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Knorr J, Lone Z, Werneburg G, Adler A, Agudelo J, Suryavanshi M, Campbell RA, Ericson K, Qiu H, Bajic P, Haber GP, Weight CJ, Ahern PP, Almassi N, Miller AW, Lee BH. An exploratory study investigating the impact of the bladder tumor microbiome on Bacillus Calmette Guerin (BCG) response in non-muscle invasive bladder cancer. Urol Oncol 2024; 42:291.e1-291.e11. [PMID: 38664180 DOI: 10.1016/j.urolonc.2024.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/29/2024] [Accepted: 04/09/2024] [Indexed: 06/23/2024]
Abstract
PURPOSE Intravesical Bacillus Calmette-Guerin (BCG) is standard of care for intermediate- and high-risk non-muscle invasive bladder cancer (NMIBC). The effect of the bladder microbiome on response to BCG is unclear. We sought to characterize the microbiome of bladder tumors in BCG-responders and non-responders and identify potential mechanisms that drive treatment response. MATERIALS AND METHODS Patients with archival pre-treatment biopsy samples (2012-2018) were identified retrospectively. Prospectively, urine and fresh tumor samples were collected from individuals with high-risk NMIBC (2020-2023). BCG response was defined as tumor-free 2 years from induction therapy. Extracted DNA was sequenced for 16S rRNA and shotgun metagenomics. Primary outcomes were species richness (α-diversity) and microbial composition (β-diversity). Paired t-tests were performed for α-diversity (Observed species/Margalef). Statistical analysis for β-diversity (weighted and unweighted UniFrac distances, weighted Bray-Curtis dissimilarity) were conducted through Permanova, with 999 permutations. RESULTS Microbial species richness (P < 0.001) and composition (P = 0.001) differed between BCG responders and non-responders. Lactobacillus spp. were significantly enriched in BCG-responders. Shotgun metagenomics identified possible mechanistic pathways such as assimilatory sulfate reduction. CONCLUSION A compositional difference exists in the tumor microbiome of BCG responders and non-responders with Lactobacillus having increased abundance in BCG responders.
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Affiliation(s)
- Jacob Knorr
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH
| | - Zaeem Lone
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Glenn Werneburg
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH
| | - Ava Adler
- Cleveland Clinic Lerner Research Institute, Cleveland, OH
| | - Jose Agudelo
- Cleveland Clinic Lerner Research Institute, Cleveland, OH
| | | | - Rebecca A Campbell
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH
| | - Kyle Ericson
- Univeristy Hospitals Department of Urology, Cleveland, OH
| | - Hong Qiu
- Cleveland Clinic Lerner Research Institute, Cleveland, OH
| | - Petar Bajic
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH
| | | | | | - Philip P Ahern
- Cleveland Clinic Lerner Research Institute, Cleveland, OH
| | - Nima Almassi
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH
| | - Aaron W Miller
- Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH; Cleveland Clinic Lerner Research Institute, Cleveland, OH.
| | - Byron H Lee
- University of Texas MD Anderson Cancer Center, Houston, TX.
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Tan X, Liu Z, Cai T, Wang Y, Wu Z, Qin Z, Li Z, Liu Z, Yuan G, Zhou Q, Yao K. Prognostic Significance of HER2 Expression in Patients with Bacillus Calmette-Guérin-exposed Non-muscle-invasive Bladder Cancer. Eur Urol Oncol 2024; 7:760-769. [PMID: 37884420 DOI: 10.1016/j.euo.2023.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/07/2023] [Accepted: 10/06/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Guidelines recommend intravesical instillation of bacillus Calmette-Guérin (BCG) as the first-choice treatment for intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC). However, there is no therapeutic biomarker for predicting BCG efficacy, especially in high-risk cases with high failure rates. HER2 expression is considered a prognostic factor for bladder cancer. OBJECTIVE To elucidate the predictive value and significance of HER2 expression in patients with BCG-exposed NMIBC. DESIGN, SETTING, AND PARTICIPANTS A total of 454 patients with NMIBC were included. All patients started BCG intravesical instillation (1.2 × 108 CFU, strain D2PB302) 2-6 wk after transurethral resection of bladder tumor and received 19 treatments over a period of 1 yr. HER2 immunohistochemistry (IHC) results available for 314 patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The outcomes investigated were recurrence-free survival (RFS) and progression-free survival (PFS). Outcome relationships were explored using multivariable Cox regression and log-rank analysis. RESULTS AND LIMITATIONS In the IHC population, 35.7% of patients had HER2 overexpression (IHC score 2/3+). This group had a poor 5-yr RFS rate of 16.5%, in comparison to 68.0% in the group with low HER2 expression (p < 0.001). Patients with high-risk NMIBC and HER2 overexpression had the highest risk of BCG treatment failure, with 5-yr RFS and PFS rates of 19.0% and 58.2%, respectively. Conversely, HER2-negative (IHC score 0) patients with high-risk NMIBC experienced a long-term BCG benefit, with 5-yr RFS and PFS rates of 80.8% and 92.1%, respectively. Limitations include the retrospective study design and the limited details regarding BCG use. CONCLUSIONS HER2 was an independent predictor of poor BCG efficacy in NMIBC. Patients with high-risk NMIBC and HER2 overexpression had the highest risk of disease recurrence and progression after exposure to BCG. Anti-HER2 targeted therapies could be considered for these patients. PATIENT SUMMARY Measurement of blood levels of the protein HER2 can be used to predict outcomes after BCG (bacillus Calmette-Guérin) bladder therapy for patients with intermediate- or high-risk non-muscle-invasive bladder cancer. Measurement results for HER2 may help in guiding personalized treatment for these patients.
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Affiliation(s)
- Xingliang Tan
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in Southern China, Guangzhou, China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Zhicheng Liu
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in Southern China, Guangzhou, China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Taonong Cai
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in Southern China, Guangzhou, China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Yanjun Wang
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in Southern China, Guangzhou, China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Zhiming Wu
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in Southern China, Guangzhou, China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Zike Qin
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in Southern China, Guangzhou, China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Zhiyong Li
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in Southern China, Guangzhou, China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Zhenhua Liu
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in Southern China, Guangzhou, China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Gangjun Yuan
- Department of Urology Oncological Surgery, Chongqing University Cancer Hospital, Chongqing, China; Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China.
| | - Qianghua Zhou
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in Southern China, Guangzhou, China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, China.
| | - Kai Yao
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in Southern China, Guangzhou, China; Collaborative Innovation Center of Cancer Medicine, Guangzhou, China.
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Abou Heidar N, Mahmood AW, Khan M, Harrington G, Ahmad A, Abdelhaq D, Colan N, Whitt J, Sullivan D, Howlader M, Plecas Z, Ahmed Z, Jing Z, Li Q, Guru KA, Hussein AA. Does Ta Low-grade Urothelial Carcinoma of the Bladder With Focal High-grade Features Carry Worse Prognosis? The Roswell Park Comprehensive Cancer Center Experience. Urology 2024:S0090-4295(24)00481-3. [PMID: 38914229 DOI: 10.1016/j.urology.2024.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/21/2024] [Accepted: 06/13/2024] [Indexed: 06/26/2024]
Abstract
OBJECTIVE To describe the management and outcomes of patients with Ta predominantly low-grade urothelial carcinoma with focal high-grade features (FHG) (<5%), compared to those with Ta low grade (LG) and Ta high grade (HG). METHODS Retrospective review of all patients who underwent transurethral resection of bladder tumor between 2005 and 2023. Patients with Ta disease were identified and categorized into LG, FHG, and HG. Kaplan Meier method was used to depict high-grade recurrence, T-stage progression, and radical cystectomy-free survival. RESULTS Four hundred forty-nine patients with Ta disease were identified (LG 48%, FHG 12%, and HG 40%). Patients with FHG (32%) had a second-look transurethral resection of bladder tumor more frequently compared to LG (7%) and HG (29%) (P <.01). They received intravesical therapy more frequently compared to LG (36% vs 20%) but lower than HG (55%) (P <.01). They received radical cystectomy less frequently (7% compared to 20% for HG and 11% for LG, P = .01). HG recurrence-free survival at 1, 3, and 5years was HG (68%, 52%, and 43%), FHG (74%, 53%, and 49%), and LG (87%, 79%, and 73%) (log-rank P <.01). T progression-free survival at 1, 3, and 5years was HG (84%, 77%, and 70%), FHG (92%, 82%, and 82%), and LG (94%, 89%, and 85%) (log-rank P = .02). Cystectomy-free survival at 1, 3, and 5years was HG (92%, 84%, and 80%), FHG (96%, 94%, and 94%), and LG (99%, 95%, and 92%) (log-rank P <.01). CONCLUSION Patients with Ta FHG seem to behave more like Ta HG disease in terms of high-grade recurrences, but they are less likely to experience T-stage progression and convert to cystectomy.
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Affiliation(s)
- Nassib Abou Heidar
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Abdul Wasay Mahmood
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Mohammad Khan
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Grace Harrington
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Ali Ahmad
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Dawod Abdelhaq
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Nicholas Colan
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Jor'Dan Whitt
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Daniel Sullivan
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Muhsinah Howlader
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Zachary Plecas
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Zaineb Ahmed
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Zhe Jing
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Qiang Li
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Khurshid A Guru
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Ahmed A Hussein
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY.
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Biswas K, Biswas L, Gangopadhyay S, Jana A, Basak T, Manna D, Mandal S. Clinico-demographic Profile of Carcinoma Urinary Bladder-5-Year Experience from a Tertiary Care Centre of Eastern India. Indian J Surg Oncol 2024; 15:206-212. [PMID: 38741638 PMCID: PMC11088605 DOI: 10.1007/s13193-023-01861-2] [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: 05/17/2023] [Accepted: 12/06/2023] [Indexed: 05/16/2024] Open
Abstract
Urinary bladder carcinoma is a disease of the elderly and often presents at an advanced stage due to ignorance and manifestation of symptoms at later stages of the disease. In India, very little data is available regarding the clinico-epidemiological pattern of urinary bladder cancers. In this study, we analysed the clinico-demographic profile of patients with urinary bladder carcinoma, attending a tertiary care centre in Eastern India over the last 5 years. We analysed the database of Oncology OPD of a tertiary care centre in West Bengal in Eastern India and collected the demographic, clinical and treatment data of urinary bladder carcinoma patients who attended our OPD between 2017 and 2021. The objective was to assess the demographic and clinical profile of these patients and compare them with those reported from other parts of India as well as the rest of the world. Majority of patients (70%) were above 50 years of age with a strikingly huge male predominance (male:female = 6.6:1). Transitional cell carcinoma (TCC) was the most common (90%) histology. 67.2% of the cases were muscle-invasive disease at presentation, and 19.3% of the patients presented with metastatic disease with bone (42%) as the most common site of metastasis. Overall, around 22% of patients underwent surgery either with definitive or palliative intent. Sixty-five percent of the patients who received radiotherapy underwent definitive radiation as a part of bladder preservation protocol. Thirty-five percent of all patients received chemotherapy; most of them (50.5%) received chemotherapy as neoadjuvant treatment before definitive therapy. To conclude, it can be said that this study is one of its first from Eastern India and will act as a stepping stone for future studies concentrating on clinico-epidemiological profile, early diagnosis and treatment of carcinoma urinary bladder.
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Affiliation(s)
- Koustav Biswas
- Department of Radiotherapy, Nilratan Sircar Medical College and Hospital, AJC Bose Road, Kolkata, 700014 West Bengal India
| | - Linkon Biswas
- Department of Radiotherapy, Nilratan Sircar Medical College and Hospital, AJC Bose Road, Kolkata, 700014 West Bengal India
| | - Soham Gangopadhyay
- Department of Radiotherapy, Nilratan Sircar Medical College and Hospital, AJC Bose Road, Kolkata, 700014 West Bengal India
| | - Arpan Jana
- Department of Radiotherapy, Nilratan Sircar Medical College and Hospital, AJC Bose Road, Kolkata, 700014 West Bengal India
| | - Tanmoy Basak
- Department of Radiotherapy, Nilratan Sircar Medical College and Hospital, AJC Bose Road, Kolkata, 700014 West Bengal India
| | - Debojyoti Manna
- Department of Radiotherapy, Nilratan Sircar Medical College and Hospital, AJC Bose Road, Kolkata, 700014 West Bengal India
| | - Srikrishna Mandal
- Department of Radiotherapy, Nilratan Sircar Medical College and Hospital, AJC Bose Road, Kolkata, 700014 West Bengal India
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Daman AW, Antonelli AC, Redelman-Sidi G, Paddock L, Cheong JG, Jurado LF, Benjamin A, Jiang S, Ahimovic D, Khayat S, Bale MJ, Loutochin O, McPherson VA, Pe'er D, Divangahi M, Pietzak E, Josefowicz SZ, Glickman M. Microbial cancer immunotherapy reprograms hematopoietic stem cells to enhance anti-tumor immunity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.21.586166. [PMID: 38562703 PMCID: PMC10983927 DOI: 10.1101/2024.03.21.586166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Mycobacterium bovis BCG is the vaccine against tuberculosis and an immunotherapy for bladder cancer. When administered intravenously, BCG reprograms bone marrow hematopoietic stem and progenitor cells (HSPCs), leading to heterologous protection against infections. Whether HSPC-reprogramming contributes to the anti-tumor effects of BCG administered into the bladder is unknown. We demonstrate that BCG administered in the bladder in both mice and humans reprograms HSPCs to amplify myelopoiesis and functionally enhance myeloid cell antigen presentation pathways. Reconstitution of naive mice with HSPCs from bladder BCG-treated mice enhances anti-tumor immunity and tumor control, increases intratumor dendritic cell infiltration, reprograms pro-tumorigenic neutrophils, and synergizes with checkpoint blockade. We conclude that bladder BCG acts systemically, reprogramming HSPC-encoded innate immunity, highlighting the broad potential of modulating HSPC phenotypes to improve tumor immunity.
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Gupta S, Yadav S, Kumar P. Efficacy of Bacillus Calmette-Guérin in Cancer Prevention and Its Putative Mechanisms. J Cancer Prev 2024; 29:6-15. [PMID: 38567111 PMCID: PMC10982520 DOI: 10.15430/jcp.23.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/31/2024] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
Bacillus Calmette-Guérin (BCG) is an attenuated strain of Mycobacterium bovis. Although it was developed as a prophylactic vaccine against tuberculosis (TB), researchers have also evaluated it for preventing cancer development or progression. These studies were inspired by the available data regarding the protective effects of microbial infection against cancers and an inverse relationship between TB and cancer mortality. Initial studies demonstrated the efficacy of BCG in preventing leukemia, melanoma and a few other cancers. However, mixed results were observed in later studies. Importantly, these studies have led to the successful use of BCG in the tertiary prevention of non-muscle invasive bladder cancer, wherein BCG therapy has been found to be more effective than chemotherapy. Moreover, in a recently published 60-year follow-up study, childhood BCG vaccination has been found to significantly prevent lung cancer development. In the present manuscript, we reviewed the studies evaluating the efficacy of BCG in cancer prevention and discussed its putative mechanisms. Also, we sought to explain the mixed results of BCG efficacy in preventing different cancers.
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Affiliation(s)
- Sakshi Gupta
- Department of Preventive Oncology (Dr. BRA-IRCH), All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Yadav
- Department of Preventive Oncology (Dr. BRA-IRCH), All India Institute of Medical Sciences, New Delhi, India
| | - Pawan Kumar
- Department of Preventive Oncology (Dr. BRA-IRCH), All India Institute of Medical Sciences, New Delhi, India
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Lone Z, Benidir T, Wood A, Campbell RA, Alaghehbandan R, Li J, Haber GP, Eltemamy M, Haywood SC, Weight CJ, Lee BH, Almassi N. Oncologic outcomes of intravesical therapy in the management of nonmuscle invasive bladder cancer with variant histology. Urol Oncol 2024; 42:71.e1-71.e7. [PMID: 38135626 DOI: 10.1016/j.urolonc.2023.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 11/10/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE There is limited data on oncologic outcomes in nonmuscle invasive bladder cancer (NMIBC) with variant histology (VH) managed with intravesical therapy. We sought to evaluate oncologic outcomes for this cohort at a high-volume center. MATERIALS AND METHODS A retrospective review of an IRB-approved bladder cancer database was performed. Patients with a history of NMIBC with VH present on transurethral resection of bladder tumor (TURBT) treated with intravesical therapy (BCG or chemotherapy) were identified. Outcomes of interest included recurrence within the bladder, progression to muscle-invasive bladder cancer (MIBC), metastatic progression, cancer-specific, and overall survival. Survival time was computed from the date of initiation of intravesical therapy to the date of event or censoring. For patients who underwent radical cystectomy, recurrence-free, cancer-specific, and overall survival were also computed. The Kaplan-Meier method with log rank was utilized to compare survival time between VH sub-groups. RESULTS Ninety patients were included in the final cohort with a median follow-up of 38 months. The majority of patients had T1 disease (72%) and received intravesical BCG (83%) as their only form of intravesical therapy. The most commonly represented VH in this series were glandular and squamous differentiation (26%). Forty-eight patients (53%) experienced recurrence within the bladder with a median recurrence-free survival of 24 months (95% Confidence Interval [CI]: 2-46 months). Five-year rates of progression to MIBC and distant metastasis were both 14% respectively. Twenty-six patients (28%) eventually required cystectomy. When stratifying by VH, patients with sarcomatoid, plasmacytoid, and micropapillary had significantly worse oncologic outcomes. CONCLUSION In this series of highly-selected patients with NMIBC and VH, bladder-sparing treatment with intravesical therapy demonstrated acceptable oncologic outcomes for most VHs. This may be an acceptable treatment option for patients without plasmacytoid, sarcomatoid, or micropapillary features who are not suitable cystectomy candidates or who prioritize bladder-sparing treatment.
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Affiliation(s)
- Zaeem Lone
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.
| | - Tarik Benidir
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Andrew Wood
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Rebecca A Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Reza Alaghehbandan
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Jianbo Li
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | | | - Mohammed Eltemamy
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Samuel C Haywood
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | - Byron H Lee
- Department of Urology, MD Anderson Cancer Center, Houston, TX
| | - Nima Almassi
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
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Heidrich V, Mariotti ACH, Inoue LT, Coser EM, Dos Santos EX, Dos Santos HDB, Asprino PF, Bettoni F, Costa GAP, Bastos DA, Jardim DL, Arap MA, Camargo AA. The bladder microbiota is not significantly altered by intravesical BCG therapy. Urol Oncol 2024; 42:22.e13-22.e21. [PMID: 38030469 DOI: 10.1016/j.urolonc.2023.11.003] [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] [Received: 06/13/2023] [Revised: 10/02/2023] [Accepted: 11/05/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION Bladder microbiota dysbiosis has been associated with several urological disorders. However, dysbiosis markers in bladder cancer have not been identified and little is known about the effect of Bacillus Calmette-Guérin (BCG) intravesical therapy on the bladder microbiota. In this study, we compared the bladder microbiota of patients with non-muscle-invasive bladder cancer (NMIBC) undergoing BCG therapy to nononcological controls. We also longitudinally analyzed the impact of BCG therapy on the bladder microbiota of NMIBC patients and addressed whether bladder microbiota is associated with BCG efficacy. METHODS We collected catheterized urine samples from males with intermediate/high-risk NMIBC (cancer group, n = 32) or benign prostatic hyperplasia (control group, n = 41). The cancer group also provided urine samples during and after BCG induction. We used 16S rRNA gene sequencing to characterize the bladder microbiota. Bladder microbiota parameters, such as diversity and taxonomic composition, were compared between groups and associated with clinicopathological data and BCG efficacy. RESULTS We observed no significant differences between the bladder microbiota of NMIBC patients and controls. BCG intravesical instillations did not significantly alter the bladder microbiota of NMIBC patients, and BCG was rarely detected in the bladder during and after BCG therapy. Microbiota diversity and overall composition before BCG induction did not influence disease persistence at 3 months. However, higher abundance of Lactobacillus, Streptococcus, and Cutibacterium in the pre-BCG bladder microbiota was associated with BCG effectiveness. CONCLUSION We were unable to identify markers of bladder microbiota dysbiosis among male NMIBC patients. Moreover, we demonstrated for the first time using longitudinally collected samples that BCG cannot persist in the bladder microbiota nor significantly alter its diversity and composition. The associations found between bladder microbes and BCG efficacy highlight the potential of microbial-based therapeutic and risk-stratification strategies in the intermediate/high-risk NMIBC setting.
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Affiliation(s)
- Vitor Heidrich
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil; Departamento de Bioquímica, Instituto de Química, Universidade de São Paulo, São Paulo, Brazil
| | | | - Lilian T Inoue
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Elisangela M Coser
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | | | - Paula F Asprino
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Fabiana Bettoni
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | - Diogo A Bastos
- Centro de Oncologia, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Denis L Jardim
- Centro de Oncologia, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Marco A Arap
- Departamento de Urologia, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Anamaria A Camargo
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil.
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Lv Z, Hou J, Wang Y, Wang X, Wang Y, Wang K. Knowledge-map analysis of bladder cancer immunotherapy. Hum Vaccin Immunother 2023; 19:2267301. [PMID: 37903500 PMCID: PMC10760393 DOI: 10.1080/21645515.2023.2267301] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/03/2023] [Indexed: 11/01/2023] Open
Abstract
This study aimed to conduct a bibliometric analysis in the field of bladder cancer (BC) immunotherapy, and explore the research trends, hotspots and frontiers from 2000 to 2022. VOSviewer software was used to analyze the collaborative relationships between authors, institutions, countries/regions, and journals through citation, co-authorship, and co-citation analysis, to identify research hotspots and frontiers in this field. Researchers based in the United States of America have published a total of 627 papers with 27,308 citations. Indeed, the USA ranked first among the top 10 most active countries and showed the most extensive collaboration with other countries. The University of Texas MD Anderson CANC CTR has published 58 articles, making it the top most institution in terms of published articles and active collaborative research. Kamat AM and Lamm DL were the most active and co-cited authors with 28 papers and 980 co-citations, respectively. Chang Yuan and Xu le were the most active collaborative authors with a total link strength of 195. The J UROLOGY was the most active and frequently co-cited journal, with 100 papers and 6,668 co-citations. Studies of BC immunotherapy can be broadly classified into three categories: "basic research", "clinical trial", and "prognosis". Our findings provide an overview of the research priorities and future directions of BC immunotherapy. Tumor microenvironment and immune checkpoint inhibitors (ICIs) of BC, as well as the combination of ICIs with other drugs, may become the main direction of future research.
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Affiliation(s)
- Zongwei Lv
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Junhui Hou
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yuan Wang
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xia Wang
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yibing Wang
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Kefeng Wang
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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DiNardo AR, Arditi M, Kamat AM, Koster KJ, Carrero S, Nishiguchi T, Lebedev M, Benjamin AB, Avalos P, Lozano M, Moule MG, McCune B, Herron B, Ladki M, Sheikh D, Spears M, Herrejon IA, Dodge C, Kumar S, Hutchison RW, Ofili TU, Opperman LA, Bernard JA, Lerner SP, Udeani G, Neal G, Netea MG, Cirillo JD. Bacillus Calmette-Guérin vaccination as defense against SARS-CoV-2 (BADAS): a randomized controlled trial to protect healthcare workers in the USA by enhanced trained immune responses. Trials 2023; 24:636. [PMID: 37794431 PMCID: PMC10548680 DOI: 10.1186/s13063-023-07662-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND A large epidemic, such as that observed with SARS-CoV-2, seriously challenges available hospital capacity, and this would be augmented by infection of healthcare workers (HCW). Bacillus Calmette-Guérin (BCG) is a vaccine against tuberculosis, with protective non-specific effects against other respiratory tract infections in vitro and in vivo. Preliminary analyses suggest that regions of the world with existing BCG vaccination programs have lower incidence and mortality from COVID-19. We hypothesize that BCG vaccination can reduce SARS-CoV-2 infection and disease severity. METHODS This will be a placebo-controlled adaptive multi-center randomized controlled trial. A total of 1800 individuals considered to be at high risk, including those with comorbidities (hypertension, diabetes, obesity, reactive airway disease, smokers), racial and ethnic minorities, elderly, teachers, police, restaurant wait-staff, delivery personnel, health care workers who are defined as personnel working in a healthcare setting, at a hospital, medical center or clinic (veterinary, dental, ophthalmology), and first responders (paramedics, firefighters, or law enforcement), will be randomly assigned to two treatment groups. The treatment groups will receive intradermal administration of BCG vaccine or placebo (saline) with groups at a 1:1 ratio. Individuals will be tracked for evidence of SARS-CoV-2 infection and severity as well as obtaining whole blood to track immunological markers, and a sub-study will include cognitive function and brain imaging. The majority of individuals will be followed for 6 months, with an option to extend for another 6 months, and the cognitive sub-study duration is 2 years. We will plot Kaplan-Meier curves that will be plotted comparing groups and hazard ratios and p-values reported using Cox proportional hazard models. DISCUSSION It is expected this trial will allow evaluation of the effects of BCG vaccination at a population level in high-risk healthcare individuals through a mitigated clinical course of SARS-CoV-2 infection and inform policy making during the ongoing epidemic. TRIAL REGISTRATION ClinicalTrials.gov NCT04348370. Registered on April 16, 2020.
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Affiliation(s)
- Andrew R DiNardo
- Global and Immigrant Health, Baylor College of Medicine, Houston, TX, 77030, USA
- Radboud Center for Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Moshe Arditi
- Departments of Pediatrics and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Ashish M Kamat
- Department of Urology, UT MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Kent J Koster
- Center for Airborne Pathogen Research and Imaging, Texas A&M School of Medicine, Bryan, TX, 77807, USA
| | - Santiago Carrero
- Global and Immigrant Health, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Tomoki Nishiguchi
- Global and Immigrant Health, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Maxim Lebedev
- Center for Airborne Pathogen Research and Imaging, Texas A&M School of Medicine, Bryan, TX, 77807, USA
| | - Aaron B Benjamin
- Center for Airborne Pathogen Research and Imaging, Texas A&M School of Medicine, Bryan, TX, 77807, USA
| | - Pablo Avalos
- Cedars-Sinai Medical Center, Regenerative Medicine Institute, Los Angeles, CA, 90048, USA
| | - Marisa Lozano
- Department of Urology, UT MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Madeleine G Moule
- Institute of Immunology & Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Malik Ladki
- Global and Immigrant Health, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Daanish Sheikh
- Global and Immigrant Health, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Matthew Spears
- College of Osteopathic Medicine, Sam Houston State University, Conroe, TX, 77304, USA
| | - Ivan A Herrejon
- Department of Psychological and Brain Sciences, Texas A&M University, College Station, TX, 77843, USA
| | - Courtney Dodge
- Texas A&M School of Medicine, Round Rock, TX, 78665, USA
| | - Sathish Kumar
- Center for Airborne Pathogen Research and Imaging, Texas A&M School of Medicine, Bryan, TX, 77807, USA
| | - Robert W Hutchison
- Department of Pharmacy Practice, Texas A&M School of Pharmacy, College Station, TX, 77843, USA
| | - Theresa U Ofili
- Department of Pharmacy Practice, Texas A&M School of Pharmacy, College Station, TX, 77843, USA
| | - Lynne A Opperman
- Center for Craniofacial Research and Diagnosis, Texas A&M School of Dentistry, Dallas, TX, 75246, USA
| | - Jessica A Bernard
- Department of Psychological and Brain Sciences, Texas A&M Institute for Neuroscience, Texas A&M University, College Station, TX, 77843, USA
| | - Seth P Lerner
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, 77030, USA
| | - George Udeani
- Department of Pharmacy Practice, Texas A&M School of Pharmacy, Kingsville, TX, 78363, USA
| | - Gabriel Neal
- Primary Care and Rural Medicine, Texas A&M School of Medicine, Bryan, TX, 77807, USA
| | - Mihai G Netea
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeffrey D Cirillo
- Center for Airborne Pathogen Research and Imaging, Texas A&M School of Medicine, Bryan, TX, 77807, USA.
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11
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Godard L, Lee L, McGuinness B, Shirsat H, Hoag N. Mycotic Abdominal Aortic Aneurysm Secondary to BCG Therapy for Non-muscle Invasive Urothelial Carcinoma of the Bladder. Vasc Endovascular Surg 2023; 57:776-780. [PMID: 37071973 PMCID: PMC10517576 DOI: 10.1177/15385744231171754] [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: 04/20/2023]
Abstract
Bacillus Calmette-Guerin (BCG) therapy for treatment of bladder cancer is a rare cause of Mycobacterium bovis infected aortic aneurysm. Typical presentations have included general malaise, fever, and lower back pain. We present a case with lower back pain and constipation as presenting symptoms, leading to diagnosis of mycotic aneurysm presumed secondary to intravesical BCG therapy. Treatment included open surgical repair with femoral vein grafting and anti-tubercular therapy. This case highlights the importance of a high index of suspicion for less common infectious complications of BCG therapy.
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Affiliation(s)
- Levi Godard
- University of British Columbia, Island Medical Program, Victoria, BC, Canada
| | - Linda Lee
- University of British Columbia, Island Medical Program, Victoria, BC, Canada
- University of British Columbia, Dept. Of Urological Sciences, Victoria, BC, Canada
| | - Brandon McGuinness
- University of British Columbia, Island Medical Program, Victoria, BC, Canada
| | | | - Nathan Hoag
- University of British Columbia, Island Medical Program, Victoria, BC, Canada
- University of British Columbia, Dept. Of Urological Sciences, Victoria, BC, Canada
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12
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Grabe-Heyne K, Henne C, Mariappan P, Geiges G, Pöhlmann J, Pollock RF. Intermediate and high-risk non-muscle-invasive bladder cancer: an overview of epidemiology, burden, and unmet needs. Front Oncol 2023; 13:1170124. [PMID: 37333804 PMCID: PMC10272547 DOI: 10.3389/fonc.2023.1170124] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/19/2023] [Indexed: 06/20/2023] Open
Abstract
Bladder cancer ranks among the most common cancers globally. At diagnosis, 75% of patients have non-muscle-invasive bladder cancer (NMIBC). Patients with low-risk NMIBC have a good prognosis, but recurrence and progression rates remain high in intermediate- and high-risk NMIBC, despite the decades-long availability of effective treatments for NMIBC such as intravesical Bacillus Calmette-Guérin (BCG). The present review provides an overview of NMIBC, including its burden and treatment options, and then reviews aspects that counteract the successful treatment of NMIBC, referred to as unmet treatment needs. The scale and reasons for each unmet need are described based on a comprehensive review of the literature, including insufficient adherence to treatment guidelines by physicians because of insufficient knowledge, training, or access to certain therapy options. Low rates of lifestyle changes and treatment completion by patients, due to BCG shortages or toxicities and adverse events as well as their impact on social activities, represent additional areas of potential improvement. Highly heterogeneous evidence for the effectiveness and safety of some treatments limits the comparability of results across studies. As a result, efforts are underway to standardize treatment schedules for BCG, but intravesical chemotherapy schedules remain unstandardized. In addition, risk-scoring models often perform unsatisfactorily due to significant differences between derivation and real-world cohorts. Reporting in clinical trials suffers from a lack of consistent outcomes reporting in bladder cancer clinical trials, paired with an under-representation of racial and ethnic minorities in many trials.
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Affiliation(s)
| | | | - Paramananthan Mariappan
- Edinburgh Bladder Cancer Surgery (EBCS), Department of Urology, Western General Hospital, Edinburgh, United Kingdom
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13
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Focus on the Use of Resveratrol in Bladder Cancer. Int J Mol Sci 2023; 24:ijms24054562. [PMID: 36901993 PMCID: PMC10003096 DOI: 10.3390/ijms24054562] [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: 01/17/2023] [Revised: 02/13/2023] [Accepted: 02/21/2023] [Indexed: 03/03/2023] Open
Abstract
Bladder cancer is the most common tumor of the urinary system, with a high incidence in the male population. Surgery and intravesical instillations can eradicate it, although recurrences are very common, with possible progression. For this reason, adjuvant therapy should be considered in all patients. Resveratrol displays a biphasic dose response both in vitro and in vivo (intravesical application) with an antiproliferative effect at high concentrations and antiangiogenic action in vivo (intraperitoneal application) at a low concentration, suggesting a potential role for it in clinical management as an adjuvant to conventional therapy. In this review, we examine the standard therapeutical approach to bladder cancer and the preclinical studies that have investigated resveratrol in xenotransplantation models of bladder cancer. Molecular signals are also discussed, with a particular focus on the STAT3 pathway and angiogenic growth factor modulation.
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14
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Chen J, Gao L, Wu X, Fan Y, Liu M, Peng L, Song J, Li B, Liu A, Bao F. BCG-induced trained immunity: history, mechanisms and potential applications. J Transl Med 2023; 21:106. [PMID: 36765373 PMCID: PMC9913021 DOI: 10.1186/s12967-023-03944-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/31/2023] [Indexed: 02/12/2023] Open
Abstract
The Bacillus Calmette-Guérin (BCG) vaccine was discovered a century ago and has since been clinically applicable. BCG can not only be used for the prevention of tuberculosis, but also has a non-specific protective effect on the human body called trained immunity that is mediated by innate immune cells such as monocytes, macrophages, and natural killer cells. Mechanisms of trained immunity include epigenetic reprogramming, metabolic reprogramming, and long-term protection mediated by hematopoietic stem cells. Trained immunity has so far shown beneficial effects on cancer, viral-infections, autoimmune diseases, and a variety of other diseases, especially bladder cancer, respiratory viruses, and type 1 diabetes. The modulation of the immune response by BCG has led to the development of a variety of recombinant vaccines. Although the specific mechanism of BCG prevention on diseases has not been fully clarified, the potential role of BCG deserves further exploration, which is of great significance for prevention and treatment of diseases.
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Affiliation(s)
- Jingjing Chen
- grid.285847.40000 0000 9588 0960The Institute for Tropical Medicine, Kunming Medical University, Kunming, 650500 Yunnan China ,grid.285847.40000 0000 9588 0960Department of Biochemistry and Molecular Biology, Kunming Medical University, Kunming, 650500 Yunnan China
| | - Li Gao
- grid.285847.40000 0000 9588 0960The Institute for Tropical Medicine, Kunming Medical University, Kunming, 650500 Yunnan China ,grid.285847.40000 0000 9588 0960Department of Biochemistry and Molecular Biology, Kunming Medical University, Kunming, 650500 Yunnan China
| | - Xinya Wu
- grid.285847.40000 0000 9588 0960The Institute for Tropical Medicine, Kunming Medical University, Kunming, 650500 Yunnan China ,grid.285847.40000 0000 9588 0960Department of Microbiology and Immunology, Kunming Medical University, Kunming, 650500 Yunnan China
| | - Yuxin Fan
- grid.285847.40000 0000 9588 0960The Institute for Tropical Medicine, Kunming Medical University, Kunming, 650500 Yunnan China ,grid.285847.40000 0000 9588 0960Department of Microbiology and Immunology, Kunming Medical University, Kunming, 650500 Yunnan China
| | - Meixiao Liu
- grid.285847.40000 0000 9588 0960The Institute for Tropical Medicine, Kunming Medical University, Kunming, 650500 Yunnan China ,grid.285847.40000 0000 9588 0960Department of Microbiology and Immunology, Kunming Medical University, Kunming, 650500 Yunnan China
| | - Li Peng
- grid.285847.40000 0000 9588 0960The Institute for Tropical Medicine, Kunming Medical University, Kunming, 650500 Yunnan China ,grid.285847.40000 0000 9588 0960Department of Biochemistry and Molecular Biology, Kunming Medical University, Kunming, 650500 Yunnan China
| | - Jieqin Song
- grid.285847.40000 0000 9588 0960The Institute for Tropical Medicine, Kunming Medical University, Kunming, 650500 Yunnan China ,grid.285847.40000 0000 9588 0960Department of Microbiology and Immunology, Kunming Medical University, Kunming, 650500 Yunnan China
| | - Bingxue Li
- grid.285847.40000 0000 9588 0960The Institute for Tropical Medicine, Kunming Medical University, Kunming, 650500 Yunnan China ,grid.285847.40000 0000 9588 0960Department of Microbiology and Immunology, Kunming Medical University, Kunming, 650500 Yunnan China
| | - Aihua Liu
- The Institute for Tropical Medicine, Kunming Medical University, Kunming, 650500, Yunnan, China. .,Yunnan Health Cell Biotechnology Company, Kunming, 650041, Yunnan, China. .,Department of Biochemistry and Molecular Biology, Kunming Medical University, Kunming, 650500, Yunnan, China.
| | - Fukai Bao
- The Institute for Tropical Medicine, Kunming Medical University, Kunming, 650500, Yunnan, China. .,Yunnan Health Cell Biotechnology Company, Kunming, 650041, Yunnan, China. .,Department of Microbiology and Immunology, Kunming Medical University, Kunming, 650500, Yunnan, China.
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15
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Khansary S, Tavilani H, Ghasemi H. Gender, Bladder Cancer Healthcare and Burden of COVID-19. Cancer Invest 2023; 41:58-69. [PMID: 36282109 DOI: 10.1080/07357907.2022.2140351] [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: 01/26/2023]
Abstract
Bladder cancer as one of the main comorbid diseases might be more susceptible to develop COVID-19 infection with a higher mortality risk during the COVID-19 pandemic. The European Association of Urology (EAU) recommended a comprehensive panel for bladder cancer diagnosis and treatment during this global health problem. The urgent need for treatments of COVID-19 during the pandemic has persuaded researchers to evaluate the different medications, which may lead to drug shortages. Therefore, in this review paper, we have focused on the least recommendations of EAU about bladder cancer during of COVID-19 pandemic to provide a comprehensive panel for high-risk patients.
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Affiliation(s)
- Shahede Khansary
- Department of Gynecology, Faculty of Medicine, Hamadan university of Medical Sciences, Hamadan, Iran
| | - Heidar Tavilani
- Department of Clinical Biochemistry, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Hadi Ghasemi
- Autophagy Research Center, Department of Biochemistry, School of Medicine, Shiraz University of Medical Science, Shiraz, Iran
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16
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Liu P, Chen S, Gao X, Liang H, Sun D, Shi B, Zhang Q, Guo H. Preoperative sarcopenia and systemic immune-inflammation index can predict response to intravesical Bacillus Calmette-Guerin instillation in patients with non-muscle invasive bladder cancer. Front Immunol 2022; 13:1032907. [PMID: 36225922 PMCID: PMC9549861 DOI: 10.3389/fimmu.2022.1032907] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/26/2022] [Indexed: 11/15/2022] Open
Abstract
Background To explore the prognostic significance of sarcopenia and systemic immune-inflammation index (SII) for response to intravesical Bacillus Calmette-Guerin (BCG) in patients with intermediate-, and high-risk non-muscle invasive bladder cancer (NMIBC). Methods We retrospectively analyzed 183 consecutive patients treated in Qilu hospital of Shandong University for a first diagnosis of intermediate and high risk NMIBC. Using computed tomography scans at the third lumbar vertebra level, we calculated skeletal muscle index (SMI). Sarcopenia was defined as SMI <43 cm2/m2 for males with BMI < 25 kg/m2, <53 cm2/m2 for males with BMI ≥ 25 kg/m2, and <41 cm2/m2 for females. The response to intravesical BCG immunotherapy and relapse-free survival (RFS) were analyzed. Results Compared with BCG responders, BCG non-responders were associated with sarcopenia (P < 0.001), carcinoma in situ (P < 0.001), T1 stage (P < 0.001), multiple tumor (P < 0.001), tumor diameter >=3cm (P < 0.001), and have a significant increase of neutrophil-to-lymphocyte ratio (NLR) (P < 0.001), platelet to lymphocyte ratio (PLR) (P = 0.004), SII (P < 0.001). The area under the ROC curve (AUC) of the BMI, NLR, PLR, and SII for response to intravesical BCG immunotherapy were 0.425, 0.693, 0.631, and 0.702 respectively. Logistic regression analysis demonstrated that sarcopenia and SII were predictors of response to intravesical BCG immunotherapy. The Kaplan-Meier survival analysis showed that the RFS of patients with BCG response, lower SII and no sarcopenia was significantly increased compared with that of patients with BCG non-response, higher SII and sarcopenia, respectively. Subgroup analysis demonstrated that the RFS of patients with high SII and sarcopenia was significantly decreased compared with those with low SII and no sarcopenia in Ta stage subgroup, T1 stage subgroup, non-Cis subgroup, multiple tumor subgroup, single tumor subgroup, tumor diameter≥3cm subgroup and tumor diameter<3cm subgroup, respectively (P < 0.05). However, there was no significant difference in RFS for patients in CIS subgroup (P > 0.05). Multivariate Cox analysis shown that sarcopenia (p=0.005) and high SII (p = 0.003) were significantly associated with poor RFS. Conclusions Both sarcopenia and high SII are useful predictors of response to intravesical BCG in intermediate- and high-risk NMIBC patients. Patients with intermediate- and high-risk NMIBC that had sarcopenia or high SII at diagnosis were associated with poor RFS, and the combination of sarcopenia and SII may be a better predictor of RFS.
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Affiliation(s)
| | | | | | | | | | | | | | - Hu Guo
- *Correspondence: Hu Guo, ; Qiujie Zhang,
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17
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Redelman-Sidi G, Binyamin A, Antonelli AC, Catalano W, Bean J, Al-Ahmadie H, Jungbluth AA, Glickman MS. BCG-Induced Tumor Immunity Requires Tumor-Intrinsic CIITA Independent of MHC-II. Cancer Immunol Res 2022; 10:1241-1253. [PMID: 36040405 PMCID: PMC9532361 DOI: 10.1158/2326-6066.cir-22-0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/09/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022]
Abstract
For decades, BCG immunotherapy has been the standard of care for non-muscle-invasive bladder cancer. Despite this clinical experience, the mechanism by which BCG stimulates tumor-eliminating immunity is unclear, and there is still a need for more accurate prediction of clinical outcomes in advance of treatment initiation. We have shown that BCG stimulates tumor-specific T-cell immunity that requires tumor cell expression of the IFNγ receptor (IFNGR); however, the downstream components of IFNGR signaling responsible for responsiveness to BCG are unknown. Here, we demonstrate that the IFNγ-driven, tumor cell intrinsic expression of the class II transactivator CIITA is required for activation of a tumor-specific CD4 T-cell response and BCG-induced tumor immunity. Despite the established role for CIITA in controlling MHC-II antigen presentation machinery, the requirement for CIITA is independent of MHC-II and associated genes. Rather, we find that CIITA is required for a broader tumor-intrinsic transcriptional program linked to critical pathways of tumor immunity via mechanisms that remain to be determined. Tumor cell intrinsic expression of CIITA is not required for a response to immunotherapy targeting programmed cell death protein 1 (PD-1), suggesting that different modalities of immunotherapy for bladder cancer could be employed based on tumor-intrinsic characteristics.
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Affiliation(s)
- Gil Redelman-Sidi
- Division of Infectious Diseases, Memorial Sloan Kettering Cancer Center
| | | | - Anthony C. Antonelli
- Immunology Program, Sloan Kettering Institute
- Immunology and Microbial Pathogenesis, Weill Cornell Medicine Graduate School of Medical Sciences
| | | | - James Bean
- Immunology Program, Sloan Kettering Institute
| | | | | | - Michael S. Glickman
- Division of Infectious Diseases, Memorial Sloan Kettering Cancer Center
- Immunology Program, Sloan Kettering Institute
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18
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Yadollahvandmiandoab R, Jalalizadeh M, Buosi K, Garcia-Perdomo HA, Reis LO. Immunogenic Cell Death Role in Urothelial Cancer Therapy. Curr Oncol 2022; 29:6700-6713. [PMID: 36135095 PMCID: PMC9498148 DOI: 10.3390/curroncol29090526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 12/05/2022] Open
Abstract
Purpose: Bladder cancer is the 13th most common cause of cancer death with the highest lifetime cost for treatment of all cancers. This scoping review clarifies the available evidence on the role of a novel therapeutic approach called immunogenic cell death (ICD) in urothelial cancer of the bladder. Methods: In accordance with the recommendations of the Joanna Briggs Institute, we searched MEDLINE (Ovid), EMBASE, CENTRAL databases, and supplemented with manual searches through the conferences, Google scholar, and clinicaltrials.gov for published studies up to April 2022. We included literature that studied molecular mechanisms of ICD and the role of certain danger-associated molecular patterns (DAMPs) in generating ICD, safety and efficacy of different ICD inducers, and their contributions in combination with other urothelial cancer treatments. Results: Oncolytic viruses, radiotherapy, certain chemo/chemo radiation therapy combinations, photodynamic therapy, and novel agents were studied as ICD-inducing treatment modalities in the included studies. ICD was observed in vitro (murine or human urothelial carcinoma) in ten studies, eight studies were performed on mouse models (orthotopic or subcutaneous), and five clinical trials assessed patient response to ICD inducing agents. The most common studied DAMPs were Calreticulin, HMGB1, ATP, and Heat Shock Proteins (HSP) 70 and 90, which were either expressed on the cancer cells or released. Conclusion: ICD inducers were able to generate lasting antitumor immune responses with memory formation in animal studies (vaccination effect). In clinical trials these agents generally had low side effects, except for one trial, and could be used alone or in combination with other cancer treatment strategies in urothelial cancer patients.
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Affiliation(s)
- Reza Yadollahvandmiandoab
- UroScience, School of Medical Sciences, University of Campinas, UNICAMP, Campinas, Sao Paulo 13083-970, Brazil
| | - Mehrsa Jalalizadeh
- UroScience, School of Medical Sciences, University of Campinas, UNICAMP, Campinas, Sao Paulo 13083-970, Brazil
| | - Keini Buosi
- UroScience, School of Medical Sciences, University of Campinas, UNICAMP, Campinas, Sao Paulo 13083-970, Brazil
| | - Herney Andrés Garcia-Perdomo
- Division of Urology/Urooncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali 72824, Colombia
| | - Leonardo Oliveira Reis
- UroScience, School of Medical Sciences, University of Campinas, UNICAMP, Campinas, Sao Paulo 13083-970, Brazil
- Center for Life Sciences, Pontifical Catholic University of Campinas, PUC-Campinas, Sao Paulo 13087-571, Brazil
- Correspondence: ; Tel.: +55-019-35217481
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19
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Howard JM, Cook GS, Tverye A, Nandy K, Margulis V, Woldu SL, Lotan Y. Outcomes of Patients with Bacillus Calmette-Guérin (BCG)-Unresponsive Non-Muscle Invasive Bladder Cancer as Defined by the U.S. Food and Drug Administration. Bladder Cancer 2022; 8:303-314. [PMID: 38993682 PMCID: PMC11181681 DOI: 10.3233/blc-211657] [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: 12/20/2021] [Accepted: 05/31/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Limited data are available on the outcomes of patients with non-muscle invasive bladder cancer (NMIBC) unresponsive to intravesical bacillus Calmette-Guérin (BCG), as defined by the United States Food and Drug Administration. OBJECTIVE To define the outcomes of patients with BCG-unresponsive NMIBC. METHODS This was a retrospective, single-institution observational cohort study. Records of patients managed at our institution for BCG-unresponsive NMIBC between 2005 and 2020 were reviewed and clinical outcomes evaluated. RESULTS The study included 149 patients. Management was with initial radical cystectomy in 60 patients (40%) and initial bladder-sparing therapy (BST) in 89 patients (60%). Overall survival was greater among patients undergoing RC than BST (HR 1.83, 95% CI 1.04-3.22, p = 0.036), potentially due to patient selection, as no significant difference was noted for metastasis-free or cancer-specific survival. Patients opting for initial BST had high rates of treatment failure, with estimated 5-year cystectomy-free survival of only 42%. Patients who received additional lines of BST after a subsequent failure were at increased risk of having ≥pT3 or pN+ disease at cystectomy (42% for ≥2 lines BST, versus 18% for 1 line BST and 15% for initial cystectomy, p = 0.038). CONCLUSION Among patients who underwent initial BST for BCG-unresponsive NMIBC, rates of treatment failure were very high. Patients who underwent delayed cystectomy after ≥2 lines of BST had elevated rates of extravesical disease. Our observations emphasize the importance of recent and ongoing clinical trials in this clinical space.
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Affiliation(s)
- Jeffrey M Howard
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Urology, Maine Medical Center, Portland, ME, USA
| | - Grayden S Cook
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Urology, Brigham and Women's Hospital / Harvard Medical School, Boston, MA, USA
| | - Aaron Tverye
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Karabi Nandy
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Solomon L Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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20
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Üçer O, Temeltaş G, Müezzinoğlu T, Ari Z, Kosova F. The Effect of Transurethral Resection and BCG Therapy on Cytokine Levels in Non-Muscle Invasive Bladder Cancer. JOURNAL OF UROLOGICAL SURGERY 2022. [DOI: 10.4274/jus.galenos.2022.2021.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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21
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Chen YK, Huang EYH, Chang YH, Kuo JY, Chung HJ, Wu HHH, Lin TP, Lin CC, Fan YH, Huang IS, Lin ATL, Huang WJ. The comparison of different BCG strains in the intravesical treatment of non-muscle invasive urothelial carcinoma of urinary bladder-A real-world practice. J Chin Med Assoc 2022; 85:928-934. [PMID: 36150105 DOI: 10.1097/jcma.0000000000000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Bacillus Calmette-Guérin (BCG) has been well recognized as the first-line intravesical therapy for high-risk non-muscle-invasive bladder cancer (NMIBC). Oncotice, the Tice strain of BCG, serves as a viable alternative to the Connaught strain owing to the worldwide shortage of the latter. We retrospectively compared these two strains in terms of efficacy and adverse effects (AE) in patients who underwent at least one maintenance course after induction. METHODS In this single-institution, retrospective study, patients diagnosed with NMIBC who were administered either Connaught or Tice intravesical therapy were enrolled. Recurrence was defined as the reappearance of urothelial carcinoma. Progression was defined as stage/grade advance, metastasis, or cancer-related death. The primary outcomes were recurrence-free survival (RFS) and progression-free survival (PFS), and the secondary outcome was AE. RESULTS A total of 76 and 84 patients receiving Tice and Connaught, respectively were enrolled. The median follow-up periods for the Tice and Connaught groups were 32.0 months (range, 7-69 months) and 81.5 months (range, 9-154 months), respectively. Kaplan-Meier method showed no intergroup difference with regard to 3-year RFS and PFS. On Cox multivariate regression analysis, Tice was a significant predictor for inferior PFS (HR = 5.30; 95% CI, 1.11-25.29; p = 0.036). The AE incidence was 38.3% in the Connaught group and 25.0% in the Tice group (p = 0.079). CONCLUSION Tice and Connaught were comparable in terms of RFS, PFS, and AE for patients with NMIBC accepting BCG induction and at least one maintenance course in our real-world practice. However, Tice was a predictor of inferior PFS on multivariate analysis.
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Affiliation(s)
- Yu-Kuang Chen
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Eric Yi-Hsiu Huang
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yen-Hwa Chang
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Junne-Yih Kuo
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hsiao-Jen Chung
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Howard Hung-Hao Wu
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tzu-Ping Lin
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chih-Chieh Lin
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu-Hua Fan
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - I-Shen Huang
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Alex T L Lin
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - William J Huang
- Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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22
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Lonati C, Baumeister P, Afferi L, Mari A, Minervini A, Krajewski W, Azizi S, Hendricksen K, Martini A, Necchi A, Montorsi F, Briganti A, Colombo R, Tafuri A, Antonelli A, Cerruto MA, Rouprêt M, Masson-Lecomte A, Laukhtina E, D'Andrea D, Shariat SF, Soria F, Marra G, Gontero P, Contieri R, Hurle R, Valiquette AS, Mir MC, Zamboni S, Simeone C, Klatte T, Teoh JYC, Yoshida S, Fujii Y, Carando R, Schulz GB, Mordasini L, Mattei A, Moschini M. Survival Outcomes After Immediate Radical Cystectomy Versus Conservative Management with Bacillus Calmette-Guérin Among T1 High-grade Micropapillary Bladder Cancer Patients: Results from a Multicentre Collaboration. Eur Urol Focus 2022; 8:1270-1277. [PMID: 34419381 DOI: 10.1016/j.euf.2021.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/12/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Literature lacks clear evidence regarding the optimal treatment for non-muscle-invasive micropapillary bladder cancer (MPBC) due to its rarity and the presence of only small sample size and single-centre studies. OBJECTIVE To assess cancer-specific mortality (CSM) and overall mortality (OM) between immediate radical cystectomy (RC) and conservative management among T1 high-grade (HG) MPBC. DESIGN, SETTING, AND PARTICIPANTS We retrospectively analysed a multicentre dataset including 119 T1 HG MPBC patients treated between 2005 and 2019 at 15 tertiary referral centres. The median follow-up time was 35 mo (interquartile range: 19-64). INTERVENTION Patients underwent immediate RC versus conservative management with bacillus Calmette-Guérin. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS Cumulative incidence functions and Kaplan-Meier methods were applied to estimate survival outcomes. Multivariable Cox analyses were performed to assess independent predictors of disease recurrence and disease progression after conservative management; covariates consisted of pure MPBC, concomitant lymphovascular invasion (LVI), and carcinoma in situ at initial diagnosis. RESULTS AND LIMITATIONS Immediate RC and conservative management were performed in 27% and 73% of patients, respectively. CSM and OM did not differ significantly among patient treated with immediate RC versus conservative management (Pepe-Mori test p = 0.5 and log-rank test p = 0.9, respectively). Overall, 66.7% and 34.5% of patients experienced disease recurrence and disease progression after conservative management, respectively. At multivariable Cox analyses, concomitant LVI was an independent predictor of disease recurrence (p = 0.01) and progression (p = 0.03), while pure MPBC was independently associated with disease progression (p = 0.03). The absence of a centralised re-review and the retrospective design represent the main limitations of our study. CONCLUSIONS Conservative management could achieve satisfactory results among T1 HG MPBC patients with neither pure MPBC nor LVI at initial diagnosis. PATIENT SUMMARY Bacillus Calmette-Guérin seems to be an effective therapy for T1 micropapillary bladder cancer patients with neither pure micropapillary disease nor lymphovascular invasion at initial diagnosis.
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Affiliation(s)
- Chiara Lonati
- Department of Urology, Spedali Civili di Brescia, Brescia, Italy; Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland.
| | | | - Luca Afferi
- Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andrea Mari
- Department of Experimental and Clinical Medicine, Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi University Hospital, University of Florence, Florence, Italy
| | - Andrea Minervini
- Department of Experimental and Clinical Medicine, Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi University Hospital, University of Florence, Florence, Italy
| | - Wojciech Krajewski
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Sosan Azizi
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Kees Hendricksen
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alberto Martini
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrea Necchi
- Department of Medical Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Francesco Montorsi
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Alberto Briganti
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Renzo Colombo
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Tafuri
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Morgan Rouprêt
- GRC 5 Predictive Onco-Uro, AP-HP, Urology, Pitie-Salpetriere Hospital, Sorbonne University, Paris, France
| | | | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna General Hospital, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, Torino School of Medicine, Torino, Italy
| | - Giancarlo Marra
- Division of Urology, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, Torino School of Medicine, Torino, Italy
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, AOU Città della Salute e della Scienza di Torino, Torino School of Medicine, Torino, Italy
| | - Roberto Contieri
- Department of Urology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Rodolfo Hurle
- Department of Urology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - M Carmen Mir
- Department of Urology, Fundación Instituto Valenciano de Oncologia, Valencia, Spain
| | - Stefania Zamboni
- Department of Urology, Spedali Civili di Brescia, Brescia, Italy
| | - Claudio Simeone
- Department of Urology, Spedali Civili di Brescia, Brescia, Italy
| | - Tobias Klatte
- Department of Urology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jeremy Yuen-Chun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Soichiro Yoshida
- Department of Urology, Tokyo Medical and Dental University Graduate School, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University Graduate School, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Roberto Carando
- Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland; Clinica Luganese Moncucco, Lugano, Switzerland; Clinica S. Anna, Swiss Medical Group, Sorengo, Switzerland; Clinica Santa Chiara, Locarno, Switzerland
| | - Gerald B Schulz
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| | - Livio Mordasini
- Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Agostino Mattei
- Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Marco Moschini
- Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland; Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
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23
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Flaig TW, Spiess PE, Abern M, Agarwal N, Bangs R, Boorjian SA, Buyyounouski MK, Chan K, Chang S, Friedlander T, Greenberg RE, Guru KA, Herr HW, Hoffman-Censits J, Kishan A, Kundu S, Lele SM, Mamtani R, Margulis V, Mian OY, Michalski J, Montgomery JS, Nandagopal L, Pagliaro LC, Parikh M, Patterson A, Plimack ER, Pohar KS, Preston MA, Richards K, Sexton WJ, Siefker-Radtke AO, Tollefson M, Tward J, Wright JL, Dwyer MA, Cassara CJ, Gurski LA. NCCN Guidelines® Insights: Bladder Cancer, Version 2.2022. J Natl Compr Canc Netw 2022; 20:866-878. [PMID: 35948037 DOI: 10.6004/jnccn.2022.0041] [Citation(s) in RCA: 104] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The NCCN Guidelines for Bladder Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up of patients with bladder cancer and other urinary tract cancers (upper tract tumors, urothelial carcinoma of the prostate, primary carcinoma of the urethra). These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines regarding the treatment of non-muscle-invasive bladder cancer, including how to treat in the event of a bacillus Calmette-Guérin (BCG) shortage; new roles for immune checkpoint inhibitors in non-muscle invasive, muscle-invasive, and metastatic bladder cancer; and the addition of antibody-drug conjugates for metastatic bladder cancer.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Shilajit Kundu
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Ronac Mamtani
- Abramson Cancer Center at the University of Pennsylvania
| | | | - Omar Y Mian
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Jeff Michalski
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | - Anthony Patterson
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Kamal S Pohar
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | | | - Jonathan L Wright
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance; and
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24
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Wu R, Li D, Zhang F, Bai Y, Wang X, Han P. Prognostic Value of Platelet-to-Lymphocyte Ratio in Non-Muscle Invasive Bladder Cancer Patients: Intravesical Bacillus Calmette-Guerin Treatment After Transurethral Resection of Bladder Tumor. Front Surg 2022; 9:907485. [PMID: 36034368 PMCID: PMC9411071 DOI: 10.3389/fsurg.2022.907485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/28/2022] [Indexed: 01/04/2023] Open
Abstract
The objective of this study was to investigate the platelet-to-lymphocyte ratio (PLR) in patients who underwent intravesical treatment for non-muscle invasive bladder cancer (NMIBC). A total of 197 patients who underwent intravesical Bacillus Calmette-Guerin treatment after transurethral resection of bladder (TURB) were included. We divided the patients into different groups according to the treatment stage before and during induction treatment as Group 1 and Group 2, and set the change value of PLR as the Group 3. The cutoff values of PLR were determined through receiver operation characteristics curves analysis. we found a significant difference in recurrence-free survival (RFS) and progression-free survival (PFS) between patients with high serum PLR and those with low serum PLR in Group 1, as well as Group 2. Cox multivariate analysis revealed that tumor number ≥3, high grade, and history of carcinoma in situ (CIS) were significant factors predicting RFS and PFS. The PLR values before and during induction therapy could be used as predictors for the progression and recurrence of NMIBC patients receiving BCG immunotherapy. the PLR values after induction therapy have a stronger predictive power.
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25
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Severe Respiratory Failure Due to Pulmonary BCGosis in a Patient Treated for Superficial Bladder Cancer. Diagnostics (Basel) 2022; 12:diagnostics12040922. [PMID: 35453970 PMCID: PMC9026867 DOI: 10.3390/diagnostics12040922] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 12/13/2022] Open
Abstract
Intra-vesical instillations with bacillus Calmette-Guerin (BCG) are the established adjuvant therapy for superficial bladder cancer. Although generally safe and well tolerated, they may cause a range of different, local, and systemic complications. We present a patient treated with BCG instillations for three years, who was admitted to our hospital due to fever, hemoptysis, pleuritic chest pain and progressive dyspnea. Chest computed tomography (CT) showed massive bilateral ground glass opacities, partly consolidated, localized in the middle and lower parts of the lungs, bronchial walls thickening, and bilateral hilar lymphadenopathy. PCR tests for SARS-CoV-2 as well as sputum, blood, and urine for general bacteriology—were negative. Initial empiric antibiotic therapy was ineffective and respiratory failure progressed. After a few weeks, a culture of M. tuberculosis complex was obtained from the patient’s specimens; the cultured strain was identified as Mycobacterium bovis BCG. Anti-tuberculous treatment with rifampin (RMP), isoniazid (INH) and ethambutol (EMB) was implemented together with systemic corticosteroids, resulting in the quick improvement of the patient’s clinical condition. Due to hepatotoxicity and finally reported resistance of the BCG strain to INH, levofloxacin was used instead of INH with good tolerance. Follow-up CT scans showed partial resolution of the pulmonary infiltrates. BCG infection in the lungs must be taken into consideration in every patient treated with intra-vesical BCG instillations and symptoms of protracted infection.
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26
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Teoh JYC, Kamat AM, Black PC, Grivas P, Shariat SF, Babjuk M. Recurrence mechanisms of non-muscle-invasive bladder cancer - a clinical perspective. Nat Rev Urol 2022; 19:280-294. [PMID: 35361927 DOI: 10.1038/s41585-022-00578-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 12/24/2022]
Abstract
Non-muscle-invasive bladder cancer (NMIBC) is an early-stage cancer without invasion into the detrusor muscle layer. Transurethral resection of bladder tumour (TURBT) is a diagnostic and potentially curative procedure for NMIBC, but has some limitations, including difficulties in ascertaining complete tumour removal upon piecemeal resection and the possibility of tumour re-implantation after the procedure. The oncological control of NMIBC is far from satisfactory, with a 1-year recurrence rate of 15-61%, and a 5-year recurrence rate of 31-78%. Various recurrence mechanisms have been described for NMIBC, such as undetected tumours upon cystoscopy, incomplete resection during TURBT, tumour re-implantation after TURBT, drop metastasis from upper tract urothelial carcinoma and field change cancerization. Understanding the recurrence mechanisms from a clinical perspective has strong implications for the optimization of NMIBC oncological outcomes, as a cure for patients with NMIBC can only be achieved by tackling all possible recurrence mechanisms in a comprehensive manner.
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Affiliation(s)
- Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China. .,European Association of Urology-Young Academic Urologists (EAU-YAU) Urothelial Cancer Working Group, Amsterdam, Netherlands.
| | - Ashish M Kamat
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Petros Grivas
- Division of Oncology, Department of Medicine, University of Washington, Washington, USA.,Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Shahrokh F Shariat
- 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, Dallas, TX, USA.,Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia.,Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan.,Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic
| | - Marek Babjuk
- Department of Urology, Medical University of Vienna, Vienna, Austria.,Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic
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27
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Lobo N, Martini A, Kamat AM. Evolution of immunotherapy in the treatment of non-muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2022; 22:361-370. [PMID: 35212590 DOI: 10.1080/14737140.2022.2046466] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Immunotherapy with intravesical bacillus Calmette-Guérin (BCG) has been the gold standard treatment for intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC) for nearly half a century. Yet, many patients with high-risk disease will experience recurrence, including those who progress and eventually become unresponsive to BCG. For decades, apart from radical cystectomy, few therapeutic options existed for this at-risk population. However, the advent of novel immunotherapeutic agents has transformed treatment in a range of tumour types, including urothelial carcinoma. These immunotherapies have yielded promising results in the treatment of metastatic urothelial carcinoma and, as such, are also being investigated for use in NIMIBC. AREAS COVERED This article provides an overview of the evolution of immunotherapy for NMIBC, beginning from the original immunotherapy- BCG - to current agents including checkpoint inhibitors, IL-15 agonists, viral gene therapies and therapeutic cancer vaccines. EXPERT OPINION The KEYNOTE-057 trial represented a pivotal moment for immunotherapy in NMIBC, but patient selection and the development of biomarkers to guide the identification of patients who will benefit most from a particular immunotherapy remains critical. As research efforts come to fruition, novel immunotherapies may become integrated into the standard treatment paradigm for intermediate- and high-risk NMBIC.
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Affiliation(s)
- Niyati Lobo
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alberto Martini
- Department of Urology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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28
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Investigation of the causes of BCG refractory in patients treated with intracavitary BCG as secondary treatment in superficial bladder tumors with transurethral resection. Int Urol Nephrol 2022; 54:533-540. [PMID: 35032249 DOI: 10.1007/s11255-022-03104-9] [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: 11/07/2021] [Accepted: 12/31/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Non-muscle invasive bladder cancers (NMIBC) tend to recur and progress over time. Bacillus Calmette-Guerin (BCG) is an effective therapy for the treatment of NMIBC in that it reduces both recurrence and progression rates. The present study investigates the causes of BCG failure, with emphasis on those attributable to application errors by the practitioner and/or patient. METHODS The demographic and histopathological characteristics of 115 patients who underwent TUR-B for primary bladder tumors and who underwent intracavitary BCG in the postoperative period in the Urology Clinic of the İzmir Katip Çelebi University Atatürk Training and Research Hospital between January 2014 and January 2019, were analyzed retrospectively. BCG-refractory patients were compared with non-BCG refractory patients after BCG administration. RESULTS The extent of the tumor, and the involvement of the tumor in the bladder trigone and/or the bladder neck were found to increase significantly the likelihood of BCG refractory. When the micturition times of both groups were compared after instillation, the differences between the groups were found to be statistically significant. In the BCG-refractory patient group, the micturition time after instillation was shorter due to the tumor involvement in the trigone/bladder neck. CONCLUSION Some modifiable factors originating from the patient and the tumoral characteristics were found to have an effect on BCG failure. It was further determined that the time until micturition after BCG administration is an important parameter to be considered in the prevention of application deficiencies. We believe these factors should be subjected to careful consideration during patient selection and follow-up.
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29
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Chen CH, Kuo CC, Chiang BJ, Yu JY, Hsieh YT, Pu YS. The comparison of efficacy between the connaught and TICE strains of bacillus calmette-guerin in patients with non-muscle-invasive bladder cancer in Taiwan. UROLOGICAL SCIENCE 2022. [DOI: 10.4103/uros.uros_141_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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30
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Lee HY, Jung SI, Lim DG, Chung HS, Hwang EC, Kwon DD. Role of oral pentosan polysulfate in Bacillus Calmette–Guérin therapy in patients with non-muscle-invasive bladder cancer. Investig Clin Urol 2022; 63:539-545. [PMID: 36067999 PMCID: PMC9448676 DOI: 10.4111/icu.20220179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/17/2022] [Accepted: 07/27/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Intravesical Bacillus Calmette–Guérin (BCG) instillation, although an important treatment for non-muscle-invasive bladder cancer, exerts local and systemic adverse effects. Pentosan polysulfate (PPS) is a bladder mucosal protective drug that acts by replacing mucus in the glycosaminoglycan layer of the damaged urothelium. We hypothesized that co-administration of oral PPS with BCG instillation would relieve BCG-related adverse effects without affecting its efficacy. Materials and Methods A total of 217 patients receiving BCG instillation were enrolled. They were placed in two groups and analyzed retrospectively: group A (n=122) received BCG instillation only and group B (n=95) received 100 mg of PPS thrice daily during the BCG treatment. Results After BCG instillation, the rate of BCG-treatment discontinuation owing to adverse effects was 15.6% in group A and 6.3% in group B (p=0.034). The proportion of patients with bacteriuria after BCG was higher in group B; however, no statistical difference was observed (28.7% vs. 41.1%; p=0.057). The proportion of patients with pyuria was significantly higher in group B (81.1% vs. 91.6%; p=0.029). The proportion of patients using antibiotics was significantly higher in group A (73.8% vs. 43.2%; p=0.001). The recurrence rate within 1 year was 29 (23.8%) in group A vs. 19 (20.0%) in group B (p=0.507). Univariate and multivariate analyses showed that antibiotic use had a statistically significant effect on BCG discontinuation. Conclusions Oral PPS effectively decreased the discontinuation rate and antibiotic use without affecting the BCG efficacy.
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Affiliation(s)
- Ho Yeon Lee
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Seung Il Jung
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Do Gyeong Lim
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Ho Seok Chung
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
| | - Dong Deuk Kwon
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea
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Lobo N, Hensley PJ, Bree KK, Nogueras-Gonzalez GM, Navai N, Dinney CP, Sylvester RJ, Kamat AM. Updated European Association of Urology (EAU) Prognostic Factor Risk Groups Overestimate the Risk of Progression in Patients with Non-muscle-invasive Bladder Cancer Treated with Bacillus Calmette-Guérin. Eur Urol Oncol 2021; 5:84-91. [PMID: 34920986 DOI: 10.1016/j.euo.2021.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/07/2021] [Accepted: 11/17/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The 2021 European Association of Urology (EAU) guidelines contain updated prognostic factor risk groups for non-muscle-invasive bladder cancer (NMIBC). These groups are based on the following predictors of progression: tumour stage, grade, number, and size; concomitant carcinoma in situ; and age. However, the groups were derived from datasets excluding patients treated with bacillus Calmette-Guérin (BCG). OBJECTIVE To determine the validity of the updated EAU prognostic factor risk groups in patients with NMIBC treated with BCG. DESIGN, SETTING, AND PARTICIPANTS We reviewed patients treated with BCG at our institution between 2000 and 2018. Patients were analysed according to the receipt of "at least induction" and "adequate" BCG (as defined by the US Food and Drug Administration). Risk groups were assigned according to the 2021 EAU NMIBC risk calculator (https://nmibc.net/). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The Kaplan-Meier method was used to estimate the risks of progression at 1 and 5 yr. Probabilities of progression obtained with the updated prognostic factor risk groups in our series were compared with those reported by the EAU. Discrimination was assessed using the concordance index (c-index). RESULTS AND LIMITATIONS A total of 529 patients received at least induction BCG with a median follow-up of 47.3 mo (interquartile range 25.3-86.9). Of these patients, 494 received adequate BCG. We found lower progression rates at 1 yr in the very-high-risk group patients receiving at least induction (6.9%) and adequate BCG (4.0%) versus 16.0% for the EAU predicted rates. Additionally, progression rates were also lower at 5 yr in the high-risk group-7.4% for at least induction and 5.3% for adequate BCG versus 9.6% for EAU predicted rates; the rates in the very-high-risk group were as follows: 16.7% for at least induction and 14.9% for adequate BCG versus 40.0% for EAU predicted rates. The c-index in our series was lower than that reported by the EAU (0.63 vs 0.80). Of interest, our multivariable analysis identified grade, stage, and age (p < 0.02) to be the predictors of progression after BCG therapy. CONCLUSIONS While the 2021 EAU prognostic factor risk groups successfully stratified progression risks in our cohort, treatment with BCG reduced their discriminative ability. Furthermore, the groups overestimate progression risks in BCG-treated patients. These findings should be used in conjunction with the updated risk groups to counsel patients with higher-risk NMIBC about their risk of progression with and without BCG. PATIENT SUMMARY Although the updated European Association of Urology prognostic factor risk groups are able to stratify patients with non-muscle-invasive bladder cancer according to their risk of progression to muscle-invasive bladder cancer, this risk is overestimated in patients treated with bacillus Calmette-Guérin (BCG).
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Affiliation(s)
- Niyati Lobo
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick J Hensley
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Bree
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Neema Navai
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Colin P Dinney
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Lobo N, Hensley PJ, Bree KK, Nogueras-Gonzalez GM, Navai N, Dinney CP, Kamat AM. Should patients with non-muscle-invasive bladder cancer discontinue fibrin clot inhibitors during bacille Calmette-Guérin? BJU Int 2021; 130:463-469. [PMID: 34854189 DOI: 10.1111/bju.15665] [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: 11/30/2022]
Abstract
OBJECTIVE To determine the impact of fibrin clot inhibitor (FCI) use on oncological outcomes in a large contemporary cohort of patients with non-muscle-invasive bladder cancer (NMIBC) treated with adequate bacille Calmette-Guérin (BCG). PATIENTS AND METHODS We performed an Institutional Review Board-approved review of patients with NMIBC treated with adequate intravesical BCG, at our institution between 2000 and 2018. FCI use at the time of BCG therapy was recorded for each patient. Patients were stratified according to use of FCI medication. Recurrence- and progression-free survival were analysed using Kaplan-Meier methods and Cox proportional hazard models. RESULTS Overall, 226 of 526 patients (43.0%) used a FCI: aspirin (205), clopidogrel (38), warfarin (18) and novel oral anticoagulant (NOAC; seven). The use of FCIs did not adversely affect either recurrence- or progression-free survival (P = 0.385 and P = 0.131, respectively). These results did not change when the impact of aspirin, clopidogrel or warfarin/NOAC use on recurrence and progression was evaluated separately. On multivariate analysis, FCI use was neither associated with tumour recurrence nor progression. CONCLUSION The use of FCIs was not associated with adverse oncological outcomes in a large contemporary cohort of patients receiving adequate intravesical BCG for NMIBC. Based on these results, FCIs may be safely continued during BCG immunotherapy.
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Affiliation(s)
- Niyati Lobo
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick J Hensley
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Bree
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Neema Navai
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Colin P Dinney
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lobo N, Bree KK, Hensley PJ, Nogueras-Gonzalez GM, Abraham P, Navai N, Dinney CP, Kamat AM. Reduced-dose bacillus Calmette-Guérin (BCG) in an era of BCG shortage: real-world experience from a tertiary cancer centre. BJU Int 2021; 130:323-330. [PMID: 34847263 DOI: 10.1111/bju.15661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the impact of one-third-dose (1/3D) bacillus Calmette-Guérin (BCG) on oncological outcomes in a large cohort of patients with non-muscle-invasive bladder cancer (NMIBC) treated with adequate BCG (as defined by the US Food & Drug Administration (FDA)) in a real-world setting. PATIENTS AND METHODS We performed an institutional review board-approved review of patients with NMIBC treated with adequate BCG at our institution between 2000 and 2020. Patients were stratified according to whether they had received 1/3D BCG or full-dose (FD) BCG. Time to recurrence, time to progression and cancer-specific survival were estimated using Kaplan-Meier methods. RESULTS Of 563 patients with NMIBC treated with adequate BCG, 150 (26.6%) received 1/3D and 413 (73.4%) received FD. The use of 1/3D BCG did not adversely affect time to recurrence (P = 0.449) or time to progression (P = 0.716), and this remained consistent when patients were stratified by individual 2021 European Association of Urology (EAU) prognostic factor risk groups. Cancer-specific survival was similar in patients receiving 1/3D and those receiving FD BCG (P = 0.320). CONCLUSION The use of 1/3D BCG was not associated with adverse oncological outcomes in a large cohort of patients receiving adequate BCG for intermediate- and high-risk NMIBC. Based on this real-world experience, risk-stratified split-vial dosing may represent a valuable approach for other institutions facing BCG shortages whilst also providing reassurance to patients who may be concerned about suboptimal outcomes.
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Affiliation(s)
- Niyati Lobo
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Bree
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick J Hensley
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Prasanth Abraham
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neema Navai
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Colin P Dinney
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Effect of Traditional Chinese Medicine Combined with Bladder Perfusion with Hydroxycamptothecin on Color Ultrasound and Clinical Efficacy in Patients with Bladder Cancer Surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:7178414. [PMID: 34795788 PMCID: PMC8594995 DOI: 10.1155/2021/7178414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022]
Abstract
Objective To observe the clinical effect of Xiaozheng Decoction combined with bladder perfusion with hydroxycamptothecin in the treatment of bladder cancer. Methods A total of 92 bladder cancer patients admitted to our hospital from January to December 2018 were selected and divided into an observation group and a control group according to the random number table method, with 46 cases in each group. The observation group was given Xiaozheng Decoction combined with bladder perfusion with hydroxycamptothecin, and the control group was given hydroxycamptothecin. The levels of serum-related factors (intercellular adhesion molecule-1 (ICAM-1), E-cadherin, cell adhesion molecules (CAM), fibroblast growth factor (FGF), and vascular endothelial growth factor (VEGF)), white blood cell (WBC) level, immune function indexes, short-term total response rate, and incidence of adverse reactions were compared between the two groups before and after treatment. Results After 2 years of postoperative treatment, the levels of ICAM-1, E-cadherin, CAM-1, FGF, and VEGF (a, b, c) in both groups were improved compared with those before treatment and the observation group was better than the control group (p < 0.01). The number of WBCs was significantly higher than in the control group after Traditional Chinese Medicine (TCM) treatment. The observation group was better than the control group in increasing CD3+ and CD4+ levels and decreasing CD8+ level (p < 0.05), indicating that this prescription could improve the immune function of patients. The recurrence rate in the observation group was 6.52% after 2 years of treatment, lower than 17.39% in the control group. Color ultrasound parameters showed that there were no statistically significant differences in arrive time (AT) and time to peak (TTP) between patients with and without recurrence and peak intensity (PI) and washout time (WT) were higher in patients with recurrence than in patients without recurrence (p < 0.01). The incidence of adverse reactions was significantly lower than that of the control group (p < 0.01). Conclusion The clinical effect of Xiaozheng Decoction combined with hydroxycamptothecin on the treatment of bladder cancer was clear and superior to that of hydroxycamptothecin, which could effectively improve the serological indicators of patients with a low incidence of adverse reactions and prolong the survival cycle of patients. Therefore, it is worthy of promotion and application.
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Mao C, Xu X, Ding Y, Xu N. Optimization of BCG Therapy Targeting Neutrophil Extracellular Traps, Autophagy, and miRNAs in Bladder Cancer: Implications for Personalized Medicine. Front Med (Lausanne) 2021; 8:735590. [PMID: 34660642 PMCID: PMC8514698 DOI: 10.3389/fmed.2021.735590] [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: 07/02/2021] [Accepted: 08/05/2021] [Indexed: 01/07/2023] Open
Abstract
Bladder cancer (BC) is the ninth most common cancer and the thirteenth most common cause of mortality worldwide. Bacillus Calmette Guerin (BCG) instillation is a common treatment option for BC. BCG therapy is associated with the less adversary effects, compared to chemotherapy, radiotherapy, and other conventional treatments. BCG could inhibit the progression and recurrence of BC by triggering apoptosis pathways, arrest cell cycle, autophagy, and neutrophil extracellular traps (NETs) formation. However, BCG therapy is not efficient for metastatic cancer. NETs and autophagy were induced by BCG and help to suppress the growth of tumor cells especially in the primary stages of BC. Activated neutrophils can stimulate autophagy pathway and release NETs in the presence of microbial pathogenesis, inflammatory agents, and tumor cells. Autophagy can also regulate NETs formation and induce production of reactive oxygen species (ROS) and NETs. Moreover, miRNAs are important regulator of gene expression. These small non-coding RNAs are also considered as an essential factor to control the levels of tumor development. However, the interaction between BCG and miRNAs has not been well-understood yet. Therefore, the present study discusses the roles of miRNAs in regulations of autophagy and NETs formation in BCG therapy in the treatment of BC. The roles of autophagy and NETs formation in BC treatment and efficiency of BCG are also discussed.
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Affiliation(s)
- Chenyu Mao
- Department of Medical Oncology Cancer Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xin Xu
- Department of Medical Oncology Cancer Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yongfeng Ding
- Department of Medical Oncology Cancer Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Nong Xu
- Department of Medical Oncology Cancer Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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COVID-19 and Beyond: Exploring Public Health Benefits from Non-Specific Effects of BCG Vaccination. Microorganisms 2021; 9:microorganisms9102120. [PMID: 34683441 PMCID: PMC8539044 DOI: 10.3390/microorganisms9102120] [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: 09/14/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 12/23/2022] Open
Abstract
Bacille Calmette–Guérin (BCG) vaccination, widely used throughout the world to protect against infant tuberculous meningitis and miliary tuberculosis (TB), can provide broad non-specific protection against infectious respiratory diseases in certain groups. Interest in BCG has seen a resurgence within the scientific community as the mechanisms for non-specific protection have begun to be elucidated. The impact of the COVID-19 pandemic on nearly every aspect of society has profoundly illustrated the pressure that respiratory infections can place on a national healthcare system, further renewing interest in BCG vaccination as a public health policy to reduce the burden of those illnesses. However, the United States does not recommend BCG vaccination due to its variable effectiveness against adult TB, the relatively low risk of Mycobacterium tuberculosis infection in most of the United States, and the vaccine’s interference with tuberculin skin test reactivity that complicates TB screening. In this review, we explore the broad immune training effects of BCG vaccination and literature on the effects of BCG vaccination on COVID-19 spread, disease severity, and mortality. We further discuss barriers to scheduled BCG vaccination in the United States and how those barriers could potentially be overcome.
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Lobo N, Brooks NA, Zlotta AR, Cirillo JD, Boorjian S, Black PC, Meeks JJ, Bivalacqua TJ, Gontero P, Steinberg GD, McConkey D, Babjuk M, Alfred Witjes J, Kamat AM. 100 years of Bacillus Calmette-Guérin immunotherapy: from cattle to COVID-19. Nat Rev Urol 2021; 18:611-622. [PMID: 34131332 PMCID: PMC8204595 DOI: 10.1038/s41585-021-00481-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 02/07/2023]
Abstract
Bacillus Calmette-Guérin (BCG) is the most widely used vaccine worldwide and has been used to prevent tuberculosis for a century. BCG also stimulates an anti-tumour immune response, which urologists have harnessed for the treatment of non-muscle-invasive bladder cancer. A growing body of evidence indicates that BCG offers protection against various non-mycobacterial and viral infections. The non-specific effects of BCG occur via the induction of trained immunity and form the basis for the hypothesis that BCG vaccination could be used to protect against the severity of coronavirus disease 2019 (COVID-19). This Perspective article highlights key milestones in the 100-year history of BCG and projects its potential role in the COVID-19 pandemic.
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Affiliation(s)
- Niyati Lobo
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Nathan A Brooks
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Alexandre R Zlotta
- Division of Urology, Department of Surgery, Sinai Health System, University of Toronto, Toronto, ON, Canada
- Department of Surgical Oncology, Division of Urology, Princess Margaret Cancer Centre, University of Toronto and University Health Network, Toronto, ON, Canada
| | - Jeffrey D Cirillo
- Department of Microbial Pathogenesis and Immunology, Texas A&M Health Science Center, Bryan, TX, USA
| | | | | | - Joshua J Meeks
- Northwestern University School of Medicine, Chicago, IL, USA
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Paolo Gontero
- Division of Urology, Molinette Hospital, University of Torino School of Medicine, Torino, Italy
| | | | - David McConkey
- Johns Hopkins Greenberg Bladder Cancer Institute, Brady Urological Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA.
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Sun K, Wang D, Wu G, Ma J, Wang T, Wu J, Wang J. Mirabegron improves the irritative symptoms caused by BCG immunotherapy after transurethral resection of bladder tumors. Cancer Med 2021; 10:7534-7541. [PMID: 34547193 PMCID: PMC8559481 DOI: 10.1002/cam4.4278] [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: 07/27/2021] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aims to explore the efficacy and safety of mirabegron in treating irritative symptoms induced by intravesical immunotherapy with Bacillus Calmette-Guerin (BCG) after transurethral resection of bladder tumors (TURBT). METHODS A total of 160 patients subjected to TURBT was randomly divided into the mirabegron group and placebo group with 80 patients in each group. Then, the patients were administered 25 mg mirabegron or placebo daily, starting the first day after BCG infusion. The first BCG perfusion was conducted at least 2 weeks after TURBT. The 3-day bladder diaries were completed in all patients, 1 day before BCG perfusion, and on the 1st, 6th, and 13th days after the first BCG perfusion. Overactive bladder symptom scores were completed 1 day before BCG perfusion, and on the 6th and 13th days after the first BCG perfusion. RESULTS Symptom scores of bladder hyperactivity were significantly different between the two groups (p < 0.001). Also, the frequency of nocturia, pollakiuria, micturition urgency, urinary incontinence and was significantly lower in group 1 than that in group two (p < 0.05). CONCLUSION Our findings demonstrate that mirabegron is a valuable clinical drug for the management of irritative symptoms after TURBT with subsequent intravesical BCG perfusion.
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Affiliation(s)
- Kai Sun
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Di Wang
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Gang Wu
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Jian Ma
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Tianqi Wang
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Jitao Wu
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Jipeng Wang
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
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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: 534] [Impact Index Per Article: 178.0] [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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Pijpers OM, Hendricksen K, Mostafid H, de Jong FC, Rosier M, Mayor N, de Jong JJ, Boormans JL. Long-term efficacy of hyperthermic intravesical chemotherapy for BCG-unresponsive non-muscle invasive bladder cancer. Urol Oncol 2021; 40:62.e13-62.e20. [PMID: 34470725 DOI: 10.1016/j.urolonc.2021.07.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/05/2021] [Accepted: 07/14/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND The recommended treatment for patients with Bacillus Calmette-Guérin (BCG) unresponsive non-muscle invasive bladder cancer (NMIBC) is radical cystectomy (RC). However, many patients refuse, or are unfit for RC. Therefore, alternative bladder-sparing treatment modalities are needed for BCG-unresponsive NMIBC. In this study we sought to assess the long-term efficacy of hyperthermic intravesical chemotherapy (HIVEC) as alternative to radical cystectomy in BCG-unresponsive non-muscle invasive bladder cancer patients. METHODS AND MATERIALS Retrospectively collected data from 56 patients with BCG-unresponsive NMIBC who received ≥5 HIVEC instillations between October 2014 and March 2020 was analyzed. All patients met the BCG-unresponsive criteria according to the current EAU guideline on NMIBC 2020. Patients were followed-up with cystoscopy and/or bladder biopsies, urine cytology and annually CT-urography. The Primary outcome was the high grade (HG) recurrence-free survival (RFS), defined as the time from the first HIVEC instillation until histologically confirmed intravesical recurrence or last follow-up. The Kaplan Meier method was used to estimate survival outcomes. Secondary outcomes were: complete response rate (CR), adverse events (AE), assessed by the Common Terminology Criteria for Adverse Events v5.0 (CTCAE) and tumor progression to muscle invasive disease or distant metastases. RESULTS The median follow-up was 32.2 months (IQR 13.7-44.8). The 1- and 2-year HG-RFS was 53% (SE:6.8) and 35% (SE:6.9), respectively. The CR for patients with CIS was 70% (21/30) at 6 months. Overall, 80% of the population developed an AE, only 1 was classified as CTCAE ≥3. Limitation of this study was the small sample size. CONCLUSION HIVEC resulted in a 2-year HG-RFS of 35% for BCG-unresponsive NMIBC patients without severe side-effects and therefore HIVEC seems to be an alternative treatment option for patients who refuse or are unfit for RC.
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Affiliation(s)
- Olga M Pijpers
- Department of Urology, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Kees Hendricksen
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Hugh Mostafid
- Department of Urology, Royal Surrrey County Hospital, Guildford, United Kingdom
| | - Florus C de Jong
- Department of Urology, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marloes Rosier
- Department of Urology, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nikhil Mayor
- Department of Urology, Royal Surrrey County Hospital, Guildford, United Kingdom
| | - Joep J de Jong
- Department of Urology, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Joost L Boormans
- Department of Urology, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, The Netherlands.
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Effectiveness of Steroid Pulse Therapy for Systemic Side Effects after Bacillus Calmette-Guérin Intravesical Instillation Therapy: A Series of Five Cases. Case Rep Urol 2021; 2021:5548054. [PMID: 34336352 PMCID: PMC8286186 DOI: 10.1155/2021/5548054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction Bacillus Calmette-Guérin (BCG) instillation is an established therapy for the treatment of carcinoma in situ (CIS) of the bladder and prevention of recurrence after transurethral resection of bladder tumor noninvasive bladder cancer. However, serious systemic side effects may occur in less than 5% of patients with BCG intravesical instillation. Systemic side effects can sometimes be fatal and require early and accurate treatment. We describe five cases wherein steroid pulse therapy was effective for treating the systemic side effects after BCG intravesical instillation. Case Presentations. BCG intravesical instillation was used to prevent the recurrence of nonmuscle invasive bladder cancer and treat CIS of the bladder; the dose used was 40–80 mg each time, and the Tokyo strain was used. The patients developed fever, impaired consciousness, arthralgia, conjunctival hyperemia, and symptoms of cystitis. The median time from installation to side effect manifestation was 6 days (0–8). One to two courses of steroid pulse therapy were administered (1 course in 3 days), and the dose of methylprednisolone was 500–1000 mg/day. BCG sepsis was observed in one case; however, in the other four cases, one course of steroid pulse therapy showed a rapid improvement in symptoms. In the case of BCG sepsis, hemodialysis and mechanical ventilation were required because of septic shock and acute renal failure. Antituberculosis drugs (isoniazid, rifampicin, and ethambutol) were started promptly; however, no improvement was noticed. Two courses of steroid pulse therapy improved the patient's general condition, and hemodialysis and mechanical ventilation were no longer required. All patients survived without relapse of symptoms. Conclusion Our cases suggest that early steroid pulse therapy may be effective for rapid symptom improvement of the systemic side effects of BCG instillation therapy.
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Kuperus JM, Busman RD, Kuipers SK, Broekhuizen HT, Noyes SL, Brede CM, Tobert CM, Lane BR. Comparison of Side Effects and Tolerability Between Intravesical Bacillus Calmette-Guerin, Reduced-Dose BCG and Gemcitabine for Non-Muscle Invasive Bladder Cancer. Urology 2021; 156:191-198. [PMID: 34217763 DOI: 10.1016/j.urology.2021.04.062] [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: 02/11/2021] [Revised: 03/28/2021] [Accepted: 04/01/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare patient-reported side effects and tolerability of full-dose Bacillus Calmette-Guérin (BCG), reduced-dose BCG, and gemcitabine one week after administration. METHODS All patients from July 2019 to November 2020 receiving intravesical therapy (IVT) for non-muscle invasive bladder cancer (NMIBC) at our institution were surveyed before repeat instillation. Survey questions recorded IVT retention times and the duration and severity of the following side effects: bladder symptoms, fatigue, body aches, hematuria, fever, chills, and other. All responses were collected and quantified in a de-identified, password-protected database. Statistical analysis was performed using SAS JMP 13. RESULTS Of 592 surveys completed, symptoms of any kind were reported on 463 surveys (78%) with the most common symptoms including bladder symptoms (59%), fatigue (52%), body aches (26%), and hematuria (18%). Patients were able to hold full-dose BCG, reduced-dose BCG, and gemcitabine for the protocol-specified duration 87%, 95%, and 71% of the time (P <0.05). The prevalence, severity, and duration of body aches were highest with gemcitabine (P <0.05) while the prevalence and duration of hematuria were higher with BCG (P <0.05). Reduced-dose BCG had the lowest prevalence, severity, and duration of fatigue (P <0.05). CONCLUSION Significant differences in the side effects and tolerability of full-dose BCG, reduced-dose BCG, and gemcitabine were demonstrated using this novel survey, and these differences are of value for informing IVT selection. Evaluation of IVTs other than gemcitabine and BCG will further inform selection of therapies for NMIBC.
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Affiliation(s)
| | - Ross D Busman
- Spectrum Health Hospital System, Grand Rapids, MI, 49503
| | | | | | | | - Christopher M Brede
- Spectrum Health Hospital System, Grand Rapids, MI, 49503; Michigan State University College of Human Medicine, East Lansing, MI, 48824
| | - Conrad M Tobert
- Spectrum Health Hospital System, Grand Rapids, MI, 49503; Michigan State University College of Human Medicine, East Lansing, MI, 48824
| | - Brian R Lane
- Spectrum Health Hospital System, Grand Rapids, MI, 49503; Michigan State University College of Human Medicine, East Lansing, MI, 48824.
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Patel A, Bisno DI, Patel HV, Ghodoussipour S, Saraiya B, Mayer T, Singer EA. Immune Checkpoint Inhibitors in the Management of Urothelial Carcinoma. JOURNAL OF CANCER IMMUNOLOGY 2021; 3:115-136. [PMID: 34263255 PMCID: PMC8276975 DOI: 10.33696/cancerimmunol.3.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Urothelial carcinoma is one of the most common cancers in the United States, yet outcomes are historically suboptimal. Since 2016, the approval of five programmed cell death 1 and programmed death-ligand 1 immune checkpoint inhibitors for locally advanced and metastatic urothelial carcinoma has led to improved oncologic outcomes for many patients in the second-line setting. Two checkpoint inhibitors, pembrolizumab and atezolizumab subsequently earned approval for first-fine therapy with restricted indications. More recently, pembrolizumab was approved for bacillus Calmette-Guérin-unresponsive high-risk non-muscle invasive bladder cancer, opening the door for other immune checkpoint inhibitors to be integrated into treatment in earlier disease stages. Recent bacillus Calmette-Guérin shortages have highlighted the need for alternative treatment options for patients with non-muscle invasive bladder cancer. Currently, there are no FDA-approved checkpoint inhibitors for non-metastatic muscle-invasive bladder cancer. Furthermore, many patients are ineligible for standard cisplatin-based chemotherapy regimens. Numerous ongoing clinical trials are employing immune checkpoint inhibitors for muscle-invasive bladder cancer patients in the neoadjuvant, adjuvant, perioperative, and bladder-sparing setting. Although up to 10% of urothelial carcinoma tumors arise in the upper urinary tract, few studies are designed for this population. We highlight the need for more trials designed for patients with upper tract disease. Overall, there are numerous clinical trials investigating the safety and efficacy of immune checkpoint inhibitors in all stages of disease as single-agents and combined with dual-immune checkpoint inhibition, chemotherapy, radiotherapy, and other pharmacologic agents. As the field continues to evolve rapidly, we aim to provide an overview of recent and ongoing immunotherapy clinical trials in urothelial carcinoma.
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Affiliation(s)
- Aakash Patel
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Daniel I Bisno
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Hiren V Patel
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.,Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA
| | - Saum Ghodoussipour
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.,Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA
| | - Biren Saraiya
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.,Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA
| | - Tina Mayer
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.,Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA
| | - Eric A Singer
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.,Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08903, USA
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Plonowska‐Hirschfeld KA, Fung M, Glastonbury C, Ha PK. Parapharyngeal tuberculoid mass: A rare complication of Bacillus Calmette-Guérin therapy for urothelial carcinoma in situ. Clin Case Rep 2021; 9:e04172. [PMID: 34194767 PMCID: PMC8222752 DOI: 10.1002/ccr3.4172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/28/2021] [Accepted: 03/27/2021] [Indexed: 01/22/2023] Open
Abstract
Local and systemic complications of Bacillus Calmette-Guérin therapy are important to recognize as they require prolonged antimicrobial therapy; molecular genomic testing may be key to diagnosis when culture data are inconclusive.
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Affiliation(s)
| | - Monica Fung
- Department of Medicine – Infectious DiseaseUniversity of California‐San FranciscoSan FranciscoCAUSA
| | - Christine Glastonbury
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of California‐San FranciscoSan FranciscoCAUSA
- Department of Clinical RadiologyUniversity of California‐San FranciscoSan FranciscoCAUSA
| | - Patrick K. Ha
- Department of Otolaryngology‐Head and Neck SurgeryUniversity of California‐San FranciscoSan FranciscoCAUSA
- Division of Head and Neck Surgical OncologyDepartment of Otolaryngology‐Head and Neck SurgeryUniversity of California‐San FranciscoSan FranciscoCAUSA
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Moe A, Liow E, Redfern A, Swarbrick N, Ferguson T, Davis ID, Hayne D. A phase I open label dose-escalation study to evaluate the tolerability, safety and immunological efficacy of sub-urothelial durvalumab injection in adults with muscle-invasive or high-risk non-muscle-invasive bladder cancer (SUBDUE-1, SUB-urothelial DUrvalumab injection-1 study): clinical trial protocol. BJU Int 2021; 128 Suppl 1:9-17. [PMID: 33960102 DOI: 10.1111/bju.15365] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES This article presents the clinical trial protocol for a phase I open label dose-escalation study to evaluate the tolerability, safety and immunological efficacy of sub-urothelial durvalumab injection in adults with muscle-invasive or high-risk non-muscle-invasive bladder cancer (NMIBC), the SUB-urothelial DUrvalumab injection-1 study (SUBDUE-1). The primary objectives of this study are to assess the safety of sub-urothelial injection of durvalumab using patient reported outcome measures and observed local or systemic adverse events. The secondary objectives are to examine the local immunological efficacy of sub-urothelial administration of durvalumab. PATIENTS AND METHODS The SUBDUE-1 trial will include adult patients with either high-risk NMIBC or MIBC, who are scheduled for radical cystectomy or who have refused or are unsuitable for systemic neoadjuvant chemotherapy. Three fixed total dose levels of durvalumab (25, 75, 150 mg) will be studied to identify a dose suitable to be taken forward into phase II trials. The primary endpoint is to evaluate the safety and tolerability of the trial intervention in terms of the incidence and severity of adverse events and the potential establishment of dose-limiting toxicities. The secondary efficacy endpoints include rates of pT0 status at resection, lymph node status, as well as the change in distribution of tumour-infiltrating lymphocytes and tumour-activated macrophages between pre- and post-injection bladder biopsies. Translational studies will focus on bladder tumour molecular sub-typing, immune infiltrate characterisation, and immune checkpoint protein expression relative to efficacy end-points. OUTCOME AND SIGNIFICANCE If proven safe and effective, this novel strategy comprising sub-urothelial durvalumab injections aimed at promoting an anti-tumour immune reaction, will provide additional treatment options for reducing tumour recurrence and progression in treatment-naïve patients with high-risk NMIBC or in patients with bacille Calmette-Guérin-refractory NMIBC. Local administration of durvalumab may be associated with a reduced rate of immunological side-effects and lower costs when compared to systemic delivery.
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Affiliation(s)
- Andrew Moe
- University of Western Australia (UWA) Medical School, University of Western Australia, Perth, WA, Australia.,Urology and Medical Oncology Departments, South Metropolitan Health Service, Perth, WA, Australia.,Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia
| | - Elizabeth Liow
- Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia
| | - Andrew Redfern
- University of Western Australia (UWA) Medical School, University of Western Australia, Perth, WA, Australia.,Urology and Medical Oncology Departments, South Metropolitan Health Service, Perth, WA, Australia.,Cancer Division, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - Nicole Swarbrick
- Department of Anatomical Pathology, PathWest Laboratory Medicine WA, Perth, WA, Australia.,Division of Pathology and Laboratory Medicine, UWA Medical School, University of Western Australia, Perth, WA, Australia
| | - Tom Ferguson
- Urology and Medical Oncology Departments, South Metropolitan Health Service, Perth, WA, Australia
| | - Ian D Davis
- Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Vic., Australia.,Department of Oncology, Eastern Health, Melbourne, Vic., Australia
| | - Dickon Hayne
- University of Western Australia (UWA) Medical School, University of Western Australia, Perth, WA, Australia.,Urology and Medical Oncology Departments, South Metropolitan Health Service, Perth, WA, Australia.,Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia
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Thyavihally YB, Dev P, Waigankar S, Pednekar A, Athikari N, Raut A, Khandekar A, Badlani N, Asari A. Intravesical bacillus Calmette-Guerin (BCG) in treating non-muscle invasive bladder cancer—analysis of adverse effects and effectiveness of two strains of BCG (Danish 1331 and Moscow). Asian J Urol 2021; 9:157-164. [PMID: 35509489 PMCID: PMC9051354 DOI: 10.1016/j.ajur.2021.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 10/26/2020] [Accepted: 02/07/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To compare the differences in adverse effects and efficacy profile between bacillus Calmette-Guerin (BCG) Danish 1331 and BCG Moscow-I strain in management of non-muscle invasive bladder cancer. Methods Clinical data of 188 cases of non-muscle invasive bladder cancer treated with BCG between January 2008 and December 2018 in our institute were collected prospectively and analysed retrospectively, and 114 patients who completed a minimum of 12 months of follow-up were analysed. Patient and tumor characteristics, strain of BCG, adverse effects, and tumor progression were included for analysis. Intravesical BCG was instilled in intermediate- and high-risk patients. Six weeks of induction BCG, followed by three weekly maintenance BCG at 3, 6, 12, 18, and 24 months was advised in high-risk patients. Results Overall 68 patients received BCG Danish 1331 strain and 46 patients received Moscow-I strain. Patient and tumor characteristics were well balanced between the two groups. The median follow-up period was 42.5 months and 34.5 months in Danish 1331 and Moscow-I groups, respectively. Adverse events like dropout rate, antitubercular treatment requirement, and need of cystectomy were higher in Moscow-I group (n=31, 67.4%) when compared to Danish 1331 strain (n=33, 48.5%) (p=0.046). On direct comparison between Danish 1331 and Moscow-I strain, there was similar 3-year recurrence-free survival (80.0% vs. 72.9%) and 3-year progression-free survival (96.5% vs. 97.8%). Conclusion Study results suggest no significant differences between Danish 1331 and Moscow-I strain in recurrence-free survival and progression-free survival, but a significantly higher incidence of moderate to severe adverse events in BCG Moscow-I strain.
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Wigner P, Grębowski R, Bijak M, Saluk-Bijak J, Szemraj J. The Interplay between Oxidative Stress, Inflammation and Angiogenesis in Bladder Cancer Development. Int J Mol Sci 2021; 22:ijms22094483. [PMID: 33923108 PMCID: PMC8123426 DOI: 10.3390/ijms22094483] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/18/2021] [Accepted: 04/22/2021] [Indexed: 02/07/2023] Open
Abstract
In 2018, 550,000 people were diagnosed with bladder cancer (BC), of which nearly 200,000 people died. Moreover, men are 4 times more likely than women to be diagnosed with BC. The risk factors include exposure to environmental and occupational chemicals, especially tobacco smoke, benzidine and genetic factors. Despite numerous studies, the molecular basis of BC development remains unclear. A growing body of evidence suggests that inflammation, oxidant-antioxidant imbalance and angiogenesis disorders may play a significant role in the development and progression of bladder cancer. The patients with bladder cancer were characterised by an increased level of reactive oxygen species (ROS), the products of lipid peroxidation, proinflammatory cytokines and proangiogenic factors as compared to controls. Furthermore, it was shown that polymorphisms localised in genes associated with these pathways may modulate the risk of BC. Interestingly, ROS overproduction may induce the production of proinflammatory cytokines, which finally activated angiogenesis. Moreover, the available literature shows that both inflammation and oxidative stress may lead to activation of angiogenesis and tumour progression in BC patients.
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Affiliation(s)
- Paulina Wigner
- Department of General Biochemistry, Faculty of Biology and Environmental Protection, University of Lodz, 90-236 Lodz, Poland;
- Correspondence: ; Tel.: +48-42-635-44-85; Fax: +48-42-635-44-84
| | - Radosław Grębowski
- Department of Urology, Provincial Integrated Hospital in Plock, 09-400 Plock, Poland;
- Department of Medical Biochemistry, Medical University of Lodz, 92-216 Lodz, Poland;
| | - Michał Bijak
- Biohazard Prevention Centre, Faculty of Biology and Environmental Protection, University of Lodz, 90-236 Lodz, Poland;
| | - Joanna Saluk-Bijak
- Department of General Biochemistry, Faculty of Biology and Environmental Protection, University of Lodz, 90-236 Lodz, Poland;
| | - Janusz Szemraj
- Department of Medical Biochemistry, Medical University of Lodz, 92-216 Lodz, Poland;
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First time intravesically administered trifunctional antibody catumaxomab in patients with recurrent non-muscle invasive bladder cancer indicates high tolerability and local immunological activity. Cancer Immunol Immunother 2021; 70:2727-2735. [PMID: 33837852 PMCID: PMC8360869 DOI: 10.1007/s00262-021-02930-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/26/2021] [Indexed: 11/30/2022]
Abstract
Transurethral resection of the tumor (TUR-B) followed by adjuvant intravesical treatment with cytostatic drugs or Bacillus Calmette–Guérin (BCG) as standard therapy of non-muscle-invasive bladder cancer (NMIBC) is associated with a high recurrence rate of about 60–70%, considerable side effects and requires close monitoring. Alternative treatment options are warranted. Two patients with epithelial cell adhesion molecule (EpCAM)-positive recurrent non-muscle invasive bladder cancer were treated the first time by an intravesical administration of the trifunctional bispecific EpCAM targeting antibody catumaxomab (total dosage of 470 and 1120 µg, respectively). The binding and killing activity of catumaxomab in urine milieu was evaluated in vitro. In contrast to its previous systemic application catumaxomab was well tolerated without any obvious signs of toxicity. Relevant cytokine plasma levels were not detected and no significant systemic drug release was observed. The induction of a human anti-mouse-antibody (HAMA) reaction was either absent or untypically weak contrary to the high immunogenicity of intraperitoneal applied catumaxomab. Tumor cells that were detectable in urine patient samples disappeared after catumaxomab therapy. Endoscopically confirmed recurrence-free intervals were 32 and 25 months. Our data suggest that intravesical administration of catumaxomab in NMIBC is feasible, safe and efficacious, thus arguing for further clinical development of catumaxomab in this indication.
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Rodrigues Pessoa R, Mueller AC, Boxley P, Flaig TW, Piper C, Konety B, Yu JB, Gershman B, Kukreja J, Kim SP. Systematic review and meta-analysis of radiation therapy for high-risk non-muscle invasive bladder cancer. Urol Oncol 2021; 39:786.e1-786.e8. [PMID: 33846085 DOI: 10.1016/j.urolonc.2021.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/28/2021] [Accepted: 03/14/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Radiation therapy (XRT) has been investigated as a possible treatment for high-risk non-muscle invasive bladder cancer (NMIBC) with the goal of bladder preservation, especially with the ongoing Bacillus Calmette-Guerin (BCG) shortage. Yet, little is known about the clinical efficacy and the quality of evidence supporting XRT for NMIBC. Herein, we performed a systematic review and meta-analysis to evaluate XRT in the treatment of patients with high-risk NMIBC. METHODS Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Web of Science were searched for high-risk NMIBC (high grade T1, T1/Ta with associated risk features: carcinoma in-situ (CIS), multifocality, > 5cm in diameter, and/or multiple recurrences) treated with primary XRT. Outcomes evaluated were recurrence-free survival (RFS), cancer-specific-survival (CSS), overall survival (OS), and salvage cystectomy and progression to metastatic disease rates. A meta-analysis was performed to assess outcomes for XRT in NMIBC. RESULTS Overall,13 studies including 746 patients met the search criteria. The 5-year rates of RFS, CSS and OS were 54% (95% CI = 38% - 70%), 86% (95% CI = 80% - 92%), and 72% (95% CI = 64% - 79%). Notably, 13% of patients proceeded to salvage radical cystectomy and 9% developed metastatic disease. All studies were of poor quality, comprising single institution and retrospective studies with only one clinical trial. CONCLUSION XRT for high-risk NMIBC provides some degree of oncologic control, although distant progression was noted. In the setting of the low-quality evidence, a prospective clinical trial is needed to clearly define the risks and benefits of this approach.
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Affiliation(s)
| | - Adam C Mueller
- University of Colorado, Department of Radiation Oncology, Aurora, CO
| | - Peter Boxley
- University of Colorado, Division of Urology, Aurora, CO
| | - Thomas W Flaig
- University of Colorado, Division of Medical Oncology, Aurora, CO
| | - Christi Piper
- University of Colorado, Strauss Health Sciences Library, Aurora, CO
| | | | - James B Yu
- Yale University, Department of Radiation Oncology, New Haven, CT; Yale University, Cancer Outcomes and Public Policy Effectiveness Research, (COPPER) Center, New Haven, CT
| | - Boris Gershman
- Beth Israel Deaconess Medical Center, Division of Urologic Surgery, Boston, MA
| | - Janet Kukreja
- University of Colorado, Division of Urology, Aurora, CO
| | - Simon P Kim
- University of Colorado, Division of Urology, Aurora, CO; Yale University, Cancer Outcomes and Public Policy Effectiveness Research, (COPPER) Center, New Haven, CT.
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Laukhtina E, Abufaraj M, Al-Ani A, Ali MR, Mori K, Moschini M, Quhal F, Sari Motlagh R, Pradere B, Schuettfort VM, Mostafaei H, Katayama S, Grossmann NC, Fajkovic H, Soria F, Enikeev D, Shariat SF. Intravesical Therapy in Patients with Intermediate-risk Non-muscle-invasive Bladder Cancer: A Systematic Review and Network Meta-analysis of Disease Recurrence. Eur Urol Focus 2021; 8:447-456. [PMID: 33762203 DOI: 10.1016/j.euf.2021.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/11/2021] [Accepted: 03/10/2021] [Indexed: 12/09/2022]
Abstract
CONTEXT Patients with intermediate-risk non-muscle-invasive bladder cancer (NMIBC) may pose a clinical dilemma without an agreed evidence-based decision tree for personalized treatment. OBJECTIVE To perform a systematic review and network meta-analysis (NMA) to summarize available evidence on the oncologic outcomes of intravesical therapy in patients with intermediate-risk NMIBC. EVIDENCE ACQUISITION The MEDLINE, EMBASE, and ClinicalTrials.gov databases were searched in October 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Studies were deemed eligible if they reported on oncologic outcomes in patients with intermediate-risk NMIBC treated with transurethral resection of bladder tumor with and without intravesical chemotherapy or bacillus Calmette-Guérin (BCG) immunotherapy. EVIDENCE SYNTHESIS Twelve studies were included in a qualitative synthesis (systematic review); three were deemed eligible for a quantitative synthesis (NMA). An NMA of five different regimens was conducted for the association of treatment with the 5-yr recurrence risk. Chemotherapy with maintenance was associated with a lower likelihood of 5-yr recurrence than chemotherapy without maintenance (odds ratio [OR] 0.51, 95% credible interval [CI] 0.26-1.03). Immunotherapy, regardless of whether a full- or reduced-dose regimen, was not associated with a significantly lower likelihood of 5-yr recurrence when compared with chemotherapy without maintenance (OR 0.90, 95% CI 0.39-2.11 vs OR 0.93, 95% CI 0.40-2.19). Analysis of the treatment ranking revealed that chemotherapy with maintenance had the lowest 5-yr recurrence risk (P score 0.9666). CONCLUSIONS Our analysis indicates that chemotherapy with a maintenance regimen confers a superior oncologic benefit in terms of 5-yr recurrence risk compared to chemotherapy without maintenance in patients with intermediate-risk NMIBC. Regardless of the dose regimen, immunotherapy with BCG does not appear to be superior to chemotherapy in patients with intermediate-risk NMIBC in term of disease recurrence. However, owing to the lack of comparative studies, there is an unmet need for well-designed, large-scale trials to validate our findings and generate robust evidence on disease recurrence and progression. PATIENT SUMMARY A maintenance schedule of chemotherapy reduces the rate of long-term recurrence of bladder cancer that has not invaded the bladder muscle. Chemotherapy inserted directly into the bladder and immunotherapy without maintenance schedules seem to have limited benefit in preventing cancer recurrence.
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Affiliation(s)
- Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Mohammad Abufaraj
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Abdallah Al-Ani
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Mustafa Rami Ali
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Keiichiro Mori
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Marco Moschini
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Urology and Division of Experimental Oncology, Urological Research Institute, Vita-Salute San Raffaele, Milan, Italy
| | - Fahad Quhal
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Reza Sari Motlagh
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Victor M Schuettfort
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hadi Mostafaei
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Satoshi Katayama
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nico C Grossmann
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Harun Fajkovic
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
| | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
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