THE LIMITS OF BACILLUS CALMETTE-GUERIN FOR CARCINOMA IN SITU OF THE BLADDER

Mathematical modeling of BCG-based bladder cancer treatment using socio-demographics

Cancer is one of the most widespread diseases around the world with millions of new patients each year. Bladder cancer is one of the most prevalent types of cancer affecting all individuals alike with no obvious "prototypical patient". The current standard treatment for BC follows a routine weekly Bacillus Calmette-Guérin (BCG) immunotherapy-based therapy protocol which is applied to all patients alike. The clinical outcomes associated with BCG treatment vary significantly among patients due to the biological and clinical complexity of the interaction between the immune system, treatments, and cancer cells. In this study, we take advantage of the patient's socio-demographics to offer a personalized mathematical model that describes the clinical dynamics associated with BCG-based treatment. To this end, we adopt a well-established BCG treatment model and integrate a machine learning component to temporally adjust and reconfigure key parameters within the model thus promoting its personalization. Using real clinical data, we show that our personalized model favorably compares with the original one in predicting the number of cancer cells at the end of the treatment, with [Formula: see text] improvement, on average.

Management of primary upper urinary tract carcinoma in situ diagnosed by ureteroscopic biopsy: Is bacillus Calmette-Guerin an alternative to nephroureterectomy?

BACKGROUND

Radical nephroureterectomy (RNU) represents the gold standard treatment for upper tract urothelial carcinoma (UTUC); however, attempts have been made to treat upper urinary tract CIS (UT-CIS) conservatively. The aim of this study was to compare the outcome of patients with primary UT-CIS treated in our center by means of RNU vs. bacillus Calmette-Guérin (BCG) instillations.

METHODS

This retrospective study included patients with diagnosis of primary UT-CIS between 1990 and 2018. All patients had histological confirmation of UT-CIS in the absence of other concomitant UTUC. Histological confirmation was obtained by ureteroscopy with multiple biopsies. Patients were treated with BCG instillations, RNU or distal ureterectomy. Clinicopathological features and outcomes were compared between RNU and BCG groups.

RESULTS

A total of 28 patients and 29 renal units (RUs) were included. Sixteen (57.1%) patients (17 RUs) received BCG. BCG was administered via nephrostomy tube in 4 patients, with a single-J ureteral stent in 5, and using a Double-J stent in 7. Complete response and persistence or recurrence were detected in ten (58.8%) and seven (41.2%) RUs treated with BCG, respectively. Eight (27.6%) RUs underwent RNU, and 4 (13.8%) Rus distal ureterectomy. No differences were found in recurrence-free survival (p=0.841) and cancer-specific survival (p=0.77) between the RNU and BCG groups.

CONCLUSIONS

Although RNU remains the gold standard treatment for UT-CIS, our results confirm that BCG instillations are also effective. Histological confirmation of UT-CIS is mandatory before any treatment.

Bacterial Therapy of Cancer: Promises, Limitations, and Insights for Future Directions

Spontaneous tumors regression has been associated with microbial infection for 100s of years and inspired the use of bacteria for anticancer therapy. Dr. William B. Coley (1862-1936), a bone- sarcoma surgeon, was a pioneer in treating his patients with both live bacterial-based and mixture of heat-killed bacteria known as "Coley's toxins." Unfortunately, Coley was forced to stop his work which interrupted this field for about half a century. Currently, several species of bacteria are being developed against cancer. The bacterial species, their genetic background and their infectious behavior within the tumor microenvironment are thought to be relevant factors in determining their anti-tumor effectiveness in vivo. In this perspective article we will update the most promising results achieved using bacterial therapy (alone or combined with other strategies) in clinically-relevant animal models of cancer and critically discuss the impact of the bacterial variants, route of administration and mechanisms of bacteria-cancer-cell interaction. We will also discuss strategies to apply this information using modern mouse models, molecular biology, genetics and imaging for future bacterial therapy of cancer patients.

Nanotechnology and cancer: improving real-time monitoring and staging of bladder cancer with multimodal mesoporous silica nanoparticles

Background

Despite being one of the most common cancers, bladder cancer is largely inefficiently and inaccurately staged and monitored. Current imaging methods detect cancer only when it has reached “visible” size and has significantly disrupted the structure of the organ. By that time, thousands of cells will have proliferated and perhaps metastasized. Repeated biopsies and scans are necessary to determine the effect of therapy on cancer growth. In this report, we describe a novel approach based on multimodal nanoparticle contrast agent technology and its application to a preclinical animal model of bladder cancer. The innovation relies on the engineering core of mesoporous silica with specific scanning contrast properties and surface modification that include fluorescence and magnetic resonance imaging (MRI) contrast. The overall dimensions of the nano-device are preset at 80–180 nm, depending on composition with a pore size of 2 nm.

Methods

To facilitate and expedite discoveries, we combined a well-known model of bladder cancer and our novel technology. We exposed nanoparticles to MB49 murine bladder cancer cells in vitro and found that 70 % of the cells were labeled by nanoparticles as measured by flow cytometry. The in vivo mouse model for bladder cancer is particularly well suited for T1- and T2-weighted MRI.

Results

Under our experimental conditions, we demonstrate that the nanoparticles considerably improve tumor definition in terms of volumetric, intensity and structural characteristics. Important bladder tumor parameters can be ascertained, non-invasively, repetitively, and with great accuracy. Furthermore, since the particles are not biodegradable, repetitive injection is not required. This feature allows follow-up diagnostic evaluations during cancer treatment. Changes in MRI signals show that in situ uptake of free particles has predilection to tumor cells relative to normal bladder epithelium. The particle distribution within the tumors was corroborated by fluorescent microscopy of sections of excised bladders. In addition, MRI imaging revealed fibrous finger-like projections into the tumors where particles insinuated themselves deeply. This morphological characteristic was confirmed by fluorescence microscopy.

Conclusions

These findings may present new options for therapeutic intervention. Ultimately, the combination of real-time and repeated MRI evaluation of the tumors enhanced by nanoparticle contrast may have the potential for translation into human clinical studies for tumor staging, therapeutic monitoring, and drug delivery.

Therapeutic Effect on Bladder Cancer with a Conditionally Replicating Oncolytic Virus Derived from Type II Herpes Simplex Virus

Purpose:

Despite recent improvements, resistance to traditional immunotherapy or chemotherapy is still common in patients with bladder cancer. We constructed an oncolytic virus from herpes simplex virus type II (HSV-2), which selectively targets tumor cells with an activated Ras signaling pathway. We evaluated the antitumor effect of this oncolytic HSV-2 (FusOn-H2) against bladder cancer, and compared with that of a first generation oncolytic virus derived from HSV-1 (Baco-1).

Materials and methods:

We established bladder tumor at the orthotopic site in C3H/He mice using the MBT-2 cells. Baco-1 or FusOn-H2 was instilled into the bladder through the urethra respectively. Tumor volume and weight were recorded by the end of the experiment. Animal spleens were also collected to determine if any anti-tumor immunity was elicited during virotherapy in this syngeneic bladder cancer model.

Results:

Two instillations of the oncolytic HSVs into bladder of tumor-bearing mice almost completely eradicated the tumor in majority of tumor bearing mice. The results of tumor-specific cytotoxic T lymphocyte activity assay showed that tumor destruction by oncolytic viruses in vivo, especially by the FusOn-H2, induced potent anti-tumor immune responses.

Conclusion:

Oncolytic virus derived from HSV-2 has potent anti-tumor activity against bladder cancer. Oncolytic effect of this virus in vivo induces tumor specific cellular immunity that further enhances the overall anti-tumor activity. Translating this novel virotherapy into the clinic could present an alternative intravesical therapy strategy for patients with bladder cancer.

Differentiation between single bladder cancer cells using principal component analysis of time-of-flight secondary ion mass spectrometry

Time-of-flight-secondary ion mass spectrometry (TOF-SIMS) mass spectra measurements combined with an appropriate sample preparation protocol are the powerful tools to obtain unique information about the chemical composition of biological materials. In our studies, two questions were addressed, i.e., whether it is possible to develop a fixative-based sample preparation protocol and whether it allows one to distinguish between cells originating from various stages of cancer progression. Therefore, four human bladder cancer cell lines (with distinct malignancy degree) have been investigated. A chemical fixation protocol has been used for TOF-SIMS measurements, and mass spectra were obtained using a Bi3(+) primary ion beam. The principal component analysis (PCA) has been applied to analyze the whole range of mass spectra (without preselection of any particular masses) using two approaches of data preprocessing, namely, mean centering and autoscaling. The PC3 versus PC2 plot has showed significant differences between nonmalignant cancer cells and the cancerous ones for both of preprocessing approaches. The analysis of mass spectra of human bladder cells allows one to find a list of mass peaks with intensities significantly larger in cancerous bladder cells compared to nonmalignant cell cancer of the ureter (HCV29 cells). These findings show that TOF-SIMS in combination with PCA can be used to identify reference, human bladder cells from cancerous ones.

A first in human phase 1 study of CG0070, a GM-CSF expressing oncolytic adenovirus, for the treatment of nonmuscle invasive bladder cancer

PURPOSE

We assessed the safety, pharmacokinetics and anticancer activity of intravesical CG0070, a cancer selective, replication competent adenovirus, for the treatment of nonmuscle invasive bladder cancer.

MATERIALS AND METHODS

A total of 35 patients received single or multiple (every 28 days × 3 or weekly × 6) intravesical infusions of CG0070 at 1 of 4 dose levels (1 × 10(12), 3 × 10(12), 1 × 10(13) or 3 × 10(13) viral particles). Response to treatment was based on cystoscopic assessment and biopsy or urine cytology. Urine and plasma CG0070, and granulocyte-monocyte colony-stimulating factor were measured in all patients. A subset of 18 patients was assessed for retinoblastoma phosphorylation status.

RESULTS

Grade 1-2 bladder toxicities were the most common adverse events observed. A maximum tolerated dose was not reached. High levels of granulocyte-monocyte colony-stimulating factor were detected in urine after administration in all patients. Virus replication was suggested based on an increase in urine CG0070 genomes between days 2 and 5 in 58.3% of tested patients (7 of 12). The complete response rate and median duration of the complete response across cohorts was 48.6% and 10.4 months, respectively. In the multidose cohorts the complete response rate for the combined groups (every 28 days and weekly × 6) was 63.6% (14 of 22 patients). In an exploratory, retrospective assessment patients with borderline or high retinoblastoma phosphorylation who received the multidose schedules had an 81.8% complete response rate (9 of 11).

CONCLUSIONS

Intravesical CG0070 was associated with a tolerable safety profile and antibladder cancer activity. Granulocyte-monocyte colony-stimulating factor transgene expression and CG0070 replication were also suggested.

Cell damage and death by autoschizis in human bladder (RT4) carcinoma cells resulting from treatment with ascorbate and menadione

A human bladder carcinoma cell line RT4 was sham-treated with buffer or treated with ascorbate (VC) alone, menadione alone (VK(3)), or a combination of ascorbate:menadione (VC+VK(3)) for 1, 2, and 4 h. Cytotoxic damage was found to be treatment-dependent in this sequence: VC+VK(3)>VC>VK(3)>sham. The combined treatment induced the greatest oxidative stress, with early tumor cell injury affecting the cytoskeletal architecture and contributing to the self-excisions of pieces of cytoplasm freed from organelles. Additional damage, including a reduction in cell size, organelle alterations, nuclear damage, and nucleic acid degradation as well as compromised lysosome integrity, is caused by reactivation of DNases and the redox cycling of VC or VC+VK(3). In addition, cell death caused by VC+VK(3) treatment as well as by prolonged VC treatment is consistent with cell demise by autoschizis, not apoptosis. This report confirms and complements previous observations about this new mode of tumor cell death. It supports the contention that a combination of VC+VK(3), also named Apatone, could be co-administered as a nontoxic adjuvant with radiation and/or chemotherapies to kill bladder tumor cells and other cancer cells without any supplementary risk or side effects for patients.

Intravesical therapy for bladder cancer

IMPORTANCE OF THE FIELD

Although transurethral resection of bladder tumor (TURBT) is effective therapy, up to 45% of patients will have a recurrence within 1 year after TURBT alone. Further, there is a 3 - 15% risk of tumor progression to muscle invasive and/or metastatic cancer. Depending on patient and tumor characteristics, a number of patients may benefit from some form of intravesical therapy. Adjuvant therapy is effective in avoiding post-TURBT implantation of tumor cells, eradicating residual disease, preventing tumor recurrence, and to delay or reduce tumor progression through direct cytoablation or immunostimulation.

AREAS COVERED IN THIS REVIEW

The role of risk assessment in the management of nonmuscle invasive bladder cancer (NMIBC) and the indications for the use of intravesical agents are discussed. Findings from major randomized clinical trials on BCG, interferon and various chemotherapeutic agents are summarized; key aspects of drug pharmacology, drug efficacy, side effects, and toxicity are also covered.

WHAT THE READER WILL GAIN

The reader will gain a basic understanding of the role of risk assessment in determining the need for intravesical therapy, as well as an overview of the different types of agents in use in the United States today.

TAKE HOME MESSAGE

The type of intravesical therapy used is based on the risk groups as noted in the European prognostic tables. Bacillus Calmette-Guerin (BCG) is the most commonly used first-line agent immunotherapeutic agent for prophylaxis and treatment of carcinoma in situ and high-grade bladder cancer. Other immunotherapeutic options include the interferons, interleukins 2 and 12, and tumor necrosis factor, all of which have activity in BCG refractory patients, although with low durable remission rates. Studies have shown that chemotherapy prevents recurrence but not progression. The available data on intravesical chemotherapy do not indicate that any single agent currently in use is clearly better than any other. Therefore, the selection of a chemotherapeutic agent is usually based on cost, toxicity, and availability as well as on physician preference and experience.

[Clinical experience with transurethral resection of bladder tumor (TUR-Bt) guided by photodynamic diagnosis (PDD)]

PURPOSE

To report our clinical experience regarding transurethral resection of bladder tumor (TUR-Bt) guided by photodynamic diagnosis (PDD) with intravesical instillations of 5-aminolevulinic acid (ALA) and to assess the usefulness of the therapeutic method.

MATERIALS AND METHODS

TUR-Bt guided by PDD was performed in 57 patients of which 47 were men and 10 women with a median age of 74.3 years (range 45-90), 36 were primary cases and 21 were recurrent cases with non-muscle invasive bladder cancer. Two to two and half hours prior to endoscopy 1.5 g ALA dissolved in 50 ml of 8.4% sodium hydrogen carbonate (NaHCO3) solution was instilled intravesically. For fluorescence excitation a blue light source (D-LIGHT System, Karl Storz Endoscopy Japan K.K.) was used. The tumorous lesions under white light guidance and the lesion with fluorescent excitation under blue (fluorescence) light guidance were taken by cold cup as a biopsy and also resected sequentially. To evaluate the accuracy of PDD, the levels in images of the ALA-induced fluorescence were compared with the pathological results. To evaluate the availability of TUR-Bt guided by PDD, survival Analysis regarding vesical recurrence was retrospectively examined compared to the cases underwent conventional TUR-Bt under white light guidance. Moreover, in these cases, multivariate analysis using Cox proportional-hazards model was performed to detect the clinico-pathological factor independently contribute to improving prognosis. (Results) In the 301 specimens obtained from 57 patients, the sensitivity and specificity of PDD were 92.5% and 60.1%, whereas the sensitivity and specificity of conventional endoscopic examination under white light guidance were 81.6% and 79.5%, respectively. Median follow-up period was 19.1 (range 8.6-49.9) months in 57 patients underwent TUR-Bt guided by PDD. Eight of 57 patients recurred and recurrence-free survival rate was 88.2 +/- 0.1% (at 12 months) and 76.2 +/- 0.1% (24-48 months). Median follow-up period was 49.9 (5.0-145.0) months in 149 patients underwent conventional TUR-Bt. Ninety-nine of 149 patients recurred and recurrence-free survival rate was 60.3 +/- 0.0% (12 months) and 31.6 +/- 0.0% (24-48 months). There was statistical significance in recurrence-free survival rate between these 2 therapeutic groups (p < 0.001). Moreover, multivariate analysis revealed the independent factor contribute to improving prognosis was only TUR-Bt guided by PDD (hazard ratio 0.279, p = 0.001).

CONCLUSION

It was suggested that TUR-Bt guided by PDD might reduce the risk of vesical recurrence in the early stage after operation of non-muscle invasive bladder cancer.

Increased infiltration of tumor associated macrophages is associated with poor prognosis of bladder carcinoma in situ after intravesical bacillus Calmette-Guerin instillation

PURPOSE

Tumor associated macrophages can regulate the growth of various cancers positively or negatively. Intravesical bacillus Calmette-Guerin instillation is now gold standard treatment for bladder carcinoma in situ. We investigated the correlation between tumor associated macrophages infiltrating bladder carcinoma in situ and the response to intravesical bacillus Calmette-Guerin therapy.

MATERIALS AND METHODS

We examined paraffin embedded tissues from 41 patients with bladder carcinoma in situ who received intravesical bacillus Calmette-Guerin therapy. Tumor associated macrophages were immunohistochemically stained by anti-CD68 monoclonal antibody.

RESULTS

The median number of tumor associated macrophages infiltrating among cancer cells and the number in the lamina propria were 4 and 24, respectively. Recurrent carcinoma in situ was found in 4.8% of cases with a lower cancer cell tumor associated macrophage count but in 47.6% of those with a higher cancer cell tumor associated macrophage count (less than 4 vs 4 or greater). Recurrence was found in 31.8% of patients with a lower lamina propria tumor associated macrophage count but in 21.1% of those with a higher lamina propria tumor associated macrophage count (less than 25 vs 25 or greater). The median ratio of tumor associated macrophages among cancer cells vs in the lamina propria was 0.2. Recurrence-free survival was significantly better in patients with a lower cancer cell tumor associated macrophage count (p = 0.0002). Those with a lower cancer cell-to-lamina propria tumor associated macrophage ratio had a higher recurrence-free rate (p <0.0001). Multivariate analysis revealed that the cancer cell tumor associated macrophage count and the cancer cell-to-lamina propria tumor associated macrophage ratio can be prognostic factors for bladder carcinoma in situ.

CONCLUSIONS

The count of tumor associated macrophages infiltrating the cancer area is useful for predicting the response of bladder carcinoma in situ to intravesical bacillus Calmette-Guerin instillation before treatment initiation.

Intravesical mycobacterial cell wall-DNA complex in the treatment of carcinoma in situ of the bladder after standard intravesical therapy has failed

PURPOSE

We assessed the clinical efficacy and safety of mycobacterial cell wall-DNA complex after intravesical administration in patients with carcinoma in situ in whom prior therapy with bacillus Calmette-Guerin failed or in those who were treatment naïve.

MATERIALS AND METHODS

Patients received 6 weekly instillations of 4 or 8 mg mycobacterial cell wall-DNA complex (formulated as an emulsion) followed by 3 weekly instillations at weeks 12 and 24. Efficacy and safety were evaluated throughout the treatment phase and at months 12 and 18.

RESULTS

A total of 55 patients (mean age 74 years, 74.6% male) received 4 mg (25) or 8 mg (30) mycobacterial cell wall-DNA complex emulsion. All patients were previously treated with bacillus Calmette-Guerin except for 8 who were treatment naïve and 2 who received chemotherapy. In the intent to treat population the complete response rate was 27.3% at weeks 12 and 26 in the 4 mg group while 46.4% of patients receiving 8 mg had a complete response at both points. Mycobacterial cell wall-DNA complex was well tolerated by both dose groups. Overall 90% of all adverse events were mild to moderate in severity.

CONCLUSIONS

Mycobacterial cell wall-DNA complex has shown antineoplastic activity in patients with bladder cancer with less toxicity than that associated with bacillus Calmette-Guerin administration. The tolerance and efficacy of mycobacterial cell wall-DNA complex might hold promise for the treatment of carcinoma in situ of the bladder.

The management of superficial bladder cancer

From review of the currently available trial evidence, several clinical recommendations for bladder tumor management become apparent. Transurethral resection should be done, but this procedure is prone to both overestimating and underestimating staging. Restaging transurethral resection for patients with T1 tumors should, therefore, be performed. Data support the immediate postoperative instillation of a chemotherapeutic agent for patients with solitary, low-grade papillary tumors, whereas patients with multiple lesions might benefit from a more intensive adjuvant regimen. Although the use of intravesical immunotherapy for reducing tumor progression or as maintenance therapy is controversial, bacillus Calmette-Guérin has demonstrated significant benefit for tumor prophylaxis when no obvious residual disease is present. Early radical cystectomy can be beneficial and should be performed in patients with refractory T1 tumors or carcinoma in situ before progression to muscle invasion. In this Review I present an overview of the management of nonmuscle invasive bladder cancer. The most common intravesical chemotherapeutic agents are described as well as the impact of chemotherapy on the recurrence and progression of tumors. The effect of intravesical immunotherapy in bladder cancer is explored as well as the role of early cystectomy.

The management of superficial transitional cell carcinoma of the bladder

Superficial transitional cell carcinomas (TCC) of the urinary bladder, defined as those that are restricted to the mucosa or the lamina propria, represent a common condition with a wide spectrum of biologic significance. High-grade superficial TCC, particularly in the presence of lamina propria invasion, has a significant risk of occult or subsequent progression to muscle-invasive or metastatic disease. Such high-risk lesions merit aggressive therapy with repeat resection followed by intravesical therapy, usually in the form of bacille Calmette-Guérin. Criteria for failure of intravesical therapy are not well defined, but persistent cytologic or cystoscopic abnormalities at 6 months are worrisome. Salvage intravesical therapy may sometimes be successful, but early cystectomy should be strongly considered, especially in younger patients. Close surveillance of patients with high-risk superficial TCC is essential.

High-grade Ta urothelial carcinoma and carcinoma in situ of the bladder

We sought to review the definition, diagnosis, prognosis, and treatment of high-grade Ta urothelioma carcinoma and carcinomas in situ (CIS) in order to provide evidence-based guidelines for their diagnosis and treatment. The English-language literature on high-grade Ta urothelial carcinoma and CIS was identified and critically reviewed by a panel of 9 international experts. The panel then met at a consensus conference to present their conclusions. Levels of evidence and grades of recommendation were assessed. Findings from approximately 100 publications appearing prior to February 2005 were reviewed and summarized. High-grade Ta urothelial carcinoma and CIS are relatively rare tumors; thus results are often based on small nonrandomized studies. Their assessment is made more difficult owing to inaccuracies in staging and grading. Although there were similar numbers of level 1, level 2, and level 3 evidence citations, guidelines have been developed based only on levels of evidence supporting grade A and grade B recommendations. These evidence-based guidelines have been developed to aid clinicians in the diagnosis and treatment of patients with high-grade Ta urothelial carcinoma and CIS.

Antisense oligodeoxynucleotide therapy for bladder cancer: recent advances and future prospects

Despite remarkable progress in therapeutic options for the management of bladder cancer, it remains a challenge for urologists to achieve successful outcomes in the treatment of both superficial and invasive bladder cancers. In this review, recent advances in the field of antisense oligodeoxynucleotide therapy targeting several genes playing functionally important roles in the progression and recurrence of bladder cancer are summarized. Data showing the synergistic antitumor activities of antisense oligodeoxynucleotide therapy, combined with several treatments, including cytotoxic chemotherapy, radiation and other molecular targeting therapies, are also presented. Finally, the future direction of antisense oligodeoxynucleotide therapy in the therapeutic strategy of bladder cancer is discussed. These findings may help clarify the significance of antisense oligodeoxynucleotide therapy as an attractive alternative to conventional strategies.

Sequential BCG and electromotive mitomycin versus BCG alone for high-risk superficial bladder cancer: a randomised controlled trial

BACKGROUND

The rationale for combining anticancer drugs has not been applied consistently to use of intravesical agents for treatment of superficial bladder cancer, for which immunotherapeutic BCG and chemotherapeutic mitomycin seem to be a potentially effective combination. We aimed to do a prospective, randomised comparison of BCG alone with that of sequential BCG and electromotive mitomycin in patients with stage pT1 bladder cancer.

METHODS

After transurethral resection and multiple biopsies, 212 patients with stage pT1 bladder cancer were randomly assigned to: 81 mg BCG infused over 120 min once a week for 6 weeks (n=105); or to 81 mg BCG infused over 120 min once a week for 2 weeks, followed by 40 mg electromotive mitomycin (intravesical electric current 20 mA for 30 min) once a week as one cycle for three cycles (n=107). Complete responders underwent maintenance treatment: those assigned BCG alone had one infusion of 81 mg BCG once a month for 10 months, and those assigned BCG and mitomycin had 40 mg electromotive mitomycin once a month for 2 months, followed by 81 mg BCG once a month as one cycle for three cycles. The primary endpoint was disease-free interval; secondary endpoints were time to progression; overall survival; and disease-specific survival. Analyses were done by intention to treat. This trial has been submitted for registration at the US National Cancer Institute website .

FINDINGS

Median follow-up was 88 months (IQR 63-110). Patients assigned sequential BCG and electromotive mitomycin had higher disease-free interval than did those assigned BCG alone (69 months [95% CI 55-86] vs 21 months [15-54]; difference between groups 48 months [42-54], log-rank p=0.0012). Patients assigned sequential BCG and electromotive mitomycin also had lower recurrence (41.9% [32.7-51.5] vs 57.9% [48.7-67.5]; difference between groups 16.0% [2.7-29.3], log-rank p=0.0012); progression (9.3% [3.8-14.8] vs 21.9% [17.9-25.9]; difference between groups 12.6% [3.0-22.2], log-rank p=0.004); overall mortality (21.5% [13.5-29.5] vs 32.4% [23.4-41.4], difference between groups 10.9% [0.6-21.2], log-rank p=0.045); and disease-specific mortality (5.6% [1.2-10.0] vs 16.2% [6.1-23.3], difference between groups 10.6% [2.5-18.7], log-rank p=0.01). Side-effects were mainly localised to the bladder.

INTERPRETATION

BCG-induced inflammation might increase the permeability of the bladder mucosa such that mitomycin can reach the target tissue more easily and exert its anticancer effect.

EAU Guidelines on the Diagnosis and Treatment of Urothelial Carcinoma in Situ

OBJECTIVES

On behalf of the European Association of Urology (EAU), guidelines for the diagnosis, therapy and follow-up of patients with urothelial carcinoma in situ (CIS) have been established.

METHOD

The recommendations in these guidelines are based on a recent comprehensive overview and meta-analysis in which two panel members have been involved (RS and AVDM). A systematic literature search was conducted using Medline, the US Physicians' Data Query (PDQ), the Cochrane Central Register of Controlled Trials, and reference lists in trial publications and review articles.

RESULTS

Recommendations are provided for the diagnosis, conservative and radical surgical treatment, and follow-up of patients with CIS. Levels of evidence are influenced by the lack of large randomized trials in the treatment of CIS.

The probiotic approach: an alternative treatment option in urology

OBJECTIVE

The prophylactic and therapeutic use of probiotic microorganisms is a wide and still controversial field. The review paper is aimed to summarize recent findings on the health-benefiting effects of probiotics in urological diseases. The use of certain beneficial strains against urogenital infections, bladder cancer recurrence and renal stone formation is discussed.

METHODS

Literature search of PubMed documented publications and abstracts from meetings.

RESULTS

Various clinical trials have now been performed which substantiate the beneficial effects of the probiotic strains L. rhamnosus GR-1, L. fermentum RC-14 and L. crispatus CTV-05 against urogenital infections, such as urinary tract infections and bacterial vaginosis. The potential of L. casei Shirota to reduce the recurrence rate of bladder cancer is one of the most intriguing examples for the use of probiotics in medical practice. The use of O. formigenes in the prevention of calcium oxalate stone disease was only recently suggested and needs to be further investigated.

CONCLUSION

Clinical trials increasingly provide a profound scientific basis for the use of probiotics in medicinal practice including urology. Efforts to make probiotic products available which are validated according to the guidelines recommended by the WHO and FAO and produced according to Good Manufacturing Practice will contribute to the acceptance of probiotic therapy by both the physicians and the patients.

Metastasis markers in bladder cancer: a review of the literature and clinical considerations

Cancer invasion and metastasis develop through a sequence of processes involving loss of cell-cell and cell-matrix adhesions, proteolysis and induction of angiogenesis. We reviewed the current literature on the molecules that have been shown to play a significant role in these three steps of metastatisation in bladder cancer (BC) cells and their host microenvironment. Particular emphasis was given to markers that are assessable through immunohistochemistry and for which an additional prognostic value over the TNM variables has been recognized, in order to identify a subset of tumour markers readily available for application in daily clinical practice. We conclude that markers such as E-cadherin, Sialosyl-LeX, laminin, collagen IV, TSP-1 and MVD are useful prognostic markers, alpha, beta, and gamma catenin, MMP-2 and -9, uPAR, PD-ECGF and Bfgf can be considered potentially useful, while research on CD44, MMP-1 and -3, uPA, cathepsin D and VEGF has proved inconclusive. Further research in this field should concentrate on the molecules listed in the first group.

Intravesical Instillation of Gemcitabine in Patients with SBC

To determine, in phase I trial, the local and systemic toxicity and pharmacodynamics of intravesical Gemcitabine in patients with superficial bladder cancer. To evaluate, in phase II trial, the activity of this treatment against superficial bladder cancer, measuring the response of a marker lesion.

Patients and methods

In phase I trial, twelve patients with histologically confirmed carcinoma to the bladder wall (stage Ta-T1) resistant to previous administration of anti-cancer drugs or BCG were enrolled. They received intravesical Gemcitabine starting at 500 mg and increased in 500 mg increments to 2000 mg. Three patients were treated at each dose level. In phase II trial twenty four patients with superficial bladder cancer resistant to previous treatments were treated by endoscopic resection, but a single lesion less than 1 cm was left in site. Patients then received Gemcitabine 2000 mg weekly for six weeks. The marker lesion was re-analyzed by cistoscopy and patients were re-evaluated every month.

Results

The phase I trial showed no evidence of systemic toxicity and minimal local toxicity. Gemcitabine was undetectable in plasma and its inactive metabolite (2’,2’-Difluorodeoxiuridine) was present at a mean concentration of 1.39 (1.05) μmol/L. In phase II trial, a complete response was obtained in 50% and a partial response in 29%. No response was seen in 5 patients (21%). No patient showed signs of progression of the marker lesion nor the appearance of new lesions.

Conclusions

Intravesical Gemcitabine appears to be well tolerated with no systemic and minimal local toxicity, even at the highest dose (2000 mg). At this dose, it also shows a good ablative action on marker lesions.

Autocrine over expression of fibronectin by human transitional carcinoma cells impairs bacillus Calmette-Guerin adherence and signaling

PURPOSE

Bacillus Calmette-Guerin (BCG) binds to the tumor cell as a result of mycobacterial receptors for fibronectin (FN). Cell surface bound FN serves as a bridge through which BCG attaches to the tumor cell. Despite the importance of FN studies have demonstrated an idiosyncratic decrease in BCG adherence in response to exogenous FN. We evaluated the effect of exogenous and autocrine FN on the ability of BCG to adhere to the tumor cell surface and initiate cellular signaling.

MATERIALS AND METHODS

BCG adherence to parental 253J and FN over expressing 253JTGFbeta1-8 cells as well as to the intrinsic FN expressing cell line 647V was quantified using green fluorescent protein-BCG. Experiments were performed to assess the effect of FN on BCG initiated signal transduction through nuclear factor kappaB and AP1. Finally, the integrity of the BCG activated signaling pathway in transforming growth factor-beta1/FN over expressors was assessed using antibody mediated cross-linking of the FN receptor.

RESULTS

BCG adherence was decreased in cell lines with high autocrine expression of FN. Exogenous FN prevented BCG induced transactivation of nuclear factor kappaB and AP1 reporter constructs. No BCG stimulated signaling to these reporters could be detected in FN over expressing 253J cells. NonFN dependent alpha5beta1 cross-linking initiated signal transduction in FN over expressing cells.

CONCLUSIONS

We propose that by saturating cellular and BCG receptors excess FN expression decreases the ability of cellular or mycobacterial bound FN to bind vacant receptors on BCG or on the cell. Excess FN inhibits BCG adherence and BCG initiated signal transduction.

Evaluation and follow-up strategies for superficial bladder cancer

Superficial bladder cancer comprises the majority of bladder tumors presenting today. Although the word "superficial" connotes a benign behaving curable disease, it is clear from long-term observations of the natural history of the disease that there are two discrete entities of superficial bladder cancer, one a low-grade innocuous tumor and the other a high-grade potentially lethal tumor. These two entities vary in their histologic appearance, risk of tumor recurrence, pattern of recurrence, and risk of tumor progression. Although work on prognostic markers is promising, currently none are sufficiently reliable; therefore, clinical factors are used to identify patients with a higher risk of tumor recurrence or progression. These include the tumor stage, tumor grade, number of tumors (multifocality), presence of associated carcinoma in situ, and initial response to therapy. Surveillance schedules are individualized based on the risks for recurrence and progression. High-risk patients who undergo successful treatment of their bladder tumor initially recur more commonly in the bladder, but have a progressive risk over time of extravesical recurrences necessitating lifelong surveillance of the bladder, urethra, prostate, and upper tracts. Patients who are refractory to conservative management with intravesical therapy and TUR should be apprised of the risks for further conservative treatment and consider early radical cystectomy in an attempt to improve long-term survival. The advent and long-term success of orthotopic continent diversions has made the decision for early radical cystectomy more palatable to both the patient and physician.

Intravesical electromotive mitomycin C versus passive transport mitomycin C for high risk superficial bladder cancer: a prospective randomized study

PURPOSE

In laboratory studies electromotive mitomycin C (MMC) demonstrated markedly increased transport rates compared with passive transport. We performed a prospective study in patients with high risk superficial bladder cancer to assess the efficacy of intravesical electromotive vs passive MMC using bacillus Calmette-Guerin (BCG) as a comparative treatment.

MATERIALS AND METHODS

Following transurethral resection and multiple biopsies 108 patients with multifocal Tis, including 98 with T1 tumors, were randomized into 3 equal groups of 36 each who underwent 40 mg electromotive MMC instillation with 20 mA electric current for 30 minutes, 40 mg passive MMC with a dwell time of 60 minutes or 81 mg BCG with a dwell time of 120 minutes. Patients were scheduled for an initial 6 weekly treatments, a further 6 weekly treatments for nonresponders and a followup 10 monthly treatments for responders. Primary end points were the complete response rate at 3 and 6 months. MMC pharmacokinetics were assessed.

RESULTS

The complete response for electromotive vs passive MMC at 3 and 6 months was 53% versus 28% (p = 0.036) and 58% versus 31% (p = 0.012). For BCG the responses were 56% and 64%. Median time to recurrence was 35 vs 19.5 months (p = 0.013) and for BCG it was 26 months. Peak plasma MMC was significantly higher following electromotive MMC than after MMC (43 vs 8 ng/ml), consistent with bladder content absorption.

CONCLUSIONS

Intravesical electromotive administration increases bladder uptake of MMC, resulting in an improved response rate in cases of high risk superficial bladder cancer.

Bladder cancer recurrence: Part II. What do I tell my patients about lifestyle changes and dietary supplements?

PURPOSE OF REVIEW

The purpose of this review is to provide the clinician with an adequate summary of current potential recommendations for reducing the risk of bladder cancer recurrence so that this topic can be discussed with patients that are dealing with this specific situation.

RECENT FINDINGS

Several potential novel methods to reduce the risk of recurrence should be discussed with patients. Non-selective and selective cyclo-oxygenase 2 inhibitors have preliminary data from from laboratory and epidemiologic investigations. Several preliminary trials have found that a combination dietary supplement of vitamins and minerals or a probiotic agent (Lactobacillus casei) may impact recurrence rates. Smoking cessation may be one of the best routes for reducing recurrence and reducing the risk of overall early morbidity and mortality. Garlic or fluid intake need more clinical data.

SUMMARY

Clinical recommendations for reducing the risk of bladder cancer recurrence need more attention. Preliminary data seem to support a potential role of numerous lifestyle and dietary supplement regimens. In the future, more reviews on the potential impact of reducing recurrence should be separated from reviews on prevention because these can be confusing when treated as a single subject.

Defining bacillus Calmette-Guerin refractory superficial bladder tumors

PURPOSE

We define bacillus Calmette-Guerin (BCG) refractory, high risk, superficial bladder cancer.

MATERIALS AND METHODS

A total of 93 patients received a 6-week induction course of BCG. They were evaluated for response after 3 and 6 months. Half of the patients received monthly maintenance BCG for 2 years and half did not. In both groups the initial responses to BCG at 3 and 6 months were correlated with subsequent tumor recurrence and progression.

RESULTS

Of the 93 cases 57% were negative for tumor at 3 months and 43% had residual tumor resected. At 6 months 80% of the patients were tumor-free and 20% had persistent or recurrent tumor. Maintenance BCG did not decrease tumor recurrence further than induction BCG. Subsequent tumor-free interval during 24 months of followup were best predicted by response to BCG after 6 months.

CONCLUSIONS

A minimum treatment and followup time of 6 months is required to identify high risk, superficial bladder tumors as truly BCG refractory.

Potential lifestyle and dietary supplement options for the prevention and postdiagnosis of bladder cancer

Apart from smoking, certain occupational exposures, and schistosomiasis, little is known about other potential lifestyle risk factors for bladder cancer. Other investigations thus far have also been important because of the large number of individuals who are diagnosed with this cancer that apparently have no known risk factors. Preventing the recurrence of bladder cancer has generated some interest because several preliminary trials have found that a combination dietary supplement of vitamins and minerals or a probiotic agent (Lactobacillus casei) may impact this outcome favorably. Advising patients on some of these lifestyle modifications is currently recommended because the majority of them are also currently recommended for cardiovascular disease reduction.

Medical management of patients with refractory carcinoma in situ of the bladder

Bladder cancer is a common genitourinary malignancy and carcinoma in situ (CIS) of the bladder exists as a potentially aggressive variant of the superficial form of the disease. Treatment must reflect the unpredictable nature of this disease entity. In 1976, the use of intravesical Bacillus Calmette-Guerin (BCG) was described for the management of early stage bladder cancer. A subsequent report demonstrated efficacy in a cohort of patients with CIS of the bladder. Since this time, intravesical BCG has been recognised as the initial therapy for CIS of the bladder. Although a 6-week treatment with intravesical BCG has been established as standard therapy in patients with CIS, there has been no consensus as to the subsequent treatment for patients in the setting of failure to initial management with BCG. In addition, a number of reports have demonstrated an increased potential of adverse effects after repeated treatment with intravesical BCG. A variety of alternative immunological and chemotherapeutic agents have been developed in response to the limitations of BCG for patients with refractory CIS of the bladder. At present, valrubicin remains the only agent that is approved by the US Food and Drug Administration for the specific indication of CIS of the bladder unresponsive to intravesical BCG. Although these agents appear promising, the most efficacious therapy remains to be determined. The specific treatment protocol for refractory CIS of the bladder remains elusive. It is ultimately the combined decision of the clinician and patient to determine which course of management is most beneficial.