Long-term mitomycin C instillation after transurethral resection of superficial bladder carcinoma: influence on recurrence, progression and survival

Comparison of intravesical adjuvant therapy in bladder cancer with two different maintenance regimens of mitomycin and BCG

OBJECTIVE

To compare recurrence rate and side effects with two different maintenance regimens of postoperative intravesical therapy with mitomycin and BCG in T1 bladder cancer.

METHODS

Eighty were enrolled in this study and all received immediate post operative mitomycin. They were then allocated to two groups of 40, one group receiving intravesicle BCG and other a combination BCG and Mitomycin. They were followed up to a period of 2 years.

RESULT

Two year recurrence rate after transurethral resection of bladder tumour with high grade T1 disease in the Combination group is low (20%) as compared to the BCG group (37.5%).

CONCLUSION

Two year recurrences reduced with use of intravesical Mitomycin during maintenance in the combination group which though not statistically significant favours the trial with combination therapy in future studies. Side effect profile did not worsen with combination of Mitomycin and BCG.

A multi-institutional retrospective study of hyperthermic plus intravesical chemotherapy versus intravesical chemotherapy treatment alone in intermediate and high risk nonmuscle-invasive bladder cancer

Objective:

To compare the efficacy and safety of hyperthermic intravesical chemotherapy (HIVEC) and intravesical chemotherapy (IVEC) in patients with intermediate and high risk nonmuscle-invasive bladder cancer (NMIBC) after transurethral resection.

Methods:

We included 560 patients diagnosed with primary or recurrent NMIBC between April 2009 and December 2015 at 1 of 6 tertiary centers. We matched 364 intermediate or high risk cases and divided them into 2 groups: the HIVEC+IVEC group [chemohyperthermia (CHT) composed of 3 consecutive sessions followed by intravesical instillation without hyperthermia] and the IVEC group (intravesical instillation without hyperthermia). The data were recorded in the database. The primary endpoint was 2-year recurrence-free survival (RFS) in all NMIBC patients (n = 364), whereas the secondary endpoints were the assessment of radical cystectomy (RC) and 5-year overall survival (OS).

Results:

There was a significant difference in the 2-year RFS between the two groups in all patients (n = 364; HIVEC+IVEC: 82.42% vs. IVEC: 74.18%, P = 0.038). Compared with the IVEC group, the HIVEC+IVEC group had a lower incidence of RC (P = 0.0274). However, the 5-year OS was the same between the 2 groups (P = 0.1434). Adverse events (AEs) occurred in 32.7% of all patients, but none of the events was serious (grades 3–4). No difference in the incidence or severity of AEs between each treatment modality was observed.

Conclusions:

This retrospective study showed that HIVEC+IVEC had a higher 2-year RFS and a lower incidence of RC than IVEC therapy in intermediate and high risk NMIBC patients. Both treatments were well-tolerated in a similar manner.

Investigational therapies for non-muscle invasive bladder cancer

IMPORTANCE OF THE FIELD

Bacillus Calmette-Guérin (BCG) is currently the most effective adjuvant intravesical agent at preventing disease recurrence and the only therapy shown to inhibit disease progression in non-muscle invasive bladder cancer (NMIBC). However, recurrence rates as high as 30% and significant local/systemic toxicity have resulted in an increased interest in the use of alternative intravesical agents.

AREAS COVERED IN THE REVIEW

Our aim is to discuss recent clinical trial evidence utilizing novel intravesical agents for treatment of NMIBC. A systematic literature review was performed via the National Center for Biotechnology Information databases to identify pertinent studies from 2000-2009.

WHAT THE READER WILL GAIN

A durable response has been demonstrated with alternative agents in patients refractory to or intolerant of BCG. This review compares the merits and shortcomings of these emerging agents, focusing on clinical trial safety and efficacy results.

TAKE HOME MESSAGE

Despite recent enthusiasm for novel agents, radical cystectomy remains the treatment of choice for patients with NMIBC who have failed intravesical therapy. However, evidence is accumulating that novel agents provide an efficacious alternative in patients refractory or intolerable to BCG or unfit for cystectomy. Further randomized prospective data are required to demonstrate a recurrence- and progression-free benefit compared with BCG.

CD10 expression in urothelial carcinoma of the bladder

Background

CD10 antigen is a 100-kDa-cell surface zinc metalloendopeptidase and it is expressed in a variety of normal and neoplastic lymphoid and nonlymphoid tissues. The aim of this study was to evaluate CD10 expression in urothelial carcinoma of the urinary bladder and to determine the correlation between immunohistochemical (IHC) CD10 expression and histopathologic parameters including grade and stage.

Methods

371 cases of urothelial bladder carcinomas, all from transurethral resections, were included in this study. Hematoxylin-eosin (HE) stained sections from each case were reevaluated histopathologically according to WHO 2004 grading system. The TNM system was used for pathologic staging. Selected slides were also studied by IHC and a semiquantitative scoring for CD10 expression based on the percentage of positive cells was performed.

Results

157 cases (42.3%) showed immunostaining while 214 cases (57.7%) were negative for CD10. 1+ staining was seen in 65 CD10 positive cases (41.4%), and 2+ in 92 cases (58.6%). Overall CD10 expression as well as 2+ immunostaining was significantly correlated with high histologic grade. Overall CD10 expression was also significantly higher in invasive pT1 and pT2-3 tumors compared to noninvasive pTa tumors. pT1 and pT2-3 tumors were also significantly correlated with 2+ immunostaining.

Conclusion

To date, only a few comparative IHC studies have assessed CD10 expression in urothelial carcinoma of the urinary bladder and this study represents the largest series. Our findings indicate that CD10 expression is strongly correlated with high tumor grade and stage in urothelial carcinoma of the bladder, and that CD10 may be associated with tumor progression in bladder cancer pathogenesis.

Transient Receptor Potential Vanilloid Type 1 (TRPV1) Expression Changes from Normal Urothelium to Transitional Cell Carcinoma of Human Bladder

OBJECTIVE

To investigate possible changes in the expression of the transient receptor potential vanilloid type 1 (TRPV1) from normal urothelium to transitional cell carcinoma (TCC) of human bladder.

METHODS

Specimens from normal bladder (n=13, mean age 62 yrs), superficial TCC (n=16, mean age 62,4 yrs) and muscle invasive bladder cancer (n=12, mean age 67 yrs), were obtained by multiple cold cup and full-thickness biopsy during open surgery. All the specimens were processed for H&E staining, immunohistochemistry and Western Blot analysis.

RESULTS

In controls, the urothelium showed a labelling whose intensity was higher in the superficial cells than in the basal and club-shaped ones. In the superficial TCC, the urothelium showed a reduced labelling intensity. In the muscle invasive TCC, a very light labelling was occasionally detected in scattered superficial cells and no labelling was present in the basal cells and in those that had invaded the muscle. In controls, Western Blot analysis recognized two thick, intensely stained bands, with a molecular weight of approximately 100 and 95 kDa. In all superficial TCC there were two bands similar to control ones and in the muscle invasive two very thin, lightly stained bands. No band was detected in the patients staged as pT4.

CONCLUSION

These data demonstrated a progressive loss of TRPV1 expression in the urothelium as TCC stage increased and cell differentiation was lower. Future studies will establish the importance of this loss for TCC differentiation and progression.

Comparison of 30 mg and 40 mg of mitomycin C intravesical instillation in Korean superficial bladder cancer patients: prospective, randomized study

PURPOSE

A prospective study was performed to compare the efficacy and safety of intravesical mitomycin C (MMC) instillation for the prophylaxis of bladder cancer at different concentrations (30 mg or 40 mg).

MATERIALS AND METHODS

Ninety-seven patients that received complete transurethral resection for superficial bladder cancer were divided into two-randomized groups. One group (n=53) received 30 mg and the other group (n=44) received 40 mg dose of MMC weekly for 8 weeks, which was followed monthly for 10 months as maintenance therapy. The recurrence rates and side effects in both groups were recorded. The mean follow-up period was 32.4 months in the 30 mg group, and 32.0 months in the 40 mg group.

RESULTS

The overall one and two year recurrence rates were 19% and 24% in the 30 mg group, and 12% and 22% in the 40 mg group, which was not significantly different (p>0.05). Most of the side effects were mild and transient. Moreover, the rates of the individual side effects were not statistically different in the two groups.

CONCLUSION

Our comparison of 30 mg and 40 mg intravesical MMC instillation showed no difference in either response or side effects. Thus, we tentatively conclude that we can use 30 mg instead of 40 mg as an intravesical MMC instillation dose.

Intravesical Mitomycin for Superficial Bladder Carcinoma

The increasing complexity of cancer chemotherapy makes it mandatory that pharmacists be familiar with these highly toxic agents. This column focuses on the commercially available and investigational agents used to treat malignant diseases and reviews issues related to the preparation, dispensing, and administration of cancer chemotherapy.

Phase II Study to Investigate the Ablative Efficacy of Intravesical Administration of Gemcitabine in Intermediate-Risk Superficial Bladder Cancer (SBC)

OBJECTIVE

Phase I studies have so far demonstrated that intravesical Gemcitabine up to a 40 mg/ml concentration is well tolerated and has a substantial ablative activity on high-risk BCG refractory SBC. New treatment options are needed for intermediate-risk SBC recurring after conventional intravesical treatments. The purpose of the present study was to investigate the ablative efficacy of intravesical Gemcitabine on intermediate-risk SBC.

METHODS

The study was designed as a two-stage phase II trial, with a sample size of 39 patients. The efficacy of intravesical Gemcitabine at a concentration of 40 mg/ml (2000 mg in 50 ml saline solution) administered weekly for 6 weeks was assessed on a single marker tumour left in the bladder after a complete TUR of all other lesions. Patients underwent TUR or biopsy at the site of the marker lesion 2 weeks after completion of the treatment.

RESULTS

Complete response was observed in 22 out of 39 patients (56%). No progression was observed among the 17 non-responders. Neither systemic nor local side effects generally exceeded grade I toxicity.

CONCLUSION

The ablative effect of Gemcitabine produced a higher number of responses than the minimum required by the protocol to indicate a significant probability of drug efficacy. It is worth testing the drug in phase III trials to assess for durability of response.

Multicentric study comparing intravesical chemotherapy alone and with local microwave hyperthermia for prophylaxis of recurrence of superficial transitional cell carcinoma

PURPOSE

To compare the efficacy and local toxicity of the intravesical instillation of a cytostatic drug versus the same cytostatic agent in combination with local hyperthermia as an adjuvant treatment, after complete transurethral resection (TURB) of superficial transitional cell carcinoma (TCC) of the bladder.

PATIENTS AND METHODS

The study was designed as a prospective, multicentric, randomized trial. Eighty-three patients suffering from primary or recurrent superficial (Ta-T1) TCC of the bladder, after a complete TURB, were randomly assigned to receive intravesical instillations of mitomycin C (MMC) alone, for 41 patients, and MMC in combination with local microwave-induced hyperthermia, for 42 patients. For the combined approach, a new system, Synergo101-1 (Medical Enterprises, Amsterdam, the Netherlands) was used. The effectiveness evaluation end points of the study were evaluation of recurrence-free survival and the estimated probability of recurrence. The safety evaluation end points included subjective and objective side effects and clinical complications. For the efficacy end point, Kaplan-Meier analysis was employed, with the log-rank test for significance. Minimum follow-up time was 24 months.

RESULTS

Of the 83 randomly assigned patients, 75 completed the study according to the protocol and had valid cystoscopy results. Survival analysis of the 75 assessable patients demonstrated a highly significant difference in the survival curves in favor of thermochemotherapy. Subjective intolerance and clinical complications were significantly higher but transient and moderate in the combined treatment group.

CONCLUSION

In our series, endovesical thermochemotherapy appears to be more effective than standard endovesical chemotherapy as an adjuvant treatment for superficial bladder tumors at 24-month follow-up, despite an increased but acceptable local toxicity.

Combination of intravesical chemotherapy and hyperthermia for the treatment of superficial bladder cancer: preliminary clinical experience

The prevalence of superficial transitional cell carcinoma of the bladder (STCCB) is still increasing in spite of improved adjuvant chemotherapeutic and/or immunoprophylaxis approaches. Thus, there is certainly an urgent need to improve our ability to control this disease. Local hyperthermia has a therapeutical potential for the treatment of many solid tumors, especially when used in combination with other treatments, such as radiation and chemotherapy. In particular, a synergistic or, at least, supra-additive anti-tumor cell killing effect was documented when local hyperthermia was administered in combination with selected cytostatic drugs. Recently, advances in miniaturized technology have allowed the development of a system specifically designed for delivering an endovesical thermo-chemotherapy regimen in humans. In preliminary clinical experiences, insofar mainly carried out as mono-institutional investigations, the combined treatment using this system was demonstrated to be feasible, minimally invasive and safe when performed on out-patient basis. Moreover, the anti-tumoral efficacy seemed to be significantly enhanced when compared with that obtained using intravesical chemotherapy alone for both adjuvant (prophylaxis) and neo-adjuvant (ablative) approaches to superficial bladder cancer.

Design and evaluation of a mucoadhesive therapeutic agent delivery system for postoperative chemotherapy in superficial bladder cancer

The most common treatment method is known as the transurethral resection (TUR) for the therapy of bladder cancer. Unfortunately, because of the recurrency of the tumoral tissues after TUR the chemotherapy or immunotherapy should be performed. In these kind of therapies the pharmacotherapeutics are infused intravesically into the bladder after TUR periodically (i.e. upto 6--36 weeks, each week). But these therapies are having very big problems (i.e. disturbancy to patients, adjustment of the suitable dosage, loss of active agents without using etc.). An alternative approach can be proposed as to design a pharmacotherapeutic agent delivery system, which will supply the suitable dosage of the agent for a certain time period to solve those problems. In this study; the pharmacotherapeutic agent (i.e. Mytomycin-C) delivery system was prepared by using a mucoadhesive polymer (i.e. chitosan) in the form of cylindirical geometry to facilitate the insertion of the carrier for in vivo studies. The chitosan carriers were prepared by cross-linking during the solvent evaporation technique. In the preparation of the chitosan carriers the chitosan polymers with different molecular weights, different amounts of cross-linker (i.e. glutaraldehyde) and different amounts of pharmacotherapeutic agent were used to obtain desired attachment onto the bladder wall and optimum release rate of the agent. On the other hand because of the gelous structure of the chitosan, the swelling behaviour of the polymer was evaluated by gravimetric determinations in aqueous media periodically.

Office evaluation and management of bladder neoplasms

Transitional cell carcinoma is the predominant bladder neoplasm. These tumors are heterogeneous, and the risk of recurrence and progression should guide further management. When this approach is used, patients at lower risk avoid the morbidity and expense of unnecessary interventions and tests, whereas higher-risk patients are treated more aggressively. Cystoscopy and IVP remain the standard initial evaluation for patients suspected of having a bladder neoplasm. Intravesical chemotherapy and immunotherapy can be administered safely in the office to reduce disease recurrence when appropriate. The advent of lasers has permitted fulgaration of low-grade neoplasms in the office with local anesthesia. Surveillance of patients with superficial disease is still largely dependent on office-based cystoscopy. Tumor markers for the identification of recurrent disease are being investigated and may prove useful to reduce the number of negative cystoscopic evaluations performed for surveillance. Patients postcystectomy are followed up with attention to detection of recurrent disease in remnant urothelium, metastatic disease, and metabolic and nutritional disturbances, which may result from urinary diversion.

Intravesical electromotive administration of drugs for treatment of superficial bladder cancer: a comparative Phase II study

OBJECTIVES

To evaluate the efficacy of electromotive administration (EMDA) of intravesical mitomycin-C (MMC) in patients with superficial bladder tumors and to evaluate the toxicity of the treatment.

METHODS

Thirteen patients with multifocal Stages Ta-T1 and G1-G2 transitional cell carcinoma (TCC) of the bladder, primary or recurrent (group A), received MMC 40 mg (retained in the bladder for 2 hours) once a week for 8 weeks. Fifteen patients with the same characteristics (group B) were treated with EMDA/MMC at a current of 15 mA for 20 minutes once a week for 8 weeks. All lesions in the bladder except one (marker) were resected in each patient.

RESULTS

In group A, 5 of 12 patients (41.6%) demonstrated complete macroscopic and histologic disappearance of the marker lesion (complete response [CR]). In group B, 6 of 15 patients (40%) had a similar CR. Recurrence rate in responders was 60% in group A versus 33% in group B after 7.6 and 6 months, respectively. Disease-free interval was 14.5 months in the EMDA/MMC group compared to 10.5 months in the MMC group. Side effects were few.

CONCLUSIONS

In intermediate risk patients with TCC of the bladder, EMDA/MMC was not superior to MMC alone with a CR rate of 41% versus 41.6%. In responders, a lower recurrence rate and a longer disease-free interval were observed in the EMDA/MMC group.

Intravesical immunoprophylaxis in recurrent superficial bladder cancer (Stage T1): multicenter trial comparing bacille Calmette-Guérin and interferon-alpha

OBJECTIVES

To estimate and compare recurrence rates, index of recurrence, and disease-free interval in patients with superficial recurrent bladder cancer receiving bacille Calmette-Guérin (BCG) or interferon (IFN) for immunoprophylaxis.

METHODS

One hundred twenty-two patients with recurrent superficial Stage pT1, grade 1 to 3 tumors were enrolled in a randomized, prospective, multicenter trial with two treatment arms of endovesical immunoprophylaxis: 150 mg of BCG versus 54 MU of recombinant IFN-alpha-2a. Administration was weekly during the first month, biweekly for 2 months, and monthly for 9 months. Both groups were similar with regard to tumor stage, grade, size, and number.

RESULTS

Sixty-one patients were evaluable in the BCG group and 49 in the IFN group. Tumors recurred in 34 (69.4%) of 49 patients in the IFN group (890 months of follow-up) and in 24 (39.3%) of 61 in the BCG group (1272 months of follow-up). The total number of recurrences (28 for BCG, 47 for IFN), disease-free interval (mean 19.3 months for BCG, 15.3 months for IFN), and index of recurrence (2.2 for BCG, 5.5 for IFN) were statistically significant (P = 0.001) in favor of BCG. Progression to invasive carcinoma was similar in both study arms. Neither systemic nor local side effects were seen in the IFN group. However, the previously reported toxicity of BCG was confirmed.

CONCLUSIONS

According to our trial, BCG remains the most efficacious agent for immunoprophylaxis of recurrent superficial bladder tumors.

Bladder wall fibrosis following intravesical mitomycin treatment for superficial bladder cancer

Mitomycin is used extensively for the prevention of recurrence of superficial bladder cancer. Most treatment regimens of mitomycin are long term, since this seems more effective in preventing recurrence. During treatment some patients develop cystitis of variable severity, which may lead to mucosal ulcerations and cessation of treatment. We report a case in which long-term treatment with mitomycin, following a single episode of transitional cell bladder cancer, has led to bladder fibrosis and loss of its function, without evidence of tumor recurrence.

Long-term monitoring of 486P 3/12 antigen pattern (quantitative immunocytology) before, during, and after mitomycin C prophylaxis in patients with superficial bladder cancer

OBJECTIVES

Quantitative pattern of 486p 3/12 antigenicity in urine cytologies (Quic) of patients with superficial bladder carcinoma during operation and chemoprophylaxis was evaluated to determine the duration of prophylaxis on an individual patient-oriented basis.

METHODS

Thirty-six patients with superficial bladder carcinoma during chemoprophylaxis (43 [range, 3 to 90] weeks of mitomycin C) have been evaluated monthly for 99 (range, 36 to 141) weeks.

RESULTS

Only 6 of 36 patients (16.7%) had tumor recurrence after mean follow-up of 67.5 weeks. During mitomycin instillations, only 5 patients converted from positive to repeated negative Quic. None of them developed tumor. Thirty-one did not convert and only 6 of them developed recurrent tumor.

CONCLUSIONS

Quic seems not to be a reliable marker during mitomycin prophylaxis. After mitomycin prophylaxis, a repeated positive Quic, however, was associated with a high risk of recurrence occurring in 3 of 8 Quic-positive patients. A repeated negative or alternating Quic identified a lower risk group, showing 3 recurrent tumors in 28 patients only. We conclude that Quic cannot be used during, but after, prophylaxis to identify risk patients requiring further treatment. During prophylaxis, its value is limited to a subgroup of patients developing negative Quic, for whom prophylaxis can be stopped individually.

Adjuvant intravesical mitoxantrone after transurethral resection of primary superficial transitional cell carcinoma of the bladder. A prospective randomised study

A prospective randomised controlled clinical trial began in 1989 on 126 patients with superficial transitional cell carcinoma of the bladder (pTa-pT1, grades 1-3) to compare the efficacy of adjuvant topical mitoxantrone after transurethral resection versus no further treatment. 62 patients received no further treatment, 64 patients received weekly 20 mg mitoxantrone intravesically for 6 weeks after differentiated TUR of all visible tumours. The endpoint of the study was any progression of stage or grade or further recurrences. The median follow up was 29 months--the minimum follow up was 24 months. The percentage of recurrences (25.8 versus 23.4), the recurrence rate (1.2 versus 0.9), the overall disease free interval and the tumour progression rate showed no statistically significant differences (P > 0.05 Mantel-Cox test). Only the comparison of time to recurrence in tumours with recurrences showed a statistically significant difference, with a longer disease free interval for the TUR plus mitoxantrone group (P = 0.016 Mantel-Cox test).

Effects of sequential intravesical administration of mitomycin C and bacillus Calmette-Guérin on the immune response in the guinea pig bladder

It has been suggested that intravesical treatment with mitomycin C (MMC) before instillation of bacillus Calmette-Guérin (BCG) improves the antitumor activity of BCG in human bladder cancer. Therefore, we studied the immunological effects of sequential intravesical treatment with MMC and BCG in the guinea pig. Four weekly intravesical instillations with MMC preceded six weekly intravesical BCG instillations. The delayed-type hypersensitivity (DTH) skin reaction evoked by tuberculin purified protein derivative (PPD) in guinea pigs receiving BCG intravesically appeared slightly earlier in animals pretreated intravesically with MMC than in phosphate-buffered saline (PBS)-pretreated animals. However, after completing BCG instillations no differences in DTH reaction were observed between these treatment groups. The extent of the local inflammatory reaction in the bladder wall, as well as the parameters measured in the draining iliacal lymph nodes (i.e., the weight, the number of leukocytes, and the composition of leukocyte subpopulations), did not differ in animals treated with BCG alone or in combination with MMC. A slight increase in the MHC class II expression on the bladder urothelium was shown if MMC and BCG treatment was combined. The adherence of mycobacteria to the bladder wall, measured using 3H-labeled mycobacteria, dit not differ between MMC/BCG- and BCG-treated animals. We conclude that MMC does not enhance the immune response against mycobacteria. Therefore, we hypothesize that a possible increased antitumor activity by the combination of MMC and BCG might be due to separate, rather than synergistic, effects of the drugs, namely a cytostatic effect of MMC on tumor cells and a local immune response in the bladder evoked by BCG.

Intravesical idarubicin--a phase-I study

In the scope of a pharmacokinetic and dose-finding study 33 patients received instillations of idarubicin in 11 different doses 1 h before scheduled transurethral resection of bladder cancer. The dose was increased continuously from 5 to 30 mg and the concentration from 0.25-1.5 mg/ml. Idarubicin uptake into tissue was measured along with the serum level. The results showed a clear correlation of the tissue levels with dose and concentration. A significantly higher concentration of idarubicin was measured in the tumor in comparison with the mucosa. Absorption into the muscle was minimal and serum levels were low. Systemic toxicity was not observed, but there were signs of local toxicity in 50% of the subjects. Cytotoxic concentrations in the mucosa were reached at doses of over 15 mg and concentrations of over 0.5 mg/ml. A phase-II study is in preparation.

Endovesical Prophylactic Mitomycin C Chemotherapy in Superficial Bladder Cancer: A Retrospective Study

The Authors report the results of a retrospective study concerning the use of mitomycin C in the prophylactic treatment of superficial bladder cancer after trans-urethral resection. The series includes 113 patients; minimum follow-up: 6 months, maximum 54, mean 17.7 months. Recurrence and progression rate was evaluated at 6, 12, 24, and 36 months. The cumulative recurrence and progression rate was 16.8% and 6.1% respectively. Patients with pTa neoplasms didn't develop progressions. G2 and G3 carcinoma recurrence and progression rate was higher than with G1 tumours. Multifocal neoplasms showed a higher trend recurrence compared to solitary tumours. The number of recurrences in the patient group with primitive neoplasms was not significantly different from that of patients with recurrent carcinoma.

Prophylactic oral UFT therapy for superficial bladder cancer

BACKGROUND

A randomized prospective trial was performed to determine whether long-term oral UFT (a 1:4 mixture of tegafur and uracil) (Taiho Pharmaceutical Co., Tokyo, Japan) therapy was effective in preventing the intravesical recurrence of superficial bladder cancer.

METHODS

A total of 112 patients with newly diagnosed superficial transitional cell carcinoma of bladder (Ta, T1 and G1 or G2) were randomized into a UFT-treated group (300-400 mg/d for 2 years) and a control group.

RESULTS

After a median follow-up period of 24.5 months, the recurrence rate was 25.7% for the UFT group and 43.3% for the control group (P = 0.015, log-rank test). Side effects of UFT administration were acceptably low.

CONCLUSIONS

These results suggest that long-term UFT administration after transurethral resection is effective in preventing the recurrence of superficial bladder cancer.

Mitomycin-C in superficial bladder cancer. Is long-term maintenance therapy worthwhile after initial treatment?

A total of 72 patients with recurrent superficial transitional cell carcinoma of the bladder (TCC) were treated with 40 mg intravesical instillations of mitomycin-C (MMC) weekly for 10 weeks, followed by monthly maintenance doses. With a mean follow-up period of 41 months, 30 patients (42%) had a complete and sustained response after the initial treatment course, and a further 14 (19%) achieved a complete response on maintenance therapy. Sixteen patients (22%) continued to have recurrent tumours and the remaining 12 (17%) developed recurrent tumours after an initial complete response. Of these, 4 patients with carcinoma in situ (CIS) showed symptomatic improvement, but the histological changes persisted and all of those with tumours > 2 cm in size did not respond. We conclude that maintenance treatment with MMC is beneficial in superficial bladder cancer but is of limited value in the presence of bulky tumours or CIS.

A randomised prospective study comparing intravesical instillations of mitomycin-C, BCG-Tice, and BCG-RIVM in pTa-pT1 tumours and primary carcinoma in situ of the urinary bladder. Dutch South-East Cooperative Urological Group

We compared intravesical instillations with mitomycin-C (MMC), Bacillus Calmette-Guerin (BCG) Tice, and BCG-RIVM in patients with pTa-pT1 papillary carcinoma and primary carcinoma in situ (CIS) of the bladder. Nine instillations with MMC were given or 6 weekly instillations with BCG. Early recurrences were treated with additional instillations. For toxicity and efficacy 437 patients were evaluated with a median follow-up of 32 months (range 12-56). Drug-induced and bacterial cystitis were the most frequent side-effects. The number and severity of side-effects (chi 2 test) were comparable in both BCG groups, but were significantly less in the MMC group for drug-induced cystitis (P = 0.009), other local side-effects (P = 0.004) and systemic side-effects (P < 0.001). The disease-free percentage (log-rank test) showed no significant difference for the three arms for papillary tumours (P = 0.08), nor the CIS (P = 0.20), although for CIS numbers are small. Additional instillations did not influence toxicity or efficacy.

Distribution of 486P 3/12 antigen, ABO(H) blood group antigen and T antigen in cystectomy specimens from patients with stage T2 transitional cell carcinoma of the bladder

We used monoclonal antibody 486P 3/12, anti-ABO(H) antibodies and anti-T antigen lectins to detect malignant transformation in cystectomy specimens from patients with stage T2 transitional cell carcinoma of the bladder. We used an immunoperoxidase technique to do extensive chessboard-like mapping studies in 6 cystectomy bladders with stage T2 lesions and 1 normal bladder from a multiorgan donor as control to characterize antigen expression. Increased 486P 3/12 antigen expression, decreased ABO(H) expression and T antigen deletion were detectable not only in the tumor area but also in tumor-surrounding areas classified as benign. We believe that cells with abnormal antigen expression are a source of tumor recurrence and can be identified with our method of quantitative immunocytology.

Adjuvant chemotherapy of recurrent superficial transitional cell carcinoma: results of a European organization for research on treatment of cancer randomized trial comparing intravesical instillation of thiotepa, doxorubicin and cisplatin. The European Organization for Research on Treatment of Cancer Genitourinary Group

A total of 356 patients with recurrent superficial transitional cell carcinoma of the bladder was entered in a randomized clinical trial to compare intravesical thiotepa, doxorubicin and cisplatin with respect to the recurrence rate and disease-free interval. After complete transurethral resection of all visible lesions, the drugs were administered weekly for 4 weeks and monthly for 11 months. The recurrence rates per year were 0.50 for thiotepa, 0.54 for doxorubicin and 0.58 for cisplatin. Of 266 patients (mean followup 41 months) 35 reported an increase in T category and 19 of them had distant metastases. No association between treatment and progression was noted. Thus, there is no difference among treatments with respect to efficacy. However, severe anaphylactic reactions were observed in the cisplatin arm and chemical cystitis was more frequently reported in patients who received doxorubicin.

Superficial bladder cancer: diagnosis, surveillance and treatment

Approximately 70% of all bladder cancers are superficial at the time of presentation. Superficial bladder cancer includes tumors confined to the urothelium (clinical stage Ta) or lamina propria (stage T1) and flat carcinoma in situ (stage Tis). Because the biological behavior of bladder neoplasms is variable, several important prognostic factors must be addressed. Multivariate analyses have shown that factors predictive of tumor recurrence and tumor progression include multifocal tumors, high grade tumors, T1 tumors and positive urinary cytology after transurethral resection (TUR). The patient with superficial bladder cancer should be monitored via endoscopy supplemented by urinary cytology, using either voided or bladder irrigation specimens and urinalysis. Frequent intravenous urography is not required, even in high grade tumors, as long as the clinical and pathologic studies remain negative and the patient is asymptomatic. The "gold standard" of treatment for superficial bladder carcinoma is TUR of the entire tumor. Despite TUR, new tumors will occur in approximately 50% of all patients; those at highest risk for tumor recurrence and progression require adjuvant intravesical therapy after TUR. A variety of drugs are used as intravesical therapy, including thiotepa, mitomycin C, doxorubicin hydrochloride, Bacillus Calmette-Guerin (BCG), epirubicin, and interferon. Although associated with the most toxicity, BCG appears to be the most efficacious agent in increasing the time to recurrence and progression and in reducing the recurrence rate.

BCG and the treatment of superficial bladder cancer

In this report, we review the evolution of bacillus Calmette-Guérin (BCG) immunotherapy as a legitimate form of treatment in superficial, nonmuscle-invasive bladder cancer. In the US, an estimated 45,000 new cases of bladder cancer are diagnosed each year and the annual death rate approaches 11,000. Approximately 70 percent of these cancers are superficial at the time of initial presentation. The treatment of superficial bladder cancer has three objectives: (1) eradication of existing disease, (2) prophylaxis against tumor recurrence, and (3) prevention of tumor progression (either muscular invasion, metastatic spread, or both). Cystectomy generally is reserved for muscle-invasive disease. Transurethral resection of the bladder tumor is the preferred initial therapy. Intravesical instillations of various chemotherapeutic agents following transurethral resection have been extensively investigated. Some of the common agents used include thiotepa, mitomycin, and doxorubicin. Despite such treatment efforts, however, over 40 percent of patients with superficial bladder cancer experience a recurrence of their tumor within three years. Approximately half of these recurrences either present as less-well-differentiated tumors or have already penetrated into the bladder musculature, metastasized, or both. Since Morales et al. first introduced intravesical BCG vaccine for prophylaxis as well as for treatment of superficial bladder tumors in 1976, support has grown rapidly for its use as an alternative to chemotherapy. When used with prophylactic intent following transurethral resection, recurrence rates are lower than those achieved with other agents. In addition, BCG is emerging as the consensus drug of choice for treating carcinoma in situ of the bladder. The mechanisms by which BCG exerts its antitumor activity remain largely unknown. BCG is thought to stimulate a localized, nonspecific inflammatory response that leads to subsequent shedding of tumor cells. A large body of clinical and experimental data suggest an association between the development of an immunologic response to BCG and successful antitumor activity. No universally accepted therapeutic regimen has been agreed upon. One regimen commonly used consists of an ampul of BCG mixed with 50 mL of NaCl 0.9%, instilled once a week for six weeks and retained for two hours prior to voiding. Maintenance therapy generally consists of intravesical doses given at three-month cycles for at least two years of recurrence-free follow-up. Because BCG is a biologic agent, the commercially available products may differ in weight, colony-forming units per vial, and antigenicity. How these product characteristics affect clinical responsiveness to different strains of BCG remains unanswered.

Residual tumor discovered in routine second transurethral resection in patients with stage T1 transitional cell carcinoma of the bladder

When a second transurethral resection was routinely performed 8 to 14 days after the initial transurethral resection in 46 patients for stage T1 bladder tumors residual disease was found in 20 despite the surgical report of complete resection in 40. In only 13 patients was residual tumor noted at repeat resection by the senior urologist performing the operation and residual tumor was confirmed histologically in 10 of them. The extent of the lesion is easily misjudged even by experienced surgeons. Early cystoscopy cannot exclude residual tumor. Residual tumor is an important cause of early recurrence and repeat resection of stage T1 lesions is recommended.

Long-term observation after intravesical metaphylaxis with mitomycin C in patients with superficial bladder tumors

After transurethral resection of a superficial bladder tumor 63 patients were treated by chemoprophylaxis with mitomycin C over a period of two years: 33.3 percent experienced recurrent disease under metaphylaxis and 42 patients who remained recurrence-free during instillation therapy were observed further for an average of 26.4 months. During this period 26.2 percent of the patients showed recurrences ranging between two to forty-four months after completing instillation. The majority of the patients in whom recurrent tumors developed also had recurrent tumor processes before the instillation therapy was begun. Of the 42 patients 73.8 percent stayed recurrence-free during the observation period of twelve to fifty-four months after completing instillation therapy. In conclusion, during an average observation period of 50.4 months, 52.4 percent of the patients in this study showed recurrences.

Systemic allergic contact dermatitis from intravesical instillation of the antitumor antibiotic mitomycin C

6 cases of contact allergy to the antitumor antibiotic mitomycin C from intravesical instillation are described. Reports suggest that up to 9% of patients treated with mitomycin C for chemoresection/prevention of superficial bladder cancer will develop cutaneous side-effects. Patients may present either with vesicular dermatitis of the hands and feet and/or dermatitis of the genitals, or with more widespread eruptions. Probably most, if not all, skin reactions are caused by contact allergy. The distribution is suggestive of systemic contact dermatitis from mitomycin C absorbed from the vesical mucosa.

Quantitative immunocytology in the management of patients with superficial bladder carcinoma. I. A marker to identify patients who do not require prophylaxis

We used monoclonal antibody 486P 3/12 to monitor 55 patients after transurethral resection of stages Ta and T1 transitional cell bladder carcinoma. The method has a high sensitivity (89%) in detecting grades 1 to 3 lesions. We examined voided urinary specimens taken every 4 weeks after transurethral resection for a mean of approximately 2 years. Of the 55 patients 22 remained negative for marker without prophylaxis and only 2 of them had another tumor. Only 6 of 33 patients who were positive for marker after transurethral resection were negative for marker at least once immediately after transurethral resection. Of the 33 patients 14 had a recurrent tumor. In all 14 patients a marker-positive urine specimen preceded visible tumor recurrence by several months. Monoclonal antibody 486P 3/12 is a safe marker to identify patients with superficial bladder carcinoma after transurethral resection who do not require prophylaxis. The 22 patients who remained negative for marker after transurethral resection had an almost equal distribution of stages Ta to T1 lesions (9 versus 13) and equal distribution of grades 1 and 2 lesions (11 versus 11).

The usefulness of the level of the muscularis mucosae in the staging of invasive transitional cell carcinoma of the urinary bladder

The initial biopsy specimens from 50 patients with high-grade invasive transitional cell carcinoma of the urinary bladder were evaluated for depth of invasion. Stages were assigned according to the following system: T1A, invasion of connective tissue superficial to the level of the muscularis mucosae; T1B, invasion to the level of the muscularis mucosae; T1C, invasion through the level of the muscularis mucosae but superficial to the muscularis propria; and B, invasion into the muscularis propria. Follow-up from the Yale Tumor Registry at a median time of 4.6 years showed that tumors invasive to levels T1A and T1B had a 75% 5-year survival, but tumors invasive through the level of the muscularis mucosae but apparently superficial to the muscularis propria (level T1C) had an 11% 5-year survival, which was comparable with the survival of patients with tumors invasive of the muscularis propria. This study suggests the prognostic importance of assessing the depth of invasion in initial biopsy specimens, even when the specimens lack a muscularis propria.

Comparison of different schedules of cytostatic intravesical instillations in patients with superficial bladder carcinoma: final evaluation of a prospective multicenter study with 419 patients

In a prospective multicenter study we compared the value of various protocols of mitomycin C and doxorubicin instillation for the prevention of recurrent tumors in patients whose superficial bladder tumors (stages TA and T1) had been removed by transurethral resection. The 3-year and short-term instillation protocols were compared to each other and to a combination of 2 protocols. Evaluation after a mean followup of 28 months confirmed the value of cytostatic bladder instillation in preventing recurrence and progression of tumor in patients with superficial bladder carcinoma. There was no significant difference between the results of long-term and short-term prophylaxis; their combination achieved the best results. Doxorubicin and mitomycin yielded similar results; mitomycin was better tolerated.

Clinical studies on bladder tumor-associated antigen in serum of patients with bladder cancer by using monoclonal antibody and sandwich ELISA

Investigations on tumor-associated antigen in the serum of patients with bladder cancer by using monoclonal antibody Hb 7A and sandwich ELISA were carried out on 36 patients with bladder cancer (BCa group), 18 patients with other tissue tumor (OTT group) and 22 normal subjects (control group). The average OD value of Hb 7A antigen of BCa group, OTT group and control group was 0.315 +/- 0.033, 0.124 +/- 0.026 and 0.12 +/- 0.021 respectively. The OD value of Hb 7A antigen in BCa group was significantly higher than that of control group and of OTT group (P less than 0.01), but there was no obvious difference between the control group and OTT group (P greater than 0.05). The positive detection rate in BCa group was 86% (31/36), while detection in all 22 normal subjects and the 18 patients of OTT group yielded negative results. The results indicated that the method of using McAb Hb 7A and sandwich ELISA, characterized by high specificity and sensitivity, is of value for clinical diagnosis and follow-up of patients with bladder cancer and general survey of persons at high risk of bladder cancer.

Bladder wall calcification after intravesical mitomycin C treatment of superficial bladder cancer

Calcification of the bladder wall associated with intravesical mitomycin C for the treatment of superficial bladder cancer is a rare complication. We report on a patient with this complication and discuss the literature.

Intravesical mitomycin C instillation as a prophylactic treatment of superficial bladder tumor

A study was performed to determine the prophylactic efficacy of intravesical mitomycin C instillation in 43 patients with recurrent (more than 3), multiple (more than 3) or large (more than 3 cm.) superficial bladder tumors (stage Ta or T1). Of the patients 21 were treated with 8 weekly intravesical instillations of 40 mg. mitomycin C after transurethral resection and 22 were followed conventionally. The recurrence rate was 42.9 per cent in the mitomycin C group and 40.9 per cent in the controls during the first 3 months, and it was 81.0 and 77.3 per cent, respectively during 24 months. Recurrences per 100 patient-months were 8.7 and 8.9, respectively. Two patients in the mitomycin C group and 4 controls had recurrent tumors with progression in stage. We conclude tentatively from these observations that intravesical mitomycin C instillation is not effective in the prophylaxis of tumor recurrence in patients at high risk. This finding is contrary to other reports indicating a marked decrease in recurrence with mitomycin C.