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Katims AB, Tallman J, Vertosick E, Porwal S, Dalbagni G, Cha EK, Smith R, Benfante N, Herr HW. Response to 2 Induction Courses of Bacillus Calmette-Guèrin Therapy Among Patients With High-Risk Non-Muscle-Invasive Bladder Cancer: 5-year Follow-Up of a Phase 2 Clinical Trial. JAMA Oncol 2024; 10:522-525. [PMID: 38358761 PMCID: PMC10870219 DOI: 10.1001/jamaoncol.2023.6804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 10/02/2023] [Indexed: 02/16/2024]
Abstract
Importance With the ongoing bacillus Calmette-Guèrin (BCG) shortage, alternate therapeutic options for patients with high-risk non-muscle-invasive bladder cancer (NMIBC) are needed. Objective To report the 5-year outcomes of a cohort from a prospective phase 2 trial of patients with high-risk NMIBC who underwent 12 instillations of induction BCG without maintenance. Design, Setting, and Participants Between November 2015 and June 2018, patients at Memorial Sloan Kettering Cancer Center with primary or recurrent NMIBC (high-grade Ta, T1 tumors, with or without carcinoma in situ) were prospectively enrolled to receive 2 induction courses (12 intravesical instillations) of BCG without maintenance therapy. The analysis itself took place on July 28, 2023. Main Outcomes and Measures Recurrence-free survival (RFS) and cancer-specific survival (CSS) was assessed by landmark analysis at 7.5 months. Recurrence was defined as pathologic high-grade disease. Results Among 81 patients (65 men [84%] and 12 women [16%] with a median [IQR] age of 72 [64-77] years) who consented to participate in the study, 75 remained evaluable for long-term follow-up analysis. Twenty-one patients experienced high-grade recurrence, yielding a 5-year RFS rate of 69% (95% CI, 58%-81%), with a median (IQR) follow-up of 4.4 (3.8-5.3) years for patients without recurrence. Three patients died of bladder cancer, corresponding to a CSS rate of 97% (95% CI, 93%-100%) with a median (IQR) follow-up of 4.9 (4.2-5.7) years for survivors. Using 2 induction courses reduced the amount of BCG per patient from 27 vials to 12 vials. Conclusion and Relevance Twelve induction instillations of BCG without maintenance for patients with high-risk NMIBC reduced the number of vials needed per patient while providing acceptable oncologic outcomes. Given the ongoing BCG shortage, this modified regimen may provide a suitable alternative in this setting.
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Affiliation(s)
- Andrew B. Katims
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jacob Tallman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily Vertosick
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shaun Porwal
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eugene K. Cha
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert Smith
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicole Benfante
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Harry W. Herr
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Bourlotos G, Baigent W, Hong M, Plagakis S, Grundy L. BCG induced lower urinary tract symptoms during treatment for NMIBC-Mechanisms and management strategies. Front Neurosci 2024; 17:1327053. [PMID: 38260019 PMCID: PMC10800852 DOI: 10.3389/fnins.2023.1327053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
Non-muscle invasive bladder cancer (NMIBC) accounts for ~70-75% of total bladder cancer tumors and requires effective early intervention to avert progression. The cornerstone of high-risk NMIBC treatment involves trans-urethral resection of the tumor followed by intravesical Bacillus Calmette-Guerin (BCG) immunotherapy. However, BCG therapy is commonly accompanied by significant lower urinary tract symptoms (LUTS) including urinary urgency, urinary frequency, dysuria, and pelvic pain which can undermine treatment adherence and clinical outcomes. Despite this burden, the mechanisms underlying the development of BCG-induced LUTS have yet to be characterized. This review provides a unique perspective on the mechanisms thought to be responsible for the development of BCG-induced LUTS by focussing on the sensory nerves responsible for bladder sensory transduction. This review focuses on how the physiological response to BCG, including inflammation, urothelial permeability, and direct interactions between BCG and sensory nerves could drive bladder afferent sensitization leading to the development of LUTS. Additionally, this review provides an up-to-date summary of the latest clinical data exploring interventions to relieve BCG-induced LUTS, including therapeutic targeting of bladder contractions, inflammation, increased bladder permeability, and direct inhibition of bladder sensory signaling. Addressing the clinical burden of BCG-induced LUTS holds significant potential to enhance patient quality of life, treatment compliance, and overall outcomes in NMIBC management. However, the lack of knowledge on the pathophysiological mechanisms that drive BCG-induced LUTS has limited the development of novel and efficacious therapeutic options. Further research is urgently required to unravel the mechanisms that drive BCG-induced LUTS.
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Affiliation(s)
- Georgia Bourlotos
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
| | - William Baigent
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
| | - Matthew Hong
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
- Urology Unit, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Sophie Plagakis
- Urology Unit, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Luke Grundy
- College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
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Hannouneh ZA, Hijazi A, Alsaleem AA, Hami S, Kheyrbek N, Tanous F, Khaddour K, Abbas A, Alshehabi Z. Novel immunotherapeutic options for BCG-unresponsive high-risk non-muscle-invasive bladder cancer. Cancer Med 2023; 12:21944-21968. [PMID: 38037752 PMCID: PMC10757155 DOI: 10.1002/cam4.6768] [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: 09/23/2023] [Revised: 11/10/2023] [Accepted: 11/17/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND High-risk non-muscle-invasive bladder cancer (HR-NMIBC) presents a challenge to many physicians due to its ability to resist Bacillus Calmette-Guérin (BCG) intravesical therapy and the substantial rate of progression into muscle-invasive bladder cancer (MIBC). Patients who are BCG-unresponsive have worse prognosis and thus require further management including radical cystectomy (RC), which significantly impacts quality of life. Moreover, the ongoing worldwide shortage of BCG warrants the need for policies that prioritize drug use and utilize alternative treatment strategies. Hence, there is a significant unmet need for bladder preserving therapy in this subset of patients. METHODS To address this issue, we searched the relevant literature in PUBMED for articles published from 2019 through May of 2023 using appropriate keywords. All clinical trials of patients with HR-NMIBC treated with immune-related agents were retrieved from clinicaltrials.gov. FINDINGS AND FUTURE PERSPECTIVES Exploratory treatments for BCG-Unresponsive HR-NMIBC included immune checkpoint inhibitors (ICI), oncolytic viral therapy, cytokine agonists, and other immunomodulators targeting TLR, EpCaM, FGFR, MetAP2, and IDO1. Some combination therapies have been found to work synergistically and are preferred therapeutically over monotherapy. Three drugs-pembrolizumab, valrubicin, and most recently, nadofaragene firadenovec-vncg-have been FDA approved for the treatment of BCG-unresponsive NMIBC in patients who are ineligible for or decline RC. However, all explored treatment options tend to postpone RC rather than provide long-term disease control. Additional combination strategies need to be studied to enhance the effects of immunotherapy. Despite the challenges faced in finding effective therapies, many potential treatments are currently under investigation. Addressing the landscape of biomarkers, mechanisms of progression, BCG resistance, and trial design challenges in HR-NMIBC is essential for the discovery of new targets and the development of effective treatments.
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Affiliation(s)
- Zein Alabdin Hannouneh
- Faculty of MedicineAl Andalus University for Medical SciencesTartusSyrian Arab Republic
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
| | - Amjad Hijazi
- Faculty of MedicineAl Andalus University for Medical SciencesTartusSyrian Arab Republic
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
| | - Alaa Aldeen Alsaleem
- Faculty of MedicineAl Andalus University for Medical SciencesTartusSyrian Arab Republic
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
| | - Siwan Hami
- Faculty of MedicineAl Andalus University for Medical SciencesTartusSyrian Arab Republic
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
| | - Nina Kheyrbek
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
- Faculty of MedicineTishreen UniversityLattakiaSyrian Arab Republic
| | - Fadi Tanous
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
- Faculty of MedicineAl‐Baath UniversityHomsSyrian Arab Republic
| | - Karam Khaddour
- Department of Medical OncologyDana‐Farber Cancer Institute, Harvard Medical SchoolBostonMassachusettsUSA
| | - Abdulfattah Abbas
- Professor of Nephrology, Faculty of MedicineAl Andalus University for Medical SciencesTartusSyrian Arab Republic
| | - Zuheir Alshehabi
- Cancer Research CenterTishreen UniversityLattakiaSyrian Arab Republic
- Department of PathologyTishreen University HospitalLattakiaSyrian Arab Republic
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Lee J, Yoo S, Choo MS, Cho MC, Son H, Jeong H. Prognostic Role of Preoperative Neutrophil-To-Lymphocyte Ratio (NLR) and Recurrence at First Evaluation after Bacillus Calmette-Guérin (BCG) Induction in Non-Muscle-Invasive Bladder Cancer. Diagnostics (Basel) 2023; 13:3114. [PMID: 37835857 PMCID: PMC10572862 DOI: 10.3390/diagnostics13193114] [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: 07/27/2023] [Revised: 09/14/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
We investigated the prognosis of BCG induction-only treatment and non-complete response (CR) at the first 3-month evaluation and examined factors associated with CR. In total, 209 patients with moderate- and high-risk NMIBC who received BCG induction-only treatment between 2008 and 2020 were retrospectively analyzed. Recurrence-free survival (RFS) and progression-free survival (PFS) were assessed based on the initial NMIBC stage. PFS and associated factors of non-CR compared to CR were also assessed. Initial T1 high-grade (HG) (n = 93) had poorer RFS and PFS after BCG induction-only treatment than Ta low-grade (LG) (p = 0.029, p = 0.002). Non-CR (n = 37) had a different neutrophil-to-lymphocyte ratio (NLR) (2.81 ± 1.02 vs. 1.97 ± 0.92) and T staging from CR (p < 0.001, p = 0.008). T1HG recurrence was associated with a worse PFS compared to non-T1HG (13.7 months vs. 101.7 months, p < 0.001). There was no difference in PFS between T1HG and T1LG. T1 and NLR were predictors of response at 3 months in multivariable analysis (p = 0.004, p = 0.029). NLR was also found to be an associated factor with RFS and PFS of bladder cancer (p < 0.001, p < 0.001). BCG induction-only treatment was effective for high-risk TaLG but not for T1HG. T1HG recurrence at 3 months after BCG induction has a poor prognosis for bladder cancer. Preoperative NLR and T1 were predictors of non-CR, and NLR was also associated with the long-term prognosis of bladder cancer.
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Affiliation(s)
- Junghoon Lee
- Department of Urology, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Republic of Korea; (J.L.)
| | - Sangjun Yoo
- Department of Urology, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Republic of Korea; (J.L.)
| | - Min Soo Choo
- Department of Urology, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Republic of Korea; (J.L.)
| | - Min Chul Cho
- Department of Urology, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Republic of Korea; (J.L.)
| | - Hwancheol Son
- Department of Urology, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Republic of Korea; (J.L.)
- Institute for Peace and Unification Studies, Seoul National University, Seoul 08826, Republic of Korea
| | - Hyeon Jeong
- Department of Urology, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul 07061, Republic of Korea; (J.L.)
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Pérez JH, Faba OR, Gaya Sopena JM, Palou Redorta J, Breda A. An aid to a better understanding of the definitions of BCG failure provided by the European Urology Association. Actas Urol Esp 2023; 47:395-397. [PMID: 36842705 DOI: 10.1016/j.acuroe.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/09/2023] [Indexed: 02/27/2023]
Affiliation(s)
| | | | | | | | - A Breda
- Fundació Puigvert, Barcelona, Spain
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Busetto GM, Finati M, Chirico M, Cinelli F, D’Altilia N, Falagario UG, Sanguedolce F, Del Giudice F, De Berardinis E, Ferro M, Crocetto F, Porreca A, Di Gianfrancesco L, Calo’ B, Mancini V, Bettocchi C, Carrieri G, Cormio L. Conservative treatment for high-risk NMIBC failing BCG treatment: who benefits from adding electromotive drug administration (EMDA) of mitomycin C (MMC) to a second BCG induction cycle? World J Urol 2023; 41:1329-1335. [PMID: 36971825 DOI: 10.1007/s00345-023-04372-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/10/2023] [Indexed: 03/29/2023] Open
Abstract
Abstract
Purpose
Radical cystectomy (RC) is the standard treatment for high-risk non muscle-invasive bladder cancer (NMIBC) failing first BCG treatment. A second BCG course is an option for those patients who refuse RC or are not eligible for it, but its success rate is quite low. Aim of the present study was to determine whether the addition of intravesical electromotive drug administration of mytomicin-C (EMDA-MMC) improved the efficacy of second BCG course.
Methods
Patients with high-risk NMIBC having failed first BCG treatment and having refused RC were offered a second BCG induction course either alone (group A) or combined with EMDA-MMC (group B). Recurrence-free survival (RFS), progression-free survival (PFS) and cancer-specific survival (CSS) were tested.
Results
Of the 80 evaluable patients, 44 were in group A and 36 in group B; median follow-up was 38 months. RFS was significantly worse in group A whereas there was no difference in PFS and CSS between the two groups. Stratifying by disease stage, Ta patients receiving combined treatment had statistically better RFS and PFS survival than those receiving BCG only; this difference did not apply to T1 patients. Multivariable analysis confirmed that combined treatment was a significant predictor of recurrence and was close to predict progression. No tested variable was predictive of recurrence or progression in T1 tumours. Among those who underwent RC, CSS was 61.5% in those who had progression and 100% in those who remained with NMIBC.
Conclusion
Combined treatment improved RFS and PFS only in patients with Ta disease.
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Elsawy AA, Laymon M, Mansour I, Elghareeb A, Harraz A. Can we offer additional BCG therapy for three-month BCG refractory high grade/T1, Tis bladder cancer patients? Arab J Urol 2023; 21:142-149. [PMID: 37521452 PMCID: PMC10373613 DOI: 10.1080/2090598x.2023.2190687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/08/2023] [Indexed: 08/01/2023] Open
Abstract
Background We lack tools to predict treatment and survival outcomes in patients receiving additional BCG therapy as a bladder-preserving therapy in high grade/T1, Tis NMIBC patients who showed persistent/recurrent tumors at three-month follow-up. Objectives To assess the predictors of additional BCG response in patients who experienced persistent/recurrent tumors at three-month follow-up after BCG induction. Patients and methods We retrospectively analyzed database for NMIBC. Between 2000 and 2019, 231 patients with high-grade T1/Tis NMIBC showed persistent/recurrent tumors at 3-month after BCG-induction, refused or were unfit to radical cystectomy (RC) and were offered additional intravesical BCG as bladder-preserving treatment. Predictors of the outcome after additional BCG were studied using univariate and multivariate logistic regression analysis. Kaplan Meier curve was utilized to estimate the recurrence-free survival (RFS) and progression-free survival (PFS). COX regression analysis was performed to identify independent predictors or RFS and PFS. Results During a median (range) of 148 (24-224) months, poor response to additional BCG (tumor recurrence and/or progression) was noted in 112 (48.5%) patients. On multivariate logistic regression analysis, 3-month tumor features (persistent T stage, persistent grade and persistent/new CIS) significantly predicted poor response to additional BCG (OR: 3.4, 95%CI: 1.3-10.8, p = 0.021, OR: 2.1, 95%CI: 1.1-4.1, p = 0.02 and OR: 16.6, 95%CI: 4.5-109, p=<0.001, respectively). The mean RFS was 26 (9-152) months with identified 3-month tumor features (persistent T stage and persistent/new CIS) as independent predictors of RFS (HR = 11.5, 95%CI = 2.7-48.3, p = 0.001 and HR = 2.5, 95%CI = 1.5-4.1, p=<0.001, respectively) on multivariate COX regression analysis. In addition, 3-month tumor features (persistent/new CIS, non-papillary shape and bladder neck involvement) were identified to significantly predict PFS (HR = 6.2, 95%CI = 3.4-11.5, p=<0.001 and HR = 2.3, 95%CI = 1.3-4.3 p = 0.001 and HR = 2.1, 95%CI = 1.2-3.8, p=<0.005, respectively). Conclusions Three-month tumor features could be utilized as a tool to predict treatment outcomes and survival benefits when additional intravesical BCG is utilized as a bladder-preserving treatment in patients with recurrent/persistent tumors at three-month follow-up.
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Affiliation(s)
- Amr A. Elsawy
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Mahmoud Laymon
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Islam Mansour
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed Elghareeb
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed Harraz
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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Miyake M, Kikuchi E, Shinozaki K, Piao Y, Hayashi N, Koto R, Jinushi M, Kobayashi T. Real-world treatment patterns and clinical outcomes of Japanese patients with non-muscle invasive bladder cancer receiving intravesical bacillus Calmette-Guérin treatment. Int J Urol 2022; 29:1120-1129. [PMID: 35598101 PMCID: PMC9790662 DOI: 10.1111/iju.14933] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 04/27/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To investigate current patterns and outcomes of intravesical bacillus Calmette-Guérin treatment in Japanese patients with bladder cancer, including the proportion of patients completing induction therapy, and time to subsequent treatments. METHODS This retrospective cohort study utilized administrative claims data from the Medical Data Vision Co., Ltd. database to identify patients with a diagnosis of bladder cancer who had received ≥1 prescription of intravesical bacillus Calmette-Guérin between April 2008 and September 2015, and had ≥1 database record dated ≥12 weeks after the initial bacillus Calmette-Guérin dose. Patients were followed until September 2018, the last date of available data, or in-hospital death. Patients receiving six doses of bacillus Calmette-Guérin at intervals of <21 days were considered to have completed induction according to guidelines. Time from initial bacillus Calmette-Guérin dose to subsequent bladder cancer treatment after the end of treatment was defined as the recurrence-free duration. RESULTS Of 6140 patients identified (median age 73.0 years; 83.4% males), 4588 (74.7%) completed induction and 1552 (25.3%) did not. Median recurrence-free duration was 64.4, 77.7, and 31.6 months in the overall, complete-induction and incomplete-induction cohorts, respectively. Corresponding 3-year recurrence-free rate was 56.3%, 59.0%, and 48.2% in these groups. The rate of cystectomy was approximately 6% at 5 years in all cohorts. CONCLUSIONS Approximately 75% of Japanese patients who undergo intravesical bacillus Calmette-Guérin treatment receive a guideline-compliant induction regimen, but outcomes were not satisfactory, highlighting the need for more effective treatments for non-muscle invasive bladder cancer.
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Affiliation(s)
- Makito Miyake
- Department of UrologyNara Medical UniversityNaraJapan
| | - Eiji Kikuchi
- Department of UrologySt. Marianna University School of MedicineKanagawaJapan
| | | | | | | | | | | | - Takashi Kobayashi
- Department of UrologyKyoto University Graduate School of MedicineKyotoJapan
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Freudenburg E, Bagheri I, Srinivas S, Martinez A, Putluri N, Klaassen Z, Kamat AM, Konety BR, Kim WY, Dyrskjøt L, McConkey DJ, Freedland SJ, Black PC, Daneshmand S, Catto JWF, Williams SB. Race reporting and disparities regarding clinical trials in bladder cancer: a systematic review. Cancer Causes Control 2022; 33:1071-1081. [PMID: 35699798 DOI: 10.1007/s10552-022-01593-8] [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: 01/12/2022] [Accepted: 05/21/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To systematically review the literature to investigate racial disparities among bladder cancer clinical trial enrollees. METHODS A systematic review was conducted using Ovid, MEDLINE® to identify clinical trials between 1970 and 2020. Articles were reviewed and were included if they assessed race in their outcomes reporting among bladder cancer patients enrolled in clinical trials. The review was conducted in accordance with the PRISMA statement. RESULTS We identified 544 clinical trials meeting our initial search criteria, with only 24 (4.4%) studies reporting racial demographic data. Enrollees were largely Caucasian (81-98%), with a strikingly small proportion of enrolled patients consisting of African-Americans (2-8%) and Hispanics (2-5%). Only one of the studies reported results on the efficacy and safety/tolerability of the tested treatment separately for racial groups and performed analyses stratified by race. CONCLUSION Race is poorly studied in bladder cancer clinical trials. Trial cohorts may not reflect multicultural populations. The potential association between race and efficacy, safety or tolerability of the tested interventions is unknown. Given the up to twofold increase in bladder cancer-specific death among African-Americans, further research is needed to address the impact of race in clinical trials, while encompassing socioeconomic factors and disease risk factor exposures.
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Affiliation(s)
- Elliott Freudenburg
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Iyla Bagheri
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Sunay Srinivas
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Ariza Martinez
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Nagireddy Putluri
- Department of Molecular and Cellular Biology, Dan L. Duncan Cancer Center, Advanced Technology Core, Alkek Center for Molecular Discovery, Baylor College of Medicine, Houston, TX, USA
| | - Zachary Klaassen
- Department of Surgery, Section of Urology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Badrinath R Konety
- Virginia Piper Cancer Center and Piper Breast Centers, Allina Health Cancer Institute, Minneapolis, MN, USA
| | - William Y Kim
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Lars Dyrskjøt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - David J McConkey
- Johns Hopkins Greenberg Bladder Cancer Institute, Brady Urological Institute, Johns Hopkins University, Baltimore, MD, USA
| | | | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Siamak Daneshmand
- Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA.
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Herr H, Vertosick EA, Dalbagni G, Cha EK, Smith R, Benfante N, Sjoberg DD, Sfakianos JP. Prospective Phase II Study to Evaluate Response to Two Induction Courses (12 intravesical instillations) of BCG Therapy for High-risk Non-muscle-invasive Bladder Cancer. Urology 2021; 157:197-200. [PMID: 34274387 PMCID: PMC9428818 DOI: 10.1016/j.urology.2021.06.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/06/2021] [Accepted: 06/30/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To test whether 2 sequential BCG-induction courses improve the response of high-risk non-muscle invasive bladder cancer. Achieving a complete response (CR) to BCG is critical to disease-free survival. Patients with preexisting BCG-specific immunity owing to prior exposure to BCG have longer disease-free survival than BCG-naïve patients likely due to heterologous immunity from the initial priming of the immune system. We evaluated this hypothesis in a phase II prospective clinical trial. METHODS From 2015 to 2018, we recruited patients with primary or recurrent NMIBC (high-grade Ta, T1 tumors, with or without CIS) to receive 2-induction courses (12 intra-vesical instillations) of BCG. The primary aim of the study was CR rate 6 months after start of the first BCG induction. CR was defined as no tumor at cystoscopy or TURB biopsy. No maintenance BCG was given. We targeted at least 75 evaluable patients, and a CR of 80% or better was deemed significant. RESULTS Eighty-one patients agreed to participate. Five withdrew before starting BCG, leaving 76 evaluable patients. Sixty-three patients (83%) completed the 12 instillations on schedule. Of these, 62 patients (91%) had a CR at 6 months. None of the patients had tumor progression. Serious adverse event was seen in 1 patient (1%). Recurrence-free survival at 2 years after complete response was 85% (95% CI 77%, 95%). CONCLUSION The high response rate in patients with high-risk non-muscle-invasive bladder cancer justifies 2 BCG induction cycles in current practice.
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Affiliation(s)
- Harry Herr
- Urology Service, Department of Surgery Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily A. Vertosick
- Department of Epidemiology and Biostatistics Memorial Sloan Kettering Cancer Center, New York
| | - Guido Dalbagni
- Urology Service, Department of Surgery Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eugene K Cha
- Urology Service, Department of Surgery Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert Smith
- Urology Service, Department of Surgery Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicole Benfante
- Urology Service, Department of Surgery Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel D. Sjoberg
- Department of Epidemiology and Biostatistics Memorial Sloan Kettering Cancer Center, New York
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
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11
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Babjuk M, Burger M, Capoun O, Cohen D, Compérat EM, Dominguez Escrig JL, Gontero P, Liedberg F, Masson-Lecomte A, Mostafid AH, Palou J, van Rhijn BWG, Rouprêt M, Shariat SF, Seisen T, Soukup V, Sylvester RJ. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (Ta, T1, and Carcinoma in Situ). Eur Urol 2021; 81:75-94. [PMID: 34511303 DOI: 10.1016/j.eururo.2021.08.010] [Citation(s) in RCA: 543] [Impact Index Per Article: 181.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/15/2021] [Indexed: 02/08/2023]
Abstract
CONTEXT The European Association of Urology (EAU) has released an updated version of the guidelines on non-muscle-invasive bladder cancer (NMIBC). OBJECTIVE To present the 2021 EAU guidelines on NMIBC. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines since the 2020 version was performed. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS Tumours staged as Ta, T1 and carcinoma in situ (CIS) are grouped under the heading of NMIBC. Diagnosis depends on cystoscopy and histological evaluation of tissue obtained via transurethral resection of the bladder (TURB) for papillary tumours or via multiple bladder biopsies for CIS. For papillary lesions, a complete TURB is essential for the patient's prognosis and correct diagnosis. In cases for which the initial resection is incomplete, there is no muscle in the specimen, or a T1 tumour is detected, a second TURB should be performed within 2-6 wk. The risk of progression may be estimated for individual patients using the 2021 EAU scoring model. On the basis of their individual risk of progression, patients are stratified as having low, intermediate, high, or very high risk, which is pivotal to recommending adjuvant treatment. For patients with tumours presumed to be at low risk and for small papillary recurrences detected more than 1 yr after a previous TURB, one immediate chemotherapy instillation is recommended. Patients with an intermediate-risk tumour should receive 1 yr of full-dose intravesical bacillus Calmette-Guérin (BCG) immunotherapy or instillations of chemotherapy for a maximum of 1 yr. For patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. For patients at very high risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is also recommended for BCG-unresponsive tumours. The extended version of the guidelines is available on the EAU website at https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/. CONCLUSIONS These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology has released updated guidelines on the classification, risk factors, diagnosis, prognostic factors, and treatment of non-muscle-invasive bladder cancer. The recommendations are based on the literature up to 2020, with emphasis on the highest level of evidence. Classification of patients as having low, intermediate, or and high risk is essential in deciding on suitable treatment. Surgical removal of the bladder should be considered for tumours that do not respond to bacillus Calmette-Guérin (BCG) treatment and tumours with the highest risk of progression.
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Affiliation(s)
- Marko Babjuk
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria.
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Otakar Capoun
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Daniel Cohen
- Department of Urology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Eva M Compérat
- Department of Pathology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | | | - Paolo Gontero
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Fredrik Liedberg
- Department of Translational Medicine, Lund University, Malmö, Sweden; Department of Urology, Skåne University Hospital, Malmö, Sweden
| | | | - A Hugh Mostafid
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Joan Palou
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Bas W G van Rhijn
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Morgan Rouprêt
- GRC 5 Predictive Onco-Uro, Department of Urology, Sorbonne University, AP-HP, Pitié Salpétrière Hospital, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Thomas Seisen
- GRC 5 Predictive Onco-Uro, Department of Urology, Sorbonne University, AP-HP, Pitié Salpétrière Hospital, Paris, France
| | - Viktor Soukup
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
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12
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Yassaie O, Chehroudi C, Black PC. Novel and emerging approaches in the management of non-muscle invasive urothelial carcinoma. Ther Adv Med Oncol 2021; 13:17588359211039052. [PMID: 34408797 PMCID: PMC8366114 DOI: 10.1177/17588359211039052] [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: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 11/16/2022] Open
Abstract
Non-muscle invasive bladder cancer (NMIBC) has traditionally been managed with transurethral resection followed by intravesical chemotherapy and/or bacillus Calmette-Guerin (BCG) in a risk-adapted manner. These tumors commonly recur and can progress potentially to lethal muscle invasive disease. A major unmet need in the field of NMIBC is bladder preserving therapy for recurrent high-grade NMIBC after adequate intravesical BCG therapy. The current gold standard treatment for these BCG-unresponsive patients is radical cystectomy, which is associated with considerable morbidity and mortality, particularly in older and frailer patients. It is therefore critical to provide alternative treatment options with acceptable oncological outcomes. In this review we explore novel bladder-sparing treatment options including combination intravesical therapy, enhanced instillation methods, immunotherapy, gene therapy, targeted therapy, photodynamic therapy and BCG variants across the spectrum of NMIBC disease states, ranging from low grade BCG-naïve patients through to high-grade BCG-unresponsive NMIBC.
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Affiliation(s)
- Omid Yassaie
- Department of Urologic Sciences, University British Columbia, Vancouver, BC, Canada
| | - Cyrus Chehroudi
- Department of Urologic Sciences, University British Columbia, Vancouver, BC, Canada
| | - Peter C Black
- Department of Urologic Sciences, University British Columbia, Level 6, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
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13
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Miyata Y, Tsurusaki T, Hayashida Y, Imasato Y, Takehara K, Aoki D, Nishikido M, Watanabe J, Mitsunari K, Matsuo T, Ohba K, Taniguchi K, Sakai H. Intravesical mitomycin C (MMC) and MMC + cytosine arabinoside for non-muscle-invasive bladder cancer: a randomised clinical trial. BJU Int 2021; 129:534-541. [PMID: 34383381 PMCID: PMC9290455 DOI: 10.1111/bju.15571] [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: 06/18/2021] [Revised: 07/29/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022]
Abstract
Objectives To compare the urinary pH, recurrence‐free survival (RFS), and safety of adjuvant intravesical therapy in patients with non‐muscle‐invasive bladder cancer (NMIBC) receiving mitomycin C (MMC) therapy and MMC + cytosine arabinoside (Ara‐C) therapy. Patients and Methods A total of 165 patients with NMIBC from six hospitals were randomly allocated to two groups: weekly instillation of MMC + Ara‐C (30 mg/30 mL + 200 mg/10 mL) for 6 weeks and the same instillation schedule of MMC (30 mg/40 mL). The primary outcome was RFS, and secondary outcomes were urinary pH and toxicity in the two groups. Results A total of 81 and 87 patients were randomised into the MMC and MMC + Ara‐C groups, respectively. Overall, the RFS in the MMC + Ara‐C group was significantly longer (P = 0.018) than that in the MMC group. A similar significant difference was detected in patients with intermediate‐risk NMIBC, but not in those with high‐risk NMIBC. The mean (SD) urinary pH was significantly higher in the MMC + Ara‐C group than in the MMC group, at 6.56 (0.61) vs 5.78 (0.64) (P < 0.001), and the frequency of a urinary pH of >7.0 in the MMC and MMC + Ara‐C groups was 6.3% and 26.7%, respectively (P < 0.001). Multivariate analysis models including clinicopathological features and second transurethral resection demonstrated that increased urinary pH was associated with better outcomes (hazard ratio 0.18, 95% confidential interval 0.18–0.038; P < 0.001). In all, there were 14 and 10 adverse events in the MMC and MMC + Ara‐C groups, respectively, without a significant difference (P = 0.113). Conclusions Our randomised clinical trial suggested that intravesical therapy with MMC and Ara‐C is useful and safe for patients with intermediate‐risk NMIBC. Increase in urinary pH with Ara‐C is speculated as a mechanism for increased anti‐cancer effects.
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Affiliation(s)
- Yasuyoshi Miyata
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Toshifumi Tsurusaki
- Department of Urology, The Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan
| | - Yasushi Hayashida
- Department of Urology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Yushi Imasato
- Department of Urology, The Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan
| | - Kosuke Takehara
- Department of Urology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Daiyu Aoki
- Department of Urology, Japan Community Health care Organization Isahaya General Hospital, Isahaya, Japan
| | - Masaharu Nishikido
- Department of Urology, National Hospital Organization Nagasaki Medical Center, Ohmura, Japan
| | - Junichi Watanabe
- Department of Urology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Kensuke Mitsunari
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tomohiro Matsuo
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kojiro Ohba
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Keisuke Taniguchi
- Department of Urology, National Hospital Organization Ureshino Medical Center, Ureshino, Japan
| | - Hideki Sakai
- Department of Urology, Nagasaki University Graduate School of Biomedical Sciences, Japan
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14
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Büchler J, Gschwend JE, Retz M, Schmid SC. [Muscle-invasive bladder cancer]. Urologe A 2021; 60:769-775. [PMID: 34014342 DOI: 10.1007/s00120-021-01536-2] [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] [Accepted: 04/12/2021] [Indexed: 11/26/2022]
Abstract
Bladder cancer, which is a complex disease, can be treated with a variety of stage-oriented treatment options. In this article, the treatment recommendations of the German S3 guideline "Early detection, diagnosis, treatment and aftercare of bladder cancer" are applied in a fictitious case study. In a patient with invasive transitional cell carcinoma, the treatment options-ranging from bladder preservation to radical cystectomy with neoadjuvant chemotherapy-are discussed on the basis of the current literature.
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Affiliation(s)
- Jakob Büchler
- Klinik und Poliklinik für Urologie, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - Jürgen E Gschwend
- Klinik und Poliklinik für Urologie, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Margitta Retz
- Klinik und Poliklinik für Urologie, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Sebastian C Schmid
- Klinik und Poliklinik für Urologie, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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15
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BCG-unresponsive high-grade non-muscle invasive bladder cancer: what does the practicing urologist need to know? World J Urol 2021; 39:4037-4046. [PMID: 33772322 PMCID: PMC7997797 DOI: 10.1007/s00345-021-03666-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/10/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose Bacille Calmette-Guérin (BCG) is a well-established treatment for preventing or delaying tumour recurrence following high-grade nonmuscle invasive bladder cancer (NMIBC) resection. However, many patients will experience recurrence or progression during or following BCG. This scenario has been one of the most challenging in urologic oncology for several decades since BCG implementation. Finally, significant progress has occurred lately. The aim of this review was to summarize for the practising urologist the current treatment options available in 2020 or expected to be ready for routine use in the near future for patients with high-risk NMIBC who experience BCG failure. Methods Narrative review using data through the end of 2020. Results First, the definition of BCG unresponsive disease which is critical in counseling and managing patients has finally reached a consensus. Second, some promising options other than radical cystectomy are finally available and many other should be in a near future. The options can be categorized as chemotherapy, device-assisted therapy, check-point inhibitors, new intravesical and systemic agents and sequential combinations of these newer modalities with conventional therapy. Conclusions Considering the options that are currently under scrutiny, many of which in phase III trials, clinicians should have at their disposal several new treatment options in the next five years.
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16
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Prognostic value of albumin to globulin ratio in non-muscle-invasive bladder cancer. World J Urol 2021; 39:3345-3352. [PMID: 33496841 PMCID: PMC8510920 DOI: 10.1007/s00345-020-03586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/29/2020] [Indexed: 11/11/2022] Open
Abstract
Purpose To investigate the prognostic value of preoperative serum albumin to globulin ratio (AGR) in patients with non-muscle-invasive bladder cancer (NMIBC) treated with transurethral resection of bladder tumor (TURB) with or without intravesical therapy (IVT). Materials and methods We retrospectively reviewed 1,096 consecutive patients with NMIBC. Levels of albumin and globulin were obtained before TURB and used to calculate the preoperative AGR level. Multivariable Cox regression analyses were performed to assess the prognostic effect of preoperative AGR on oncologic outcomes. Subgroup analyses were performed in patients based on the European Association of Urology (EAU) risk groups for NMIBC. Results Low AGR levels were observed in 389 (35.5%) patients. The median follow-up was 63.7 months (IQR 25.3–111). On multivariable Cox regression analysis, low AGR was associated with increased risk of progression to muscle-invasive BCa (MIBC) (HR 1.81, 95% CI 1.22–2.68, P = 0.003). The addition of AGR only minimally improved the discrimination ability of a base model that included established clinicopathologic features (C-index = 0.7354 vs. C-index = 0.7162). Low preoperative AGR was not significantly associated with the risk of disease recurrence (P = 0.31). In subgroup analyses based on patients’ EAU risk groups, low preoperative AGR was not associated with recurrence-free survival (RFS) (P = 0.59) or progression-free survival (PFS) (P = 0.22) in any of the risk groups. Additionally, in patients treated with Bacillus Calmette–Guerin (BCG) for intermediate- or high-risk NMIBC, low AGR failed to predict disease recurrence or progression. Conclusion Preoperative serum AGR levels independently predicted the risk of disease progression in patients with NMIBC. However, it was not found to be associated with either RFS or PFS in NMIBC patients based on their EAU risk group. This marker seems to have a limited role in NMIBC at the present time. However, further research is needed to investigate this marker in combination with other systemic inflammatory markers to help improve prediction in this heterogeneous group of patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00345-020-03586-1.
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17
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Can random bladder biopsies be eliminated after bacillus Calmette-Guérin therapy against carcinoma in situ? Int Urol Nephrol 2020; 53:465-469. [PMID: 33025406 DOI: 10.1007/s11255-020-02667-9] [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: 07/07/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Intravesical bacillus Calmette-Guérin (BCG) is the standard of care for bladder carcinoma in situ (CIS). The response to BCG therapy against CIS is generally assessed by random bladder biopsy (RBB). In this study, we examined the necessity of routine RBB after BCG therapy. METHODS We retrospectively identified 102 patients who were initially diagnosed with CIS with or without papillary tumor and received subsequent 6-8-week BCG therapy. Thereafter, all patients underwent voiding cytology analysis, cystoscopy, and RBB to evaluate the effects of BCG therapy. We evaluated the association between clinical parameters (voiding cytology and cystoscopy findings) and the final pathological results by RBB specimens. RESULTS According to the pathological results of RBB, 30 (29%) patients had BCG-unresponsive disease (remaining urothelial carcinoma was confirmed pathologically) and 20 were diagnosed with CIS. Positive/suspicious voiding cytology and positive cystoscopy findings were well observed in patients who had BCG-unresponsive disease compared with their counterparts (p = 0.116, and p < 0.001, respectively). The sensitivity (Sen.), specificity (Spe.), positive predictive value (PPV), and negative predictive value (NPV) of voiding cytology were 50%, 68%, 39%, and 77%, respectively. The values for cystoscopy findings were as follows: Sen.: 87%, Spe.: 57%, PPV: 46%, and NPV: 91%. The values for their combination (having either of them) were as follows: Sen.: 100%, Spe.: 44%, PPV: 43%, and NPV: 100%. CONCLUSION RBB after BCG therapy for patients with negative voiding cytology and negative cystoscopy may be omitted because their risk of BCG-unresponsive disease is significantly low (NPV: 100%).
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18
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Kiełbik A, Szlasa W, Saczko J, Kulbacka J. Electroporation-Based Treatments in Urology. Cancers (Basel) 2020; 12:E2208. [PMID: 32784598 PMCID: PMC7465806 DOI: 10.3390/cancers12082208] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 02/06/2023] Open
Abstract
The observation that an application of a pulsed electric field (PEF) resulted in an increased permeability of the cell membrane has led to the discovery of the phenomenon called electroporation (EP). Depending on the parameters of the electric current and cell features, electroporation can be either reversible or irreversible. The irreversible electroporation (IRE) found its use in urology as a non-thermal ablative method of prostate and renal cancer. As its mechanism is based on the permeabilization of cell membrane phospholipids, IRE (as well as other treatments based on EP) provides selectivity sparing extracellular proteins and matrix. Reversible EP enables the transfer of genes, drugs, and small exogenous proteins. In clinical practice, reversible EP can locally increase the uptake of cytotoxic drugs such as cisplatin and bleomycin. This approach is known as electrochemotherapy (ECT). Few in vivo and in vitro trials of ECT have been performed on urological cancers. EP provides the possibility of transmission of genes across the cell membrane. As the protocols of gene electrotransfer (GET) over the last few years have improved, EP has become a well-known technique for non-viral cell transfection. GET involves DNA transfection directly to the cancer or the host skin and muscle tissue. Among urological cancers, the GET of several plasmids encoding prostate cancer antigens has been investigated in clinical trials. This review brings into discussion the underlying mechanism of EP and an overview of the latest progress and development perspectives of EP-based treatments in urology.
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Affiliation(s)
- Aleksander Kiełbik
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (A.K.); (W.S.)
| | - Wojciech Szlasa
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (A.K.); (W.S.)
| | - Jolanta Saczko
- Department of Molecular and Cellular Biology, Wroclaw Medical University, 50-556 Wroclaw, Poland;
| | - Julita Kulbacka
- Department of Molecular and Cellular Biology, Wroclaw Medical University, 50-556 Wroclaw, Poland;
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19
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Chehroudi AC, Black PC. Emerging intravesical therapies for the management of bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer: Charting a path forward. Can Urol Assoc J 2020; 14:204-213. [PMID: 31977307 DOI: 10.5489/cuaj.6101] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Management of patients with bacillus Calmette-Guérin (BCG)-unresponsive, high-risk, non-muscle-invasive bladder cancer (NMIBC) presents a formidable clinical challenge that requires urologists to weigh the competing risks of progression during further intravesical therapy vs. the morbidity of radical cystectomy. The prognosis of high-risk NMIBC recurring after BCG depends on the adequacy of prior BCG, timing of recurrence, and tumor histology. The standard of care is currently radical cystectomy, as effective salvage intravesical therapy has not been established. The development of bladder-sparing treatments has been hampered to date by inconsistent definitions of BCG failure and difficulties in identifying appropriate control treatments in clinical trials. Despite these limitations, the spectrum of salvage therapy is expanding to include enhanced intravesical chemo-, gene, and immuno-therapies. In this review, we provide an overview of these emerging agents in the context of our current understanding of BCG failure and the unique considerations for clinical trial design in this disease state.
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Affiliation(s)
- Ali Cyrus Chehroudi
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
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20
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Babjuk M, Burger M, Compérat EM, Gontero P, Mostafid AH, Palou J, van Rhijn BWG, Rouprêt M, Shariat SF, Sylvester R, Zigeuner R, Capoun O, Cohen D, Escrig JLD, Hernández V, Peyronnet B, Seisen T, Soukup V. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ) - 2019 Update. Eur Urol 2019; 76:639-657. [PMID: 31443960 DOI: 10.1016/j.eururo.2019.08.016] [Citation(s) in RCA: 822] [Impact Index Per Article: 164.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022]
Abstract
CONTEXT This overview presents the updated European Association of Urology (EAU) guidelines for non-muscle-invasive bladder cancer (NMIBC), TaT1, and carcinoma in situ (CIS). OBJECTIVE To provide practical recommendations on the clinical management of NMIBC with a focus on clinical presentation and recommendations. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines has been performed annually since the last published version in 2017. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS Tumours staged as Ta, T1, and/or CIS are grouped under the heading of NMIBC. Diagnosis depends on cystoscopy and histological evaluation of the tissue obtained by transurethral resection (TURB) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TURB is essential for the patient's prognosis and correct diagnosis. Where the initial resection is incomplete, where there is no muscle in the specimen, or where a T1 tumour is detected, a second TURB should be performed within 2-6 wk. The risks of both recurrence and progression may be estimated for individual patients using the European Organisation for Research and Treatment of Cancer (EORTC) scoring system. Stratification of patients into low-, intermediate-, and high-risk groups is pivotal to the recommendation of adjuvant treatment. In patients with tumours presumed to be at a low risk and in those presumed to be at an intermediate risk with a low previous recurrence rate and an expected EORTC recurrence score of <5, one immediate chemotherapy instillation is recommended. Patients with intermediate-risk tumours should receive 1 yr of full-dose bacillus Calmette-Guérin (BCG) intravesical immunotherapy or instillations of chemotherapy for a maximum of 1 yr. In patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. In patients at the highest risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is recommended in BCG-unresponsive tumours. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/. CONCLUSIONS These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology Non-muscle-invasive Bladder Cancer (NMIBC) Panel has released an updated version of their guidelines, which contains information on classification, risk factors, diagnosis, prognostic factors, and treatment of NMIBC. The recommendations are based on the current literature (until the end of 2018), with emphasis on high-level data from randomised clinical trials and meta-analyses. Stratification of patients into low-, intermediate-, and high-risk groups is essential for deciding appropriate use of adjuvant intravesical chemotherapy or bacillus Calmette-Guérin (BCG) instillations. Surgical removal of the bladder should be considered in case of BCG-unresponsive tumours or in NMIBCs with the highest risk of progression.
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Affiliation(s)
- Marko Babjuk
- Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria.
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Eva M Compérat
- Department of Pathology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, UPMC Paris VI, Paris, France
| | - Paolo Gontero
- Division of Urology, Molinette Hospital, University of Studies of Torino, Torino, Italy
| | - A Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Bas W G van Rhijn
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany; Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Morgan Rouprêt
- Urology Department, Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Richard Sylvester
- European Association of Urology Guidelines Office, Brussels, Belgium
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Otakar Capoun
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Daniel Cohen
- Department of Urology, Royal Free London NHS Foundation Trust, London, UK
| | | | - Virginia Hernández
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Thomas Seisen
- Urology Department, Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Viktor Soukup
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
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How Should I Manage a Patient with Tumor Recurrence Despite Adequate Bacille Calmette-Guérin? Eur Urol Oncol 2019; 3:252-257. [PMID: 31307960 DOI: 10.1016/j.euo.2019.06.013] [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: 03/26/2019] [Revised: 05/31/2019] [Accepted: 06/14/2019] [Indexed: 11/24/2022]
Abstract
Intravesical immunotherapy with bacille Calmette-Guérin (BCG) vaccine is the main treatment for non-muscle-invasive bladder cancer (NMIBC), with proven effects on reducing recurrence, progression, and death from NMIBC. However, it is not effective in all patients, and recurrence after adequate BCG therapy can frequently lead to progression to more life-threatening disease. This point-counterpoint review considers how to treat a healthy 60-yr-old patient with T1 high-grade NMIBC fitting the new definition of BCG-unresponsive disease, that is, persistent high-grade disease at 6-12mo, despite an adequate course of induction and maintenance with BCG. PATIENT SUMMARY: When T1 high-grade non-muscle-invasive bladder cancer is persistent or recurs shortly after a full course of bacille Calmette-Guérin (BCG) plus maintenance, further BCG is not likely to work; this meets the new definition of a "BCG unresponsive" disease. For this situation, the safest (curative) option is removal of the bladder. If that is not an accepted alternative, then a clinical trial or combination intravesical chemotherapy or hyperchemotherapy may be another option.
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The Role and Importance of Timely Radical Cystectomy for High-Risk Non-muscle-Invasive Bladder Cancer. Cancer Treat Res 2019; 175:193-214. [PMID: 30168123 DOI: 10.1007/978-3-319-93339-9_9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Non-muscle-invasive bladder cancer accounts for the majority of incident bladder cancers but is a heterogeneous disease with variation in clinical presentation, course, and outcomes. Risk stratification techniques have attempted to identify those at highest risk of cancer recurrence and progression to help personalize and individualize treatment options. Radical cystectomy during the optimal window of curability could improve cancer outcomes; however, identifying the disease and patient characteristics as well as the correct timing to intervene remains difficult. We review the natural history of non-muscle-invasive bladder cancer, discuss different risk-stratification techniques and how they can help identify those most likely to benefit from radical treatment, and examine the evidence supporting the benefit of timely cystectomy.
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Urothelial Carcinoma In Situ and Treatment of Bacillus Calmette-Guérin Failures. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Racioppi M, Di Gianfrancesco L, Ragonese M, Palermo G, Sacco E, Bassi PF. ElectroMotive drug administration (EMDA) of Mitomycin C as first-line salvage therapy in high risk "BCG failure" non muscle invasive bladder cancer: 3 years follow-up outcomes. BMC Cancer 2018; 18:1224. [PMID: 30522445 PMCID: PMC6282335 DOI: 10.1186/s12885-018-5134-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 11/26/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In case of high grade non-muscle invasive bladder cancer (HG-NMIBC), intravesical BCG represents the first-line treatment; despite the "gold" standard therapy, up to 50% of patients relapse, needing radical cystectomy. Hence, alternative therapeutic strategies have been developed. The aim of the study was to evaluate a first-line salvage treatment with EMDA®-MMC in patients with HGNMIBC unresponsive to BCG. METHODS We carried out a prospective, single-center, single-arm Phase II study in order to evaluate the efficacy (in terms of recurrence and progression) and the safety of the EMDA®-MMC treatment in 26 (21 male, 5 female) consecutive patients with "BCG refractory" HGNMIBC on a 3 years follow-up. EMDA®-MMC treatment consisted of 40 mg of MMC diluted in 100 ml of sterile water retained in the bladder for 30 min with 20 mA pulsed electric current. EMDA®-MMC regimen consisted of an induction course of 6 weekly instillations followed by a maintenance course of 6 monthly instillations. Follow-up was performed with systematic mapping biopsies of the bladder (with sampling in the prostatic urethra for men), voiding and washing urinary cytology, radiological study of the upper urinary tract. We performed Survival Kaplan-Meier curves and Log-rank test in order to analyze high grade disease-free survival. RESULTS At the end of follow-up, 16 patients (61.5%) preserved their native bladder; 10 patients (38.4%) underwent radical cystectomy, in 6 patients (23.1%) for recurrent HGNMIBC and in 4 patients (15.4%) for progression to muscle-invasive disease. At the end of follow-up, stratifying patients based on TNM classification (TaG3, T1G3, Cis, TaT1G3 + Cis), disease-free rates were 75, 71.4, 50 and 25%, respectively; survival curves showed statistically significant differences (p value < 0.05). Regarding toxicity, we reported severe adverse systemic event of hypersensitivity to the MMC in 3 patients (11.5%), and local side effects in 6 patients (26.1%). CONCLUSIONS In the field of alternative strategies to radical cystectomy, the EMDA®-MMC could be considered safe and effective in high-risk NMIBC unresponsive to BCG, as a "bladder sparing" therapy in selected patients. Multicenter studies with a larger number of patients and a longer follow-up might confirm our preliminary results. TRIAL REGISTRATION EudraCT2017-002585-43. 17 June 2017 (retrospectively registered).
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Affiliation(s)
- Marco Racioppi
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Luca Di Gianfrancesco
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Mauro Ragonese
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Giuseppe Palermo
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Emilio Sacco
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
| | - Pier Francesco Bassi
- Department of Urology, Fondazione Policlinico Universitario “A. Gemelli” IRCSS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli, 8, 00168 Rome, Italy
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D’Andrea D, Witjes F, Soria F, Shariat SF. Urothelial Carcinoma In Situ and Treatment of Bacillus Calmette-Guérin Failures. Urol Oncol 2018. [DOI: 10.1007/978-3-319-42603-7_21-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Herr H. Re: Marko Babjuk, Andreas Böhle, Maximilian Burger, et al. EAU Guidelines on Non–muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol 2017;71:447–61. Eur Urol 2017; 71:e171-e172. [DOI: 10.1016/j.eururo.2016.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 11/24/2016] [Indexed: 11/26/2022]
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Scott SN, Ostrovnaya I, Lin CM, Bouvier N, Bochner B, Iyer G, Solit D, Berger MF, Lin O. Next-generation sequencing of urine specimens: A novel platform for genomic analysis in patients with non-muscle-invasive urothelial carcinoma treated with bacille Calmette-Guérin. Cancer 2017; 125:416-426. [PMID: 28339163 PMCID: PMC5477237 DOI: 10.1002/cncy.21847] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 01/25/2017] [Accepted: 01/27/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Biopsies from patients with high-risk (HR) non-muscle-invasive urothelial carcinoma (NMIUC), especially flat urothelial carcinoma in situ, frequently contain scant diagnostic material or denuded mucosa only, and this precludes further extensive genomic analysis. This study evaluated the use of next-generation sequencing (NGS) analysis of urine cytology material from patients with HR NMIUC in an attempt to identify genetic alterations that might correlate with clinical features and responses to bacille Calmette-Guérin (BCG) treatment. METHODS Forty-one cytology slides from patients with HR NMIUC treated with intravesical BCG were selected for this study. Histological confirmation was available for all cases. The specimens were subjected to NGS analysis with a customized targeted exome capture assay composed of 341 genes. RESULTS In this cohort, genomic alterations were successfully identified in all cytology samples. Mutations were detected down to a 2% allele frequency and chromosomal rearrangements including copy number alterations and gene fusions were identified. The most frequently altered genes included telomerase reverse transcriptase (TERT), tumor protein 53 (TP53), Erb-B2 receptor tyrosine kinase 2 (ERBB2), and chromatin remodeling genes such as lysine demethylase 6A (KDM6A) and AT-rich interaction domain 1A (ARID1A). For patients with matched tumor tissue, cytology specimens revealed all mutations detected in tissue as well as additional mutations, and this suggested that urine might more effectively capture the full genetic heterogeneity of disease than an individual cystectomy. Alterations in multiple genes correlated with clinical and histopathological features, including responses to BCG treatment, flat architecture versus papillary architecture, and smoking history. CONCLUSIONS Urine specimens can replace tissue as a substrate for NGS analysis of HR NMIUC. Several genomic alterations identified in urine specimens might be associated with histological features and clinical characteristics. Cancer Cytopathol 2017;125:416-26. © 2017 American Cancer Society.
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Affiliation(s)
- Sasinya N. Scott
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Irina Ostrovnaya
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Caroline M. Lin
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nancy Bouvier
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bernard Bochner
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gopakumar Iyer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Solit
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael F. Berger
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oscar Lin
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Abstract
Non-muscle-invasive bladder cancer (NMIBC) represents the vast majority of bladder cancer diagnoses, but this definition represents a spectrum of disease with a variable clinical course, notable for significant risk of recurrence and potential for progression. Management involves risk-adapted strategies of cystoscopic surveillance and intravesical therapy with the goal of bladder preservation when safe to do so. Multiple organizational guidelines exist to help practitioners manage this complicated disease process, but adherence to management principles among practising urologists is reportedly low. We review four major organizational guidelines on NMIBC: the American Urological Association (AUA)/Society of Urologic Oncology (SUO), European Association of Urology (EAU), National Comprehensive Cancer Network (NCCN), and National Institute for Health and Care Excellence (NICE) guidelines.
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Affiliation(s)
- Solomon L Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aditya Bagrodia
- 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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Babjuk M, Burger M, Compérat E, Palou J, Rouprêt M, van Rhijn B, Shariat S, Sylvester R, Zigeuner R, Gontero P, Mostafid H. Reply to Harry Herr's Letter to the Editor re: Marko Babjuk, Andreas Böhle, Maximilian Burger, et al. EAU Guidelines on Non-muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol 2017;71:447-61. Eur Urol 2016; 71:e173-e174. [PMID: 27939074 DOI: 10.1016/j.eururo.2016.11.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 11/24/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Eva Compérat
- Department of Pathology, Hôpital La Pitié-Salpétrière, UPMC, Paris, France
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Morgan Rouprêt
- AP-HP, Hôpital La Pitié-Salpétrière, Service d'Urologie, Paris, France; UPMC University Paris 06, GRC5, ONCOTYPE-Uro, Institut Universitaire de Cancérologie, Paris, France
| | - Bas van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Shahrokh Shariat
- Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Richard Sylvester
- European Association of Urology Guidelines Office, Brussels, Belgium
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Paolo Gontero
- Urology Clinic, Citta della Salute e della Scienza di Torino, University of Studies of Turin, Turin, Italy
| | - Hugh Mostafid
- Department of Urology, North Hampshire Hospital, Basingstoke, Hampshire
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30
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Abstract
Intravesical Bacillus Calmette-Guérin (BCG) has long been the gold standard treatment of nonmuscle invasive bladder cancer. Recently, there has been an emergence of novel immunotherapeutic agents, which have shown promise in the treatment of urothelial cell carcinoma. These agents aim to augment, modify, or enhance the immune response. Such strategies include recombinant BCG, monoclonal antibodies, vaccines, gene therapy, and adoptive T-cell therapy. Here, we review the emerging immunotherapeutics in the treatment of nonmuscle invasive bladder cancer.
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Affiliation(s)
- Mahir Maruf
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Sam J Brancato
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Piyush K Agarwal
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
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31
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Mmeje CO, Guo CC, Shah JB, Navai N, Grossman HB, Dinney CP, Kamat AM. Papillary Recurrence of Bladder Cancer at First Evaluation after Induction Bacillus Calmette-Guérin Therapy: Implication for Clinical Trial Design. Eur Urol 2016; 70:778-785. [PMID: 26922408 DOI: 10.1016/j.eururo.2016.02.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/04/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recurrence with papillary tumor(s) by 3-mo after induction bacillus Calmette-Guérin (BCG) is historically believed to be a poor prognostic indicator in patients with high-risk non-muscle invasive bladder cancer. However, the impact of a clinical Ta (cTa) papillary recurrence at 3 mo after BCG is often debated. OBJECTIVE To evaluate the prognostic implications of cTa papillary recurrence found 3 mo after induction BCG therapy and to evaluate its significance in clinical trial design. DESIGN, SETTING, AND PARTICIPANTS We reviewed our database of 917 patients who underwent transurethral resection and induction of BCG from 1995 to 2012. Clinical characteristics were compared between 3-mo recurrence stages. INTERVENTION Transurethral resection of bladder tumor and intravesical therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Chi-square analysis and Student t test were used to compare clinical characteristics between 3-mo recurrence stages. Kaplan-Meier method was used to determine bladder-preservation time, progression-free survival, and disease-specific survival. RESULTS AND LIMITATIONS We identified 84 patients who met the study criteria (66 patients with cTa and 18 patients with clinical T1 [cT1]). The median follow-up for the entire cohort was 74 mo. Of the patients with cTa recurrence, 60 continued with bladder-sparing therapy. Patients with a high-grade cTa recurrence who continued bladder-sparing therapy had a 17% incidence of disease progression and a 62% incidence of recurrence within 1 yr. No patients with low-grade cTa recurrence (n=13) developed disease progression or underwent radical cystectomy. Patients with an initial cTa at diagnosis had a higher 5-yr bladder preservation rate than those with an initial cT1 diagnosis (84% vs 61%; p=0.041). Patients with high-grade cTa recurrence and those with cT1 recurrence had similar outcomes with respect to death rates over the entire follow-up period (11% and 15%, respectively), as well as 5-yr progression-free survival (77% vs 83%). Limitations include using a single institution and a retrospective review. CONCLUSIONS Patients with low-grade cTa papillary recurrence 3 mo after induction of BCG can safely continue with bladder-sparing therapy. Patients with high-grade cTa papillary recurrence at that time have risks of recurrence and progression similar to those of patients with cT1 recurrence. These are important factors to consider during clinical trial design. PATIENT SUMMARY Low-grade clinical Ta papillary recurrence following induction of bacillus Calmette-Guérin therapy can be safely managed conservatively, although a high-grade clinical Ta recurrence should be treated similar to a clinical T1 recurrence due to its comparable progression rates.
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Affiliation(s)
- Chinedu O Mmeje
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles C Guo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jay B Shah
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neema Navai
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - H Barton Grossman
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Colin P Dinney
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Abstract
Intravesical immunotherapy with bacille-Calmette-Guerin (BCG) is indicated in the treatment of high-risk and intermediate-risk non-muscle invasive bladder cancer (NMIBC). Our goal is to describe the various disease states following induction and maintenance BCG and to describe contemporary treatment options and the current and projected clinical trial landscape for patients who recur following BCG therapy.
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Affiliation(s)
- Friedrich-Carl von Rundstedt
- 1 Scott of Department of Urology, Translational Biology and Molecular Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Urology, Helios Medical Center, University Witten-Herdecke, Wuppertal, Germany
| | - Seth P Lerner
- 1 Scott of Department of Urology, Translational Biology and Molecular Medicine, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Urology, Helios Medical Center, University Witten-Herdecke, Wuppertal, Germany
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Power NE, Izawa J. Comparison of Guidelines on Non-Muscle Invasive Bladder Cancer (EAU, CUA, AUA, NCCN, NICE). Bladder Cancer 2016; 2:27-36. [PMID: 27376122 PMCID: PMC4927900 DOI: 10.3233/blc-150034] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Non-muscle invasive bladder cancer (NMIBC) represents a considerably diverse patient group and the management of this complex disease is debatable. A number of panels from Europe and North America have convened on the topic and recently released guideline documents. Objective: The purpose was to compare and contrast the NMIBC guideline recommendations from the EAU (Europe), CUA (Canada), NCCN (United States), AUA (United States), and NICE (United Kingdom). Methods: All unabridged guideline documents were reviewed by the authors and comparisons were completed according to major topics in NMIBC. Results: Despite a paucity of high level evidence regarding the majority of management topics in NMIBC, there was general agreement among the various guideline panels. Differences mainly centered on the categories of evidence synthesized and grades of recommendations. Each document offers a unique presentation of the available literature and guideline recommendation. Conclusions: The guidelines for NMIBC from the EAU, CUA, AUA, NCCN, and NICE provide considerable consensus regarding the management of this often difficult disease. Clinicians are encouraged to familiarize themselves with all of the guidelines in order to determine which style of presentation would be most useful to their current practice.
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Affiliation(s)
- Nicholas E Power
- Department of Surgery & Oncology, Divisions of Urology and Surgical Oncology, Western University , London, ON, Canada
| | - Jonathan Izawa
- Department of Surgery & Oncology, Divisions of Urology and Surgical Oncology, Western University , London, ON, Canada
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Patel S, Dinh T, Noah-Vanhoucke J, Rengarajan B, Mayo K, Clark PE, Kamat AM, Lee CT, Sexton WJ, Steinberg GD. Novel Simulation Model of Non-Muscle Invasive Bladder Cancer: A Platform for a Virtual Randomized Trial of Conservative Therapy vs. Cystectomy in BCG Refractory Patients. Bladder Cancer 2015; 1:143-150. [PMID: 27376114 PMCID: PMC4927810 DOI: 10.3233/blc-150020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: There have been no randomized controlled trials (RCTs) evaluating the clinical or economic benefit of mitomycin C intravesical therapy vs. radical cystectomy in patients with high-risk non-muscle invasive bladder cancer (NMIBC). We used the Archimedes computational model to simulate RCT comparing radical cystectomy versus intravesical mitomycin C (MMC) therapy to evaluate the clinical and economic outcomes for BCG-refractory NMIBC as well demonstrate the utility of computer based models to simulate a clinical trial. Methods: The Archimedes model was developed to generate a virtual population using the Surveillance Epidemiology and End Results database, other clinical trials, and expert opinions. Patients selected were diagnosed with NMIBC (<cT2 disease) who recurred or progressed despite BCG therapy and were randomized to 1) immediate radical cystectomy vs. 2) MMC induction intravesical therapy. Clinical (progression, overall survival, and disease specific survival) and economic outcomes were reported. Results: A total of 1300 virtual patients were evaluation. Progression to MIBC in the MMC treatment arm was 30% over the lifetime. Disease specific death at 5 years was 1.6% and 8.7% for the immediate cystectomy and MMC treatment arms respectively; while, overall death was 17.8% and 23.8% at 5 years. Over a 5-year period the average cost of immediate cystectomy was $64,675 vs $68,517 in the MMC arm. Conclusion: Immediate radical cystectomy after BCG failure for NMIBC has improved survival and is more cost-effective when compared to those undergoing MMC. Simulation of clinical trials using computational models similar to the Archimedes model can overcome shortcomings of real-world clinical trials and may prove useful in the face of current medical cost-conscious era.
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Affiliation(s)
| | - Tuan Dinh
- Archimedes Inc., San Francisco, CA, USA
| | | | | | | | - Peter E Clark
- Vanderbilt University Medical Center, Nashville, TN, USA
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Spaliviero M, Dalbagni G, Nielsen M. What to do when bacillus Calmette-Guérin fails. Bladder Cancer 2015. [DOI: 10.1002/9781118674826.ch9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Soria F, Milla P, Fiorito C, Pisano F, Sogni F, Di Marco M, Pagliarulo V, Dosio F, Gontero P. Efficacy and safety of a new device for intravesical thermochemotherapy in non-grade 3 BCG recurrent NMIBC: a phase I-II study. World J Urol 2015; 34:189-95. [PMID: 26026818 DOI: 10.1007/s00345-015-1595-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/16/2015] [Indexed: 11/29/2022] Open
Abstract
PURPOSE We report for the first time the activity and safety of Unithermia(®) (Elmedical Ltd, Hod-Hasharon, Israel), a novel device for administration of MMC-C with hyperthermia (HT), that employs conductive heating, in a series of non-grade 3 non-muscle-invasive bladder cancer (NMIBC) that failed Bacillus Calmette-Guerin (BCG). METHODS Patients with non-grade 3 NMIBC recurring after at least a full induction course of BCG were eligible for this phase I-II prospective single-arm study. Six weekly instillations with Unithermia(®) were scheduled following complete TUR. Primary end points were treatment safety and response rate (RR), and the latter defined as the absence of any unfavourable outcome at 12 months. Any grade 3 and/or muscle-invasive (T > 1) recurrence was considered disease progression. Kaplan-Meier estimation of the time to recurrence and progression, cancer-specific survival and overall survival was taken as secondary end points. RESULTS Thirty-four eligible patients entered the study between January 2009 and April 2011. RR was documented in 20/34 (59%). Among the 14/34 (41%) non-responders, four developed G3 disease, one developed carcinoma in situ, and one progressed to muscle-invasive bladder cancer, with an overall 18% progression rate at 1 year. At a median follow-up of 41 months, recurrence and progression rates were 35.3 and 23.5%, respectively. Toxicity did not go beyond grade 2 except in five cases. CONCLUSIONS Initial experience with MMC-HT with Unithermia(®) showed an interesting activity and safety profile in non-grade 3 NMIBC recurring after BCG, suggesting a role as second-line therapy in this selected subgroup of NMIBC.
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Affiliation(s)
- Francesco Soria
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, C.so Bramante 88/90, 10126, Turin, Italy
| | - Paola Milla
- Department of Pharmacology, University of Studies of Torino, Turin, Italy
| | - Chiara Fiorito
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, C.so Bramante 88/90, 10126, Turin, Italy
| | - Francesca Pisano
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, C.so Bramante 88/90, 10126, Turin, Italy
| | - Filippo Sogni
- Urology Clinic, Maggiore della Carità Hospital, Novara, Italy
| | | | | | - Franco Dosio
- Department of Pharmacology, University of Studies of Torino, Turin, Italy
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, C.so Bramante 88/90, 10126, Turin, Italy.
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Cockerill PA, Knoedler JJ, Frank I, Tarrell R, Karnes RJ. Intravesical gemcitabine in combination with mitomycin C as salvage treatment in recurrent non-muscle-invasive bladder cancer. BJU Int 2015; 117:456-62. [PMID: 25682834 DOI: 10.1111/bju.13088] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate oncological outcomes after combination intravesical therapy with gemcitabine (GC) and mitomycin C (MMC) in the setting of recurrent non-muscle-invasive bladder cancer (NMIBC) after failure of previous intravesical therapy. PATIENTS AND METHODS We retrospectively identified patients with recurrent NMIBC after previous intravesical therapy, who refused or were not candidates for cystectomy, between 2005 and 2011. GC and MMC were sequentially instilled weekly for 6-8 weeks. Data were collected regarding patient demographics, bladder cancer history, and number and type of intravesical therapies before GC/MMC. Outcomes evaluated included time to recurrence and/or progression after GC/MMC. Recurrence-free outcomes were estimated using the Kaplan-Meier method, and Cox proportional hazards regression models were used to test the association of clinicopathological features with outcomes. RESULTS In all, 27 patients were identified, 23 with high-risk disease (high-grade or carcinoma in situ) and four with intermediate-risk disease (multifocal or recurrent low-grade). All patients received prior intravesical therapy, and 17 patients (63%) received multiple courses. Twenty-four patients were treated with BCG. The median (range) disease-free survival of all patients was 15.2 (1.7-39.3) months. Seventeen patients (63%) developed recurrent bladder cancer, a median of 15.2 months after therapy. One patient progressed to muscle-invasive disease 5 months after treatment, and one developed metastatic disease 22 months after treatment. Three patients went on to cystectomy. Ten patients (37%) had no evidence of disease at last follow-up, with a median follow-up of 22.1 months. CONCLUSION The combination of intravesical GC and MMC could offer durable recurrence-free survival to some patients with recurrent NMIBC who are not candidates for, or refuse, cystectomy.
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Affiliation(s)
| | | | - Igor Frank
- Department of Urology, Mayo Clinic, Rochester, MN, USA
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Svatek RS, Zhao XR, Morales EE, Jha MK, Tseng TY, Hugen CM, Hurez V, Hernandez J, Curiel TJ. Sequential intravesical mitomycin plus Bacillus Calmette-Guérin for non-muscle-invasive urothelial bladder carcinoma: translational and phase I clinical trial. Clin Cancer Res 2014; 21:303-11. [PMID: 25424854 DOI: 10.1158/1078-0432.ccr-14-1781] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the safety and toxicities of sequential MMC (mitomycin C) + BCG (bacillus Calmette-Guérin) in patients with non-muscle-invasive bladder cancer (NMIBC) and explore evidence for potentiation of BCG activity by MMC. EXPERIMENTAL DESIGN A 3 + 3 phase I dose-escalation trial of six weekly treatments was conducted in patients with NMIBC. MMC (10, 20, or 40 mg) was instilled intravesically for 30 minutes, followed by a 10-minute washout with gentle saline irrigation and then instillation of BCG (half or full strength) for 2 hours. Urine cytokines were monitored and compared with levels in a control cohort receiving BCG only. Murine experiments were carried out as described previously. RESULTS Twelve patients completed therapy, including 3 patients receiving full doses. The regimen was well tolerated with no treatment-related dose-limiting toxicities. Urinary frequency and urgency, and fatigue were common. Eleven (91.7%) patients were free of disease at a mean (range) follow-up of 21.4 (8.4-27.0) months. Median posttreatment urine concentrations of IL2, IL8, IL10, and TNFα increased over the 6-week treatment period. A greater increase in posttreatment urinary IL8 during the 6-week period was observed in patients receiving MMC + BCG compared with patients receiving BCG monotherapy. In mice, intravesical MMC + BCG skewed tumor-associated macrophages (TAM) toward a beneficial M1 phenotype. CONCLUSIONS Instillation of sequential MMC + BCG is safe tolerable up to 40-mg MMC plus full-strength BCG. This approach could provide improved antitumor activity over BCG monotherapy by augmenting beneficial M1 TAMs.
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Affiliation(s)
- Robert S Svatek
- The Cancer Therapy and Research Center/Adult Cancer Program, The University of Texas Health Science Center San Antonio, San Antonio, Texas. Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas.
| | - Xiang Ru Zhao
- The Cancer Therapy and Research Center/Adult Cancer Program, The University of Texas Health Science Center San Antonio, San Antonio, Texas. Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Edwin E Morales
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Mithilesh K Jha
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Timothy Y Tseng
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Cory M Hugen
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Vincent Hurez
- Department of Medical Oncology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Javier Hernandez
- Department of Urology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Tyler J Curiel
- The Cancer Therapy and Research Center/Adult Cancer Program, The University of Texas Health Science Center San Antonio, San Antonio, Texas. Department of Medical Oncology, The University of Texas Health Science Center San Antonio, San Antonio, Texas
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Nishiyama N, Kitamura H, Hotta H, Takahashi A, Yanase M, Itoh N, Tachiki H, Miyao N, Matsukawa M, Kunishima Y, Taguchi K, Masumori N. Construction of predictive models for cancer-specific survival of patients with non-muscle-invasive bladder cancer treated with bacillus Calmette-Guérin: results from a multicenter retrospective study. Jpn J Clin Oncol 2014; 44:1101-8. [PMID: 25139163 DOI: 10.1093/jjco/hyu119] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aims of this study were to clarify the prognostic factors and to validate the bacillus Calmette-Guérin failure classification advocated by Nieder et al. in patients with non-muscle-invasive bladder cancer who had intravesical recurrence after bacillus Calmette-Guérin therapy. METHODS Data from 402 patients who received intravesical bacillus Calmette-Guérin therapy between January 1990 and November 2011 were collected from 10 institutes. Among these patients, 187 with bacillus Calmette-Guérin failure were analyzed for this study. RESULTS Twenty-nine patients (15.5%) were diagnosed with progression at the first recurrence after bacillus Calmette-Guérin therapy. Eighteen (62.1%) of them died of bladder cancer. A total of 158 patients were diagnosed with non-muscle-invasive bladder cancer at the first recurrence after bacillus Calmette-Guérin therapy. Of them, 23 (14.6%) underwent radical cystectomy. No patients who underwent radical cystectomy died of bladder cancer during the follow-up. On multivariate analysis of the 135 patients with bladder preservation, the independent prognostic factors for cancer-specific survival were age (≥70 [P = 0.002]), tumor size (≥3 cm [P = 0.015]) and the Nieder classification (bacillus Calmette-Guérin refractory [P < 0.001]). In a subgroup analysis, the estimated 5-year cancer-specific survival rates in the groups with no positive, one positive and two to three positive factors were 100, 93.4 and 56.8%, respectively (P < 0.001). CONCLUSIONS Patients with stage progression at the first recurrence after bacillus Calmette-Guérin therapy had poor prognoses. Three prognostic factors for predicting survival were identified and used to categorize patients with non-muscle-invasive bladder cancer treated with bacillus Calmette-Guérin into three risk groups based on the number of prognostic factors in each one.
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Affiliation(s)
- Naotaka Nishiyama
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo
| | - Hiroshi Kitamura
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo
| | - Hiroshi Hotta
- Department of Urology, Asahikawa Red Cross Hospital, Asahikawa
| | | | - Masahiro Yanase
- Department of Urology, Sunagawa City Medical Center, Sunagawa
| | - Naoki Itoh
- Department of Urology, NTT East Japan Sapporo Hospital, Sapporo
| | - Hitoshi Tachiki
- Department of Urology, Steel Memorial Muroran Hospital, Muroran
| | - Noriomi Miyao
- Department of Urology, Muroran City General Hospital, Muroran
| | | | - Yasuharu Kunishima
- Department of Urology, Hokkaido Social Work Association Obihiro Hospital, Obihiro
| | - Keisuke Taguchi
- Department of Urology, Oji General Hospital, Tomakomai, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo
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Oosterlinck W, Decaestecker K. Current strategies in the treatment of non-muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2014; 12:1097-106. [DOI: 10.1586/era.12.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bladder cancer: Always consider extravesical sites when BCG fails. Nat Rev Urol 2013; 11:11-2. [PMID: 24346003 DOI: 10.1038/nrurol.2013.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Sternberg IA, Dalbagni G, Chen LY, Donat SM, Bochner BH, Herr HW. Intravesical Gemcitabine for High Risk, Nonmuscle Invasive Bladder Cancer after Bacillus Calmette-Guérin Treatment Failure. J Urol 2013; 190:1686-91. [DOI: 10.1016/j.juro.2013.04.120] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Itay A. Sternberg
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ling Y. Chen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Sherri M. Donat
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Bernard H. Bochner
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Harry W. Herr
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
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Dinney CP, Greenberg RE, Steinberg GD. Intravesical valrubicin in patients with bladder carcinoma in situ and contraindication to or failure after bacillus Calmette-Guérin. Urol Oncol 2013; 31:1635-42. [DOI: 10.1016/j.urolonc.2012.04.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 04/10/2012] [Accepted: 04/10/2012] [Indexed: 10/28/2022]
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Babjuk M, Burger M, Zigeuner R, Shariat SF, van Rhijn BWG, Compérat E, Sylvester RJ, Kaasinen E, Böhle A, Palou Redorta J, Rouprêt M. EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder: update 2013. Eur Urol 2013; 64:639-53. [PMID: 23827737 DOI: 10.1016/j.eururo.2013.06.003] [Citation(s) in RCA: 913] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT The first European Association of Urology (EAU) guidelines on bladder cancer were published in 2002 [1]. Since then, the guidelines have been continuously updated. OBJECTIVE To present the 2013 EAU guidelines on non-muscle-invasive bladder cancer (NMIBC). EVIDENCE ACQUISITION Literature published between 2010 and 2012 on the diagnosis and treatment of NMIBC was systematically reviewed. Previous guidelines were updated, and the levels of evidence and grades of recommendation were assigned. EVIDENCE SYNTHESIS Tumours staged as Ta, T1, or carcinoma in situ (CIS) are grouped as NMIBC. Diagnosis depends on cystoscopy and histologic evaluation of the tissue obtained by transurethral resection (TUR) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TUR is essential for the patient's prognosis. Where the initial resection is incomplete, where there is no muscle in the specimen, or where a high-grade or T1 tumour is detected, a second TUR should be performed within 2-6 wk. The risks of both recurrence and progression may be estimated for individual patients using the EORTC scoring system and risk tables. The stratification of patients into low-, intermediate-, and high-risk groups is pivotal to recommending adjuvant treatment. For patients with a low-risk tumour, one immediate instillation of chemotherapy is recommended. Patients with an intermediate-risk tumour should receive one immediate instillation of chemotherapy followed by 1 yr of full-dose bacillus Calmette-Guérin (BCG) intravesical immunotherapy or by further instillations of chemotherapy for a maximum of 1 yr. In patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. In patients at highest risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is recommended in BCG-refractory tumours. The long version of the guidelines is available from the EAU Web site: http://www.uroweb.org/guidelines/. CONCLUSIONS These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice. PATIENT SUMMARY The EAU Panel on Non-muscle Invasive Bladder Cancer released an updated version of their guidelines. Current clinical studies support patient selection into different risk groups; low, intermediate and high risk. These risk groups indicate the likelihood of the development of a new (recurrent) cancer after initial treatment (endoscopic resection) or progression to more aggressive (muscle-invasive) bladder cancer and are most important for the decision to provide chemo- or immunotherapy (bladder installations). Surgical removal of the bladder (radical cystectomy) should only be considered in patients who have failed chemo- or immunotherapy, or who are in the highest risk group for progression.
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Affiliation(s)
- Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
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Smith PJ, Lotan Y, Raj GV, Sagalowsky AI, Margulis V. Assessing treatment response after induction Bacillus Calmette-Guerin for carcinomain situof the urinary bladder: can post-induction random bladder biopsies be avoided? Cytopathology 2013; 25:108-11. [DOI: 10.1111/cyt.12064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2013] [Indexed: 11/30/2022]
Affiliation(s)
- P. J. Smith
- Department of Urology; UT Southwestern Medical School; Dallas TX USA
| | - Y. Lotan
- Department of Urology; UT Southwestern Medical School; Dallas TX USA
| | - G. V. Raj
- Department of Urology; UT Southwestern Medical School; Dallas TX USA
| | - A. I. Sagalowsky
- Department of Urology; UT Southwestern Medical School; Dallas TX USA
| | - V. Margulis
- Department of Urology; UT Southwestern Medical School; Dallas TX USA
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Hansel DE, Miller JS, Cookson MS, Chang SS. Challenges in the pathology of non-muscle-invasive bladder cancer: a dialogue between the urologic surgeon and the pathologist. Urology 2013; 81:1123-30. [PMID: 23522296 DOI: 10.1016/j.urology.2013.01.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 01/16/2013] [Accepted: 01/18/2013] [Indexed: 11/25/2022]
Abstract
Approximately 70%-80% of urothelial carcinomas are detected at the stage of non-muscle-invasive bladder cancer (NMIBC). Initial management is often successful, but recurrence is common and leads to a long, burdensome, costly disease course. The quality and efficiency of care depends in part on accurate, clearly communicated descriptions of tumor characteristics. This review identifies current best practices, unmet needs, and key issues in the pathology of NMIBC for the practicing urologist. Reasonable and objective recommendations are provided with the goal of improving urologist-pathologist communication, the efficiency of healthcare utilization, and outcomes for patients with NMIBC.
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Macek P, Sanchez-Salas R, Rozet F, Barret E, Galiano M, Hanus T, Cathelineau X. Prostate-Sparing Radical Cystectomy for Selected Patients with Bladder Cancer. Urol Int 2013; 91:89-96. [DOI: 10.1159/000348332] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 01/18/2013] [Indexed: 11/19/2022]
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Abstract
PURPOSE OF REVIEW Although the conservative approach including Bacillus Calmette-Guerin (BCG) therapy is considered as the first-line option in high-risk nonmuscle invasive bladder tumors, cystectomy is often required as an alternative treatment in the case of BCG failure. Considering all the parameters, including clinical data, endoscopic aspects and new biological markers, the question of the indication, and moreover timing, of cystectomy has become crucial. RECENT FINDINGS In fact, the real positive effect of BCG remains controversial and its actual benefit in terms of survival is not evident. Therefore, early cystectomy for this population with high risk of progression and metastasis diffusion is clearly a radical approach which can lead to a reduction in specific mortality. Recent articles have studied the parameters involved in this issue to determine the exact timing of cystectomy. SUMMARY To avoid delay of appropriate treatment, it is crucial to determine the non-BCG responder population. Unfortunately, no consensual marker is currently available. Nevertheless, multifocal tumors, associated carcinoma in situ, prostatic urethral involvement, tumoral size greater than 3 cm and depth of infiltration are useful parameters in clinical practice to propose early cystectomy. In the future, the crucial question of cystectomy timing may be answered by progress in molecular signatures for bladder cancers.
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Yates DR, Brausi MA, Catto JW, Dalbagni G, Rouprêt M, Shariat SF, Sylvester RJ, Witjes JA, Zlotta AR, Palou-Redorta J. Treatment Options Available for Bacillus Calmette-Guérin Failure in Non–muscle-invasive Bladder Cancer. Eur Urol 2012; 62:1088-96. [DOI: 10.1016/j.eururo.2012.08.055] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 08/27/2012] [Indexed: 11/17/2022]
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Anastasiadis A, de Reijke TM. Best practice in the treatment of nonmuscle invasive bladder cancer. Ther Adv Urol 2012; 4:13-32. [PMID: 22295042 DOI: 10.1177/1756287211431976] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Bladder carcinoma is the most common malignancy of the urinary tract. Approximately 75-85% of patients with bladder cancer present with a disease that is confined to the mucosa (stage Ta, carcinoma in situ) or submucosa (stage T1). These categories are grouped as nonmuscle invasive bladder cancer (NMIBC). Although the management of NMIBC tumours has significantly improved during the past few years, it remains difficult to predict the heterogeneous outcome of such tumours, especially if high-grade NMIBC is present. Transurethral resection is the initial treatment of choice for NMIBC. However, the high rates of recurrence and significant risk of progression in higher-grade tumours mandate additional therapy with intravesical agents. We discuss the role of various intravesical agents currently in use, including the immunomodulating agent bacillus Calmette-Guérin (BCG) and chemotherapeutic agents. We also discuss the current guidelines and the role of these therapeutic agents in the context of higher-grade Ta and T1 tumours. Beyond the epidemiology, this article focuses on the risk factors, classification and diagnosis, the prediction of recurrence and progression in NMIBC, and the treatments advocated for this invasive disease.
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