Topical instillation of doxorubicin hydrochloride in the treatment of recurring superficial transitional cell carcinoma of the bladder

Ampelopsin sodium exhibits antitumor effects against bladder carcinoma in orthotopic xenograft models

The aim of this study was to establish xenograft models of tumor in mice bladder and evaluate the antitumor efficacy of ampelopsin sodium (Amp-Na). A total of 2×10 human bladder carcinoma EJ cells and murine sarcoma 180 cells were instilled into the bladder of BALB/c nu/nu mice and Swiss mice after preconditioning to establish the tumor model. Mice bearing orthotopic tumors were treated with Amp-Na by intravenous, intraperitoneal, or intravesical instillation. In addition, the pharmacokinetics property of Amp-Na was investigated in normal BALB/c mice. Our results showed that Amp-Na was excreted mainly through the urine, where it existed at a high concentration. Amp-Na significantly inhibited the proliferation of EJ and sarcoma 180 cells both in vivo and in vitro and this can be at least partially attributed to the cell cycle arrest induced by Amp-Na. This study suggests that the use of Amp-Na is an attractive chemotherapeutic modality for bladder cancer patients.

Intravesical therapy with adriamycin and 4-epirubicin for superficial bladder cancer: the experience of the EORTC GU Group

The anthracycline derivatives Adriamycin and 4-epirubicin are used to prevent recurrent tumors after transurethral resection of superficial bladder tumors. Both drugs are instilled intravesically. The present report describes the results of two multicenter, prospective, randomized phase III studies carried out by the EORTC GU Group. In protocol 30,790, after a mean follow-up period of 26.6 months, the recurrence rate for 165 patients treated with Adriamycin was 0.29 and the tumor rate was 0.74. For 156 patients treated with Epodyl, the recurrence rate was 0.29 and the tumor rate was 0.57. This difference was not statistically significant. For 70 patients who received transurethral resection alone, the recurrence rate was 0.65 and the tumor rate, 2.04. In protocol 30,763, patients with good prognostic factors were treated with one single instillation of 4-epirubicin versus sterile water. After a mean follow-up period of 16 months, in 190 patients treated with 4-epirubicin the recurrence rate was 0.20 and the tumor rate was 0.35; in 196 patients treated with sterile water, the recurrence rate was 0.37 and the tumor rate was 0.65 (P = 0.0001). Adriamycin and 4-epirubicin were efficacious, and severe side effects were not encountered. The superiority of Adriamycin over Epodyl could not be proven.

Histopathological effects and recovery rate of rat bladders following intravesical instillation of thiotepa, doxorubicin and mitomycin C

A study was made of the local reactions and systemic effects induced by intravesical instillations of thiotepa, doxorubicin and mitomycin C in rats. The control group received normal saline. In the 1-dose short-term experiments, rats treated with doxorubicin and mitomycin C had a high incidence of chemical reactions, including congestion of the mucosa with methylene blue stain, increased bladder weight with oedematous changes either in the mucosa (doxorubian) or the muscle layer (mitomycin C), and infiltration of polymorphonuclear cells 3 days after instillation. These local changes disappeared within 10 days. In long-term experiments with weekly instillations of chemotherapeutic drugs, the rats showed no significant change in weight, methylene blue staining or mucosal congestion. A high percentage of pyuria and microscopic haematuria with submucosal/muscular fibrosis was noted in rats receiving doxorubicin or mitomycin C. A severe dysplastic change in the urothelium was noted in rats treated with mitomycin C. These results suggest that careful follow-up is required in patients receiving intravesical doxorubicin or mitomycin C because of possible severe side effects in the bladder.

Efficacy of intravesical mitomycin C in the treatment of superficial transitional cell carcinoma of the urinary bladder

We treated 47 patients with recurrent transitional cell carcinoma of the bladder with intravesical chemotherapy. Twenty milligrams of mitomycin C per treatment was introduced 7 days after transurethral resection (TUR) or diagnostic cystoscopy, and was repeated at 2-week intervals for five times followed again by cystoscopy. Two more similar courses were administered for a total of 36 weeks. Clinical data revealed no toxicity-related symptoms. Cystoscopic follow-up showed a gradual decline in the presence of tumor to a complete response rate of 87.1% at 36 weeks. Thirteen patients who were previously treatment failures with other drugs responded to mitomycin C.

Effects of intravesical instillation of antitumor chemotherapeutic and immunotherapeutic agents on bladder lesion development in rats pretreated with N-butyl-N-(4-hydroxybutyl)nitrosamine

The effects of 12 weeks of intravesical instillation of bleomycin, cisplatinum and picibanyl on development of urinary bladder tumors and preneoplastic lesions were examined in rats pretreated with N-butyl-N-(4-hydroxybutyl)-nitrosamine (BBN) for four weeks. Upon sacrifice at week 36, histopathological examination revealed a significantly reduced incidence of PN hyperplasia and a tendency for decreased papilloma generation in rats given cisplatinum. However, the other treatments were not associated with any effect on carcinogen-induced lesion development. The results demonstrate that cisplatinum has a potential for postinitiation inhibition of rat bladder carcinogenesis.

Approaches to the treatment of bladder cancer at Stanford

The treatment of bladder cancer is one of the most active areas of clinical cancer research. The use of new classes of intravesical agents, such as the interferons, and analogues of effective intravesical chemotherapies, such as epirubicin, the 4-epimer of doxorubicin, show promise of controlling the sequela of this common urologic problem. In metastatic transitional cell carcinoma, the CMV regimen holds promise of palliation for many and or long-term remission for some patients with advanced bladder cancer.

Absorption of epi-doxorubicin after intravesical administration in patients with in situ transitional cell carcinoma of the bladder

Nine patients with in situ bladder cancer (TIS) were treated by intravesical instillation of epi-doxorubicin (epi-DOX). The amount of anthracycline in 1 ml plasma was in the nanogram range. 78.9 +/- 12.0% and 84.2 +/- 10.6% of the administered dose (30 and 50 mg, respectively) could be recovered.

Adverse reactions to the intravesical administration of doxorubicin hydrochloride: report of 6 cases

We report 6 cases of adverse systemic reactions to the intravesical instillation of doxorubicin hydrochloride for the treatment of recurrent superficial transitional cell carcinoma of the bladder. Although local reactions to this drug are common they rarely are life-threatening. Significant systemic toxicity has not been reported.

Verapamil enhanced in vitro chemosensitivity of a murine bladder carcinoma, FCB

The in vitro enhancement of chemotherapeutic efficacy by verapamil, a calcium antagonist, was assessed using FCB, a transplantable murine transitional cell carcinoma. Exponentially growing FCB cells were partially resistant to treatment with both thiotepa (10(-4) M) and Adriamycin (10(-5) M), however, there was a significant reduction in cell growth when either agent was administered in combination with verapamil (10(-5) M); the effect was evident over a wide range of drug concentrations (10(-4) - 10(-9) M). There was also a pronounced inhibition of DNA precursor incorporation when verapamil was used in combination with either agent. Fluorometric analysis of Adriamycin uptake indicated that verapamil caused an increase in the intracellular concentration of the agent. The data presented are consistent with the postulate that verapamil enhances chemotherapeutic efficacy by altering cellular permeability to the cytotoxic agents. Our study indicates that the use of verapamil in combination with cytotoxic agents for intravesical chemotherapy of bladder tumors may prove to be beneficial in human patients.

Intravesical instillation of doxorubicin hydrochloride and its incorporation into bladder tumors

We studied single dose intravesical doxorubicin instillation (50 mg. dissolved in 30 ml. saline) in 29 patients with bladder tumor and 2 with dysplasia of the bladder. The results demonstrated that 1) the levels of doxorubicin hydrochloride in extracts of tumors were significantly higher than those of histologically normal bladder tissues in all regions examined except the dome, 2) the incorporation concentration of the drug into the smallest tumor was 3-fold greater than that of larger tumors, 3) tissue concentration of the drug in histologically normal bladder tissues was 2.4-fold greater in patients with recurrent than with primary bladder tumors, and 4) a high concentration of the agent was noted in unifocal, multifocal and primary tumors classified as papillary noninvasive or invasive transitional cell carcinoma. These findings indicate that intravesical installation of doxorubicin hydrochloride can be incorporated to a high degree by relatively small papillary noninvasive or invasive transitional cell carcinoma located in almost all regions except the bladder dome.

Prophylactic use of topical adriamycin after transurethral resection of transitional cell bladder tumours

Thirty-five patients with carcinoma of the bladder were subjected to weekly intravesical instillation treatment with 30 mg adriamycin/50 ml solution for a period of 6 weeks following transurethral resection of the tumour. The oncolytic and thus recurrence-preventive value of treatment was determined by endoscopic controls with exploratory excisions and exfoliative cytology. All in all, a recurrence-free rate was found in 77% over a minimum observation period of one year. These results are definitely better than those of comparable instillation treatments with surface-active or immunologically active substances.

Intravesical methotrexate in the treatment of superficial bladder cancer

Thirty patients with superficial bladder cancer (Tis, Ta, Tl) difficult to control by endoscopic means were given a total of 49 courses of methotrexate at fortnightly intervals. Four concentrations were investigated. In 14 courses this was the sole treatment and in the remainder the methotrexate was given as prophylaxis. Toxicity was not a problem but in both groups, although there was some evidence of anti-tumour activity, there were high recurrence rates and intravesical methotrexate cannot be recommended.

Effects of intravesical instillation of antitumor chemotherapeutic agents on bladder carcinogenesis in rats treated with N-butyl-N-(4-hydroxybutyl)nitrosamine

The effects of intravesical instillation of Adriamycin (doxorubicin) (ADR), and mitomycin C (MMC), as inhibitors of development of rat bladder tumors, were examined in rats treated with N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN). Intravesical instillation of ADR or MMC once a week for 12 weeks into rats pretreated with BBN for 4 weeks markedly enhanced development of bladder tumors. That is, one week after the end of intravesical instillation of these compounds the incidence of papillary or nodular hyperplasias, namely preneoplastic lesions, was significantly increased, and at the end of the experiment the incidence of not only papillary or nodular hyperplasias but also of papillomas and cancers was significantly increased. These results indicate that the intravesical instillation of ADR or MMC promotes two-stage bladder carcinogenesis in rats.

Verapamil enhancement of chemotherapeutic efficacy in human bladder cancer cells

The calcium influx blocker verapamil has been used to overcome drug resistance in several tumor systems. The possible in vitro enhancement of drug efficacy was assessed in bladder cancer cell line T24. Combination of thiotepa and doxorubicin hydrochloride with verapamil significantly reduced the survival and growth of T24 cells after as little as 1 hour of drug exposure. An increase in doxorubicin hydrochloride-induced inhibition of [3H]thymidine uptake resulted when verapamil was administered. However, this trend was not demonstrated when combined with thiotepa. It appears that verapamil enhances thiotepa-induced cytotoxicity while it potentiates the antimitotic nature of doxorubicin hydrochloride. The data presented is consistent with the postulate that verapamil alters active efflux of drug from malignant cells and suggests that verapamil has a role in the clinical management of bladder cancer.

Intravesical doxorubicin for the prophylaxis of superficial bladder tumors. A multicenter study. Blinst Italian Cooperative Group

A multicenter trial was carried out with patients with superficial Ta-T1 bladder tumors in 37 urology centers throughout Italy. After transurethral resection (TUR) patients were given intravesical doxorubicin instillations at the mean dose of 50 mg per instillation diluted in 50 ml of distilled water or physiologic saline. Chemoprophylaxis was performed at weekly intervals for the first 4 weeks and then monthly. Cystoscopies were taken every 3 months during the first year, every 4 months during the second year, and every 6 months thereafter. A total of 435 patients, with a median follow-up time of 436 days, were considered eligible for the evaluation of activity. The lowest recurrence rate and the longest disease-free interval was observed in the group of patients with primary or single tumor. Treatment was well tolerated; 119 patients (22.7%) complained of local adverse reactions, and 10 (1.9%) of systemic adverse reactions. In 34 of the patients (6.5%) treatment had to be discontinued.

Adjuvant chemotherapy of superficial transitional cell bladder carcinoma: preliminary results of a European organization for research on treatment of cancer. Randomized trial comparing doxorubicin hydrochloride, ethoglucid and transurethral resection alone

Patients with superficial transitional cell carcinoma of the bladder were entered in a randomized clinical trial to compare the efficacies of transurethral resection alone or followed by bladder instillation of doxorubicin hydrochloride or ethoglucid (Epodyl) for 1 year. Results showed that adjuvant chemotherapy with the selected drugs prolonged the mean interval between recurrences. Mild systemic toxicity and chemical cystitis were observed in 3 and 3 per cent, respectively, of the patients given ethoglucid, and in 5 and 4 per cent, respectively, of those taking doxorubicin.

Intravesical high dose 5-fluorouracil instillations combined with allopurinol--a therapeutic alternative in the treatment of multiple bladder tumors

Chemical cystitis and systemic toxic effects limit the therapeutic use of intravesical cytotoxic agents against bladder tumors. In our series 1,000 mg. 5-fluorouracil could be instilled 2 hours daily, 5 days per week for 5 weeks if 100 mg. allopurinol were given 3 times daily simultaneously. After 6 weeks all patients were macroscopically free of tumors. Another instillation was performed because of recurrences within 6 months in 3 patients. This preliminary report of 5 patients with multiple superficial transitional cell bladder tumors shows that a combined treatment of high dose 5-fluorouracil instillation and simultaneous oral allopurinol will abolish temporarily all tumor tissue without signs of general absorption or chemical cystitis. The observation time is too short to predict definitive cure.

Prophylactic long-term treatment of bladder tumors with oral chemotherapy (tegafur)

A total of 107 patients with bladder tumor (from Ta to T2) was studied. Patients were treated with or without prophylactic intravesical chemotherapy using mitomycin C or doxorubicin hydrochloride (Adriamycin) after the excision of tumor. After the preliminary treatment, 55 patients were given tegafur 600 mg p.o. daily (study group), and the other 52 patients (control group) were treated without tegafur. Both groups were followed up with periodic cystoscopy every three months. Actuarial nonrecurrence rate of the two groups were examined statistically. The results revealed that tegafur was a good prophylaxis against recurrence of the bladder tumor, significant differences at P from less than 0.001 to 0.025 were noted at every observation period except at six months. A significant difference at P less than 0.005 was also recognized from an overall comparison between two nonrecurrence curves.

Absorption of doxorubicin-hydrochloride and mitomycin-C after instillation into noninfected and infected bladders of dogs

The described investigations were carried out in order to determine the degree of absorption of doxorubicin, and mitomycin-C after intravesical instillation into noninfected or Staphylococcus aureus-infected bladders in beagle dogs. The drug concentrations in the bladder wall were determined using diffusion chambers with permeable membranes. Two hours after end of instillation of 10 mg. doxorubicin, a concentration of 1.4 ng. per ml. was measured in the bladder wall of noninfected animals, and 3.75 ng. per ml. in that of infected animals (p less than 0.05). The simultaneously measured serum concentration reached mean peak levels after 30 minutes. The concentrations in infected animals were 3 times higher (1.9 ng. per ml.) than in noninfected animals (0.6 ng. per ml.) (p less than 0.05). After instillation of 1 mg. per kg. bw. mitomycin-C the concentration in both groups of animals was below 0.06 micrograms per ml. Doxorubicin concentrations were determined with a radioimmunoassay and mitomycin-C with a micro-agar diffusion method.

Local chemotherapeutic effects in bladder cancer demonstrated by selective sampling and flow cytometry

A method is described by which the effect of intravesical chemotherapy can be monitored. Cytological samples obtained selectively during treatment were used for morphological and flow cytometric studies, and isoantigen (A, B and H) assessment in 2 patients with urothelial cancer. With flow cytometry even small aneuploid populations in the urothelium could be identified. From the histograms the urothelium was seen to contain 2 different cell populations: 1) diploid and 2) aneuploid. The ratio between aneuploid and diploid cells decreased significantly during treatment. Treatment was continued until no evidence of aneuploid cells could be identified in the histograms. Thus, it is demonstrated that intravesical chemotherapy for certain types of bladder cancer can eradicate the aneuploid cell population. A good correlation was found between cytological studies and flow cytometric measurements. Isoantigen assessment was done in the cell suspension used for morphological and flow cytometric studies. Isoantigen assessment also showed loss of antigens after completion of treatment, indicating that the diploid population was not normal biologically. Thus, 3 parameters can be correlated and related also to topography.

Plasma pharmacokinetics of adriamycin after intrapleural administration

The plasma pharmacokinetics of adriamycin after intrapleural administration have been studied. The maximum plasma concentration found after intrapleural instillation of 50 mg was 100 ng ml-1, the adriamycin half-life being about 2.5 h. Large amounts of the drug are adsorbed from the pleura. Hence risks for cardiomyopathy, previously associated with the repeated intravenous administration of adriamycin, must also be considered after intrapleural administration.

Cooperative studies of chemoprophylaxis after transurethral resection of bladder tumors

Large cooperative trials are more likely than series studied by small groups to bring about significant progress in the field of intravesical adjuvant chemotherapy of superficial bladder tumor. Multicenter randomized trials involving large numbers of patients have been conducted in Europe by the EORTC Urological Group. The Group's main objectives were to compare the efficacy of thio-TEPA, VM-26, epodyl, Adriamycin, and cisplatin, against no treatment, and to study the prophylactic effect of oral pyridoxine and evaluate the main prognostic factors. The results obtained so far are reported. Preliminary information is also given about the Blinst study, a multicenter open investigation of local chemotherapy with doxorubicin (Adriamycin), with special reference to evaluation of the importance of different modalities of treatment with a single drug.

Bladder instillation of adriamycin in the treatment of bladder cancer

Intravesical Adriamycin instillation was used in 10 patients with transitional cell carcinoma of the bladder as postoperative prophylactic treatment against recurrence. The protocol for bladder instillation was 20 mg/10 ml of Adriamycin twice weekly for a total of eight doses. One patient developed recurrence in 3 months and three, in 6 months. The main local side-effects were frequency and dysuria which occurred in four cases. Leukopenia and increased SGOT and SGPT values each occurred in one case. No cases of cardiotoxicity, fibrosis, or atrophy of the bladder mucosa were found. Further studies are necessary to achieve the best possible results.

Severely contracted bladder following intravesical mitomycin C therapy

Most superficial bladder tumors are best treated by transurethral resection. However, because of their multifocal origin and high rate of recurrence they often present challenging therapeutic problems. Intravesical chemotherapy often is used in such cases in the treatment and prevention of recurrent transitional cell carcinoma of the bladder. Recently, mitomycin C intravesical chemotherapy was shown to be effective in the treatment of superficial bladder tumors. No systemic toxicities were described but bladder irritation and drug-related palmar desquamation were noted. We report a case of a severely contracted bladder requiring urinary diversion following intravesical chemotherapy with mitomycin C. A possible relationship of this complication to the mitomycin C treatment is suggested.

Adriamycin permeability of the rat bladder under different conditions

Fifty female Sprague-Dawley rats were treated with 1.4 or 2.4 mg. adriamycin intravesically. Radioimmunological measurement of serum concentrations were performed up to 3 hours post-instillation in normal bladder mucosa, cystitis, and after electrocoagulation, under different filling conditions, as well as with the use of a detergent (Tween 80). The serum concentrations achieved were markedly higher after electrocoagulation or cystitis; altogether they reached only 1/6,000 of the instilled concentration. These studies on the rat bladder suggest that perioperative instillation of adriamycin to prevent recurrence is not contraindicated shortly before or after transurethral resection (TUR) of superficial bladder tumors.

Intravesical cisplatin for superficial bladder tumors

Cisplatin, 50-150 mg in a maximum concentration of 1 mg/ml, was administered intravesically each week to 24 patients with multiple, recurrent carcinoma in situ and/or bladder tumors confined to the mucosa and lamina propria. All patients had a history of multiple transurethral resections and four had received prior chemotherapy. Response was evaluated by urinary cytology, cystoscopy, and biopsy. In a total of 237 weekly doses, toxicities included mild dysuria, pruritus, rash and in one patient, acute anaphylaxis. Only three (13%) patients were classified as achieving complete remission. Cisplatin, in the dose and schedule employed, is ineffective in controlling superficial bladder cancer.

Pathologic effects of pre-cystectomy therapy with combination intra-arterial doxorubicin hydrochloride and local bladder hyperthermia for bladder cancer

Nine patients with bulky pelvic bladder cancer underwent combination doxorubicin hydrochloride hypogastric artery infusion and local bladder hyperthermia as a preoperative adjunct to radical cystectomy in a phase I study. Pathologic examination of the cystectomy specimens showed extensive tumor necrosis on the bladder luminal side, with a gradient of tumor destruction to viable tumor on the bladder serosal surface in 8 of the 9 bladders. Normal portions of the bladder showed minor changes in the urothelium, marked submucosal edema and hyperemia, and viable detrusor muscle. One bladder showed no viable tumor and fibrosis of the entire bladder wall. Adjunctive preoperative hypogastric artery infusion of doxorubicin hydrochloride/bladder hyperthermia is safe, well tolerated and merits further study to determine the upper limits of safety of doxorubicin hydrochloride and hyperthermia temperature.

A controlled trial of single dose intravesical adriamycin in superficial bladder tumours

Sixty patients with recurrent superficial bladder tumours (Ta or T1) entered an open controlled trial of single dose Adriamycin. After transurethral resection of tumor recurrences, patients were alternately allocated to the control group or to the Adriamycin group, who received an instillation of 50 mg of Adriamycin in 50 ml of saline for 30 min. Six months later all patients were readmitted for endoscopy. In the Adriamycin group significantly more patients showed a decrease in the number of recurrent papillomas (72%) than in the control group (39%). This study shows that the use of adjuvant chemotherapy in the form of single dose Adriamycin is effective in reducing tumour recurrence.