Does cyclophosphamide induce bladder cancer?

Cyclophosphamide-associated bladder cancers and considerations for survivorship care: A systematic review

PURPOSE

We performed a systematic review to assess the clinical features of cyclophosphamide-associated bladder cancer.

MATERIALS AND METHODS

MEDLINE, Web of Science, and Cochrane Library were searched from inception to August 2020 according to PRISMA guidelines. Studies that associated bladder cancer with prior cyclophosphamide use on an individual level were included.

RESULTS

We identified 121 studies spanning over a 50-year period with 285 patients. The most common malignant indication for cyclophosphamide was lymphoma (25%), while the most common non-malignant indication was ANCA-associated vasculitides (26%). Hematuria and dysuria were the most prevalent symptoms prior to a cyclophosphamide-associated bladder cancer diagnosis, and median age at diagnosis was 55 years. Conventional urothelial carcinoma (UC) was the most common bladder-associated diagnosis (74%), although a broad range of cancer types were represented, notably leiomyosarcoma and squamous cell carcinoma. About half of bladder cancers were muscle invasive at diagnosis and median latency time was 10.0 years; 33% of patients had a bladder cancer related death.

CONCLUSIONS

We describe the largest pooled analysis of patients with cyclophosphamide-associated bladder cancer. These bladder cancers have a propensity for younger age at diagnosis, more advanced stage at diagnosis, and variant histology. There was a substantial number of patients with latency time of ≥20 years independent of cumulative cyclophosphamide dose. These findings support consideration of screening and long-term surveillance of cancer survivors with a history of cyclophosphamide therapy for bladder cancer.

Cyclophosphamide is contraindicated in patients with a history of transitional cell carcinoma

Cyclophosphamide is a urotoxic agent that increases the incidence of malignant neoplasms of the urinary tract. The aim of this study was to evaluate the long-term impact of cyclophosphamide on patients with a history of superficial bladder cancer. Between July 1986 and January 1988, 58 consecutive patients with primary superficial transitional cell carcinoma of the bladder were included in this study. All patients had a transurethral R0 resection. Then 6 weekly intravesical instillations of 120 mg bacillus Calmette-Guérin (BCG) were performed. Until June 1987, 22 consecutive patients (group A) received an additional intravenous application of 700 mg/m(2) cyclophosphamide prior to the BCG immunotherapy, while from July 1987 36 patients were treated without cyclophosphamide. Survival was calculated using the Kaplan-Meier method and comparison of survival using the log rank test. Tumor staging, grading, and size were equally distributed in both groups. No significant difference could be observed regarding the 10-year overall survival rate (group A: 59%, group B: 58%), the 10-year tumor-specific survival rate (89 vs 94%), and the 10-year progression-free survival rate (85 vs 97%). There was a statistically significant deterioration of the 10-year recurrence-free survival rate in the cyclophosphamide group (44 vs 70%, log rank test: p < 0.05). Whereas there were no recurrences in the upper urinary tract among the patients of group B, 2 of the 22 patients from group A developed cancer of the renal pelvis. In patients with a history of superficial bladder cancer, a single dose of cyclophosphamide poses a significantly increased risk of tumor recurrence in the lower and in the upper urinary tract as well.

Mucinous (colloid) carcinoma of urinary bladder following long-term cyclophosphamide therapy for Waldenstrom's macroglobulinemia

Carcinoma of the urinary bladder is a known complication of cyclophosphamide therapy. Almost all such cases have been transitional cell carcinomas. We report here the second example of an adenocarcinoma of bladder and the first purely mucinous (colloid) carcinoma of urinary bladder developing after long-term cyclophosphamide therapy. The patient, a 77-year-old woman, had been treated for Waldenstrom's macroglobulinemia for at least 24 years, during which time treatment for this disease varied from 50 to 100 mg per day. The disease terminated in acute myelogenous leukemia, and she died of severe disseminated intravascular coagulopathy associated with hypermacroglobulinemia. The mucinous (colloid) carcinoma of the urinary bladder was an incidental finding at autopsy.

Bladder leiomyosarcoma following cyclophosphamide therapy for lupus nephritis

We report 2 cases of leiomyosarcoma of the bladder that occurred after long-term cyclophosphamide chemotherapy for lupus nephritis and rheumatoid arthritis. One patient had a tumor at the end of an 11-year course of chemotherapy and 1 approximately 7 years after completing a 7-year course of chemotherapy. Patient 1 underwent left partial cystectomy and patient 2 underwent cystectomy with ileal conduit urinary diversion. In patient 1 the tumor was a typical leiomyosarcoma and patient 2 had a myxoid variant. Both patients were free of disease at 4 months and 3 years, respectively. Whereas previous reports of the carcinogenic effects of cyclophosphamide have been questioned, since the induced tumors occurred in patients being treated for other neoplasms (lymphoproliferative and myeloproliferative disorders), the disease in both of our patients followed cyclophosphamide therapy for nonneoplastic disorders.

Carcinoma of the urinary bladder after treatment with cyclophosphamide for non-Hodgkin's lymphoma

We observed nine cases of transitional-cell carcinoma of the urinary bladder among patients who had had long-term treatment of other cancers with cyclophosphamide. Seven of the bladder carcinomas occurred within a cohort of 471 patients treated for non-Hodgkin's lymphomas. In this cohort the relative risk of bladder cancer was 6.8 (95 percent confidence interval, 3.2 to 14.2). The cumulative risk (mean +/- SE) was 3.5 +/- 1.8 percent 8 years after the start of treatment with cyclophosphamide and 10.7 +/- 4.9 percent after 12 years. Three of the nine patients were 50 years of age or younger; seven died with progressive bladder cancer. Subsequently, an additional patient had acute nonlymphocytic leukemia. Hemorrhagic cystitis was observed in 33 patients (cumulative risk, 11.8 +/- 2.1 percent after five years). Development of carcinoma of the urinary bladder was not related to previous hemorrhagic cystitis. The results caution against long-term treatment with cyclophosphamide for diseases with a favorable prognosis.

Cyclophosphamide-induced hemorrhagic cystitis. A review of 100 patients

Cyclophosphamide is an alkylating agent used intravenously or orally in the treatment of both malignant and nonneoplastic diseases. A known adverse effect of such treatment is hemorrhagic cystitis. A series of 100 patients with hemorrhagic cystitis induced by cyclophosphamide was studied. Major symptoms were gross hematuria (78%) and irritative voiding symptoms (45%). Microhematuria developed in 93% of patients. Hemorrhagic cystitis developed at significantly lower doses and shorter durations of therapy in patients treated intravenously than in patients treated orally. Cystectomy was required in nine patients and bladder cancer developed in five. Urine cytologic study, urinalysis, and cystoscopy are important in the diagnosis of hemorrhagic cystitis, and these studies plus periodic excretory urography are important for surveillance. In addition, new methods of protecting against the urotoxicity are available.

Does 2-mercaptoethane sulphonate (mesna) prevent cyclophosphamide and azathioprine induced immunosuppression? In vitro studies

The effect of 2-mercaptoethane sulphonate (mesna) on the inhibition of the human MLR by 4-hydroxycyclophosphamide or azathioprine was studied. 4-Hydroxycyclophosphamide (34 microM) completely inhibited the MLR and this inhibition was unaffected by 122 microM of 2-mercaptoethane sulphonate or its disulphide. At high concentrations (mM) 2-mercaptoethane sulphonate inhibited the MLR reaching 85% at 24 mM. 2-Mercaptoethane sulphonate (15-122 microM) had no effect on azathioprine (36 microM) inhibition. The results of these in vitro studies suggest that 2-mercaptoethane sulphonate does not interfere with cyclophosphamide or azathioprine induced suppression of cellular immunity.

Sequential studies of rat urinary bladder epithelial lesions induced by ifosfamide (Z4942)

Urinary bladder damage caused by ifosfamide in male F344 rats was studied by light microscopy and scanning electron microscopy. Ifosfamide was injected intraperitoneally at doses of 30, 60 and 120 mg. per kg. body weight, and rats were killed at several intervals following treatment. The changes in the epithelium observed by light microscopy and scanning electron microscopy following ifosfamide injection were compared to those observed following cyclophosphamide injection. Necrosis and exfoliation of the urinary bladder epithelium occurred after day 1 of ifosfamide treatment and were followed by regenerative hyperplasia. This hyperplasia was reversible. A dose response was evident in the number and size of lesions induced and the time of regeneration and repair. Scanning electron microscopy disclosed short, uniform microvilli on the luminal surface of cells during the early phases of hyperplasia. These microvilli persisted for only 1 day, from days 1 to 7, and days 1 to 12 respectively, following injection of 30, 60 and 120 mg. per kg. of ifosfamide. The hyperplastic lesions also contained cells with pleomorphic microvilli and ropy or leafy microridges on their surfaces. These findings after ifosfamide administration were similar to those reported to be induced in the urinary bladder by cyclophosphamide.

Bladder carcinoma following cyclophosphamide therapy. A case report

Cyclophosphamide was introduced in 1958 in an effort to minimize the side effects of nitrogen mustard. Cyclophosphamide (Cytoxan, Endoxan) is not an alkylating agent which has been used for the treatment of a variety of non-malignant as well as malignant diseases. It has also recently been the focus of considerable interest as an immunosuppressive agent, perhaps the most potent immunosuppressive drug that has been synthesized. Reports of urologic complications from this drug are haemorrhagic cystitis, vesical fibrosis and urothelial carcinoma.

Leimyosarcoma of the urinary bladder. 13 years after cyclophosphamide therapy for Hodgkin's disease

A leiomyosarcoma of the urinary bladder occurred in a 17-year-old boy who was treated with a total dose of 67 g cyclophosphamide over a period of 5 years for Hodgkin's disease diagnosed at the age of 4. Cyclophosphamide was discontinued at the age of 9 because of gross hematuria, and intermittent hematuria recurred 8 years after (at the age of 17) the cessation of this drug. A large exophytic tumor found in the urinary bladder was diagnosed as leiomyosarcoma by light and electron microscopic studies. In addition, there were microscopic features of long-term cyclophosphamide toxicity throughout the bladder wall.

Second cancers following antineoplastic therapy

The occurrence of metachronous malignancies has long been a phenomenon of interest to physicians. The problem of treatment-related malignancies has added to that interest and has contributed to the understanding of carcinogenesis. Prolonged survival of patients with previously lethal diseases is now allowing the expression of long-term toxicities of the intensive therapies being used in many disease settings. Although the oncogenic potential of the various alkylating agents may not be equivalent, they have all been implicated as causing cancer in man. Procarbazine also appears to be highly carcinogenic in man. The intensity of treatment (duration and total dose) is a significant factor in the carcinogenesis of these agents. The dose-response relationship between radiation and cancer induction is less clear, but most believe that increasing radiation exposure increases the risk of cancer in a linear fashion. The combination of intensive chemotherapy and intensive radiotherapy yields the greatest risk for treatment-related hematologic and solid malignancies. To replace effective therapy with less carcinogenic therapy of unproved effectiveness would be difficult since survival curves have not been significantly affected by the evolution of treatment-related cancers. Whether that will hold true for the adjuvant use of intensive therapy remains to be seen. Where feasible, the design of such adjuvant trials should keep the dose-response relationship in mind. If the virtual absence of metachronous leukemia in Hodgkin's disease patients treated with ABVD holds true over time, the search for noncarcinogenic combination therapy will be well worth the effort. Therapeutic options in cancer treatment currently are few, and the benefits of potentially carcinogenic chemotherapy and radiotherapy continue to outweigh the risks.

Urinary bladder tumors following cyclophosphamide therapy: a report of two cases with a review of the literature

Sterile hemorrhagic cystitis following cyclophosphamide (Cph) therapy is a relatively frequent and well-documented phenomenon. On the other hand, cancer of the urinary bladder associated with Cph therapy is rarely observed. We present two cases and summarize 32 patients reported in the literature. Thirty patients had malignant disease elsewhere, 27 of them nonsolid tumors. The other four patients received treatment with Cph for nonmalignant disease (systemic lupus erythematosus--3; rheumatoid arthritis--1). The bladder tumor developed several months to years after treatment. In 20 patients hemorrhagic cystitis antedated the tumors. We conclude that hemorrhagic cystitis in patients on Cph therapy should indicate at least temporary withdrawal of the drug. The decision to resume treatment should be taken with extreme caution considering the risk of the development of bladder cancer.

Chemically induced renal papillary necrosis and upper urothelial carcinoma. Part 1

In the past, renal papillary necrosis (RPN) has been commonly associated with long-term abusive analgesic intake, but over recent years a wide variety of industrially and therapeutically used chemicals have been shown to induce this lesion experimentally or in man. Destruction of the renal papilla may result in: (1) secondary degenerative cortical changes which precede chronic renal failure or (2) a rapidly metastasizing upper urothelial carcinoma, which has a very poor prognosis. This article will briefly review the published data on the morphology, function, and biochemistry of the normal renal medulla and the pathology associated with RPN, together with the secondary changes which give rise to cortical degeneration or epithelial carcinoma. It will then examine in detail those chemicals which have been reported to cause RPN in an attempt to delineate structure-activity relationships. Finally, the many different theories that have been proposed to explain the pathophysiology of RPN will be examined and an hypothesis will be put forward to explain the primary pathogenesis of the lesion and its secondary consequences.

Chemically induced renal papillary necrosis and upper urothelial carcinoma. Part 2

In the past, renal papillary necrosis (RPN) has been commonly associated with long-term abusive analgesic intake, but over recent years a wide variety of industrially and therapeutically used chemicals have been shown to induce this lesion experimentally or in man. Destruction of the renal papilla may result in: (1) secondary degenerative cortical changes which precede chronic renal failure or (2) a rapidly metastasizing upper urothelial carcinoma, which has a very poor prognosis. This article will briefly review the published data on the morphology, function, and biochemistry of the normal renal medulla and the pathology associated with RPN, together with the secondary changes which give rise to cortical degeneration or epithelial carcinoma. It will then examine in detail those chemicals which have been reported to cause RPN in an attempt to delineate structure-activity relationships. Finally, the many different theories that have been proposed to explain the pathophysiology of RPN will be examined and an hypothesis will be put forward to explain the primary pathogenesis of the lesion and its secondary consequences.

Multiple primary tumors in association with prostatic cancer

One hundred forty-six patients with clinically nonmetastatic carcinoma of the prostate were treated at Columbia-Presbyterian Medical Center from 1964 through 1976. Of these 146 patients, 24 (16.4%) had developed at least one additional primary cancer. This review contrasts the 122 patients who had a single primary prostate cancer only with the 24 patients who had additional primary carcinomas with respect to age, racial distribution, clinical stage, and prostate cancer histology including Gleason's score, patterns of failure of prostate cancer, and survival data. Local failure and distant failure were less in the multiple primary group. Patients with high Gleason's scores appear to be at greater risk for second primaries. Five-year observed survival (by actuarial life table method) for the single prostate primary group was 76.5%, and 5-year observed survival of the prostate multiple primary group where prostate cancer appeared first was 71%.

Evaluation of hematuria

A basic problem in evaluating hematuria is the large number of diagnostic possibilities. The causation may be suspected after the initial history and physical examination, and can be confirmed with appropriate studies. The addition of standard tests such as urine culture, intravenous pyelography, and cystoscopy will reveal the source of hematuria in many other cases and will bring the percentage of patients with a clear diagnosis up to 60 or 70 per cent. The physician must be careful in selecting further studies in the remaining patients, since the procedures necessary for diagnosis may be expensive, unpleasant, and potentially harmful, and the probability of finding a treatable condition is low. The diagnostic protocol described in this article is designed to reduce the studies performed to a minimum, while still identifying those individuals who can benefit from therapy.

Urothelial carcinoma after cyclophosphamide therapy

We report a case of transitional cell carcinoma of the bladder after cyclophosphamide therapy for chronic lymphocytic leukemia. Urologic evaluation and histologic confirmation occurred only after low grade tumor cells were identified in multiple urine samples. Malignant cells can be distinguished from drug effect in urinary specimens from patients treated with cyclophosphamide and all such cases should include regular cytologic evaluations.

Pancreatic carcinoma in a ten-year survivor of acute myeloblastic leukemia

Adenocarcinoma of the pancreas developed in a young man who was a 10-year survivor of acute myeloblastic leukemia (AML). His extensive cytotoxic chemotherapy for AML is reviewed along with a discussion of its possible oncogenic effects. Other case reports of second malignant neoplasms (SMN) following acute leukemia are cited; available data suggest that the overall risk of SMN in AML may be in the range of 6%. While our patient's second malignancy may have been a chance association, his and other cases of pancreatic carcinoma in young survivors of hematologic neoplasia suggest that the cytotoxic treatment may have had a role in the pathogenesis of the pancreatic carcinoma.

Uroepithelial carcinoma in association with cyclophosphamide ingestion

The association of daily oral cyclophosphamide with the development of transitional cell carcinoma or squamous cell carcinoma of the bladder had been documented. We report the first 2 cases of transitional cell carcinoma of the renal pelvis and an additional 4 cases of transitional cell carcinoma of the bladder following cyclophosphamide ingestion. Patients who have been taking daily oral cyclophosphamide for a prolonged period should have excretory urography, cystoscopy and bladder mucosal biopsies performed as part of a cancer surveillance protocol.

Invasive carcinoma of the renal pelvis following cyclophosphamide therapy for nonmalignant disease

A 47-year-old woman with right hydroureteronephrosis due to ureterovesical junction obstruction had gross hematuria after being treated for five years wtih cyclophosphamide for cerebral vasculitis. A right nephroureterectomy was required for control of bleeding. The pathology specimen contained clinically occult invasive carcinoma of the renal pelvis. Although the ability of cyclophosphamide to cause hemorrhagic cystitis and urine cytologic abnormalities indistinguishable from high grade carcinoma is well known, it is less widely appreciated that it is also associated with carcinoma of the urinary tract. Twenty carcinomas of the urinary bladder and one carcinoma of the prostate have been reported in association with its use. The present case is the first carcinoma of the renal pelvis reported in association with cyclophosphamide treatment. It is the third urinary tract cancer reported in association with cyclophosphamide treatment for nonmalignant disease. The association of the tumor with preexisting hydroureteronephrosis suggests that stasis prolonged and intensified exposure of upper urinary tract epithelium to cyclophosphamide. Patients who are candidates for long-term cyclophosphamide treatment should be routinely evaluated for obstructive uropathy.

Simultaneous occurrence of transitional, squamous and adenocarcinoma of the bladder after 15 years of cyclophosphamide ingestion

We report on a patient who had a urothelial tumor with tri-differentiation into transitional squamous and adenocarcinoma after ingestion of 285 gm. cyclophosphamide during a 15-year-period. The possibility is again raised that the use of high doses of this drug over long periods may be associated with an increased incidence of carcinoma of the bladder. Frequent cystoscopic examinations may be warranted in patients who have received large cumulative amounts of the drug

Bladder cancer following administration of cyclophosphamide

The relationship between cyclophosphamide and hemorrhagic cystitis is well documented; its role in inducing bladder cancer is less clear. To date, 18 cases of cyclophosphamide-associated bladder tumors have been reported. We present 3 additional cases of transitional cell bladder cancer, all preceded by hemorrhagic cystitis. Data implicating cyclophosphamide as a direct carcinogen as well as an immunosuppressive agent allowing bladder tumor development in the compromised host are discussed. While no direct relationship has been established, we suggest patients receiving this drug are at risk for developing bladder cancer, more likely transitional cell rather than squamous cell as has been reported previously.