dose of the vaccine.

Intravesical BCG: current results, natural history and implications for urothelial cancer prevention

Bacillus Calmette-Guerin (BCG) has been shown in randomized trials to be the most effective agent against superficial bladder tumors. BCG therapy prevents or reduces tumor recurrences, abrogates tumor progression and improves survival over surgery alone. The optimal BCG schedule varies among patients, reflecting a heterogeneous tumor population. Multifocality, high grade (G2,3) and T1 tumors are risk factors for tumor recurrence or invasion. Patients presenting with such features are most likely to benefit from BCG. An incomplete response to BCG portends a high risk of tumor progression. Non-responders have a 40-60% risk of developing muscle invasion or metastases within 10 years, compared with 10-15% for BCG responders. Further, 80% of non-responders progress in the bladder within 3-5 years. After 5 years, relapses are more common in the prostate (13-35%) and upper collecting system (15-33%); one-half of these are invasive tumors. This suggests that intense therapy directed at premalignant and early bladder lesions coupled with a chemoprevention strategy designed to protect the whole urothelium will be required to reverse a pan-urothelial tumor diathesis.

Comparison of final values in the prophylaxis of superficial transitional cell papillary carcinoma of the bladder, T1G2, treated with mitomycin C, doxorubicin and Bacillus Calmette-Guerin Pasteur intravesical instillations, after therapeutic transurethral resection

In our Department of Urology, from June ‘88 to February ‘92, 135 patients, with superficial transitional cell papillary carcinoma of the bladder, T1G2, were treated with intravesical antiblastic instillations, after therapeutic transurethral resection. 45 patients (33%) were treated with Mitomycin C; 40 patients (30%) were treated with Doxorubicin; 50 patients (37%) were treated with B.C.G. Pasteur. In the Mitomycin Ck group (follow-up 6.’88 ÷ 2.’92), only 20 patients out of 45 (i.e. 44%) were free of tumor at 30.5 months. Of the 16 patients with unifocal carcinoma, 12 patients (i.e. 75%) had no recurrences at 31.2 months, while of the 29 patients with multifocal carcinoma only 8 patients (i.e. 25%) were free of tumor at 29.1 months. In the Doxorubicin group, (follow-up 10.’89 ÷ 2.’92) 33 patients out of 40 (i.e. 82%) were free of tumor at 16.5 months. Of the 15 patients with unifocal carcinoma, 13 (i.e. 86%) had no recurrences at 17 months, while of the 25 patients with multifocal carcinoma 20 (i.e. 80%) were free of tumor at 18.4 months. As to the B.C.G. group (follow-up 11.’89 ÷ 2.’92), 35 patients out of 50 (i.e. 70%) were free of tumor at 13 months. Of the 6 patients with unifocal carcinoma 5 (i.e. 83%) had no recurrences at 7 months, while of the 44 patients with multifocal carcinoma 30 (i.e. 68%) were free of tumor at 13 months. In conclusion, the above reported data show that the best results were obtained in patients treated with Doxorubicin instillations, without significant difference between the results of unifocal and of multifocal carcinoma. Intermediate results were obtained in patients treated with B.C.G., with a moderate but significant difference between unifocal and multifocal carcinoma. The patients treated with Mitomycin C yielded the worst results, and the difference between unifocal and multifocal carcinoma was substantial