A Randomized Trial of Radical Cystectomy Versus Radical Cystectomy Plus Cisplatin, Vinblastine and Methotrexate Chemotherapy for Muscle Invasive Bladder Cancer

Novel therapeutics in the treatment of bladder cancer

PURPOSE OF REVIEW

The successful treatment of bladder cancer remains a challenge for urologists and oncologists. There have been substantial changes in the therapeutic options for the management of both superficial and muscle-invasive bladder cancer in the last 5 years. Here we review the preclinical and clinical developments over the last year in bladder cancer therapeutics.

RECENT FINDINGS

There is a growing trend toward the use of multimodal treatments for all bladder cancers. For superficial disease, intravesical instillation of chemotherapeutic agents after transurethral resection is quickly becoming the standard of care. Novel therapeutic modalities under investigation include DNA vaccines, magnetically targeted carriers, bio-adhesive microspheres and antisense oligodeoxynucleotides. For muscle-invasive bladder cancer, systemic perioperative chemotherapy is being used with increasing frequency and the latest preclinical research efforts are focused on the inhibition of angiogenesis and other processes predisposing to metastatic disease.

SUMMARY

Treatment goals for bladder cancer of any stage are complete removal of the initial tumor, prevention of disease recurrence and effective inhibition of progression to advanced disease with the ultimate aim of reducing mortality. The myriad novel therapeutic modalities currently being explored suggest that these goals may perhaps be achievable within our lifetime.

Treatment of invasive bladder cancer: lessons from the past and perspective for the future

Radical cystectomy with lymphadenectomy is the gold standard for treatment of invasive bladder cancer. However, the treatment alone does not always provide a satisfactory result for the disease extending outside the bladder. In this review we discuss several clinical issues in the diagnosis and treatment of this invasive disease. Although the quality of diagnostic imaging modalities has improved, they are still not sensitive enough for the staging of the disease, especially for early invasive disease. In addition, lack of serum markers hinders appropriate monitoring of patients with the disease. Regarding the surgical aspect of lymphadenectomy, the area of its dissection, the standard number of nodes retrieved and the method of pathological examination should be established so that the clinical benefits of surgery can be more clearly defined. Neoadjuvant chemotherapy for invasive disease is promising for improvement of survival of patients. A chemotherapy regimen as effective as, but less toxic than, MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) has been reported and several phase III clinical trials have been launched to determine the benefits of adjuvant or neoadjuvant chemotherapy with newly developed agents. However, we still lack a chemotherapy regimen more effective than MVAC, which is the most crucial issue in the treatment of this invasive disease. An alternative option for such disease may be bladder preservation with transurethral resection of tumor followed by chemoradiotherapy. However, patients who are indicated for this treatment may be limited to those with early invasive disease having certain favorable clinical and pathological features.

Chemotherapy and cystectomy for invasive transitional cell carcinoma of bladder

Invasive transitional cell bladder cancer is associated with occult metastasis. Approximately 50% of patients with clinically localized, invasive bladder cancer ultimately die of their disease. Systemic chemotherapy has been combined with radical cystectomy in an attempt to improve survival. Phase I and II trials have achieved tumor down-staging. Initial randomized trials did not show a statistically significant survival benefit from systemic single agent chemotherapy. More recently, two multi-center randomized trials have shown a significant survival benefit from neoadjuvant combination chemotherapy. Adjuvant chemotherapy trials, to date, have failed to show statistically improved survival, although most published studies have been methodologically flawed. For invasive, clinically nonmetastatic bladder cancer, neo-adjuvant chemotherapy followed by radical cystectomy is one of the new standards of care. The role of postsurgical systemic chemotherapy appears promising, but has not been proven in a randomized trial. Molecular prognostication is now being incorporated into the design of clinical trials of adjuvant chemotherapy for bladder cancer.

Systemic chemotherapy for patients with bladder cancer – current controversies and future directions

Many localised, superficial bladder cancers can be effectively controlled. However, disease which has spread to nodes outside the pelvis or to distant organs is generally incurable and systemic therapies, rather than surgery, are appropriate. Combination chemotherapy based around established cytotoxic drugs such as cisplatin has proven benefit in palliating symptoms and prolonging survival in responsive patients with advanced disease. Combination chemotherapies which include newer cytotoxic drugs such as gemcitabine provide the potential for equivalent efficacy with less toxicity than established regimens. Between the extremes of superficial and advanced disease, muscle-invasive bladder cancers have traditionally been treated, with curative intent, by radical surgery or radiotherapy. However, newly published data suggest, for the first time, genuine survival benefits from peri-operative chemotherapy. This article reviews the evidence for cisplatin-based chemotherapy in advanced disease, assesses the potential benefits of newer cytotoxic drugs, discusses the latest evidence pertaining to peri-operative chemotherapy in muscle-invasive disease, and looks forward to potential new biological agents in the systemic therapy of bladder cancer.

Adjuvant Chemotherapy With Paclitaxel and Carboplatin in Patients With Advanced Carcinoma of the Upper Urinary Tract: A Study by the Hellenic Cooperative Oncology Group

Purpose

Radical surgery represents the treatment of choice for carcinoma of the upper urinary tract. Nevertheless, approximately 50% of patients with stage T ≥ 3 or lymph node involvement die from their disease, mainly as a result of the development of distant metastases. Therefore, there is a need for effective adjuvant systemic treatment. We prospectively studied a cohort of patients who underwent surgery for high-risk carcinoma of the upper urinary tract to assess the feasibility of the combination of paclitaxel and carboplatin as adjuvant treatment.

Patients and Methods

Thirty-six patients with tumor stage ≥ 3 or lymph node involvement were treated with four cycles of paclitaxel at 175 mg/m2 and carboplatin (area under the curve 5, Calvert Formula) every 3 weeks following surgery.

Results

Median follow-up was 40.6 months. Chemotherapy was well tolerated with 32 patients (89%) receiving full carboplatin and paclitaxel doses without delays. The most frequent grade 3/4 toxicity was neutropenia (39%), which was complicated with fever in only one case (3%). Nonhematologic grade 3 or 4 toxicities were reported in only one case. Five-year survival was 52% (95% CI, 35% to 69%), while 5-year disease-free survival was 40.2% (95% CI, 15.8% to 64.6%). Local failure rate was 30%, as opposed to 17% of patients who developed distant metastases. No patients with grade 2 tumors relapsed during follow-up, as opposed to 60% of patients with grade 3 tumors.

Conclusion

Adjuvant chemotherapy with paclitaxel and carboplatin is feasible and may reduce the risk of distant metastases in high-risk upper urinary tract carcinoma.

ADJUVANT CHEMOTHERAPY WITH PACLITAXEL AND CARBOPLATIN IN PATIENTS WITH ADVANCED BLADDER CANCER: A STUDY BY THE HELLENIC COOPERATIVE ONCOLOGY GROUP

PURPOSE

Radical cystectomy represents the treatment of choice for muscle infiltrative bladder carcinoma. Adjuvant chemotherapy has been used to improve outcome after cystectomy. We report results in a prospective cohort of patients at high risk for relapse who were treated with the combination of paclitaxel and carboplatin as adjuvant treatment following cystectomy for muscle invasive bladder cancer.

MATERIALS AND METHODS

A total of 92 patients with extravesical tumor extension (pT 3b or greater) or lymph node involvement (N+) were treated with 4 cycles of paclitaxel at 175 mg/m and carboplatin (area under the curve 5 according to the Calvert formula) every 3 weeks following radical cystectomy. Patients were followed every 6 months thereafter.

RESULTS

Median followup was 36.6 months. Chemotherapy was well tolerated with 62% of patients receiving 100% of the expected chemotherapy doses without delays. Grade 3 or 4 neutropenia was reported in 19% of patients, while neutropenic fever was reported in 7%. Five-year overall, cause specific and disease-free survival was 28.9% (95% CI 14.8 to 43.0), 36.6% (95% CI 24.4 to 49.7) and 29% (95% CI 16.3 to 42.4), respectively.

CONCLUSIONS

Adjuvant chemotherapy with paclitaxel and carboplatin is feasible and could be used as adjuvant treatment for high risk bladder carcinoma. Its true value should be assessed in prospective, randomized trials.

Neoadjuvant Chemotherapy for Transitional Cell Carcinoma of the Bladder: A Systematic Review and Meta-Analysis

PURPOSE

Despite local therapy most patients with muscle invasive transitional cell carcinoma (TCC) of the bladder die of systemic relapse, indicating a need for effective adjunctive systemic treatment. We determined whether neoadjuvant chemotherapy improved overall survival.

MATERIALS AND METHODS

A systematic review and meta-analysis were performed of all known randomized controlled trials (RCTs) of neoadjuvant chemotherapy for stages II and III TCC conducted between 1984 and 2002.

RESULTS

A total of 16 eligible RCTs (3,315 patients) were identified. Of these trials 11 (2,605 patients) provided data suitable for a meta-analysis of overall survival and the pooled HR was 0.90 (95% CI 0.82 to 0.99, p = 0.02). Eight trials used cisplatin based combination chemotherapy and the pooled HR was 0.87 (95% CI 0.78 to 0.96, p = 0.006), consistent with an absolute overall survival benefit of 6.5% (95% CI 2 to 11%) from 50% to 56.5%. Reported progression-free survival data were insufficient for meta-analysis but they appeared concordant with overall survival results. Mortality due to combination chemotherapy was 1.1%. A major pathological response was associated with improved overall survival in 4 trials. CONCLUSIONS Neoadjuvant cisplatin based chemotherapy improves overall survival in muscle invasive TCC. The size of the effect is modest and combination chemotherapy can be administered safely without adverse outcomes resulting in delayed local therapy. An optimal chemotherapy regimen was not identified and newer regimens have not been tested in RCTs in this setting. Further efforts to identify the patients most likely to benefit from neoadjuvant therapy are necessary to optimize its use.

The Prognostic Significance of Metastatic Perivesical Lymph Nodes Identified in Radical Cystectomy Specimens for Transitional Cell Carcinoma of the Bladder

PURPOSE

We determined the prognostic significance of metastatic perivesical lymph nodes (PVLN) in transitional cell carcinoma of the bladder (TCC).

MATERIALS AND METHODS

A retrospective review of 198 consecutive patients who underwent radical cystectomy for clinically organ confined TCC identified 32 patients with PVLN in pathology specimens. Patient characteristics were compared. Overall survival, disease-specific survival (DSS) and disease-free survival were estimated using Kaplan-Meier actuarial methodology. The log-rank test was used to compare the differences between patients with and without metastatic TCC to PVLN. Cox multivariate regression analysis was used to determine whether the effect of metastatic PVLN on survival was independent of pathological stage.

RESULTS

Metastatic TCC was found in the PVLN of 14 patients. Median followup and age were 13.5 months and 66.5 years, respectively. Patients with and without metastatic PVLN had similar characteristics and pathological disease staging. The overall survival, DSS and disease-free survival were significantly less for patients with metastatic TCC in PVLN (p = 0.002, p = 0.013 and p <0.001, respectively), and involvement of PVLN and pelvic nodes (p = 0.001, p = 0.010 and p = 0.041, respectively). Metastatic PVLN was an independent predictor of OS and DSS (p = 0.016 and p = 0.025, respectively).

CONCLUSIONS

Metastases to PVLN appear to confer a significantly worse prognosis for patients undergoing radical cystectomy. Patients with identifiable metastatic PVLN may benefit from early adjuvant therapies.

The systemic treatment of advanced and metastatic bladder cancer

Bladder cancer is the second most common genitourinary tumour and is a significant cause of morbidity and mortality. Trials of neoadjuvant and adjuvant chemotherapy have failed to show a survival advantage, although these studies generally had suboptimum design and an insufficient number of patients. Despite the introduction of newer agents, the median survival for metastatic disease is about 1 year; however, improvements in quality of life have been achieved. Platinum drugs should be included in studies of combination chemotherapy regimens wherever possible. There have been various studies exploring the role of taxanes, gemcitabine, ifosfamide, and platinum in double and triple combinations in different schedules to maximise dose intensity and improve effectiveness but large phase III trials are needed. The current tumour, node, and metastasis staging system is insufficient to predict outcome in patients with bladder cancer irrespective of the treatment they received. Evaluation of molecular prognostic markers should be incorporated into phase II and III trials to define their roles in clinical outcome. Future studies should stratify patients according to the number of risk factors they have to avoid imbalance in treatment groups and patients should be carefully selected.

Proapoptotic genes BAX and CD40L are predictors of survival in transitional cell carcinoma of the bladder

The purpose of the study was to investigate the effects of expression of a range of genes involved in apoptosis on outcome in bladder cancer. Immunohistochemistry was used to examine expression of BCL2, BAX, P53, CD40 and CD40L in archival tissues of patients included in various treatment trials for transitional cell carcinoma (TCC) of the bladder. Data were collected on 94 patients who first presented with either invasive or superficial bladder cancer. Median follow-up for alive patients was 83 months (m) (range 12-195 m). Median survival was 80 m (95% CI=56-128 m). Median survivals for the various markers were as follows: BAX-positive patients 110 m vs BAX-negative patients 18 m (P=0.0002); CD40L-positive patients 95 m vs CD40L-negative patients 45 m (P=0.04); BCL2-positive patients 44 m and BCL2-negative patients 74 m, (P=0.64); CD40-positive patients 110 m and CD40 negative patients 45 m (P=0.12); and P53 positive patients 80 m and P53 negative patients 45 m (P=0.58). In conclusion, it was seen that overexpressions of BAX and CD40L are prognostic of better survival in TCC of the bladder. Our results also raise the possibility of the future development of CD40- and CD40 ligand-based immunotherapy for bladder cancer. This study links proapoptotic and antiapoptotic markers to overall survival.

The role of systemic chemotherapy in the management of muscle-invasive bladder cancer

Patients with localised but muscle-invasive transitional-cell carcinoma (TCC) of the bladder are at high risk of relapse and death from metastatic disease after local treatment by cystectomy, radiation, or both. Despite improvements in treatment, patients with metastatic TCC have a median survival of about a year. TCC is quite sensitive to chemotherapy, and patients are able to tolerate newer regimens such as gemcitabine plus cisplatin better than older regimens such as methotrexate, vinblastine, doxorubicin, and cisplatin. However, the role of chemotherapy in the management of locally advanced muscle-invasive TCC remains uncertain. Most trials of neoadjuvant or adjuvant chemotherapy have shown no significant improvement in survival, but many of these studies had suboptimum design, evaluated chemotherapy that was less effective than regimens in current use, and had sample sizes that were too small for important changes in survival to be detected or ruled out. Recent trials show trends in the direction of improved survival when optimum chemotherapy is used. Large trials that recruit more than 1000 patients are required to assess the effectiveness of adjunctive chemotherapy, and a large intergroup trial is in progress. Other trials should address the role of molecular markers in selecting patients for chemotherapy. Whenever possible, chemotherapy for locally advanced muscle-invasive TCC should be given in the context of a well-designed clinical trial.

Localized and locally advanced bladder cancer

Localized and locally advanced bladder cancer represents a heterogeneous spectrum of diseases with different biologic and clinical behavior. It varies with respect to invasive potential, propensity for metastases, and sensitivity to chemotherapy. Although several significant surgical advances have been made over the past 20 years in the treatment of muscle-invasive bladder cancer, resulting in decreases in perioperative morbidity and mortality and improvement of quality of life in patients with continent urinary diversions, the natural history of the disease has remained unaltered. Advances in chemotherapy for metastatic disease have prompted trials of systemic therapy in patients with early stage, high-risk disease administered before or after local therapy consisting of cystectomy or radiotherapy. The data available from nonrandomized and randomized trials have not definitively established the exact role of neoadjuvant chemotherapy and its impact on survival. Even if neoadjuvant chemotherapy does not improve survival, preliminary data suggest that bladder preservation may be possible in selected patients and that such combined therapy will hopefully lead to better patient management. The trials of postoperative chemotherapy provide insufficient evidence to support the routine use of adjuvant chemotherapy in clinical practice as a result of small sample size, confusing analyses, and the reporting of questionable conclusions. New large-scale, multicenter trials are imperative to provide convincing results. A better understanding of the microbiology of bladder cancer will influence the search for new therapeutic modalities. Molecular-targeted small-molecule therapy and monoclonal antibodies have begun to dominate contemporary studies.

Surgery and adjunctive chemotherapy for invasive bladder cancer

Invasive bladder cancer has a predilection for early, occult metastasis. Despite effective local control from radiotherapy or cystectomy, approximately 50% of the patients with clinically localized, invasive bladder cancer ultimately die of their disease. Over the past 25 years, systemic chemotherapy has been combined with definitive local treatment in an attempt to improve cure rates. Non-randomized phase I-II trials have shown promising results, with significant tumor down-staging. However, many randomized trials have failed to show a statistically significant survival benefit from adjunctive systemic chemotherapy. Recently, two intergroup randomized trials have shown a survival benefit from neoadjuvant combination chemotherapy, although the differences between the arms have not been dramatic. Adjuvant chemotherapy trials to date have failed to show statistically improved survival, although most published studies have been methodologically flawed. This review analyzes the results of published data and constructs a practical paradigm for patient management.

Bladder cancer

Bladder cancer is a common and chemotherapy-responsive tumor, related to tobacco smoking, environmental arsenic exposure, industrial dye exposure, and parasitic schistosomiasis exposure. Both reduction of carcinogen exposure and chemoprevention, possibly with cyclooxygenase 2 inhibitors, should reduce the incidence. The search for the ideal screening and monitoring test continues with some promising new candidates, including survivin. Although 10-year survival can be achieved in 87% of early-stage patients with muscle-invasive disease rendered T(0) and 57% of those rendered T(1) at second look after transurethral resection bladder tumor, most still require radical cystectomy. Continued improvements in surgical techniques permit gains in quality of life after the procedure. Ten-year survival can still be achieved with cystectomy in the face of grossly positive lymph nodes in 32% of T(2) and 10% of T(3) patients. A recent meta-analysis indicates that preoperative irradiation is unlikely to be beneficial, but definitive chemoradiation can produce significant 5-year survival rates in nonoperative candidates and those desiring bladder preservation. The Intergroup now has preliminary data from a Southwest Oncology Group-based trial showing a significant benefit for neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin. The regimen of gemcitabine and cisplatin is equally efficacious with less toxicity than methotrexate, vinblastine, doxorubicin, and cisplatin. It has been adopted as the standard arm in a phase III trial for advanced bladder cancer, comparing it with the triplet of gemcitabine, paclitaxel, and cisplatin. Other active agents in bladder cancer include ifosfamide, carboplatin, docetaxel, and vinorelbine, and various doublets of these agents are being tested in phase II trials, with promising results.

Current perspectives in muscle invasive bladder cancer

Muscle-infiltrating bladder cancer should be dealt with in a multimodality approach with collaboration between the urologist, medical oncologist and radiotherapist. Neo-adjuvant chemotherapy has not been proven to improve survival, but may be useful in programs of bladder preservation. Response to M-VAC neo-adjuvant chemotherapy is an important prognostic factor, but may represent patient selection factors. It is not known whether it is better to administer chemotherapy in the neo-adjuvant or in the adjuvant setting, that may spare some patients unnecessary chemotherapy. The international adjuvant chemotherapy trial coordinated by the EORTC (protocol 30994) will hopefully clarify some of the unanswered questions concerning whether or not adjuvant chemotherapy immediately following cystectomy improves survival.

Integrated therapy for locally advanced bladder cancer: final report of a randomized trial of cystectomy plus adjuvant M-VAC versus cystectomy with both preoperative and postoperative M-VAC

PURPOSE

We conducted a phase III trial to investigate the timing of chemotherapy with respect to surgery for patients with resectable but high-risk urothelial cancer. The trial was also designed to evaluate the accuracy of clinical staging in patients with locally advanced cancer and the prognostic significance of chemotherapy-induced downstaging.

PATIENTS AND METHODS

A total of 140 uniformly evaluated patients with locally advanced urothelial cancer were studied. Planned treatment was five cycles of chemotherapy (M-VAC: methotrexate, vinblastine, doxorubicin, and cisplatin) plus radical cystectomy and pelvic lymph node dissection. Patients were randomly assigned to receive either two courses of neoadjuvant M-VAC followed by surgery plus three additional cycles of chemotherapy, or, alternatively, to have initial cystectomy followed by five cycles of adjuvant chemotherapy.

RESULTS

There were no significant differences in outcome between the two groups. By intent-to-treat, 81 patients (58%) remain disease-free, with median follow-up of 6.8 years. We confirmed a high rate of clinical understaging in this cohort, especially among patients showing lymphovascular invasion on biopsy. Patients with no residual muscle-invasive disease at cystectomy after neoadjuvant chemotherapy were likely to be cured.

CONCLUSION

These results lend further support to the impression from small randomized trials that, in a high-risk cohort, there is an improved cure fraction by the combination of multiagent chemotherapy and surgery, although we found no preferred sequence. Importantly, it is possible to select appropriate patients for such therapy on the basis of clinical staging information. These results establish a benchmark of outcome for this cohort.

A phase I-II study of synchronous chemoradiotherapy for poor prognosis locally advanced bladder cancer

BACKGROUND

The management of locally advanced bladder cancer remains controversial with poor local control with radiotherapy alone. Synchronous chemotherapy regimens have yielded encouraging results in other primary sites.

PATIENTS AND METHODS

Patients with T2-T4a N0/NX M0 bladder cancer were entered into this single centre phase I-II study. Patients received radiotherapy to 55 Gy in 20 fractions over four weeks. Concurrent chemotherapy was given with Mitomycin C 12 mg/m2 day 1 and 5-fluorouracil 500 mg/m2/24 hours weeks one and four of radiotherapy for five or seven days on each occasion.

RESULTS

Thirty-one patients entered the trial from March 1998 to December 1999 (22: 5-day; 9: 7-day schedule). Median age was 68 (range 58-79) years, 23 males and 8 females. T2: 9 (29%); T3a: 4 (12%); T3b: 9 (29%); T4: 9 (29%); TCC grade 2: 8 (26%) and grade 3: 23 (74%); 14 of 31 had hydronephrosis. Ten of thirty-one had a GFR < 50 ml/min. Toxicity was mild to moderate with the five-day schedule. More severe toxicity was seen with the seven-day schedule: five of nine patients failed to complete planned therapy. Pathological complete response rate at three months was 74% (5-day regimen) and 50% (7-day regimen). Overall 12-month survival was 65%.

CONCLUSION

Chemoradiotherapy with the five-day schedule is feasible with acceptable toxicity in poor prognosis patients. A randomised trial is being launched.

AN ORGAN-PRESERVING APPROACH TO MUSCLE-INVADING TRANSITIONAL CELL CANCER OF THE BLADDER

Bladder-preserving treatment for muscle-invasive disease is based on the response of the tumor to induction combined modality therapy. In the future, an organ-conserving approach will be widely offered as a safe and reasonable alternative to radical cystectomy.

Advances in chemotherapy of invasive bladder cancer

A survey of the literature published during 1999 identified the following advances in the chemotherapy of advanced bladder cancer. At present there are no new chemotherapy regimens superior to MTX + VBL + ADR + CDDP (M-VAC), but improvements in multidrug therapies and the development of new drugs suggest that a new first-line chemotherapy will be established. The efficacy of neoadjuvant chemotherapy could not be validated by meta-analysis, but neoadjuvant chemotherapy can be expected to be a useful tool for individualizing therapy. If it was possible to select accurately those patients who show complete response to a certain chemotherapy regimen, then this selected group would show a 100% complete response rate on that regimen, regardless of the complete response rate of this regimen in an unselected population. Such individualization of therapy would aid in future establishment of bladder-preserving treatment methods for invasive bladder cancers.

Adjuvant and neoadjuvant chemotherapy for invasive bladder cancer

Despite technical advances in the surgical or radiotherapeutic treatment of localized invasive bladder cancer, at least 50% of patients ultimately succumb from the growth and progression of microscopic disease beyond the reach of these local treatment modalities. Systemic chemotherapy prior to or immediately following surgery or radiotherapy or concurrently with radiotherapy has been explored in numerous uncontrolled phase II trials and in several randomized phase III trials in an attempt to eradicate this micrometastatic disease burden. Many of these studies have significant flaws in design, implementation, and analysis. All suffer from the lack of highly effective or well-tolerated chemotherapy. These failed attempts and lessons from successful adjuvant chemotherapy trials in other tumor types indicate directions to be pursued in this highly lethal disease.

Advanced bladder and urothelial cancers

After more than 40 years of use, cytotoxic chemotherapy has an evolving role in the management of advanced bladder cancer. Standard single-agent regimens, such as methotrexate, doxorubicin, vinblastine and cisplatin, have produced objective response rates of 15-25%, and combination chemotherapy causes objective regression in 50-75% of cases. Novel compounds such as ifosfamide, the taxanes and gemcitabine are now being incorporated into combination regimens, having shown activity in this disease, both in previously treated and untreated cases. The phenomenon of stage migration, with increased precision of imaging, leads to the inclusion of different populations of patients with advanced disease into protocols of assessment of chemotherapy. This may cause an artifact of improved outcome, when in fact the higher response rates and longer survival figures may reflect a reduced burden of disease and case selection. It is thus essential to validate novel approaches in well structured, randomised clinical trials that compare new strategies against established standard protocols. Historical comparisons serve only to confuse the issue by introducing errors from case selection bias, stage migration and differences in duration of follow-up and supportive technologies.

The role of adjuvant combination chemotherapy after cystectomy in locally advanced bladder cancer: what we do not know and why

BACKGROUND

Radical cystectomy is the standard treatment for patients with muscle invasive bladder cancer. Three to four cycles of adjuvant chemotherapy is widely used in patients with pT3-pT4a and/or pN+ M0 disease in an effort to delay recurrence and prolong survival. Although a number of clinical trials have been carried out, this paper questions whether the use of adjuvant combination chemotherapy is actually justified.

PATIENTS AND METHODS

A review of published randomized trials of adjuvant cisplatin-containing combination chemotherapy in locally advanced bladder cancer was undertaken. Four trials including a total of 278 randomized patients were identified.

RESULTS

Although these trials appear to show a significant difference in favor of adjuvant chemotherapy, serious methodological flaws were found. They have major deficiencies in terms of sample size, early stopping of patient entry, statistical analyses, reporting of results and drawing conclusions.

CONCLUSIONS

These trials provide insufficient evidence to support the routine use of adjuvant chemotherapy in clinical practice due to small sample sizes, confusing analyses and terminology, and the reporting of questionable conclusions. Analyses of the duration of survival were either not done or were inconclusive and quality of life has not been considered. New large scale, multicenter trials are imperative in order to provide convincing results.

Negative p53/positive p21 immunostaining is a predictor of favorable response to chemotherapy in patients with locally advanced bladder cancer

The relationship between clinical response to DNA-damaging drugs and p53 and p21 status in patients with locally advanced transitional cell carcinoma (TCC) of the bladder was assessed. The response to intraarterial chemotherapy (IAC) comprising 100 mg / m(2) of cisplatin (CDDP) and 40 mg / m(2) of pirarubicin (THP) and the prognosis were assessed in 23 patients (the mean follow-up period was 19 months). The p53 gene status of tumors was analyzed at exons 5 - 8 using polymerase chain reaction-single strand conformation polymorphism analysis in 19 patients, and paraffin-embedded tumor sections were immunostained for p53 and p21 in 23 patients. The overall objective response rate (incidence of good responders) was 70%. The negative p53 group (n = 17) showed a significantly higher objective response rate than the positive p53 group (n = 6) (82% vs. 33%; P = 0.045). The p53 gene status or p21 staining status was not significantly associated with responsiveness. When the p53 and p21 immunostaining results were combined, good responders were more accurately predicted than by p53 staining status alone; the negative p53 / positive p21 group (n = 12) showed an objective response rate of 92%, which was significantly higher than that of the positive p53 and / or negative p21 group (45%, n = 11) (P = 0.027). Cause-specific survival of the negative p53 group was significantly superior to that of the positive p53 group (P = 0.015). Negative p53 / positive p21 immunostaining is a possible predictor of favorable chemotherapeutic response in patients with TCC of the bladder.

Organ-conserving approaches to muscle-invasive bladder cancer: future alternatives to radical cystectomy

In the USA radical surgery remains the golden standard for invasive bladder cancer. Yet in most other areas of surgical oncology the trend of the 1990s has been towards organ conservation with chemoradiation with or without limited local surgery. Patients with breast, oesophageal, anal, lung and larynx cancer are routinely offered conservative therapies as valid options in the management of their diseases but bladder stands apart from the crowd. Evidence is presented here to show that this need not be the case. Four older randomized trials failed to show a survival advantage when immediate cystectomy was compared with radiation followed by salvage cystectomy, if required. Five and 8-year survival rates for clinically staged patients treated by transurethral resection and chemoradiation (trimodality therapy) in several modern, large and mature series show survival rates comparable to those reported in contemporary radical cystectomy series. Eighty per cent of those alive 5 years after chemoradiation still retain their native bladder. Although superficial relapse occurs in 20% of cases, it remains responsive to BCG (Bacilles bilie de Calmette-Guerin) in the manner of de novo superficial disease. Quality-of-life studies show that the retained bladder functions well. At the Massachusetts General Hospital and in the multicentre prospective trials, less than 1% of patients needed cystectomy for bladder morbidity. It is of note that continent diversions may be performed as salvage after contemporary radiation therapy. Trimodality therapy is a novel and contemporary approach that owes little to the radiation treatment offered in the 1970s. While it will never entirely take the place of radical cystectomy, it should be offered as a reasonable alternative to patients with a new diagnosis of bladder cancer. This multidisciplinary approach will allow uro-oncology to keep in step with the oncological vanguard.

High risk of vascular events in patients with urothelial transitional cell carcinoma treated with cisplatin based chemotherapy

PURPOSE

We define the incidence of thromboembolic events in patients receiving multiagent chemotherapy for urothelial cancer.

MATERIALS AND METHODS

A retrospective chart review of 271 consecutive patients who received multi-agent cisplatin based chemotherapy for transitional cell carcinoma at Princess Margaret Hospital between 1986 and 1996 was performed. Indications for chemotherapy included adjuvant treatment following resection of high risk disease (13%), and primary management of locally advanced and metastatic disease (87%).

RESULTS

Vascular events occurred in 35 patients (12.9%) receiving chemotherapy, including 18 deep vein thromboses, 9 pulmonary emboli, 7 arterial thromboses, 3 cerebrovascular events, 1 superficial phlebitis and 1 angina pectoris (4 patients had deep vein thrombosis and pulmonary embolus). Three events were directly fatal. Overall, 3.6% of chemotherapy cycles were complicated by vascular events with 27 events (77%) occurring during the first 2 cycles. Risk factors for vascular events included a large pelvic mass and concomitant peripheral vascular or coronary artery disease. Substantial morbidity was associated with vascular events and median hospital stay of 10 days.

CONCLUSIONS

There is a substantial risk of venous and arterial vascular events in patients receiving cisplatin based chemotherapy for urothelial transitional cell carcinoma. Prophylactic anticoagulation should be considered in patients with risk factors for thromboembolic disease.

Adjuvant chemotherapy for high-risk urothelial transitional cell carcinoma: the Princess Margaret Hospital experience

OBJECTIVE

To review the outcome of adjuvant systemic chemotherapy after surgery for patients with locally advanced urothelial transitional cell carcinoma (TCC) of the bladder and upper urinary tract who were at high risk for recurrence or metastatic spread.

PATIENTS AND METHODS

Thirty-five patients (27 men and eight women, median age 59 years) received adjuvant chemotherapy and were followed for a median of 31 months from surgery (range 12-109). All patients had undergone surgery (cystectomy, nephrectomy, nephrouretectomy), with removal of all evident tumour from the following primary sites: bladder (29), renal pelvis (three) and ureter (three). Thirty patients had stage pT3 or greater, 22 had node-positive disease and 16 had vascular invasion. The median interval from surgery to chemotherapy was 2 months. Patients received a median of four courses of cisplatin, methotrexate and vinblastine (n = 23) or the same drugs with doxorubicin (n = 12).

RESULTS

Toxicity included nine episodes of febrile neutropenia (one fatal) and six episodes of thromboembolism (one fatal). Eighteen patients (51%) remain alive and free of apparent disease with a median follow-up of 31 months. Actuarial overall and relapse-free survival were 64% and 57% at 2 years and 47% and 53% at 5 years, respectively. For the 22 node-positive patients, the median relapse-free survival and overall survival was 22 months and 33 months, respectively.

CONCLUSIONS

Patients with urothelial TCC at high risk of relapse after radical surgery can have a reasonable chance of long-term survival with systemic adjuvant chemotherapy. Treatment is associated with toxicity. The benefits of treatment should be addressed in a large randomized controlled trial.

[Chemotherapy for urothelial infiltrating tumors]

Since 1985, the gold standard regimen for metastatic tumours of the urothelial tract is a combination of methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC protocol). Randomised studies have shown the superiority of the M-VAC regimen over cisplatin alone or in combination with cyclophosphamide and doxorubicin. The limited gain in survival shows that, although chemosensitive, metastatic tumours cannot be cured by the available drug combinations. Amongst new cytotoxic drugs in development, paclitaxel and gemcitabine are likely to be involved in the standard regimen of the future. The studies published to date do not support the routine use of chemotherapy in the neo-adjuvant or adjuvant setting for the management of early stage urothelial tumours.

Opportunities for the treatment of erectile dysfunction by modulation of the NO axis--alternatives to sildenafil citrate

Erectile function in man depends upon a complex interaction of psychogenic, neurologic, hormonal and vascular factors, and therefore the management of erectile dysfunction (ED) reflects this complexity of control. Therapeutic options include psychological and non-pharmacological approaches as well as drug treatments. The effectiveness of the type-5 cGMP phosphodiesterase inhibitor sildenafil citrate (Viagra) confirms the pivotal role of the NO-cGMP axis in promoting and maintaining erection. Although widely acclaimed, sildenafil leaves many questions unanswered, especially regarding its susceptibility to pharmacokinetic drug interactions, and its safety in patients with ischaemic heart disease and those taking nitrates. In view of the epidemiological link between erectile dysfunction and cardiovascular disease in the elderly, this limitation might have much broader implications. The presently available scientific documentation, although less extensive, indicates that NO donors, such as topically applied nitroglycerin (GTN; for example, 1-2 puffs of an ordinary GTN spray applied to the shaft of the penis), might be a reasonable alternative. Further larger-scale research on the efficacy and tolerability of topical GTN is needed to establish its full therapeutic potential in the treatment of erectile dysfunction.

Systemic chemotherapy of transitional cell carcinoma of the urothelium

Although the incidence of bladder cancer has increased in recent years, survival has also improved. Chemotherapy has made a substantial impact on this disease and now is used in patients with advanced or metastatic disease as well as in select patients with high-risk muscle invasive disease. While cisplatin remains the most active single antineoplastic agent, several other agents including methotrexate, vinblastine, and Adriamycin (doxorubicin) have important activity. More recently, paclitaxel and gemcitabine have shown promising activity in bladder cancer. Multidrug combination therapy has provided more frequent and durable responses than single agent therapy. Regimens containing cisplatin and methotrexate have been shown to be most effective in the treatment of advanced disease. Adjuvant chemotherapy regimes typically have included cisplatin or cisplatin and methotrexate combinations. However, studies have been limited and further prospective trials are required to determine the role of adjuvant chemotherapy. Multiple studies have investigated neoadjuvant chemotherapy with cisplatin and methotrexate combinations or anthracycline-based regimens, but study results are mixed. Further trials will be required to define the role of neoadjuvant chemotherapy in bladder cancer.

Bladder cancer: natural history, tumor markers, and early detection strategies

Transitional cell bladder carcinoma is characterized by a dichotomous, multichronotopic natural history. Low and moderate grade Ta lesions frequently recur, yet rarely invade, and carry an excellent prognosis with currently available treatments. High grade Ta lesions, tumors with lamina propria invasion (T1), and carcinoma in situ often progress to invasive disease, at which time overall prognosis is significantly decreased, despite various treatment alternatives. Although early detection of bladder tumors, prior to muscle invasion, should vastly improve our ability to save both bladders and lives, current methods of detection are neither sufficiently sensitive nor specific. Tumor marker analysis is an exciting new frontier in bladder cancer evaluation, and may have important applications to early detection strategies, in combination with simple hematuria testing and other selected noninvasive screening methods.

Future therapies for the treatment of bladder neoplasms

The last several decades have witnessed an exponential growth in the understanding of the biology of human neoplasms. As a consequence, a number of new strategies for the treatment of urologic cancers are currently under evaluation. We provide an overview of promising new treatment approaches as they apply to the management of transitional cell carcinoma of the urinary bladder.

Signal transduction in cavernous smooth muscle

Knowledge of intracellular signal propagation in smooth-muscle tone regulation is of major importance to the understanding of both the physiology of erection and the pathophysiology of erectile dysfunction and the development of new and selective pharmacological agents in the treatment of erectile dysfunction. Cavernous smooth-muscle tone depends heavily on the amount of intracellular free Ca2+. In the resting state the sarcoplasmic free Ca2+ amounts to about 120-270 nM, whereas in the extracellular fluid the Ca2+ level is in the range of 1.5-2 mM. Electromechanical and pharmacomechanical coupling induces an increase in the levels of free sarcoplasmic Ca2+ by a factor of 2-3 to 550-700 nM that triggers myosin phosphorylation and subsequent smooth muscle contraction. In this case, modulation of membrane-bound ion channels and regulation of the intracellular second-messenger system are attractive and feasible targets for pharmacological intervention. Besides the amount of free sarcoplasmic Ca2+, smooth-muscle tone is also modulated by the regulation of Ca2+ sensitivity ("Ca-sensitization") and Ca(2+)-independent contraction processes.

Radical cystectomy with or without adjuvant polychemotherapy for non-organ-confined transitional cell carcinoma of the urinary bladder: prognostic impact of lymph node involvement

OBJECTIVES

To analyze the effectiveness of adjuvant polychemotherapy after radical cystectomy for non-organ-confined transitional cell bladder cancer (Stages pT3b, pT4a, and/or pN1 or pN2).

METHODS

Of 166 consecutive patients undergoing cystectomy at two institutions from 1987 to 1993, 80 received adjuvant polychemotherapy with methotrexate, vinblastine, and cisplatin plus doxorubicin (MVAC) or epirubicin (MVEC), whereas 86 had cystectomy only. The patients were evaluated for relapse-free survival and length of progression-free interval on the basis of follow-up data obtained in 1995 and 1996.

RESULTS

Kaplan-Meier analysis revealed a significantly higher progression-free rate for patients after adjuvant chemotherapy (P = 0.0002, log-rank test). With and without adjuvant chemotherapy, prognosis declined in a stepwise manner, depending on the extent of lymph node involvement. Nevertheless, the superior prognosis of the chemotherapy group could be demonstrated at each lymph node stage. Of the 166 patients, 49 had initially entered a prospective trial comparing adjuvant with no adjuvant treatment. That study was discontinued in December 1990 after an interim analysis revealed a significant prognostic advantage in favor of the 26 patients randomized to receive chemotherapy compared with the 23 control patients. Current follow-up data continue to demonstrate a significant improvement in progression-free survival in favor of patients randomized to receive adjuvant chemotherapy (P = 0.0040). The follow-up period of patients living free of disease ranges from 58 to 96 months.

CONCLUSIONS

Adjuvant chemotherapy with MVAC/MVEC leads to significant prolongation of relapse-free survival and improvement of the definitive cure rate after radical cystectomy for locally advanced transitional cell carcinoma of the urinary bladder.

Systemic Therapy for Invasive Bladder Cancer

BACKGROUND: Bladder cancer is one of the most common malignancies in Western society. In the United States, approximately 10,000 of these patients present with invasive disease, and more progress from superficial bladder cancer. METHODS: The authors review the literature on systemic treatment for both localized and metastatic bladder cancer, and they include their experience in defining approaches to various stages of disease. RESULTS: Cisplatin-based combination chemotherapy is the most effective systemic approach for advanced bladder cancers, although few patients are cured. Neoadjuvant, perspective, and adjuvant trials, as well as concurrent chemoradiation studies, are in progress to attempt to demonstrate better outcomes. CONCLUSIONS: The combination of systemic chemotherapy and definitive local therapy may have a useful role in the management of locally advanced bladder cancers, but optimal schedules and true survival benefit have not been established.