151
|
Smaldone MC, Casella DP, Welchons DR, Gingrich JR. Investigational therapies for non-muscle invasive bladder cancer. Expert Opin Investig Drugs 2010; 19:371-83. [PMID: 20078248 DOI: 10.1517/13543780903563372] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Bacillus Calmette-Guérin (BCG) is currently the most effective adjuvant intravesical agent at preventing disease recurrence and the only therapy shown to inhibit disease progression in non-muscle invasive bladder cancer (NMIBC). However, recurrence rates as high as 30% and significant local/systemic toxicity have resulted in an increased interest in the use of alternative intravesical agents. AREAS COVERED IN THE REVIEW Our aim is to discuss recent clinical trial evidence utilizing novel intravesical agents for treatment of NMIBC. A systematic literature review was performed via the National Center for Biotechnology Information databases to identify pertinent studies from 2000-2009. WHAT THE READER WILL GAIN A durable response has been demonstrated with alternative agents in patients refractory to or intolerant of BCG. This review compares the merits and shortcomings of these emerging agents, focusing on clinical trial safety and efficacy results. TAKE HOME MESSAGE Despite recent enthusiasm for novel agents, radical cystectomy remains the treatment of choice for patients with NMIBC who have failed intravesical therapy. However, evidence is accumulating that novel agents provide an efficacious alternative in patients refractory or intolerable to BCG or unfit for cystectomy. Further randomized prospective data are required to demonstrate a recurrence- and progression-free benefit compared with BCG.
Collapse
Affiliation(s)
- Marc C Smaldone
- University of Pittsburgh Medical Center, Department of Urology, Kaufmann Building, 3471 5th Avenue, Pittsburgh, PA 15213, USA.
| | | | | | | |
Collapse
|
152
|
Yates DR, Rouprêt M. Failure of bacille Calmette-Guérin in patients with high risk non-muscle-invasive bladder cancer unsuitable for radical cystectomy: an update of available treatment options. BJU Int 2010; 106:162-7. [DOI: 10.1111/j.1464-410x.2010.09272.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
153
|
Gontero P, Bohle A, Malmstrom PU, O’Donnell MA, Oderda M, Sylvester R, Witjes F. The Role of Bacillus Calmette-Guérin in the Treatment of Non–Muscle-Invasive Bladder Cancer. Eur Urol 2010; 57:410-29. [DOI: 10.1016/j.eururo.2009.11.023] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 11/03/2009] [Indexed: 11/26/2022]
|
154
|
Ayres BE, Griffiths TL, Persad RA. Is the role of intravesical bacillus Calmette-Guérin in non-muscle-invasive bladder cancer changing? BJU Int 2010; 105 Suppl 2:8-13. [DOI: 10.1111/j.1464-410x.2009.09151.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
155
|
Intravesical therapy for superficial bladder cancer: a systematic review of randomised trials and meta-analyses. Cancer Treat Rev 2010; 36:195-205. [PMID: 20079574 DOI: 10.1016/j.ctrv.2009.12.005] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 12/01/2009] [Accepted: 12/05/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND In 2002 there were estimated to be 357,000 new cases of bladder cancer worldwide and 145,000 deaths making bladder cancer the 9th most common malignancy globally. At diagnosis, 60-80% of tumours are superficial and endoscopic resection is the initial treatment for this disease. In patients with low, medium or high risk disease, about 20%, 40% and 90%, respectively, will develop tumour recurrence. To delay or prevent recurrence, intravesical therapy is routinely used. Commonly used intravesical agents include immunotherapy with BCG and chemotherapy with cytotoxics such as Mitomycin C, Adriamycin, Epirubicin and Gemcitabine. However, controversy exists as to which agent and schedule should be used. METHODS An overarching search of the literature was used to identify relevant studies to assess the clinical benefit of intravesical therapy and provide clinical guidance in a comprehensive systematic review of randomised trials and meta-analyses of intravesical therapy for superficial bladder cancer. Findings and interpretation the search identified over 80 randomised trials and 11 meta-analyses. The extensive evidence suggests that an immediate post-operative instillation of a chemotherapeutic agent, such as Mitomycin C or Epirubicin, is effective in reducing tumour recurrence. In intermediate or high risk patients, further intravesical induction and maintenance therapy with BCG is recommended. CONCLUSION Intravesical chemotherapy with either Mitomycin C or Epirubicin would be an option for those patients failing or who are unsuitable for BCG therapy. Intravesical BCG is superior to chemotherapy in terms of complete response and disease-free survival. However, there is no conclusive evidence that one agent is superior in terms of overall survival.
Collapse
|
156
|
Abd El Mohsen M, Shelbaia A, El Ghobashy S, Swellam T, El Ganzoury H, Ali M, El Leithy T. Sequential Chemoimmunotherapy Using Mitomycin Followed by Bacillus Calmette-Guerin (MCC + BCG) Versus Single-Agent Immunotherapy (BCG) for Recurrent Superficial Bladder Tumors. ACTA ACUST UNITED AC 2010. [DOI: 10.3834/uij.1944-5784.2010.06.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
157
|
Kulkarni GS, Hakenberg OW, Gschwend JE, Thalmann G, Kassouf W, Kamat A, Zlotta A. An Updated Critical Analysis of the Treatment Strategy for Newly Diagnosed High-grade T1 (Previously T1G3) Bladder Cancer. Eur Urol 2010; 57:60-70. [DOI: 10.1016/j.eururo.2009.08.024] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 08/26/2009] [Indexed: 11/16/2022]
|
158
|
Hussain MHA, Wood DP, Bajorin DF, Bochner BH, Dreicer R, Lamm DL, O'Donnell MA, Siefker-Radtke AO, Theodorescu D, Dinney CP. Bladder cancer: narrowing the gap between evidence and practice. J Clin Oncol 2009; 27:5680-4. [PMID: 19858384 DOI: 10.1200/jco.2009.23.6901] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Maha H A Hussain
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
159
|
[Intravesical therapy in non-muscle-invasive bladder cancer: indications and practical considerations]. Urologe A 2009; 48:1263-4, 1266-8, 1270-2. [PMID: 19795104 DOI: 10.1007/s00120-009-2105-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Intravesical treatment with various agents is an accepted standard for treating patients with non-muscle-invasive bladder cancer; all guidelines recommend its use. Depending on the agent and the instillation schedule, a reduction in recurrence and a decrease in the progression rate can be achieved.However, many of the recommendations in the various guidelines are currently under debate. Early instillation with a chemotherapeutic agent is probably overtreatment in patients requiring further induction or maintenance therapy because it adds no further benefit. The economic aspects of early instillations are also being discussed. Recent studies question the ability of bacillus Calmette-Guérin (BCG) instillations to reduce the progression of non-muscle-invasive bladder cancer. Furthermore, the superiority of maintenance therapies compared with induction schedules is under debate.There is a great body of evidence that the effectiveness of intravesical chemotherapy can be increased by simple measures. Reduction of BCG side effects without compromising the oncological outcome is possible.
Collapse
|
160
|
Chiong E, Esuvaranathan K. New therapies for non-muscle-invasive bladder cancer. World J Urol 2009; 28:71-8. [PMID: 19763584 DOI: 10.1007/s00345-009-0474-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Accepted: 09/02/2009] [Indexed: 10/20/2022] Open
Abstract
The treatment of non-muscle-invasive bladder cancer (NMIBC) remains a challenge owing to its increased tendency to recur and the possibility of progression to potentially dangerous muscle-invasive disease. Treatment outcomes by current therapeutic modalities are still not optimal. In recent years, there have been a number of substantive advances in the therapeutic options for the management of NMIBC. New chemotherapeutic drugs have been introduced, along with efforts made to improve the efficacy of existing agents and enhance delivery of agents to the bladder. There is also a growing trend toward combination of agents and multimodal therapy. Also of considerable interest are the investigation of newer approaches such as gene therapy, chemoenhancement and newer forms of immunotherapy. Here, we review the recent pre-clinical and clinical developments in the treatment of NMIBC, described in the broad categories of immunotherapy, chemotherapeutic agents, improved or device-assisted agent delivery and gene therapy.
Collapse
Affiliation(s)
- Edmund Chiong
- Department of Urology, National University Hospital, Singapore 119074, Singapore
| | | |
Collapse
|
161
|
Martin FM, Kamat AM. Definition and management of patients with bladder cancer who fail BCG therapy. Expert Rev Anticancer Ther 2009; 9:815-20. [PMID: 19496718 DOI: 10.1586/era.09.35] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intravesical administration of bacillus Calmette-Guérin (BCG) following resection of non-muscle-invasive bladder tumor is the current 'gold standard'. However, up to 40% of patients will fail therapy within the first year and response rates to salvage intravesical therapy after appropriate trial of BCG (i.e., after induction and one maintenance course) average 15-20% at 1 year. Radical cystectomy remains the only treatment with proven long-term benefit after BCG failure. Nonetheless, with appropriate selection, certain patients who 'fail' BCG (but have other favorable risk factors, e.g., a long interval between BCG and recurrence) can be managed with intravesical regimens including repeated BCG, BCG plus cytokines and/or intravesical chemotherapy. In this review, optimal risk stratification, appropriate definitions and management of BCG failures are discussed.
Collapse
Affiliation(s)
- Frances M Martin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | | |
Collapse
|
162
|
Recurrence and progression of disease in non-muscle-invasive bladder cancer: from epidemiology to treatment strategy. Eur Urol 2009; 56:430-42. [PMID: 19576682 DOI: 10.1016/j.eururo.2009.06.028] [Citation(s) in RCA: 514] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Accepted: 06/17/2009] [Indexed: 01/01/2023]
Abstract
CONTEXT This review focuses on the prediction of recurrence and progression in non-muscle invasive bladder cancer (NMIBC) and the treatments advocated for this disease. OBJECTIVE To review the current status of epidemiology, recurrence, and progression of NMIBC and the state-of-the art treatment for this disease. EVIDENCE ACQUISITION A literature search in English was performed using PubMed and the guidelines of the European Association of Urology and the American Urological Association. Relevant papers on epidemiology, recurrence, progression, and management of NMIBC were selected. Special attention was given to fluorescent cystoscopy, the new World Health Organisation 2004 classification system for grade, and the role of substaging of T1 NMIBC. EVIDENCE SYNTHESIS In NMIBC, approximately 70% of patients present as pTa, 20% as pT1, and 10% with carcinoma in situ (CIS) lesions. Bladder cancer (BCa) is the fifth most frequent type of cancer in western society and the most expensive cancer per patient. Recurrence (in < or = 80% of patients) is the main problem for pTa NMIBC patients, whereas progression (in < or = 45% of patients) is the main threat in pT1 and CIS NMIBC. In a recent European Organisation for Research and Treatment of Cancer analysis, multiplicity, tumour size, and prior recurrence rate are the most important variables for recurrence. Tumour grade, stage, and CIS are the most important variables for progression. Treatment ranges from transurethral resection (TUR) followed by a single chemotherapy instillation in low-risk NMIBC to, sometimes, re-TUR and adjuvant intravesical therapy in intermediate- and high-risk patients to early cystectomy for treatment-refractory high-risk NMIBC. CONCLUSIONS NMIBC is a heterogeneous disease with varying therapies, follow-up strategies, and oncologic outcomes for an individual patient.
Collapse
|
163
|
Wirth M, Plattner VE, Gabor F. Strategies to improve drug delivery in bladder cancer therapy. Expert Opin Drug Deliv 2009; 6:727-44. [DOI: 10.1517/17425240903022758] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
164
|
Management of the first recurrence of T1G3 bladder cancer: Does intravesical chemotherapy deserve a chance? Urol Oncol 2009; 27:322-4. [DOI: 10.1016/j.urolonc.2008.10.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 10/24/2008] [Accepted: 10/28/2008] [Indexed: 11/23/2022]
|
165
|
Alfred Witjes J, Hendricksen K, Gofrit O, Risi O, Nativ O. Intravesical hyperthermia and mitomycin-C for carcinoma in situ of the urinary bladder: experience of the European Synergo working party. World J Urol 2009; 27:319-24. [PMID: 19234857 PMCID: PMC2694311 DOI: 10.1007/s00345-009-0384-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 01/26/2009] [Indexed: 11/05/2022] Open
Abstract
Objectives To study the results of chemotherapy combined with intravesical hyperthermia in patients with mainly BCG-failing carcinoma in situ (CIS). Methods Patients with histologically confirmed CIS were included retrospectively. Outpatient thermochemotherapy treatment was done with mitomycin-C (MMC) and the Synergo® system SB-TS 101 (temperature range between 41 and 44°C), weekly for 6–8 weeks, followed by 4–6 sessions every 6–8 weeks. Results Fifty-one patients were treated between 1997 and 2005 from 15 European centers. Thirty-four were pre-treated with BCG. Mean age was 69.9 years. Twenty-four patients had concomitant papillary tumors. The mean number of hyperthermia/MMC treatments per patient was 10.0. Of the 49 evaluable patients 45 had a biopsy and cytology proven complete response. In two patients CIS disappeared, but they had persistent papillary tumors. Follow-up of 45 complete responders showed 22 recurrences after a mean of 27 months (median 22): T2 (4), T1 (4), T1/CIS (1), CIS (5), Ta/CIS (2), Ta (5) and Tx (1). Side effects (bladder complaints) were generally mild and transient. Conclusions In patients with primary or BCG-failing CIS, treatment with intravesical hyperthermia and MMC appears a safe and effective treatment. The initial complete response rate is 92%, which remains approximately 50% after 2 years.
Collapse
Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, PO Box 9101, Nijmegen 6500 HB, The Netherlands.
| | | | | | | | | |
Collapse
|
166
|
Di Stasi SM, Riedl C. Updates in intravesical electromotive drug administration® of mitomycin-C for non-muscle invasive bladder cancer. World J Urol 2009; 27:325-30. [DOI: 10.1007/s00345-009-0389-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Accepted: 01/29/2009] [Indexed: 10/21/2022] Open
|
167
|
Bartoletti R, Cai T. Endocavitary Prophylaxis of Superficial Urothelial Bladder Tumours: New Compounds. Urologia 2009. [DOI: 10.1177/039156030907600101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Bladder urothelial carcinoma is the fourth most frequent cancer among European men, accounting for about 7% of the total cancers. Transurethral resection (TUR) is usually indicated as the standard treatment for non-muscle invasive bladder cancer (NMIBC). However, TUR is unable to guarantee a complete eradication of Ta, T1 tumors with a recurrence rate ranging from 50 to 70%, and a progression rate to muscle invasive disease ranging from 10 to 15%. Methods The European Association of Urology guidelines recommend adjuvant intravesical chemotherapy after definitive diagnosis of intermediate/high risk NMIBC to reduce both recurrence and progression of the disease. To provide a comprehensive review of intravesical treatment options for NMIBC, we performed a search of the PubMed database for articles between 1980 and 2009 that reported on intravesical agents for treating this disease. Results A critical analysis of the findings resulting from large multicenter trials, phase I, II, III studies for pertinent novel agents and from review articles was carried out. We focused on the following issues: 1) the role of the treatment with Bacillus Calmette-Guérin (BCG) and the need of maintaining the drug schedule (with or without interferon-alpha); 2) the correct timing of adjuvant immuno- and chemotherapy; 3) the use of the novel chemotherapeutic agents; 4) the use of the novel technique of chemotherapeutic agents administration, with a particular interest on electromotive administration of mitomycin.
Collapse
Affiliation(s)
- R. Bartoletti
- Dipartimento di Area Critica Medico Chirurgica, Università degli Studi di Firenze
| | - T. Cai
- Dipartimento di Area Critica Medico Chirurgica, Università degli Studi di Firenze
| |
Collapse
|
168
|
Affiliation(s)
- Kyung Seok Han
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Joon Hong
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
169
|
Affiliation(s)
- Seth P Lerner
- Scott Department of Urology, Baylor College of Medicine, Houston, TX 77030, USA.
| | | |
Collapse
|
170
|
Horvath A, Mostafid H. Therapeutic options in the management of intermediate-risk nonmuscle-invasive bladder cancer. BJU Int 2008; 103:726-9. [PMID: 19007379 DOI: 10.1111/j.1464-410x.2008.08094.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Non-muscle-invasive bladder cancers form a heterogeneous group of tumours with varying recurrence and progression rates. Recently low-, intermediate- and high-risk categories, based on tumour stage and grade, have been used to predict prognosis and guide treatment. Whilst the therapeutic options for the low- and high-risk groups are well defined, the optimal treatment for patients in the intermediate-risk group is unknown. We review current treatment options, recent advances and future developments in the treatment of patients with intermediate-risk non-muscle-invasive bladder cancer.
Collapse
Affiliation(s)
- Andras Horvath
- Department of Urology, North Hampshire Hospital, Basingstoke, UK
| | | |
Collapse
|
171
|
Di Stasi S, Dutto L, Verri C. Intravesical Electromotive Drug Administration® (EMDA) with Mitomycin-C for non-muscle invasive bladder cancer. Urologia 2008. [DOI: 10.1177/039156030807500403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Electromotive Drug Administration® (EMDA) offers a means of controlling and enhancing the tissue transport of certain drugs, when applied to a surface epithelium, where they have a local therapeutic effect, in order to increase their efficacy. One application option is the treatment of non-muscle invasive bladder cancer with intravesical mitomycin-C (MMC). Laboratory studies demonstrated that EMDA/MMC can reduce the variability and enhance the drug administration rate into all layers of the bladder wall, and that the applied electric current causes no histological damage to tissue and no chemical modification of MMC. A prospective randomized study, performed in patients with in situ carcinoma, validated the prediction that electromotive enhancement of MMC delivery would provide results superior to those achieved using passive MMC transport. A further randomized study in patients with pT1 bladder cancer demonstrated that a regimen combining intravesical BCG and EMDA/MMC increased the disease-free interval and reduced the recurrence rate, as well as the disease progression and mortality rate if compared with BCG alone. The possibility that BCG may enhance the efficacy of MMC against high-grade pT1 transitional cell carcinoma and in situ carcinoma represents an important new therapeutic perspective in the high-risk non-muscle invasive bladder cancer.
Collapse
Affiliation(s)
- S.M. Di Stasi
- Dipartimento di Chirurgia/Urologia, Università “Tor Vergata”, Roma
| | - L. Dutto
- Dipartimento di Chirurgia/Urologia, Università “Tor Vergata”, Roma
| | - C. Verri
- Dipartimento di Chirurgia/Urologia, Università “Tor Vergata”, Roma
| |
Collapse
|
172
|
Intravesical Chemotherapy and BCG for the Treatment of Bladder Cancer: Evidence and Opinion. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.eursup.2008.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
173
|
Witjes JA, Kolli PS. Apaziquone for non-muscle invasive bladder cancer: a critical review. Expert Opin Investig Drugs 2008; 17:1085-96. [DOI: 10.1517/13543784.17.7.1085] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- J Alfred Witjes
- Radboud University Nijmegen Medical Centre, Department of Urology (659), PO Box 9101, 6500 H.B Nijmegen, The Netherlands ;
| | - Prasad S Kolli
- Spectrum Pharmaceuticals, Department of biopharmaceuticals, Irvine, California, USA
| |
Collapse
|
174
|
|
175
|
Abstract
For bladder cancer, intravesical chemo/immunotherapy is widely used as adjuvant therapies after surgical transurethal resection, while systemic therapy is typically reserved for higher stage, muscle-invading, or metastatic diseases. The goal of intravesical therapy is to eradicate existing or residual tumors through direct cytoablation or immunostimulation. The unique properties of the urinary bladder render it a fertile ground for evaluating additional novel experimental approaches to regional therapy, including iontophoresis/electrophoresis, local hyperthermia, co-administration of permeation enhancers, bioadhesive carriers, magnetic-targeted particles and gene therapy. Furthermore, due to its unique anatomical properties, the drug concentration-time profiles in various layers of bladder tissues during and after intravesical therapy can be described by mathematical models comprised of drug disposition and transport kinetic parameters. The drug delivery data, in turn, can be combined with the effective drug exposure to infer treatment efficacy and thereby assists the selection of optimal regimens. To our knowledge, intravesical therapy of bladder cancer represents the first example where computational pharmacological approach was used to design, and successfully predicted the outcome of, a randomized phase III trial (using mitomycin C). This review summarizes the pharmacological principles and the current status of intravesical therapy, and the application of computation to optimize the drug delivery to target sites and the treatment efficacy.
Collapse
|
176
|
Lamm DL. Re: A randomized trial of radical radiotherapy for the management of pT1G3 NXM0 transitional cell carcinoma of the bladder. S. J. Harland, H. Kynaston, K. Grigor, D. M. Wallace, C. Beacock, R. Kockelbergh, S. Clawson, T. Barlow, M. K. Parmar and G. O. Griffiths; National Cancer Research Institute Bladder Clinical Studies Group. J Urol 2007; 178: 807-813. J Urol 2008; 179:1639-40; author reply 1640-1. [PMID: 18295248 DOI: 10.1016/j.juro.2007.11.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2007] [Indexed: 11/24/2022]
|
177
|
Witjes JA, Hendricksen K. Intravesical Pharmacotherapy for Non–Muscle-Invasive Bladder Cancer: A Critical Analysis of Currently Available Drugs, Treatment Schedules, and Long-Term Results. Eur Urol 2008; 53:45-52. [PMID: 17719169 DOI: 10.1016/j.eururo.2007.08.015] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 08/07/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Review adjuvant intravesical pharmacotherapy for non-muscle-invasive bladder cancer (NMIBC), emphasising treatment schedules and long-term results. METHODS Search of published literature on conventional treatment of NMIBC, emerging drugs, and device-assisted therapies. RESULTS In low-risk NMIBC patients an immediate instillation with chemotherapy is sufficient. For patients with intermediate- or high-risk tumours, additional adjuvant instillations are needed. For intermediate-risk patients chemotherapeutic instillations, usually with mitomycin C or epirubicin, are safe and effective in reducing the risk of recurrence in the short term, but efficacy is only marginal in the long term. Newer drugs have promising results, but long term follow-up is limited or lacking. In these patients bacillus Calmette-Guérin (BCG) does not seem to be more effective, only more toxic. In high-risk NMIBC, or patients in whom chemotherapy fails, BCG is the best choice with lower rates of recurrence and progression. For BCG failures cystectomy is therapy of choice, although the combination of BCG and interferon-alpha can be considered, just as device-assisted therapies such as thermochemotherapy and electromotive drug administration. CONCLUSIONS Risk-adapted first-line adjuvant therapy for NMIBC after TURBT is well established but has its limitations because recurrences are still numerous. Some new drugs and second-line therapies are promising, but efficacy should be confirmed.
Collapse
Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | | |
Collapse
|
178
|
Kalsi J, Harland SJ, Feneley MR. Electromotive drug administration with mitomycin C for intravesical treatment of non-muscle invasive transitional cell carcinoma. Expert Opin Drug Deliv 2007; 5:137-45. [DOI: 10.1517/17425247.5.1.137] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
179
|
Hendricksen K, Witjes JA. Current strategies for first and second line intravesical therapy for nonmuscle invasive bladder cancer. Curr Opin Urol 2007; 17:352-7. [PMID: 17762630 DOI: 10.1097/mou.0b013e3281c55f2b] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW Nonmuscle invasive bladder cancer is a common malignancy, usually treated by transurethral resection and adjuvant intravesical instillations of chemotherapy or immunotherapy. Appropriate adjuvant treatment can be selected based on several prognostic factors that determine risk for recurrence or progression. We discuss options for first-line and second-line adjuvant therapy for nonmuscle invasive bladder cancer. RECENT FINDINGS Mitomycin-C and epirubicin are the mostly used adjuvant chemotherapeutic drugs for tumours of low and intermediate risk. Bacillus Calmette-Guérin remains first-choice therapy in high-risk nonmuscle invasive bladder cancer. Gemcitabine and apaziquone are especially promising for treatment of intermediate risk nonmuscle invasive bladder cancer but require further study. Device-assisted therapies, such as thermochemotherapy and electromotive drug administration, have yielded good results in high-risk nonmuscle invasive bladder cancer and could be considered second-line therapy in this setting. SUMMARY Primary problems in nonmuscle invasive bladder cancer are its tendency to recur and its elusiveness (especially high-risk nonmuscle invasive bladder cancer) of progression to muscle invasive disease. First-line adjuvant therapies are well established but suboptimal. Some second-line therapies are promising but should be used cautiously, because in some patients the best option is not always the conservative one.
Collapse
Affiliation(s)
- Kees Hendricksen
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | |
Collapse
|
180
|
Hendricksen K, Witjes JA. Treatment of Intermediate-Risk Non–Muscle-Invasive Bladder Cancer (NMIBC). ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.eursup.2007.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
181
|
Dalbagni G. The management of superficial bladder cancer. ACTA ACUST UNITED AC 2007; 4:254-60. [PMID: 17483810 DOI: 10.1038/ncpuro0784] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 02/15/2007] [Indexed: 11/08/2022]
Abstract
From review of the currently available trial evidence, several clinical recommendations for bladder tumor management become apparent. Transurethral resection should be done, but this procedure is prone to both overestimating and underestimating staging. Restaging transurethral resection for patients with T1 tumors should, therefore, be performed. Data support the immediate postoperative instillation of a chemotherapeutic agent for patients with solitary, low-grade papillary tumors, whereas patients with multiple lesions might benefit from a more intensive adjuvant regimen. Although the use of intravesical immunotherapy for reducing tumor progression or as maintenance therapy is controversial, bacillus Calmette-Guérin has demonstrated significant benefit for tumor prophylaxis when no obvious residual disease is present. Early radical cystectomy can be beneficial and should be performed in patients with refractory T1 tumors or carcinoma in situ before progression to muscle invasion. In this Review I present an overview of the management of nonmuscle invasive bladder cancer. The most common intravesical chemotherapeutic agents are described as well as the impact of chemotherapy on the recurrence and progression of tumors. The effect of intravesical immunotherapy in bladder cancer is explored as well as the role of early cystectomy.
Collapse
Affiliation(s)
- Guido Dalbagni
- Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
| |
Collapse
|
182
|
Sylvester R. Interview with Dr Richard Sylvester: Transition Cell Carcinoma of the Bladder. Eur Urol 2007; 51:1748-50. [PMID: 17374436 DOI: 10.1016/j.eururo.2007.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Accepted: 03/05/2007] [Indexed: 11/25/2022]
|
183
|
Abstract
PURPOSE OF REVIEW This article reviews the diagnosis and management of bladder cancer with an emphasis on studies and developments over the past year. RECENT FINDINGS Cystoscopy remains the mainstay in the detection and surveillance of bladder cancer, though efforts continue in the development of urinary bladder cancer markers. Superficial bladder cancer continues to be managed predominantly through transurethral resection with perioperative instillation of chemotherapy recommended for most patients. Intravesical bacille Calmette-Guerin (including a maintenance regimen) should be used for those at high risk for progression. Muscle invasive disease continues to be managed by radical cystectomy. Research continues on the use of laparoscopy, the effect on patient's health-related quality of life, and the potential role for bladder preservation strategies. The role of neoadjuvant versus adjuvant chemotherapy around the time of cystectomy remains to be resolved. The mainstays of chemotherapy remain methotrexate, vinblastine, doxorubicin, and cisplatin, and gemcitabine and cisplatin, but work is ongoing to develop new regimens, especially in patients who cannot take cisplatin. SUMMARY Although great strides continue to be made each year in the diagnosis and management of bladder cancer considerably more work needs to be done in order to improve the lives of our patients with this disease.
Collapse
Affiliation(s)
- Peter E Clark
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2765, USA.
| |
Collapse
|
184
|
Kassouf W, Spiess PE, Brown GA, Munsell MF, Grossman HB, Siefker-Radtke A, Dinney CP, Kamat AM. P0 stage at radical cystectomy for bladder cancer is associated with improved outcome independent of traditional clinical risk factors. Eur Urol 2007; 52:769-74. [PMID: 17434254 PMCID: PMC2691552 DOI: 10.1016/j.eururo.2007.03.086] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Accepted: 03/16/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Final pathologic specimen free of detectable disease (P0) is not uncommon in patients undergoing cystectomy for bladder cancer, especially in the era of neoadjuvant chemotherapy. To improve our understanding of its significance in a contemporary series, we performed an outcomes analysis of this cohort of patients. METHODS Over the last 15 yr, 1104 patients with bladder cancer underwent radical cystectomy at our institution. Of these, 120 (11%) were pT0N0M0 (P0) in the surgical specimen and form the basis of this report. Survival data were estimated by method of Kaplan and Meier, with Cox proportional hazards regression model used to evaluate associations between survival and variables studied. RESULTS Clinical stages were cT1, 21 patients; cT2, 65; cT3b, 20; cT4a, 11; and cT4b, 3. The 5-yr estimates of overall (OS), disease-specific (DSS), and recurrence-free survival (RFS) rates were 84%, 88%, and 84%, respectively. With mean follow-up of 43 mo, 11 patients developed recurrences, 9 of whom died of disease. Median time to recurrence was 7.7 mo (range: 2.2-45 mo). On multivariate analysis, presence of lymphovascular invasion and concomitant carcinoma in situ on the transurethral resection of the bladder tumor specimen were the only significant prognostic factors associated with shorter OS (p = 0.04) and RFS (p = 0.049), respectively. Notably, patients who received preoperative chemotherapy (n = 77) had 5-yr survival rates similar to those of patients who did not. CONCLUSION Although patients who are P0 at cystectomy have a good prognosis, not all can be considered cured. The favorable prognosis conferred by a P0 state appears to be independent of whether this is achieved by neoadjuvant chemotherapy or by thorough transurethral resection before cystectomy.
Collapse
Affiliation(s)
- Wassim Kassouf
- Division of Urology, McGill University Health Center, Montreal, Canada
| | - Philippe E. Spiess
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Gordon A. Brown
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Mark F. Munsell
- Department of Biostatistics and Applied Mathematics, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - H. Barton Grossman
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Arlene Siefker-Radtke
- Department of Genitourinary Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Colin P.N. Dinney
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
- Department of Cancer Biology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Ashish M. Kamat
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
- Department of Cancer Biology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
- Correspondence: Ashish M. Kamat, Department of Urology, Unit 1373, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA, Tel: 713-792-3250, Fax: 713-794-4824, E-mail:
| |
Collapse
|
185
|
Irani J, Mottet N, Ribal Caparrós MJ, Teillac P. New Trends in Bladder Cancer Management. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.eursup.2006.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
186
|
Giannantoni A, Di Stasi SM, Chancellor MB, Costantini E, Porena M. New Frontiers in Intravesical Therapies and Drug Delivery. Eur Urol 2006; 50:1183-93; discussion 1193. [PMID: 16963179 DOI: 10.1016/j.eururo.2006.08.025] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Accepted: 08/16/2006] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The intravesical route permits site-specific delivery of drugs with a reduced side-effect profile as compared to oral delivery systems, either by avoiding first-pass metabolism or by obtaining a local effect. We investigated mechanisms related to urothelium permeability and new physical and chemical developments in intravesical drug delivery that potentially permit successful treatment of several bladder dysfunction. METHODS A literature review. RESULTS Pharmacologic agents increasing urothelial permeability and useful for clinical purposes have been described, such as dimethylsulfoxide, protamine sulphate, chitosan, and nystatin. Among physical approaches, electromotive drug administration appears to be more effective than intravesical passive diffusion in delivering drugs through the urothelium into deeper layers of the bladder. Experimental and clinical reports demonstrated that electric current significantly increases the transport of local anaesthetics, mytomicin C, oxybutynin, resiniferatoxin, epinephrine, and dexamethasone. Among new chemical approaches, cell-penetrating peptides posses the ability to translocate macromolecular drugs across membranes of urothelial cells. The therapeutic benefits of sustained delivery afforded by thermosensitive hydrogel, which forms a depot for hydrophilic and hydrophobic drugs, have been demonstrated by delivering anti-inflammatory drugs. Liposomes improve the aqueous solubility of several hydrophobic drugs such as taxol, amphotericin, and capsaicin. CONCLUSIONS Electromotive drug administration, new in situ delivery systems, and bioadhesive liposomes may make it possible to extend intravesical therapy and drug administration to many bladder diseases. Research to expand knowledge of the chemical and physical properties of the bladder and processes regulating drug transport across biologic membranes is needed to make this a reality.
Collapse
|
187
|
Maffezzini M. Re: Intravesical Bacillus Calmette-Guérin versus Mitomycin C for Ta and T1 Bladder Cancer. Eur Urol 2006. [DOI: 10.1016/j.eururo.2006.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
188
|
Tyagi P, Tyagi S, Kaufman J, Huang L, de Miguel F. Local drug delivery to bladder using technology innovations. Urol Clin North Am 2006; 33:519-30, x. [PMID: 17011388 DOI: 10.1016/j.ucl.2006.06.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Local delivery of drugs directly into the bladder by way of a urethral catheter is a clever approach to optimize drug delivery to the disease site while reducing systemic bioavailability. Pharmacotherapy by this route is referred to as intravesical delivery. In recent years, intravesical delivery has been used in combination with and oral regimen of drugs or as second-line treatment for neurogenic bladder and detrusor overactivity. Negligible absorption of instilled drugs into the systemic circulation explains the near-minimal adverse toxicity reported with this form of therapy. The authors discuss shortcomings of the current options available for intravesical delivery and provide a broad overview of the latest advances through technology innovation to overcome these drawbacks.
Collapse
Affiliation(s)
- Pradeep Tyagi
- Department of Urology, University of Pittsburgh School of Medicine, Kaufmann Medical Building, Suite 700, 3471 Fifth Avenue, Pittsburgh, PA 15213-3221, USA.
| | | | | | | | | |
Collapse
|
189
|
Bolenz C, Cao Y, Arancibia MF, Trojan L, Alken P, Michel MS. Intravesical mitomycin C for superficial transitional cell carcinoma. Expert Rev Anticancer Ther 2006; 6:1273-82. [PMID: 16925493 DOI: 10.1586/14737140.6.8.1273] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intravesical instillation of mitomycin C after a transurethral resection of a bladder tumor constitutes a standard treatment modality in the management of superficial transitional cell carcinoma in the urinary bladder. An immediate instillation of mitomycin C after transurethral resection has been shown to reduce the recurrence rate of superficial transitional cell carcinoma. Intravesical mitomycin C is generally considered to be a safe treatment option, but the past few years have seen the publication of a number of case reports on severe complications following mitomycin C instillation. This article reports on the mode of action, as well as the intravesical effects and current indications for mitomycin C instillation. This review will summarize the oncological benefits of mitomycin C in comparison with other intravesical treatments, such as bacillus Calmette-Guérin, and elucidate the incidence and types of possible complications associated with intravesical mitomycin C chemotherapy.
Collapse
Affiliation(s)
- Christian Bolenz
- Department of Urology, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | | | | | | | | | | |
Collapse
|
190
|
Gasión JPB, Cruz JFJ. Improving Efficacy of Intravesical Chemotherapy. Eur Urol 2006; 50:225-34. [PMID: 16793196 DOI: 10.1016/j.eururo.2006.05.035] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Accepted: 05/18/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This paper reviews the most relevant findings published recently on intravesical chemotherapy for superficial bladder tumours and provides recommendations based on documented research. METHODS The evidence was categorised according to the North of England Evidence Based Guideline Development Project. Levels of evidence were based on the source of the information, meta-analyses, systematic reviews, well-designed randomised or nonrandomised controlled clinical trials, and uncontrolled studies or consensus. Three levels of recommendations were assigned to the evidence obtained. RESULTS Despite intravesical chemotherapy being used prophylactically after endoscopic resection of superficial bladder tumours, the recurrence rate is still 36-44%. Researchers have focused on improving the effectiveness of intravesical chemotherapy, each adopting a different strategy. Some have aimed to identify the optimum timing for instillations and others to improve the pharmacokinetics of agents by avoiding their dilution, increasing their stability, or improving the absorption of the drug by bladder mucosa. Some researchers are looking into new, single chemotherapeutic agents or combinations for intravesical use and others into avoiding chemoresistance with resistance-reverting agents (modulating agents) or by using in vitro chemosensitivity tests to identify the most sensitive drug. CONCLUSION Progress has been made in optimising intravesical chemotherapy for timing of instillations and pharmacokinetic interventions. Simple and inexpensive approaches may have a widespread, practical acceptance by urologists, but it is more difficult to extend new techniques requiring more complex and sometimes expensive instrumentation to the urologic community. Further research into finding more effective cytotoxic drugs, combinations, or modulating agents should be encouraged.
Collapse
|
191
|
Harland SJ. Electromotive drug delivery and bladder cancer. Lancet Oncol 2006; 7:6-7. [PMID: 16389175 DOI: 10.1016/s1470-2045(05)70515-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|