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Föhse K, Debisarun PA, Kilic G, van Dodewaard-de Jong JM, Netea MG. Evaluation of the safety and immunological effects of Bacillus Calmette-Guérin in combination with checkpoint inhibitor therapy in a patient with neuroendocrine carcinoma: a case report. J Med Case Rep 2023; 17:377. [PMID: 37661259 PMCID: PMC10476294 DOI: 10.1186/s13256-023-04117-3] [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: 12/30/2022] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors have revolutionized therapy of advanced and metastatic cancers. However, a significant proportion of patients do not respond to immune checkpoint inhibitors or develop resistance. Therefore, novel therapies or combinations of therapies that may act synergistically are needed. It has been suggested that induction of trained immunity may increase the response to immune checkpoint inhibitor therapy, through reprogramming myeloid cells toward an antitumor phenotype. On the other hand, activation of the immune system also carries the risk of potentially sustaining tumorgenicity and increasing immune- related toxicity. CASE PRESENTATION We report the case of a 37-year-old Dutch male suffering from gastric neuroendocrine carcinoma with liver metastases and high risk for an unfavorable outcome, who was treated with a combination of programmed cell death protein 1 inhibitor nivolumab and the trained immunity-inducer Bacillus Calmette-Guérin vaccine as a salvage therapy. Three doses of BCG vaccine were administered at 3-month intervals, in conjunction with the immune checkpoint inhibitor regimen. At a certain point, radiation therapy was added to the treatment regimen. During the combination of these therapies, the patient developed immune-mediated colitis, which necessitated discontinuation of all treatments. Bacillus Calmette-Guérin vaccination induced a trained immune response with elevated monocyte-derived interleukin-6 and interleukin-1β production capacity. From the first vaccination with Bacillus Calmette-Guérin until 3 months after the last vaccination with Bacillus Calmette-Guérin, the patient displayed only mild progression of the primary tumor and no progression of the metastases. CONCLUSION In this study, we show the feasibility to combine checkpoint inhibitor therapy with inducers of trained immunity in a patient with an aggressive neuroendocrine tumor. Autoimmune side effects are common under programmed cell death protein 1 inhibitor therapy, which was considered the most likely cause of colitis, although an additive effect of Bacillus Calmette-Guérin vaccination or radiotherapy cannot be excluded. The patient displayed only mild progression during the combination therapy, but larger studies are warranted to fully explore the potential benefit of trained immunity inducers as an adjuvant to immune checkpoint inhibitor therapy.
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Affiliation(s)
- Konstantin Föhse
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Priya A Debisarun
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gizem Kilic
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Mihai G Netea
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
- Department for Genomics & Immunoregulation, Life and Medical Sciences Institute (LIMES), University of Bonn, Bonn, Germany.
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Basak D, Mondal S, Srivastava SK, Sarkar D, Sarkar I, Basu S, Bhoumik A, Chowdhury S, Pal DK, Chatterjee S. Intratumoral PD1 +CD38 +Tim3 + CD8 + T Cells in Pre-BCG Tumor Tissues Are Associated with Poor Responsiveness to BCG Immunotherapy in Patients with Non-Muscle Invasive Bladder Cancer. Cells 2023; 12:1939. [PMID: 37566017 PMCID: PMC10416886 DOI: 10.3390/cells12151939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/09/2023] [Accepted: 06/06/2023] [Indexed: 08/12/2023] Open
Abstract
Intravesical immunotherapy with Bacillus Calmette-Guerin (BCG) is a standard of care therapy for non-muscle invasive bladder cancer (NMIBC), which accounts for about 75% of newly diagnosed urothelial cancer. However, given the frequent recurrence and progression, identification of a pre-treatment biomarker capable of predicting responsiveness to BCG in NMIBC is of utmost importance. Herein, using multiparametric flow cytometry, we characterized CD8+ T cells from peripheral blood and tumor tissues collected from 27 pre-BCG patients bearing NMIBC to obtain immune correlates of bladder cancer prognosis and responsiveness to BCG therapy. We observed that intratumoral CD8+ T cell subsets were highly heterogenous in terms of their differentiation state and exist at different proportions in tumor tissues. Remarkably, among the different CD8+ T cell subsets present in the tumor tissues, the frequency of the terminally exhausted-like CD8+ T cell subset, marked as PD1+CD38+Tim3+ CD8+ T cells, was inversely correlated with a favorable outcome for patients and a responsiveness to BCG therapy. Moreover, we also noted that the intratumoral abundance of the progenitor exhausted-like PD1+CD8+ T cell subset in pre-BCG NMIBC tumor tissues was indicative of better recurrence-free survival after BCG. Collectively, our study led to the identification of biomarkers that can predict the therapeutic responsiveness of BCG in NMIBC.
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Affiliation(s)
- Debashree Basak
- Division of Cancer Biology and Inflammatory Disorder, IICB-Translational Research Unit of Excellence, CSIR-Indian Institute of Chemical Biology, Kolkata 700032, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Soumya Mondal
- Department of Urology, IPGME&R and SSKM Hospital, Kolkata 700020, India
| | | | - Deborpita Sarkar
- Division of Cancer Biology and Inflammatory Disorder, IICB-Translational Research Unit of Excellence, CSIR-Indian Institute of Chemical Biology, Kolkata 700032, India
| | - Ishita Sarkar
- Division of Cancer Biology and Inflammatory Disorder, IICB-Translational Research Unit of Excellence, CSIR-Indian Institute of Chemical Biology, Kolkata 700032, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Sukanya Basu
- Division of Cancer Biology and Inflammatory Disorder, IICB-Translational Research Unit of Excellence, CSIR-Indian Institute of Chemical Biology, Kolkata 700032, India
| | - Arpita Bhoumik
- Division of Cancer Biology and Inflammatory Disorder, IICB-Translational Research Unit of Excellence, CSIR-Indian Institute of Chemical Biology, Kolkata 700032, India
| | - Snehanshu Chowdhury
- Division of Cancer Biology and Inflammatory Disorder, IICB-Translational Research Unit of Excellence, CSIR-Indian Institute of Chemical Biology, Kolkata 700032, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Dilip Kumar Pal
- Department of Urology, IPGME&R and SSKM Hospital, Kolkata 700020, India
| | - Shilpak Chatterjee
- Division of Cancer Biology and Inflammatory Disorder, IICB-Translational Research Unit of Excellence, CSIR-Indian Institute of Chemical Biology, Kolkata 700032, India
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
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3
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Anis O, Yogev D, Dotan A, Tsur AM, David P, Vishnevskia VD, Laufer M, Dotan Z, Shoenfeld Y. Autoimmune disorders caused by intravesical bacillus Calmette-Guerine treatment: A systemic review. Autoimmun Rev 2023; 22:103329. [PMID: 37061015 DOI: 10.1016/j.autrev.2023.103329] [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: 03/09/2023] [Accepted: 04/03/2023] [Indexed: 04/17/2023]
Abstract
Intravesical bacillus Calmette-Guérin (BCG) is a common and highly effective treatment for non-muscle invasive urothelial carcinoma of the urinary bladder. BCG may cause an autoimmune reaction in some patients. One hundred and fifty-eight papers were analyzed, for a total of hundred and thirty patients with reactive arthritis, sixty patients with ocular manifestations and eighteen patients with other rheumatologic diseases. Among 130 subjects with reactive arthritis, an autoimmune symptom occurred after 5 instillations of intravesical BCG (IQR 4-6), which represents 5 weeks in most cases. Fifty-one patients had concurrent ocular involvement. The resolution of symptoms was achieved in a median of 32.5 days (IQR 14-90). Forty-two men and twenty women had ocular manifestations, most commonly conjunctivitis. Patients with HLA-B27 typing had earlier presentation of ocular symptoms related to the number of instillations (4.5 vs 6 [p < 0.05]. Resolution of symptoms was achieved at a median of 128 days (IQR 21-150). Among patients treated with NSAIDs (either with or without steroids), the duration of the disease was significantly shorter in both the articular and the ocular groups (28 vs. 120 [p < 0.05] and 30 vs.105 [p < 0.05], respectively). Other autoimmune manifestations included general autoimmune diseases, such as vasculitis, psoriasis and myasthenia gravis.
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Affiliation(s)
- Omer Anis
- Department of Urology, Chaim Sheba Medical Center, Israel; The Mina & Everard Goodman Faculty of Life Sciences, Bar Ilan University, Israel.
| | - David Yogev
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arad Dotan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Israel
| | - Avishai M Tsur
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Israel Defence Forces, Medical Corps, Tel HaShomer, Ramat Gan, Israel; Department of Military Medicine, Faculty of Medicine of Hebrew University of Jerusalem, Jerusalem, Israel; Department of Medicine, Chaim Sheba Medical Center, Israel
| | - Paula David
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medicine, Chaim Sheba Medical Center, Israel; Leeds Institute of Rheumatic and Muskuloskeletal Medicine, University of Leeds, Leeds, UK
| | - Vicktoria Dai Vishnevskia
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Ocular Oncology Service, Department of Ophthalmology, Chaim Sheba Medical Center, Israel
| | - Menachem Laufer
- Department of Urology, Chaim Sheba Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zohar Dotan
- Department of Urology, Chaim Sheba Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Israel
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Senserrich J, Guallar-Garrido S, Gomez-Mora E, Urrea V, Clotet B, Julián E, Cabrera C. Remodeling the bladder tumor immune microenvironment by mycobacterial species with changes in their cell envelope composition. Front Immunol 2022; 13:993401. [PMID: 36304456 PMCID: PMC9593704 DOI: 10.3389/fimmu.2022.993401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Intravesical BCG instillation after bladder tumor resection is the standard treatment for non-muscle invasive bladder cancer; however, it is not always effective and frequently has undesirable side effects. Therefore, new strategies that improve the clinical management of patients are urgently needed. This study aimed to comprehensively evaluate the bladder tumor immune microenvironment profile after intravesical treatment with a panel of mycobacteria with variation in their cell envelope composition and its impact on survival using an orthotopic murine model to identify more effective and safer therapeutic strategies. tumor-bearing mice were intravesically treated with a panel of BCG and M. brumae cultured under different conditions. Untreated tumor-bearing mice and healthy mice were also included as controls. After mycobacterial treatments, the infiltrating immune cell populations in the bladder were analysed by flow cytometry. We provide evidence that mycobacterial treatment triggered a strong immune infiltration into the bladder, with BCG inducing higher global absolute infiltration than M. brumae. The induced global immune microenvironment was strikingly different between the two mycobacterial species, affecting both innate and adaptive immunity. Compared with M. brumae, BCG treated mice exhibited a more robust infiltration of CD4+ and CD8+ T-cells skewed toward an effector memory phenotype, with higher frequencies of NKT cells, neutrophils/gMDSCs and monocytes, especially the inflammatory subset, and higher CD4+ TEM/CD4+ Treg and CD8+ TEM/CD4+ Treg ratios. Conversely, M. brumae treatment triggered higher proportions of total activated immune cells and activated CD4+ and CD8+ TEM cells and lower ratios of CD4+ TEM cells/CD4+ Tregs, CD8+ TEM cells/CD4+ Tregs and inflammatory/reparative monocytes. Notably, the mycobacterial cell envelope composition in M. brumae had a strong impact on the immune microenvironment, shaping the B and myeloid cell compartment and T-cell maturation profile and thus improving survival. Overall, we demonstrate that the bladder immune microenvironment induced by mycobacterial treatment is species specific and shaped by mycobacterial cell envelope composition. Therefore, the global bladder immune microenvironment can be remodelled, improving the quality of infiltrating immune cells, the balance between inflammatory and regulatory/suppressive responses and increasing survival.
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Affiliation(s)
- Jordi Senserrich
- AIDS Research Institute IrsiCaixa, Institut de Recerca en Ciències de la Salut Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sandra Guallar-Garrido
- Departament de Genètica i de Microbiologia, Facultat de Biociències, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elisabet Gomez-Mora
- AIDS Research Institute IrsiCaixa, Institut de Recerca en Ciències de la Salut Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victor Urrea
- AIDS Research Institute IrsiCaixa, Institut de Recerca en Ciències de la Salut Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Bonaventura Clotet
- AIDS Research Institute IrsiCaixa, Institut de Recerca en Ciències de la Salut Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
- Fundació lluita contra la SIDA, Infectious Diseases Department, Hospital Germans Trias i Pujol, Catalonia, Spain
- University of Vic-Central University of Catalonia (UVic - UCC), Vic, Spain
- Consorcio Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Esther Julián
- Departament de Genètica i de Microbiologia, Facultat de Biociències, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cecilia Cabrera
- AIDS Research Institute IrsiCaixa, Institut de Recerca en Ciències de la Salut Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
- *Correspondence: Cecilia Cabrera, ; Esther Julián,
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5
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Bibby AC, Zahan-Evans N, Keenan E, Comins C, Harvey JE, Day H, Rahman NM, Fallon JE, Gooberman-Hill R, Maskell NA. A trial of intra-pleural bacterial immunotherapy in malignant pleural mesothelioma (TILT) - a randomised feasibility study using the trial within a cohort (TwiC) methodology. Pilot Feasibility Stud 2022; 8:196. [PMID: 36057634 PMCID: PMC9440504 DOI: 10.1186/s40814-022-01156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/24/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Malignant pleural mesothelioma (MPM) is an aggressive thoracic malignancy with a poor prognosis. Systemic immunotherapy is an effective frontline treatment for MPM, and there is a scientific rationale supporting the possible efficacy of local, i.e. intra-pleural immune modulators. Trial of intra-pleural bacterial immunotherapy (TILT) investigated the feasibility of performing a randomised trial of intra-pleural bacterial immunotherapy in people with MPM, using the trials within cohorts (TwiC) methodology. METHODS TILT was a multicentre, three-armed, randomised, feasibility TwiC of intra-pleural OK432, BCG, or usual care in people with MPM. Eligible participants were identified from within the ASSESS-meso study, a prospective, longitudinal, observational cohort study, and were randomly selected to be offered a single dose of OK432 or BCG, via an indwelling pleural catheter. The primary outcome was feasibility, evaluated against prespecified recruitment, attrition and data completeness targets. The acceptability of trial processes and interventions was assessed during qualitative interviews with participants and family members at the end of the trial. TILT was registered prospectively on the European Clinical Trials Registry (EudraCT number 2016-004,727-23) and the ISRCTN Register on 04 December 2017. RESULTS Seven participants were randomised from a planned sample size of 12; thus, the 66% recruitment rate target was not met. Two participants withdrew after randomisation, breaching the pre-stated attrition threshold of 10%. It was not possible to maintain blinding of control participants, which negated a fundamental tenet of the TwiC design. The trial processes and methodology were generally acceptable to participants and relatives, despite several recipients of intra-pleural bacterial agents experiencing significant local and systemic inflammatory responses. CONCLUSION It was possible to design a clinical trial of an investigational medicinal product based on the TwiC design and to obtain the necessary regulatory approvals. However, whilst acceptable to participants and relatives, the TwiC design was not a feasible method of investigating intra-pleural bacterial immunotherapy in people with MPM. Future trials investigating this topic should consider the eligibility constraints and recruitment difficulties encountered. TRIAL REGISTRATION TILT was registered prospectively on the European Clinical Trials Registry (EudraCT number 2016-004727-23 ) and the ISRCTN Register ( 10432197 ) on 04 December 2017.
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Affiliation(s)
- Anna C Bibby
- Academic Respiratory Unit, University of Bristol Medical School, Bristol, UK.
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK.
| | | | - Emma Keenan
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
| | - Charles Comins
- Bristol Haematology & Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - John E Harvey
- Academic Respiratory Unit, University of Bristol Medical School, Bristol, UK
| | - Helen Day
- Academic Respiratory Unit, University of Bristol Medical School, Bristol, UK
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Janet E Fallon
- Respiratory Department, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, UK
| | - Rachael Gooberman-Hill
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol Medical School, Bristol, UK
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
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6
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Jiang S, Redelman-Sidi G. BCG in Bladder Cancer Immunotherapy. Cancers (Basel) 2022; 14:3073. [PMID: 35804844 PMCID: PMC9264881 DOI: 10.3390/cancers14133073] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 01/18/2023] Open
Abstract
BCG is a live attenuated strain of Mycobacterium bovis that is primarily used as a vaccine against tuberculosis. In the past four decades, BCG has also been used for the treatment of non-muscle invasive bladder cancer (NMIBC). In patients with NMIBC, BCG reduces the risk of tumor recurrence and decreases the likelihood of progression to more invasive disease. Despite the long-term clinical experience with BCG, its mechanism of action is still being elucidated. Data from animal models and from human studies suggests that BCG activates both the innate and adaptive arms of the immune system eventually leading to tumor destruction. Herein, we review the current data regarding the mechanism of BCG and summarize the evidence for its clinical efficacy and recommended indications and clinical practice.
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Affiliation(s)
- Song Jiang
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA;
| | - Gil Redelman-Sidi
- Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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7
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Lou K, Feng S, Zhang G, Zou J, Zou X. Prevention and Treatment of Side Effects of Immunotherapy for Bladder Cancer. Front Oncol 2022; 12:879391. [PMID: 35669417 PMCID: PMC9164628 DOI: 10.3389/fonc.2022.879391] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/19/2022] [Indexed: 12/12/2022] Open
Abstract
Bladder cancer (BC) is one of the most important tumors of the genitourinary system, associated with high morbidity and mortality rates. Over the years, various antitumor treatments have been developed, and immunotherapy is one of the most effective methods. Immunotherapy aims to activate the body’s immune system to kill cancer cells. It has been established that immunotherapy drugs can be classified into “non-targeted” and “targeted” drugs depending on their site of action. Immunotherapy is reportedly effective for BC. Even though it can attack cancer cells, it can also cause the immune system to attack healthy cells, which can occur at any time during treatment and sometimes even after immunotherapy is stopped. Importantly, different types of immunotherapies can cause different side effects. Side effects may manifest themselves as signs or as symptoms. The prevention and treatment of side effects caused by immunotherapy is an important part of cancer patient management.
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Affiliation(s)
- Kecheng Lou
- The First Clinical College, Gannan Medical University, Ganzhou, China.,Department of Urology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Shangzhi Feng
- The First Clinical College, Gannan Medical University, Ganzhou, China.,Department of Urology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Guoxi Zhang
- Department of Urology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Urology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Jiangxi Engineering Technology Research Center of Calculi Prevention, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Junrong Zou
- Department of Urology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Urology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Jiangxi Engineering Technology Research Center of Calculi Prevention, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Xiaofeng Zou
- Department of Urology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Urology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Jiangxi Engineering Technology Research Center of Calculi Prevention, Gannan Medical University, Ganzhou, Jiangxi, China
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8
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Nguyen KG, Wagner ES, Vrabel MR, Mantooth SM, Meritet DM, Zaharoff DA. Safety and Pharmacokinetics of Intravesical Chitosan/Interleukin-12 Immunotherapy in Murine Bladders. Bladder Cancer 2021. [DOI: 10.3233/blc-211542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Intravesical administration of interleukin 12 (IL-12) co-formulated with the biopolymer, chitosan (CS/IL-12), has demonstrated remarkable antitumor activity against preclinical models of bladder cancer. However, given historical concerns regarding severe toxicities associated with systemic IL-12 administration in clinical trials, it is important to evaluate the safety of intravesical CS/IL-12 prior to clinical translation. OBJECTIVE: To evaluate the pharmacokinetics as well as the local and systemic toxicities of intravesical CS/IL-12 immunotherapy in laboratory mice. METHODS: Local inflammatory responses in mouse bladders treated with intravesical IL-12 or CS/IL-12 were assessed via histopathology. Serum cytokine levels following intravesical and subcutaneous (s.c.) administrations of IL-12 or CS/IL-12 in laboratory mice were compared. Systemic toxicities were evaluated via body weight and liver enzyme levels. RESULTS: Intravesical IL-12 and CS/IL-12 treatments did not induce significant local or systemic toxicity. IL-12 dissemination and exposure from intravesical administration was significantly lower compared to s.c. injections. Weekly intravesical CS/IL-12 treatments were well-tolerated and did not result in blunted immune responses. CONCLUSIONS: Intravesical CS/IL-12 is safe and well-tolerated in mice. In particular, the lack of cystitis and acute inflammation justifies continued investigation of intravesical CS/IL-12 immunotherapy in larger animals and patients with bladder cancer.
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Affiliation(s)
- Khue G. Nguyen
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina-Chapel Hill, Raleigh, NC, USA
| | - Ethan S. Wagner
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina-Chapel Hill, Raleigh, NC, USA
| | - Maura R. Vrabel
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina-Chapel Hill, Raleigh, NC, USA
| | - Siena M. Mantooth
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina-Chapel Hill, Raleigh, NC, USA
| | - Danielle M. Meritet
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - David A. Zaharoff
- Joint Department of Biomedical Engineering, North Carolina State University and University of North Carolina-Chapel Hill, Raleigh, NC, USA
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Kennedy A, Sahu KK, Cerny J. Role of Immunomodulation of BCG Therapy on AML Remission. Int Med Case Rep J 2021; 14:115-119. [PMID: 33658865 PMCID: PMC7920581 DOI: 10.2147/imcrj.s296387] [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: 12/22/2020] [Accepted: 01/30/2021] [Indexed: 12/05/2022] Open
Abstract
Bacillus Calmette–Guérin (BCG) has been studied in various cancers for its immune modulation. Although the mechanism is yet to be completely understood, we do have positive experiences in many oncological cases. Hereby, we present a case of an 82-year-old male with acute myeloid leukemia (AML) post allogeneic Stem Cell Transplants (AlloSCT) as a salvage therapy, now in remission, who presented with hematuria. Workup confirmed non-muscle invasive Bladder Cancer (NMIBC), for which he was treated with nine sessions of intravesical BCG therapy. During BCG treatment, the patient developed gradually increasing lymphocyte counts. Flowcytometry of a peripheral blood sample showed polyclonal cell lymphocytosis with CD8+ T-cell expansion. Although further work up his lymphocytosis to be polyclonal, it has persisted at follow-up for the last 4 years. Also, we did not find any evidence of leukemia recurrence at follow-up prompting us to associate the BCG use for this patient and it is role as immunomodulation to keep AML disease in remission.
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Affiliation(s)
- Alice Kennedy
- Department of Internal Medicine, University of Massachusetts Medical School, Worcester, MA, 01655, USA
| | - Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA, 01608, USA
| | - Jan Cerny
- Division of Hematology and Oncology, Department of Internal Medicine, UMass Memorial Health Care, University of Massachusetts Medical School, Worcester, MA, 01655, USA
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Lim CJ, Nguyen PHD, Wasser M, Kumar P, Lee YH, Nasir NJM, Chua C, Lai L, Hazirah SN, Loh JJH, Khor LY, Yeong J, Lim TKH, Low AWX, Albani S, Chong TW, Chew V. Immunological Hallmarks for Clinical Response to BCG in Bladder Cancer. Front Immunol 2021; 11:615091. [PMID: 33584702 PMCID: PMC7879685 DOI: 10.3389/fimmu.2020.615091] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022] Open
Abstract
Intravesical Bacillus Calmette-Guerin (BCG) is an effective immunotherapy for non-muscle invasive bladder cancer (NMIBC). However, recurrence and progression remain frequent warranting deeper insights into its mechanism. We herein comprehensively profiled blood and tissues obtained from NMIBC patients before, during and after BCG treatment using cytometry by time-of-flight (CyTOF) and RNA sequencing to identify the key immune subsets crucial for anti-tumor activity. We observed the temporal changes of peripheral immune subsets including NKT cells, central memory CD4+ T cells, CD8+ T cells and regulatory T cells (Treg) during the course of BCG. Gene expression analysis revealed enriched immune pathways involving in T cell activation and chemotaxis, as well as a more diversified T cell receptor repertoire in post-BCG tissues. Moreover, tissue multiplexed-immunofluorescence (mIF) showed baseline densities of non-Treg and CD8+PD-1+ T cells were predictive of response and better recurrence-free survival after BCG. Remarkably, post-BCG tissues from responders were found to be infiltrated with more active CD8+PD-1- T cells and non-Treg CD4+FOXP3- T cells; but increased exhausted CD8+PD-1+ T cells were found in non-responders. Taken together, we identified predictive biomarkers for response and uncovered the post-treatment expansion of exhausted PD-1+CD8+ T cells as key to BCG resistance, which could potentially be restored by combining with anti-PD-1 immunotherapy.
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Affiliation(s)
- Chun Jye Lim
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore
| | - Phuong Hoang Diem Nguyen
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore
| | - Martin Wasser
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore
| | - Pavanish Kumar
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore
| | - Yun Hua Lee
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore
| | - Nurul Jannah Mohamed Nasir
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Camillus Chua
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore
| | - Liyun Lai
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore
| | - Sharifah Nur Hazirah
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore
| | - Josh Jie Hua Loh
- Division of Pathology, Singapore General Hospital, Singapore, Singapore
| | - Li Yan Khor
- Duke-NUS Medical School, Singapore, Singapore.,Division of Pathology, Singapore General Hospital, Singapore, Singapore
| | - Joe Yeong
- Division of Pathology, Singapore General Hospital, Singapore, Singapore.,Institute of Molecular Cell Biology (IMCB), Agency of Science, Technology and Research (ASTAR), Singapore, Singapore
| | - Tony Kiat Hon Lim
- Duke-NUS Medical School, Singapore, Singapore.,Division of Pathology, Singapore General Hospital, Singapore, Singapore
| | | | - Salvatore Albani
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore
| | - Tsung Wen Chong
- Duke-NUS Medical School, Singapore, Singapore.,Department of Urology, Singapore General Hospital, Singapore, Singapore
| | - Valerie Chew
- Translational Immunology Institute (TII), SingHealth-DukeNUS Academic Medical Centre, Singapore, Singapore
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11
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The double-sided effects of Mycobacterium Bovis bacillus Calmette-Guérin vaccine. NPJ Vaccines 2021; 6:14. [PMID: 33495451 PMCID: PMC7835355 DOI: 10.1038/s41541-020-00278-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 12/14/2020] [Indexed: 01/30/2023] Open
Abstract
Bacillus Calmette-Guérin (BCG), the only vaccine proven to be effective against tuberculosis (TB), is the most commonly used vaccine globally. In addition to its effects on mycobacterial diseases, an increasing amount of epidemiological and experimental evidence accumulated since its introduction in 1921 has shown that BCG also exerts non-specific effects against a number of diseases, such as non-mycobacterial infections, allergies and certain malignancies. Recent Corona Virus Disease 2019 (COVID-19) outbreak has put BCG, a classic vaccine with significant non-specific protection, into the spotlight again. This literature review briefly covers the diverse facets of BCG vaccine, providing new perspectives in terms of specific and non-specific protection mechanisms of this old, multifaceted, and controversial vaccine.
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12
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Moulson AJ, Av-Gay Y. BCG immunomodulation: From the 'hygiene hypothesis' to COVID-19. Immunobiology 2020; 226:152052. [PMID: 33418320 PMCID: PMC7833102 DOI: 10.1016/j.imbio.2020.152052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/07/2020] [Accepted: 12/17/2020] [Indexed: 12/23/2022]
Abstract
The century-old tuberculosis vaccine BCG has been the focus of renewed interest due to its well-documented ability to protect against various non-TB pathogens. Much of these broad spectrum protective effects are attributed to trained immunity, the epigenetic and metabolic reprogramming of innate immune cells. As BCG vaccine is safe, cheap, widely available, amendable to use as a recombinant vector, and immunogenic, it has immense potential for use as an immunotherapeutic agent for various conditions including autoimmune, allergic, neurodegenerative, and neoplastic diseases as well as a preventive measure against infectious agents. Of particular interest is the use of BCG vaccination to counteract the increasing prevalence of autoimmune and allergic conditions in industrialized countries attributable to reduced infectious burden as described by the ‘hygiene hypothesis.’ Furthermore, BCG vaccination has been proposed as a potential therapy to mitigate spread and disease burden of COVID-19 as a bridge to development of a specific vaccine and recombinant BCG expression vectors may prove useful for the introduction of SARS-CoV-2 antigens (rBCG-SARS-CoV-2) to induce long-term immunity. Understanding the immunomodulatory effects of BCG vaccine in these disease contexts is therefore critical. To that end, we review here BCG-induced immunomodulation focusing specifically on BCG-induced trained immunity and how it relates to the ‘hygiene hypothesis’ and COVID-19.
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Affiliation(s)
- Aaron J Moulson
- Faculty of Medicine, University of British Columbia, Vancouver, Canada.
| | - Yossef Av-Gay
- Faculty of Medicine, University of British Columbia, Vancouver, Canada; Division of Infectious Disease, University of British Columbia, Vancouver, Canada; Department of Microbiology and Immunology, University of British Columbia, Vancouver, Canada
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13
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Bacillus Calmette-Guerin (BCG): Its fight against pathogens and cancer. Urol Oncol 2020; 39:121-129. [PMID: 33262028 DOI: 10.1016/j.urolonc.2020.09.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/26/2020] [Accepted: 09/29/2020] [Indexed: 01/06/2023]
Abstract
Bacillus Calmette-Guerin (BCG) is the only FDA approved first line therapy for patients with nonmuscle invasive bladder cancer. Since the turn of the 20th century BCG has been used as a vaccine for protection against Mycobacterium tuberculosis (Mtb) and has also been found to have protection against nontuberculosis related pathogens. Recently the role of "trained immunity" has been identified as a possible mechanism for BCG vaccine-mediated immunity to Mtb. Similarly, BCG has been used as an immunotherapy for bladder cancer for more than 40 years, and the underlying mechanisms for BCG-mediated anti-tumor activity is poorly characterized. Several studies have shown that multiple immune pathways contribute to the immune response, and efficacy of intravesicle BCG as a cancer therapy. It is vital that we integrate our understanding of BCG as a vaccine and as a cancer therapeutic to facilitate design of future studies in order to maximize the immunotherapeutic potential of BCG. In this review we will outline the role of BCG as a vaccine, the known immune pathways that are activated by intravesical BCG and outline a potential clinical study integrating BCG vaccination prior to intravesicle instillation of BCG.
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14
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Roumiguié M, Compérat E, Chaltiel L, Nouhaud FX, Verhoest G, Masson-Lecomte A, Colin P, Audenet F, Houédé N, Larré S, Xylinas E, Brunelle S, Piana-Thomassin J, Cotte J, Pignot G, Neuzillet Y, Rouprêt M. PD-L1 expression and pattern of immune cells in pre-treatment specimens are associated with disease-free survival for HR-NMIBC undergoing BCG treatment. World J Urol 2020; 39:4055-4065. [PMID: 32666225 DOI: 10.1007/s00345-020-03329-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To assess the association between PD-L1 expression and disease-free survival (DFS) in High-Risk Non-Muscle Invasive Bladder Cancer (HR-NMIBC) patients treated with intravesical Bacillus Calmette-Guerin (BCG) instillations (IBI). METHODS Retrospective study in five French centres between 2001 and 2015. Participants were 140 patients with histologically confirmed HR-NMIBC. All patients received induction and maintenance IBI. Pathological stage/grade, concomitant carcinoma in situ, lesion number and tumour size were recorded. CD3, CD8 and PD-L1 expression in tumour cells and in T cells in the tumour microenvironment (TME) was determined immunohistochemically. Median follow-up was 54.2 months. The primary outcome measure was DFS. Univariable and multivariable analyses were performed using the log rank test and Cox proportional hazards model. RESULTS Of the 140 NMIBC, 52 (37.1%) were Ta, 88 (62.9%) were T1 and 100% were high grade. Median number of maintenance IBI was six (range 1-30). Twenty-five (17.9%) patients had recurrence/progression. In multivariable analysis, age (HR 1.07 [95% CI 1.02-1.13], p = 0.009), PD-L1 expression in tumour cells (HR per 10 units = 1.96 [95% CI 1.28-3.00], p = 0.02) and CD3/CD8 ratio (HR per 10 units = 3.38 [95% CI 1.61-7.11], p = 0.01) were significantly associated with DFS. However, using the cut-off corresponding for each PD-L1 antibodies, PD-L1 + status was not associated with DFS. CONCLUSION Despite an association between PD-L1 expression and BCG failure in HR-NMIBC, the PD-L1 + status was not a prognostic factor in the response of BCG. Moreover, we confirmed the key role played by the IC within the microenvironment in BCG treatment. These findings highlighted the rationale to combine BCG and PD-L1/PD-1 antibodies in early bladder cancer.
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Affiliation(s)
- Mathieu Roumiguié
- Department of Urology, Institut Universitaire du Cancer de Toulouse Oncopole, Rangueil University Hospital, 31059, Toulouse, France.
| | - Eva Compérat
- GRC n°5, PREDICTIVE ONCO-URO, AP-HP Service de Pathology, Tenon Hospital, Sorbonne University, 75020, Paris, France
| | - Léonor Chaltiel
- Biostatistics Unit, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - François Xavier Nouhaud
- Urology Department, Rouen University Hospital, Rouen, France.,UNIROUEN, IRON Group, Rouen University Hospital, Normandy University, Rouen, France
| | - Gregory Verhoest
- Department of Urology, Rennes University Hospital, Rennes, France
| | | | - Pierre Colin
- Urology Department, Hôpital privé de la Louvière, 59042, Lille, France
| | - François Audenet
- Urology Department, Georges Pompidou European Hospital, University Paris Descartes, AP-HP, 75015, Paris, France
| | - Nadine Houédé
- Department of Medical Oncology, CHU Caremeau, Montpellier University, 30029, Nimes, France
| | | | - Evanguelos Xylinas
- Urology Department, Bichat-Claude Bernard Hospital, Paris Descartes University, AP-HP, 75018, Paris, France
| | - Serge Brunelle
- Department of Radiology, Institut Paoli-Calmettes, 13009, Marseille, France
| | | | - Juliette Cotte
- Urology Department, GRC n°5, PREDICTIVE ONCO-URO, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne University, 75013, Paris, France
| | - Géraldine Pignot
- Department of Surgical Oncology 2, Institut Paoli-Calmettes, 13009, Marseille, France
| | - Yann Neuzillet
- Urology Department, Foch Hospital, Versailles-Saint-Quentin-en-Yvelines University, 92150, Suresnes, France
| | - Morgan Rouprêt
- Urology Department, GRC n°5, PREDICTIVE ONCO-URO, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne University, 75013, Paris, France.
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15
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Covián C, Fernández-Fierro A, Retamal-Díaz A, Díaz FE, Vasquez AE, Lay MK, Riedel CA, González PA, Bueno SM, Kalergis AM. BCG-Induced Cross-Protection and Development of Trained Immunity: Implication for Vaccine Design. Front Immunol 2019; 10:2806. [PMID: 31849980 PMCID: PMC6896902 DOI: 10.3389/fimmu.2019.02806] [Citation(s) in RCA: 190] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/15/2019] [Indexed: 12/18/2022] Open
Abstract
The Bacillus Calmette-Guérin (BCG) is a live attenuated tuberculosis vaccine that has the ability to induce non-specific cross-protection against pathogens that might be unrelated to the target disease. Vaccination with BCG reduces mortality in newborns and induces an improved innate immune response against microorganisms other than Mycobacterium tuberculosis, such as Candida albicans and Staphylococcus aureus. Innate immune cells, including monocytes and natural killer (NK) cells, contribute to this non-specific immune protection in a way that is independent of memory T or B cells. This phenomenon associated with a memory-like response in innate immune cells is known as "trained immunity." Epigenetic reprogramming through histone modification in the regulatory elements of particular genes has been reported as one of the mechanisms associated with the induction of trained immunity in both, humans and mice. Indeed, it has been shown that BCG vaccination induces changes in the methylation pattern of histones associated with specific genes in circulating monocytes leading to a "trained" state. Importantly, these modifications can lead to the expression and/or repression of genes that are related to increased protection against secondary infections after vaccination, with improved pathogen recognition and faster inflammatory responses. In this review, we discuss BCG-induced cross-protection and acquisition of trained immunity and potential heterologous effects of recombinant BCG vaccines.
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Affiliation(s)
- Camila Covián
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile.,Departamento de Biotecnología, Facultad de Ciencias del Mar y Recursos Biológicos, Universidad de Antofagasta, Antofagasta, Chile
| | - Ayleen Fernández-Fierro
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Angello Retamal-Díaz
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Fabián E Díaz
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Abel E Vasquez
- Sección de Biotecnología, Instituto de Salud Pública de Chile, Santiago, Chile.,Facultad de Medicina y Ciencia, Universidad San Sebastián, Providencia, Santiago, Chile
| | - Margarita K Lay
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile.,Departamento de Biotecnología, Facultad de Ciencias del Mar y Recursos Biológicos, Universidad de Antofagasta, Antofagasta, Chile
| | - Claudia A Riedel
- Millennium Institute on Immunology and Immunotherapy, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile
| | - Pablo A González
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Susan M Bueno
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alexis M Kalergis
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile.,Departamento de Endocrinología, Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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16
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Song D, Powles T, Shi L, Zhang L, Ingersoll MA, Lu YJ. Bladder cancer, a unique model to understand cancer immunity and develop immunotherapy approaches. J Pathol 2019; 249:151-165. [PMID: 31102277 PMCID: PMC6790662 DOI: 10.1002/path.5306] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/02/2019] [Accepted: 05/15/2019] [Indexed: 12/11/2022]
Abstract
With the mechanistic understanding of immune checkpoints and success in checkpoint blockade using antibodies for the treatment of certain cancers, immunotherapy has become one of the hottest areas in cancer research, with promise of long‐lasting therapeutic effect. Currently, however, only a proportion of cancers have a good response to checkpoint inhibition immunotherapy. Better understanding of the cancer response and resistance mechanisms is essential to fully explore the potential of immunotherapy to cure the majority of cancers. Bladder cancer, one of the most common and aggressive malignant diseases, has been successfully treated both at early and advanced stages by different immunotherapeutic approaches, bacillus Calmette–Guérin (BCG) intravesical instillation and anti‐PD‐1/PD‐L1 immune checkpoint blockade, respectively. Therefore, it provides a good model to investigate cancer immune response mechanisms and to improve the efficiency of immunotherapy. Here, we review bladder cancer immunotherapy with equal weight on BCG and anti‐PD‐1/PD‐L1 therapies and demonstrate why and how bladder cancer can be used as a model to study the predictors and mechanisms of cancer immune response and shine light on further development of immunotherapy approaches and response predictive biomarkers to improve immunotherapy of bladder cancer and other malignancies. We review the success of BCG and anti‐PD‐1/PD‐L1 treatment of bladder cancer, the underlying mechanisms and the therapeutic response predictors, including the limits to our knowledge. We then highlight briefly the adaptation of immunotherapy approaches and predictors developed in other cancers for bladder cancer therapy. Finally, we explore the potential of using bladder cancer as a model to investigate cancer immune response mechanisms and new therapeutic approaches, which may be translated into immunotherapy of other human cancers. © 2019 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Dongkui Song
- Department of Urology, The First Affiliated Hospital and Academy of Medical Sciences, Zhengzhou University, Zhengzhou, PR China
| | - Thomas Powles
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, UK.,Department of Medical Oncology, Barts Health NHS, London, UK
| | - Lei Shi
- Department of Urology, The First Affiliated Hospital and Academy of Medical Sciences, Zhengzhou University, Zhengzhou, PR China
| | - Lirong Zhang
- Department of Pharmacology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, PR China
| | - Molly A Ingersoll
- Department of Immunology, Institut Pasteur, Paris, France.,Inserm U1223, Paris, France
| | - Yong-Jie Lu
- Department of Urology, The First Affiliated Hospital and Academy of Medical Sciences, Zhengzhou University, Zhengzhou, PR China.,Centre for Molecular Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
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17
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BCG-induced formation of neutrophil extracellular traps play an important role in bladder cancer treatment. Clin Immunol 2019; 201:4-14. [PMID: 30771501 DOI: 10.1016/j.clim.2019.02.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/15/2019] [Accepted: 02/12/2019] [Indexed: 01/03/2023]
Abstract
Bacillus Calmette-Guerin (BCG) is one of the most effective treatments for bladder cancer. Little attention has been paid to the possible role of neutrophils in BCG immunotherapy. In this study, we examined neutrophil extracellular traps (NETs) formation induced by BCG stimulation, and found that BCG-induced NETs exerted cytotoxicity, induced apoptosis and cell-cycle arrest, and inhibited migration in bladder tumor cells. BCG-activated tumor cells but not non-activated ones elicited NETs formation, in which IL-8 and TNF-α from activated tumor cells both took effect. Moreover, NETs activated peripheral blood mononuclear cells (PBMCs) exhibited a higher expression of CD4 and Th1 cytokines. Additionally, the role of NETs in vivo contributed to the recruitment of T cells and monocytes-macrophages and tissue damage, thus preventing tumor growth. NETs proteins mainly caused these effects on tumor and cellular immunity. In conclusion, we demonstrated a novel immunoregulatory role for NETs in the early stages of BCG immunotherapy.
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18
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Shan G, Tang T, Qian H, Xia Y. Certain BCG-reactive responses are associated with bladder cancer prognosis. Cancer Immunol Immunother 2018; 67:797-803. [PMID: 29478100 PMCID: PMC11028363 DOI: 10.1007/s00262-018-2127-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 02/09/2018] [Indexed: 11/30/2022]
Abstract
A subset of bladder patients does not respond to BCG treatment effectively and the underlying reason behind this observation is currently unclear. CD4+ T cells are composed of various subsets that each expresses a distinctive set of cytokines and can potently shift the immune response toward various directions. In this study, we examined the CD4+ T-cell cytokine response in bladder cancer patients toward BCG stimulation. We found that bladder cancer patients presented a variety of responses toward BCG, with no uniform characteristics. Those patients with high IFN-γ and IL-21 expression in CD4+ T cells presented significantly better prognosis than patients with low cytokine secretion in CD4+ T cells. Tumor-infiltrating CD4+ T cells were significantly less potent in expressing IFN-γ, IL-4, and IL-17, and more potent in expressing IL-10 than circulating CD4+ T cells. In addition, we found no difference in CD80, CD86, or MHC II expression by macrophages from patients with different IFN-γ and IL-21 levels. However, the secretion of IL-12, a Th1-skewing cytokine, was released at significantly higher level by macrophages from patients with high IFN-γ or high IL-21 secretion. We also identified that modulating monocytes/macrophages by GM-CSF-mediated polarization resulted in significantly elevated expression of IFN-γ and IL-21 from CD4+ T cells. Overall, these results suggested that the specific types of responses mounted by CD4+ T cells were critical to the final outcome of bladder cancer patients and can be influenced by monocyte/macrophage polarization.
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Affiliation(s)
- Guang Shan
- Departments of Urology II, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei, China.
| | - Tian Tang
- Departments of Oncology II, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Huijun Qian
- Departments of Urology II, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei, China
| | - Yue Xia
- Departments of Urology II, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, Hubei, China
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19
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Kamat AM, Li R, O’Donnell MA, Black PC, Roupret M, Catto JW, Comperat E, Ingersoll MA, Witjes WP, McConkey DJ, Witjes JA. Predicting Response to Intravesical Bacillus Calmette-Guérin Immunotherapy: Are We There Yet? A Systematic Review. Eur Urol 2018; 73:738-748. [DOI: 10.1016/j.eururo.2017.10.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 10/02/2017] [Indexed: 10/24/2022]
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20
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Marciscano AE, Madan RA. Targeting the Tumor Microenvironment with Immunotherapy for Genitourinary Malignancies. Curr Treat Options Oncol 2018. [PMID: 29520448 DOI: 10.1007/s11864-018-0523-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OPINION STATEMENT Bacillus Calmette-Guérin in urothelial carcinoma, high-dose interleukin-2 in renal cell carcinoma, and sipuleucel-T in prostate cancer serve as enduring examples that the host immune response can be harnessed to promote effective anti-tumor immunity in genitourinary malignancies. Recently, cancer immunotherapy with immune checkpoint inhibitors has transformed the prognostic landscape leading to durable responses in a subset of urothelial carcinoma and renal cell carcinoma patients with traditionally poor prognosis. Despite this success, many patients fail to respond to immune checkpoint inhibitors and progression/relapse remains common. Furthermore, modest clinical activity has been observed with ICIs as a monotherapy in advanced PCa. As such, novel treatment approaches are warranted and improved biomarkers for patient selection and treatment response are desperately needed. Future efforts should focus on exploring synergistic and rational combinations that safely and effectively boost response rates and survival in genitourinary malignancies. Specific areas of interest include (1) evaluating the optimal sequencing, disease burden, and timing of immuno-oncology agents with other anti-cancer therapeutics and (2) validating novel biomarkers of response to immunotherapy to optimize patient selection and to identify individuals most likely to benefit from immunotherapy across the heterogenous spectrum of genitourinary malignancies.
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Affiliation(s)
- Ariel E Marciscano
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive 13N240B, Bethesda, MD, 20892, USA
| | - Ravi A Madan
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Drive 13N240B, Bethesda, MD, 20892, USA.
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21
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Purified protein derivative skin test reactions are associated with clinical outcomes of patients with nonmuscle invasive bladder cancer treated with induction bacillus Calmette-Guérin therapy. Urol Oncol 2018; 36:77.e15-77.e21. [DOI: 10.1016/j.urolonc.2017.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/29/2017] [Accepted: 10/06/2017] [Indexed: 11/23/2022]
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22
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Shang Z, Li Y, Hsu I, Zhang M, Tian J, Wen S, Han R, Messing EM, Chang C, Niu Y, Yeh S. Targeting estrogen/estrogen receptor alpha enhances Bacillus Calmette-Guérin efficacy in bladder cancer. Oncotarget 2017; 7:27325-35. [PMID: 27092883 PMCID: PMC5053653 DOI: 10.18632/oncotarget.8756] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 01/24/2016] [Indexed: 12/21/2022] Open
Abstract
Recent studies showed the potential linkage of estrogen/estrogen receptor signaling with bladder tumorigenesis, yet detailed mechanisms remain elusive. Here we found a new potential therapy with the combination of Bacillus Calmette Guerin (BCG) and the anti-estrogen ICI 182,780 led to better suppression of bladder cancer (BCa) than BCG alone. Mechanism dissection found ICI 182,780 could promote BCG attachment/internalization to the BCa cells through increased integrin-α5β1 expression and IL-6 release, which may enhance BCG-induced suppression of BCa cell growth via recruiting more monocytes/macrophages to BCa cells and increased TNF-α release. Consistently, in vivo studies found ICI 182,780 could potentiate the anti-BCa effects of BCG in the carcinogen-induced mouse BCa models. Together, these in vitro and in vivo results suggest that combining BCG with anti-estrogen may become a new therapeutic approach with better efficacy to suppress BCa progression and recurrence.
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Affiliation(s)
- Zhiqun Shang
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China.,George Whipple Lab for Cancer Research, Departments of Urology, Pathology and the Cancer Center, University of Rochester, Rochester, New York, United States of America
| | - Yanjun Li
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China
| | - Iawen Hsu
- George Whipple Lab for Cancer Research, Departments of Urology, Pathology and the Cancer Center, University of Rochester, Rochester, New York, United States of America
| | - Minghao Zhang
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China
| | - Jing Tian
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China.,George Whipple Lab for Cancer Research, Departments of Urology, Pathology and the Cancer Center, University of Rochester, Rochester, New York, United States of America
| | - Simeng Wen
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China.,George Whipple Lab for Cancer Research, Departments of Urology, Pathology and the Cancer Center, University of Rochester, Rochester, New York, United States of America
| | - Ruifa Han
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China
| | - Edward M Messing
- George Whipple Lab for Cancer Research, Departments of Urology, Pathology and the Cancer Center, University of Rochester, Rochester, New York, United States of America
| | - Chawnshang Chang
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China.,George Whipple Lab for Cancer Research, Departments of Urology, Pathology and the Cancer Center, University of Rochester, Rochester, New York, United States of America
| | - Yuanjie Niu
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China.,George Whipple Lab for Cancer Research, Departments of Urology, Pathology and the Cancer Center, University of Rochester, Rochester, New York, United States of America
| | - Shuyuan Yeh
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China.,George Whipple Lab for Cancer Research, Departments of Urology, Pathology and the Cancer Center, University of Rochester, Rochester, New York, United States of America
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23
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Steinberg RL, Nepple KG, Velaer KN, Thomas LJ, O'Donnell MA. Quadruple immunotherapy of Bacillus Calmette-Guérin, interferon, interleukin-2, and granulocyte-macrophage colony-stimulating factor as salvage therapy for non-muscle-invasive bladder cancer. Urol Oncol 2017; 35:670.e7-670.e14. [PMID: 28801026 DOI: 10.1016/j.urolonc.2017.07.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/19/2017] [Accepted: 07/18/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Bacillus Calmette-Guérin (BCG) is the most effective initial intravesical therapy for high-grade non-muscle invasive bladder cancer, but many patients still fail. Combination intravesical BCG and interferon (IFN) will salvage some patients but results remain suboptimal. OBJECTIVE We hypothesized that further immunostimulation with intravesical interleukin-2 and subcutaneous granulocyte-macrophage colony-stimulating factor may improve response to intravesical BCG and IFN in patient with prior BCG failure(s). METHODS A retrospective review was performed. Patients received 6 treatments of quadruple immunotherapy (intravesical solution with one-third dose BCG, 50 million units IFN, and 22 million units interleukin-2, along with a 250-mcg subcutaneous sargramostim injection). Surveillance began 4 to 6 weeks after treatment completion. Patients received maintenance if recurrence-free. Success was defined as no recurrence (bladder or extravesical) and bladder preservation. Analysis was performed by Kaplan-Meier method (P<0.05). RESULTS Fifty-two patients received treatment with a median recurrence follow-up of 16.3 months and overall follow-up of 41.8 months. All patients had at least 1 prior BCG failure and 13% had 2 or more prior failures. Only 3 patients (6%) were unable to tolerate full induction. Treatment success was 55% at 1 year, and 53% at 2 years. Thirteen patients (25%) underwent cystectomy at a median time of 17.3 months with disease progression to T2 in 1 patient and T3 in 2 patients. No patients had positive surgical margins or positive lymph nodes. CONCLUSIONS In patients with non-muscle-invasive bladder cancer with prior BCG failure, quadruple immunotherapy demonstrated good treatment success in some patients and warrants further evaluation.
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Affiliation(s)
| | | | - Kyla N Velaer
- Department of Urology, Stanford University, Palo Alto, CA
| | - Lewis J Thomas
- Department of Urology, University of Iowa, Iowa City, IA
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24
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Davis RL, Le W, Cui Z. Granulocytes as an effector mechanism of BCG therapy for bladder cancer. Med Hypotheses 2017; 104:166-169. [DOI: 10.1016/j.mehy.2017.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/08/2017] [Indexed: 02/08/2023]
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25
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Kates M, Nirschl T, Sopko NA, Matsui H, Kochel CM, Reis LO, Netto GJ, Hoque M, Hahn NM, McConkey DJ, Baras AS, Drake CG, Bivalacqua TJ. Intravesical BCG Induces CD4 + T-Cell Expansion in an Immune Competent Model of Bladder Cancer. Cancer Immunol Res 2017; 5:594-603. [PMID: 28588015 DOI: 10.1158/2326-6066.cir-16-0267] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 01/24/2017] [Accepted: 05/30/2017] [Indexed: 01/12/2023]
Abstract
Intravesical bacillus Calmette-Guérin (BCG) immunotherapy is the standard of care in treating non-muscle-invasive bladder cancer, yet its mechanism of action remains elusive. Both innate and adaptive immune responses have been implicated in BCG activity. Although prior research has indirectly demonstrated the importance of T cells and shown a rise in CD4+ T cells in bladder tissue after BCG, T-cell subpopulations have not been fully characterized. We investigated the relationship between effector and regulatory T cells in an immune competent, clinically relevant rodent model of bladder cancer. Our data demonstrate that cancer progression in the N-methyl-N-nitrosourea (MNU) rat model of bladder cancer was characterized by a decline in the CD8/FoxP3 ratio, consistent with decreased adaptive immunity. In contrast, treatment with intravesical BCG led to a large, transient rise in the CD4+ T-cell population in the urothelium and was both more effective and immunogenic compared with intravesical chemotherapy. Whole-transcriptome expression profiling of posttreatment intravesical CD4+ and CD8+ T cells revealed minimal differences in gene expression after BCG treatment. Together, our results suggest that although BCG induces T-cell recruitment to the bladder, the T-cell phenotype does not markedly change, implying that combining T-cell-activating agents with BCG might improve clinical activity. Cancer Immunol Res; 5(7); 594-603. ©2017 AACR.
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Affiliation(s)
- Max Kates
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - Thomas Nirschl
- Department of Immunology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nikolai A Sopko
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Hotaka Matsui
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christina M Kochel
- Department of Immunology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Leonardo O Reis
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - George J Netto
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Mohammad Hoque
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Noah M Hahn
- The Greenberg Bladder Cancer Institute, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David J McConkey
- The Greenberg Bladder Cancer Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alex S Baras
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland.,The Greenberg Bladder Cancer Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Charles G Drake
- Department of Immunology, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland.,The Greenberg Bladder Cancer Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
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26
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Liang Z, Xin W, Qiang L, Xiang C, Bang-Hua L, Jin Y, De-Yi L, Hong L, Kun-Jie W. Hydrostatic pressure and muscarinic receptors are involved in the release of inflammatory cytokines in human bladder smooth muscle cells. Neurourol Urodyn 2016; 36:1261-1269. [PMID: 27576172 DOI: 10.1002/nau.23104] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 07/27/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Zhou Liang
- Department of Urology, West China Hospital; Sichuan University; Chengdu P.R. China
| | - Wei Xin
- Department of Urology, West China Hospital; Sichuan University; Chengdu P.R. China
| | - Liu Qiang
- Department of Urology, West China Hospital; Sichuan University; Chengdu P.R. China
| | - Cai Xiang
- Department of Urology, West China Hospital; Sichuan University; Chengdu P.R. China
| | - Liao Bang-Hua
- Department of Urology, West China Hospital; Sichuan University; Chengdu P.R. China
| | - Yang Jin
- Department of Urology; Affiliated Hospital/Clinical Medical College of Chengdu University; Chengdu P.R. China
| | - Luo De-Yi
- Department of Urology, West China Hospital; Sichuan University; Chengdu P.R. China
| | - Li Hong
- Department of Urology, West China Hospital; Sichuan University; Chengdu P.R. China
| | - Wang Kun-Jie
- Department of Urology, West China Hospital; Sichuan University; Chengdu P.R. China
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27
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Takeuchi A, Eto M, Tatsugami K, Shiota M, Yamada H, Kamiryo Y, Dejima T, Kashiwagi E, Kiyoshima K, Inokuchi J, Takahashi R, Yokomizo A, Ohara N, Yoshikai Y. Antitumor activity of recombinant Bacille Calmette-Guérin secreting interleukin-15-Ag85B fusion protein against bladder cancer. Int Immunopharmacol 2016; 35:327-331. [DOI: 10.1016/j.intimp.2016.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/21/2016] [Accepted: 03/04/2016] [Indexed: 10/21/2022]
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28
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Bahria-Sediki IB, Yousfi N, Paul C, Chebil M, Cherif M, Zermani R, El Gaaied ABA, Bettaieb A. Clinical significance of T-bet, GATA-3, and Bcl-6 transcription factor expression in bladder carcinoma. J Transl Med 2016; 14:144. [PMID: 27237631 PMCID: PMC4885121 DOI: 10.1186/s12967-016-0891-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/02/2016] [Indexed: 11/15/2022] Open
Abstract
Background The aim of this study was to investigate the clinical significance of three immune cell-related transcription factors, T-bet, GATA-3 and Bcl-6 in bladder cancer in Tunisian patients. Methods Expression of T-bet, GATA-3 and Bcl-6 genes was assessed using RT-qPCR in 65 bladder cancers from patients: 32 being diagnosed as low- and medium-grade, 31 as high-grade, 25 as muscle invasive stage and 39 as non-muscle invasive stage. Gene expression was statistically correlated according to the grade, the stage, tobacco consumption, the BCG response and disease severity. Results T-bet levels in patients with high-grade bladder cancer were significantly elevated compared to patients with low- or medium-grade bladder cancer (p = 0.005). In invasive carcinoma (T2–T4), the T-bet levels were significantly higher than in superficial non-invasive bladder tumors (Tis, Ta, and T1) (p = 0.02). However, T-bet is predictive of the response to BCG. Its expression is high in good responders to BCG (p = 0.02). In contrast, the expression of GATA-3 and Bcl-6 in non-invasive carcinoma (p = 0.008 and p = 0.0003) and in patients with low- and medium-grade cancers (p = 0.001 and p < 0.0001) is significantly higher than in invasive bladder tumors and in patients with high-grade bladder carcinoma, respectively. In addition, heavy smokers, whose tumors express low levels of GATA-3 and Bcl-6, are poor responders to BCG (p = 0.01 and p = 0.03). Finally, better patient survival correlated with GATA-3 (p = 0.04) and Bcl-6 (p = 0.04) but not T-bet expression. Conclusions Our results suggest that T-bet expression in bladder tumors could be a positive prognostic indicator of BCG therapy, even if high levels are found in high-grade and stage of the disease. However, GATA-3 and Bcl-6 expression could be considered as predictive factors for good patient survival.
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Affiliation(s)
- Islem Ben Bahria-Sediki
- Laboratoire d'Immunologie et Immunothérapie des Cancers (LIIC), EPHE, PSL Research University, 75014, Paris, France.,Université Bourgogne Franche-Comté, EA7269, 21000, Dijon, France.,Laboratoire de Génétique, Immunologie et Pathologies Humaines, Faculté de Sciences Tunis, Université de Tunis El Manar, Tunis, Tunisia
| | - Nadhir Yousfi
- Laboratoire d'Immunologie et Immunothérapie des Cancers (LIIC), EPHE, PSL Research University, 75014, Paris, France.,Université Bourgogne Franche-Comté, EA7269, 21000, Dijon, France
| | - Catherine Paul
- Laboratoire d'Immunologie et Immunothérapie des Cancers (LIIC), EPHE, PSL Research University, 75014, Paris, France.,Université Bourgogne Franche-Comté, EA7269, 21000, Dijon, France
| | | | | | | | - Amel Ben Ammar El Gaaied
- Laboratoire de Génétique, Immunologie et Pathologies Humaines, Faculté de Sciences Tunis, Université de Tunis El Manar, Tunis, Tunisia
| | - Ali Bettaieb
- Laboratoire d'Immunologie et Immunothérapie des Cancers (LIIC), EPHE, PSL Research University, 75014, Paris, France. .,Université Bourgogne Franche-Comté, EA7269, 21000, Dijon, France. .,UFR des Sciences de Santé, 7 boulevard Jeanne d'Arc, BP 87900, 21079, Dijon, France.
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29
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Shang Z, Li Y, Zhang M, Tian J, Han R, Shyr CR, Messing E, Yeh S, Niu Y, Chang C. Antiandrogen Therapy with Hydroxyflutamide or Androgen Receptor Degradation Enhancer ASC-J9 Enhances BCG Efficacy to Better Suppress Bladder Cancer Progression. Mol Cancer Ther 2015; 14:2586-94. [PMID: 26264279 DOI: 10.1158/1535-7163.mct-14-1055-t] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 08/06/2015] [Indexed: 11/16/2022]
Abstract
Recent studies suggest that the androgen receptor (AR) might play important roles in influencing bladder cancer progression, yet its clinical application remains unclear. Here, we developed a new combined therapy with Bacillus Calmette-Guérin (BCG) and the AR degradation enhancer ASC-J9 or antiandrogen hydroxyflutamide (HF) to better suppress bladder cancer progression. Mechanism dissection revealed that ASC-J9 treatment enhanced BCG efficacy to suppress bladder cancer cell proliferation via increasing the recruitment of monocytes/macrophages that involved the promotion of BCG attachment/internalization to the bladder cancer cells through increased integrin-α5β1 expression and IL6 release. Such consequences might then enhance BCG-induced bladder cancer cell death via increased TNFα release. Interestingly, we also found that ASC-J9 treatment could directly promote BCG-induced HMGB1 release to enhance the BCG cytotoxic effects for suppression of bladder cancer cell growth. In vivo approaches also concluded that ASC-J9 could enhance the efficacy of BCG to better suppress bladder cancer progression in BBN-induced bladder cancer mouse models. Together, these results suggest that the newly developed therapy combining BCG plus ASC-J9 may become a novel therapy to better suppress bladder cancer progress.
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Affiliation(s)
- Zhiqun Shang
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China. George Whipple Laboratory for Cancer Research, Departments of Pathology, Urology, Radiation Oncology, and The Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York
| | - Yanjun Li
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China
| | - Minghao Zhang
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China. Department of Urology, Tianjin Third Central Hospital, Tianjin, China
| | - Jing Tian
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China. George Whipple Laboratory for Cancer Research, Departments of Pathology, Urology, Radiation Oncology, and The Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York
| | - Ruifa Han
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China
| | - Chih-Rong Shyr
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China
| | - Edward Messing
- George Whipple Laboratory for Cancer Research, Departments of Pathology, Urology, Radiation Oncology, and The Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York
| | - Shuyuan Yeh
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China. George Whipple Laboratory for Cancer Research, Departments of Pathology, Urology, Radiation Oncology, and The Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York
| | - Yuanjie Niu
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China. George Whipple Laboratory for Cancer Research, Departments of Pathology, Urology, Radiation Oncology, and The Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York.
| | - Chawnshang Chang
- Chawnshang Chang Sex Hormone Research Center, Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University, Tianjin, China. George Whipple Laboratory for Cancer Research, Departments of Pathology, Urology, Radiation Oncology, and The Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York. Sex Hormone Research Center, China Medical University/Hospital, Taichung, Taiwan.
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30
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Abstract
It is nearly 40 years since Bacillus Calmette-Guérin (BCG) was first used as an immunotherapy to treat superficial bladder cancer. Despite its limitations, to date it has not been surpassed by any other treatment. As a better understanding of its mechanism of action and the clinical response to it have evolved, some of the questions around optimal dosing and treatment protocols have been answered. However, its potential for toxicity and failure to produce the desired clinical effect in a significant cohort of patients presents an ongoing challenge to clinicians and researchers alike. This review summarizes the evidence behind the established mechanism of action of BCG in bladder cancer, highlighting the extensive array of immune molecules that have been implicated in its action. The clinical aspects of BCG are discussed, including its role in reducing recurrence and progression, the optimal treatment regime, toxicity and, in light of new evidence, whether or not there is a superior BCG strain. The problems of toxicity and non-responders to BCG have led to development of new techniques aimed at addressing these pitfalls. The progress made in the laboratory has led to the identification of novel targets for the development of new immunotherapies. This includes the potential augmentation of BCG with various immune factors through to techniques avoiding the use of BCG altogether; for example, using interferon-activated mononuclear cells, BCG cell wall, or BCG cell wall skeleton. The potential role of gene, virus, or photodynamic therapy as an alternative to BCG is also reviewed. Recent interest in the immune check point system has led to the development of monoclonal antibodies against proteins involved in this pathway. Early findings suggest benefit in metastatic disease, although the role in superficial bladder cancer remains unclear.
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Affiliation(s)
- Oliver Fuge
- Department of Urology, Lister Hospital, Stevenage, UK
| | - Nikhil Vasdev
- Department of Urology, Lister Hospital, Stevenage, UK
| | - Paula Allchorne
- Department of Urology, Bartshealth NHS Trust, Whipps Cross Rd, London, UK
| | - James Sa Green
- Department of Urology, Bartshealth NHS Trust, Whipps Cross Rd, London, UK
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31
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Wu Y, Enting D, Rudman S, Chowdhury S. Immunotherapy for urothelial cancer: from BCG to checkpoint inhibitors and beyond. Expert Rev Anticancer Ther 2015; 15:509-23. [PMID: 25882710 DOI: 10.1586/14737140.2015.1015419] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Since its introduction almost 40 years ago, intravesical BCG for non-muscle invasive bladder cancer remains one of the most successful cancer immunotherapies. However, up to 40% of patients will progress after BCG therapy and develop invasive bladder cancer. Despite its extensive clinical use, we are only beginning to understand how BCG works. Here we review preclinical and clinical data that implicate BCG-induced Th1 and cytotoxic cellular immune responses in cancer regression. We propose that future immunotherapies should aim to augment Th1 and/or cellular responses in those that fail BCG therapy. We review clinical trials of immunotherapy in bladder cancer with a focus on the promising role of checkpoint blockade inhibitors that target the programmed cell death 1/programmed death-ligand 1 (PD-L1) axis and/or cytotoxic T lymphocyte antigen 4.
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Affiliation(s)
- Yin Wu
- Peter Gorer Department of Immunobiology, Programme of Infection and Immunity, 2nd Floor, Borough Wing, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK
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32
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Zhang GW, Qin GF, Han B, Li CX, Yang HG, Nie PH, Zeng X. Efficacy of Zhuling polyporus polysaccharide with BCG to inhibit bladder carcinoma. Carbohydr Polym 2014; 118:30-5. [PMID: 25542103 DOI: 10.1016/j.carbpol.2014.11.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 10/28/2014] [Accepted: 11/10/2014] [Indexed: 11/26/2022]
Abstract
There is growing interest in reducing Bacille Calmette-Guerin (BCG) side effects while keeping intact its therapeutic efficacy. In the present study, we evaluated the efficacy of Sclerotia of Polyporus umbellatus FRIES (Zhuling) and its main ingredient Polyporus Polysaccharide (PPS) to attenuate side effects of BCG therapy in vivo. The results show that bladder cancer development in model rats exhibited significantly reduced cancer invasiveness with Zhuling PPS combined with BCG. Flow cytometric (FCM) analysis showed expression of costimulatory molecules CD86, CD40, and TLR4/CD14 significantly increased with Zhuling PPS in combination with BCG. Similarly, immunohistochemical analysis revealed stronger CD86 and CD40 staining. Our findings show Zhuling PPS strongly reduced side effects and displayed synergistic effects during BCG instillation in rat bladder cancer models. The findings also suggest that the attenuation effect may result from direct activation of dendritic cell (DC) TLR4.
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Affiliation(s)
- Guo-Wei Zhang
- College of Chinese Medicine, Hebei University, Baoding 071002, China.
| | - Gui-Fang Qin
- College of Chinese Medicine, Hebei University, Baoding 071002, China
| | - Bo Han
- College of Chinese Medicine, Hebei University, Baoding 071002, China
| | - Cai-Xia Li
- The School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou 510006, Guangdong Province, China
| | - Hong-Gai Yang
- College of Chinese Medicine, Hebei University, Baoding 071002, China
| | - Pi-Hu Nie
- College of Chinese Medicine, Hebei University, Baoding 071002, China
| | - Xing Zeng
- Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Traditional Chinese Medicine Hospital, Guangzhou 510006, Guangdong Province, China.
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33
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Abstract
Cytokine-based immunotherapy is executed by harnessing cytokines to activate the immune system to suppress tumors. Th1-type cytokines including IL-1, IL-2, IL-12 and granulocyte-macrophage colony-stimulating factor are potent stimulators of Th1 differentiation and Th1-based antitumor response. Many preclinical studies demonstrated the antitumor effects of Th1 cytokines but their clinical efficacy is limited. Multiple factors influence the efficacy of immunotherapy for tumors. For instance immunosuppressive cells in the tumor microenvironment can produce inhibitory cytokines which suppress antitumor immune response. Most studies on cytokine immunotherapy focused on how to boost Th1 response; many studies combined cytokine-based therapy with other treatments to reverse immunosuppression in tumor microenvironment. In addition, cytokines have pleiotropic functions and some cytokines show paradoxical activities under different settings. Better understanding the physiological and pathological functions of cytokines helps clinicians to design Th1-based cancer therapy in clinical practice.
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Affiliation(s)
- Hong-Mei Xu
- Sir William Dunn School of Pathology, University of Oxford, OX1 3RE, United Kingdom.
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34
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Redelman-Sidi G, Glickman MS, Bochner BH. The mechanism of action of BCG therapy for bladder cancer--a current perspective. Nat Rev Urol 2014; 11:153-62. [PMID: 24492433 DOI: 10.1038/nrurol.2014.15] [Citation(s) in RCA: 460] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Bacillus Calmette-Guérin (BCG) has been used to treat non-muscle-invasive bladder cancer for more than 30 years. It is one of the most successful biotherapies for cancer in use. Despite long clinical experience with BCG, the mechanism of its therapeutic effect is still under investigation. Available evidence suggests that urothelial cells (including bladder cancer cells themselves) and cells of the immune system both have crucial roles in the therapeutic antitumour effect of BCG. The possible involvement of bladder cancer cells includes attachment and internalization of BCG, secretion of cytokines and chemokines, and presentation of BCG and/or cancer cell antigens to cells of the immune system. Immune system cell subsets that have potential roles in BCG therapy include CD4(+) and CD8(+) lymphocytes, natural killer cells, granulocytes, macrophages, and dendritic cells. Bladder cancer cells are killed through direct cytotoxicity by these cells, by secretion of soluble factors such as TRAIL (tumour necrosis factor-related apoptosis-inducing ligand), and, to some degree, by the direct action of BCG. Several gaps still exist in our knowledge that should be addressed in future efforts to understand this biotherapy of cancer.
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Affiliation(s)
- Gil Redelman-Sidi
- Sloan-Kettering Cancer Center, 1275 York Avenue, Box 9, New York, NY 10065, USA
| | - Michael S Glickman
- Sloan-Kettering Cancer Center, 1275 York Avenue, Box 9, New York, NY 10065, USA
| | - Bernard H Bochner
- Sloan-Kettering Cancer Center, 1275 York Avenue, Box 9, New York, NY 10065, USA
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Jallad S, Goubet S, Symes A, Larner T, Thomas P. Prognostic value of inflammation or granuloma after intravesival BCG in non-muscle-invasive bladder cancer. BJU Int 2013; 113:E22-7. [DOI: 10.1111/bju.12334] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Samer Jallad
- Urology Department; Brighton and Sussex University Hospitals; Brighton UK
| | - Stephanie Goubet
- Clinical Investigation and Research Unit; Royal Sussex County Hospital; Brighton UK
| | - Andrew Symes
- Urology Department; Brighton and Sussex University Hospitals; Brighton UK
| | - Timothy Larner
- Urology Department; Brighton and Sussex University Hospitals; Brighton UK
| | - Philip Thomas
- Urology Department; Brighton and Sussex University Hospitals; Brighton UK
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Ingersoll MA, Albert ML. From infection to immunotherapy: host immune responses to bacteria at the bladder mucosa. Mucosal Immunol 2013; 6:1041-53. [PMID: 24064671 DOI: 10.1038/mi.2013.72] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/20/2013] [Indexed: 02/04/2023]
Abstract
The pathogenesis of urinary tract infection and mechanisms of the protective effect of Bacillus Calmette-Guerin (BCG) therapy for bladder cancer highlight the importance of studying the bladder as a unique mucosal surface. Innate responses to bacteria are reviewed, and although our collective knowledge remains incomplete, we discuss how adaptive immunity may be generated following bacterial challenge in the bladder microenvironment. Interestingly, the widely held belief that the bladder is sterile has been challenged recently, indicating the need for further study of the impact of commensal microorganisms on the immune response to uropathogen infection or intentional instillation of BCG. This review addresses the aspects of bladder biology that have been well explored and defines what still must be discovered about the immunobiology of this understudied organ.
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Affiliation(s)
- M A Ingersoll
- 1] Unité d'Immunobiologie des Cellules Dendritiques, Department of Immunology, Institut Pasteur, Paris, France [2] INSERM U818, Department of Immunology, Institut Pasteur, Paris, France [3] Université Paris Descartes, Paris, France
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Antigen-specific CD4 T cells are induced after intravesical BCG-instillation therapy in patients with bladder cancer and show similar cytokine profiles as in active tuberculosis. PLoS One 2013; 8:e69892. [PMID: 24039703 PMCID: PMC3770812 DOI: 10.1371/journal.pone.0069892] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 06/13/2013] [Indexed: 11/19/2022] Open
Abstract
Specific T cell immunity in patients with active tuberculosis is associated with a decrease in multifunctionality. However, it is unknown whether cytokine profiles differ in patients with primary infection and those with prior contact. We therefore used intravesical immunotherapy with attenuated live Bacille Calmette–Guérin (BCG) in patients with urothelial carcinoma as a model to characterise the induction of systemic immunity towards purified protein derivate (PPD) and to study whether cytokine profiles differ depending on pre-existing immunity. Eighteen patients with non-muscle invasive bladder cancer were recruited during the BCG-induction course. Fifty-four healthy individuals served as controls. Interferon (IFN)-γ and interleukin (IL)-2 producing PPD-specific CD4 T cells were analysed longitudinally before each instillation using a rapid flow-cytometric whole blood immunoassay. Baseline levels of IFN-γ producing PPD-specific T cells were comparable to controls. T cells showed a 5-fold increase to 0.23% by week 2/3, and further increased 8-fold by week 4/5 (to 0.42%, p=0.0007). Systemic immunity was induced in all patients, although the increase was less pronounced in patients with pre-existing immunity. As in active TB, cytokine profiling during therapy revealed a lower percentage of multifunctional IFN-γ/IL-2 double-positive T cells compared to controls (60.2% vs. 71.9%, p=0.0003). Of note, when comparing patients with and without pre-existing immunity, cytokine profiles in patients with primary immunity were shifted towards IL-2 single producing T cells (p=0.02), whereas those in patients with pre-existing immunity were shifted towards IFN-γ single-positivity (p=0.01). In conclusion, systemic T cell responses were induced after BCG-therapy, and their kinetics and cytokine profile depended on pre-existing immunity. Decreased functionality is a typical feature of specific immunity in both patients with active tuberculosis and BCG-therapy. Among patients with active infection, a shift towards IL-2 or IFN-γ single-positive cells may allow distinction between patients with primary infection and cases with boosted immunity after prior contact, respectively.
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Systemic BCG-Osis as a Rare Side Effect of Intravesical BCG Treatment for Superficial Bladder Cancer. Case Rep Urol 2013; 2013:821526. [PMID: 23844314 PMCID: PMC3703374 DOI: 10.1155/2013/821526] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 06/04/2013] [Indexed: 11/17/2022] Open
Abstract
Intravesical Bacilli Calmette-Guérin (BCG) immunotherapy is a commonly used treatment for superficial bladder cancer. Although the treatment is well tolerated in 95% of cases, life-threatening side effects including BCG sepsis can occur. This report describes the case of an 82-year-old man with a background of lung disease. He developed septic shock and type two respiratory failure after receiving the sixth installation of intravesical BCG (TICE strain) immunotherapy for recurrent bladder Transitional Cell Carcinoma in situ. Despite the early initiation of broad spectrum antibiotics (tazocin and gentamicin), he remained pyrexial. There was a rapid deterioration, and on the second day of his admission, he developed type two respiratory failure secondary to Acute Respiratory Distress Syndrome (ARDS) prompting transfer to Intensive Care for Bilevel Positive Airway Pressure (BiPAP) Ventilation. The blood cultures taken before the induction of antibiotics results were negative. Increasing clinical suspicion of systemic BCG-osis prompted the initiation of antituberculosis therapy (ethambutol, isoniazid rifampicin) and steroids. Following six days of BiPAP and anti-tuberculosis therapy in ITU, his condition started to improve. Following a prolonged hospital stay he was discharged on long term ethambutol therapy. BCG-osis is a well-known though rare side effect of intravesical BCG therapy. We would like to highlight the importance of having a low threshold for starting anti-TB treatment.
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Gandhi NM, Morales A, Lamm DL. Bacillus Calmette-Guérin immunotherapy for genitourinary cancer. BJU Int 2013; 112:288-97. [DOI: 10.1111/j.1464-410x.2012.11754.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Nilay M. Gandhi
- James Buchanan Brady Urological Institute; Johns Hopkins Medical Institutions; Baltimore; MD; USA
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Brincks EL, Risk MC, Griffith TS. PMN and anti-tumor immunity--the case of bladder cancer immunotherapy. Semin Cancer Biol 2013; 23:183-9. [PMID: 23410637 DOI: 10.1016/j.semcancer.2013.02.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 01/21/2013] [Accepted: 02/01/2013] [Indexed: 12/01/2022]
Abstract
Urothelial carcinoma of the bladder accounts for ∼5% of all cancer deaths in humans. The majority of bladder tumors are non-muscle invasive at diagnosis, and there is a high rate of tumor recurrence and progression even after local surgical therapy. Thus, many patients require lifelong follow-up examinations that include additional prophylactic treatments in the event of recurrence. Since its first use in 1976, Mycobacterium bovis bacillus Calmette-Guerin (BCG) has been the treatment of choice for non-muscle invasive bladder cancer. Despite nearly 40 years of clinical use, the mechanism(s) by which intravesical administration of BCG results in elimination of bladder tumors remains undefined. Granulocytes (polymorphonuclear neutrophils (PMN)) are the predominant immune cell (in number) that enters the bladder after BCG installation, and a number of studies have highlighted the importance of PMN in the antitumor activity of BCG. Studies from our laboratory demonstrated presence of intracellular stores of the apoptosis-inducing protein TNF-related apoptosis-inducing ligand (TRAIL) in PMN that are rapidly released after interaction with BCG cell wall components, along with a correlation between increased urinary levels of TRAIL and BCG responsiveness. Mature PMN in circulation are terminally differentiated cells with limited biosynthetic capacity, so the proteins located in the distinct PMN granule populations are compartmentalized concomitant with their synthesis during myelopoiesis. Thus, understanding PMN production, localization, and release of TRAIL is important in the design of future BCG-based bladder tumor immunotherapy protocols.
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Affiliation(s)
- Erik L Brincks
- Department of Urology, University of Minnesota, Minneapolis, MN 55455, United States
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Mundinger GS, Douglas KC, Higgins JP. Acute mycobacterial flexor tenosynovitis following accidental bacillus calmette-guérin inoculation in a health care worker: case report. J Hand Surg Am 2013; 38:362-5. [PMID: 23294648 DOI: 10.1016/j.jhsa.2012.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 11/08/2012] [Accepted: 11/08/2012] [Indexed: 02/02/2023]
Abstract
Solutions containing bacillus Calmette-Guérin (BCG), a live attenuated form of Mycobacterium bovis or Mycobacterium tuberculosis, commonly are injected intravesically to treat tumors of the urinary bladder. We report a case of acute mycobacterial flexor tenosynovitis in a health care worker who inadvertently inoculated her finger via needlestick while preparing BCG solution for intravesicular administration. She was treated successfully with immediate operative intervention followed by 6 months of antimycobacterial antibiotics. Of 3 previous reports of hand infections following self-inoculation with BCG solutions, this case is unique owing to rapid onset of acute mycobacterial flexor tenosynovitis and positive intraoperative mycobacterial cultures. Needlesticks with BCG-containing solutions, especially into the flexor tendon sheath, should be treated with timely surgical debridement and appropriate antimycobacterial management.
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Affiliation(s)
- Gerhard S Mundinger
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland 21218, USA
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Kawai K, Miyazaki J, Joraku A, Nishiyama H, Akaza H. Bacillus Calmette-Guerin (BCG) immunotherapy for bladder cancer: current understanding and perspectives on engineered BCG vaccine. Cancer Sci 2013. [PMID: 23181987 DOI: 10.1111/cas.12075] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Since the first report in 1976, accumulated clinical evidence has supported intravesical Bacillus Calmette-Guerin (BCG) therapy as one of the standard methods of management of intermediate- and high-risk non-muscle invasive bladder cancer. Despite its efficacy, intravesical BCG therapy is associated with a variety of adverse events (AEs), most of which are tolerable or controllable with supportive care. However, some patients receiving intravesical BCG therapy may experience uncommon but severe AEs, leading to cessation of BCG therapy. Not all, but most severe AEs result from either local or systemic infection with live BCG. Intravesical instillation of BCG elicits multiple immune reactions, although the precise immunological mechanism of BCG therapy is not clear. It is convenient to separate the complex reactions into the following three categories: infection of urothelial cells or bladder cancer cells, induction of immune reactions, and induction of antitumor effects. Recently, our knowledge about each category has increased. Based on this understanding, predictors of the efficacy of intravesical BCG therapy, such as urinary cytokine measurement and cytokine gene polymorphism, have been investigated. Recently, preclinical studies using a novel engineered mycobacterium vaccine have been conducted to overcome the limitations of BCG therapy. One approach is Th1 cytokine-expressing recombinant forms of BCG; another approach is development of non-live bacterial agents to avoid AEs due to live BCG infection. We also briefly describe our approach using an octaarginine-modified liposome-incorporating BCG cell wall component to develop future substitutes for live BCG.
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Affiliation(s)
- Koji Kawai
- Department of Urology, Faculty of Medicine, University of Tsukuba, Tokyo, Japan.
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Can C, Baseskioglu B, Yılmaz M, Colak E, Ozen A, Yenilmez A. Pretreatment parameters obtained from peripheral blood sample predicts invasiveness of bladder carcinoma. Urol Int 2012; 89:468-72. [PMID: 23128367 DOI: 10.1159/000343278] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 08/31/2012] [Indexed: 01/30/2023]
Abstract
PURPOSE To predict the invasiveness of urothelial bladder carcinoma using a logistic regression model on preoperative peripheral blood samples. PATIENTS AND METHODS Hospital data of patients operated for urothelial carcinoma were reviewed retrospectively. Preoperative blood samples were collected before the first cystoscopic examination. Any kind of infection or inflammation was an exclusion criterion. Patients were grouped as having a non-muscle-invasive or muscle-invasive urothelial carcinoma. The mean age was 69 years and was determined as the cut-off value. According to receiver operating characteristic curves, threshold points were determined for lymphocytes, neutrophil count, neutrophil-to-lymphocyte ratio (NLR), thrombocytes and mean platelet volume. Demographic specialties, parameters obtained from blood samples, tumor size and multiplicity were evaluated and significant parameters were put into a logistic regression model. RESULTS The study group consisted of 80 non-muscle-invasive and 102 muscle-invasive patients. Age (≤69 vs. >69), female gender, NLR (2.57), mean platelet volume (7.9/fl) and platelet count (400,000/µl) were significant parameters and put in a model. Using odds ratios, the probability of tumor invasiveness was calculated by a formula. CONCLUSION Age, female gender, NLR and platelet count were found to be the predictors of invasiveness of urothelial carcinoma.
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Affiliation(s)
- C Can
- Department of Urology, Osmangazi University Faculty of Medicine, Eskişehir, Turkey
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[Acute arthritis secondary to intravesical bacillus Calmette-Guérin for bladder cancer]. Actas Urol Esp 2012; 36:461-6. [PMID: 22824081 DOI: 10.1016/j.acuro.2012.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 02/04/2012] [Indexed: 12/21/2022]
Abstract
INTRODUCTION We sought to identify the prevalence, presentation, treatment, and prognosis of acute arthritis secondary to intravesical bacilli Calmette-Guérin (BCG) therapy for bladder cancer. METHODS We performed a structured, systematic review of the English language literature pertaining to BCG and reactive arthritis among bladder cancer patients. We extracted data pertaining to prevalence, presentation, management, and prognosis. RESULTS We extracted 23 individual case reports and 4 review articles. Thirty-nine patients -31 (80%) male and 8 (20%) female- were described in these publications; we also identified 1 patient from our institution. Although prevalence estimates of reactive arthritis range from 0.5 to 1.0% of all bladder cancer patients receiving BCG, the true prevalence remains unclear. Polyarthritis (68%) and fever (58%) were the most common presenting symptoms. Among patients presenting with joint pain, the knees (41%), ankles (26%), and wrists (19%) were most often affected. The most common time of presentation was immediately following the 4th instillation of a 6-week induction course (25%). Initial therapy in 100% of patients was discontinuation of BCG. Other therapies included nonsteroidal anti-inflammatory drugs (NSAIDs) (25%); steroids (8%); anti-tubercular medications (8%); and combined NSAIDs, steroids, and anti-tubercular medications (20%). CONCLUSIONS Reactive arthritis is an infrequent but potentially severe complication of intravesical BCG for bladder cancer that typically presents with polyarthritis and fever during induction. The most common treatments include immediate discontinuation of BCG and systemic anti-inflammatory therapy. Further studies are needed to determine prevalence, pathophysiology, and long-term prognosis.
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Biot C, Rentsch CA, Gsponer JR, Birkhauser FD, Jusforgues-Saklani H, Lemaitre F, Auriau C, Bachmann A, Bousso P, Demangel C, Peduto L, Thalmann GN, Albert ML. Preexisting BCG-Specific T Cells Improve Intravesical Immunotherapy for Bladder Cancer. Sci Transl Med 2012; 4:137ra72. [DOI: 10.1126/scitranslmed.3003586] [Citation(s) in RCA: 181] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Th1 cytokine-secreting recombinant Mycobacterium bovis bacillus Calmette-Guérin and prospective use in immunotherapy of bladder cancer. Clin Dev Immunol 2011; 2011:728930. [PMID: 21941579 PMCID: PMC3173967 DOI: 10.1155/2011/728930] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 07/17/2011] [Indexed: 12/03/2022]
Abstract
Intravesical instillation of Mycobacterium bovis bacillus Calmette-Guérin (BCG) has been used for treating bladder cancer for 3 decades. However, BCG therapy is ineffective in approximately 30–40% of cases. Since evidence supports the T helper type 1 (Th1) response to be essential in BCG-induced tumor destruction, studies have focused on enhancing BCG induction of Th1 immune responses. Although BCG in combination with Th1 cytokines (e.g., interferon-α) has demonstrated improved efficacy, combination therapy requires multiple applications and a large quantity of cytokines. On the other hand, genetic manipulation of BCG to secrete Th1 cytokines continues to be pursued with considerable interest. To date, a number of recombinant BCG (rBCG) strains capable of secreting functional Th1 cytokines have been developed and demonstrated to be superior to BCG. This paper discusses current rBCG research, concerns, and future directions with an intention to inspire the development of this very promising immunotherapeutic modality for bladder cancer.
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Kitamura H, Tsukamoto T. Immunotherapy for urothelial carcinoma: current status and perspectives. Cancers (Basel) 2011; 3:3055-72. [PMID: 24212945 PMCID: PMC3759186 DOI: 10.3390/cancers3033055] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 07/22/2011] [Accepted: 07/26/2011] [Indexed: 12/14/2022] Open
Abstract
Intravesical instillation of bacillus Calmette Guérin (BCG) for the treatment of urothelial carcinoma (UC) of the bladder is based on the BCG-induced immune response, which eradicates and prevents bladder cancer. The results of recent studies have suggested that not only major histocompatibility complex (MHC)-nonrestricted immune cells such as natural killer cells, macrophages, neutrophils, etc., but also MHC-restricted CD8+ T cells play an important role and are one of the main effectors in this therapy. Better understanding of the mechanism of BCG immunotherapy supports the idea that active immunotherapy through its augmented T cell response can have great potential for the treatment of advanced UC. In this review, progress in immunotherapy for UC is discussed based on data from basic, translational and clinical studies. We also review the escape mechanism of cancer cells from the immune system, and down-regulation of MHC class I molecules.
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Affiliation(s)
- Hiroshi Kitamura
- Department of Urology, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo 060-8543, Japan.
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Lamm D, Persad R, Colombel M, Brausi M. Maintenance Bacillus Calmette-Guérin: The Standard of Care for the Prophylaxis and Management of Intermediate- and High-Risk Non–Muscle-Invasive Bladder Cancer. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.eursup.2010.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Uppal GS, Shah AN, Tossounis CM, Tappin MJ. Bilateral panuveitis following intravesical BCG immunotherapy for bladder carcinoma. Ocul Immunol Inflamm 2010; 18:292-6. [PMID: 20662661 DOI: 10.3109/09273948.2010.486099] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To report a case of bilateral panuveitis following local treatment with Bacille Calmette-Guérin (BCG) immunotherapy for superficial bladder carcinoma. DESIGN Case report and literature review. METHODS A 70-year-old female presented with severe bilateral anterior chamber inflammation 5 days after intravesical BCG instillation. Despite topical steroids and mydriatics, inflammation worsened and bilateral optic nerve swelling developed. RESULTS Oral corticosteroids settled the ocular inflammation, and optic nerve function recovered. A trial of steroid cessation caused rebound uveitis, so she remains on maintenance doses of oral corticosteroid. CONCLUSIONS Ocular inflammations following BCG therapy for bladder cancer are rare, and little is known about the management of such cases. This is the first report of bilateral panuveitis with optic nerve edema following such treatment.
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Preclinical evaluation of a gene therapy treatment for transitional cell carcinoma. Cancer Gene Ther 2010; 18:34-41. [PMID: 20847752 DOI: 10.1038/cgt.2010.50] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Three drugs were compared for their efficacy in treating murine transitional cell carcinoma (TCC) of the bladder. Intravesical gene therapy treatments utilizing expression-targeted plasmids, where the murine cyclooxygenase-2 (Cox-2) promoter was used to drive the expression of exogenously inducible forms of caspases 3 and 9, were compared with treatment modalities employing Bacille Calmette-Guérin (BCG) and celecoxib. When administered via lavage, only the gene therapy regimen was found to be effective at restricting tumor progression following a 7-day incubation of tumor tissues. Celecoxib was also administered via the diet to allow for systemic delivery of the drug. The most efficacious celecoxib use tested yielded tumors with masses of (18.3±8.4 mg) versus the gene delivery method, which yielded tumors with masses of (3.6±7.7 mg). The difference was significant (t-test, n≥4, P<0.025). The results showed that the Cox-2 expression-targeted gene therapy system could efficiently bypass the bladder permeability barrier and more effectively inhibit tumor growth and development than either BCG or celecoxib treatments. Long-term data further demonstrated that the gene therapy system could effectively inhibit tumor growth and elongate life expectancy.
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