Best practice in the treatment of nonmuscle invasive bladder cancer

Intravesical chitosan/interleukin-12 immunotherapy induces tumor-specific systemic immunity against murine bladder cancer

Bladder cancer is a highly recurrent disease in need of novel, durable treatment strategies. This study assessed the ability of an intravesical immunotherapy composed of a coformulation of the biopolymer chitosan with interleukin-12 (CS/IL-12) to induce systemic adaptive tumor-specific immunity. Intravesical CS/IL-12 immunotherapy was used to treat established orthotopic MB49 and MBT-2 bladder tumors. All mice receiving intravesical CS/IL-12 immunotherapy experienced high cure rates of orthotopic disease. To investigate the durability and extent of the resultant adaptive immune response, cured mice were rechallenged both locally (intravesically) and distally. Cured mice rejected 100 % of intravesical tumor rechallenges and 50-100 % of distant subcutaneous rechallenges in a tumor-specific manner. The ability of splenocytes from cured mice to lyse targets in a tumor-specific manner was assessed in vitro, revealing that lytic activity of splenocytes from cured mice was robust and tumor specific. Protective immunity was durable, lasting for at least 18 months after immunotherapy. In an advanced bladder cancer model, intravesical CS/IL-12 immunotherapy controlled simultaneous orthotopic and subcutaneous tumors in 70 % of treated mice. Intravesical CS/IL-12 immunotherapy creates a robust and durable tumor-specific adaptive immune response against bladder cancer. The specificity, durability, and potential of this therapy to treat both superficial and advanced disease are deserving of consideration for clinical translation.

Exosomal protein interactors as emerging therapeutic targets in urothelial bladder cancer

BACKGROUND

Exosomes are rich sources of biological material (proteins and nucleic acids) secreted by both tumor and normal cells, and found in urine of urinary bladder cancer patients.

OBJECTIVE

The objective of the study was to identify interacting exosomal proteins in bladder cancer for future use in targeted therapy.

METHODS

The Exocarta database (www.exocarta.org) was mined for urinary bladder cancer specific exosomal proteins. The urinary bladder cancer specific exosomal proteins (n=248) were analyzed to identify enriched pathways by Onto-tool Pathway Express (http://vortex.cs.wayne.edu/ontoexpress).

RESULTS

Enriched pathways included cellular architecture, motility, cell to cell adhesion, tumorigenesis and metastasis. Proteins in the 9 top-ranked pathways included CTNNA1 (alpha-catenin), CTNNB1 (beta-catenin), VSAP, ITGA4, PAK1, DDR1, CDC42, RHOA, NRAS, RHO, PIK3AR1, MLC1, MMRN1, and CTTNBP2 and network analysis revealed 10 important hub proteins and identified inferred interactor NF2.

CONCLUSIONS

The importance of identifying interactors is that that they can be used as targets for therapy, for example, using Bevacizumab (avastin--an angiogenesis inhibitor) against NF2 to inhibit protein-protein interactions will inhibit tumor growth and progression by hindering the exosome biogenesis.

Characterization of different carbon nanotubes for the development of a mucoadhesive drug delivery system for intravesical treatment of bladder cancer

In order to increase the effectiveness of therapeutics for bladder carcinoma (BCa) treatment, alternative strategies for intravesical applications are needed. The use of carbon nanotubes (CNTs) as basis for a multifunctional drug transporter is a promising possibility to combine traditional chemotherapeutics with innovative therapeutic agents such as antisense oligodeoxynucleotides or small interfering RNA. In the current study four CNT types varying in length and diameter (CNT-1, CNT-2, CNT-3, CNT-4) were synthesized and then characterized with different spectroscopic techniques. Compared to the pristine CNT-1 and CNT-3, the shortened CNT-2 and CNT-4 exhibited more defects and lower aspect ratios. To analyze their mucoadhesive properties, CNTs were exposed to mouse bladders ex vivo by using Franz diffusion cells. All four tested CNT types were able to adhere to the urothelium with a mean covering area of 5-10%. In vitro studies on UM-UC-3 and EJ28 BCa cells were conducted to evaluate the toxic potential of these CNTs. Viability and cytotoxicity assays revealed that the shortened CNT-2 and CNT-4 induced stronger inhibitory effects on BCa cells than CNT-1 and CNT-3. In conclusion, CNT-1 and CNT-3 showed the most promising properties for further optimization of a multifunctional drug transporter.

Expression and clinical significance of Centrosomal protein 55 (CEP55) in human urinary bladder transitional cell carcinoma

Bladder cancer (BC) is one among the most common and lethal urothelial malignancies worldwide. The expression of cancer-testis (CT) antigens in some tumours and restricted expression among normal tissues make CT antigens as attractive vaccine targets. In this context, we evaluated Centrosomal protein 55 kDa (CEP55), which is specifically expressed in normal human testis and various malignancies. Until the expression pattern of CEP55 in transitional cell carcinoma (TCC) of human urinary bladder and its clinical significance are not known. The aim of the present study is to evaluate mRNA/protein expression of CEP55 in TCCs of urinary bladder and correlate its expression with the clinicopathological characteristics of BC patients. In this study, the methods of quantitative real-time polymerase chain reaction (qRT-PCR) and immunohistochemistry (IHC) were used to investigate mRNA/protein expression of CEP55 in TCC. Independent Student's t test, ANOVA and Chi-square (χ(2)) were used to analyze the data statistically. We observed CEP55 mRNA overexpression in testis and 48.7% of BC patients. Relative mean fold expression of CEP55 mRNA was found to be significantly (p<0.01) higher in muscle-invasive bladder cancer (MIBC) as compared to non-muscle-invasive bladder cancer (NMIBC) patients (7.88±3.88 vs. 4.75±2.30, p=0.01). CEP55 protein expression was evaluated using IHC and cytoplasmic staining pattern was recorded in formalin fixed, paraffin-embedded (FFPE) bladder tumour tissues. No significant difference was observed in protein expression of CEP55 between the two groups (NMIBC and MIBC patients) (72.2% vs. 69.0%, p=0.774). No significant protein expression of CEP55 was observed among adjacent noncancerous tissues (ANCTs) and benign prostatic hyperplasia (BPH) used as control. Our study results suggest that CEP55 mRNA/protein expression was observed is specific to TCC of human urinary bladder and might be used as a diagnostic biomarker and vaccine target in development of BC specific immunotherapy.

Prognostic role of substaging in T1G3 transitional cell carcinoma of the urinary bladder

This study was conducted to test a new substaging system in a population of patients with stage T1 bladder cancer (BC) at diagnosis and assess its prognostic role in terms of disease progression and disease-specific survival (DSS). Patients with primary stage T1G3 urothelial carcinoma of the bladder were stratified according to the following models: i) T1a [the tumour does not infiltrate the muscularis mucosae-vascular plexus, (MM-VP)]; T1b (the tumour partially infiltrates the MM-VP); and T1c (the tumour infiltrates and invades the MM-VP). ii) T1m (diameter of tumour infiltrating the lamina propria ≤0.5 mm under a high-resolution microscope; and T1e (diameter of tumour infiltrating the lamina propria >0.5 mm). Age, gender, tumour size and multifocality were not found to be of statistical significance. Using the T1a/T1b/T1c system, patients with stage T1a disease exhibited a 5- and 10-year progression rate of 13.3 and 20%, respectively, without reaching statistical significance. Moreover, patients with stage T1a disease exhibited a 5- and 10-year DSS of 93.3 and 73.3%, respectively, which was higher compared to T1b and T1c but not statistically significant. Using the T1m/T1e system, patients with stage T1m disease exhibited a disease progression rate of 8.3 and 16.7% at 5 and 10 years, respectively, which was not statistically significant. Moreover, patients in group T1m presented with DSS rates of 91.7 and 83.3% at 5 and 10 years, respectively, which were higher compared to those in the T1e group (71.4 and 60.7%), although not reaching statistical significance. In conclusion, in our study, neither of the two substaging systems of stage T1 BC reached the prognostic conventional significance level for tumour progression or DSS.

Functional polymorphisms in the matrix metalloproteinase genes and their association with bladder cancer risk and recurrence: a mini-review

Molecular pathogenesis of muscle invasive bladder cancer and non-muscle invasive bladder cancer is incompletely elucidated. It is believed that matrix metalloproteinases, which are involved in the processes of uncontrolled extracellular matrix substrates degradation and participate in modulating the activity of a variety of non-matrix proteins, can contribute to carcinogenesis. Polymorphisms in the MMP genes associated with unique genomic changes in bladder cancer patients are still being investigated to discover direct links with pathophysiological mechanisms. Because of the functional polymorphisms in the MMP genes, which have a proven or likely effect on their protein expression, they could possibly affect the tumor process. The current mini-review synthesizes findings regarding the association of genetic polymorphisms in the MMP genes with bladder cancer risk and recurrence in patients. We discuss the current views on the feasibility of genetic polymorphisms in the MMP1, 2, 3, 7, 8, 9 and 12 genes as a risk, and prognostic markers for patients with bladder cancer. The majority of the research described in the present mini-review proves that the genetic polymorphism in the MMP1 (rs1799750) is the most widely studied, and suggests that the rare genotype, 2G2G, of that gene might show increased susceptibility for bladder cancer, especially among smokers. However, existing statistically significant associations between the genetic polymorphisms in the MMP genes and bladder cancer risk have not been clearly shown, and further studies are necessary in order to positively confirm them or dispel potential false hopes.

Fluid intake and risk of bladder cancer in the Nurses' Health Studies

Increase in fluid intake may reduce bladder cancer risk by decreasing the contact time between carcinogens in urine and bladder epithelium. However, this association has not been examined in a large cohort of women. The association between total fluid intake and bladder cancer risk in two large prospective women's cohorts with 427 incident bladder cancer cases was examined. Detailed information on total fluid intake was collected by repeated food frequency questionnaires over time. Multivariable relative risks (RRs) and 95% confidence intervals (95% CIs) were estimated by using Cox proportional hazards regression models. Results from the two cohorts were pooled together using the random-effects model. Using the average values from the earliest two dietary assessments and lowest quartile as reference, a suggestive inverse association was observed between total fluid intake and overall bladder cancer risk (RR: 0.83, 95% CI: 0.61-1.12, p-value for trend: 0.08), and invasive bladder cancer risk (RR: 0.47, 95% CI: 0.23-0.97, p-value for trend: 0.04). Among heavy cigarette smokers, women with the highest quartile of total fluid intake had a 38% decrease in bladder cancer risk (RR: 0.62, 95% CI: 0.41-0.93, p-value for trend: 0.02). The findings suggested that total fluid intake may reduce bladder cancer risk for female smokers, as well as reduce the risk of invasive bladder cancer.

Is photodynamic diagnosis ready for introduction in urological clinical practice?

The aim of this review is to provide an up-to-date review of the available literature on photodynamic diagnosis (PDD) for nonmuscle-invasive bladder cancer, to present the technique in a comprehensive approach and, finally, to discuss the relevance of PDD in clinical practice in terms of indications, outcomes and its development trend. A literature search was conducted up to July 2012, using MEDLINE and EMBASE via Ovid databases to identify published studies on PDD for nonmuscle-invasive bladder cancer. Only English-language and human-based full manuscripts that reported on case series and studies with >40 participants, concerning clinical evidence of the technique, its efficacy and safety data were included. Evidence showed that PDD significantly improves detection of bladder cancer compared with standard white-light cystoscopy, having proven to be more effective for the diagnosis of carcinoma in situ. This condition seems to facilitate more complete resections, resulting in a lower residual tumor rate, which, in turn consecutively leads to higher recurrence-free survival rates. The literature search demonstrated that for mid- and long-term follow-up, PDD showed acceptable outcomes in terms of tumor detection, as well as lower residual tumor and lower recurrence rates compared with white-light cystoscopy. It has proven to be safe and well tolerated; the major limitations of PDD are its low specificity and elevated costs.

Novel multisensor probe for monitoring bladder temperature during locoregional chemohyperthermia for nonmuscle-invasive bladder cancer: technical feasibility study

BACKGROUND AND PURPOSE

The effectiveness of locoregional hyperthermia combined with intravesical instillation of mitomycin C to reduce the risk of recurrence and progression of intermediate- and high-risk nonmuscle-invasive bladder cancer is currently investigated in clinical trials. Clinically effective locoregional hyperthermia delivery necessitates adequate thermal dosimetry; thus, optimal thermometry methods are needed to monitor accurately the temperature distribution throughout the bladder wall. The aim of the study was to evaluate the technical feasibility of a novel intravesical device (multi-sensor probe) developed to monitor the local bladder wall temperatures during loco-regional C-HT.

MATERIALS AND METHODS

A multisensor thermocouple probe was designed for deployment in the human bladder, using special sensors to cover the bladder wall in different directions. The deployment of the thermocouples against the bladder wall was evaluated with visual, endoscopic, and CT imaging in bladder phantoms, porcine models, and human bladders obtained from obduction for bladder volumes and different deployment sizes of the probe. Finally, porcine bladders were embedded in a phantom and subjected to locoregional heating to compare probe temperatures with additional thermometry inside and outside the bladder wall.

RESULTS

The 7.5 cm thermocouple probe yielded optimal bladder wall contact, adapting to different bladder volumes. Temperature monitoring was shown to be accurate and representative for the actual bladder wall temperature.

CONCLUSIONS

Use of this novel multisensor probe could yield a more accurate monitoring of the bladder wall temperature during locoregional chemohyperthermia.

Urothelial carcinoma in both adnexa following perforation during transurethral resection of a non-muscle-invasive bladder tumor: a case report and literature review

In this article case report of urothelial carcinoma implantation in both adnexa is reported, following a perforation of the bladder wall during a transurethral resection of a bladder tumor. The 81-year-old female patient had an extensive history of multiple recurrent non-muscle-invasive urothelial carcinoma of the bladder. Intraperitoneal perforation was detected and managed conservatively. Fifteen months after the procedure, the patient presented at the gynecology department with a mass in the left adnex, which was suspicious for malignancy, for which she subsequently underwent hysterectomy in combination with bilateral resection of the adnexa. Pathology showed papillary urothelial carcinoma in both ovaries. A literature search was performed to present an up-to-date review of the available data on bladder perforations during transurethral resection of the bladder and tumor implantation, its management and oncological outcomes.

Oncolytic viruses in the treatment of bladder cancer

Bladder carcinoma is the second most common malignancy of the urinary tract. Up to 85% of patients with bladder cancer are diagnosed with a tumor that is limited to the bladder mucosa (Ta, T1, and CIS). These stages are commonly termed as non-muscle-invasive bladder cancer (NMIBC). Although the treatment of NMIBC has greatly improved in recent years, there is a need for additional therapies when patients fail bacillus Calmette-Guérin (BCG) and chemotherapeutic agents. We propose that bladder cancer may be an ideal target for oncolytic viruses engineered to selectively replicate in and lyse tumor cells leaving normal cells unharmed. In support of this hypothesis, here we review current treatment strategies for bladder cancer and their shortcomings, as well as recent advancements in oncolytic viral therapy demonstrating encouraging safety profiles and antitumor activity.