Doxorubicin chemotherapy in advanced transitional cell carcinoma

The Current and Future Application of Adjuvant Systemic Chemotherapy in Patients with Bladder Cancer Following Cystectomy

Urothelial transitional cell cancer has a high rate of response to combination cytotoxic therapy. Approximately 50% of patients with high-grade bladder cancer and deep muscle invasion ultimately die of disseminated disease. Translating the high response seen in locally advanced disease into long-term survival in the metastatic setting and to improved survival in the advanced setting has proved difficult. This article reviews the use of adjuvant chemotherapy in localized or locally advanced transitional cell cancer. The chemotherapy of urological malignancies, including bladder cancer, has recently been reviewed in detail; this article does not contain an extensive review of the drugs used.

Systemic chemotherapy of transitional cell carcinoma of the urothelium

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

Chemotherapy of advanced transitional-cell carcinoma of the bladder

A number of single agents and multidrug combinations are useful in the therapy of advanced transitional-cell carcinoma of the bladder. Phase II studies have identified cisplatin, Adriamycin (doxorubicin), methotrexate, and vinblastine as the most active cytotoxic agents. Combination chemotherapy based on cisplatin has shown greater efficacy than older regimens based on Adriamycin or methotrexate. Trials of regimens containing both cisplatin and methotrexate, such as those conducted by the Northern California Oncology Group using CMV (cisplatin, methotrexate, and vinblastine), have reported that a significant number of patients respond to treatment, with frequent complete responses being noted. Anthracycline-containing regimens such as M-VAC (methotrexate, vinblastine, Adriamycin, and cisplatin) have also played an important role in the therapy of advanced bladder cancer. Trials comparing cisplatin- and methotrexate-containing regimens with single-agent cisplatin or other cisplatin combinations have shown the apparent superiority of the former in terms of greater overall response rates and improved survival. However, the toxicity of such regimens can be significant, and phase III studies are under way to validate their use in the neoadjuvant setting.

Results of systemic chemotherapy of advanced bladder carcinomas (phase II study)

At the time of operation advanced carcinomas of the urinary bladder often have developed subclinical metastases. In 20 patients with metastases, inoperable carcinoma of the bladder responded to chemotherapy with a combination of adriamycin and 5-FU. 55% of the patients experienced either a complete or incomplete remission, which lasted long in some cases. In the future, suitable combinations of chemotherapeutics could participate in improving the prognosis of advanced carcinoma of the urinary bladder.

Effects of N-trifluoroacetyladriamycin-14-valerate (AD-32) on human bladder tumor cell lines

We have compared the in vitro activity of N-trifluoroacetyladriamycin-14-valerate (AD-32) and doxorubicin hydrochloride (ADR) on the clonal growth of human bladder tumor cell lines (HBTCL). In order to determine the relatively toxicity of ADR and AD-32 on hematopoietic stem cells, CFU-GM assays were set up using 10 normal human bone marrow samples. The mean lethal dose for 50% of the colonies (LD-50) for ADR was 1.6 +/- 1.4 microM and that for AD-32, 3.9 +/- 4.9 microM (P less than 0.55), suggesting that these agents have similar bone marrow toxicity. Both drugs produced enhanced inhibition of clonal growth of HBTCL with increasing C X Ts. The spectrum of activity of the two drugs was similar against a panel of seven HBTCL. The activity of ADR was inhibited at 4 degrees C while the activity of AD-32 was unaffected by temperature. ADR was more effective against HBTCL in the log growth phase than the plateau phase while the reverse was found using AD-32. Verapamil was found to enhance the activity of both ADR and AD-32 against a HBTCL (T24), found to be resistant to both agents. The lipophilic properties of AD-32, along with its enhanced activity when used over prolonged periods of time and its activity against tumor cells in the plateau phase, suggest that AD-32 could be useful in the management of patients with superficial bladder cancer.

Advanced transitional cell bladder cancer: a treatable disease

Although metastatic bladder cancer is difficult to treat effectively, chemotherapy combinations and schedules have emerged recently that can result in long-lasting complete responses in some patients. Response rates, response durations, and survival patterns of the entire patient population are, however, unsatisfactory. Whereas survival times of these patients following therapy with cisplatin alone or in combination with other drugs are not significantly different, complete response rates are higher and disease-free survival is longer when combinations are used. Higher dosages are associated with better response rates but also with substantial toxicity. Extensive local pretreatment or prior systemic chemotherapy reduces the likelihood of clinically meaningful disease response. Several adjuvant studies have demonstrated an advantage in length of disease-free survival for chemotherapy-treated patients when compared to those who are observed following operation. Metastatic transitional cell bladder cancer is a chemotherapeutically treatable malignancy. Locally advanced disease may be most effectively treated by aggressive surgery followed by cisplatin-based combination chemotherapy. The highest response rates and longest disease-free survivals are uniformly associated with aggressive and prolonged multidrug therapy.

Systemic influence of intravesical chemotherapy with verapamil

The influence of the calcium blocker verapamil (VR) on systemic toxicity resulting from the intravesical instillation of Adriamycin (ADM) and thiotepa (THT) was assessed in mice. Eighty per cent of the animals receiving THT + VR developed a generalized alopecia. Data gathered at necroscopy failed to reveal any trauma to the major organs or the presence of a drug-induced myelosuppression. Combination of ADM and VR did not produce an enhancement of systemic toxicity, manifest as myelosuppression. The drug combination did not produce a cardiomyopathy as assessed by histologic examination. The use of VR in combination with antineoplastic agents posed no more of a threat to the animals than did the use of cytotoxin alone.

Evaluation of multidisciplinary treatment of bladder cancer, especially in chemoimmunotherapy (ADM and OK-432) as a consolidation therapy

The relapse rate of bladder cancer (transitional cell Ca) is said to be about 45%-80% even after tumor resection. Multidisciplinary treatment was designed and studied to prevent such recurrence. This treatment was designed to have three steps: induction, consolidation, and maintenance therapy. Following surgical tumor removal, OK-432 and Adriamycin (ADM) were administered as consolidation therapy, followed by administration of PSK and carboquone (CQ) in small amounts as maintenance therapy continuously for about 3 years, and the course was observed. In both consolidation and maintenance groups various non-specific immunoparameters were superior in groups receiving combined immunotherapeutic agents. Thus, the use of immunotherapeutic agents in combination with chemotherapeutic agents was considered to be effective. The 3-year recurrence rate was only 8% in the multidisciplinary treatment group, while that in the non-multidisciplinary treatment group was 61%. This approach, especially with chemoimmunotherapy (ADM and OK-432) as a consolidation therapeutic mode, is therefore considered to be useful for the prevention of recurrence.

A phase II evaluation of a 3-drug combination of cyclophosphamide, doxorubicin and 5-fluorouracil and of 5-fluorouracil in patients with advanced bladder carcinoma or stage D prostatic carcinoma

The Southeastern Cancer Study Group has evaluated 5-fluorouracil administered intravenously weekly at a dosage of 600 mg. per M.2 as a single agent, and the 3-drug combination of cyclophosphamide, doxorubicin and 5-fluorouracil in patients with metastatic carcinoma of the bladder and of the prostate previously untreated with cytotoxic chemotherapy in a prospectively randomized phase II study. In 4 of 18 patients with bladder carcinoma 5-fluorouracil induced an objective response, and cyclophosphamide, doxorubicin and 5-fluorouracil induced an objective response in 3 of 21 patients. In patients with prostatic carcinoma 5-fluorouracil induced an objective response as measured by a 50 per cent decrease in prostatic acid phosphatase determined in a central reference laboratory in 3 of 25 patients and objective stability by National Prostatic Cancer Project criteria in 14 of 29 patients. Cyclophosphamide, doxorubicin and 5-fluorouracil induced an objective response in 7 of 22 patients and objective stability in 20 of 29. Thus, 5-fluorouracil administered in an adequate weekly dosage is established as an effective single agent in some patients with stage D carcinoma of the bladder or prostate. However, there is no significant added benefit as measured by survival obtained for these patients by combining cyclophosphamide and doxorubicin with 5-fluorouracil.

Cis-diamminedichloroplatinum II in advanced urothelial cancer

Thirteen patients with advanced urothelial cancer received a minimum of 2 courses of cis-diamminedichloroplatinum II. Of these patients 6 (46 per cent) achieved a partial response with an average duration of more than 6 months. One patient has received cis-diamminedichloroplatinum for more than 1 year and has no clinical evidence of tumor (complete response in lung metastasis plus excision of local recurrence). The routine administration of intravenous fluids and mannitol immediately before cis-diamminedichloroplatinum prevented the nephrotoxicity associated with this drug. An outpatient setting was well tolerated in most instances. This report confirms the activity of cis-diamminedichloroplatinum in urothelial cancer and suggests its use as an adjuvant to operation and/or radiotherapy in selected cases.