Clinical outcome of conservative therapy for stage T1, grade 3 transitional cell carcinoma of the bladder

Bacillus Calmette-Guérin (BCG) Treatment Failures in Non-Muscle Invasive Bladder Cancer: What Truly Constitutes Unresponsive Disease

Bacillus Calmette-Guérin (BCG) remains the most effective intravesical therapy for non-muscle invasive bladder cancer but will fail in up to 40% of patients. The ability to identify patients who are least likely to respond to further BCG therapy allows urologists to pursue secondary treatments more likely to convey a recurrence or survival benefit to the patient. We examined the literature to determine what constitutes BCG unresponsive disease. After review, we believe that BCG unresponsive disease should be defined as (1) patients with recurrent high grade T1 disease within 6 months of their primary tumor after at least one course of BCG or patients who have failed at least 2 courses of BCG with either (2) persistent or recurrent pure papillary (Ta) disease within 6 months or (3) persistent or recurrent carcinoma in situ (CIS) within 12 months.

Salvage combination intravesical immunotherapy with Bacillus Calmette-Guérin and interferon-α2B: impact on recurrence, progression, and survival

BACKGROUND

The population of patients with bladder cancer who have recurrence following an initial instillation of Bacillus Calmette-Guérin (BCG) is critical to study, as treatment delay with repeated courses of intravesical therapy may yield poor prognosis in patients with disease progression.

OBJECTIVE

To evaluate our institution's experience with use of BCG alone and in combination with interferon (INF)-α2B in regard to the rates of bladder cancer recurrence, disease progression, need for eventual cystectomy, and survival in patients with initial BCG failure.

STUDY DESIGN

We identified a combined series of 139 patients who had undergone intravesical instillations of BCG alone (n = 114) or in combination with INF-α2B (n = 25) performed at Brigham and Women's Hospital, Boston, between 2002 and 2007. All patients previously received an initial 6-week course of BCG therapy and subsequently had BCG failure on follow-up cystoscopy. Study outcome measures included: time to cancer recurrence in patients, progression of disease, eventual cystectomy, and patient mortality.

RESULTS

At a median follow-up of 64.7 months from initial BCG administration, 84% of patients treated with BCG + INF-α2B had disease recurrence. The average time to recurrence was < 1 year, and 63% of patients had recurrence on the first post-treatment biopsy. Among patients with a positive first biopsy, 52% had disease progression on initial surveillance. Overall, disease progression was seen in 48% of patients receiving BCG + INF-α2B therapy, and 28% of all patients eventually underwent radical cystectomy. All outcomes occurred more frequently in patients undergoing combination intravesical therapy compared with patients given BCG monotherapy.

CONCLUSIONS

Patients with bladder cancer undergoing salvage intravesical BCG + INF-α2B at our institution had a > 50% chance of disease recurrence and progression, and > 25% of patients eventually proceeded to radical cystectomy. Randomized trials are needed to clarify the issues present in our findings and to determine the appropriate role for concomitant INF therapy in patients when BCG monotherapy has failed.

Controversial issues and optimal management of stage T1G3 bladder cancer

The management of T1G3 bladder cancer is controversial. Diagnostic methods, such as bladder mapping or second-look transurethral resection are recommended to assess risk. Bacillus Calmette-Guérin intravesical therapy with a maintenance regimen is recommended for solitary T1G3 tumors. The timing of radical cystectomy for these patients is controversial, but early recurrence during intravesical therapy is an indication for radical cystectomy. Multifocal disease, concomitant carcinoma in situ and disease in the prostatic urethra and bladder neck also suggest aggressive disease and cystectomy should be considered in these patients.

Livin-α promotes cell proliferation by regulating G1-S cell cycle transition in prostate cancer

BACKGROUND

Prostate cancer is the third most common cancer and the second leading cause of cancer death for males in US. Livin has recently been described as a cancer-associated member of inhibitor of apoptosis proteins family, highly expressed in prostate cancer. Livin gene encodes two splicing variants, termed Livin-α and Livin-β. We hypothesized that deregulation of proliferation could be due in part to Livin expression.

METHODS

Pathological analysis of Livin was performed in 20 prostate cancer tissues and 5 benign prostatic hyperplasia tissues. The expression of Livin isoforms was also investigated by Western blot in prostate cancer cell lines LNCaP and PC3. The role of Livin-α in vitro was further studied. Using Livin-α knockdown and overexpression models, cell cycle analysis, Ki-67 immunocytostaining, and MTT assay were performed respectively.

RESULTS

Livin expression positive ratio was shown to be 5.4%, 23.6%, 52.4%, 73.4% in benign prostatic hyperplasia, low, medium, and high grade of prostate cancer respectively, and Livin was positively correlated with clinical pathological grades of prostate cancer. Livin-α was expressed in both LNCaP and PC3; meanwhile; Livin-β was only detected in the PC3. Livin-α siRNA not only resulted in G(1)-S cell cycle arrest, but also strongly correlated with the descended proliferation index and survival rate in LNCaP. In comparison, overexpression of Livin-α resulted in an accelerated S phase entry combined with elevated proliferation index and survival in LNCaP.

CONCLUSIONS

Livin-α may promote cell proliferation by regulating G(1)-S cell cycle transition and possibly play an important part in initiation of prostate cancer.

Is T1G3 bladder cancer having a definite muscle layer in TUR specimens a highly progressive disease?

OBJECTIVE

Patients with T1G3 bladder cancer are at high risk of progression to muscle-invasive cancer, and early cystectomy is considered as a treatment option in this particular situation. On the other hand, understaging of T1G3 bladder cancer has been gradually proven as second or repeat transurethral resection (TUR) has been widely applied. To evaluate the real rate of progression, we investigated the prognosis of T1G3 bladder cancer in which a muscle layer was histologically confirmed in the TUR specimens.

METHODS

We retrospectively reviewed 48 patients with primary T1G3 bladder cancer in which a muscle layer in the TUR specimens was confirmed between 1990 and 2006 in our institute. We investigated recurrence and progression in 45 patients, excluding 3 who were immediately treated with radical cystectomy. Fifteen and 12 patients received intravesical treatment with bacillus Calmette-Guérin (BCG) and anticancer agents just after TUR, respectively. The remaining 18 did not have any such treatment.

RESULTS

Recurrence and progression were observed in 21 (47%) and 3 patients (6.7%), respectively, during a median follow-up period of 42.1 months. The 3-year recurrence-free and progression-free survival rates were 54% and 91%, respectively. No significant differences were observed in the rates between the patients with and without BCG treatment in the study.

CONCLUSIONS

There is a possibility that the progression rate in patients with T1G3 bladder cancer is not as high as previously reported when only patients whose muscle layer was histologically confirmed were analyzed. An adequate technique for TUR that unmistakably collects the muscle layer may be important to predict the outcome accurately.

Livin may serve as a marker for prognosis of bladder cancer relapse and a target of bladder cancer treatment

OBJECTIVES

To evaluate the expression of Livin in bladder cancer, investigate its clinical and prognostic implications, and explore the effect of gene Livin transfection on the proliferation and apoptosis in bladder cancer cells.

METHODS

The expression of Livinalpha and beta was detected in 48 bladder cancer samples (G(1) in 23 cases, G(2) in 17 cases, and G(3) in 8 cases. Of the 48 cases, 17 developed relapse) and 15 non-tumor bladder tissues by Western blot and reverse transcription PCR (RT-PCR). Livinalpha-pcDNA3.1(+) was constructed and transfected into T24, BIU-87 and EJ bladder cancer cells. The clone activity of the transfected cells was detected by colony formation analysis. MTT was used to determine the cell proliferation assay. Flow cytometry and acridine orange staining were used to examine apoptosis. Caspase 3 activity assay was also measured.

RESULTS

Expression of Livinalpha, but not beta, was detected in 19 of the 48 bladder cancer samples; G(1) was 39.13%, G(2) and G(3) were 41.18% and 37.50%, respectively, which showed no significant (P > 0.05), but not in 15 non-tumor bladder tissues. The positive rate of Livinalpha was significant higher in relapse tumors (58.82%) than in primary tumors (29.03%) (P < 0.05). By the end of 2 years follow-up, the relapse rate in Livin positive patients was 68.42%, and 37.93% in Livin negative group. The difference between the two groups was significant (P < 0.05). Additionally, overexpression of Livinalpha clearly stimulated cell proliferation and inhibited chemical induced apoptosis in bladder cancer cells.

CONCLUSIONS

Livin may serve as a promising marker to identify the relapse risk in bladder cancer, and targeting Livin could offer a therapeutic benefit in apoptosis-inducing treatment.

Recurrence pattern for superficial bladder cancer

AIM

Patients with superficial bladder tumors sometimes have long recurrence-free intervals. We evaluated whether patients with long recurrence-free periods had subsequent recurrences. We also clarified how these patients should be followed.

MATERIALS AND METHODS

We enrolled 244 patients with superficial bladder cancer (62 pTa and 182 pT1) treated by transurethral resection of bladder tumor (TURBT) and adjuvant chemotherapy with pirarubicin. Median follow up was 75.5 months. Patients were stratified by the length of their recurrence-free interval.

RESULTS

Recurrences occurred in 124 patients (50.8%). Of 185 patients who did not have a recurrence for the first 3 years, subsequent recurrences occurred in 65 patients; in more than half the first recurrence developed after 5 years or more. Ta tumors had a low recurrence rate (14.5%) with the first recurrence often developing after a long recurrence-free period. Of 40 patients who remained recurrence-free for 3 years or more after at least one recurrence occurred, 16 patients (40%) had subsequent recurrences. Furthermore, most of these patients who remained free of recurrence for more than 5 years eventually had a recurrence. The overall progression rate was 15.6%, and this did not relate to the length of the recurrence-free interval.

CONCLUSION

When patients did not have a recurrence for the first 3 years, tumors subsequently often recurred, even in pTa tumors. In patients with at least once recurrence, subsequent recurrences appear to occur irrespective of the length of the recurrence-free period. Thus, we recommend that all patients with superficial bladder tumors be followed for as long as possible.

Can intravesical bacillus Calmette-Guérin reduce recurrence in patients with superficial bladder cancer? A meta-analysis of randomized trials

OBJECTIVES

To determine whether intravesical bacillus Calmette-Guérin (BCG) administration reduces recurrence after transurethral resection of superficial bladder cancer using a meta-analysis.

METHODS

Published data of randomized clinical trials comparing transurethral resection plus intravesical BCG to either resection alone or resection plus another treatment were analyzed, considering possible confounding factors such as disease type, maintenance therapy, and others. Both the fixed effect model and the randomized effect model were applied, and the odds ratio (OR) with its 95% confidence interval (CI) was used as the effect size estimate.

RESULTS

We searched 176 trials, eliminated 151 of them, and identified 25 trials with recurrence information on 4767 patients. Of 2342 patients undergoing BCG therapy, 949 (40.5%) had tumor recurrence compared with 1205 (49.7%) of 2425 patients in the non-BCG group. In the combined results, a statistically significant difference in the OR for tumor recurrence between the BCG and no BCG-treated groups was found (randomized combined effect OR 0.61, 95% CI 0.46 to 0.80, P <0.0001). Stratified by BCG maintenance and disease type, the combined results of the individual reports showed statistical significance for BCG maintenance (OR 0.47, 95% CI 0.28 to 0.78, P = 0.004) and treatment of papillary carcinoma (OR 0.50, 95% CI 0.33 to 0.75, P = 0.0008). Chemotherapy and BCG plus chemotherapy/immunotherapy were not better than BCG alone.

CONCLUSIONS

Adjuvant intravesical BCG with maintenance treatment is effective for the prophylaxis of tumor recurrence in superficial bladder cancer. For patients with papillary carcinoma, adjuvant intravesical BCG with maintenance therapy should be offered as the treatment of choice.

Randomized study of single instillation of epirubicin for superficial bladder carcinoma: long-term clinical outcomes

PURPOSE

Intravesical instillation of epirubicin (EPI) is one of the most effective adjuvant therapies for nonmuscle-invasive bladder cancer postoperation. We evaluated the long-term efficacy of single dose intravesical epirubicin for superficial bladder carcinoma recurrence.

METHODS

Between June 1997 and May 1998, a total of 47 patients with resectable superficial bladder carcinoma (Ta-1, Grade 1-2), primary or recurrent with no recurrence during last one year, were enrolled in this study. All patients were randomized into 3 study groups: Group A-single epirubicin (80 mg/40 mL of normal saline) was administered into the bladder within 6 hours postoperation; Group B-40 mg Epirubicin consecutively; Group C-40 mg mitomycin C, consecutively. In Group B and C, instillation were given every week for 6- 8 weeks and then every one month for 10 months. Patients were followed up at 3, 6, 9, 12, 18, 24, 36, 48, and 60 months of treatment. The analyzed background factors were the therapeutic method, tumor recurrence, and side effects.

RESULTS

Of the 47 patients, 43 (91.5 percent) were eligible and were followed up for 5 years postoperation. The disease free intervals of the three groups were found to have no significant differences (F = 10.28, p > 0.05). The recurrence rates were 35.7 percent (5/14), 33.3 percent (5/15), and 40 percent (6/15), respectively (chi(2)= 0.83, p > 0.05). Side effects of group A (13.6 percent) was lower than that of Group B or C (53.3 percent and 46.7 percent, respectively) significantly (chi(2) test, p < 0.01).

CONCLUSIONS

These data indicate that single dose of epirubicin instillation postoperation can reduce the recurrence of superficial bladder carcinoma and has low side effects.

Limited significance of routine excretory urography in the follow-up of patients with superficial bladder cancer after transurethral resection

OBJECTIVES

To evaluate the utility of routine excretory intravenous urography (IVU) for detecting subsequent upper urinary tract cancer (UUTC) during the follow-up of patients with superficial bladder cancer.

PATIENTS AND METHODS

The study included 413 patients who had transurethral resection (TUR) of superficial bladder cancer between January 1986 and December 2003, and were followed for at least 1 year. After TUR, patients were followed by periodic cystoscopy, urinary cytology and IVU. The risk factors for UUT recurrence after TUR were analysed, and based on this outcome, we then determined whether routine IVU should be used for patients with superficial bladder cancer.

RESULTS

During the observation period, UUTCs developed in 20 of the 413 patients (4.8%) within a median of 33 months from the initial TUR to the detection of UUTCs. Among several factors examined, only multiplicity was significantly associated with UUT recurrence after TUR. Of the 20 patients with secondary UUTCs, only two, who had multiple superficial bladder cancers at initial presentation, were diagnosed as having UUTCs by routine IVU, while the remaining 18 presented with symptoms suggesting possible UUT recurrence before IVU, including macrohaematuria (10 patients), intravesical recurrence (five), positive urinary cytology (five), abdominal pain (three) and high fever (two).

CONCLUSIONS

Most patients with recurrent UUTCs presented with some subjective and/or objective symptoms, and routine IVU failed to detect recurrent diseases in such patients. Therefore, routine IVU may not be required for all patients who have TUR of superficial bladder cancer.

Effect of Adjuvant Transarterial Infusion of Anticancer Agents after Transurethral Resection in Patients with pT2a Muscle Invasive Transitional Cell Carcinoma of the Bladder: Five and Ten-year Outcome

Five- and ten-year survival rates in patients who had transurethral resection for pT2aN0M0 muscle invasive transitional cell carcinoma of the bladder was studied with emphasis on the effect of adjuvant transarterial infusions of anticancer agents (TAI). A total of 17 patients out of 290 patients with bladder cancer who had initial treatment in our department between January 1991 and May 2001 were found to be pT2aN0M0 and were included in the present study. Fifteen patients received intravesical instillations of BCG after transurethral resection of the bladder tumor and 8 patients received TAI which was given two weeks after bacillus Calmette-Guerin therapy, with the exception of 1 patient. Five- and ten-year overall survival rates were 76.0% and 52.1%, respectively, and both five- and ten-year cancer-specific survival rates were 76.0% with an average follow up of 71 months. Significant prognostic factor associated with survival rates was only the infiltration pattern of the tumor cells between the alpha and beta group and gamma group (P = 0.0420) in cancer-specific survival rates. The data support conservative management of transurethral resection followed by intravesical instillation of BCG and TAI in patients with pT2a bladder cancer.