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Serretta V. BCG and bladder cancer. Forty-eight years after Morales report. Urologia 2024; 91:459-467. [PMID: 38757638 DOI: 10.1177/03915603241252909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Although BCG use as an anticancer drug was nearly abandoned due to the poor results in most tumors, in 1976 Morales reported a relevant reduction in recurrence with intravesical BCG in few patients affected by NMIBC. Since then BCG was globally accepted as an empirical and effective therapy in treating Tis and preventing recurrence of intermediate and high risk NMIBC. Forty-eight years after Morales' report, although some open questions remain object of debate, we have been able to find answers to many doubts improving BCG activity and toxicity. We better select patients undergoing BCG and many trials have indicated the best dosage and schedule. Moreover, we are able to better identify the patient unresponsive to BCG who might benefit of a timely radical cystectomy. We are also aware of the difficulties and toxicities that can be encountered with BCG use in every-day clinical practice. Research is ongoing to obtain genetically modified BCG to increase its efficacy and reduce toxicity. Moreover, the combination of BCG with other immunotherapeutic drugs given intravesically or systemically, first immune checkpoint inhibitors, is under study to obtain a response in patients unresponsive or intolerant to BCG. Almost 50 years after Morales publication, intravesical BCG remains an inalienable tool against NMIBC.
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Affiliation(s)
- Vincenzo Serretta
- Urology Unit, Candela Clinic, Palermo, Italy
- III Level Oncologic Department "La Maddalena" Palermo, Italy
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2
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Liu K, Wang L, Peng J, Lyu Y, Li Y, Duan D, Zhang W, Wei G, Li T, Niu Y, Zhao Y. Drug-Loaded Bacillus Calmette-Guérin Bacteria for Immuno-Chemo Combo Therapy in Bladder Cancer. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2310735. [PMID: 38330363 DOI: 10.1002/adma.202310735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 02/02/2024] [Indexed: 02/10/2024]
Abstract
Intravesical Bacillus Calmette-Guérin (BCG) is a well-established strategy for managing high-risk nonmuscle-invasive bladder cancer (NMIBC); however, over half of patients still experience disease recurrence or progression. Although the combined intravesical instillation of various chemotherapeutic drugs is implemented in clinical trials to enhance the BCG therapy, the outcome is far from satisfying due to severe irritative effects and treatment intolerance at high doses. Therefore, it is adopted the "biotin-streptavidin strategy" to doxorubicin (DOX)-encapsulated nanoparticles within live BCG bacteria (DOX@BCG) to improve treatment outcomes. Adherence of BCG to the bladder epithelium helps precisely target DOX@BCG to the local tumor cells and simultaneously increases intratumoral transport of therapeutic drugs. DOX@BCG effectively inhibits cancer progression and prolongs the survival of rats/mice with orthotopic bladder cancer owing to synergism between BCG-immunotherapy, DOX-chemotherapy, and DOX-induced immunogenic tumor cell death; furthermore, it exhibits improved tolerance and biosafety, and establishes antitumor immunity in the tumor microenvironment. Therefore, the drug-loaded live BCG bacterial delivery system holds considerable potential for clinical translation in the intravesical treatment of bladder cancer.
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Affiliation(s)
- Kangkang Liu
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Lining Wang
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Jing Peng
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Yuanji Lyu
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Yiming Li
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Dengyi Duan
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Wenyi Zhang
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Guojiang Wei
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Taipeng Li
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Yuanjie Niu
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Yang Zhao
- Department of Radiology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
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Lim Y, Park J, Lim JE, Park M, Koh SK, Lee M, Kim SK, Lee SH, Song KH, Park DG, Kim HY, Jeong BC, Cho D. Evaluating a combination treatment of NK cells and reovirus against bladder cancer cells using an in vitro assay to simulate intravesical therapy. Sci Rep 2024; 14:7390. [PMID: 38548803 PMCID: PMC10979019 DOI: 10.1038/s41598-024-56297-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/05/2024] [Indexed: 04/01/2024] Open
Abstract
Intravesical treatment using either reovirus or natural killer (NK) cells serves as an efficient strategy for the treatment of bladder cancer cells (BCCs); however, corresponding monotherapies have often shown modest cytotoxicity. The potential of a locoregional combination using high-dose reovirus and NK cell therapy in an intravesical approach has not yet been studied. In this study, we evaluated the effectiveness of reoviruses and expanded NK cells (eNK) as potential strategies for the treatment of bladder cancer. The anti-tumor effects of mono-treatment with reovirus type 3 Dearing strain (RC402 and RP116) and in combination with interleukin (IL)-18/-21-pretreated eNK cells were investigated on BCC lines (5637, HT-1376, and 253J-BV) using intravesical therapy to simulate in vitro model. RP116 and IL-18/-21-pretreated eNK cells exhibited effective cytotoxicity against grade 1 carcinoma (5637 cells) when used alone, but not against HT-1376 (grade 2 carcinoma) and 253J-BV cells (derived from a metastatic site). Notably, combining RP116 with IL-18/-21-pretreated eNK cells displayed effective cytotoxicity against both HT-1376 and 253J-BV cells. Our findings underscore the potential of a combination therapy using reoviruses and NK cells as a promising strategy for treating bladder cancer.
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Affiliation(s)
- Yuree Lim
- Department of Biopharmaceutical Convergence, Sungkyunkwan University (SKKU), Suwon, Korea
| | - Jeehun Park
- Department of Molecular Bioscience, College of Biomedical Science, Kangwon National University, Chuncheon, Korea
| | - Joung Eun Lim
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Minji Park
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Seung Kwon Koh
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Mijeong Lee
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Sang-Ki Kim
- Department of Companion & Laboratory Animal Science, Kongju National University, Yesan, Korea
| | - Seung-Hwan Lee
- Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Dong Guk Park
- ViroCure Inc., Seoul, Republic of Korea
- Department of Surgery, School of Medicine, Dankook University, Cheonan, South Korea
| | - Hyun-Young Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-Ro, Gangnam-Gu, Seoul, 06351, Republic of Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea.
| | - Duck Cho
- Department of Biopharmaceutical Convergence, Sungkyunkwan University (SKKU), Suwon, Korea.
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea.
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-Ro, Gangnam-Gu, Seoul, 06351, Republic of Korea.
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Melgarejo Segura MT, Morales Martínez A, Yáñez Castillo Y, Arrabal Polo MÁ, Gutiérrez Tejero F, Pareja Vílchez M, Arrabal Martín M. Electromotive Drug Administration Chemotherapy with Mitomycin C Versus Bacillus Calmette-Guerin for the Treatment of Non-Muscle Invasive Bladder Cancer. Bladder Cancer 2023; 9:159-166. [PMID: 38993293 PMCID: PMC11181766 DOI: 10.3233/blc-230042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 06/07/2023] [Indexed: 07/13/2024]
Abstract
BACKGROUND Devices that increase the penetrance of intravesical chemotherapeutics are emerging as alternatives to classical Bacillus Calmette Guérin (BCG) treatment. OBJECTIVE To compare the efficacy of mitomycin C applied with the electromotive drug delivery device (MMC-EMDA) versus BCG in patients with intermediate and high-risk non-muscle-invasive bladder cancer (NMIBC) without carcinoma in situ (CIS). METHODS Prospective non-randomized study in which 47 patients received MMC-EMDA (40 mg of MMC diluted in 50 mg of distilled water at 20 mA for 30 min. Regimen of 6 weekly and then 6 monthly instillations) and 48 patients received BCG (50 mg of OncoCITE® diluted in 50 ml of normal saline for 60 min. Regimen of 6 weekly instillations and then 3 weekly instillations at months 3, 6 and 12). The primary endpoint was the recurrence-free rate (RFR) at 24 months. Secondary endpoints were time to recurrence and progression-free rate (PFR) at 24 months follow-up. RESULTS Baseline patient assessment and mean follow-up time were similar in both groups (MMC-EMDA group: 26.4 months; BCG group: 28.4 months (p = 0.44)). The RFR at 24 months was 80.9% for the MMC-EMDA group and 77.1% for the BCG group (p = 0.969). The mean time to recurrence was 12.5 months in the MMC-EMDA group and 14 months in the BCG group (p = 0.681). At 24 months, PFR was 97.9% in the MMC-EMDA group and 93.8% in the BCG group (p = 0.419). CONCLUSIONS No differences were found between MMC-EMDA and BCG treatments in patients with high-risk and intermediate-risk NMIBC without CIS.
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Affiliation(s)
| | | | | | - Miguel Ángel Arrabal Polo
- Department of Urology, University Hospital SanCecilio, Granada, Spain
- Instituto de Investigación Biosanitaria ibs. GRANADA, Complejo Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
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Joyce DD, Sharma V, Williams SB. Cost-Effectiveness and Economic Impact of Bladder Cancer Management: An Updated Review of the Literature. PHARMACOECONOMICS 2023; 41:751-769. [PMID: 37088844 DOI: 10.1007/s40273-023-01273-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/03/2023]
Abstract
Bladder cancer remains one of the costliest malignancies to manage. We provide a narrative review of literature assessing the economic burden and cost-effectiveness of bladder cancer treatment and surveillance. This is an update to a previous review and focuses on data published within the past 10 years. We queried PubMed and MEDLINE for all bladder cancer cost-related literature between 2013 and 2023. After initial screening, 117 abstracts were identified, 50 of which were selected for inclusion in our review. Management of disease recurrence and treatment complications contributes significantly to the high cost of care. High-value interventions are therefore treatments that improve recurrence-free and overall survival at minimal additional toxicity. De-escalation of surveillance and diagnostic interventions may help to reduce costs in this space without compromising oncologic control. The persistently rising cost of novel cancer drugs undermines their value when only modest gains in efficacy are observed. Multiple cost-effectiveness analyses have been published and are useful for contextualizing the cost, efficacy, and impact on quality of life that interventions have in this population. Further cost-effectiveness work is needed to better characterize the impact that treatment costs have on patients' financial well-being and quality of life.
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Affiliation(s)
| | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Stephen B Williams
- Division of Urology, High Value Care, UTMB Health System, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555-0540, USA.
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA.
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6
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Busetto GM, Finati M, Chirico M, Cinelli F, D’Altilia N, Falagario UG, Sanguedolce F, Del Giudice F, De Berardinis E, Ferro M, Crocetto F, Porreca A, Di Gianfrancesco L, Calo’ B, Mancini V, Bettocchi C, Carrieri G, Cormio L. Conservative treatment for high-risk NMIBC failing BCG treatment: who benefits from adding electromotive drug administration (EMDA) of mitomycin C (MMC) to a second BCG induction cycle? World J Urol 2023; 41:1329-1335. [PMID: 36971825 DOI: 10.1007/s00345-023-04372-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/10/2023] [Indexed: 03/29/2023] Open
Abstract
Abstract
Purpose
Radical cystectomy (RC) is the standard treatment for high-risk non muscle-invasive bladder cancer (NMIBC) failing first BCG treatment. A second BCG course is an option for those patients who refuse RC or are not eligible for it, but its success rate is quite low. Aim of the present study was to determine whether the addition of intravesical electromotive drug administration of mytomicin-C (EMDA-MMC) improved the efficacy of second BCG course.
Methods
Patients with high-risk NMIBC having failed first BCG treatment and having refused RC were offered a second BCG induction course either alone (group A) or combined with EMDA-MMC (group B). Recurrence-free survival (RFS), progression-free survival (PFS) and cancer-specific survival (CSS) were tested.
Results
Of the 80 evaluable patients, 44 were in group A and 36 in group B; median follow-up was 38 months. RFS was significantly worse in group A whereas there was no difference in PFS and CSS between the two groups. Stratifying by disease stage, Ta patients receiving combined treatment had statistically better RFS and PFS survival than those receiving BCG only; this difference did not apply to T1 patients. Multivariable analysis confirmed that combined treatment was a significant predictor of recurrence and was close to predict progression. No tested variable was predictive of recurrence or progression in T1 tumours. Among those who underwent RC, CSS was 61.5% in those who had progression and 100% in those who remained with NMIBC.
Conclusion
Combined treatment improved RFS and PFS only in patients with Ta disease.
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7
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Del Giudice F, Asero V, Bologna E, Scornajenghi CM, Carino D, Dolci V, Viscuso P, Salciccia S, Sciarra A, D'Andrea D, Pradere B, Moschini M, Mari A, Albisinni S, Krajewski W, Szydełko T, Małkiewicz B, Nowak Ł, Laukhtina E, Gallioli A, Mertens LS, Marcq G, Cimadamore A, Afferi L, Soria F, Mori K, Tully KH, Pichler R, Ferro M, Tataru OS, Autorino R, Crivellaro S, Crocetto F, Busetto GM, Basran S, Eisenberg ML, Chung BI, De Berardinis E. Efficacy of Different Bacillus of Calmette-Guérin (BCG) Strains on Recurrence Rates among Intermediate/High-Risk Non-Muscle Invasive Bladder Cancers (NMIBCs): Single-Arm Study Systematic Review, Cumulative and Network Meta-Analysis. Cancers (Basel) 2023; 15:cancers15071937. [PMID: 37046598 PMCID: PMC10093360 DOI: 10.3390/cancers15071937] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND In an era of Bacillus of Calmette-Guérin (BCG) shortages, the comparative efficacy from different adjuvant intravesical BCG strains in non-muscle invasive bladder cancer (NMIBC) has not been clearly elucidated. We aim to compare, through a systematic review and meta-analysis, the cumulative BC recurrence rates and the best efficacy profile of worldwide available BCG strains over the last forty years. METHODS PubMed, Scopus, Web of Science, Embase, and Cochrane databases were searched from 1982 up to 2022. A meta-analysis of pooled BC recurrence rates was stratified for studies with ≤3-y vs. >3-y recurrence-free survival (RFS) endpoints and the strain of BCG. Sensitivity analysis, sub-group analysis, and meta-regression were implemented to investigate the contribution of moderators to heterogeneity. A random-effect network meta-analysis was performed to compare BCG strains on a multi-treatment level. RESULTS In total, n = 62 series with n = 15,412 patients in n = 100 study arms and n = 10 different BCG strains were reviewed. BCG Tokyo 172 exhibited the lowest pooled BC recurrence rate among studies with ≤3-y RFS (0.22 (95%CI 0.16-0.28). No clinically relevant difference was noted among strains at >3-y RFS outcomes. Sub-group and meta-regression analyses highlighted the influence of NMIBC risk-group classification and previous intravesical treated categories. Out of the n = 11 studies with n = 7 BCG strains included in the network, BCG RIVM, Tice, and Tokyo 172 presented with the best-predicted probability for efficacy, yet no single strain was significantly superior to another in preventing BC recurrence risk. CONCLUSION We did not identify a BCG stain providing a clinically significant lower BC recurrence rate. While these findings might discourage investment in future head-to-head randomized comparison, we were, however, able to highlight some potential enhanced benefits from the genetically different BCG RIVM, Tice, and Tokyo 172. This evidence would support the use of such strains for future BCG trials in NMIBCs.
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Affiliation(s)
- Francesco Del Giudice
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Vincenzo Asero
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Eugenio Bologna
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Carlo Maria Scornajenghi
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Dalila Carino
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Virginia Dolci
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Pietro Viscuso
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Stefano Salciccia
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - Alessandro Sciarra
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1030 Vienna, Austria
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1030 Vienna, Austria
- Department of Urology, La Croix du Sud Hospital, 31130 Quint-Fonsegrives, France
| | - Marco Moschini
- Department of Urology and Division of Experimental Oncology, Urological Research Institute, Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Andrea Mari
- Department of Experimental and Clinical Medicine, University of Florence-Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, 50134 Florence, Italy
| | - Simone Albisinni
- Urology Unit, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Tomasz Szydełko
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Bartosz Małkiewicz
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Łukasz Nowak
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-367 Wrocław, Poland
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, 1030 Vienna, Austria
- Institute for Urology and Reproductive Health, Sechenov University, 119435 Moscow, Russia
| | - Andrea Gallioli
- Department of Urology, Fundacio Puigvert, 16444 Barcelona, Spain
| | - Laura S Mertens
- Department of Urology, The Netherlands Cancer Institute, 1066 Amsterdam, The Netherlands
| | - Gautier Marcq
- Urology Department, Claude Huriez Hospital, CHU Lille, 59000 Lille, France
- Cancer Heterogeneity Plasticity and Resistance to Therapies, UMR9020-U1277-CANTHER, Institut Pasteur de LilleCHU Lille, Inserm, CNRS University of Lille, 59000 Lille, France
| | - Alessia Cimadamore
- Department of Medical Area (DAME), Institute of Pathological Anatomy, University of Udine, 33100 Udine, Italy
| | - Luca Afferi
- Department of Urology, Luzerner Kantonsspital, 6004 Luzern, Switzerland
| | - Francesco Soria
- Urology Division, Department of Surgical Sciences, University of Studies of Torino, 10124 Turin, Italy
| | - Keiichiro Mori
- Department of Urology, The Jikei University School of Medicine, Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Karl Heinrich Tully
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, 44780 Herne, Germany
| | - Renate Pichler
- Department of Urology, Comprehensive Cancer Center Innsbruck, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Matteo Ferro
- Division of Urology, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Octavian Sabin Tataru
- Department of Simulation Applied in Medicine, The Institution Organizing University Doctoral Studies (I.O.S.U.D.), George Emil Palade University of Medicine, Pharmacy, Sciences, and Technology, 540142 Târgu Mureș, Romania
| | - Riccardo Autorino
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Simone Crivellaro
- Health Sciences System, Department of Urology, University of Illinois Hospital e Camp, Chicago, IL 60612, USA
| | - Felice Crocetto
- Reproductive Sciences and Odontostomatology, Urology Unit, Department of Neurosciences, University of Naples "Federico II", 80138 Naples, Italy
| | - Gian Maria Busetto
- Department of Urology and Organ Transplantation, University of Foggia, 71122 Foggia, Italy
| | - Satvir Basran
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Michael L Eisenberg
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Benjamin Inbeh Chung
- Department of Urology, Stanford University School of Medicine, Stanford, CA 94305-5101, USA
| | - Ettore De Berardinis
- Department of Maternal-Infant and Urological Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, 00185 Rome, Italy
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8
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Gómez IS, Huguet J, Bravo A, Robalino J, Faba ÓR, Territo Á, Gaya JM, Palou J, Breda A. Sequential treatment with Bacillus Calmette-Güerin (BCG) and mitomycin C administered with Electromotive Drug Administration (EMDA) in patients with high-risk non-muscle invasive bladder cancer after BCG failure. Clin Genitourin Cancer 2023:S1558-7673(23)00061-7. [PMID: 37076337 DOI: 10.1016/j.clgc.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/22/2023] [Accepted: 03/04/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Nowadays, there is no standard non-surgical treatment for patients with nonmuscle invasive bladder cancer (NMIBC) in whom Bacillus Calmette-Güerin (BCG) therapy has failed. OBJECTIVES To assess the clinical and oncological outcomes of sequential treatment with Bacillus Calmette-Guerin (BCG) and Mitomycin C (MMC) administered with Electromotive Drug Administration (EMDA) in patients with high-risk NMIBC who fail BCG immunotherapy. MATERIAL AND METHODS We retrospectively studied patients with NMIBC who failed BCG and received alternating BCG and Mitomycin C with EMDA between 2010 and 2020. Treatment schedule consisted in an induction therapy with 6 instillations (BCG, BCG, MMC + EMDA, BCG, BCG, MMC + EMDA) and a 1-year maintenance. Complete response (CR) was defined as the absence of high-grade (HG) recurrences during follow-up, and progression was defined as the occurrence of muscle invasive or metastatic disease. CR rate was estimated at 3, 6, 12, and 24 months. Progression rate and toxicity were also assessed. RESULTS Twenty-two patients were included with a median age of 73 years. Fifty percent of tumors were single, 90% were smaller than 1.5cm, 40% were GII (HG) and 40% were Ta. CR rate was 95.5%, 81% and 70% at 3 and 6 months, 12 months and 24 months, respectively. With a median follow-up of 28.8 months, 6 patients (27%) presented HG recurrence and only 1 patient (4.5%) progressed and ended in cystectomy. This patient died due to metastatic disease. Treatment was well tolerated and 22% of the patients presented adverse effects, being dysuria the most frequent one. CONCLUSION Sequential treatment with BCG and Mitomycin C with EMDA achieved good responses and low toxicity in selected patients who did not respond to BCG. Only 1 patient ended in cystectomy and died due to metastatic disease, therefore, cystectomy was avoided in most cases.
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9
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Replacement Instead of Discontinuation of Bacillus Calmette-Guérin Instillation in Non-Muscle-Invasive Bladder Cancer. Cancers (Basel) 2023; 15:cancers15041345. [PMID: 36831686 PMCID: PMC9954124 DOI: 10.3390/cancers15041345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/17/2023] [Accepted: 02/18/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND To evaluate the efficacy of intravesical chemotherapy replacement in patients with intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC), who underwent bacillus Calmette-Guérin (BCG) instillation but discontinued due to global shortages or toxicity of BCG. METHODS This retrospective study included patients with intermediate- and high-risk NMIBC who received BCG intravesical instillation. Those who discontinued the treatment were divided into the pure BCG group and chemotherapy replacement group. Comparisons between these groups were performed. The primary endpoint was bladder recurrence-free survival (RFS). RESULTS A total of 480 patients were included. Baseline characteristics were similar between groups, but the total instillation times were higher in the chemotherapy replacement group than in the pure BCG group (n = 14.9 vs. 10.5). The chemotherapy replacement group had a better three-year RFS (p = 0.022). On multivariate analysis, the pure BCG group had significantly increased all-time and 3-year recurrences (hazard ratio 2.015 and 2.148) compared to the chemotherapy replacement group. CONCLUSIONS Chemotherapy replacement has a better three-year RFS than no instillation in patients with intermediate- and high-risk NMIBC who received BCG instillation but facing treatment stoppage.
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10
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Abstract
PURPOSE OF REVIEW The treatment options for high-risk non-muscle invasive bladder cancer (NMIBC), particularly following BCG, remain limited. We highlight recent, promising therapies for high-risk NMIBC. RECENT FINDINGS Several therapies utilizing different mechanisms of action have demonstrated favorable results in the BCG-naïve and BCG-unresponsive settings. These treatments include intravenous and intravesical immunotherapy, viral- and bacterial-based intravesical therapies, combination intravesical chemotherapy regimens, and novel intravesical chemotherapy administration. Overall, the efficacy and tolerability of emerging treatments for NMIBC appear promising and provide potential alternatives to radical cystectomy. As the landscape of managing BCG-unresponsive disease evolves, clinical trials will explore future options and determine effective alternatives.
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11
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R11 modified tumor cell membrane nanovesicle-camouflaged nanoparticles with enhanced targeting and mucus-penetrating efficiency for intravesical chemotherapy for bladder cancer. J Control Release 2022; 351:834-846. [DOI: 10.1016/j.jconrel.2022.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022]
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12
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The clinical efficacy and safety of equipment-assisted intravesical instillation of mitomycin C after transurethral resection of bladder tumour in patients with nonmuscular invasive bladder cancer: A meta-analysis. PLoS One 2022; 17:e0276453. [PMID: 36269742 PMCID: PMC9586381 DOI: 10.1371/journal.pone.0276453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
Background This review and meta-analysis aimed to systematically evaluate the clinical efficacy and safety of equipment-assisted intravesical instillation of mitomycin C (MMC) in patients with nonmuscular invasive bladder cancer (NMIBC) after transurethral resection of bladder tumour (TURBT). Methods The Embase, PubMed, CNKI, CBM, WANGFANG, VIP, Cochrane Library, and Clinicaltrial.com databases were searched for articles published before April 2022. The experimental group was treated with intravesical instillation of MMC assisted by equipment, including radiofrequency-induced thermochemotherapy, conductive thermochemical therapy, electromotive drug administration, or locoregional hyperthermia. The control group was treated with simple MMC perfusion. The outcomes of interest in the meta-analysis were recurrence, progression, side-effects, gross haematuria, and bladder irritation. Results A total of 15 studies that enrolled 1,190 patients were included in the meta-analysis. Compared to that of the control group, device-assisted intravesical instillation of MMC significantly reduced both tumour recurrence (odds ratio [OR] = 0.32, 95% confidence interval [CI] [0.24, 0.42], P <0.00001) and progression (OR = 0.29, 95% CI [0.12, 0.67], P = 0.004). There were no significant differences between the two groups in terms of safety (OR = 1.21, 95% CI [0.66,2.21], P = 0.54), bladder irritation (OR = 1.06, 95% CI [0.72,1.55], P = 0.78), or gross haematuria (OR = 1.11, 95% CI [0.64,1.94], P = 0.72). Conclusions Equipment-assisted intravesical instillation of MMC significantly reduced the recurrence and progression of patients with NMIBC who underwent TURBT and improved their quality of life. Given the significant heterogeneity in research quality and sample size among earlier studies, more prospective, multicentre, large sample randomized controlled trials are needed to supplement and verify this in the future.
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13
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Min JWS, Saeed N, Coene A, Adriaens M, Ceelen W. Electromotive Enhanced Drug Administration in Oncology: Principles, Evidence, Current and Emerging Applications. Cancers (Basel) 2022; 14:4980. [PMID: 36291762 PMCID: PMC9599758 DOI: 10.3390/cancers14204980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/05/2022] [Accepted: 10/08/2022] [Indexed: 08/30/2023] Open
Abstract
Local-regional administration of cytotoxic drugs is an important adjunct to systemic chemotherapy amongst cancer patients. It allows for targeted delivery of agents at high concentration to target sites while minimizing systemic side effects. Despite the pharmacokinetic advantages of the local-regional approach, drug transport into tumor nodules remains limited due to the biophysical properties of these tissues. Electromotive enhanced drug administration (EMDA) represents a potential solution to overcome challenges in local drug transport by applying electric currents. Through electrokinetic phenomena of electromigration, electroosmosis and electroporation, electric currents have been shown to improve drug penetration and distribution in a wide variety of clinical applications. Amongst patients with non-muscular invasive bladder cancer (NMIBC) and basal and squamous cell skin cancers, EMDA has been successfully adopted and proven efficacious in several pre-clinical and clinical studies. Its application in ophthalmological and other conditions has also been explored. This review provides an overview of the underlying principles and factors that govern EMDA and discusses its application in cancer patients. We also discuss novel EMDA approaches in pre-clinical studies and explore future opportunities of developments in this field.
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Affiliation(s)
- Jolene Wong Si Min
- Department of GI Surgery, Ghent University Hospital, 9000 Ghent, Belgium
| | - Nidda Saeed
- Department of GI Surgery, Ghent University Hospital, 9000 Ghent, Belgium
| | - Annelies Coene
- Department of Electromechanical, Systems and Metal Engineering, Faculty of Engineering and Architecture, Ghent University, 9000 Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium
| | - Mieke Adriaens
- Department of Chemistry, Faculty of Sciences, Ghent University, 9000 Ghent, Belgium
| | - Wim Ceelen
- Department of GI Surgery, Ghent University Hospital, 9000 Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium
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14
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Melgarejo-Segura MT, Morales-Martínez A, Yáñez-Castillo Y, Arrabal-Polo MÁ, Gómez-Lechuga P, Pareja-Vílchez M, Jiménez-Moleón JJ, Martín MA. A systematic review of the efficacy of intravesical electromotive drug administration therapy for non-muscle invasive bladder cancer. Urol Oncol 2022; 41:166-176. [PMID: 36328923 DOI: 10.1016/j.urolonc.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/13/2022] [Accepted: 09/22/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Non-muscle invasive bladder cancer (NMIBC) is characterized by a high rate of recurrence and progression, despite surgery and adjuvant therapies. OBJECTIVE To analyze the published results on the effectiveness of mitomycin C (MMC) applied with an electromotive drug administration device (EMDA) in the treatment of patients with non-muscle invasive bladder tumors. METHOD A systematic review was conducted using the PubMed and Google Scholar search platforms. We selected the studies that included the recurrence and/or progression rates or complete response rate in patients diagnosed with NMIBC according to their treatment and included MMC applied with EMDA. The last search was performed in November 2021. RESULTS The search yielded 64 articles; 11 articles met the selection criteria. In two of the 11 selected articles, mitomycin C was applied with an EMDA device (MMC-EMDA) as an ablative treatment, avoiding surgery in 50% of the patients. In 1 of the 11 studies, the application of MMC-EMDA was used as an induction treatment using a single preoperative instillation with promising results. In the remaining 8 studies, adjuvant MMC was applied with the EMDA device; in 3 of these 8 cases, treatment with MMC-EMDA alone was applied initially. In another3 cases the same treatment was applied after nonresponse to bacillus Calmette Guerin (BCG), and in the last 2 studies, MMC-EMDA was applied in combination with the classic therapy (BCG). All the studies selected supported the efficacy and safety of MMC-EMDA in patients with intermediate and high- risk bladder cancer. In 3 studies, adjuvant therapy with MMC-EMDA was performed in nonresponders to BCG, finding that adjuvant therapy with MMC-EMDA applied to BCG nonresponders without CIS avoided or delayed surgery. CONCLUSIONS The application of EMDA-enhanced MMC has been studied at different times of disease and with different administration protocols. It appears to delay bladder tumor recurrence and progression in certain populations. However, the methodological limitations of the published studies prevent definitive conclusions about its efficacy.
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Affiliation(s)
| | | | | | - Miguel Ángel Arrabal-Polo
- Department of Urology, University Hospital San Cecilio, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Complejo Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
| | | | | | - José Juan Jiménez-Moleón
- Instituto de Investigación Biosanitaria ibs.GRANADA, Complejo Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain; Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
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15
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Fujita N, Hatakeyama S, Momota M, Narita T, Tobisawa Y, Yoneyama T, Yamamoto H, Ito H, Yoneyama T, Hashimoto Y, Yoshikawa K, Ohyama C. Single immediate instillation of chemotherapy is associated with decreased recurrence and progression in patients with high-risk non-muscle-invasive bladder cancer who receive adjuvant induction bacillus Calmette-Guérin therapy. Int J Urol 2022; 29:867-875. [PMID: 35577361 DOI: 10.1111/iju.14926] [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: 01/23/2022] [Accepted: 04/24/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate whether a single intravesical instillation of chemotherapy is associated with improved oncological outcomes in patients with high-risk non-muscle-invasive bladder cancer who receive adjuvant induction bacillus Calmette-Guérin therapy. METHODS This multi-institutional retrospective study included 205 patients with high-risk non-muscle-invasive bladder cancer who received adjuvant induction bacillus Calmette-Guérin therapy. Patients were divided into two groups: those who received the combined therapy of a single instillation of chemotherapy plus subsequent adjuvant induction bacillus Calmette-Guérin therapy (combined therapy group), and those who received adjuvant induction bacillus Calmette-Guérin therapy alone (bacillus Calmette-Guérin monotherapy group). Multivariable analyses using the inverse probability of treatment weighting method and Fine-Gray competing risk regression models were performed to evaluate the impact of a single instillation of chemotherapy on intravesical recurrence-free survival and muscle-invasive bladder cancer-free survival. RESULTS Among the 205 patients, 130 (63%) and 75 (37%) were classified as the combined therapy and bacillus Calmette-Guérin monotherapy groups, respectively. Multivariable analyses using the inverse probability of treatment weighting method showed that a single instillation of chemotherapy was significantly associated with longer intravesical recurrence-free survival (hazard ratio 0.279; P < 0.001) and muscle-invasive bladder cancer-free survival (hazard ratio 0.078; P < 0.001). Fine-Gray competing risk regression model revealed that a single instillation of chemotherapy was associated with a significantly lower probability of intravesical recurrence and muscle-invasive bladder cancer progression, with an adjusted subdistribution hazard ratio of 0.477 (P = 0.008) and 0.261 (P = 0.043), respectively. CONCLUSION A single intravesical instillation of chemotherapy may be a potential treatment option in patients with high-risk non-muscle-invasive bladder cancer who receive adjuvant induction bacillus Calmette-Guérin therapy.
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Affiliation(s)
- Naoki Fujita
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shingo Hatakeyama
- Department of Advanced Blood Purification Therapy, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Masaki Momota
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takuma Narita
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuki Tobisawa
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tohru Yoneyama
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hayato Yamamoto
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hiroyuki Ito
- Department of Urology, Aomori Rosai Hospital, Hachinohe, Japan
| | - Takahiro Yoneyama
- Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuhiro Hashimoto
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | | | - Chikara Ohyama
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.,Department of Advanced Blood Purification Therapy, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.,Department of Advanced Transplant and Regenerative Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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16
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Gakis G. [Adjuvant instillation therapy for non-muscle invasive bladder cancer - beyond BCG and mitomycin C]. Aktuelle Urol 2022; 53:148-152. [PMID: 35172349 DOI: 10.1055/a-1677-0952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Due to limited local efficacy of BCG and mitomycin C and the worldwide shortage of BCG, there is a clinical need to develop novel intravesical agents and application forms in order to improve the oncological outcomes in non-muscle invasive bladder cancer (NMIBC). Gemcitabine has been investigated in various clinical trials. It has proven to be superior to BCG rechallenge and MMC in BCG-unresponsive high-risk NMIBC. GemRIS is an implantable novel form of intravesical drug delivery of gemcitabine and is currently being investigated with cetrelimab, a checkpoint inhibitor, in patients with high-risk NMIBC and MIBC. Hyperthermic intravesical chemotherapy (HIVEC) leads to increased concentrations of MMC in the bladder wall and is also being investigated in various NMIBC settings. Nadofaragene firadenovec (rAd-IFN-α/Syn3) is a recombinant adenovirus that induces release of interferon-alpha in the urothelium. In a randomised study on patients with BCG-unresponsive NMIBC, it has shown relatively superior efficacy and tolerability compared with studies evaluating the role of checkpoint inhibitor monotherapies. Opportuzumab monatox is a recombinant fusion protein which binds to EpCAM and induces release of exotoxins, resulting in cytotoxic cell death. N-803 is an interleukin (IL)-15 analogue, which has been investigated in a phase 1b study in combination with BCG and has shown durable complete response in all nine patients for 72 months. It was granted breakthrough designation status by the FDA in 2019.
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Affiliation(s)
- Georgios Gakis
- Department of Urology and Pediatric Urology, University Hospital of Würzburg, Würzburg, Germany
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17
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Eilender BM, Katims AB, Pfail JL, Sfakianos J. Evolving Treatment in Non-muscle-Invasive Bladder Cancer. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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18
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Unsworth-White SR, Kitchen MO, Bryan RT. Immunotherapy for non-muscle-invasive bladder cancer: from the origins of BCG to novel therapies. Future Oncol 2021; 18:105-115. [PMID: 34763531 DOI: 10.2217/fon-2021-0781] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplies of intravesical Bacillus Calmette-Guérin (BCG), the first-line treatment for most intermediate- and high-risk non-muscle-invasive bladder cancers (NMIBC), have proven unreliable over the past decade. This review considers the evolution of BCG immunotherapy for NMIBC: from the discovery of the antitumour side effects of tuberculosis and subsequently the BCG vaccine, to recent advances in novel immunotherapeutic agents. We summarize the evidence for alternative options to standard intravesical BCG therapy regimens and describe the potential for immune response manipulating drugs in the treatment of NMIBC. These new agents, including immune checkpoint inhibitors, toll-like receptor agonists and recombinant viral vectors, may provide better options in the management of NMIBC in the future.
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Affiliation(s)
- Samantha R Unsworth-White
- Bladder Cancer Research Centre, Institute of Cancer & Genomic Sciences, College of Medical & Dental Sciences, University of Birmingham, UK
| | - Mark O Kitchen
- School of Medicine, Keele, UK.,Urology Department, University Hospitals of North Midlands NHS Trust, UK
| | - Richard T Bryan
- Bladder Cancer Research Centre, Institute of Cancer & Genomic Sciences, College of Medical & Dental Sciences, University of Birmingham, UK
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19
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Babjuk M, Burger M, Capoun O, Cohen D, Compérat EM, Dominguez Escrig JL, Gontero P, Liedberg F, Masson-Lecomte A, Mostafid AH, Palou J, van Rhijn BWG, Rouprêt M, Shariat SF, Seisen T, Soukup V, Sylvester RJ. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (Ta, T1, and Carcinoma in Situ). Eur Urol 2021; 81:75-94. [PMID: 34511303 DOI: 10.1016/j.eururo.2021.08.010] [Citation(s) in RCA: 543] [Impact Index Per Article: 181.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/15/2021] [Indexed: 02/08/2023]
Abstract
CONTEXT The European Association of Urology (EAU) has released an updated version of the guidelines on non-muscle-invasive bladder cancer (NMIBC). OBJECTIVE To present the 2021 EAU guidelines on NMIBC. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines since the 2020 version was performed. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS Tumours staged as Ta, T1 and carcinoma in situ (CIS) are grouped under the heading of NMIBC. Diagnosis depends on cystoscopy and histological evaluation of tissue obtained via transurethral resection of the bladder (TURB) for papillary tumours or via multiple bladder biopsies for CIS. For papillary lesions, a complete TURB is essential for the patient's prognosis and correct diagnosis. In cases for which the initial resection is incomplete, there is no muscle in the specimen, or a T1 tumour is detected, a second TURB should be performed within 2-6 wk. The risk of progression may be estimated for individual patients using the 2021 EAU scoring model. On the basis of their individual risk of progression, patients are stratified as having low, intermediate, high, or very high risk, which is pivotal to recommending adjuvant treatment. For patients with tumours presumed to be at low risk and for small papillary recurrences detected more than 1 yr after a previous TURB, one immediate chemotherapy instillation is recommended. Patients with an intermediate-risk tumour should receive 1 yr of full-dose intravesical bacillus Calmette-Guérin (BCG) immunotherapy or instillations of chemotherapy for a maximum of 1 yr. For patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. For patients at very high risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is also recommended for BCG-unresponsive tumours. The extended version of the guidelines is available on the EAU website at https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/. CONCLUSIONS These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology has released updated guidelines on the classification, risk factors, diagnosis, prognostic factors, and treatment of non-muscle-invasive bladder cancer. The recommendations are based on the literature up to 2020, with emphasis on the highest level of evidence. Classification of patients as having low, intermediate, or and high risk is essential in deciding on suitable treatment. Surgical removal of the bladder should be considered for tumours that do not respond to bacillus Calmette-Guérin (BCG) treatment and tumours with the highest risk of progression.
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Affiliation(s)
- Marko Babjuk
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria.
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Otakar Capoun
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Daniel Cohen
- Department of Urology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Eva M Compérat
- Department of Pathology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | | | - Paolo Gontero
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Fredrik Liedberg
- Department of Translational Medicine, Lund University, Malmö, Sweden; Department of Urology, Skåne University Hospital, Malmö, Sweden
| | | | - A Hugh Mostafid
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Joan Palou
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Bas W G van Rhijn
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Morgan Rouprêt
- GRC 5 Predictive Onco-Uro, Department of Urology, Sorbonne University, AP-HP, Pitié Salpétrière Hospital, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Thomas Seisen
- GRC 5 Predictive Onco-Uro, Department of Urology, Sorbonne University, AP-HP, Pitié Salpétrière Hospital, Paris, France
| | - Viktor Soukup
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
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20
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Yassaie O, Chehroudi C, Black PC. Novel and emerging approaches in the management of non-muscle invasive urothelial carcinoma. Ther Adv Med Oncol 2021; 13:17588359211039052. [PMID: 34408797 PMCID: PMC8366114 DOI: 10.1177/17588359211039052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 11/16/2022] Open
Abstract
Non-muscle invasive bladder cancer (NMIBC) has traditionally been managed with transurethral resection followed by intravesical chemotherapy and/or bacillus Calmette-Guerin (BCG) in a risk-adapted manner. These tumors commonly recur and can progress potentially to lethal muscle invasive disease. A major unmet need in the field of NMIBC is bladder preserving therapy for recurrent high-grade NMIBC after adequate intravesical BCG therapy. The current gold standard treatment for these BCG-unresponsive patients is radical cystectomy, which is associated with considerable morbidity and mortality, particularly in older and frailer patients. It is therefore critical to provide alternative treatment options with acceptable oncological outcomes. In this review we explore novel bladder-sparing treatment options including combination intravesical therapy, enhanced instillation methods, immunotherapy, gene therapy, targeted therapy, photodynamic therapy and BCG variants across the spectrum of NMIBC disease states, ranging from low grade BCG-naïve patients through to high-grade BCG-unresponsive NMIBC.
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Affiliation(s)
- Omid Yassaie
- Department of Urologic Sciences, University British Columbia, Vancouver, BC, Canada
| | - Cyrus Chehroudi
- Department of Urologic Sciences, University British Columbia, Vancouver, BC, Canada
| | - Peter C Black
- Department of Urologic Sciences, University British Columbia, Level 6, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
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21
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Oresta B, Pozzi C, Braga D, Hurle R, Lazzeri M, Colombo P, Frego N, Erreni M, Faccani C, Elefante G, Barcella M, Guazzoni G, Rescigno M. Mitochondrial metabolic reprogramming controls the induction of immunogenic cell death and efficacy of chemotherapy in bladder cancer. Sci Transl Med 2021; 13:13/575/eaba6110. [PMID: 33408185 DOI: 10.1126/scitranslmed.aba6110] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 10/15/2020] [Indexed: 12/22/2022]
Abstract
Although chemotherapeutic agents have been used for decades, the mechanisms of action, mechanisms of resistance, and the best treatment schedule remain elusive. Mitomycin C (MMC) is the gold standard treatment for non-muscle-invasive bladder cancer (NMIBC). However, it is effective only in a subset of patients, suggesting that, aside from cytotoxicity, other mechanisms could be involved in mediating the success of the treatment. Here, we showed that MMC promotes immunogenic cell death (ICD) and in vivo tumor protection. MMC-induced ICD relied on metabolic reprogramming of tumor cells toward increased oxidative phosphorylation. This favored increased mitochondrial permeability leading to the cytoplasmic release of mitochondrial DNA, which activated the inflammasome for efficient IL-1β (interleukin-1β) secretion that promoted dendritic cell maturation. Resistance to ICD was associated with mitochondrial dysfunction related to low abundance of complex I of the respiratory chain. Analysis of complex I in patient tumors indicated that low abundance of this mitochondrial complex was associated with recurrence incidence after chemotherapy in patients with NMIBC. The identification of mitochondria-mediated ICD as a mechanism of action of MMC offers opportunities to optimize bladder cancer management and provides potential markers of treatment efficacy that could be used for patient stratification.
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Affiliation(s)
- Bianca Oresta
- Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Chiara Pozzi
- Department of Experimental Oncology, European Institute of Oncology-IRCCS, via Ripamonti 435, 20141 Milan, Italy
| | - Daniele Braga
- Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Rodolfo Hurle
- Department of Urology, Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Massimo Lazzeri
- Department of Urology, Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Piergiuseppe Colombo
- Department of Pathology, Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Nicola Frego
- Department of Urology, Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Marco Erreni
- Unit of Advanced Optical Microscopy, Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Cristina Faccani
- Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Grazia Elefante
- Department of Pathology, Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Matteo Barcella
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20142 Milan, Italy
| | - Giorgio Guazzoni
- Department of Urology, Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy.,Humanitas University, Department of Biomedical Sciences, via Rita Levi Montalcini 4, 20090 Pieve Emanuele (Milan), Italy
| | - Maria Rescigno
- Humanitas Clinical and Research Center-IRCCS, via Manzoni 56, 20089 Rozzano (Milan), Italy. .,Humanitas University, Department of Biomedical Sciences, via Rita Levi Montalcini 4, 20090 Pieve Emanuele (Milan), Italy
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22
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Kim HS, Seo HK. Emerging treatments for bacillus Calmette-Guérin-unresponsive non-muscle-invasive bladder cancer. Investig Clin Urol 2021; 62:361-377. [PMID: 34085791 PMCID: PMC8246016 DOI: 10.4111/icu.20200602] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
Intravesical bacillus Calmette–Guérin (BCG) immunotherapy has been the gold standard adjuvant treatment for intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC) after transurethral resection of bladder tumor (TURBT). BCG immunotherapy prevents disease recurrence and progression to muscle-invasive disease following TURBT. Although most patients initially respond well to intravesical BCG, considerable concern has been raised for patients with BCG failure who are refractory or recur in 6 months after their last BCG, which implies ‘BCG-unresponsiveness’. Based on current clinical guidelines, early radical cystectomy (RC) is recommended to treat BCG-unresponsive NMIBC. However, due to the high risk of morbidity and mortality of RC and patients' desire to preserve their own bladder, there is a critical unmet need for alternative conservative treatments as bladder-sparing strategies in BCG-unresponsive patients. Trials for effective bladder-sparing treatments are ongoing, and several novel agents have been recently tested in the NMIBC setting. The goal of this review is to introduce and summarize recently reported novel and emerging drugs and ongoing clinical trials for BCG-unresponsive NMIBC.
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Affiliation(s)
- Hyung Suk Kim
- Department of Urology, Dongguk University Ilsan Medical Center, Dongguk University School of Medicine, Goyang, Korea
| | - Ho Kyung Seo
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, Korea.,Division of Tumor Immunology, Department of Cancer Biomedical Science, Research Institute, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea.
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Moe A, Liow E, Redfern A, Swarbrick N, Ferguson T, Davis ID, Hayne D. A phase I open label dose-escalation study to evaluate the tolerability, safety and immunological efficacy of sub-urothelial durvalumab injection in adults with muscle-invasive or high-risk non-muscle-invasive bladder cancer (SUBDUE-1, SUB-urothelial DUrvalumab injection-1 study): clinical trial protocol. BJU Int 2021; 128 Suppl 1:9-17. [PMID: 33960102 DOI: 10.1111/bju.15365] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES This article presents the clinical trial protocol for a phase I open label dose-escalation study to evaluate the tolerability, safety and immunological efficacy of sub-urothelial durvalumab injection in adults with muscle-invasive or high-risk non-muscle-invasive bladder cancer (NMIBC), the SUB-urothelial DUrvalumab injection-1 study (SUBDUE-1). The primary objectives of this study are to assess the safety of sub-urothelial injection of durvalumab using patient reported outcome measures and observed local or systemic adverse events. The secondary objectives are to examine the local immunological efficacy of sub-urothelial administration of durvalumab. PATIENTS AND METHODS The SUBDUE-1 trial will include adult patients with either high-risk NMIBC or MIBC, who are scheduled for radical cystectomy or who have refused or are unsuitable for systemic neoadjuvant chemotherapy. Three fixed total dose levels of durvalumab (25, 75, 150 mg) will be studied to identify a dose suitable to be taken forward into phase II trials. The primary endpoint is to evaluate the safety and tolerability of the trial intervention in terms of the incidence and severity of adverse events and the potential establishment of dose-limiting toxicities. The secondary efficacy endpoints include rates of pT0 status at resection, lymph node status, as well as the change in distribution of tumour-infiltrating lymphocytes and tumour-activated macrophages between pre- and post-injection bladder biopsies. Translational studies will focus on bladder tumour molecular sub-typing, immune infiltrate characterisation, and immune checkpoint protein expression relative to efficacy end-points. OUTCOME AND SIGNIFICANCE If proven safe and effective, this novel strategy comprising sub-urothelial durvalumab injections aimed at promoting an anti-tumour immune reaction, will provide additional treatment options for reducing tumour recurrence and progression in treatment-naïve patients with high-risk NMIBC or in patients with bacille Calmette-Guérin-refractory NMIBC. Local administration of durvalumab may be associated with a reduced rate of immunological side-effects and lower costs when compared to systemic delivery.
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Affiliation(s)
- Andrew Moe
- University of Western Australia (UWA) Medical School, University of Western Australia, Perth, WA, Australia.,Urology and Medical Oncology Departments, South Metropolitan Health Service, Perth, WA, Australia.,Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia
| | - Elizabeth Liow
- Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia
| | - Andrew Redfern
- University of Western Australia (UWA) Medical School, University of Western Australia, Perth, WA, Australia.,Urology and Medical Oncology Departments, South Metropolitan Health Service, Perth, WA, Australia.,Cancer Division, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - Nicole Swarbrick
- Department of Anatomical Pathology, PathWest Laboratory Medicine WA, Perth, WA, Australia.,Division of Pathology and Laboratory Medicine, UWA Medical School, University of Western Australia, Perth, WA, Australia
| | - Tom Ferguson
- Urology and Medical Oncology Departments, South Metropolitan Health Service, Perth, WA, Australia
| | - Ian D Davis
- Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Vic., Australia.,Department of Oncology, Eastern Health, Melbourne, Vic., Australia
| | - Dickon Hayne
- University of Western Australia (UWA) Medical School, University of Western Australia, Perth, WA, Australia.,Urology and Medical Oncology Departments, South Metropolitan Health Service, Perth, WA, Australia.,Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia
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24
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Álvarez-Maestro M, Guerrero-Ramos F, Rodríguez-Faba O, Domínguez-Escrig J, Fernández-Gómez J. Current treatments for BCG failure in non-muscle invasive bladder cancer (NMIBC). Actas Urol Esp 2021; 45:93-102. [PMID: 33012593 DOI: 10.1016/j.acuro.2020.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/22/2020] [Indexed: 12/17/2022]
Abstract
The treatment of choice for high-risk non-muscle invasive bladder cancer (NMIBC) is bacillus Calmette-Guérin (BCG). However, when this fails, the indicated treatment is radical cystectomy. In recent years, trials are being developed with various drugs to avoid this surgery in patients with BCG failure. The aim of this article is to update the treatments under study for bladder preservation in this patient population. Non-systematic review, searching PubMed with the terms "Bladder cancer", "Non-muscle invasive bladder cancer", "NMIBC", "BCG", "BCG-refractory", "Mitomycin C", "MMC", "Hyperthermia", "Electromotive Drug Administration", "EMDA". We used the search engines clinicaltrials.gov and clinicaltrialsregister.eu to find clinical trials. The only intravesical drug approved by the Food and Drug Administration (FDA) for carcinoma in situ (CIS) after failure to BCG is Valrubicin. Recently, the FDA has approved intravenous Pembrolizumab, following the publication of preliminary data from the KEYNOTE-057 study. Atezolizumab has demonstrated similar preliminary efficacy results. Only microwave-induced chemohyperthermia and EMDA-MMC (Electromotive Drug Administration) are recognized as alternatives in European guidelines. Other options under investigation are taxanes and gemcitabine, alone or in combination, recombinant viruses and device-assisted intravesical chemohyperthermia. The results of new drugs are promising, with a large number of trials underway. Knowing the mechanisms of resistance to BCG is essential to explore new therapeutic options.
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25
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Cuzzubbo S, Mangsbo S, Nagarajan D, Habra K, Pockley AG, McArdle SEB. Cancer Vaccines: Adjuvant Potency, Importance of Age, Lifestyle, and Treatments. Front Immunol 2021; 11:615240. [PMID: 33679703 PMCID: PMC7927599 DOI: 10.3389/fimmu.2020.615240] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/23/2020] [Indexed: 12/13/2022] Open
Abstract
Although the discovery and characterization of multiple tumor antigens have sparked the development of many antigen/derived cancer vaccines, many are poorly immunogenic and thus, lack clinical efficacy. Adjuvants are therefore incorporated into vaccine formulations to trigger strong and long-lasting immune responses. Adjuvants have generally been classified into two categories: those that ‘depot’ antigens (e.g. mineral salts such as aluminum hydroxide, emulsions, liposomes) and those that act as immunostimulants (Toll Like Receptor agonists, saponins, cytokines). In addition, several novel technologies using vector-based delivery of antigens have been used. Unfortunately, the immune system declines with age, a phenomenon known as immunosenescence, and this is characterized by functional changes in both innate and adaptive cellular immunity systems as well as in lymph node architecture. While many of the immune functions decline over time, others paradoxically increase. Indeed, aging is known to be associated with a low level of chronic inflammation—inflamm-aging. Given that the median age of cancer diagnosis is 66 years and that immunotherapeutic interventions such as cancer vaccines are currently given in combination with or after other forms of treatments which themselves have immune-modulating potential such as surgery, chemotherapy and radiotherapy, the choice of adjuvants requires careful consideration in order to achieve the maximum immune response in a compromised environment. In addition, more clinical trials need to be performed to carefully assess how less conventional form of immune adjuvants, such as exercise, diet and psychological care which have all be shown to influence immune responses can be incorporated to improve the efficacy of cancer vaccines. In this review, adjuvants will be discussed with respect to the above-mentioned important elements.
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Affiliation(s)
- Stefania Cuzzubbo
- Université de Paris, PARCC, INSERM U970, 75015, Paris, France.,Laboratoire de Recherches Biochirurgicales (Fondation Carpentier), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
| | - Sara Mangsbo
- Ultimovacs AB, Uppsala, Sweden.,Department of Pharmaceutical Biosciences, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Divya Nagarajan
- Department of Immunology, Genetics and Clinical pathology Rudbeck laboratories, Uppsala University, Uppsala, Sweden
| | - Kinana Habra
- The School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom.,The John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Alan Graham Pockley
- The John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom.,Centre for Health, Ageing and Understanding Disease (CHAUD), School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Stephanie E B McArdle
- The John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom.,Centre for Health, Ageing and Understanding Disease (CHAUD), School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
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26
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[Treatment of Ta and T1 intermediate or high risk bladder cancer with intravesical Bacillus Calmette-Guérin or mitomycin C]. Urologe A 2021; 60:234-237. [PMID: 33479803 DOI: 10.1007/s00120-021-01443-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
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27
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Witjes JA. Device-Assisted Therapies for Nonmuscle-Invasive Bladder Cancer: A Practical Approach. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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28
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Di Gianfrancesco L, Ragonese M, Palermo G, Sacco E, Bassi P, Racioppi M. Second-Line Conservative Device-Assisted Intravesical Treatment in Selected Patients With Recurrent High-Risk Non-Muscle-Invasive Bladder Cancer. Clin Genitourin Cancer 2020; 19:e100-e119. [PMID: 33309565 DOI: 10.1016/j.clgc.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/31/2020] [Accepted: 11/02/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In cases of recurrent high-risk non-muscle-invasive bladder cancer, radical cystectomy (RC) is recommended. We compared oncologic and treatment-related outcomes of second-line conservative device-assisted therapy to RC. PATIENTS AND METHODS In a retrospective cohort study, we analyzed 209 consecutive patients with recurrent bacillus Calmette-Guérin-unresponsive high-risk non-muscle-invasive bladder cancer; 107 subjects refused RC and were offered electromotive drug administration (n = 44) or chemohyperthermia (n = 63) (group A), and 102 patients underwent RC (group B). In group A, patients who did not benefit from device-assisted treatment underwent RC. The endpoints were high-grade disease-free survival, progression-free survival, cancer-specific survival, overall survival, and treatment-related complications. Follow-up was based on international guideline recommendations. Analyses were performed with log-rank and Fisher exact tests. RESULTS The median follow-up was 59 months (SD ± 5.3). When comparing group A to B, overall survival rates were 91.6% and 90.2%, respectively (P > .05); cancer-specific survival was 94.4% and 96.1%, respectively (P > .05); high-grade disease-free survival was 43% and 74.5%, respectively (P < .05); and progression-free survival was 59.8% and 75.5%, respectively (P < .05). Patients with carcinoma-in-situ had worse oncologic outcomes compared to patients with papillary disease. In the multivariate analysis, multifocality, disease recurrence, and progression risk group were independently associated with device treatment failure. The 90-day RC-related overall complications rates were 63.9% in group A and 66.6% in group B (P = .63); grade 3 to 5 complications were 9.8% in group A and 9.8% in group B(P = .99). Complications within group A were comparable (P > .05). CONCLUSION Device-assisted treatment may a represent a valid second-line conservative tool in selected patients with recurrent high-risk non-muscle-invasive bladder cancer.
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Affiliation(s)
- Luca Di Gianfrancesco
- Department of Urology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore di Roma, Rome, Italy.
| | - Mauro Ragonese
- Department of Urology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore di Roma, Rome, Italy
| | - Giuseppe Palermo
- Department of Urology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore di Roma, Rome, Italy
| | - Emilio Sacco
- Department of Urology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore di Roma, Rome, Italy
| | - PierFrancesco Bassi
- Department of Urology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore di Roma, Rome, Italy
| | - Marco Racioppi
- Department of Urology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore di Roma, Rome, Italy
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Hashemi S, Sahai A, Malde S. Applications of electromotive drug administration in urology. Urol Ann 2020; 12:301-308. [PMID: 33776323 PMCID: PMC7992521 DOI: 10.4103/ua.ua_152_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 06/19/2020] [Indexed: 11/04/2022] Open
Abstract
To review all published evidence regarding the use of Electromotive Drug Administration (EMDA) for the management of urological conditions, focusing on efficacy and safety, and highlighting areas that require further study. The PubMed and Medline databases were searched up to July 23, 2019. All studies reporting the use of EMDA to enhance the intravesical administration of therapeutic drugs for urological conditions were included. Two reviewers independently screened all articles, searched the reference lists of retrieved articles, and performed the data extraction. Thirty-two studies were included. The use of EMDA has been reported in the following urological conditions: (1) nonmuscle-invasive bladder cancer (NMIBC); (2) overactive bladder; (3) bladder pain syndrome; (4) radiation cystitis; (5) detrusor acontractility; and (6) for analgesia prior to transurethral procedures. Overall, most studies are nonrandomized trials with small numbers of patients. The use of EMDA is reported to be safe and effective in all these conditions, with the highest level of evidence in NMIBC in the neoadjuvant and adjuvant setting. However, the low overall quality of evidence limits the conclusions that can be reached. The use of EMDA to improve the efficacy of intravesical treatments is promising, but the low overall quality of the evidence base has limited its widespread use. Future studies should compare EMDA to passive diffusion and current standard of care in large, randomized, and long-term studies to determine the efficacy, safety, and cost-effectiveness of this modality.
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Affiliation(s)
| | - Arun Sahai
- Department of Urology, Guy's Hospital, London, UK
| | - Sachin Malde
- Department of Urology, Guy's Hospital, London, UK
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30
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Carando R, Soldini E, Cotrufo S, Zazzara M, Ludovico GM. Electro-mediated drug administration of mitomycin C in preventing non-muscle-invasive bladder cancer recurrence and progression after transurethral resection of the bladder tumour in intermediate- and high-risk patients. Arab J Urol 2020; 19:71-77. [PMID: 33763251 PMCID: PMC7954506 DOI: 10.1080/2090598x.2020.1816150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective To evaluate the effectiveness of electro-mediated drug administration of mitomycin C (EMDA/MMC) after transurethral resection of the bladder tumour (TURBT) in preventing non-muscle-invasive bladder cancer (NMIBC) recurrence and progression and to explore clinical and demographic factors associated with treatment response. Patients and methods Between April 2016 and August 2019, 112 patients diagnosed with intermediate- or high-risk NMIBC underwent a TURBT followed by an EMDA/MMC treatment. The percentage of treatment responders and progression-free survivors at 3 and 6 months were evaluated. Results Follow-up data were available for 101 patients (90%) at 3 months and 92 (82%) at 6 months. Response rates to EMDA/MMC treatment were 85% at 3 months and 75% at 6 months, and progression-free rates were 94% and 90%, respectively. No statistically significant differences were seen between intermediate- and high-risk patients. A higher risk of tumour recurrence and progression was associated with previous Bacillus Calmette–Guérin (BCG) failure. According to the Clavien–Dindo classification, only low-grade complications were observed. Conclusions EMDA/MMC after TURBT was associated with high response and progression-free rates at 3 and 6 months, with only low-grade adverse events. These results confirm the efficacy and safety of EMDA/MMC as a therapeutic option for both intermediate- and high-risk patients. However, patients with BCG failure responded poorly to EMDA/MMC. Abbreviations: ACCI: age-adjusted Charlson Comorbidity Index; CHT: chemohyperthermia; CIS: carcinoma in situ; EMDA: electro-mediated drug administration; EORTC: European Organisation for Research and Treatment of Cancer; IQR: interquartile range; (N)MIBC: (non-)muscle-invasive bladder cancer; MMC: mitomycin C; OR, odds ratio; TURBT: transurethral resection of the bladder tumour
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Affiliation(s)
- Roberto Carando
- Klinik für Urologie, Luzerner Kantonsspital, Luzern, Switzerland.,Clinica Luganese Moncucco, Lugano, Switzerland.,Clinica S. Anna, Sorengo, Switzerland.,Clinica S. Chiara, Locarno, Switzerland
| | - Emiliano Soldini
- Department of Business Economics, Health and Social Care, Research Methodology Competence Centre, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland
| | - Simone Cotrufo
- Department of Urology, Ospedale F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Michele Zazzara
- Department of Urology, Ospedale F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Giuseppe M Ludovico
- Department of Urology, Ospedale F. Miulli, Acquaviva delle Fonti, Bari, Italy
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31
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Kiełbik A, Szlasa W, Saczko J, Kulbacka J. Electroporation-Based Treatments in Urology. Cancers (Basel) 2020; 12:E2208. [PMID: 32784598 PMCID: PMC7465806 DOI: 10.3390/cancers12082208] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 02/06/2023] Open
Abstract
The observation that an application of a pulsed electric field (PEF) resulted in an increased permeability of the cell membrane has led to the discovery of the phenomenon called electroporation (EP). Depending on the parameters of the electric current and cell features, electroporation can be either reversible or irreversible. The irreversible electroporation (IRE) found its use in urology as a non-thermal ablative method of prostate and renal cancer. As its mechanism is based on the permeabilization of cell membrane phospholipids, IRE (as well as other treatments based on EP) provides selectivity sparing extracellular proteins and matrix. Reversible EP enables the transfer of genes, drugs, and small exogenous proteins. In clinical practice, reversible EP can locally increase the uptake of cytotoxic drugs such as cisplatin and bleomycin. This approach is known as electrochemotherapy (ECT). Few in vivo and in vitro trials of ECT have been performed on urological cancers. EP provides the possibility of transmission of genes across the cell membrane. As the protocols of gene electrotransfer (GET) over the last few years have improved, EP has become a well-known technique for non-viral cell transfection. GET involves DNA transfection directly to the cancer or the host skin and muscle tissue. Among urological cancers, the GET of several plasmids encoding prostate cancer antigens has been investigated in clinical trials. This review brings into discussion the underlying mechanism of EP and an overview of the latest progress and development perspectives of EP-based treatments in urology.
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Affiliation(s)
- Aleksander Kiełbik
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (A.K.); (W.S.)
| | - Wojciech Szlasa
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (A.K.); (W.S.)
| | - Jolanta Saczko
- Department of Molecular and Cellular Biology, Wroclaw Medical University, 50-556 Wroclaw, Poland;
| | - Julita Kulbacka
- Department of Molecular and Cellular Biology, Wroclaw Medical University, 50-556 Wroclaw, Poland;
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Juvet T, Mari A, Lajkosz K, Wallis CJ, Kuk C, Erlich A, Krimus L, Fleshner NE, Kulkarni GS, Zlotta AR. Sequential administration of Bacillus Calmette-Guerin (BCG) and Electromotive Drug Administration (EMDA) of mitomycin C (MMC) for the treatment of high-grade nonmuscle invasive bladder cancer after BCG failure. Urol Oncol 2020; 38:850.e9-850.e15. [PMID: 32712139 DOI: 10.1016/j.urolonc.2020.06.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/08/2020] [Accepted: 06/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a need for effective nonsurgical treatment options in patients with nonmuscle invasive bladder cancer (NMIBC) in whom Bacillus Calmette-Guerin (BCG) therapy has failed. OBJECTIVE We aimed to determine the efficacy of Electromotive Drug Administration (EMDA) of mitomycin C (MMC) with NMIBC after BCG failure. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of 26 NMIBC patients in whom BCG therapy failed who received BCG/EMDA-MMC between 2013 and 2017 was performed. All but 4 patients fulfilled the FDA criteria for BCG unresponsive disease. Progression and recurrence-free survival (RFS)were calculated using Kaplan-Meier curves. Progression was defined as development of muscle invasive disease, presence of metastasis on imaging or treatment. We used FDA-defined criteria as complete response (CR) for single-arm trials of BCG-unresponsive patients. RESULTS AND LIMITATIONS Twenty-six patients were included. Initial pathology was carcinoma in situ (CIS) in 53.8% (14/26), pT1 in 34.6% (9/26), and pTa HG disease in 11.6% (3/26). Twelve of 26 patients progressed (46.2%). Following BCG/EMDA-MMC treatment, progression-free survival rates were 58.3% (95% confidence interval [CI] 41.1-82.1) at 1 year and 48.9% (95% CI 48.9) at 2 years from the date of induction of BCG/EMDA-MMC, respectively. RFS was 41.9% (95% CI 25.9-67.8) at 1 year and 27.2% (95% CI 13.6-54.4) at 2 years. CR at 6, 12, and 18 months was observed in 16 (61.5%), 11 (44.0%), and 7 patients (30.4%), respectively. Side effects included dysuria (19.2%), hematuria (19.2%), and frequency (11.5%). Three patients were admitted for side effects but managed conservatively. Four patients (15.4%) died of bladder cancer over the course of the study. CONCLUSIONS EMDA-MMC BCG represents a viable option in patients with BCG unresponsive NMIBC with close to 50% progression-free survival at 2 years. However, these patients have a high risk of death from bladder cancer (15% in our cohort at 2 years) thus warranting extremely close surveillance.
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Affiliation(s)
- Tristan Juvet
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada
| | - Andrea Mari
- Department of Urology, University of Florence, Florence, Italy
| | - Katherine Lajkosz
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada; Department of Biostatistics, University Health Network, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Christopher Jd Wallis
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada
| | - Cynthia Kuk
- Department of Surgery, Urology, Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - Annette Erlich
- Department of Surgery, Urology, Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - Lior Krimus
- University of Toronto, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Neil E Fleshner
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada
| | - Girish S Kulkarni
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada
| | - Alexandre R Zlotta
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada; Department of Surgery, Urology, Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada.
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33
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Jobczyk M, Stawiski K, Fendler W, Różański W. Validation of EORTC, CUETO, and EAU risk stratification in prediction of recurrence, progression, and death of patients with initially non-muscle-invasive bladder cancer (NMIBC): A cohort analysis. Cancer Med 2020; 9:4014-4025. [PMID: 32216043 PMCID: PMC7286464 DOI: 10.1002/cam4.3007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/25/2020] [Accepted: 03/01/2020] [Indexed: 11/09/2022] Open
Abstract
BRIEF DESCRIPTION The results demonstrate that the European Organisation for Research and Treatment of Cancer (EORTC) scale provides the best recurrence and progression prediction in comparison with European Association of Urology (EAU) and Club Urologico Espanol de Tratamiento Oncologico (CUETO) risk scores among a mixed population of patients with non-muscle-invasive bladder who were treated with, or without, Bacillus Calmette-Guerin (BCG) and without any immediate postoperative chemotherapy. The study highlights the role of tumor diameter and extent in transition prediction. This retrospective cohort analysis of 322 patients with newly diagnosed non-muscle-invasive bladder cancer (NMIBC) assesses the concordance and accuracy of predicting recurrence and progression by EAU-recommended tools (EAU risk groups, EORTC, and CUETO). One-year and five-year c-indices ranged from 0.55 to 0.66 for recurrence and from 0.72 to 0.82 for progression. AUCROC of predictions ranged from 0.46 for 1-year recurrence risk based on CUETO groups, to 0.82 for 1-year progression risk based on EAU risk groups. Diameter (HR: 1.91; 95% CI: 1.39-2.61) and tumor extent (HR: 1.21; 95% CI: 1.01-1.46 for recurrence; HR: 3.1; 95% CI: 1.40-6.87 for progression) were shown to be significant predictors in multistate analysis. Lower accuracy of prediction was observed for patients treated with BCG maintenance immunotherapy. The EORTC model (overall c-index c = 0.64; 95% CI: 0.61-0.68) was superior to the EAU (P = .035; .62; 95% CI: 0.59-0.66) and CUETO (P < .001; c = 0.53; 95% CI: 0.50-0.56) models in predicting recurrence. The EORTC model (c = 0.82; 95% CI: 0.77-0.86) also performed better than CUETO (P = .008; c = 0.73; 95% CI: 0.66-0.81) but there was no sufficient evidence that it performed better than EAU (P = .572; c = 0.81; 95% CI: 0.77-0.84) for predicting progression. EORTC and CUETO gave similar predictions for progression in BCG-treated EAU high-risk patients (P = .48). We share anonymized individual patient data. In conclusion, despite moderate accuracy, EORTC provided the best recurrence and progression prediction for a mixed population of patients treated with, or without BCG, and without immediate postoperative chemotherapy.
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Affiliation(s)
- Mateusz Jobczyk
- Department of UrologyCopernicus Memorial HospitalMedical University of LodzLodzPoland
- Department of UrologyThe Hospital Ministry of the Interior and AdministrationLodzPoland
| | - Konrad Stawiski
- Department of Biostatistics and Translational MedicineMedical University of LodzLodzPoland
| | - Wojciech Fendler
- Department of Biostatistics and Translational MedicineMedical University of LodzLodzPoland
- Department of Radiation OncologyDana‐Farber Cancer InstituteHarvard Medical SchoolBostonMAUSA
| | - Waldemar Różański
- Department of UrologyCopernicus Memorial HospitalMedical University of LodzLodzPoland
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Immunotherapy in Bladder Cancer: Current Methods and Future Perspectives. Cancers (Basel) 2020; 12:cancers12051181. [PMID: 32392774 PMCID: PMC7281703 DOI: 10.3390/cancers12051181] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/02/2020] [Accepted: 05/05/2020] [Indexed: 02/06/2023] Open
Abstract
Bladder cancer is one of the most significant genitourinary cancer, causing high morbidity and mortality in a great number of patients. Over the years, various treatment methods for this type of cancer have been developed. The most common is the highly efficient method using Bacillus Calmette-Guerin, giving a successful effect in a high percentage of patients. However, due to the genetic instability of bladder cancer, together with individual needs of patients, the search for different therapy methods is ongoing. Immune checkpoints are cell surface molecules influencing the immune response and decreasing the strength of the immune response. Among those checkpoints, the PD-1 (programmed cell death protein-1)/PD-L1 (programmed cell death protein ligand 1) inhibitors aim at blocking those molecules, which results in T cell activation, and in bladder cancer the use of Atezolizumab, Avelumab, Durvalumab, Nivolumab, and Pembrolizumab has been described. The inhibition of another pivotal immune checkpoint, CTLA-4 (cytotoxic T cell antigen), may result in the mobilization of the immune system against bladder cancer and, among anti-CTLA-4 antibodies, the use of Ipilimumab and Tremelimumab has been discussed. Moreover, several different approaches to successful bladder cancer treatment exists, such as the use of ganciclovir and mTOR (mammalian target of rapamycin) kinase inhibitors, IL-12 (interleukin-12) and COX-2 (cyclooxygenase-2). The use of gene therapies and the disruption of different signaling pathways are currently being investigated. Research suggests that the combination of several methods increases treatment efficiency and the positive outcome in individual.
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Treatment options and results of adjuvant treatment in nonmuscle-invasive bladder cancer (NMIBC) during the Bacillus Calmette–Guérin shortage. Curr Opin Urol 2020; 30:365-369. [DOI: 10.1097/mou.0000000000000739] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Larsen ES, Joensen UN, Poulsen AM, Goletti D, Johansen IS. Bacillus Calmette-Guérin immunotherapy for bladder cancer: a review of immunological aspects, clinical effects and BCG infections. APMIS 2020; 128:92-103. [PMID: 31755155 DOI: 10.1111/apm.13011] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/10/2019] [Indexed: 12/29/2022]
Abstract
Bacillus Calmette-Guérin (BCG) immunotherapy for bladder cancer has been used since 1976 when the first evidence of its ability to lower recurrence and progression rates was published. Today, BCG immunotherapy is the choice of care for high-grade non-muscle invasive bladder cancer (NMIBC) after transurethral resection. This article presents indications and procedure of BCG instillations, and outlines the effects on recurrence and progression of NMIBC. The BCG-induced immunity in NMIBC is not yet fully understood. Animal studies point towards BCG inducing specific tumour immunity. We describe the current knowledge of how this immunity is induced, from internalization of BCG bacilli in urothelial cells, to cytokine- and chemokine-mediated recruitment of neutrophils, monocytes, macrophages, T cells, B cells and natural killer cells. In addition, we describe the process of trained immunity, the non-specific protective effects of BCG. Recent studies also indicate that dysbiosis of the urinary microbiome may cause lower urinary tract dysfunction. Side effects of BCG bladder instillations range from common, mild and transient symptoms, such as dysuria and flu-like symptoms, to more severe and rarely occurring life-threatening complications. We review the literature and give an overview of reported incidences and management of BCG infections after intravesical instillation.
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Affiliation(s)
| | - Ulla Nordström Joensen
- Department of Urology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Alicia Martin Poulsen
- Department of Urology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases IRCCS L. Spallanzani, Rome, Italy
| | - Isik Somuncu Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Mycobacterial Centre for Research Southern Denmark - MyCRESD, Odense, Denmark
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Chehroudi AC, Black PC. Emerging intravesical therapies for the management of bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer: Charting a path forward. Can Urol Assoc J 2020; 14:204-213. [PMID: 31977307 DOI: 10.5489/cuaj.6101] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Management of patients with bacillus Calmette-Guérin (BCG)-unresponsive, high-risk, non-muscle-invasive bladder cancer (NMIBC) presents a formidable clinical challenge that requires urologists to weigh the competing risks of progression during further intravesical therapy vs. the morbidity of radical cystectomy. The prognosis of high-risk NMIBC recurring after BCG depends on the adequacy of prior BCG, timing of recurrence, and tumor histology. The standard of care is currently radical cystectomy, as effective salvage intravesical therapy has not been established. The development of bladder-sparing treatments has been hampered to date by inconsistent definitions of BCG failure and difficulties in identifying appropriate control treatments in clinical trials. Despite these limitations, the spectrum of salvage therapy is expanding to include enhanced intravesical chemo-, gene, and immuno-therapies. In this review, we provide an overview of these emerging agents in the context of our current understanding of BCG failure and the unique considerations for clinical trial design in this disease state.
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Affiliation(s)
- Ali Cyrus Chehroudi
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
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Schmidt S, Kunath F, Coles B, Draeger DL, Krabbe L, Dersch R, Kilian S, Jensen K, Dahm P, Meerpohl JJ. Intravesical Bacillus Calmette-Guérin versus mitomycin C for Ta and T1 bladder cancer. Cochrane Database Syst Rev 2020; 1:CD011935. [PMID: 31912907 PMCID: PMC6956215 DOI: 10.1002/14651858.cd011935.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND People with urothelial carcinoma of the bladder are at risk for recurrence and progression following transurethral resection of a bladder tumour (TURBT). Mitomycin C (MMC) and Bacillus Calmette-Guérin (BCG) are commonly used, competing forms of intravesical therapy for intermediate- or high-risk non-muscle invasive (Ta and T1) urothelial bladder cancer but their relative merits are somewhat uncertain. OBJECTIVES To assess the effects of BCG intravesical therapy compared to MMC intravesical therapy for treating intermediate- and high-risk Ta and T1 bladder cancer in adults. SEARCH METHODS We performed a systematic literature search in multiple databases (CENTRAL, MEDLINE, Embase, Web of Science, Scopus, LILACS), as well as in two clinical trial registries. We searched reference lists of relevant publications and abstract proceedings. We applied no language restrictions. The latest search was conducted in September 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared intravesical BCG with intravesical MMC therapy for non-muscle invasive urothelial bladder cancer. DATA COLLECTION AND ANALYSIS Two review authors independently screened the literature, extracted data, assessed risk of bias and rated the quality of evidence according to GRADE per outcome. In the meta-analyses, we used the random-effects model. MAIN RESULTS We identified 12 RCTs comparing BCG versus MMC in participants with intermediate- and high-risk non-muscle invasive bladder tumours (published from 1995 to 2013). In total, 2932 participants were randomised. Time to death from any cause: BCG may make little or no difference on time to death from any cause compared to MMC (hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.79 to 1.20; participants = 1132, studies = 5; 567 participants in the BCG arm and 565 in the MMC arm; low-certainty evidence). This corresponds to 6 fewer deaths (40 fewer to 36 more) per 1000 participants treated with BCG at five years. We downgraded the certainty of the evidence two levels due to study limitations and imprecision. Serious adverse effects: 12/577 participants treated with BCG experienced serious non-fatal adverse effects compared to 4/447 participants in the MMC group. The pooled risk ratio (RR) is 2.31 (95% CI 0.82 to 6.52; participants = 1024, studies = 5; low-certainty evidence). Therefore, BCG may increase the risk for serious adverse effects compared to MMC. This corresponds to nine more serious adverse effects (one fewer to 37 more) with BCG. We downgraded the certainty of the evidence two levels due to study limitations and imprecision. Time to recurrence: BCG may reduce the time to recurrence compared to MMC (HR 0.88, 95% CI 0.71 to 1.09; participants = 2616, studies = 11, 1273 participants in the BCG arm and 1343 in the MMC arm; low-certainty evidence). This corresponds to 41 fewer recurrences (104 fewer to 29 more) with BCG at five years. We downgraded the certainty of the evidence two levels due to study limitations, imprecision and inconsistency. Time to progression: BCG may make little or no difference on time to progression compared to MMC (HR 0.96, 95% CI 0.73 to 1.26; participants = 1622, studies = 6; 804 participants in the BCG arm and 818 in the MMC arm; low-certainty evidence). This corresponds to four fewer progressions (29 fewer to 27 more) with BCG at five years. We downgraded the certainty of the evidence two levels due to study limitations and imprecision. Quality of life: we found very limited data for this outcomes and were unable to estimate an effect size. AUTHORS' CONCLUSIONS Based on our findings, BCG may reduce the risk of recurrence over time although the Confidence Intervals include the possibility of no difference. It may have no effect on either the risk of progression or risk of death from any cause over time. BCG may cause more serious adverse events although the Confidence Intervals once again include the possibility of no difference. We were unable to determine the impact on quality of life. The certainty of the evidence was consistently low, due to concerns that include possible selection bias, performance bias, given the lack of blinding in these studies, and imprecision.
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Affiliation(s)
- Stefanie Schmidt
- UroEvidence@Deutsche Gesellschaft für UrologieMartin‐Buber‐Str. 10BerlinGermany14163
| | - Frank Kunath
- UroEvidence@Deutsche Gesellschaft für UrologieMartin‐Buber‐Str. 10BerlinGermany14163
- University Hospital ErlangenDepartment of UrologyKrankenhausstrasse 12ErlangenGermany91054
| | - Bernadette Coles
- Cardiff University Library ServicesVelindre NHS TrustVelindre Cancer CentreWhitchurchCardiffUKCF14 2TL
| | - Desiree Louise Draeger
- UroEvidence@Deutsche Gesellschaft für UrologieMartin‐Buber‐Str. 10BerlinGermany14163
- University of RostockDepartment of UrologyErnst‐Heydemann‐Strasse 7RostockMecklenburg‐VorpommernGermany18057
| | - Laura‐Maria Krabbe
- UroEvidence@Deutsche Gesellschaft für UrologieMartin‐Buber‐Str. 10BerlinGermany14163
- University of Muenster Medical CenterDepartment of UrologyAlbert‐Schweitzer Campus 1, GB A1MuensterNRWGermany48149
| | - Rick Dersch
- Medical Center – University of FreiburgDepartment of Neurology and NeurophysiologyBerliner Allee 29FreiburgGermany79110
| | - Samuel Kilian
- University of HeidelbergInstitute of Medical Biometry and InformaticsHeidelbergGermany
| | - Katrin Jensen
- University of HeidelbergInstitute of Medical Biometry and InformaticsHeidelbergGermany
| | - Philipp Dahm
- Minneapolis VA Health Care SystemUrology SectionOne Veterans DriveMail Code 112DMinneapolisMinnesotaUSA55417
- University of MinnesotaDepartment of Urology420 Delaware Street SEMMC 394MinneapolisMinnesotaUSA55455
| | - Joerg J Meerpohl
- Medical Center ‐ University of Freiburg, Faculty of Medicine, University of
FreiburgInstitute for Evidence in MedicineBreisacher Str. 153FreiburgGermanyD‐79110
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Tan WP, Longo TA, Inman BA. Heated Intravesical Chemotherapy: Biology and Clinical Utility. Urol Clin North Am 2019; 47:55-72. [PMID: 31757301 DOI: 10.1016/j.ucl.2019.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Non-muscle-invasive bladder cancer can be a challenging disease to manage. In recent years, hyperthermia therapy in conjunction with intravesical therapy has been gaining traction as a treatment option for bladder cancer, especially if Bacillus Calmette-Guerin might not be available. Trials of intravesical chemotherapy with heat are few and there has been considerable heterogeneity between studies. However, multiple new trials have accrued and high-quality data are forthcoming. In this review, we discuss the role of combined intravesical hyperthermia and chemotherapy as a novel approach for the treatment of bladder cancer.
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Affiliation(s)
- Wei Phin Tan
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
| | - Thomas A Longo
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA
| | - Brant A Inman
- Division of Urology, Duke University Medical Center, Durham, NC 27710, USA.
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Arends TJH, Alfred Witjes J. Apaziquone for Nonmuscle Invasive Bladder Cancer: Where Are We Now? Urol Clin North Am 2019; 47:73-82. [PMID: 31757302 DOI: 10.1016/j.ucl.2019.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Apaziquone is an interesting drug for intravesical use in patients with nonmuscle invasive bladder cancer; however, more research is needed to prove its actual benefit. Although the apaziquone trials demonstrate the potential of this new drug, the singular phase 3 trials did not reach their primary endpoint. To date, no new trials are recruiting, so the development of apaziquone seems to have stopped.
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Affiliation(s)
- Tom J H Arends
- Department of Urology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Johannes Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Geert Groote plein zuid 10, 6525 GA Nijmegen, The Netherlands.
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Hobbs C, Bass E, Crew J, Mostafid H. Intravesical BCG: where do we stand? Past, present and future. JOURNAL OF CLINICAL UROLOGY 2019. [DOI: 10.1177/2051415818817120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
High and intermediate risk non-muscle invasive bladder cancer poses a real challenge for treatment. Approximately 70% of bladder cancer presents as non-muscle invasive and 20–25% will progress to muscle invasive disease. Recurrences occur in up to 70% but treatment options are limited. Intravesical bacillus Calmette–Guérin is still considered the bladder sparing treatment of choice despite its well documented pitfalls. This review considers how bacillus Calmette–Guérin has become the recommended treatment, its benefits and risks and the alternative options for treatment. Level of evidence: Not applicable for this multicentre audit.
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Affiliation(s)
| | - Edward Bass
- Department of Urology, Royal Surrey County NHS Foundation Trust, UK
| | - Jeremy Crew
- Department of Urology, Churchill Hospital, UK
| | - Hugh Mostafid
- Department of Urology, Royal Surrey County NHS Foundation Trust, UK
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Abstract
PURPOSE OF REVIEW To review the current literature concerning the intravesical treatment of nonmuscle invasive bladder cancer. RECENT FINDINGS Bladder cancer is a high prevalent disease. Despite the recognized efficacy of traditional intravesical therapies, the best treatment strategy still needs to be found. Improvement in bladder cancer research lead to develop new intravesical agents and drug delivery systems for nonmuscle invasive bladder cancer tumours. Moreover, the emerging knowledge of bladder cancer immune profile strongly improves and provides new available treatment strategies. SUMMARY The future of nonmuscle invasive bladder cancer therapy will be influenced by the development of immunotherapy and new technologies for device-assisted treatment. Moreover, nanotechnology and delivery systems present promising results.
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Abstract
Non-muscle-invasive bladder cancer (NMIBC), the most prevalent type of bladder cancer, accounts for ~75% of bladder cancer diagnoses. This disease has a 50% risk of recurrence and 20% risk of progression within 5 years, despite the use of intravesical adjuvant treatments (such as BCG or mitomycin C) that are recommended by clinical guidelines. Intravesical device-assisted therapies, such as radiofrequency-induced thermochemotherapeutic effect (RITE), conductive hyperthermic chemotherapy, and electromotive drug administration (EMDA), have shown promising efficacy. These device-assisted treatments are an attractive alternative to BCG, as issues with supply have been a problem in some countries. RITE might be an effective treatment option for some patients who have experienced BCG failure and are not candidates for radical cystectomy. Data from trials using EMDA suggest that it is effective in high-risk disease but requires further validation, and results of randomized trials are eagerly awaited for conductive hyperthermic chemotherapy. Considerable heterogeneity in patient cohorts, treatment sessions, use of maintenance regimens, and single-arm study design makes it difficult to draw solid conclusions, although randomized controlled trials have been reported for RITE and EMDA.
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Anderson B. Bladder cancer: overview and disease management. Part 1: non-muscle-invasive bladder cancer. ACTA ACUST UNITED AC 2019; 27:S27-S37. [PMID: 29749774 DOI: 10.12968/bjon.2018.27.9.s27] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Part 1 of this two-part article provides an overview of bladder cancer and discusses its management. Since publication of a previous article entitled 'Understanding the role of smoking in the aetiology of bladder cancer' ( Anderson, 2009 ), the author has received many requests for an update. This article provides an overview of bladder cancer and its current management practices, underlining the continued role of smoking as the predominant risk factor in the disease's development. The management of bladder cancer is governed by specific guidelines. Management of non-muscle-invasive cancers, including surgical intervention with transurethral resection, and intravesical therapy using chemotherapy and immunotherapy agents, is discussed. Cystectomy (removal of the bladder), is sometimes necessary. Treatments are effective in reducing tumour recurrence, but the effects of the risks and side-effects on the individual's quality of life can be significant. The prevalence of bladder cancer, and the nature of its management make this cancer one of the most expensive for the NHS to treat. The effectiveness of health promotional strategies in increasing peoples' awareness of their risk of developing the disease, and in enabling them to change long-term health behaviours is discussed. The role of the multidisciplinary team is explored, along with that of the uro-oncology cancer nurse specialist. Part 2 will consider the management of muscle-invasive and metastatic bladder cancer.
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Affiliation(s)
- Beverley Anderson
- Macmillan Uro-oncology Clinical Nurse Specialist, Epsom and St Helier University Hospitals NHS Trust
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Joice GA, Bivalacqua TJ, Kates M. Optimizing pharmacokinetics of intravesical chemotherapy for bladder cancer. Nat Rev Urol 2019; 16:599-612. [PMID: 31434998 DOI: 10.1038/s41585-019-0220-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2019] [Indexed: 12/20/2022]
Abstract
Non-muscle-invasive bladder cancer (NMIBC) remains one of the most common malignancies and is associated with considerable treatment costs. Patients with intermediate-risk or high-risk disease can be treated with intravesical BCG, but many of these patients will experience tumour recurrence, despite adequate treatment. Standard of care in these patients is radical cystectomy with urinary diversion, but this approach is associated with considerable morbidity and lifestyle modification. As an alternative, perioperative intravesical chemotherapy is recommended for low-risk papillary NMIBC, and induction intravesical chemotherapy is an option for patients with intermediate-risk NMIBC and BCG-unresponsive NMIBC. However, poor pharmaceutical absorption and drug washout during normal voiding can limit sustained drug concentrations in the urothelium, which reduces efficacy, and small-molecule chemotherapeutic agents can be absorbed through the urothelium into the bloodstream, leading to systemic adverse effects. Several novel drug delivery methods - including hyperthermia, mechanical sustained released devices and nanoparticle drug conjugation - have been developed to overcome these limitations. These novel methods have the potential to be combined with established chemotherapeutic agents to change the paradigm of NMIBC treatment.
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Affiliation(s)
- Gregory A Joice
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Max Kates
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Babjuk M, Burger M, Compérat EM, Gontero P, Mostafid AH, Palou J, van Rhijn BWG, Rouprêt M, Shariat SF, Sylvester R, Zigeuner R, Capoun O, Cohen D, Escrig JLD, Hernández V, Peyronnet B, Seisen T, Soukup V. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ) - 2019 Update. Eur Urol 2019; 76:639-657. [PMID: 31443960 DOI: 10.1016/j.eururo.2019.08.016] [Citation(s) in RCA: 822] [Impact Index Per Article: 164.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022]
Abstract
CONTEXT This overview presents the updated European Association of Urology (EAU) guidelines for non-muscle-invasive bladder cancer (NMIBC), TaT1, and carcinoma in situ (CIS). OBJECTIVE To provide practical recommendations on the clinical management of NMIBC with a focus on clinical presentation and recommendations. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines has been performed annually since the last published version in 2017. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS Tumours staged as Ta, T1, and/or CIS are grouped under the heading of NMIBC. Diagnosis depends on cystoscopy and histological evaluation of the tissue obtained by transurethral resection (TURB) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TURB is essential for the patient's prognosis and correct diagnosis. Where the initial resection is incomplete, where there is no muscle in the specimen, or where a T1 tumour is detected, a second TURB should be performed within 2-6 wk. The risks of both recurrence and progression may be estimated for individual patients using the European Organisation for Research and Treatment of Cancer (EORTC) scoring system. Stratification of patients into low-, intermediate-, and high-risk groups is pivotal to the recommendation of adjuvant treatment. In patients with tumours presumed to be at a low risk and in those presumed to be at an intermediate risk with a low previous recurrence rate and an expected EORTC recurrence score of <5, one immediate chemotherapy instillation is recommended. Patients with intermediate-risk tumours should receive 1 yr of full-dose bacillus Calmette-Guérin (BCG) intravesical immunotherapy or instillations of chemotherapy for a maximum of 1 yr. In patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. In patients at the highest risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is recommended in BCG-unresponsive tumours. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/. CONCLUSIONS These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology Non-muscle-invasive Bladder Cancer (NMIBC) Panel has released an updated version of their guidelines, which contains information on classification, risk factors, diagnosis, prognostic factors, and treatment of NMIBC. The recommendations are based on the current literature (until the end of 2018), with emphasis on high-level data from randomised clinical trials and meta-analyses. Stratification of patients into low-, intermediate-, and high-risk groups is essential for deciding appropriate use of adjuvant intravesical chemotherapy or bacillus Calmette-Guérin (BCG) instillations. Surgical removal of the bladder should be considered in case of BCG-unresponsive tumours or in NMIBCs with the highest risk of progression.
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Affiliation(s)
- Marko Babjuk
- Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria.
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Eva M Compérat
- Department of Pathology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, UPMC Paris VI, Paris, France
| | - Paolo Gontero
- Division of Urology, Molinette Hospital, University of Studies of Torino, Torino, Italy
| | - A Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Bas W G van Rhijn
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany; Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Morgan Rouprêt
- Urology Department, Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, 2nd Faculty of Medicine, Hospital Motol, Charles University, Prague, Czech Republic; Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Richard Sylvester
- European Association of Urology Guidelines Office, Brussels, Belgium
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Otakar Capoun
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Daniel Cohen
- Department of Urology, Royal Free London NHS Foundation Trust, London, UK
| | | | - Virginia Hernández
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Thomas Seisen
- Urology Department, Sorbonne Université, GRC n°5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Viktor Soukup
- Department of Urology, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
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48
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Li G, Lei Q, Wang F, Deng D, Wang S, Tian L, Shen W, Cheng Y, Liu Z, Wu S. Fluorinated Polymer Mediated Transmucosal Peptide Delivery for Intravesical Instillation Therapy of Bladder Cancer. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2019; 15:e1900936. [PMID: 31074941 DOI: 10.1002/smll.201900936] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/29/2019] [Indexed: 06/09/2023]
Abstract
Surgical intervention combined with intravesical instillation of chemotherapeutics to clear residual cancer cells after operation is the current standard treatment method for bladder cancer. However, the poor bioavailability of active pharmaceutical ingredients for bladder cancer cells on account of the biological barriers of bladder mucosa, together with significant side effects of currently used intravesical medicine, have limited the clinical outcomes of localized adjuvant therapy for bladder cancer. Aiming at improved intravesical instillation therapy of bladder cancer, a fluorinated polyethylenimine (F-PEI) is employed here for the transmucosal delivery of an active venom peptide, polybia-mastoparan I (MPI), which shows selective antiproliferative effect against various bladder cancer cell lines. Upon simple mixing, MPI and F-PET would coassemble to form stable nanoparticles, which show greatly improved cross-membrane and transmucosal penetration capacities compared with MPI alone or nonfluorinated MPI/PEI nanoparticles. MPI/F-PEI shows higher in vivo tumor growth inhibition efficacy for local treatment of a subcutaneous tumor model. More excitingly, as further demonstrated in an orthotopic bladder cancer model, MPI/F-PEI offers remarkably improved therapeutic effects compared to those achieved by free MPI or the first-line bladder cancer drug mitomycin C. This work presents a new transmucosal delivery carrier particularly promising for intravesical instillation therapy of bladder cancer.
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Affiliation(s)
- Guangzhi Li
- Department of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen, 518000, China
- Shenzhen Following Precision Medical Research Institute, Shenzhen, 518000, China
| | - Qifang Lei
- Department of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen, 518000, China
- Shenzhen Following Precision Medical Research Institute, Shenzhen, 518000, China
| | - Fei Wang
- Department of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen, 518000, China
- Shenzhen Following Precision Medical Research Institute, Shenzhen, 518000, China
| | - Dashi Deng
- Department of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen, 518000, China
- Shenzhen Following Precision Medical Research Institute, Shenzhen, 518000, China
| | - Shupeng Wang
- Department of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen, 518000, China
- Shenzhen Following Precision Medical Research Institute, Shenzhen, 518000, China
| | - Longlong Tian
- Institute of Functional Nano and Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-Based Functional Materials and Devices, Soochow University, Suzhou, 215123, China
| | - Wanwan Shen
- Shanghai Key Laboratory of Regulatory Biology, School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Yiyun Cheng
- Shanghai Key Laboratory of Regulatory Biology, School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Zhuang Liu
- Institute of Functional Nano and Soft Materials (FUNSOM), Jiangsu Key Laboratory for Carbon-Based Functional Materials and Devices, Soochow University, Suzhou, 215123, China
| | - Song Wu
- Department of Urology, The Affiliated Luohu Hospital of Shenzhen University, Shenzhen University, Shenzhen, 518000, China
- Shenzhen Following Precision Medical Research Institute, Shenzhen, 518000, China
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49
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Abstract
Non-muscle invasive bladder cancer (NMIBC) is a challenging disease, with a high risk of recurrence and even progression to muscle invasive disease. The present standard treatment is suboptimal, and consists of a complete transurethral resection of the visible bladder tumour(s), followed by prophylactic intravesical instillations mitomycin-C (MMC) or bacillus Calmette-Guérin (BCG). In search for higher efficacy, several adjuvant device-assisted intravesical therapies are developed. Chemohyperthermia may be based on microwave-/radiofrequency-induced (RF) hyperthermia systems, for which most evidence exists, or on hyperthermic intravesical chemotherapy, which is applied by conductive or loco-regional heating systems. RF-induced CHT has shown superiority over MMC alone, and in one prospective study superiority over BCG in per-protocol analysis, which has led to the ‘weak’ recommendation in the EAU guidelines to consider RF-based CHT as a bladder preservation strategy in patients with BCG-refractory tumours, who are not candidates for radical cystectomy due to comorbidities. Prospective studies on hyperthermic intravesical chemotherapy for patients with intermediate-risk NMIBC are awaited next year. The combination of electromotive drug administration (EMDA) with MMC has shown superiority over MMC as well, and seems promising when combined with BCG in sequential treatment. Photodynamic therapy should still be considered experimental, in which a study with the intravenous photosensitizer Radachlorin® has shown promising results.
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Affiliation(s)
- Kees Hendricksen
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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50
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Urothelial Carcinoma In Situ and Treatment of Bacillus Calmette-Guérin Failures. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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