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Zeng N, Xu MY, Sun JX, Liu CQ, Xu JZ, An Y, Zhong XY, Ma SY, He HD, Xia QD, Wang SG. Hyperthermia intravesical chemotherapy acts as a promising alternative to bacillus Calmette-Guérin instillation in non-muscle-invasive bladder cancer: a network meta-analysis. Front Oncol 2023; 13:1164932. [PMID: 37251942 PMCID: PMC10213538 DOI: 10.3389/fonc.2023.1164932] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction With the shortage of bacillus Calmette-Guérin (BCG) vaccine, it is important to find an alternative to BCG instillation, which is the most commonly used adjuvant treatment for non-muscle-invasive bladder cancer (NMIBC) patients after transurethral resection of bladder tumor treatment (TURBt) to delay tumor recurrence. Hyperthermia intravesical chemotherapy (HIVEC) with mitomycin C (MMC) is a potential treatment choice. We aim to compare HIVEC with BCG instillation for the preventive efficacy of bladder tumor recurrence and progression. Methods A network meta-analysis (NMA) was taken with MMC instillation and TURBt as the attached comparators. Randomized controlled trials (RCTs) with NIMBC patients after TURBt were included. Articles with pure BCG unresponsive patients and combined therapies were excluded. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023390363). Results It was found that HIVEC had a non-significant 22% relative reduction in bladder tumor recurrence compared with BCG instillation [HIVEC vs. BCG: HR 0.78, 95% credible interval (CrI) 0.55-1.08] and a nonsignificant higher risk of bladder tumor progression (BCG vs. HIVEC: HR 0.77, 95% CrI 0.22-3.03). Discussion HIVEC is a potential alternative to BCG, and it is expected to be the standard therapy for NMIBC patients after TURBt during the global shortage of BCG. Systematic Review Registration PROSPERO identifier, CRD42023390363.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Qi-Dong Xia
- *Correspondence: Qi-Dong Xia, ; Shao-Gang Wang,
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Jin YH, Zeng XT, Liu TZ, Bai ZM, Dou ZL, Ding DG, Fan ZL, Han P, Huang YR, Huang X, Li M, Li XD, Li YN, Li XH, Liang CZ, Liu JM, Ma HS, Qi J, Shi JQ, Wang J, Wang DL, Wang ZP, Wang YY, Wang YB, Wei Q, Xia HB, Xing JC, Yan SY, Zhang XP, Zheng GY, Xing NZ, He DL, Wang XH. Treatment and surveillance for non-muscle-invasive bladder cancer: a clinical practice guideline (2021 edition). Mil Med Res 2022; 9:44. [PMID: 35978389 PMCID: PMC9382792 DOI: 10.1186/s40779-022-00406-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Non-muscle invasive bladder cancer (NMIBC) is a major type of bladder cancer with a high incidence worldwide, resulting in a great disease burden. Treatment and surveillance are the most important part of NIMBC management. In 2018, we issued "Treatment and surveillance for non-muscle-invasive bladder cancer in China: an evidence-based clinical practice guideline". Since then, various studies on the treatment and surveillance of NMIBC have been published. There is a need to incorporate these materials and also to take into account the relatively limited medical resources in primary medical institutions in China. Developing a version of guideline which takes these two issues into account to promote the management of NMIBC is therefore indicated. We formed a working group of clinical experts and methodologists. Through questionnaire investigation of clinicians including primary medical institutions, 24 clinically concerned issues, involving transurethral resection of bladder tumor (TURBT), intravesical chemotherapy and intravesical immunotherapy of NMIBC, and follow-up and surveillance of the NMIBC patients, were determined for this guideline. Researches and recommendations on the management of NMIBC in databases, guideline development professional societies and monographs were referred to, and the European Association of Urology was used to assess the certainty of generated recommendations. Finally, we issued 29 statements, among which 22 were strong recommendations, and 7 were weak recommendations. These recommendations cover the topics of TURBT, postoperative chemotherapy after TURBT, Bacillus Calmette-Guérin (BCG) immunotherapy after TURBT, combination treatment of BCG and chemotherapy after TURBT, treatment of carcinoma in situ, radical cystectomy, treatment of NMIBC recurrence, and follow-up and surveillance. We hope these recommendations can help promote the treatment and surveillance of NMIBC in China, especially for the primary medical institutions.
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Affiliation(s)
- Ying-Hui Jin
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Xian-Tao Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Tong-Zu Liu
- Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Zhi-Ming Bai
- Department of Urology, Haikou People’s Hospital, Haikou Affiliated Hospital of Central South University Xiangya School of Medicine, Haikou, 570208 China
| | - Zhong-Ling Dou
- Department of Urology, the First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, 450052 Henan China
| | - De-Gang Ding
- Department of Urology, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Zhengzhou, 450003 China
| | - Zhi-Lu Fan
- Department of Urology, the Second Hospital of Dalian Medical University, Dalian, 116023 Liaoning China
| | - Ping Han
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041 China
| | - Yi-Ran Huang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200120 China
| | - Xing Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Ming Li
- Department of Urology, the People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, 830002 China
| | - Xiao-Dong Li
- Department of Urology, Huaihe Hospital of Henan University, Kaifeng, 475000 Henan China
- Institutes of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000 Henan China
| | - Yi-Ning Li
- Department of Urology, the Second Affiliated Hospital and Second Clinical Medical College of Fujian Medical University, Quanzhou, 362000 Fujian China
| | - Xu-Hui Li
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Chao-Zhao Liang
- Department of Urology, the First Affiliated Hospital of Anhui Medical University, Hefei, 230022 China
| | - Jiu-Min Liu
- Department of Urology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080 China
| | - Hong-Shun Ma
- Department of Urology, Tianjin First Central Hospital, Tianjin, 300190 China
| | - Juan Qi
- Department of Urology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092 China
| | - Jia-Qi Shi
- Department of Urology, Affiliated Hospital of Guizhou Medical University, Guiyang, 550004 China
| | - Jian Wang
- Department of Urology, Qinghai University Affiliated Hospital, Xining, 810012 China
| | - De-Lin Wang
- Department of Urology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400042 China
| | - Zhi-Ping Wang
- Department of Urology, Institute of Urology, Lanzhou University Second Hospital, Key Laboratory of Urological Diseases in Gansu Province, Lanzhou, 730030 China
| | - Yun-Yun Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Yong-Bo Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Qiang Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041 China
| | - Hai-Bo Xia
- Department of Urology, Chifeng Cancer Hospital, the Second Affiliated Hospital of Chifeng University, Chifeng, 024000 Inner Mongolia Autonomous Region China
| | - Jin-Chun Xing
- Key Laboratory of Urinary Tract Tumors and Calculi, Department of Urology, the First Affiliated Hospital of Xiamen University, Xiamen, 361003 China
| | - Si-Yu Yan
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Xue-Pei Zhang
- Department of Urology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Guo-You Zheng
- Department of Urology, the Second Division of the First Hospital of Jilin University, Changchun, 130061 China
| | - Nian-Zeng Xing
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021 China
| | - Da-Lin He
- Department of Urology, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
| | - Xing-Huan Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - the Chinese Urological Doctor Association (CUDA), Urological Association of Chinese Research Hospital Association (CRHA-UA), Uro-Health Promotive Association of China International Exchange, Promotive Association for Medical, Health Care (CPAM-UHPA)
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Department of Urology, Institute of Urology, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
- Department of Urology, Haikou People’s Hospital, Haikou Affiliated Hospital of Central South University Xiangya School of Medicine, Haikou, 570208 China
- Department of Urology, the First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, 450052 Henan China
- Department of Urology, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Zhengzhou, 450003 China
- Department of Urology, the Second Hospital of Dalian Medical University, Dalian, 116023 Liaoning China
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041 China
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200120 China
- Department of Urology, the People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, 830002 China
- Department of Urology, Huaihe Hospital of Henan University, Kaifeng, 475000 Henan China
- Institutes of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, 475000 Henan China
- Department of Urology, the Second Affiliated Hospital and Second Clinical Medical College of Fujian Medical University, Quanzhou, 362000 Fujian China
- Department of Urology, the First Affiliated Hospital of Anhui Medical University, Hefei, 230022 China
- Department of Urology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080 China
- Department of Urology, Tianjin First Central Hospital, Tianjin, 300190 China
- Department of Urology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, 200092 China
- Department of Urology, Affiliated Hospital of Guizhou Medical University, Guiyang, 550004 China
- Department of Urology, Qinghai University Affiliated Hospital, Xining, 810012 China
- Department of Urology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400042 China
- Department of Urology, Institute of Urology, Lanzhou University Second Hospital, Key Laboratory of Urological Diseases in Gansu Province, Lanzhou, 730030 China
- Department of Urology, Chifeng Cancer Hospital, the Second Affiliated Hospital of Chifeng University, Chifeng, 024000 Inner Mongolia Autonomous Region China
- Key Laboratory of Urinary Tract Tumors and Calculi, Department of Urology, the First Affiliated Hospital of Xiamen University, Xiamen, 361003 China
- Department of Urology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
- Department of Urology, the Second Division of the First Hospital of Jilin University, Changchun, 130061 China
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021 China
- Department of Urology, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
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Rajendran G, Taylor JA, Woolbright BL. Natural products as a means of overcoming cisplatin chemoresistance in bladder cancer. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2021; 4:69-84. [PMID: 35582013 PMCID: PMC9019192 DOI: 10.20517/cdr.2020.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/05/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Abstract
Cisplatin remains an integral part of the treatment for muscle invasive bladder cancer. A large number of patients do not respond to cisplatin-based chemotherapy and efficacious salvage regimens are limited. Immunotherapy has offered a second line of treatment; however, only approximately 20% of patients respond, and molecular subtyping of tumors indicates there may be significant overlap in those patients that respond to cisplatin and those patients that respond to immunotherapy. As such, restoring sensitivity to cisplatin remains a major hurdle to improving patient care. One potential source of compounds for enhancing cisplatin is naturally derived bioactive products such as phytochemicals, flavonoids and others. These compounds can activate a diverse array of different pathways, many of which can directly promote or inhibit cisplatin sensitivity. The purpose of this review is to understand current drug development in the area of natural products and to assess how these compounds may enhance cisplatin treatment in bladder cancer patients.
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Affiliation(s)
- Ganeshkumar Rajendran
- Department of Urology, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - John A Taylor
- Department of Urology, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Benjamin L Woolbright
- Department of Urology, University of Kansas Medical Center, Kansas City, KS 66160, USA
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Lu J, Xue Y, Shen F, Gu H, Liu H, Hou J, Miao H. Transurethral holmium laser resection and transurethral electrocision combined with intravesical epirubicin within 24 hours postoperatively for treatment of bladder cancer. J Int Med Res 2020; 48:300060519887267. [PMID: 31885339 PMCID: PMC7309393 DOI: 10.1177/0300060519887267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/17/2019] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To investigate the efficacy and safety of transurethral holmium laser resection (THOLR) and transurethral electrocision (TUR) combined with intravesical epirubicin within 24 hours postoperatively for treatment of non-muscular invasive bladder cancer. METHODS A total of 218 consecutive patients who were newly diagnosed with bladder cancer were enrolled in this prospective study from July 2014 to December 2017. The patients were randomly divided into THOLR and TUR groups. All patients received intravesical epirubicin (30 mg dissolved in 5% glucose solution) within 24 hours postoperatively. The operation time, blood loss, rate of obturator reflex, hospitalization time, catheterization time, complications, and recurrence were analyzed. RESULTS Operation, hospitalization, and catheterization times were significantly greater in the TUR group than in the THOLR group. The rates of blood loss and intraoperative obturator reflex were also significantly greater in the TUR group. There were no significant differences in complications, recurrence rate survival, or recurrence-free survival between the two groups, with the exception of bladder perforation rate. CONCLUSIONS THOLR and TUR combined with intravesical epirubicin within 24 hours postoperatively were both safe and effective for treatment of bladder tumor; however, patients who undergo THOLR might experience more rapid recovery.
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Affiliation(s)
- Jiawei Lu
- Department of Urology, The Affiliated Zhangjiagang Hospital of Soochow University, Zhangjiagang, jiangsu, China
| | - Yagang Xue
- Department of Urology, The Affiliated Zhangjiagang Hospital of Soochow University, Zhangjiagang, jiangsu, China
| | - Feng Shen
- Department of Urology, The Affiliated Zhangjiagang Hospital of Soochow University, Zhangjiagang, jiangsu, China
| | - Hongxing Gu
- Department of Urology, The Affiliated Zhangjiagang Hospital of Soochow University, Zhangjiagang, jiangsu, China
| | - Haiyong Liu
- Department of Urology, The Affiliated Zhangjiagang Hospital of Soochow University, Zhangjiagang, jiangsu, China
| | - Jianhua Hou
- Department of Urology, The Affiliated Zhangjiagang Hospital of Soochow University, Zhangjiagang, jiangsu, China
| | - Huidong Miao
- Department of Urology, The Affiliated Zhangjiagang Hospital of Soochow University, Zhangjiagang, jiangsu, China
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GuhaSarkar S, More P, Banerjee R. Urothelium-adherent, ion-triggered liposome-in-gel system as a platform for intravesical drug delivery. J Control Release 2017; 245:147-156. [DOI: 10.1016/j.jconrel.2016.11.031] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 11/05/2016] [Accepted: 11/26/2016] [Indexed: 10/20/2022]
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Ali-El-Dein B, Barakat TS, Nabeeh A, Ibrahiem EHI. Weekly intravesical bacillus Calmette-Guerin (BCG) alternating with epirubicin in Ta and T1 urothelial bladder cancer: An approach to decrease BCG toxicity. Urol Ann 2013; 5:103-8. [PMID: 23798868 PMCID: PMC3685738 DOI: 10.4103/0974-7796.110008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 04/07/2012] [Indexed: 11/04/2022] Open
Abstract
Context: Bacillus Calmette-Guerin (BCG) therapy is the standard treatment for nonmuscle-invasive bladder cancer (NMIBC). However, its toxicity is a major concern. Aim: If we reduce the number of BCG doses by half and replace the second half with epirubicin, we may have a lower toxicity while maintaining the same efficacy of BCG. To test this hypothesis, we conducted this study as an update of our previous report. Setting and Design: The study included 607 patients with Ta and T1 NMIBC between January 1994 and December 2008. Materials and Methods: After transurethral resection of bladder tumor (TURBT), the patients received weekly doses of 120 mg BCG alternating with 50 mg epirubicin for six weeks (three weekly doses of each). Maintenance was given. Recurrence, progression rates, and toxicity were assessed. End points were progression, recurrence, and cancer-specific survival. Results: A total of 532 patients were eligible for evaluation (mean age: 58 years; median follow-up: 45 months). Of these, 291 (55%) were free, 157 (29.5%) showed recurrence, and 84 (15.8%) showed muscle-invasive progression. Toxicity developed in 221 patients. These were mild in the majority (167), whereas 10 developed hematuria, 30 severe cystitis, and five systemic complications. The rate of permanent therapy discontinuation was 3.8%. Statistical Analysis Used: SPSS package version 16 and Kaplan-Meier curves were used to evaluate survival. Conclusions: Reducing the frequency of BCG instillations by half and replacing the second half with epirubicin results in a similar efficacy and a lower toxicity compared with historical cases receiving BCG alone. However, further trials are required to support these results.
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Affiliation(s)
- Bedeir Ali-El-Dein
- Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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Shang PF, Kwong J, Wang ZP, Tian J, Jiang L, Yang K, Yue ZJ, Tian JQ. Intravesical Bacillus Calmette-Guérin versus epirubicin for Ta and T1 bladder cancer. Cochrane Database Syst Rev 2011:CD006885. [PMID: 21563157 DOI: 10.1002/14651858.cd006885.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Bladder cancer accounts for approximately 4.4% of adult malignancies, and approximately 80% of bladder cancer presents initially as transitional cell carcinoma that is confined to the urothelium (stage Ta) or lamina propria (stage T1). Intravesical administration of Bacillus Calmette-Guérin (BCG) and epirubicin (EPI) has been proven to reduce tumour recurrence and prevent or delay progression to muscle invasion and metastases. However, comparison of the effectiveness and safety of intravesical BCG and EPI in bladder cancer has yet to be explored. OBJECTIVES To compare the effectiveness and safety of BCG with EPI in the treatment of Ta and T1 bladder cancer. SEARCH STRATEGY A comprehensive search of MEDLINE (1966 to April 2010), EMBASE (1980 to April 2010), Health Services Technology, Administration, and Research (HealthSTAR), the Cochrane Central Register of Controlled Trials (CENTRAL), CancerLit, and Database of Abstracts of Reviews of Effectiveness (DARE), was performed, and handsearching of relevant journals was undertaken. SELECTION CRITERIA All randomised or quasi-randomised trials (in which allocation was obtained by alternation - e.g., alternate medical records, date of birth, or other predictable methods) in patients with Ta or T1 bladder cancer that compared intravesical BCG with EPI were included. No language restrictions were applied. DATA COLLECTION AND ANALYSIS Trial eligibility, methodological quality and data extraction were assessed independently by two reviewers. We compared dichotomous outcomes (frequency of tumour recurrence, progressive disease by stage, mortality, distant metastases, local and systemic adverse effects, treatment delayed or stopped due to adverse effects) using risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS Five trials of 1111 participants were included in this review. For BCG, 549 patients were treated, and 562 with EPI. Of the evaluated patients, 35.5% (195/549) in the BCG group and 51.4% (289/562) in the EPI group had tumour recurrence (P < 0.05). For disease progression (BCG, 44/549; EPI, 58/562) and distant metastases (BCG, 23/487; EPI, 31/495), there were no significant differences (P = 0.19 and P = 0.29, respectively). Only two trials, including 769 patients, had sufficient data for us to analyze disease-specific (BCG, 22/383; EPI, 26/386) and overall mortality (BCG, 125/383; EPI, 147/386). Neither comparison was significant (P = 0.93 and P = 0.12, respectively). In four studies reporting toxicity, BCG was associated with significantly more drug-induced cystitis [BCG, 54.1% (232/429); EPI, 31.7% (140/441)] and haematuria [BCG, 30.8% (132/429); EPI, 16.1% (71/440)]. Similarly, in three studies reporting systemic toxicity, BCG had significantly higher toxicity than the EPI (34.8% (134/385) versus 1.3% (5/393), respectively). In a meta-analysis comparing 'treatment delayed or stopped' (BCG, 40/431; EPI, 33/441), there was no significant difference between BCG and EPI treatments (P = 0.82). AUTHORS' CONCLUSIONS The data from the present meta-analysis indicate that intravesical BCG treatment is more efficacious than EPI in reducing tumour recurrence for Ta and T1 bladder cancer. However, BCG appears to be associated with a higher incidence of adverse effects, such as drug-induced cystitis, haematuria and systemic toxicity, than EPI. The overall quality of the evidence is rather low. Well-designed, high quality randomised controlled trials with good allocation concealment are required.
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Affiliation(s)
- Pan Feng Shang
- Department of Urology, Second Hospital of Lanzhou University, No. 82, Cui Ying Men Street, Lanzhou City, Gansu, China, 730030
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GuhaSarkar S, Banerjee R. Intravesical drug delivery: Challenges, current status, opportunities and novel strategies. J Control Release 2010; 148:147-59. [PMID: 20831887 DOI: 10.1016/j.jconrel.2010.08.031] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 08/15/2010] [Indexed: 01/12/2023]
Abstract
The urinary bladder has certain unique anatomical features which enable it to form an effective barrier to toxic substances diffusing from the urine into the blood. The barrier function is due to the epithelial surface of the urinary bladder, the urothelium, which has characteristic umbrella cells, joined by tight junctions and covered by impenetrable plaques, as well as an anti-adherent mucin layer. Diseases of the urinary bladder, such as bladder carcinomas and interstitial cystitis, cause acute damage to the bladder wall and cannot be effectively treated by systemic administration of drugs. Such conditions may benefit from intravesical drug delivery (IDD), which involves direct instillation of drug into the bladder via a catheter, to attain high local concentrations of the drug with minimal systemic effects. IDD however has its limitations, since the permeability of the urothelial layer is very low and instilled drug solutions become diluted with urine and get washed out of the bladder during voiding, necessitating repeated infusions of the drug. Permeation enhancers serve to overcome these problems to some extent by using electromotive force to enhance diffusion of the drug into the bladder wall or chemical molecules, such as chitosan, dimethylsulphoxide, to temporarily disrupt the tight packing of the urothelium. Nanotechnology can be integrated with IDD to devise drug-encapsulated nanoparticles that can greatly improve chemical interactions with the urothelium and enhance penetration of drugs into the bladder wall. Nanocarriers such as liposomes, gelatin nanoparticles, polymeric nanoparticles and magnetic particles, have been found to enhance local drug concentrations in the bladder as well as target diseased cells. Intravesical drug carriers can be further improved by using mucoadhesive biomaterials which are strongly adhered to the urothelial cell lining, thus preventing the carrier from being washed away during urine voiding. This increases the residence time of the drug at the target site and enables sustained delivery of the drug over a prolonged time span. Polymeric hydrogels, such as the temperature sensitive PEG-PLGA-PEG polymer, have been used to develop in situ gelling systems to deliver drugs into the bladder cavity. Recent advances and future prospects of biodegradable nanocarriers and in situ gels as drug delivery agents for intravesical drug delivery are reviewed in this paper.
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Affiliation(s)
- Shruti GuhaSarkar
- Department of Biosciences & Bioengineering, Indian Institute of Technology, Bombay, Powai, Mumbai 400076, India
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Optimization of epirubicin nanoparticles using experimental design for enhanced intravesical drug delivery. Int J Pharm 2009; 376:195-203. [DOI: 10.1016/j.ijpharm.2009.04.045] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Revised: 04/22/2009] [Accepted: 04/25/2009] [Indexed: 11/20/2022]
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Uchida A, Yonou H, Hayashi E, Iha K, Oda M, Miyazato M, Oshiro Y, Hokama S, Sugaya K, Ogawa Y. Intravesical Instillation of Bacille Calmette-Guérin for Superficial Bladder Cancer: Cost-Effectiveness Analysis. Urology 2007; 69:275-9. [PMID: 17320663 DOI: 10.1016/j.urology.2006.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 08/14/2006] [Accepted: 10/05/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Frequent recurrence of superficial bladder cancer is a major problem that impairs patients' quality of life. We studied the current treatment of superficial bladder cancer, including the economic aspects of intravesical instillation. METHODS A total of 138 superficial bladder cancers were assessed. The tumor characteristics and treatments were investigated during a mean observation period of 86 months by univariate and multivariate analyses. The costs associated with intravesical instillation of bacille Calmette-Guérin (BCG) and its side effects were subjected to cost-effectiveness analysis. RESULTS Tumor histologic examination revealed grade 1 in 21 lesions, grade 2 in 60 lesions, grade 3 in 40 lesions, and unclassified in 17 lesions. The pathologic stage was Stage Ta in 85 lesions, T1 in 47 lesions, and Tis in 6 lesions. Univariate and multivariate analyses showed that intravesical instillation of BCG was the most significant factor preventing recurrence, and intravesical chemotherapy had no impact on recurrence. The 5-year recurrence-free survival rate was 78% and 28% for tumors with and without BCG instillation, respectively. The cost-effectiveness ratio of BCG instillation was approximately 3900 dollars/5-yr recurrence-free period. CONCLUSIONS Our results have indicated that BCG is an effective adjuvant therapy after transurethral resection of superficial bladder cancer in the current medical environment.
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Affiliation(s)
- Atsushi Uchida
- Department of Urology, University of the Ryukyus School of Medicine, Okinawa, Japan.
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11
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van der Heijden AG, Moonen PMJ, Cornel EB, Vergunst H, de Reijke TM, van Boven E, Barten EJ, Puri R, van Kalken CK, Witjes JA. Phase II Marker Lesion Study With Intravesical Instillation of Apaziquone for Superficial Bladder Cancer: Toxicity and Marker Response. J Urol 2006; 176:1349-53; discussion 1353. [PMID: 16952629 DOI: 10.1016/j.juro.2006.06.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Indexed: 11/28/2022]
Abstract
PURPOSE We studied the ablative activity of intravesical apaziquone (EOquin) on a papillary marker tumor and determined the incidence of side effects. MATERIALS AND METHODS A total of 46 patients with multiple pTa or pT1 bladder tumors underwent visible lesion resection except for 1 marker tumor. Patients were then treated with 6 instillations of apaziquone at weekly intervals. The response was determined 2 to 4 weeks after the last instillation. RESULTS One patient withdrew informed consent and refused the last treatment due to side effects. A histologically proven complete response was seen in 30 patients. Progression to invasive stage was not observed. Local side effects in this study were comparable to those due to other chemotherapy instillations, such as mitomycin C and epirubicin, but less severe and less frequent compared to those of bacillus Calmette-Guerin instillations. CONCLUSIONS The histological complete response rate after 6 consecutive instillations of apaziquone in patients with superficial bladder cancer was 67% (95% CI 51 to 80). Local side effects were comparable to side effects due to other chemotherapy instillations.
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Sylvester RJ, van der Meijden A, Witjes JA, Jakse G, Nonomura N, Cheng C, Torres A, Watson R, Kurth KH. High-grade Ta urothelial carcinoma and carcinoma in situ of the bladder. Urology 2006; 66:90-107. [PMID: 16399418 DOI: 10.1016/j.urology.2005.06.135] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Accepted: 06/22/2005] [Indexed: 10/25/2022]
Abstract
We sought to review the definition, diagnosis, prognosis, and treatment of high-grade Ta urothelioma carcinoma and carcinomas in situ (CIS) in order to provide evidence-based guidelines for their diagnosis and treatment. The English-language literature on high-grade Ta urothelial carcinoma and CIS was identified and critically reviewed by a panel of 9 international experts. The panel then met at a consensus conference to present their conclusions. Levels of evidence and grades of recommendation were assessed. Findings from approximately 100 publications appearing prior to February 2005 were reviewed and summarized. High-grade Ta urothelial carcinoma and CIS are relatively rare tumors; thus results are often based on small nonrandomized studies. Their assessment is made more difficult owing to inaccuracies in staging and grading. Although there were similar numbers of level 1, level 2, and level 3 evidence citations, guidelines have been developed based only on levels of evidence supporting grade A and grade B recommendations. These evidence-based guidelines have been developed to aid clinicians in the diagnosis and treatment of patients with high-grade Ta urothelial carcinoma and CIS.
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Affiliation(s)
- Richard J Sylvester
- European Organization for Research and Treatment of Cancer Data Center, Brussels, Belgium.
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13
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Di Stasi SM, Giannantoni A, Giurioli A, Valenti M, Zampa G, Storti L, Attisani F, De Carolis A, Capelli G, Vespasiani G, Stephen RL. Sequential BCG and electromotive mitomycin versus BCG alone for high-risk superficial bladder cancer: a randomised controlled trial. Lancet Oncol 2006; 7:43-51. [PMID: 16389183 DOI: 10.1016/s1470-2045(05)70472-1] [Citation(s) in RCA: 209] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The rationale for combining anticancer drugs has not been applied consistently to use of intravesical agents for treatment of superficial bladder cancer, for which immunotherapeutic BCG and chemotherapeutic mitomycin seem to be a potentially effective combination. We aimed to do a prospective, randomised comparison of BCG alone with that of sequential BCG and electromotive mitomycin in patients with stage pT1 bladder cancer. METHODS After transurethral resection and multiple biopsies, 212 patients with stage pT1 bladder cancer were randomly assigned to: 81 mg BCG infused over 120 min once a week for 6 weeks (n=105); or to 81 mg BCG infused over 120 min once a week for 2 weeks, followed by 40 mg electromotive mitomycin (intravesical electric current 20 mA for 30 min) once a week as one cycle for three cycles (n=107). Complete responders underwent maintenance treatment: those assigned BCG alone had one infusion of 81 mg BCG once a month for 10 months, and those assigned BCG and mitomycin had 40 mg electromotive mitomycin once a month for 2 months, followed by 81 mg BCG once a month as one cycle for three cycles. The primary endpoint was disease-free interval; secondary endpoints were time to progression; overall survival; and disease-specific survival. Analyses were done by intention to treat. This trial has been submitted for registration at the US National Cancer Institute website . FINDINGS Median follow-up was 88 months (IQR 63-110). Patients assigned sequential BCG and electromotive mitomycin had higher disease-free interval than did those assigned BCG alone (69 months [95% CI 55-86] vs 21 months [15-54]; difference between groups 48 months [42-54], log-rank p=0.0012). Patients assigned sequential BCG and electromotive mitomycin also had lower recurrence (41.9% [32.7-51.5] vs 57.9% [48.7-67.5]; difference between groups 16.0% [2.7-29.3], log-rank p=0.0012); progression (9.3% [3.8-14.8] vs 21.9% [17.9-25.9]; difference between groups 12.6% [3.0-22.2], log-rank p=0.004); overall mortality (21.5% [13.5-29.5] vs 32.4% [23.4-41.4], difference between groups 10.9% [0.6-21.2], log-rank p=0.045); and disease-specific mortality (5.6% [1.2-10.0] vs 16.2% [6.1-23.3], difference between groups 10.6% [2.5-18.7], log-rank p=0.01). Side-effects were mainly localised to the bladder. INTERPRETATION BCG-induced inflammation might increase the permeability of the bladder mucosa such that mitomycin can reach the target tissue more easily and exert its anticancer effect.
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Okeke AA, Probert JL, Gillatt DA, Schwaibold H. Is intravesical chemotherapy for superficial bladder cancer still justified? BJU Int 2005; 96:763-7. [PMID: 16153195 DOI: 10.1111/j.1464-410x.2005.05711.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Aloysius A Okeke
- Department of Urology, Bristol Urological Institute, Southmead Hospital, Bristol, UK
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van der Meijden APM, Sylvester R, Oosterlinck W, Solsona E, Boehle A, Lobel B, Rintala E. EAU Guidelines on the Diagnosis and Treatment of Urothelial Carcinoma in Situ. Eur Urol 2005; 48:363-71. [PMID: 15994003 DOI: 10.1016/j.eururo.2005.05.011] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2005] [Accepted: 05/13/2005] [Indexed: 11/24/2022]
Abstract
OBJECTIVES On behalf of the European Association of Urology (EAU), guidelines for the diagnosis, therapy and follow-up of patients with urothelial carcinoma in situ (CIS) have been established. METHOD The recommendations in these guidelines are based on a recent comprehensive overview and meta-analysis in which two panel members have been involved (RS and AVDM). A systematic literature search was conducted using Medline, the US Physicians' Data Query (PDQ), the Cochrane Central Register of Controlled Trials, and reference lists in trial publications and review articles. RESULTS Recommendations are provided for the diagnosis, conservative and radical surgical treatment, and follow-up of patients with CIS. Levels of evidence are influenced by the lack of large randomized trials in the treatment of CIS.
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Bassi P, Serretta V, Pinto F, Calpista A, Galuffo A, Dispensa N. Superficial Bladder Cancer Therapy: A Review. Urologia 2005. [DOI: 10.1177/039156030507200302] [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
Most bladder cancers present as a superficial disease, confined to the bladder mucosa or submucosal layer, without muscle invasion. Most superficial tumors have a propensity for recurrence after transurethral resection; some have a high risk for progression to muscle invasion. The treatment aim in superficial bladder cancer with intravesical therapy is three-fold: (1) eradicate existing disease, (2) prevention of recurrence, (3) prevention of tumor progression. The prognostic factors (tumor stage, grade, size, number and recurrence pattern) allow the stratification of tumors in different risk groups to plan treatment. Studies on pharmacokinetics have proved the efficacy of optimized drug delivery. Comparing resection with and without intravesical chemotherapy, a short-term reduction, approximately 15%, in tumor recurrence with chemotherapy can be obtained, but no effect on progression was proven. No agent has proved to be more effective than the others. A single instillation of chemotherapy immediately after transurethral resection has proven to be effective, but the role of maintenance therapy is controversial. Immunotherapy, in the form of Bacillus Calmette-Guerin, is generally shown to be more effective than chemotherapy, even if the results in comparison to mitomycin C do not result conclusive. Several new approaches are being explored to improve the efficacy of this therapy.
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Affiliation(s)
- P.F. Bassi
- Dipartimento di Scienze Oncologiche e Chirurgiche, Sezione di Clinica Urologia, Università degli Studi di Padova
| | - V. Serretta
- Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche, Sezione di Clinica Urologica Università degli Studi di Palermo
| | - F. Pinto
- Dipartimento di Scienze Oncologiche e Chirurgiche, Sezione di Clinica Urologia, Università degli Studi di Padova
| | - A. Calpista
- Dipartimento di Scienze Oncologiche e Chirurgiche, Sezione di Clinica Urologia, Università degli Studi di Padova
| | - A. Galuffo
- Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche, Sezione di Clinica Urologica Università degli Studi di Palermo
| | - N. Dispensa
- Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche, Sezione di Clinica Urologica Università degli Studi di Palermo
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Sylvester RJ, van der Meijden APM, Witjes JA, Kurth K. BACILLUS CALMETTE-GUERIN VERSUS CHEMOTHERAPY FOR THE INTRAVESICAL TREATMENT OF PATIENTS WITH CARCINOMA IN SITU OF THE BLADDER: A META-ANALYSIS OF THE PUBLISHED RESULTS OF RANDOMIZED CLINICAL TRIALS. J Urol 2005; 174:86-91; discussion 91-2. [PMID: 15947584 DOI: 10.1097/01.ju.0000162059.64886.1c] [Citation(s) in RCA: 248] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We determined the short-term and long-term efficacy of bacillus Calmette-Guerin (BCG) and chemotherapy in the treatment of patients with carcinoma in situ (CIS). MATERIALS AND METHODS A meta-analysis was performed on published results of randomized clinical trials comparing intravesical BCG to intravesical chemotherapy. RESULTS Nine randomized trials including 700 patients with CIS compared BCG to either mitomycin C (MMC), epirubicin, adriamycin, or sequential MMC/adriamycin. Of 298 patients on BCG 203 (68.1%) had a complete response compared with 158 of 307 patients on chemotherapy (51.5%), a reduction of 47% in the odds of nonresponse on BCG (OR 0.53, p =0.0002). Based on a median followup of 3.6 years, 161 of 345 patients on BCG (46.7%) had no evidence of disease compared with 93 of 355 patients on chemotherapy (26.2%), a reduction of 59% in the odds of treatment failure on BCG (OR 0.41, p <0.0001). Although the long-term benefit of BCG was smaller in trials with MMC, BCG was superior to MMC in trials with maintenance BCG (OR 0.57, p =0.04). The reduction of 26% in the risk of progression on BCG (p =0.20) is consistent with the reduction of 27% (p =0.001) previously reported in a larger superficial bladder cancer meta-analysis. CONCLUSIONS Intravesical BCG significantly reduces the risk of short and long-term treatment failure compared with intravesical chemotherapy. Therefore, it is considered to be the intravesical agent of choice in the treatment of CIS.
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Affiliation(s)
- Richard J Sylvester
- European Organization for the Research and Treatment of Cancer Data Center, Brussels, Belgium.
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18
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Cheng CW, Chan SFP, Chan LW, Chan CK, Ng CF, Cheung HY, Chan SYE, Wong WS, Lai FMM, To KF, Li ML. Twelve-year follow up of a randomized prospective trial comparing bacillus Calmette-Guerin and epirubicin as adjuvant therapy in superficial bladder cancer. Int J Urol 2005; 12:449-55. [PMID: 15948743 DOI: 10.1111/j.1442-2042.2005.01064.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM To compare bacillus Calmette-Guerin (BCG) with epirubicin in adjuvant therapy of superficial bladder transitional cell carcinoma, with respect to recurrence, progression and survival. Prognostic factors are also evaluated. METHODS Between October 1991 and September 1999, all patients harboring superficial bladder cancers (Ta or T1) with any of the relevant criteria (stage>a, grade>1, size>1 cm, multiple or recurrent tumors), after complete transurethral resection were randomized to receive either 81 mg Connaught strain BCG or 50 mg epirubicin. Patients with recurrences were eligible to crossover, even repeatedly, until progression. Recurrence, progression and survival were analyzed in relation to initial treatment, patient characteristics and tumor characteristics. RESULTS There were 209 patients included in the study, 149 men and 60 women. The mean age was 69.9 years (range, 24-92). The BCG group consisted of 102 patients and the epirubicin group contained 107 patients. Final analysis was made at a median follow up of 23, 47 and 61 months for recurrence, progression and survival, respectively. The 10-year Kaplan-Meier estimates for recurrence-free, progression-free and disease-specific survival were 61%, 78% and 80%, respectively, for the BCG group. The corresponding figures were 32%, 74% and 92%, respectively, for the epirubicin group. Time to recurrence differed significantly between two treatment groups (P=0.0004). Multiplicity increased the risk of recurrence, while grading influenced recurrence, progression and disease specific survival. CONCLUSIONS Bacillus Calmette-Guerin prolonged time to recurrence when compared with epirubicin. Grading was shown to be a universal prognostic factor for recurrence, progression and disease specific survival.
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Affiliation(s)
- Chi Wai Cheng
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
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19
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Sylvester RJ, van der MEIJDEN APM, Lamm DL. Intravesical bacillus Calmette-Guerin reduces the risk of progression in patients with superficial bladder cancer: a meta-analysis of the published results of randomized clinical trials. J Urol 2002; 168:1964-70. [PMID: 12394686 DOI: 10.1016/s0022-5347(05)64273-5] [Citation(s) in RCA: 758] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE We determine if intravesical bacillus Calmette-Guerin (BCG) reduces the risk of progression after transurethral resection to stage T2 disease or higher in patients with superficial (stage Ta, T1 or carcinoma in situ) bladder cancer. MATERIALS AND METHODS A meta-analysis was performed of the published results of randomized clinical trials comparing transurethral resection plus intravesical BCG to either resection alone or resection plus another treatment other than BCG. RESULTS We identified 24 trials with progression information on 4,863 patients. Based on a median followup of 2.5 years and a maximum of 15 years, 260 of 2,658 patients on BCG (9.8%) had progression compared to 304 of 2,205 patients in the control groups (13.8%), a reduction of 27% in the odds of progression on BCG (OR 0.73, p = 0.001). The percent of patients with progression was low (6.4% of 2,880 patients with papillary tumors and 13.9% of 403 patients with carcinoma in situ, reflecting the short followup and relatively low risk patients entered in many of the trials. The size of the treatment effect was similar in patients with papillary tumors and in those with carcinoma in situ. However, only patients receiving maintenance BCG benefited. There was no statistically significant difference in treatment effect for either overall survival or death due to bladder cancer. CONCLUSIONS Intravesical BCG significantly reduces the risk of progression after transurethral resection in patients with superficial bladder cancer who receive maintenance treatment. Thus, it is the agent of choice for patients with intermediate and high risk papillary tumors and those with carcinoma in situ.
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Affiliation(s)
- Richard J Sylvester
- European Organisation for Research and Treatment of Cancer Data Center, Brussels, Belgium
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20
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Intravesical Bacillus Calmette-Guerin Reduces the Risk of Progression in Patients with Superficial Bladder Cancer:. J Urol 2002. [DOI: 10.1097/00005392-200211000-00016] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Bladder cancer is the fourth leading cause of cancer in American men, accounting for more than 12,000 deaths annually. It was one of the first malignancies in which carcinogens were recognized as an important factor in its cause. Currently, cigarette smoking is by far the most common cause of bladder cancer, although occupational exposure to arylamines has been implicated in the past. Gross or microscopic hematuria is the most common sign at presentation. Initial radiologic evaluation usually includes the excretory urography (intravenous pyelography), although further evaluation of the renal parenchyma with ultrasound or computed tomography scanning has been advocated by some. These radiologic studies are unable to provide adequate bladder imaging, and thus cystoscopy is required for the diagnosis of bladder cancer. Most bladder cancers present as "superficial" disease, confined to the bladder mucosa or submucosal layer, without muscle invasion. Superficial tumors consist of papillary tumors that are mucosally confined (Ta), papillary or sessile tumors extending into the lamina propria (T1), and carcinoma in situ, which occurs as "flat" mucosal dysplasia, which can be focal, diffuse, or associated with a papillary or sessile tumor. The natural history of these pathologic subtypes differ significantly. Most superficial tumors (60% to 70%) have a propensity for recurrence after transurethral resection. Some (15% to 25%) are at high risk for progression to muscle invasion. Most superficial tumors can be stratified into high- or low-risk groups depending on tumor stage, grade, size, number, and recurrence pattern. It is important to identify those tumors at risk for recurrence or progression so that adjuvant intravesical therapies can be instituted. Many intravesical chemotherapeutic agents have been shown to reduce tumor recurrence when used in conjunction with transurethral tumor resection. Unfortunately, however, none of these agents have proved to be of benefit in preventing disease progression. Most are given intravesically on a weekly basis, although many studies suggest that a single instillation immediately after transurethral resection may be as good as a longer course of therapy. Although all of these drugs have toxicity, they usually are well tolerated. Intravesical bacille Calmette-Guérin (BCG) is an immunotherapeutic agent that when given intravesically is very effective in the treatment of superficial transitional cell carcinoma. Compared with controls, BCG has a 43% advantage in preventing tumor recurrence, a significantly better rate than the 16% to 21% advantage of intravesical chemotherapy. In addition, BCG is particularly effective in the treatment of carcinoma in situ, eradicating it in more than 80% of cases. In contrast to intravesical chemotherapy, BCG has also been shown to decrease the risk of tumor progression. The optimal course of BCG appears to be a 6-week course of weekly instillations, followed by a 3-week course at 3 months in those tumors that do not respond. In high-risk cancers, maintenance BCG administered for 3 weeks every 6 months may be optimal in limiting recurrence and preventing progression. Unfortunately, adverse effects associated with this prolonged therapy may limit its widespread applicability. In those patients at high risk in whom BCG therapy fails, intravesical interferon-alpha with or without BCG may be beneficial in some. Photodynamic therapy has also been used but is limited by its toxicity. In patients who progress or do not respond to intravesical therapies, cystectomy should be considered. With the development of orthotopic lower urinary tract reconstruction to the native urethra, the quality of life impact of radical cystectomy has been lessened.
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Affiliation(s)
- C L Amling
- Department of Urology, Naval Medical Center, San Diego, California, USA
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22
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Bazarbashi S, Raja MA, El Sayed A, Ezzat A, Ibrahim E, Kattan S, Kardar A, Peracha A, Lindstedt E, Hanash K. Prospective phase II trial of alternating intravesical Bacillus Calmette-Guérin (BCG) and interferon alpha IIB in the treatment and prevention of superficial transitional cell carcinoma of the urinary bladder: preliminary results. J Surg Oncol 2000; 74:181-4. [PMID: 10951412 DOI: 10.1002/1096-9098(200007)74:3<181::aid-jso3>3.0.co;2-f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVE Evaluate the efficacy and toxicity of alternating intravesical instillation of Bacillus Calmette-Guerin(BCG) and Interferon alpha2-b (IFN) in the treatment and prevention of recurrence of superficial transitional cell carcinoma (TCC) of the urinary bladder. METHODS Patients with Ta, T1 tumors and carcinoma in situ, either recurrent (TaG1, T1G1) or primary/recurrent TaG2 TaG3, T1G2, T1G3 and Tis (T: Tumor stage, G: grade) are eligible. All patients received intravesical BCG 81 mg on Weeks 1, 3, 5 and 7 and IFN 100 million units on Weeks 2, 4, 6 and 8. Cystoscopy performed 4 weeks after completion of therapy, and every 3 months thereafter. RESULTS There was a total of 37 patients. Thirteen had TaG2, 13 T1G2, 1 T1G1, 4 TaG1, 1 TaG3, 3 T1G3 and 7 Tis (5 concurrent with other above tumors). Index lesion cleared in 7/10 patients. With a median follow-up of 26.2 month, 22 patients (59%) failed above therapy. Median time to treatment failure was 7 months. Seven, 6 and 9 patients recurred at a higher, lower and same stage or grade respectively. No grade 3 or 4 toxicity was encountered. CONCLUSIONS Alternating intravesical BCG and IFN is effective and well tolerated therapy for superficial TCC of urinary bladder.
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Affiliation(s)
- S Bazarbashi
- Department of Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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&NA;. Epirubicin: better option for patients at low risk of tumour recurrence after TUR. DRUGS & THERAPY PERSPECTIVES 2000. [DOI: 10.2165/00042310-200015090-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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24
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Leung NJ, Aldovini A, Young R, Jarvis MA, Smith JM, Meyer D, Anderson DE, Carlos MP, Gardner MB, Torres JV. The kinetics of specific immune responses in rhesus monkeys inoculated with live recombinant BCG expressing SIV Gag, Pol, Env, and Nef proteins. Virology 2000; 268:94-103. [PMID: 10683331 DOI: 10.1006/viro.1999.0131] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Development of an effective preventive or therapeutic vaccine against HIV-1 is an important goal in the fight against AIDS. Effective virus clearance and inhibition of spread to target organs depends principally on the cellular immune response. Therefore, a vaccine against HIV-1 should elicit virus-specific cytotoxic lymphocyte (CTL) responses to eliminate the virus during the cell-associated stages of its life cycle. The vaccine should also be capable of inducing immunity at the mucosal surfaces, the primary route of transmission. Recombinant Bacille Calmette-Guérin (BCG) expressing viral proteins offers an excellent candidate vaccine in view of its safety and ability to persist intracellularly, resulting in the induction of long-lasting immunity and stimulation of the cellular immune response. BCG can be administered orally to induce HIV-specific immunity at the mucosal surfaces. The immunogenicity of four recombinant BCG constructs expressing simian immunodeficiency virus (SIV) Gag, Pol, Env, and Nef proteins was tested in rhesus macaques. A single simultaneous inoculation of all four recombinants elicited SIV-specific IgA and IgG antibody, and cellular immune responses, including CTL and helper T cell proliferation. Our results demonstrate that BCG recombinant vectors can induce concomitant humoral and cellular immune responses to the major proteins of SIV.
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MESH Headings
- Animals
- Antibodies, Viral/blood
- BCG Vaccine/genetics
- BCG Vaccine/immunology
- Blotting, Western
- Cloning, Molecular
- Cytotoxicity, Immunologic
- Gene Products, env/genetics
- Gene Products, env/immunology
- Gene Products, env/metabolism
- Gene Products, gag/genetics
- Gene Products, gag/immunology
- Gene Products, gag/metabolism
- Gene Products, nef/genetics
- Gene Products, nef/immunology
- Gene Products, nef/metabolism
- Gene Products, pol/genetics
- Gene Products, pol/immunology
- Gene Products, pol/metabolism
- Immunoglobulin A/blood
- Immunoglobulin G/blood
- Lymphocyte Activation
- Macaca mulatta
- SAIDS Vaccines/genetics
- SAIDS Vaccines/immunology
- Simian Acquired Immunodeficiency Syndrome/prevention & control
- Simian Immunodeficiency Virus/genetics
- Simian Immunodeficiency Virus/immunology
- Simian Immunodeficiency Virus/metabolism
- T-Lymphocytes, Cytotoxic/immunology
- Vaccination
- Vaccines, Synthetic/genetics
- Vaccines, Synthetic/immunology
- Viral Proteins/genetics
- Viral Proteins/immunology
- Viral Proteins/metabolism
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Affiliation(s)
- N J Leung
- Department of Medical Microbiology, School of Medicine, University of California, Davis, California, 95616, USA
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Affiliation(s)
- A M Kamat
- Department of Urology, West Virginia University School of Medicine, Morgantown, USA
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26
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Onrust SV, Wiseman LR, Goa KL. Epirubicin: a review of its intravesical use in superficial bladder cancer. Drugs Aging 1999; 15:307-33. [PMID: 10582777 DOI: 10.2165/00002512-199915040-00006] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
UNLABELLED The anthracycline epirubicin has been investigated for intravesical use in patients with superficial bladder cancer. In multicentre, randomised trials, prophylaxis with intravesical epirubicin 30 to 80 mg after transurethral resection (TUR) was more effective than no prophylaxis in the prevention of disease recurrence. Intravesical prophylaxis with epirubicin was as effective as that with equivalent dosages of doxorubicin after TUR. Data are conflicting concerning the relative efficacy of intravesical epirubicin and bacillus Calmette-Guerin (BCG) in patients at intermediate risk of recurrence after TUR, but epirubicin was less effective than BCG in those at high risk. The efficacy and tolerability of prophylaxis with epirubicin relative to that with mitomycin is not yet established. The efficacy of epirubicin as prophylaxis after TUR in combination with BCG or interferon-alpha-2b, or as treatment in patients with superficial bladder cancer has been evaluated in small, noncomparative trials, but requires clarification. Adverse events associated with intravesical epirubicin were generally mild and transient. The most common adverse events were localised to the bladder (cystitis, haematuria and urinary tract infection). Systemic adverse events (cardiac, haematological or related to hypersensitivity) were not reported in many trials of intravesical epirubicin, and when reported generally occurred in < or =5% of patients who received the drug. Intravesical epirubicin was generally tolerated as well as intravesical doxorubicin and was associated with a lower incidence of mild chemical cystitis in 1 clinical trial. The incidence of adverse events associated with intravesical epirubicin was markedly lower than that associated with intravesical BCG. CONCLUSIONS Intravesical epirubicin has shown efficacy in preventing disease recurrence after TUR of superficial bladder cancer. In comparison with equivalent dosages of doxorubicin, the efficacy of epirubicin for this indication is generally similar, and the tolerability profile may be more favourable. Epirubicin is less effective than BCG as intravesical prophylaxis in patients at high risk of recurrence after TUR; the relative efficacy of epirubicin and BCG after TUR in patients at intermediate risk is not yet clear. Intravesical epirubicin is generally tolerated better than BCG. Intravesical epirubicin may be used as prophylaxis after TUR in patients who are at low or intermediate risk of recurrence of superficial bladder cancer.
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Affiliation(s)
- S V Onrust
- Adis International Limited, Mairangi Bay, Auckland, New Zealand.
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ALI-EL-DEIN BEDEIR, NABEEH ADEL, ISMAIL ELHOUSSAINI, GHONEIM MOHAMEDA. SEQUENTIAL BACILLUS CALMETTE-GUERIN AND EPIRUBICIN VERSUS BACILLUS CALMETTE-GUERIN ALONE FOR SUPERFICIAL BLADDER TUMORS: A RANDOMIZED PROSPECTIVE STUDY. J Urol 1999. [DOI: 10.1016/s0022-5347(05)68555-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Intravesical therapy has been used in the management of superficial transitional cell carcinoma (TCC) of the urinary bladder (i.e., Ta, Tl, and carcinoma in situ) with specific objectives which include treating existing/residual tumor, preventing recurrence of tumor, preventing disease progression, and prolonging survival. The initial clinical stage and grade remain the main determinant factors in survival irrespective of the treatment. Presently, bacillus Calmette-Guerin (BCG) immunotherapy remains the most effective treatment and prophylaxis for TCC (Ta, Tl, CIS) and has positive outcomes on tumor recurrence rate, disease progression, and prolongation of survival. Prostatic urethral mucosal involvement with bladder cancer can be effectively treated with BCG intravesical immunotherapy-it has demonstrated a reduction in tumor recurrence rates, but has had no positive impact on disease progression or prolongation of survival. Interferons, keyhole-limpet hemocyanin (KLH), bropirimine, and PHOTOFRIN-photodynamic therapy (PDT) are under investigation in the management of TCC and early results are encouraging. This comprehensive review highlights recent developments in intravesical therapy of bladder cancer and summarizes the mechanisms of action of BCG, and the important role of intravesical BCG immunotherapy and other immunotherapeutic agents in the therapy and prophylaxis of superficial TCC of the urinary bladder.
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Affiliation(s)
- U O Nseyo
- Department of Urology, West Virginia University School of Medicine, Morgantown, USA.
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29
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Ali-el-Dein B, el-Baz M, Aly AN, Shamaa S, Ashamallah A. Intravesical epirubicin versus doxorubicin for superficial bladder tumors (stages pTa and pT1): a randomized prospective study. J Urol 1997; 158:68-73; discussion 73-4. [PMID: 9186325 DOI: 10.1097/00005392-199707000-00018] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE We performed a prospective, randomized, controlled study to compare intravesical epirubicin and doxorubicin as adjuvant therapy after endoscopic resection of superficial bladder tumor. MATERIALS AND METHODS We randomly allocated 253 eligible patients to 4 study arms. Seven to 14 days after transurethral bladder tumor resection instillation of the intravesical agent was instituted, including 50 and 80 mg. epirubicin in study arms 1 and 2, respectively, and 50 mg. doxorubicin in arm 3. Control arm 4 included patients who underwent transurethral bladder tumor resection alone. Instillation was repeated weekly for 8 weeks and monthly thereafter to complete 1 year of treatment. All patients were followed every 3 months by cystourethroscopy, urine cytology and deoxyribonucleic acid flow cytometry for 12 to 48 months (mean 30.1). RESULTS Rates of recurrence were significantly lower in the chemotherapy groups than in controls (p < 0.001) and in the epirubicin groups than in the doxorubicin group (p = 0.02). In arms 1 to 4 recurrence rates were 25, 17.6, 36.7 and 65.6%, respectively. Recurrence rates per 100 patient months were 0.83, 0.60, 1.18 and 2.73, respectively, which were significant statistically, and lower after chemotherapy in general and epirubicin in particular (p < 0.05). Mean interval to first recurrence was 16, 15.4, 18.9 and 6.3 months, respectively, with a significant difference between the chemotherapy and control groups (p < 0.05). Progression to muscle invasive disease occurred in 7 (10.9%), 3 (4.4%), 6 (10%) and 5 patients (8.2%), respectively, in arms 1 to 4 (p > 0.05). We studied the relationships among different risk factors, and patterns of recurrence and progression. For pT1 tumors recurrence rates in arms 1 to 4 were 26.3, 17.8, 39.3 and 70.9%, respectively, which were significantly lower in the chemotherapy group than in controls (p < 0.001) and in the epirubicin groups than in the doxorubicin group (p = 0.01). Toxic and untoward side effects developed in 10 (15.6%), 16 (23.5%) and 25 (41.7%) patients in chemotherapy arms 1 to 3, respectively, with a marginal insignificant difference between low and high dose epirubicin (p = 0.3), and significantly lower toxicity rates in arms 1 and 2 than in 3 (p = 0.002). A contracted bladder developed in 2.1% of all patients who received chemotherapy. CONCLUSIONS This study demonstrates that epirubicin has better efficacy and lower toxicity than doxorubicin when used as an intravesical agent.
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Affiliation(s)
- B Ali-el-Dein
- Department of Pathology, Faculty of Medicine, Mansoura University, Egypt
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Melekos MD, Zarakovitis I, Dandinis K, Fokaefs E, Chionis H, Dauaher H, Barbalias G. BCG versus epirubicin in the prophylaxis of multiple superficial bladder tumours: results of a prospective randomized study using modified treatment schemes. Int Urol Nephrol 1996; 28:499-509. [PMID: 9119635 DOI: 10.1007/bf02550957] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A prospective randomized trial on 94 eligible patients evaluated and compared the efficacy of adjuvant intravesical epirubicin and bacillus Calmette-Guérin (BCG) after complete resection of multifocal superficial bladder cancer. BCG treatment schedule consisted of an induction 6-week course of instillations (150 mg Pasteur BCG per instillation) and single maintenance doses to patients who remained free of recurrences at follow-up examinations for a total treatment period of 2 years. These initial responders received additionally a separate 4-week course of therapy 6 months after the start of treatment. Chemoprophylaxis included an early (on the second postoperative day) instillation followed by 4 weekly treatments with epirubicin (50 mg per instillation) and then by 10 monthly treatments for the initial responders during the first year of follow-up and at every follow-up examination for a total treatment period of 2 years. The overall treatment results did not differ significantly between the 2 arms (54% of patients of the epirubicin group remained free of recurrences compared to 65% of those treated with BCG) for an identical mean follow-up of 35.1 months. However, a significant benefit in favour of BCG when compared with epirubicin was shown in patients who had stage T1 and grade 3 tumours and in terms of relative risk of recurrences, disease-free interval and recurrence rate per 100 patient-months. Both drugs were proved to be safe with manageable toxicity.
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Affiliation(s)
- M D Melekos
- Department of Urology, University of Patras School of Medicine, Greece
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