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Cicione A, Lombardo R, Nacchia A, Franco A, Simone G, Pastore A, Leonardo C, Franco G, Tubaro A, DE Nunzio C. No clinical benefit from sequential combination of mitomycin C plus bacillus Calmette-Guérin (BCG) than BCG alone in the adjuvant treatment of high risk non muscle invasive bladder cancer: result of a planned interim analysis of a prospective randomized trial. Minerva Urol Nephrol 2024; 76:458-466. [PMID: 38842053 DOI: 10.23736/s2724-6051.24.05777-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND The aim of this study was to evaluate whether the sequential use of Mitomycin C (MMC) and Bacillus Calmette-Guérin (BCG) is superior to BCG alone in reducing the risk of disease recurrence in patients with non-muscle invasive bladder cancer (NMIBC) with high risk of progression. METHODS Prospective randomized trial was conducted from March 2021 to March 2023 and included 72 patients with high risk NMIBC. Trial registration number: NCT03790384; EUDRACT Number: 2017-004540-37. Thirty-one patients underwent to BCG alone and forty-one to MMC plus BCG during the induction course. The BCG schedule comprised six weekly instillation of 81 mg Connaught strain BCG as the induction course, followed by a further three-monthly instillation at three, six and twelve months, as the maintenance course. Forty mg of MMC were administered the day prior to each weekly BCG instillation in BCG plus MMC arm. A planned interim analysis was carried out in June 2023, at the end of the 12mo follow-up period. RESULTS Six out of thirteen 6/31(19.3%) and 10/41 (24.4%) patients experienced recurrence in BCG and BCG plus MMC group (P=0.611), respectively. BCG plus MMC did not improve Disease Free Interval (HR: 1.23 95% CI:0.46-3.50; P=0.640). Patients receiving sequential treatment experienced similar AEs (P>0.05) and more urinary symptoms (P<0.05). CONCLUSIONS This interim pre-planned analysis suggested absence of clinical advantages in terms of disease recurrence rate when MMC is administered one day prior to BCG during induction course.
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Affiliation(s)
- Antonio Cicione
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Riccardo Lombardo
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Antonio Nacchia
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Antonio Franco
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy -
| | - Giuseppe Simone
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Antonio Pastore
- Department of Urology, ICOT Latina, Sapienza University, Latina, Italy
| | - Costantino Leonardo
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giorgio Franco
- Department of Urology, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Andrea Tubaro
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Cosimo DE Nunzio
- Department of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
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Serretta V. BCG and bladder cancer. Forty-eight years after Morales report. Urologia 2024; 91:459-467. [PMID: 38757638 DOI: 10.1177/03915603241252909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Although BCG use as an anticancer drug was nearly abandoned due to the poor results in most tumors, in 1976 Morales reported a relevant reduction in recurrence with intravesical BCG in few patients affected by NMIBC. Since then BCG was globally accepted as an empirical and effective therapy in treating Tis and preventing recurrence of intermediate and high risk NMIBC. Forty-eight years after Morales' report, although some open questions remain object of debate, we have been able to find answers to many doubts improving BCG activity and toxicity. We better select patients undergoing BCG and many trials have indicated the best dosage and schedule. Moreover, we are able to better identify the patient unresponsive to BCG who might benefit of a timely radical cystectomy. We are also aware of the difficulties and toxicities that can be encountered with BCG use in every-day clinical practice. Research is ongoing to obtain genetically modified BCG to increase its efficacy and reduce toxicity. Moreover, the combination of BCG with other immunotherapeutic drugs given intravesically or systemically, first immune checkpoint inhibitors, is under study to obtain a response in patients unresponsive or intolerant to BCG. Almost 50 years after Morales publication, intravesical BCG remains an inalienable tool against NMIBC.
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Affiliation(s)
- Vincenzo Serretta
- Urology Unit, Candela Clinic, Palermo, Italy
- III Level Oncologic Department "La Maddalena" Palermo, Italy
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3
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Liu K, Wang L, Peng J, Lyu Y, Li Y, Duan D, Zhang W, Wei G, Li T, Niu Y, Zhao Y. Drug-Loaded Bacillus Calmette-Guérin Bacteria for Immuno-Chemo Combo Therapy in Bladder Cancer. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2310735. [PMID: 38330363 DOI: 10.1002/adma.202310735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 02/02/2024] [Indexed: 02/10/2024]
Abstract
Intravesical Bacillus Calmette-Guérin (BCG) is a well-established strategy for managing high-risk nonmuscle-invasive bladder cancer (NMIBC); however, over half of patients still experience disease recurrence or progression. Although the combined intravesical instillation of various chemotherapeutic drugs is implemented in clinical trials to enhance the BCG therapy, the outcome is far from satisfying due to severe irritative effects and treatment intolerance at high doses. Therefore, it is adopted the "biotin-streptavidin strategy" to doxorubicin (DOX)-encapsulated nanoparticles within live BCG bacteria (DOX@BCG) to improve treatment outcomes. Adherence of BCG to the bladder epithelium helps precisely target DOX@BCG to the local tumor cells and simultaneously increases intratumoral transport of therapeutic drugs. DOX@BCG effectively inhibits cancer progression and prolongs the survival of rats/mice with orthotopic bladder cancer owing to synergism between BCG-immunotherapy, DOX-chemotherapy, and DOX-induced immunogenic tumor cell death; furthermore, it exhibits improved tolerance and biosafety, and establishes antitumor immunity in the tumor microenvironment. Therefore, the drug-loaded live BCG bacterial delivery system holds considerable potential for clinical translation in the intravesical treatment of bladder cancer.
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Affiliation(s)
- Kangkang Liu
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Lining Wang
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Jing Peng
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Yuanji Lyu
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Yiming Li
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Dengyi Duan
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Wenyi Zhang
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Guojiang Wei
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Taipeng Li
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Yuanjie Niu
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Yang Zhao
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
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Vieira de Sousa T, Guedes de Pinho P, Pinto J. Metabolomic Signatures of Treatment Response in Bladder Cancer. Int J Mol Sci 2023; 24:17543. [PMID: 38139377 PMCID: PMC10743932 DOI: 10.3390/ijms242417543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
Bladder cancer (BC) stands as one of the most prevalent urological malignancies, with over 500 thousand newly diagnosed cases annually. Treatment decisions in BC depend on factors like the risk of recurrence, the type of tumor, and the stage of the disease. While standard therapeutic approaches encompass transurethral resection of the bladder tumor, radical cystectomy, and chemo- or immunotherapy, these methods exhibit limited efficacy in mitigating the aggressive and recurrent nature of bladder tumors. To overcome this challenge, it is crucial to develop innovative methods for monitoring and predicting treatment responses among patients with BC. Metabolomics is gaining recognition as a promising approach for discovering biomarkers. It has the potential to reveal metabolic disruptions that precisely reflect how BC patients respond to particular treatments, providing a revolutionary method to improve accuracy in monitoring and predicting outcomes. In this article, we present a comprehensive review of studies employing metabolomics approaches to investigate the metabolic responses associated with different treatment modalities for BC. The review encompasses an exploration of various models, samples, and analytical techniques applied in this context. Special emphasis is placed on the reported changes in metabolite levels derived from these studies, highlighting their potential as biomarkers for personalized medicine in BC.
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Affiliation(s)
- Tiago Vieira de Sousa
- Associate Laboratory i4HB–Institute for Health and Bioeconomy, University of Porto, 4050-313 Porto, Portugal;
- UCIBIO–Applied Molecular Biosciences Unit, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Paula Guedes de Pinho
- Associate Laboratory i4HB–Institute for Health and Bioeconomy, University of Porto, 4050-313 Porto, Portugal;
- UCIBIO–Applied Molecular Biosciences Unit, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
| | - Joana Pinto
- Associate Laboratory i4HB–Institute for Health and Bioeconomy, University of Porto, 4050-313 Porto, Portugal;
- UCIBIO–Applied Molecular Biosciences Unit, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313 Porto, Portugal
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Inman BA, Hahn NM, Stratton K, Kopp R, Sankin A, Skinner E, Pohar K, Gartrell BA, Pham S, Rishipathak D, Mariathasan S, Davarpanah N, Carter C, Steinberg GD. A Phase 1b/2 Study of Atezolizumab with or Without Bacille Calmette-Guérin in Patients with High-risk Non-muscle-invasive Bladder Cancer. Eur Urol Oncol 2023; 6:313-320. [PMID: 36803840 DOI: 10.1016/j.euo.2023.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/02/2022] [Accepted: 01/20/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Bacille Calmette-Guérin (BCG) is the standard therapy after transurethral resection of bladder tumour for high-risk non-muscle-invasive bladder cancer (NMIBC). However, post-BCG recurrence/progression occurs frequently, and noncystectomy options are limited. OBJECTIVE To evaluate the safety and clinical activity of atezolizumab ± BCG in high-risk BCG-unresponsive NMIBC. DESIGN, SETTING, AND PARTICIPANTS This phase 1b/2 GU-123 study (NCT02792192) treated patients with BCG-unresponsive NMIBC who had carcinoma in situ with atezolizumab ± BCG. INTERVENTION Patients in cohorts 1A and 1B received atezolizumab 1200 mg IV q3w for ≤96 wk. Those in cohort 1B also received standard BCG induction (six weekly doses) and maintenance courses (three doses weekly starting at month 3) with optional maintenance at 6, 12, 18, 24, and 30 mo. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Coprimary endpoints were safety and 6-mo complete response (CR) rate. Secondary endpoints included 3-mo CR rate and duration of CR; 95% confidence intervals were calculated using the Clopper-Pearson method. RESULTS AND LIMITATIONS At data cut-off (September 29, 2020), 24 patients were enrolled (cohort 1A, n = 12; cohort 1B, n = 12), and the recommended BCG dose was 50 mg in cohort 1B. Four patients (33%) had adverse events (AEs) leading to BCG dose modification/interruption. Three patients (25%) in cohort 1A reported atezolizumab-related grade 3 AEs; cohort 1B had no atezolizumab- or BCG-related grade ≥3 AEs. No grade 4/5 AEs were reported. The 6-mo CR rate was 33% in cohort 1A (median duration of CR, 6.8 mo) and 42% in cohort 1B (median duration of CR, not reached [≥12 mo]). These results are limited by the small sample size of GU-123. CONCLUSIONS In this first report of the atezolizumab-BCG combination in NMIBC, atezolizumab ± BCG was well tolerated, with no new safety signals or treatment-related deaths. Preliminary results suggested clinically meaningful activity; the combination favoured a longer duration of response. PATIENT SUMMARY We studied atezolizumab with and without bacille Calmette-Guérin (BCG) to determine whether this combination was safe and had clinical activity in patients with high-risk noninvasive bladder cancer (high-grade bladder tumours that affect the outermost lining of the bladder wall) that has previously been treated with BCG and is still present or occurred again. Our results suggest that atezolizumab with or without BCG was generally safe and could be used to treat patients unresponsive to BCG.
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Affiliation(s)
- Brant A Inman
- Duke Cancer Institute, Duke University, Durham, NC, USA.
| | - Noah M Hahn
- Department of Oncology, Johns Hopkins Greenberg Bladder Cancer Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Urology, Johns Hopkins Greenberg Bladder Cancer Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly Stratton
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ryan Kopp
- Department of Urology, Oregon Health & Science University, Portland, OR, USA; VA Portland Healthcare System, Portland, OR, USA
| | - Alex Sankin
- Department of Urology, Montefiore Medical Center, Bronx, NY, USA
| | - Eila Skinner
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | - Kamal Pohar
- Department of Urology, Ohio State University, Columbus, OH, USA
| | | | - Song Pham
- Genentech Inc, South San Francisco, CA, USA
| | | | | | | | | | - Gary D Steinberg
- Goldstein Bladder Cancer Program, NYU Langone Health, New York, NY, USA; Department of Urology, New York University School of Medicine, New York, NY, USA
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6
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Melgarejo-Segura MT, Morales-Martínez A, Yáñez-Castillo Y, Arrabal-Polo MÁ, Gómez-Lechuga P, Pareja-Vílchez M, Jiménez-Moleón JJ, Martín MA. A systematic review of the efficacy of intravesical electromotive drug administration therapy for non-muscle invasive bladder cancer. Urol Oncol 2022; 41:166-176. [PMID: 36328923 DOI: 10.1016/j.urolonc.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/13/2022] [Accepted: 09/22/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Non-muscle invasive bladder cancer (NMIBC) is characterized by a high rate of recurrence and progression, despite surgery and adjuvant therapies. OBJECTIVE To analyze the published results on the effectiveness of mitomycin C (MMC) applied with an electromotive drug administration device (EMDA) in the treatment of patients with non-muscle invasive bladder tumors. METHOD A systematic review was conducted using the PubMed and Google Scholar search platforms. We selected the studies that included the recurrence and/or progression rates or complete response rate in patients diagnosed with NMIBC according to their treatment and included MMC applied with EMDA. The last search was performed in November 2021. RESULTS The search yielded 64 articles; 11 articles met the selection criteria. In two of the 11 selected articles, mitomycin C was applied with an EMDA device (MMC-EMDA) as an ablative treatment, avoiding surgery in 50% of the patients. In 1 of the 11 studies, the application of MMC-EMDA was used as an induction treatment using a single preoperative instillation with promising results. In the remaining 8 studies, adjuvant MMC was applied with the EMDA device; in 3 of these 8 cases, treatment with MMC-EMDA alone was applied initially. In another3 cases the same treatment was applied after nonresponse to bacillus Calmette Guerin (BCG), and in the last 2 studies, MMC-EMDA was applied in combination with the classic therapy (BCG). All the studies selected supported the efficacy and safety of MMC-EMDA in patients with intermediate and high- risk bladder cancer. In 3 studies, adjuvant therapy with MMC-EMDA was performed in nonresponders to BCG, finding that adjuvant therapy with MMC-EMDA applied to BCG nonresponders without CIS avoided or delayed surgery. CONCLUSIONS The application of EMDA-enhanced MMC has been studied at different times of disease and with different administration protocols. It appears to delay bladder tumor recurrence and progression in certain populations. However, the methodological limitations of the published studies prevent definitive conclusions about its efficacy.
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Affiliation(s)
| | | | | | - Miguel Ángel Arrabal-Polo
- Department of Urology, University Hospital San Cecilio, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Complejo Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
| | | | | | - José Juan Jiménez-Moleón
- Instituto de Investigación Biosanitaria ibs.GRANADA, Complejo Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain; Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
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7
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Tan WS, Steinberg G, Witjes JA, Li R, Shariat SF, Roupret M, Babjuk M, Bivalacqua TJ, Psutka SP, Williams SB, Cookson MS, Palou J, Kamat AM. Intermediate-risk Non-muscle-invasive Bladder Cancer: Updated Consensus Definition and Management Recommendations from the International Bladder Cancer Group. Eur Urol Oncol 2022; 5:505-516. [PMID: 35718695 DOI: 10.1016/j.euo.2022.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/22/2022] [Accepted: 05/19/2022] [Indexed: 11/29/2022]
Abstract
CONTEXT Intermediate-risk (IR) non-muscle-invasive bladder cancer (NMIBC) is a heterogeneous disease. OBJECTIVE To update the International Bladder Cancer Group (IBCG) guidance and provide practical recommendations on IR NMIBC management. EVIDENCE ACQUISITION A collaborative review of published randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidance on IR NMIBC published before January 2022 was undertaken using PubMed/Medline. EVIDENCE SYNTHESIS Variation exists between guidelines in defining IR NMIBC. The IBCG recommends defining IR NMIBC as any TaLG tumor that is either recurrent or multifocal or has size ≥3 cm, OR any T1LG tumor. If the 3 tier grading system is used, than any TaG2 tumor would also be considered IR diease regardless of whether new diagnosis or recurrent. Accurate grading and staging of tumor, particularly in ruling out HG/G3 disease and/or carcinoma in situ, are crucial. The IBCG recommends that management of IR NMIBC should be further based on the following risk factors: multifocal tumor (more than one), early recurrence (<1 yr), frequent recurrence (>1/yr), tumor size (≥3 cm), and failure of prior intravesical treatment. Patients with no risk factors are best managed by one dose of postoperative intravesical chemotherapy. Patients with one to two risk factors should be offered additional adjuvant induction intravesical chemotherapy (or bacillus Calmette-Guérin (BCG) if prior chemotherapy has been used). Patients with three or more risk factors should be offered induction plus 1-yr maintenance BCG. Where BCG is not available or recurrent disease following BCG is present, alternative intravesical treatments such as chemotherapy (single agent, combination, or chemohyperthermia) or a clinical trial are recommended. CONCLUSIONS Standardizing the definition of IR NMIBC is critical for appropriate management of patients and for allowing a comparison of outcomes across clinical trials. The IBCG recommends defining IR NMIBC as any TaLG tumor that is either recurrent or multifocal or ≥3 cm, OR any T1LG tumor. If the 3 tier grading system is used, than any TaG2 tumor would also be considered IR disease regardless of whether new diagnosis or recurrent. Adjunctive management should then be based on established risk factors. PATIENT SUMMARY Standardizing the definition of intermediate-risk (IR) non-muscle-invasive bladder cancer (NMIBC), which is a heterogeneous disease, is critical for appropriate management of patients. The International Bladder Cancer Group recommends classification of IR NMIBC tumors and personalized management based on the following risk factors: multifocal tumor (more than one), early recurrence (<1 yr), frequent recurrence (>1/yr), tumor size (≥3 cm), and previous intravesical treatment.
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Affiliation(s)
- Wei Shen Tan
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals, London, UK
| | - Gary Steinberg
- Department of Urology, New York University, New York City, NY, USA
| | - J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna, Austria; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Morgan Roupret
- Urology, GRC n°5, Predictive ONCO-URO, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Praha, Czech Republic
| | - Trinity J Bivalacqua
- Department of Urology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Michael S Cookson
- Department of Urology, The University of Oklahoma Health Sciences Center & The Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Juan Palou
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Fujita N, Hatakeyama S, Momota M, Narita T, Tobisawa Y, Yoneyama T, Yamamoto H, Ito H, Yoneyama T, Hashimoto Y, Yoshikawa K, Ohyama C. Single immediate instillation of chemotherapy is associated with decreased recurrence and progression in patients with high-risk non-muscle-invasive bladder cancer who receive adjuvant induction bacillus Calmette-Guérin therapy. Int J Urol 2022; 29:867-875. [PMID: 35577361 DOI: 10.1111/iju.14926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/24/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate whether a single intravesical instillation of chemotherapy is associated with improved oncological outcomes in patients with high-risk non-muscle-invasive bladder cancer who receive adjuvant induction bacillus Calmette-Guérin therapy. METHODS This multi-institutional retrospective study included 205 patients with high-risk non-muscle-invasive bladder cancer who received adjuvant induction bacillus Calmette-Guérin therapy. Patients were divided into two groups: those who received the combined therapy of a single instillation of chemotherapy plus subsequent adjuvant induction bacillus Calmette-Guérin therapy (combined therapy group), and those who received adjuvant induction bacillus Calmette-Guérin therapy alone (bacillus Calmette-Guérin monotherapy group). Multivariable analyses using the inverse probability of treatment weighting method and Fine-Gray competing risk regression models were performed to evaluate the impact of a single instillation of chemotherapy on intravesical recurrence-free survival and muscle-invasive bladder cancer-free survival. RESULTS Among the 205 patients, 130 (63%) and 75 (37%) were classified as the combined therapy and bacillus Calmette-Guérin monotherapy groups, respectively. Multivariable analyses using the inverse probability of treatment weighting method showed that a single instillation of chemotherapy was significantly associated with longer intravesical recurrence-free survival (hazard ratio 0.279; P < 0.001) and muscle-invasive bladder cancer-free survival (hazard ratio 0.078; P < 0.001). Fine-Gray competing risk regression model revealed that a single instillation of chemotherapy was associated with a significantly lower probability of intravesical recurrence and muscle-invasive bladder cancer progression, with an adjusted subdistribution hazard ratio of 0.477 (P = 0.008) and 0.261 (P = 0.043), respectively. CONCLUSION A single intravesical instillation of chemotherapy may be a potential treatment option in patients with high-risk non-muscle-invasive bladder cancer who receive adjuvant induction bacillus Calmette-Guérin therapy.
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Affiliation(s)
- Naoki Fujita
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shingo Hatakeyama
- Department of Advanced Blood Purification Therapy, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Masaki Momota
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takuma Narita
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuki Tobisawa
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tohru Yoneyama
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hayato Yamamoto
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hiroyuki Ito
- Department of Urology, Aomori Rosai Hospital, Hachinohe, Japan
| | - Takahiro Yoneyama
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuhiro Hashimoto
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | | | - Chikara Ohyama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.,Department of Advanced Blood Purification Therapy, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.,Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Li Y, Youssef SF, Buanz ABM. Intravesical combination therapies for non-muscle invasive bladder cancer: Recent advances and future directions. Eur J Pharmacol 2022; 926:175024. [DOI: 10.1016/j.ejphar.2022.175024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/30/2022] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
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10
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Lu D, Yang T, Tang N, Li C, Song Y, Wang L, Wong WY, Yin SF, Xing Y, Kambe N, Qiu R. A pH-Dependent rhodamine fluorophore with antiproliferative activity of bladder cancer in Vitro/Vivo and apoptosis mechanism. Eur J Med Chem 2022; 236:114293. [DOI: 10.1016/j.ejmech.2022.114293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/04/2022] [Accepted: 03/13/2022] [Indexed: 02/04/2023]
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Gupta S, Dutta A, Pal DK. Comparison of intravesical adjuvant therapy in bladder cancer with two different maintenance regimens of mitomycin and BCG. Urologia 2021; 89:53-57. [PMID: 34668805 DOI: 10.1177/03915603211050783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare recurrence rate and side effects with two different maintenance regimens of postoperative intravesical therapy with mitomycin and BCG in T1 bladder cancer. METHODS Eighty were enrolled in this study and all received immediate post operative mitomycin. They were then allocated to two groups of 40, one group receiving intravesicle BCG and other a combination BCG and Mitomycin. They were followed up to a period of 2 years. RESULT Two year recurrence rate after transurethral resection of bladder tumour with high grade T1 disease in the Combination group is low (20%) as compared to the BCG group (37.5%). CONCLUSION Two year recurrences reduced with use of intravesical Mitomycin during maintenance in the combination group which though not statistically significant favours the trial with combination therapy in future studies. Side effect profile did not worsen with combination of Mitomycin and BCG.
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Affiliation(s)
- Sandeep Gupta
- Department of Urology, Institute of Post Graduate Medical Education and Research (IPGME&R), Kolkata, West Bengal, India
| | - Avisek Dutta
- Department of Urology, Institute of Post Graduate Medical Education and Research (IPGME&R), Kolkata, West Bengal, India
| | - Dilip Kumar Pal
- Department of Urology, Institute of Post Graduate Medical Education and Research (IPGME&R), Kolkata, West Bengal, India
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12
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Babjuk M, Burger M, Capoun O, Cohen D, Compérat EM, Dominguez Escrig JL, Gontero P, Liedberg F, Masson-Lecomte A, Mostafid AH, Palou J, van Rhijn BWG, Rouprêt M, Shariat SF, Seisen T, Soukup V, Sylvester RJ. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (Ta, T1, and Carcinoma in Situ). Eur Urol 2021; 81:75-94. [PMID: 34511303 DOI: 10.1016/j.eururo.2021.08.010] [Citation(s) in RCA: 543] [Impact Index Per Article: 181.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/15/2021] [Indexed: 02/08/2023]
Abstract
CONTEXT The European Association of Urology (EAU) has released an updated version of the guidelines on non-muscle-invasive bladder cancer (NMIBC). OBJECTIVE To present the 2021 EAU guidelines on NMIBC. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines since the 2020 version was performed. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS Tumours staged as Ta, T1 and carcinoma in situ (CIS) are grouped under the heading of NMIBC. Diagnosis depends on cystoscopy and histological evaluation of tissue obtained via transurethral resection of the bladder (TURB) for papillary tumours or via multiple bladder biopsies for CIS. For papillary lesions, a complete TURB is essential for the patient's prognosis and correct diagnosis. In cases for which the initial resection is incomplete, there is no muscle in the specimen, or a T1 tumour is detected, a second TURB should be performed within 2-6 wk. The risk of progression may be estimated for individual patients using the 2021 EAU scoring model. On the basis of their individual risk of progression, patients are stratified as having low, intermediate, high, or very high risk, which is pivotal to recommending adjuvant treatment. For patients with tumours presumed to be at low risk and for small papillary recurrences detected more than 1 yr after a previous TURB, one immediate chemotherapy instillation is recommended. Patients with an intermediate-risk tumour should receive 1 yr of full-dose intravesical bacillus Calmette-Guérin (BCG) immunotherapy or instillations of chemotherapy for a maximum of 1 yr. For patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. For patients at very high risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is also recommended for BCG-unresponsive tumours. The extended version of the guidelines is available on the EAU website at https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/. CONCLUSIONS These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology has released updated guidelines on the classification, risk factors, diagnosis, prognostic factors, and treatment of non-muscle-invasive bladder cancer. The recommendations are based on the literature up to 2020, with emphasis on the highest level of evidence. Classification of patients as having low, intermediate, or and high risk is essential in deciding on suitable treatment. Surgical removal of the bladder should be considered for tumours that do not respond to bacillus Calmette-Guérin (BCG) treatment and tumours with the highest risk of progression.
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Affiliation(s)
- Marko Babjuk
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria.
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Otakar Capoun
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Daniel Cohen
- Department of Urology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Eva M Compérat
- Department of Pathology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | | | - Paolo Gontero
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Fredrik Liedberg
- Department of Translational Medicine, Lund University, Malmö, Sweden; Department of Urology, Skåne University Hospital, Malmö, Sweden
| | | | - A Hugh Mostafid
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Joan Palou
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Bas W G van Rhijn
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Morgan Rouprêt
- GRC 5 Predictive Onco-Uro, Department of Urology, Sorbonne University, AP-HP, Pitié Salpétrière Hospital, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Thomas Seisen
- GRC 5 Predictive Onco-Uro, Department of Urology, Sorbonne University, AP-HP, Pitié Salpétrière Hospital, Paris, France
| | - Viktor Soukup
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
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13
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Morelli M, Baboudjian M, Vanacore D, Gondran-Tellier B, McManus R, Karsenty G, Lechavallier E, Montanari E, Boissier R. Early PDD Cystoscopy after BCG Induction for High-risk Non-Muscle Invasive Bladder Cancer Significantly Increased the Detection of BCG-refractory Tumors. J Endourol 2021; 35:1824-1828. [PMID: 34107773 DOI: 10.1089/end.2021.0313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To compare the detection rate of BCG refractory tumors between white light cystoscopy (WL-C) and Photodynamic Diagnosis cystoscopy (PDD-C). METHODS We performed a monocentric retrospective study that included all consecutive patients with high-risk non-muscle-invasive bladder cancer (NMIBC) diagnosed from January 2017 to January 2021. All patients had an initial Transurethral resection of bladder tumor (TURBT) with PDD ± restaging TURBT if needed, followed by full-dose BCG induction. Within 8 weeks following BCG induction all patients had both WL-C and PDD-C under general anesthesia ± TURBT in case of suspicious lesion. The primary endpoint was the detection of bladder cancer (BC) at post-BCG cystoscopy. RESULTS A total of 136 consecutive patients met inclusion criteria. Initial BC characteristics were: 35.6% of T1 tumor, 92.6% high-grade and 48.6% associated cis. BC was diagnosed in 33/136 cases (24%) at early PDD-C after BCG induction: 77% Ta, 23% T1, 56% associated cis, 68% high grade and 6% MIBC. Sensibility and Specificity of WL-C and PDD-C: 41 vs 91% (p<0.001) and 86 vs 75% (p=0.001). PDD-C detected 16 additional tumors: 81.3% Ta, 18.7% T1, 75% associated cis and 75% high grade. CONCLUSIONS Systematic use of PDD after BCG induction increased the detection of BCG-refractory tumors and lead to significant modification in the treatment of high-risk NMIBC. Future studies are needed to evaluate long-term oncological benefit of early PDD reevaluation and its cost-effectiveness.
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Affiliation(s)
- Michele Morelli
- Aix-Marseille-University, 128791, Urology, Marseille, Provence-Alpes-Côte d'Azur, France;
| | - Michael Baboudjian
- Aix-Marseille Université, APHM, Department of Urology and Renal transplantation, 147 bd baille, Marseille, France, 13005.,Marseille, France;
| | - Davide Vanacore
- Aix-Marseille-University, 128791, Urology, Marseille, Provence-Alpes-Côte d'Azur, France;
| | - Bastien Gondran-Tellier
- Aix-Marseille Université, APHM, Department of Urology and Renal transplantation, Marseille, France;
| | - Robin McManus
- Aix-Marseille Université, APHM, Department of Urology and Renal transplantation, Conception Academic Hospital, Aix Marseille University, Marseille, Marseille, France, France;
| | - Gilles Karsenty
- Assistance Publique Hopitaux de Marseille, 36900, Urologie, Marseille, Provence-Alpes-Côte d'Azu, France;
| | - Eric Lechavallier
- hopital La Conception, Urologie, 147 bd Baille, Marseille, France, 13385;
| | - Emanuele Montanari
- IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Urology, via della Commenda 15, Milan, Italy, 20122;
| | - Romain Boissier
- Aix-Marseille-University, 128791, Urology, Marseille, Provence-Alpes-Côte d'Azur, France;
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14
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Shih KW, Chen WC, Chang CH, Tai TE, Wu JC, Huang AC, Liu MC. Non-Muscular Invasive Bladder Cancer: Re-envisioning Therapeutic Journey from Traditional to Regenerative Interventions. Aging Dis 2021; 12:868-885. [PMID: 34094648 PMCID: PMC8139208 DOI: 10.14336/ad.2020.1109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/09/2020] [Indexed: 01/01/2023] Open
Abstract
Non-muscular invasive bladder cancer (NMIBC) is one of the most common cancer and major cause of economical and health burden in developed countries. Progression of NMIBC has been characterized as low-grade (Ta) and high grade (carcinoma in situ and T1). The current surgical intervention for NMIBC includes transurethral resection of bladder tumor; however, its recurrence still remains a challenge. The BCG-based immunotherapy is much effective against low-grade NMIBC. BCG increases the influx of T cells at bladder cancer site and inhibits proliferation of bladder cancer cells. The chemotherapy is another traditional approach to address NMIBC by supplementing BCG. Notwithstanding, these current therapeutic measures possess limited efficacy in controlling NMIBC, and do not provide comprehensive long-term relief. Hence, biomaterials and scaffolds seem an effective medium to deliver therapeutic agents for restructuring bladder post-treatment. The regenerative therapies such as stem cells and PRP have also been explored for possible solution to NMIBC. Based on above-mentioned approaches, we have comprehensively analyzed therapeutic journey from traditional to regenerative interventions for the treatment of NMIBC.
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Affiliation(s)
- Kuan-Wei Shih
- 1Department of Urology, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Wei-Chieh Chen
- 1Department of Urology, Taipei Medical University Hospital, Taipei 11031, Taiwan.,2Graduate Institute of Clinical Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.,3TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei 11031, Taiwan
| | - Ching-Hsin Chang
- 1Department of Urology, Taipei Medical University Hospital, Taipei 11031, Taiwan.,3TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei 11031, Taiwan.,4Institute of Microbiology and Immunology, National Yang-Ming University, Taipei 11031, Taiwan
| | - Ting-En Tai
- 1Department of Urology, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Jeng-Cheng Wu
- 1Department of Urology, Taipei Medical University Hospital, Taipei 11031, Taiwan.,3TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei 11031, Taiwan.,5Department of Education, Taipei Medical University Hospital, Taipei 11031, Taiwan.,6Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Andy C Huang
- 8Institute of Traditional Medicine, School of Medicine, National Yang-Ming University, Taipei,11221, Taiwan.,9Department of Urology, Department of Surgery, Taipei City Hospital Ren-Ai Branch, Taipei 10629, Taiwan
| | - Ming-Che Liu
- 1Department of Urology, Taipei Medical University Hospital, Taipei 11031, Taiwan.,2Graduate Institute of Clinical Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan.,3TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei 11031, Taiwan.,7Clinical Research Center, Taipei Medical University Hospital, Taipei 11031, Taiwan.,10School of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
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15
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Kim HS, Seo HK. Emerging treatments for bacillus Calmette-Guérin-unresponsive non-muscle-invasive bladder cancer. Investig Clin Urol 2021; 62:361-377. [PMID: 34085791 PMCID: PMC8246016 DOI: 10.4111/icu.20200602] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
Intravesical bacillus Calmette–Guérin (BCG) immunotherapy has been the gold standard adjuvant treatment for intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC) after transurethral resection of bladder tumor (TURBT). BCG immunotherapy prevents disease recurrence and progression to muscle-invasive disease following TURBT. Although most patients initially respond well to intravesical BCG, considerable concern has been raised for patients with BCG failure who are refractory or recur in 6 months after their last BCG, which implies ‘BCG-unresponsiveness’. Based on current clinical guidelines, early radical cystectomy (RC) is recommended to treat BCG-unresponsive NMIBC. However, due to the high risk of morbidity and mortality of RC and patients' desire to preserve their own bladder, there is a critical unmet need for alternative conservative treatments as bladder-sparing strategies in BCG-unresponsive patients. Trials for effective bladder-sparing treatments are ongoing, and several novel agents have been recently tested in the NMIBC setting. The goal of this review is to introduce and summarize recently reported novel and emerging drugs and ongoing clinical trials for BCG-unresponsive NMIBC.
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Affiliation(s)
- Hyung Suk Kim
- Department of Urology, Dongguk University Ilsan Medical Center, Dongguk University School of Medicine, Goyang, Korea
| | - Ho Kyung Seo
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, Korea.,Division of Tumor Immunology, Department of Cancer Biomedical Science, Research Institute, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea.
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16
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Peng M, Xiao D, Bu Y, Long J, Yang X, Lv S, Yang X. Novel Combination Therapies for the Treatment of Bladder Cancer. Front Oncol 2021; 10:539527. [PMID: 33585182 PMCID: PMC7873600 DOI: 10.3389/fonc.2020.539527] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 12/07/2020] [Indexed: 12/29/2022] Open
Abstract
Bladder cancer is the ninth most frequently diagnosed cancer world-wide and ranks 13th in cancer-related deaths. Two tremendous breakthroughs in bladder cancer therapy over the last decades are the approval of immune checkpoint inhibitors(ICIs)and the fibroblast growth factor receptor tyrosine kinase inhibitor (FGFR-TKI) erdafitinib for treating this deadly disease. Despite the beneficial effects of these approaches, the low response rate and the potential resistance of the cancer are major concerns. Hence, novel combination therapies to overcome these limitations have been investigated. In this context, combining immunotherapy with targeted drugs is an appealing therapeutic option to improve response and reduce the emergence of resistance in the management of bladder cancer. In this review, the rationale of using different therapeutic combinations is discussed according to the mechanistic differences, emphasizing the efficacy and safety based on evidence collected from preclinical and clinical studies. Finally, we highlight the limitations of these combinations and provide suggestions for further efforts in this challenging field.
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Affiliation(s)
- Mei Peng
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China.,Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, China
| | - Di Xiao
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, China
| | - Yizhi Bu
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, China
| | - Jiahui Long
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, China
| | - Xue Yang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
| | - Shuhe Lv
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaoping Yang
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, Department of Pharmacy, School of Medicine, Hunan Normal University, Changsha, China
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17
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Piszczek R, Krajewski W, Małkiewicz B, Krajewski P, Tukiendorf A, Zdrojowy R, Kołodziej A. Clinical outcomes and survival differences between primary, secondary and concomitants carcinoma in situ of urinary bladder treated with BCG immunotherapy. Transl Androl Urol 2020; 9:1338-1344. [PMID: 32676418 PMCID: PMC7354324 DOI: 10.21037/tau.2020.03.40] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background The carcinoma in situ (CIS) of urinary bladder is a flat, high-grade and aggressive manifestation of urothelial cancer which carries a great risk for progression to muscle invasive disease and metastatic spread. The aim of the study was to analyse the clinical history and survival differences between primary, secondary and concomitants CIS of the bladder. Methods We analysed a database of 301 patients who were treated between 1998 and 2017 in university BCG outpatient department. Primary, secondary and concomitants CIS cases were included in the study with minimum follow-up of 12 months. Recurrence-free survival (RSF), progression-free survival (PFS) and cancer specific survival (CSS) were analysed by Kaplan–Meier curves and log-rank test. Additionally, Cox regression models were performed. Results Seventy-two patients with primary, 58 with secondary and 171 with CIS concomitants were analysed. The patients were followed from mean 61,9 months. RFS rates at 5-years follow-up were 54.9%, 55.3% and 60.4% for primary, concomitants and secondary CIS (P>0.05). PFS rates at 5-years follow-up were 65.8%, 72.1% and 77% for primary, concomitants and secondary CIS (P>0.05). CSS rates at 5-years follow-up were 83.1%, 81.9% and 90.1% for primary, concomitants and secondary CIS (P>0.05). There were no statistically significant differences between any CIS subtype in any of analysed endpoints in multivariate analysis. Female gender was associated with worse RFS and the instillation number was positively associated with all analysed survival rates. On contrary, age was not statistically related to RFS, PFS nor CSS. Conclusions In this study it was shown that when compared with secondary and concomitants CIS, primary CIS presented the worst RFS and PFS, however, the differences between subgroups were not statistically significant.
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Affiliation(s)
- Radosław Piszczek
- Department of Urology and Oncologic Urology, Lowersilesian Specialistic Hospital, Wroclaw, Poland
| | - Wojciech Krajewski
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Bartosz Małkiewicz
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Piotr Krajewski
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Andrzej Tukiendorf
- Department of Public Health, Wrocław Medical University, Wrocław, Poland
| | - Romuald Zdrojowy
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Anna Kołodziej
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
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18
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Immunotherapy in Bladder Cancer: Current Methods and Future Perspectives. Cancers (Basel) 2020; 12:cancers12051181. [PMID: 32392774 PMCID: PMC7281703 DOI: 10.3390/cancers12051181] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/02/2020] [Accepted: 05/05/2020] [Indexed: 02/06/2023] Open
Abstract
Bladder cancer is one of the most significant genitourinary cancer, causing high morbidity and mortality in a great number of patients. Over the years, various treatment methods for this type of cancer have been developed. The most common is the highly efficient method using Bacillus Calmette-Guerin, giving a successful effect in a high percentage of patients. However, due to the genetic instability of bladder cancer, together with individual needs of patients, the search for different therapy methods is ongoing. Immune checkpoints are cell surface molecules influencing the immune response and decreasing the strength of the immune response. Among those checkpoints, the PD-1 (programmed cell death protein-1)/PD-L1 (programmed cell death protein ligand 1) inhibitors aim at blocking those molecules, which results in T cell activation, and in bladder cancer the use of Atezolizumab, Avelumab, Durvalumab, Nivolumab, and Pembrolizumab has been described. The inhibition of another pivotal immune checkpoint, CTLA-4 (cytotoxic T cell antigen), may result in the mobilization of the immune system against bladder cancer and, among anti-CTLA-4 antibodies, the use of Ipilimumab and Tremelimumab has been discussed. Moreover, several different approaches to successful bladder cancer treatment exists, such as the use of ganciclovir and mTOR (mammalian target of rapamycin) kinase inhibitors, IL-12 (interleukin-12) and COX-2 (cyclooxygenase-2). The use of gene therapies and the disruption of different signaling pathways are currently being investigated. Research suggests that the combination of several methods increases treatment efficiency and the positive outcome in individual.
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19
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Schmidt S, Kunath F, Coles B, Draeger DL, Krabbe L, Dersch R, Kilian S, Jensen K, Dahm P, Meerpohl JJ. Intravesical Bacillus Calmette-Guérin versus mitomycin C for Ta and T1 bladder cancer. Cochrane Database Syst Rev 2020; 1:CD011935. [PMID: 31912907 PMCID: PMC6956215 DOI: 10.1002/14651858.cd011935.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND People with urothelial carcinoma of the bladder are at risk for recurrence and progression following transurethral resection of a bladder tumour (TURBT). Mitomycin C (MMC) and Bacillus Calmette-Guérin (BCG) are commonly used, competing forms of intravesical therapy for intermediate- or high-risk non-muscle invasive (Ta and T1) urothelial bladder cancer but their relative merits are somewhat uncertain. OBJECTIVES To assess the effects of BCG intravesical therapy compared to MMC intravesical therapy for treating intermediate- and high-risk Ta and T1 bladder cancer in adults. SEARCH METHODS We performed a systematic literature search in multiple databases (CENTRAL, MEDLINE, Embase, Web of Science, Scopus, LILACS), as well as in two clinical trial registries. We searched reference lists of relevant publications and abstract proceedings. We applied no language restrictions. The latest search was conducted in September 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared intravesical BCG with intravesical MMC therapy for non-muscle invasive urothelial bladder cancer. DATA COLLECTION AND ANALYSIS Two review authors independently screened the literature, extracted data, assessed risk of bias and rated the quality of evidence according to GRADE per outcome. In the meta-analyses, we used the random-effects model. MAIN RESULTS We identified 12 RCTs comparing BCG versus MMC in participants with intermediate- and high-risk non-muscle invasive bladder tumours (published from 1995 to 2013). In total, 2932 participants were randomised. Time to death from any cause: BCG may make little or no difference on time to death from any cause compared to MMC (hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.79 to 1.20; participants = 1132, studies = 5; 567 participants in the BCG arm and 565 in the MMC arm; low-certainty evidence). This corresponds to 6 fewer deaths (40 fewer to 36 more) per 1000 participants treated with BCG at five years. We downgraded the certainty of the evidence two levels due to study limitations and imprecision. Serious adverse effects: 12/577 participants treated with BCG experienced serious non-fatal adverse effects compared to 4/447 participants in the MMC group. The pooled risk ratio (RR) is 2.31 (95% CI 0.82 to 6.52; participants = 1024, studies = 5; low-certainty evidence). Therefore, BCG may increase the risk for serious adverse effects compared to MMC. This corresponds to nine more serious adverse effects (one fewer to 37 more) with BCG. We downgraded the certainty of the evidence two levels due to study limitations and imprecision. Time to recurrence: BCG may reduce the time to recurrence compared to MMC (HR 0.88, 95% CI 0.71 to 1.09; participants = 2616, studies = 11, 1273 participants in the BCG arm and 1343 in the MMC arm; low-certainty evidence). This corresponds to 41 fewer recurrences (104 fewer to 29 more) with BCG at five years. We downgraded the certainty of the evidence two levels due to study limitations, imprecision and inconsistency. Time to progression: BCG may make little or no difference on time to progression compared to MMC (HR 0.96, 95% CI 0.73 to 1.26; participants = 1622, studies = 6; 804 participants in the BCG arm and 818 in the MMC arm; low-certainty evidence). This corresponds to four fewer progressions (29 fewer to 27 more) with BCG at five years. We downgraded the certainty of the evidence two levels due to study limitations and imprecision. Quality of life: we found very limited data for this outcomes and were unable to estimate an effect size. AUTHORS' CONCLUSIONS Based on our findings, BCG may reduce the risk of recurrence over time although the Confidence Intervals include the possibility of no difference. It may have no effect on either the risk of progression or risk of death from any cause over time. BCG may cause more serious adverse events although the Confidence Intervals once again include the possibility of no difference. We were unable to determine the impact on quality of life. The certainty of the evidence was consistently low, due to concerns that include possible selection bias, performance bias, given the lack of blinding in these studies, and imprecision.
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Affiliation(s)
- Stefanie Schmidt
- UroEvidence@Deutsche Gesellschaft für UrologieMartin‐Buber‐Str. 10BerlinGermany14163
| | - Frank Kunath
- UroEvidence@Deutsche Gesellschaft für UrologieMartin‐Buber‐Str. 10BerlinGermany14163
- University Hospital ErlangenDepartment of UrologyKrankenhausstrasse 12ErlangenGermany91054
| | - Bernadette Coles
- Cardiff University Library ServicesVelindre NHS TrustVelindre Cancer CentreWhitchurchCardiffUKCF14 2TL
| | - Desiree Louise Draeger
- UroEvidence@Deutsche Gesellschaft für UrologieMartin‐Buber‐Str. 10BerlinGermany14163
- University of RostockDepartment of UrologyErnst‐Heydemann‐Strasse 7RostockMecklenburg‐VorpommernGermany18057
| | - Laura‐Maria Krabbe
- UroEvidence@Deutsche Gesellschaft für UrologieMartin‐Buber‐Str. 10BerlinGermany14163
- University of Muenster Medical CenterDepartment of UrologyAlbert‐Schweitzer Campus 1, GB A1MuensterNRWGermany48149
| | - Rick Dersch
- Medical Center – University of FreiburgDepartment of Neurology and NeurophysiologyBerliner Allee 29FreiburgGermany79110
| | - Samuel Kilian
- University of HeidelbergInstitute of Medical Biometry and InformaticsHeidelbergGermany
| | - Katrin Jensen
- University of HeidelbergInstitute of Medical Biometry and InformaticsHeidelbergGermany
| | - Philipp Dahm
- Minneapolis VA Health Care SystemUrology SectionOne Veterans DriveMail Code 112DMinneapolisMinnesotaUSA55417
- University of MinnesotaDepartment of Urology420 Delaware Street SEMMC 394MinneapolisMinnesotaUSA55455
| | - Joerg J Meerpohl
- Medical Center ‐ University of Freiburg, Faculty of Medicine, University of
FreiburgInstitute for Evidence in MedicineBreisacher Str. 153FreiburgGermanyD‐79110
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20
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Abstract
PURPOSE OF REVIEW To review the current literature concerning the intravesical treatment of nonmuscle invasive bladder cancer. RECENT FINDINGS Bladder cancer is a high prevalent disease. Despite the recognized efficacy of traditional intravesical therapies, the best treatment strategy still needs to be found. Improvement in bladder cancer research lead to develop new intravesical agents and drug delivery systems for nonmuscle invasive bladder cancer tumours. Moreover, the emerging knowledge of bladder cancer immune profile strongly improves and provides new available treatment strategies. SUMMARY The future of nonmuscle invasive bladder cancer therapy will be influenced by the development of immunotherapy and new technologies for device-assisted treatment. Moreover, nanotechnology and delivery systems present promising results.
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21
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Murakami K, Hamada A, Teramoto Y, Matsumoto K, Kita Y, Saito R, Yamasaki T, Matsui Y, Inoue T, Ogawa O, Kobayashi T. Efficacy of Immediate Postoperative Instillation of Chemotherapy for Primary Non–Muscle-Invasive Bladder Cancer in Real-World Clinical Practice. Clin Genitourin Cancer 2019; 17:e1003-e1010. [DOI: 10.1016/j.clgc.2019.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/20/2019] [Accepted: 05/26/2019] [Indexed: 11/24/2022]
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22
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Babjuk M, Burger M, Compérat EM, Gontero P, Mostafid AH, Palou J, van Rhijn BWG, Rouprêt M, Shariat SF, Sylvester R, Zigeuner R, Capoun O, Cohen D, Escrig JLD, Hernández V, Peyronnet B, Seisen T, Soukup V. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ) - 2019 Update. Eur Urol 2019; 76:639-657. [PMID: 31443960 DOI: 10.1016/j.eururo.2019.08.016] [Citation(s) in RCA: 822] [Impact Index Per Article: 164.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022]
Abstract
CONTEXT This overview presents the updated European Association of Urology (EAU) guidelines for non-muscle-invasive bladder cancer (NMIBC), TaT1, and carcinoma in situ (CIS). OBJECTIVE To provide practical recommendations on the clinical management of NMIBC with a focus on clinical presentation and recommendations. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines has been performed annually since the last published version in 2017. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS Tumours staged as Ta, T1, and/or CIS are grouped under the heading of NMIBC. Diagnosis depends on cystoscopy and histological evaluation of the tissue obtained by transurethral resection (TURB) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TURB is essential for the patient's prognosis and correct diagnosis. Where the initial resection is incomplete, where there is no muscle in the specimen, or where a T1 tumour is detected, a second TURB should be performed within 2-6 wk. The risks of both recurrence and progression may be estimated for individual patients using the European Organisation for Research and Treatment of Cancer (EORTC) scoring system. Stratification of patients into low-, intermediate-, and high-risk groups is pivotal to the recommendation of adjuvant treatment. In patients with tumours presumed to be at a low risk and in those presumed to be at an intermediate risk with a low previous recurrence rate and an expected EORTC recurrence score of <5, one immediate chemotherapy instillation is recommended. Patients with intermediate-risk tumours should receive 1 yr of full-dose bacillus Calmette-Guérin (BCG) intravesical immunotherapy or instillations of chemotherapy for a maximum of 1 yr. In patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. In patients at the highest risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is recommended in BCG-unresponsive tumours. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/. CONCLUSIONS These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology Non-muscle-invasive Bladder Cancer (NMIBC) Panel has released an updated version of their guidelines, which contains information on classification, risk factors, diagnosis, prognostic factors, and treatment of NMIBC. The recommendations are based on the current literature (until the end of 2018), with emphasis on high-level data from randomised clinical trials and meta-analyses. Stratification of patients into low-, intermediate-, and high-risk groups is essential for deciding appropriate use of adjuvant intravesical chemotherapy or bacillus Calmette-Guérin (BCG) instillations. Surgical removal of the bladder should be considered in case of BCG-unresponsive tumours or in NMIBCs with the highest risk of progression.
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Affiliation(s)
- Marko Babjuk
- Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria.
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Eva M Compérat
- Department of Pathology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, UPMC Paris VI, Paris, France
| | - Paolo Gontero
- Division of Urology, Molinette Hospital, University of Studies of Torino, Torino, Italy
| | - A Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Bas W G van Rhijn
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany; Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Morgan Rouprêt
- Urology Department, Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Richard Sylvester
- European Association of Urology Guidelines Office, Brussels, Belgium
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Otakar Capoun
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Daniel Cohen
- Department of Urology, Royal Free London NHS Foundation Trust, London, UK
| | | | - Virginia Hernández
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Thomas Seisen
- Urology Department, Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Viktor Soukup
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
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23
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Radziszewski P, Poletajew S. Re: Radiofrequency-induced Thermo-chemotherapy Effect Versus a Second Course of Bacillus Calmette-Guérin or Institutional Standard in Patients with Recurrence of Non-muscle-invasive Bladder Cancer Following Induction or Maintenance Bacillus Calmette-Guérin Therapy (HYMN): A Phase III, Open-label, Randomised Controlled Trial. Eur Urol 2019; 75:879-880. [PMID: 30712968 DOI: 10.1016/j.eururo.2019.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 01/21/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Piotr Radziszewski
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, Warsaw, Poland.
| | - Sławomir Poletajew
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, Warsaw, Poland
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24
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Huang D, Jin YH, Weng H, Huang Q, Zeng XT, Wang XH. Combination of Intravesical Bacille Calmette-Guérin and Chemotherapy vs. Bacille Calmette-Guérin Alone in Non-muscle Invasive Bladder Cancer: A Meta-Analysis. Front Oncol 2019; 9:121. [PMID: 30881921 PMCID: PMC6405446 DOI: 10.3389/fonc.2019.00121] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/11/2019] [Indexed: 12/18/2022] Open
Abstract
Background: About 75% of newly diagnosed bladder cancer cases suffer from non-muscle invasive bladder cancer (NMIBC), which used to recur and progress despite transurethral resection of bladder tumor (TURBT). This meta-analysis was conducted to examine if combined application of intravesical bacille Calmette-Guérin (BCG) with chemotherapy is associated with better prognosis. Methods: Systematic searches of randomized controlled trials (RCTs) concerning NMIBC were performed in PubMed, EMbase, CENTRAL, CNKI, WanFang, VIP, CBM databases, and some specialized websites. Two researchers independently implemented study selection, quality assessment and data extraction. Hazard ratios (HRs) and their 95% confidence intervals (CIs) for treatment effects on recurrence-free survival (RFS), progression-free survival (PFS), overall survival (OS) and disease-specific survival (DSS) were directly extracted, if available, or estimated using relevant data from included studies. Side effects, such as fever, gastrointestinal reaction, cystitis, irritative bladder symptoms and hematuria, were also extracted as outcome measurements, and associated relative risks (RRs) were calculated to assess treatment safety. RevMan 5.3 software was used to perform statistical analyses. Results: Thirteen RCTs containing 1,754 patients with NMIBC were included in this meta-analysis. Compared with BCG alone, the combination therapy significantly improved RFS (HR = 0.53, 95% CI: 0.43-0.66, P < 0.01), OS (HR = 0.66, 95%CI: 0.50-0.86, P = 0.002), and DSS (HR = 0.48, 95%CI: 0.29-0.80, P = 0.005). While PFS showed no obvious difference between combination therapy and BCG alone (HR = 0.65, 95%CI: 0.25-1.68, P = 0.38). The rate of fever (RR = 0.50, 95%CI: 0.27-0.91, P = 0.02), irritative bladder symptoms (RR = 0.69, 95%CI: 0.52-0.90, P = 0.007) and hematuria (RR = 0.50, 95%CI: 0.28-0.89, P = 0.02) were significantly decreased in patients treated with combination therapy compared to those with BCG alone. There were no statistically significant differences between combination therapy and BCG alone in toxicity (RR = 0.69, 95%CI: 0.34-1.40, P = 0.30), gastrointestinal reaction (RR = 2.54, 95%CI: 0.61-10.60, P = 0.20) or cystitis (RR = 0.67, 95%CI: 0.29-1.54, P = 0.34). Conclusions: Combined application of intravesical BCG and chemotherapy appears to be an effective treatment for patients with intermediate- to high-risk NMIBC, but not for those with tumor in situ alone or recurrent bladder cancer.
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Affiliation(s)
- Di Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ying-Hui Jin
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hong Weng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Qiao Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xian-Tao Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xing-Huan Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
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25
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Klaassen Z, Kamat AM, Kassouf W, Gontero P, Villavicencio H, Bellmunt J, van Rhijn BW, Hartmann A, Catto JW, Kulkarni GS. Treatment Strategy for Newly Diagnosed T1 High-grade Bladder Urothelial Carcinoma: New Insights and Updated Recommendations. Eur Urol 2018; 74:597-608. [DOI: 10.1016/j.eururo.2018.06.024] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/20/2018] [Indexed: 10/28/2022]
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26
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Abstract
PURPOSE OF REVIEW The optimal management of high-grade T1 (HGT1) urothelial carcinoma (UC) is complex given its high rate of recurrence, progression, and cancer-specific mortality as well as its clinical variability. Our current treatment paradigm has been supplemented by recent data describing the expanding options for salvage intravesical therapy, bladder preservation, and the promising role of molecular epidemiology. In the current review, we attempt to summarize and critically analyze these studies. RECENT FINDINGS Evidence describing new intravesical therapies has demonstrated an adequate safety profile and some efficacy in BCG-unresponsive patients who desire bladder preservation. However, response rates are still poor in this high-risk patient population, and it is important to keep these data in perspective when counseling patients. Concomitantly, the continued molecular characterization of non-muscle-invasive bladder cancer may suggest potential therapeutic targets as well as predictors of treatment response in the future. The integration of new intravesical therapies and molecular data into the current treatment paradigm for HGT1 urothelial carcinoma will be critical to improving oncologic outcomes in this particularly high-risk population.
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Affiliation(s)
- Peter A Reisz
- Department of Urology, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN, 37232, USA.
| | - Aaron A Laviana
- Department of Urology, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN, 37232, USA
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN, 37232, USA
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27
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Zhuo C, Li X, Zhuang H, Tian S, Cui H, Jiang R, Liu C, Tao R, Lin X. Evaluating the efficacy and safety of intravesical chemotherapies for non-muscle invasive bladder cancer: a network meta-analysis. Oncotarget 2018; 7:82567-82579. [PMID: 27788495 PMCID: PMC5347714 DOI: 10.18632/oncotarget.12856] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/04/2016] [Indexed: 11/25/2022] Open
Abstract
Various intravesical therapies have been introduced into clinical practices for controlling non-muscle invasive bladder cancer (NMIBC). However, evidence with respect to the efficacy and safety of those intravesical therapies is very limited. Hence, we present a network meta-analysis in order to address this limitation in the current literature. The primary outcomes were the risk of tumor recurrence (TR), tumor progression (TP) and disease-specific mortality (DM). Secondary outcomes included the risk of fever, cystitis and haematuria. Conventional pair-wise and network meta-analysis were both performed for each endpoint. The surface under the cumulative ranking curve (SUCRA) was incorporated in our analysis for ranking the corresponding intravesical instillation interventions. In total, 23 randomized clinical trials (RCTs) were finally included in our study after irrelevant papers were screened out. Results of network meta-analysis suggested that Epirubicin (EPI) was less preferable than Bacille Calmette Guerin (BCG), BCG+EPI, BCG+ Isoniazid (INH), BCG+ Mytomicin C (MMC), Gemcitabine (GEM) and MMC with respect to TR. As suggested by the corresponding ranking probabilities and SUCRA, incorporating EPI or MMC into BCG may enhance the efficacy of BCG monotherapy.
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Affiliation(s)
- Chuanjun Zhuo
- Department of Psychological Medicine, Wenzhou Seventh People's Hospital, Wenzhou, Zhejiang, 325005, China.,Department of Psychological Medicine, Jining Medical University, Jining, Shandong, 272067, China.,Department of Psychological Medicine, Tianjin Anding Hospital, Tianjin, 300222, China
| | - Xubin Li
- Department of Radiotherapy, Tianjin Cancer Institute & Hospital, Tianjin, 30000, China
| | - Hongqing Zhuang
- Department of Radiotherapy, Tianjin Cancer Institute & Hospital, Tianjin, 30000, China
| | - Shunli Tian
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin, 300075, China
| | - Hailong Cui
- Intensive Care Unit, Tianjin Medical University General Hospital, Tianjin, 300075, China
| | - Ronghuan Jiang
- Department of Psychological Medicine, Chinese PLA (People's Liberation Army) General Hospital; Chinese PLA (People's Liberation Army) Medical School, Beijing, 100853, China
| | - Chuanxin Liu
- Department of Psychological Medicine, Jining Medical University, Jining, Shandong, 272067, China
| | - Ran Tao
- Beijing Shijian Integrated Medicine Science Institute, Beijing, 100700, China
| | - Xiaodong Lin
- Department of Psychological Medicine, Wenzhou Seventh People's Hospital, Wenzhou, Zhejiang, 325005, China
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28
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Bhandari P, Novikova G, Goergen CJ, Irudayaraj J. Ultrasound beam steering of oxygen nanobubbles for enhanced bladder cancer therapy. Sci Rep 2018; 8:3112. [PMID: 29449656 PMCID: PMC5814559 DOI: 10.1038/s41598-018-20363-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 01/10/2018] [Indexed: 12/23/2022] Open
Abstract
New intravesical treatment approaches for bladder cancer are needed as currently approved treatments show several side effects and high tumor recurrence rate. Our study used MB49 murine urothelial carcinoma model to evaluate oxygen encapsulated cellulosic nanobubbles as a novel agent for imaging and ultrasound guided drug delivery. In this study, we show that oxygen nanobubbles (ONB) can be propelled (up to 40 mm/s) and precisely guided in vivo to the tumor by an ultrasound beam. Nanobubble velocity can be controlled by altering the power of the ultrasound Doppler beam, while nanobubble direction can be adjusted to different desired angles by altering the angle of the beam. Precise ultrasound beam steering of oxygen nanobubbles was shown to enhance the efficacy of mitomycin-C, resulting in significantly lower tumor progression rates while using a 50% lower concentration of chemotherapeutic drug. Further, dark field imaging was utilized to visualize and quantify the ONB ex vivo. ONBs were found to localize up to 500 µm inside the tumor using beam steering. These results demonstrate the potential of an oxygen nanobubble drug encapsulated system to become a promising strategy for targeted drug delivery because of its multimodal (imaging and oxygen delivery) and multifunctional (targeting and hypoxia programming) properties.
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Affiliation(s)
- Pushpak Bhandari
- Department of Agricultural and Biological Engineering, Purdue University, West Lafayette, Indiana, 47907, United States
- Purdue University Center for Cancer Research, West Lafayette, Indiana, 47907, United States
| | - Gloriia Novikova
- Davidson School of Chemical Engineering, Purdue University, West Lafayette, Indiana, 47907, United States
- Purdue University Center for Cancer Research, West Lafayette, Indiana, 47907, United States
| | - Craig J Goergen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, 47907, United States
- Purdue University Center for Cancer Research, West Lafayette, Indiana, 47907, United States
| | - Joseph Irudayaraj
- Department of Agricultural and Biological Engineering, Purdue University, West Lafayette, Indiana, 47907, United States.
- Purdue University Center for Cancer Research, West Lafayette, Indiana, 47907, United States.
- Department of Bioengineering, UIUC, Urbana, IL 61801, United States.
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29
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Deng T, Liu B, Duan X, Zhang T, Cai C, Zeng G. Systematic Review and Cumulative Analysis of the Combination of Mitomycin C plus Bacillus Calmette-Guérin (BCG) for Non-Muscle-Invasive Bladder Cancer. Sci Rep 2017; 7:3172. [PMID: 28600516 PMCID: PMC5466691 DOI: 10.1038/s41598-017-03421-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 05/05/2017] [Indexed: 11/08/2022] Open
Abstract
This systematic review and cumulative analysis aimed to explore the efficacy and safety of the combination of intravesical mitomycin C (MMC) plus bacillus Calmette-Guerin (BCG) for non-muscle-invasive bladder cancer (NMIBC) patients. A comprehensive literature search using Pubmed, Embase, Medline, Cochrane Library, CBM, CNKI and VIP databases was performed to identify studies applying intravesical MMC plus BCG therapy on NMIBC patients up to June 2016. Summarized unadjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to assess the efficacy and safety of the combination therapy. A total of 25 studies containing 2749 NMIBC patients were included in this systematic review. Compared with BCG monotherapy, the combination therapy could significantly reduce the tumor recurrence rate (OR = 0.64, 95% CI: 0.44-0.94, P = 0.02) and cancer-specific mortality (OR = 0.54, 95% CI: 0.34-0.87, P = 0.01), without more toxicities (OR = 0.58, 95% CI: 0.17-1.94, P = 0.37). The combination therapy could also lead to significant lower tumor recurrence rate than MMC monotherapy (OR = 0.41, 95% CI: 0.24-0.69, P = 0.0009). Our study indicates that the combination of MMC plus BCG instillation is an effective and safe adjuvant treatment for NMIBC patients.
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Affiliation(s)
- Tuo Deng
- Department of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Guangzhou Institute of Urology, Guangzhou, China
- Guangdong Key Laboratory of Urology, Guangzhou, China
| | - Bing Liu
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaolu Duan
- Department of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Guangzhou Institute of Urology, Guangzhou, China
- Guangdong Key Laboratory of Urology, Guangzhou, China
| | - Tao Zhang
- Department of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Guangzhou Institute of Urology, Guangzhou, China
- Guangdong Key Laboratory of Urology, Guangzhou, China
| | - Chao Cai
- Department of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Guangzhou Institute of Urology, Guangzhou, China
- Guangdong Key Laboratory of Urology, Guangzhou, China
| | - Guohua Zeng
- Department of Urology, Minimally Invasive Surgery Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
- Guangzhou Institute of Urology, Guangzhou, China.
- Guangdong Key Laboratory of Urology, Guangzhou, China.
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30
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Kates M, Nirschl T, Sopko NA, Matsui H, Kochel CM, Reis LO, Netto GJ, Hoque M, Hahn NM, McConkey DJ, Baras AS, Drake CG, Bivalacqua TJ. Intravesical BCG Induces CD4 + T-Cell Expansion in an Immune Competent Model of Bladder Cancer. Cancer Immunol Res 2017; 5:594-603. [PMID: 28588015 DOI: 10.1158/2326-6066.cir-16-0267] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 01/24/2017] [Accepted: 05/30/2017] [Indexed: 01/12/2023]
Abstract
Intravesical bacillus Calmette-Guérin (BCG) immunotherapy is the standard of care in treating non-muscle-invasive bladder cancer, yet its mechanism of action remains elusive. Both innate and adaptive immune responses have been implicated in BCG activity. Although prior research has indirectly demonstrated the importance of T cells and shown a rise in CD4+ T cells in bladder tissue after BCG, T-cell subpopulations have not been fully characterized. We investigated the relationship between effector and regulatory T cells in an immune competent, clinically relevant rodent model of bladder cancer. Our data demonstrate that cancer progression in the N-methyl-N-nitrosourea (MNU) rat model of bladder cancer was characterized by a decline in the CD8/FoxP3 ratio, consistent with decreased adaptive immunity. In contrast, treatment with intravesical BCG led to a large, transient rise in the CD4+ T-cell population in the urothelium and was both more effective and immunogenic compared with intravesical chemotherapy. Whole-transcriptome expression profiling of posttreatment intravesical CD4+ and CD8+ T cells revealed minimal differences in gene expression after BCG treatment. Together, our results suggest that although BCG induces T-cell recruitment to the bladder, the T-cell phenotype does not markedly change, implying that combining T-cell-activating agents with BCG might improve clinical activity. Cancer Immunol Res; 5(7); 594-603. ©2017 AACR.
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Affiliation(s)
- Max Kates
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - Thomas Nirschl
- Department of Immunology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nikolai A Sopko
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Hotaka Matsui
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christina M Kochel
- Department of Immunology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Leonardo O Reis
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - George J Netto
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Mohammad Hoque
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Noah M Hahn
- The Greenberg Bladder Cancer Institute, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David J McConkey
- The Greenberg Bladder Cancer Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alex S Baras
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland.,The Greenberg Bladder Cancer Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Charles G Drake
- Department of Immunology, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland.,The Greenberg Bladder Cancer Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
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31
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Hayne D, Stockler M, McCombie SP, Lawrence N, Martin A, Sengupta S, Davis ID. BCG + Mitomycin trial for high-risk non-muscle-invasive bladder cancer: progress report and lessons learned. BJU Int 2017; 119 Suppl 5:55-57. [PMID: 28391606 DOI: 10.1111/bju.13873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Dickon Hayne
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP), Camperdown, NSW, Australia.,University of Western Australia Medical School, Crawley, WA, Australia.,Fiona Stanley Hospital Urology, Murdoch, WA, Australia
| | - Martin Stockler
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP), Camperdown, NSW, Australia.,NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Steve P McCombie
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP), Camperdown, NSW, Australia.,Fiona Stanley Hospital Urology, Murdoch, WA, Australia
| | - Nicola Lawrence
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP), Camperdown, NSW, Australia.,NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Andrew Martin
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP), Camperdown, NSW, Australia.,NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Shomik Sengupta
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP), Camperdown, NSW, Australia.,Department of Urology, Austin Health, Melbourne, Vic., Australia.,Austin Department of Surgery, University of Melbourne, Melbourne, Vic., Australia.,Ludwig Institute for Cancer Research, Austin Hospital, Melbourne, Vic., Australia
| | - Ian D Davis
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP), Camperdown, NSW, Australia.,Monash University Eastern Health Clinical School, Box Hill, Vic., Australia
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New developments in the management of nonmuscle invasive bladder cancer. Curr Opin Oncol 2017; 29:179-183. [PMID: 28282341 DOI: 10.1097/cco.0000000000000362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW In this review, we summarize the core principles in the management of nonmuscle invasive bladder cancer (NMIBC) with an emphasis on new developments that have emerged over the last year. RECENT FINDINGS NMIBC has a propensity to recur and progress. Risk stratification has facilitated appropriate patient selection for treatment but improved tools, including biomarkers, are still needed. Enhanced cystoscopy with photodynamic imaging and narrow band imaging show promise for diagnosis, risk stratification, and disease monitoring and has been formally recommended this year by the American Urological Association. Attempts at better treatment, especially in refractory high-risk cases, include the addition of intravesical hyperthermia, combination and sequential therapy with existing agents, and the use of novel agents such as mycobacterial cell wall extract. New data are emerging regarding the potential role of early cystectomy in bacillus Calmette-Guerin-refractory NMIBC patients. SUMMARY NMIBC represents an assortment of disease states and continues to pose management challenges. Continued research is needed to bolster the evidence needed for patients and providers to make data-driven treatment decisions.
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Babjuk M, Böhle A, Burger M, Capoun O, Cohen D, Compérat EM, Hernández V, Kaasinen E, Palou J, Rouprêt M, van Rhijn BW, Shariat SF, Soukup V, Sylvester RJ, Zigeuner R. EAU Guidelines on Non–Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol 2017; 71:447-461. [DOI: 10.1016/j.eururo.2016.05.041] [Citation(s) in RCA: 1330] [Impact Index Per Article: 190.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 05/30/2016] [Indexed: 12/15/2022]
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Mitomycin C: new strategies to improve efficacy of a well-known therapy. Urologia 2016; 83:24-28. [PMID: 27647081 DOI: 10.5301/uro.5000193] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2016] [Indexed: 11/20/2022]
Abstract
Mitomycin C (MMC) as an intravesical chemotherapeutic agent is a well-known option for treatment of nonmuscle invasive bladder cancer (NMIBC) recurrence; it is probably the most commonly used agent given its low rate of side effects and its efficacy.Both the American Urologic Association (AUA) and European Association of Urology (EAU) consider MMC as a standard treatment for immediate single-dose postoperative treatment and for adjuvant therapy in low and intermediate-risk NMIBC.Despite the popularity of this agent in the treatment of NMIBCs, many questions regarding the optimal approach to MMC therapy remain unanswered and the schedule widely used is empirical.Nevertheless, even when the current optimal approaches to MMC administration are used, a large proportion of NMIBCs recur.This apparent treatment resistance might be overcome by an optimization of standard MMC therapy or with a combination of MMC with other agents that have different mechanisms of action.Strategies to enhance passive delivery of MMC have been well studied and multiple measures are recommended for implementation of use in routine clinical practice.A modified scheme of instillation seems to be an easy and inexpensive alternative to increase efficacy of intravesical MMC and to also use this agent with an ablative intent.Enhancing tumor response with a sequential therapy is another option that has been investigated, mostly for chemo-immunotherapy wherein the different mechanisms of action of Bacillus of Calmette and Guerìn (BCG) and MMC are combined to achieve a higher response.
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Kaasinen E, Wijkström H, Rintala E, Mestad O, Jahnson S, Malmström PU. Seventeen-year follow-up of the prospective randomized Nordic CIS study: BCG monotherapy versus alternating therapy with mitomycin C and BCG in patients with carcinomain situof the urinary bladder. Scand J Urol 2016; 50:360-8. [DOI: 10.1080/21681805.2016.1210672] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Intravesical Bacillus Calmette-Guérin Versus Combination of Epirubicin and Interferon-α2a in Reducing Recurrence of Non–Muscle-invasive Bladder Carcinoma: FinnBladder-6 Study. Eur Urol 2016; 70:341-7. [DOI: 10.1016/j.eururo.2016.03.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/26/2016] [Indexed: 11/18/2022]
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Abstract
PURPOSE OF REVIEW This article reviews the natural biology of noninvasive bladder cancer and its management strategies while summarizing the most recent advances in the field. RECENT FINDINGS Nonmuscle invasive bladder cancer (NMIBC) has a tendency to recur and progress. Risk stratification has helped triage patients but improved tools, including biomarkers, are still needed. Enhanced endoscopy with photodynamic imaging, narrow band imaging, optical coherence tomography and confocal laser endomicroscopy show promise for diagnosis, risk stratification and disease monitoring. Attempts at better treatment, especially in refractory high-risk cases, include the addition of intravesical hyperthermia, combination and sequential therapy with existing agents and the use of novel agents such as mycobacterial cell wall extract. New data are emerging regarding the potential role of active surveillance in low-risk patients. SUMMARY NMIBC represents a variety of disease states and continues to pose management challenges. As our understanding of tumor biology improves and technology advances, achieving better outcomes through individualized care may be possible.
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Gan C, Amery S, Chatterton K, Khan MS, Thomas K, O'Brien T. Sequential bacillus Calmette-Guérin/Electromotive Drug Administration of Mitomycin C as the Standard Intravesical Regimen in High Risk Nonmuscle Invasive Bladder Cancer: 2-Year Outcomes. J Urol 2016; 195:1697-703. [PMID: 26845426 DOI: 10.1016/j.juro.2016.01.103] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE Sequential bacillus Calmette-Guérin/electromotive drug administration of mitomycin C is reported to be superior to bacillus Calmette-Guérin alone but it has not been widely adopted. We aimed to determine the efficacy and tolerability of sequential bacillus Calmette-Guérin/electromotive drug administration of mitomycin C in high risk, nonmuscle invasive bladder cancer. MATERIALS AND METHODS Starting in 2009 bacillus Calmette-Guérin/electromotive drug administration of mitomycin C was introduced as the standard induction regime in patients with high risk, nonmuscle invasive bladder cancer undergoing bladder conservation. As induction bacillus Calmette-Guérin was administered in weeks 1 and 2. Mitomycin C was administered in electromotive fashion (40 mg and 20 mA current for 30 minutes) in week 3 and repeated thrice for a total of 9 weeks. As maintenance 3 doses of bacillus Calmette-Guérin were given 3 months after induction and then every 6 months for 3 years. Outcome measures were disease recurrence at first check, 1 and 2-year cystoscopy, and treatment tolerability. RESULTS Of the 151 patients with high risk, nonmuscle invasive bladder cancer treated between June 2009 and 2013, 44 underwent primary cystectomy and 107 received sequential bacillus Calmette-Guérin/electromotive drug administration of mitomycin C. Disease was high grade Ta/T1 in 86 patients (80%), of whom 34 (32%) also had carcinoma in situ. A total of 19 patients (18%) had primary carcinoma in situ and 2 had recurrent large volume, low grade disease. Of 107 patients 104 underwent first check cystoscopy, including 90 (87%) who were clear. Of the 90 complete responders 86 underwent 1-year cystoscopy, including 74 (86%) who were recurrence-free. Of the 74 patients 71 underwent 2-year cystoscopy, of whom 66 (93%) remained recurrence-free. The full induction schedule was not completed in 30 patients (28%), including 16 and 14 with minor and major schedule alterations, respectively. There was no difference in recurrence between patients who received a full vs a reduced induction schedule. CONCLUSIONS This study confirms the excellent oncologic efficacy of sequential bacillus Calmette-Guérin/electromotive drug administration of mitomycin C in cases of high risk, nonmuscle invasive bladder cancer. Tolerability is a challenge but alterations to the 9-week schedule appeared to have a negligible impact on outcomes.
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Affiliation(s)
- Christine Gan
- Urology Centre, Guy's and St. Thomas' National Health Service Trust, London, United Kingdom.
| | - Suzanne Amery
- Urology Centre, Guy's and St. Thomas' National Health Service Trust, London, United Kingdom
| | - Kathryn Chatterton
- Urology Centre, Guy's and St. Thomas' National Health Service Trust, London, United Kingdom
| | - Muhammad Shamim Khan
- Urology Centre, Guy's and St. Thomas' National Health Service Trust, London, United Kingdom
| | - Kay Thomas
- Urology Centre, Guy's and St. Thomas' National Health Service Trust, London, United Kingdom
| | - Tim O'Brien
- Urology Centre, Guy's and St. Thomas' National Health Service Trust, London, United Kingdom
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Cui J, Wang W, Chen S, Chen P, Yang Y, Guo Y, Zhu Y, Chen F, Shi B. Combination of Intravesical Chemotherapy and Bacillus Calmette-Guerin Versus Bacillus Calmette-Guerin Monotherapy in Intermediate- and High-risk Nonmuscle Invasive Bladder Cancer: A Systematic Review and Meta-analysis. Medicine (Baltimore) 2016; 95:e2572. [PMID: 26817914 PMCID: PMC4998288 DOI: 10.1097/md.0000000000002572] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Urothelial carcinoma of the bladder has become a major cause of morbidity, mortality, and health-related costs. There is still no standard instillation therapy against bladder cancer. A meta-analysis was conducted to evaluate the efficacy and toxicity of adding chemotherapy to Bacillus Calmette-Guerin (BCG) in intermediate- and high-risk nonmuscle invasive bladder cancer (NMIBC).All randomized controlled trials (RCTs) that evaluated the efficacy of combination therapy and BCG monotherapy for intermediate- and high-risk NMIBC were comprehensively searched. Relevant databases, including PubMed, Embase, Cochrane Central Register of Controlled trials databases, and American Society of Clinical Oncology (http://www.asco.org/ASCO), the clinical trial registration website (ClinicalTrials.gov), and relevant trials from the references of selected studies were searched from initial state up to June 6, 2015. Random-effects model was used to estimate hazard ratios (HRs) statistics. All statistical analyses were performed by STATA (version 13.0, College Station, TX).Seven studies, including 1373 patients with intermediate- and high-risk NMIBC, were identified. For disease-free survival, the pooled HRs from all studies was 0.69 (95% confidence interval [CI], 0.48-1.00; P = 0.048). The disease-free survival benefit was more apparent among patients with intermediate-risk NMIBC (P = 0.002) or Ta/T1 with/without carcinoma in situ (P < 0.01). In subgroup analysis, a significant reduction in recurrence was found in studies that explored the influence of a perioperative single dose instillation compared with delayed BCG monotherapy (HR = 0.60; 95% CI, 0.38-0.92; P = 0.021). No significant difference was found for progression-free survival (HR = 0.78; 95% CI, 0.43-1.44; P = 0.435).Patients with intermediate- and high-risk NMIBC who underwent combination therapy achieved lower rates of recurrence than those who underwent BCG therapy alone. No difference in progression-free survival was found between the 2 different therapy schedules. Better efficacy for a perioperative single dose instillation compared with delayed BCG monotherapy was found in this meta-analysis.
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Affiliation(s)
- Jianfeng Cui
- From the Department of Urology, Qilu Hospital of Shandong University (JC, SC, YY, YZ, FC, BS); Department of Endocrinology and Metabolism, Shandong Provincial Hospital affiliated to Shandong University (WW); Department of Radiation Oncology, Qilu Hospital of Shandong University (PC); and Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, People's Republic of China (YG)
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Tang DH, Chang SS. Management of carcinoma in situ of the bladder: best practice and recent developments. Ther Adv Urol 2015; 7:351-64. [PMID: 26622320 DOI: 10.1177/1756287215599694] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Management of carcinoma in situ of the bladder remains a complex and challenging endeavor due to its high rate of recurrence and progression. Although it is typically grouped with other nonmuscle invasive bladder cancers, its higher grade and aggressiveness make it a unique clinical entity. Intravesical bacillus Calmette-Guérin is the standard first-line treatment given its superiority to other agents. However, high rates of bacillus Calmette-Guérin failure highlight the need for additional therapies. Radical cystectomy has traditional been the standard second-line therapy, but additional intravesical therapies may be more appealing for non-surgical candidates and patients refusing cystectomy. The subject of this review is the treatment strategies and available therapies currently available for carcinoma in situ of the bladder. It discusses alternative intravesical treatment options for patients whose condition has failed to respond to bacillus Calmette-Guérin therapy and who are unfit or unwilling to undergo cystectomy.
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Affiliation(s)
- Dominic H Tang
- Department of Urologic Surgery, Vanderbilt University Medical Center, MCN A-1302, Nashville, TN 37027, USA
| | - Sam S Chang
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Porten SP, Leapman MS, Greene KL. Intravesical chemotherapy in non-muscle-invasive bladder cancer. Indian J Urol 2015; 31:297-303. [PMID: 26604440 PMCID: PMC4626913 DOI: 10.4103/0970-1591.166446] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Non-muscle-invasive bladder cancer (NMIBC) is characterized by a tendency for recurrence and capacity for progression. Intravesical instillation therapy has been employed in various clinical settings, which are summarized within this review. Several chemotherapeutic agents have shown clinical efficacy in reducing recurrence rates in the post-transurethral resection of bladder tumor (TURBT) setting, including mitomycin C (MMC), doxorubicin, and epirubicin. Mounting evidence also supports the use of intravesical MMC following nephroureterectomy to reduce later urothelial bladder recurrence. In the adjuvant setting, bacillus Calmette-Guérin (BCG) immunotherapy is an established first-line agent in the management of carcinoma in situ (CIS) and high-grade non muscle invasive urothelial carcinoma (UC). Among high and intermediate-risk patients (based on tumor grade, size, and focality) improvements in disease-free intervals have been seen with adjunctive administration of MMC prior to scheduled BCG dosing. Following failure of first-line intravesical therapy, gemcitabine and valrubicin have demonstrated modest activity, though valrubicin remains the only agent currently Food and Drug Administration (FDA)-approved for the treatment of BCG-refractory CIS. Techniques to optimize intravesical chemotherapy delivery have also been explored including pharmacokinetic methods such as urinary alkalization and voluntary dehydration. Chemohyperthermia and electromotive instillation have been associated with improved freedom from recurrence intervals but may be associated with increased urinary toxicity. Improvements in therapeutic selection may be heralded by novel opportunities for genomic profiling and refinements in clinical risk stratification.
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Affiliation(s)
- Sima P Porten
- Department of Urology, University of California, San Francisco, California, USA
| | - Michael S Leapman
- Department of Urology, University of California, San Francisco, California, USA
| | - Kirsten L Greene
- Department of Urology, University of California, San Francisco, California, USA
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Järvinen R, Marttila T, Kaasinen E, Rintala E, Aaltomaa S, Kallio J, Liukkonen T, Puolakka VM, Seppänen M, Tuhkanen K, Vaarala M, Viitanen J, Boström PJ. Long-term Outcome of Patients with Frequently Recurrent Non–muscle-invasive Bladder Carcinoma Treated with One Perioperative Plus Four Weekly Instillations of Mitomycin C Followed by Monthly Bacillus Calmette-Guérin (BCG) or Alternating BCG and Interferon-α2b Instillations: Prospective Randomised FinnBladder-4 Study. Eur Urol 2015; 68:611-7. [DOI: 10.1016/j.eururo.2015.02.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 02/18/2015] [Indexed: 11/16/2022]
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Ekin RG, Akarken I, Zorlu F, Tarhan H, Kucuk U, Yildirim Z, Divrik RT. Intravesical bacillus Calmette-Guérin versus chemohyperthermia for high-risk non-muscle-invasive bladder cancer. Can Urol Assoc J 2015; 9:E278-83. [PMID: 26029295 DOI: 10.5489/cuaj.2708] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Patients with high-risk non-muscle invasive bladder cancer (NMIBC) need adjuvant intravesical treatment after surgery. Although bacillus Calmette-Guérin (BCG) is highly effective, new adjuvant treatments to decrease recurrences and toxicity have been studies. We performed a retrospective propensity score-matched study to compare the efficacy of BCG and chemohyperthermia (C-HT). METHODS We included 1937 patients diagnosed with bladder cancer between January 2004 and January 2014. The primary efficacy endpoint was recurrence-free interval. Patients treated with C-HT were matched with patients treated with BCG using propensity score-matched analysis. Cox-regression models were used to estimate the association between intravesical treatments and the presence of recurrence and progression. RESULTS Of the 710 patients treated with intravesical treatments, 40 and 142 were eligible for inclusion in C-HT and BCG groups, respectively. Following case matching, there were no differences in patient or tumour characteristics between treatment groups. The 2-year recurrence-free interval in C-HT and BCG groups were 76.2% and 93.9%, respectively (p = 0.020). C-HT treatment (hazard ratio [HR] 5.42; 95% confidence interval [CI] 1.11-26.43; p = 0.036) and high-grade tumour (HR 4.60; 95% CI 1.01-20.88; p = 0.048) are associated with an elevated odds of tumour recurrence. In multivariate Cox-regression analysis, there was no significant difference between C-HT and BCG in the odds of recurrence (p = 0.054). There were no differences in progression between C-HT and BCG. CONCLUSION C-HT is not as effective treatment as BCG in high-risk NMIBC patients who are BCG-naive. Although, there were no significant difference in the odds of recurrence, recurrence-free interval is significantly improved by the administration of BCG.
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Affiliation(s)
- Rahmi Gokhan Ekin
- Tepecik Teaching and Research Hospital, Department of Urology, Turkey
| | | | - Ferruh Zorlu
- Tepecik Teaching and Research Hospital, Department of Urology, Turkey
| | - Huseyin Tarhan
- Tepecik Teaching and Research Hospital, Department of Urology, Turkey
| | - Ulku Kucuk
- Tepecik Teaching and Research Hospital, Department of Pathology, Turkey
| | - Zubeyde Yildirim
- Tepecik Teaching and Research Hospital, Department of Pathology, Turkey
| | - Rauf Taner Divrik
- Department of Urology, Sifa University, Faculty of Medicine, Izmir, Turkey
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Oosterlinck W, Decaestecker K. The Correct Sequence of Intravesical Chemotherapy and Bacillus Calmette-Guérin for Non–Muscle-invasive Bladder Cancer. Eur Urol 2015; 67:517-8. [DOI: 10.1016/j.eururo.2014.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 11/12/2014] [Indexed: 11/25/2022]
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Svatek RS, Zhao XR, Morales EE, Jha MK, Tseng TY, Hugen CM, Hurez V, Hernandez J, Curiel TJ. Sequential intravesical mitomycin plus Bacillus Calmette-Guérin for non-muscle-invasive urothelial bladder carcinoma: translational and phase I clinical trial. Clin Cancer Res 2014; 21:303-11. [PMID: 25424854 DOI: 10.1158/1078-0432.ccr-14-1781] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the safety and toxicities of sequential MMC (mitomycin C) + BCG (bacillus Calmette-Guérin) in patients with non-muscle-invasive bladder cancer (NMIBC) and explore evidence for potentiation of BCG activity by MMC. EXPERIMENTAL DESIGN A 3 + 3 phase I dose-escalation trial of six weekly treatments was conducted in patients with NMIBC. MMC (10, 20, or 40 mg) was instilled intravesically for 30 minutes, followed by a 10-minute washout with gentle saline irrigation and then instillation of BCG (half or full strength) for 2 hours. Urine cytokines were monitored and compared with levels in a control cohort receiving BCG only. Murine experiments were carried out as described previously. RESULTS Twelve patients completed therapy, including 3 patients receiving full doses. The regimen was well tolerated with no treatment-related dose-limiting toxicities. Urinary frequency and urgency, and fatigue were common. Eleven (91.7%) patients were free of disease at a mean (range) follow-up of 21.4 (8.4-27.0) months. Median posttreatment urine concentrations of IL2, IL8, IL10, and TNFα increased over the 6-week treatment period. A greater increase in posttreatment urinary IL8 during the 6-week period was observed in patients receiving MMC + BCG compared with patients receiving BCG monotherapy. In mice, intravesical MMC + BCG skewed tumor-associated macrophages (TAM) toward a beneficial M1 phenotype. CONCLUSIONS Instillation of sequential MMC + BCG is safe tolerable up to 40-mg MMC plus full-strength BCG. This approach could provide improved antitumor activity over BCG monotherapy by augmenting beneficial M1 TAMs.
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Affiliation(s)
- Robert S Svatek
- The Cancer Therapy and Research Center/Adult Cancer Program, The University of Texas Health Science Center San Antonio, San Antonio, Texas. Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas.
| | - Xiang Ru Zhao
- The Cancer Therapy and Research Center/Adult Cancer Program, The University of Texas Health Science Center San Antonio, San Antonio, Texas. Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Edwin E Morales
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Mithilesh K Jha
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Timothy Y Tseng
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Cory M Hugen
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Vincent Hurez
- Department of Medical Oncology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Javier Hernandez
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Tyler J Curiel
- The Cancer Therapy and Research Center/Adult Cancer Program, The University of Texas Health Science Center San Antonio, San Antonio, Texas. Department of Medical Oncology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
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