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Plata A, Guerrero-Ramos F, Garcia C, González-Díaz A, Gonzalez-Valcárcel I, de la Morena JM, Díaz-Goizueta FJ, del Álamo JF, Gonzalo V, Montero J, Sousa-Escandón A, León J, Pontones JL, Delgado F, Adriazola M, Pascual Á, Calleja J, Ruano A, Martínez-Piñeiro L, Angulo JC. Long-Term Experience with Hyperthermic Chemotherapy (HIVEC) Using Mitomycin-C in Patients with Non-Muscle Invasive Bladder Cancer in Spain. J Clin Med 2021; 10:jcm10215105. [PMID: 34768625 PMCID: PMC8584886 DOI: 10.3390/jcm10215105] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 12/23/2022] Open
Abstract
(1) Background: Intravesical mitomycin-C (MMC) combined with hyperthermia is increasingly used in non-muscle invasive bladder cancer (NMIBC), especially in the context of a relative BCG shortage. We aim to determine real-world data on the long-term treatment outcomes of adjunct hyperthermic intravesical chemotherapy (HIVEC) with MMC and a COMBAT® bladder recirculation system (BRS); (2) Methods: A prospective observational trial was performed on patients with NMIBC treated with HIVEC using BRS in nine academic institutions in Spain between 2012–2020 (HIVEC-E). Treatment effectiveness (recurrence, progression and overall mortality) was evaluated in patients treated with HIVEC MMC 40mg in the adjuvant setting, with baseline data and a clinical follow-up, that comprise the Full Analysis Set (FAS). Safety, according to the number and severity of adverse effects (AEs), was evaluated in the safety (SAF) population, composed by patients with at least one adjunct HIVEC MMC instillation; (3) Results: The FAS population (n = 502) received a median number of 8.78 ± 3.28 (range 1–20) HIVEC MMC instillations. The median follow-up duration was 24.5 ± 16.5 (range 1–81) months. Its distribution, based on EAU risk stratification, was 297 (59.2%) for intermediate and 205 (40.8%) for high-risk. The figures for five-year recurrence-free and progression-free survival were 50.37% (53.3% for intermediate and 47.14% for high-risk) and 89.83% (94.02% for intermediate and 84.23% for high-risk), respectively. A multivariate analysis identified recurrent tumors (HR 1.83), the duration of adjuvant HIVEC therapy <4 months (HR 1.72) and that high-risk group (HR 1.47) were at an increased risk of recurrence. Independent factors of progression were high-risk (HR 3.89), recurrent tumors (HR 3.32) and the induction of HIVEC therapy without maintenance (HR 2.37). The overall survival was determined by patient age at diagnosis (HR 3.36) and the treatment duration (HR 1.82). The SAF population (n = 592) revealed 406 (68.58%) patients without AEs and 186 (31.42%) with at least one AE: 170 (28.72%) of grade 1–2 and 16 (2.7%) of grade 3–4. The most frequent AEs were dysuria (10%), pain (7.1%), urgency (5.7%), skin rash (4.9%), spasms (3.7%) and hematuria (3.6%); (4) Conclusions: HIVEC using BRS is efficacious and well tolerated. A longer treatment duration, its use in naïve patients and the intermediate-risk disease are independent determinants of success. Furthermore, a monthly maintenance of adjunct MMC HIVEC diminishes the progression rate of NMIBC.
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Affiliation(s)
- Ana Plata
- Urology Department, Hospital Universitario de Canarias, Carretera Ofra s/n, 38320 San Cristóbal de La Laguna, Spain; (A.P.); (C.G.)
| | - Félix Guerrero-Ramos
- Urology Department, Hospital Universitario 12 de Octubre, Avenida de Córdoba s/n, 28041 Madrid, Spain; (F.G.-R.); (A.G.-D.)
| | - Carlos Garcia
- Urology Department, Hospital Universitario de Canarias, Carretera Ofra s/n, 38320 San Cristóbal de La Laguna, Spain; (A.P.); (C.G.)
| | - Alejandro González-Díaz
- Urology Department, Hospital Universitario 12 de Octubre, Avenida de Córdoba s/n, 28041 Madrid, Spain; (F.G.-R.); (A.G.-D.)
| | - Ignacio Gonzalez-Valcárcel
- Urology Department, Hospital Universitario Infanta Sofía, Paseo de Europa 34, San Sebastián de los Reyes, 28702 Madrid, Spain; (I.G.-V.); (J.M.d.l.M.)
| | - José Manuel de la Morena
- Urology Department, Hospital Universitario Infanta Sofía, Paseo de Europa 34, San Sebastián de los Reyes, 28702 Madrid, Spain; (I.G.-V.); (J.M.d.l.M.)
| | | | - Julio Fernández del Álamo
- Urology Department, Hospital Universitario de Torrejón, Mateo Inurria, s/n, Torrejón de Ardoz, 28850 Madrid, Spain;
| | - Victoria Gonzalo
- Urology Department, Hospital Universitario de Burgos, Avenida Islas Baleares 3, 09006 Burgos, Spain; (V.G.); (J.M.)
| | - Javier Montero
- Urology Department, Hospital Universitario de Burgos, Avenida Islas Baleares 3, 09006 Burgos, Spain; (V.G.); (J.M.)
| | - Alejandro Sousa-Escandón
- Urology Department, Hospital Comarcal de Monforte, Rúa Corredoira s/n, 27400 Monforte de Lemos, Spain; (A.S.-E.); (J.L.)
| | - Juan León
- Urology Department, Hospital Comarcal de Monforte, Rúa Corredoira s/n, 27400 Monforte de Lemos, Spain; (A.S.-E.); (J.L.)
| | - Jose Luis Pontones
- Urology Department, Hospital Universitario La Fe, Avinguda de Fernando Abril Martorell 106, 46026 Valencia, Spain; (J.L.P.); (F.D.)
| | - Francisco Delgado
- Urology Department, Hospital Universitario La Fe, Avinguda de Fernando Abril Martorell 106, 46026 Valencia, Spain; (J.L.P.); (F.D.)
| | - Miguel Adriazola
- Urology Department, Hospital General Rio Carrión, Avenida Donantes de Sangre s/n, 34005 Palencia, Spain; (M.A.); (Á.P.)
| | - Ángela Pascual
- Urology Department, Hospital General Rio Carrión, Avenida Donantes de Sangre s/n, 34005 Palencia, Spain; (M.A.); (Á.P.)
| | - Jesús Calleja
- Urology Department, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal 3, 47003 Valladolid, Spain; (J.C.); (A.R.)
| | - Ana Ruano
- Urology Department, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal 3, 47003 Valladolid, Spain; (J.C.); (A.R.)
| | - Luis Martínez-Piñeiro
- Urology Department, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain;
| | - Javier C. Angulo
- Urology Department, Hospital Universitario Getafe, Carretera de Toledo, Km 12.500, Getafe, 28905 Madrid, Spain;
- Clinical Department, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Carretera de Toledo, Km 12.500, Getafe, 28905 Madrid, Spain
- Correspondence: ; Tel.: +34-699497569
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Huang Z, Liu H, Wang Y, Zhang C, Xu T. Determining optimal maintenance schedules for adjuvant intravesical bacillus Calmette-Guerin immunotherapy in non-muscle-invasive bladder cancer: a systematic review and network meta-analysis. Curr Med Res Opin 2017; 33:1379-1387. [PMID: 28471272 DOI: 10.1080/03007995.2017.1326889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To figure out optimal bacillus Calmette-Guerin (BCG) maintenance schedules for non-muscle-invasive bladder cancer (NMIBC) patients by comparing different schedules in a systematic review using conventional and network meta-analysis. MATERIALS AND METHODS Literature was searched in the databases of Medline, Embase, Cochrane library, Clinicaltrials.gov, Wanfang, CNKI and SinoMed in April 2016 and 9 randomized clinical trials comparing intravesical BCG maintenance therapy with BCG induction-only therapy or comparing different BCG maintenance schedules (induction-only, 1 year, 1.5 year, 2 year, 3 year maintenance) in NMIBC patients were included. Conventional and network meta-analyses within a Bayesian framework were performed to calculate odds ratios of tumor recurrence, progression and side effects (cystitis, hematuria, general malaise and fever). The surface under the cumulative ranking curve (SUCRA) mean ranking was used to obtain schedule hierarchy. RESULTS Data from 1951 patients showed that longer-term maintenance BCG therapy does not significantly decrease tumor recurrence and progression rate of NMIBC compared to shorter-term maintenance BCG therapy. However, longer-maintenance therapy does not increase side effect incidence compared to induction-only therapy. According to SUCRA results, induction-only therapy has the highest probability of recurrence and progression but least probability of side effects. CONCLUSIONS Longer BCG maintenance therapy (such as 3 years) is not superior to shorter maintenance therapy (such as 1 year). But maintenance therapy overall is better than induction-only BCG therapy while not increasing side effects. Though further evidence and clinical practice with balanced confounding factors (risk stratification and BCG strain) are wished for, the current study suggests the common use of 1 year intravesical BCG instillation for NMIBC patients.
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Affiliation(s)
- Zixiong Huang
- a Department of Urology , Peking University People's Hospital , Beijing , China
| | - Huixin Liu
- b Department of Clinical Epidemiology , Peking University People's Hospital , Beijing , China
| | - Yizeng Wang
- c Department of Vascular Surgery , Peking University People's Hospital , Beijing , China
| | - Chunfang Zhang
- b Department of Clinical Epidemiology , Peking University People's Hospital , Beijing , China
| | - Tao Xu
- a Department of Urology , Peking University People's Hospital , Beijing , China
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3
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Saluja M, Gilling P. Intravesical bacillus Calmette-Guérin instillation in non-muscle-invasive bladder cancer: A review. Int J Urol 2017; 25:18-24. [PMID: 28741703 DOI: 10.1111/iju.13410] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/02/2017] [Indexed: 01/18/2023]
Abstract
Intravesical bacillus Calmette-Guérin has been the standard of care for high-risk non-muscle-invasive bladder cancer for 40 years. It remains one of the most successful immunotherapies ever used. Bacillus Calmette-Guérin shows superior efficacy to alternative intravesical treatments, and has an established role in reducing both recurrence and progression in non-muscle-invasive bladder cancer. It remains relatively safe, and has acceptable tolerability of both local and systemic side-effects. The present review provides insights into the role of bacillus Calmette-Guérin compared with alternative treatments both in primary and refractory settings.
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Affiliation(s)
- Manmeet Saluja
- Department of Urology, Auckland City Hospital, Auckland, New Zealand
| | - Peter Gilling
- Department of Urology, Tauranga Hospital, Tauranga, New Zealand
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4
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Abstract
Non-muscle-invasive bladder cancer (NMIBC) represents the vast majority of bladder cancer diagnoses, but this definition represents a spectrum of disease with a variable clinical course, notable for significant risk of recurrence and potential for progression. Management involves risk-adapted strategies of cystoscopic surveillance and intravesical therapy with the goal of bladder preservation when safe to do so. Multiple organizational guidelines exist to help practitioners manage this complicated disease process, but adherence to management principles among practising urologists is reportedly low. We review four major organizational guidelines on NMIBC: the American Urological Association (AUA)/Society of Urologic Oncology (SUO), European Association of Urology (EAU), National Comprehensive Cancer Network (NCCN), and National Institute for Health and Care Excellence (NICE) guidelines.
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Affiliation(s)
- Solomon L Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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5
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Babjuk M, Böhle A, Burger M, Capoun O, Cohen D, Compérat EM, Hernández V, Kaasinen E, Palou J, Rouprêt M, van Rhijn BW, Shariat SF, Soukup V, Sylvester RJ, Zigeuner R. EAU Guidelines on Non–Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol 2017; 71:447-461. [DOI: 10.1016/j.eururo.2016.05.041] [Citation(s) in RCA: 1330] [Impact Index Per Article: 190.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 05/30/2016] [Indexed: 12/15/2022]
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6
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Yang GL, Zhang LH, Liu Q, Wang ZL, Duan XH, Huang YR, Bo JJ. A novel treatment strategy for newly diagnosed high-grade T1 bladder cancer: Gemcitabine and cisplatin adjuvant chemotherapy-A single-institution experience. Urol Oncol 2016; 35:38.e9-38.e15. [PMID: 28040419 DOI: 10.1016/j.urolonc.2016.08.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 08/10/2016] [Accepted: 08/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Management of high-grade T1 (formerly T1G3) bladder cancer continues to be controversial. Should patients with T1G3 bladder cancer have an immediate radical cystectomy or should they receive intravesical bacillus Calmette-Guérin-preserving bladder? Gemcitabine and cisplatin (GC) adjuvant chemotherapy may help to strike a balance between intravesical and early cystectomy. For purposes of this study, we continue to refer high-grade T1 lesion as "T1G3." OBJECTIVE To evaluate the characteristics and the long-term outcome of GC adjuvant chemotherapy in T1G3 bladder cancer after transurethral resection of bladder tumor (TURBT). MATERIALS AND METHODS We retrospectively reviewed 48 patients who were newly diagnosed with T1G3 bladder cancer between January 2009 and December 2012. A total of 48 patients received 4 cycles of GC adjuvant chemotherapy after TURBT. One month after 4 cycles of GC adjuvant chemotherapy, response was evaluated by re-TURBT. Median follow-up was 59.5 (range: 18-70) months, all patients have been observed for more than 3 years. Salvage cystectomy was recommended for patients with persistent disease and for tumor progression after initial complete response. RESULT Complete response was achieved in 44 (91.7%) patients. Of complete responders, 5 patients experienced recurrence and 5 patients showed progression. The progression rate and disease-specific survival rate were 10.4% and 91.7% at 3 years, respectively. More than 80% of survivors preserved their bladder. Kaplan-Meier curves showed that concomitant carcinoma in situ (CIS) was the only factor that had an influence on progression-free survival (P = 0.022) and disease-specific survival (P = 0.017). Concomitant CIS was the prognostic factor for progression rate and disease-specific survival rate at 3 years (P = 0.008 and P = 0.035). CONCLUSION GC adjuvant chemotherapy is a safe conservative treatment for T1G3 bladder cancer, but effective is really a phase II study. Patients with T1G3 bladder cancer with concomitant CIS should be treated more aggressively because of the high risk of progression.
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Affiliation(s)
- Guo-Liang Yang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lian-Hua Zhang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Liu
- Department of Pathology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhao-Liang Wang
- Department of Pathology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xue-Hui Duan
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi-Ran Huang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Juan-Jie Bo
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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7
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Pagano MJ, Badalato G, McKiernan JM. Optimal treatment of non-muscle invasive urothelial carcinoma including perioperative management revisited. Curr Urol Rep 2015; 15:450. [PMID: 25234184 DOI: 10.1007/s11934-014-0450-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Non-muscle invasive urothelial carcinoma is a heterogeneous disease that requires the practicing urologist to implement a variety of surgical and non-surgical treatment strategies. The disease course can range from recurrent low grade papillary disease to aggressive disease concerning for progression from initial presentation. Depending on the particular patient and goals of care, treatments similarly span the range from minimally invasive fulgurations to immediate radical cystectomy. For most patients some form of intravesical therapy will bridge the gap between transurethral resections (TUR) and radical surgery. Recent advances in the field continue to emphasize the importance of quality TUR and its strong impact on outcomes. In addition, continued research to optimize intravesical therapies has provided more information about how, when, and in whom these agents should be utilized to enhance their efficacy. This review covers the current state of NMIBC and the standards of care for the management of this disease.
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Affiliation(s)
- Matthew J Pagano
- Department of Urology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave., 11th Floor, New York, NY, 10032, USA,
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Garg M, Sankhwar SN, Goel A, Kumar M, Singh BP, Singh V, Dalela D, Kumar A, Paul S. Effect of Intravesical Immunotherapy on Sperm Parameters in Young Patients With Non–Muscle-Invasive Bladder Carcinoma: Prospective Analysis. Clin Genitourin Cancer 2014; 12:e83-6. [DOI: 10.1016/j.clgc.2013.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 10/04/2013] [Accepted: 11/08/2013] [Indexed: 11/16/2022]
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9
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Kausch I, Doehn C, Jocham D. Recent improvements in the detection and treatment of nonmuscle-invasive bladder cancer. Expert Rev Anticancer Ther 2014; 6:1301-11. [PMID: 17020462 DOI: 10.1586/14737140.6.9.1301] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In total, 70-80% of newly diagnosed bladder cancers are confined to the mucosa and staged as Ta, T1 or carcinoma in situ according to the 2002 tumor, lymph nodes and metastasis classification. The standard treatment for these nonmuscle-invasive bladder cancers is transurethral tumor resection with or without adjuvant intravesical chemotherapy or intravesical immunotherapy and subsequent follow-up. Diagnosis and follow-up of nonmuscle-invasive bladder cancer offers two main problems. First, approximately 10-20% of all tumors are not seen in standard cystoscopy. Additionally, frequently repeated follow-up cystoscopies are bothersome for the patient. As an adjunct to standard cystoscopy, fluorescence-guided cystoscopy has demonstrated significantly higher tumor detection rates and optimized patient treatment in recent Phase III studies. Second, routinely performed urine cytology is characterized by high specificity but low sensitivity. Today, several urine tests are available that may increase diagnostic accuracy and potentially prolong intervals of follow-up cystocopy. Owing to rather high recurrence rates after transurethral tumor resection in most tumors and high progression rates in poorly differentiated tumors, adjuvant intravesical chemotherapy or intravesical immunotherapy has gained widespread use in patients with nonmuscle-invasive bladder cancer. Only a few further immunomodulatory drugs, such as recombinant cytokines, have shown significant clinical effectiveness. Additional approaches, such as photodynamic therapy with different photosensitizers and thermotherapy in combination with intravesical chemotherapy, have been evaluated in Phase III studies.
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Affiliation(s)
- Ingo Kausch
- Department of Urology, University of Lubeck Medical School, Ratzeburger Allee 160, 23538 Lubeck, Germany.
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10
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Johnson DC, Pruthi RS, Woods ME. Perioperative chemotherapy: when to use it, what to use, and why. Urol Clin North Am 2013; 40:183-95. [PMID: 23540777 DOI: 10.1016/j.ucl.2013.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This article provides an overview of intravesical chemotherapy agents used for non-muscle invasive bladder cancer; summarizes the evidence on single-dose perioperative administration, induction therapy, and maintenance therapy; and briefly discusses ongoing research.
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Affiliation(s)
- David C Johnson
- Department of Urology, University of North Carolina, Chapel Hill, NC 27599-7235, USA
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Abstract
• Intravesical therapy is a well-established treatment option for non-muscle-invasive bladder cancer (NMIBC). • Choosing the appropriate intravesical agent, schedule and duration of treatment has long been an area of debate. • We review the intravesical agents that are currently used in the management of NMIBC and examine the indications and limitations of their use. • Given the relative high rates of toxicity, failure and non-completion of traditional treatments we also examine some of the newer treatment options available.
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Affiliation(s)
- Callum Logan
- School of Surgery, University of Western Australia, Fremantle, Western Australia, Australia
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12
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Oncolytic viruses in the treatment of bladder cancer. Adv Urol 2012; 2012:404581. [PMID: 22899907 PMCID: PMC3414001 DOI: 10.1155/2012/404581] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 06/05/2012] [Indexed: 01/22/2023] Open
Abstract
Bladder carcinoma is the second most common malignancy of the urinary tract. Up to 85% of patients with bladder cancer are diagnosed with a tumor that is limited to the bladder mucosa (Ta, T1, and CIS). These stages are commonly termed as non-muscle-invasive bladder cancer (NMIBC). Although the treatment of NMIBC has greatly improved in recent years, there is a need for additional therapies when patients fail bacillus Calmette-Guérin (BCG) and chemotherapeutic agents. We propose that bladder cancer may be an ideal target for oncolytic viruses engineered to selectively replicate in and lyse tumor cells leaving normal cells unharmed. In support of this hypothesis, here we review current treatment strategies for bladder cancer and their shortcomings, as well as recent advancements in oncolytic viral therapy demonstrating encouraging safety profiles and antitumor activity.
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Abstract
Transurethral resection is an effective therapy for non-muscle-invasive bladder cancer. However, the high rates of recurrence and significant risk of progression in higher grade tumors mandates additional therapy with intravesical agents. In this review we discuss the role of various intravesical agents currently in use including the immunomodualtory agent BCG and chemotherapeutic agents. We discuss the current guidelines and the role of these therapeutic agents in the context of higher grade Ta and T1 tumors.
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Affiliation(s)
- M Manoharan
- Department of Urology, University of Miami, Miami, FL, USA
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14
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Shang PF, Kwong J, Wang ZP, Tian J, Jiang L, Yang K, Yue ZJ, Tian JQ. Intravesical Bacillus Calmette-Guérin versus epirubicin for Ta and T1 bladder cancer. Cochrane Database Syst Rev 2011:CD006885. [PMID: 21563157 DOI: 10.1002/14651858.cd006885.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Bladder cancer accounts for approximately 4.4% of adult malignancies, and approximately 80% of bladder cancer presents initially as transitional cell carcinoma that is confined to the urothelium (stage Ta) or lamina propria (stage T1). Intravesical administration of Bacillus Calmette-Guérin (BCG) and epirubicin (EPI) has been proven to reduce tumour recurrence and prevent or delay progression to muscle invasion and metastases. However, comparison of the effectiveness and safety of intravesical BCG and EPI in bladder cancer has yet to be explored. OBJECTIVES To compare the effectiveness and safety of BCG with EPI in the treatment of Ta and T1 bladder cancer. SEARCH STRATEGY A comprehensive search of MEDLINE (1966 to April 2010), EMBASE (1980 to April 2010), Health Services Technology, Administration, and Research (HealthSTAR), the Cochrane Central Register of Controlled Trials (CENTRAL), CancerLit, and Database of Abstracts of Reviews of Effectiveness (DARE), was performed, and handsearching of relevant journals was undertaken. SELECTION CRITERIA All randomised or quasi-randomised trials (in which allocation was obtained by alternation - e.g., alternate medical records, date of birth, or other predictable methods) in patients with Ta or T1 bladder cancer that compared intravesical BCG with EPI were included. No language restrictions were applied. DATA COLLECTION AND ANALYSIS Trial eligibility, methodological quality and data extraction were assessed independently by two reviewers. We compared dichotomous outcomes (frequency of tumour recurrence, progressive disease by stage, mortality, distant metastases, local and systemic adverse effects, treatment delayed or stopped due to adverse effects) using risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS Five trials of 1111 participants were included in this review. For BCG, 549 patients were treated, and 562 with EPI. Of the evaluated patients, 35.5% (195/549) in the BCG group and 51.4% (289/562) in the EPI group had tumour recurrence (P < 0.05). For disease progression (BCG, 44/549; EPI, 58/562) and distant metastases (BCG, 23/487; EPI, 31/495), there were no significant differences (P = 0.19 and P = 0.29, respectively). Only two trials, including 769 patients, had sufficient data for us to analyze disease-specific (BCG, 22/383; EPI, 26/386) and overall mortality (BCG, 125/383; EPI, 147/386). Neither comparison was significant (P = 0.93 and P = 0.12, respectively). In four studies reporting toxicity, BCG was associated with significantly more drug-induced cystitis [BCG, 54.1% (232/429); EPI, 31.7% (140/441)] and haematuria [BCG, 30.8% (132/429); EPI, 16.1% (71/440)]. Similarly, in three studies reporting systemic toxicity, BCG had significantly higher toxicity than the EPI (34.8% (134/385) versus 1.3% (5/393), respectively). In a meta-analysis comparing 'treatment delayed or stopped' (BCG, 40/431; EPI, 33/441), there was no significant difference between BCG and EPI treatments (P = 0.82). AUTHORS' CONCLUSIONS The data from the present meta-analysis indicate that intravesical BCG treatment is more efficacious than EPI in reducing tumour recurrence for Ta and T1 bladder cancer. However, BCG appears to be associated with a higher incidence of adverse effects, such as drug-induced cystitis, haematuria and systemic toxicity, than EPI. The overall quality of the evidence is rather low. Well-designed, high quality randomised controlled trials with good allocation concealment are required.
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Affiliation(s)
- Pan Feng Shang
- Department of Urology, Second Hospital of Lanzhou University, No. 82, Cui Ying Men Street, Lanzhou City, Gansu, China, 730030
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15
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Leliveld AM, Bastiaannet E, Doornweerd BH, Schaapveld M, Jong IJD. High risk bladder cancer: current management and survival. Int Braz J Urol 2011; 37:203-10; discussion 210-2. [DOI: 10.1590/s1677-55382011000200007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2010] [Indexed: 11/21/2022] Open
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16
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Urinary pH Is Highly Associated With Tumor Recurrence During Intravesical Mitomycin C Therapy for Nonmuscle Invasive Bladder Tumor. J Urol 2011; 185:802-6. [DOI: 10.1016/j.juro.2010.10.081] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Indexed: 11/15/2022]
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17
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Lamm D, Persad R, Colombel M, Brausi M. Maintenance Bacillus Calmette-Guérin: The Standard of Care for the Prophylaxis and Management of Intermediate- and High-Risk Non–Muscle-Invasive Bladder Cancer. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.eursup.2010.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Shariat SF, Chade DC, Karakiewicz PI, Scherr DS, Dalbagni G. Update on intravesical agents for non-muscle-invasive bladder cancer. Immunotherapy 2010; 2:381-92. [PMID: 20635902 DOI: 10.2217/imt.10.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Major controversies still exist with regard to the indication, type and regimen of intravesical therapy for non-muscle-invasive bladder cancer. Other areas of controversy are the criteria for response/failure of treatment and for decisions regarding secondary intravesical therapy versus radical cystectomy. In this article, we analyze the different intravesical therapeutic strategies and compare their safety and efficacy. Well-designed clinical trials have found that the addition of bacillus Calmette-Guerin (BCG) to transurethral resection (TUR) decreases the risk for both disease recurrence and progression. These encouraging results are sustained even in patients with recurrent or aggressive disease, including patients whose prior intravesical chemotherapy has failed. Most investigators believe that the efficacy of BCG therapy can be maximized with maintenance therapy. Mitomycin C (MMC), the most commonly used intravesical chemotherapy to date, decreases the risk of disease recurrence but not disease progression when used after TUR compared with TUR alone. The oncologic efficacy of intravesical MMC can be optimized by increasing its concentration in addition to alkalinizing and reducing urine production. For patients at high risk of disease progression, BCG with maintenance therapy should be the preferred primary intravesical therapeutic strategy. However, MMC can be considered as a viable alternative for patients with papillary tumors (no carcinoma in situ) that are at low or intermediate risk of disease progression. Combination intravesical therapy may be more successful than single-agent strategies. Intravesical therapy failures indicate the need to include radical cystectomy as an option in the management decision.
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Gontero P, Bohle A, Malmstrom PU, O’Donnell MA, Oderda M, Sylvester R, Witjes F. The Role of Bacillus Calmette-Guérin in the Treatment of Non–Muscle-Invasive Bladder Cancer. Eur Urol 2010; 57:410-29. [DOI: 10.1016/j.eururo.2009.11.023] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 11/03/2009] [Indexed: 11/26/2022]
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Characteristics and Outcomes of Patients with Clinical T1 Grade 3 Urothelial Carcinoma Treated with Radical Cystectomy: Results from an International Cohort. Eur Urol 2010; 57:300-9. [DOI: 10.1016/j.eururo.2009.09.024] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Accepted: 09/03/2009] [Indexed: 11/23/2022]
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Babjuk M, Oosterlinck W, Sylvester R, Kaasinen E, Bohle A, Palou-Redorta J. [EAU guidelines on non-muscle-carcinoma of the bladder]. Actas Urol Esp 2009; 33:361-71. [PMID: 19579886 DOI: 10.1016/s0210-4806(09)74161-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
CONTEXT AND OBJECTIVE To present the updated version of 2008 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer. EVIDENCE ACQUISITION A systematic review of the recent literature on the diagnosis and treatment of non-muscle-invasive bladder cancer was performed. The guidelines were updated and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS The diagnosis of bladder cancer depends on cystoscopy and histologic evaluation of the resected tissue. A complete and correct transurethral resection (TUR) is essential for the prognosis of the patient. When the initial resection is incomplete or when a high-grade or T1 tumour is detected, a second TUR within 2-6 wk should be performed. The short- and long-term risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients to low, intermediate, and high-risk groups-separately for recurrence and progression-represents the cornerstone for indication of adjuvant treatment. In patients at low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is strongly recommended. In those at an intermediate or high risk of recurrence and an intermediate risk of progression, one immediate instillation of chemotherapy should be followed by further instillations of chemotherapy or a minimum of 1 yr of bacillus Calmette-Guerin (BCG). In patients at high risk of tumour progression, after an immediate instillation of chemotherapy, intravesical BCG for at least 1 yr is indicated. Immediate cystectomy may be offered to the highest risk patients and in patients with BCG failure. The long version of the guidelines is available on www.uroweb.org. CONCLUSIONS These EAU guidelines present the updated information about the diagnosis and treatment of non-muscle-invasive bladder cancer and offer the recent findings for the routine clinical application.
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Grammatikos AP, Mantadakis E, Falagas ME. Meta-analyses on Pediatric Infections and Vaccines. Infect Dis Clin North Am 2009; 23:431-57. [DOI: 10.1016/j.idc.2009.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Breyer BN, Whitson JM, Carroll PR, Konety BR. Sequential intravesical gemcitabine and mitomycin C chemotherapy regimen in patients with non-muscle invasive bladder cancer. Urol Oncol 2009; 28:510-4. [PMID: 19171491 DOI: 10.1016/j.urolonc.2008.11.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Revised: 11/25/2008] [Accepted: 11/26/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Currently, there are few options other than cystectomy for the management of BCG refractory non-muscle invasive bladder cancer. We report our experience with intravesical combination chemotherapy using gemcitabine and MMC in such patients. MATERIALS AND METHODS We identified all patients with non-muscle invasive bladder cancer who were BCG refractory or intolerant and had been treated with intravesical gemcitabine and MMC at our institution. Patients were treated with a combination of intravesical gemcitabine (1000 mg in 50 ml sterile water) followed sequentially by intravesical MMC (40 mg in 20 ml sterile water) every week for 6 weeks (induction). Induction therapy was followed by a maintenance regimen using the same dose of gemcitabine and MMC once a month for 12 months. Data regarding patient demographics and disease information such as previous intravesical therapy, previous cystoscopy, cytology results, time to recurrence, and side effect profile were collected. RESULTS A total of 10 patients (6 male and 4 female) aged 48 to 85 years (median 67 years) underwent treatment with a median follow-up of 26.5 months (4-34 months). Six patients were recurrence free and have maintained their response at a median of 14 months (4-34 months). Four patients had biopsy proven recurrence. Median time to recurrence was 6 months (range 4-13 months). The therapy was well tolerated in all patients. There were no major complications. Two patients experienced irritative lower urinary tract symptoms, which did not require cessation of therapy and one experienced a maculopapillary rash that improved with benadryl. CONCLUSIONS In patients with recurrent BCG refractory bladder cancer, intravesical combination chemotherapy with gemcitabine and MMC appears to be well tolerated and yields a response in a good proportion number of patients.
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Affiliation(s)
- Benjamin N Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA 94143, USA
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Affiliation(s)
- Seth P Lerner
- Scott Department of Urology, Baylor College of Medicine, Houston, TX 77030, USA.
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Babjuk M, Oosterlinck W, Sylvester R, Kaasinen E, Böhle A, Palou-Redorta J. EAU Guidelines on Non-Muscle-Invasive Urothelial Carcinoma of the Bladder. Eur Urol 2008; 54:303-14. [PMID: 18468779 DOI: 10.1016/j.eururo.2008.04.051] [Citation(s) in RCA: 543] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Accepted: 04/22/2008] [Indexed: 11/25/2022]
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Oosterlinck W, Witjes F, Sylvester R. Diagnostic and Prognostic Factors in Non-Muscle-Invasive Bladder Cancer and Their Influence on Treatment and Outcomes. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.eursup.2008.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Isbarn H, Budäus L, Pichlmeier U, Conrad S, Huland H, Friedrich M. Vergleich der Effektivität der Langzeitinstillation mit Mitomycin C gegen Kurzzeitprophylaxen mit MMC oder Bacillus Calmette-Guerin. Urologe A 2008; 47:608-15. [DOI: 10.1007/s00120-008-1671-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hall MC, Chang SS, Dalbagni G, Pruthi RS, Seigne JD, Skinner EC, Wolf JS, Schellhammer PF. Guideline for the management of nonmuscle invasive bladder cancer (stages Ta, T1, and Tis): 2007 update. J Urol 2008; 178:2314-30. [PMID: 17993339 DOI: 10.1016/j.juro.2007.09.003] [Citation(s) in RCA: 572] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Indexed: 01/12/2023]
Affiliation(s)
- M Craig Hall
- American Urological Association Education and Research, Inc., USA.
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Friedrich MG, Pichlmeier U, Schwaibold H, Conrad S, Huland H. Long-Term Intravesical Adjuvant Chemotherapy Further Reduces Recurrence Rate Compared with Short-Term Intravesical Chemotherapy and Short-Term Therapy with Bacillus Calmette-Guérin (BCG) in Patients with Non–Muscle-Invasive Bladder Carcinoma. Eur Urol 2007; 52:1123-29. [PMID: 17383080 DOI: 10.1016/j.eururo.2007.02.063] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2006] [Accepted: 02/21/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We present a randomised, parallel group, multicentre phase 4 trial comparing short- and long-term chemoprophylaxis with Mitomycin C (MMC) with short-term immunoprophylaxis with Bacillus Calmette-Guérin (BCG) after transurethral resection of the bladder for non-muscle-invasive bladder carcinoma. METHODS Four hundred ninety-five patients with intermediate- to high-risk non-muscle-invasive bladder cancer (recurrent and/or multifocal pTaG1, TaG2-3, and T1G1-3) were randomised to BCG RIVM 2 x 10(8) CFU weekly for 6 wk, MMC 20 mg weekly for 6 wk, or MMC 20 mg weekly for 6 wk followed by monthly instillations for 3 yr. RESULTS The 3-yr recurrence-free rates were 65.5% (95%CI, 55.9-73.5%) for short-term BCG, and 68.6% (59.9-75.7%) for short-term MMC, whereas recurrence-free rates were significantly increased to 86.1% (77.9-91.4%) in patients with MMC long-term therapy (log-rank test, p=0.001). CONCLUSIONS Long-term MMC significantly reduced the risk of tumour recurrence without enhanced toxicity compared with both short-term BCG and MMC in patients with intermediate- and high-risk non-muscle-invasive bladder carcinoma. Our data provide a rationale for maintenance intravesical chemotherapy in this population.
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Affiliation(s)
- Martin G Friedrich
- Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Gårdmark T, Jahnson S, Wahlquist R, Wijkström H, Malmström PU. Analysis of progression and survival after 10 years of a randomized prospective study comparing mitomycin-C and bacillus Calmette-Guérin in patients with high-risk bladder cancer. BJU Int 2007; 99:817-20. [PMID: 17244282 DOI: 10.1111/j.1464-410x.2006.06706.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the 10-year follow-up of a study randomizing between instillations of bacillus Calmette-Guérin (BCG) and mitomycin-C (MMC) for treating high-risk and not muscle-invasive urinary bladder cancer to assess progression, the need for more aggressive treatment and survival (cancer-specific and overall), as many of the published studies comparing different treatments for disease that is not muscle-invasive have a short follow-up. PATIENTS AND METHODS Between 1987 and 1992, 261 patients were included; they had frequently recurring Ta/T1G1-G2, T1G3 or primary Tis-dysplasia. The patients were randomized to treatment with either 40 mg of MMC or 120 mg of BCG (Danish strain 1331) given weekly for 6 weeks, then monthly up to a year and finally every third month for a further year. The 250 evaluable patients were followed using hospital files and national registers on causes of death. RESULTS The median follow-up for survivors was 123 months. The disease progressed in 58 (23%) of the patients, 34 in the MMC group and 24 in the BCG group (P = 0.26). Of the 140 patients who died, 68 were in the BCG and 72 in the MMC group (log-rank P = 0.98); most (95, 68%) died from other causes. CONCLUSION Based on the follow-up of the present patients it cannot be concluded that the drugs originally administered, MMC or BCG, differed in their effect on progression, need for subsequent treatment or survival.
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Affiliation(s)
- Truls Gårdmark
- Department of Urology, Surgical Sciences, Uppsala, Sweden.
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Burgués JP, Gómez L, Pontones JL, Vera CD, Jiménez-Cruz JF, Ozonas M. A chemosensitivity test for superficial bladder cancer based on three-dimensional culture of tumour spheroids. Eur Urol 2006; 51:962-9; discussion 969-70. [PMID: 17084017 DOI: 10.1016/j.eururo.2006.10.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2006] [Accepted: 10/17/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Three-dimensional (3D) spheroids are a good model for studying in vitro chemosensitivity because they reproduce unicellular and multicellular mechanisms of drug resistance. We aimed to develop a chemosensitivity test for intravesical drugs and to also verify the effects of verapamil (VPM) and ciprofloxacin (CIPRO). METHODS Cold cup biopsies from 40 superficial bladder tumours were taken, fragmented, and left in culture. 3D-spheroids were obtained and transferred into a 24 multiwell dish containing (1) wells 1-3: 1 mg/ml epirubicin (EPI); (2) 4-6: 1 mg/ml EPI+0.5 mg/ml VPM; (3) 7-9: 1 mg/ml adriamycin (ADR); (4) 10-12: 1 mg/ml thiotepa (THIO); (5) 13-15: 1 mg/ml mitomycin C (MMC); (6) 16-18: 1mg/ml EPI+0.2 mg/ml CIPRO; (7) 19-21: 0.2 mg/ml CIPRO; (8) 22-24: controls. Sensitivity was calculated by using the trypan blue assay. RESULTS Evaluability of clinically relevant tests (G1-G2 lesions) was 84% (21 of 25 patients). MMC was the best agent (p<0.001) with mean sensitivity being 50%, followed by THIO (37%), EPI (7%), and ADR (3%). We found no significant difference (p=0.370) between CIPRO and the control, or between EPI+CIPRO and EPI alone (p=0.550). VPM markedly enhanced sensitivity to EPI compared with EPI alone (97% vs. 7%, p<0.001). CONCLUSIONS Our assay allows determining sensitivity to several drugs in superficial bladder tumours. It might be used in clinical practice to select the best drug for each patient. It also has experimental utility in investigating the effect of new drugs or combinations. VPM reverted resistance to EPI. CIPRO showed no effect on bladder tumour spheroids.
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Affiliation(s)
- Juan Pablo Burgués
- Department of Urology, University Hospital Son Dureta, Palma de Mallorca, Spain.
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Bolenz C, Cao Y, Arancibia MF, Trojan L, Alken P, Michel MS. Intravesical mitomycin C for superficial transitional cell carcinoma. Expert Rev Anticancer Ther 2006; 6:1273-82. [PMID: 16925493 DOI: 10.1586/14737140.6.8.1273] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intravesical instillation of mitomycin C after a transurethral resection of a bladder tumor constitutes a standard treatment modality in the management of superficial transitional cell carcinoma in the urinary bladder. An immediate instillation of mitomycin C after transurethral resection has been shown to reduce the recurrence rate of superficial transitional cell carcinoma. Intravesical mitomycin C is generally considered to be a safe treatment option, but the past few years have seen the publication of a number of case reports on severe complications following mitomycin C instillation. This article reports on the mode of action, as well as the intravesical effects and current indications for mitomycin C instillation. This review will summarize the oncological benefits of mitomycin C in comparison with other intravesical treatments, such as bacillus Calmette-Guérin, and elucidate the incidence and types of possible complications associated with intravesical mitomycin C chemotherapy.
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Affiliation(s)
- Christian Bolenz
- Department of Urology, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Colombel M, Saint F, Chopin D, Malavaud B, Nicolas L, Rischmann P. The Effect of Ofloxacin on Bacillus Calmette-Guerin Induced Toxicity in Patients With Superficial Bladder Cancer: Results of a Randomized, Prospective, Double-Blind, Placebo Controlled, Multicenter Study. J Urol 2006; 176:935-9. [PMID: 16890660 DOI: 10.1016/j.juro.2006.04.104] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2005] [Indexed: 11/29/2022]
Abstract
PURPOSE We determined whether prophylaxis with ofloxacin could decrease the toxicity of bacillus Calmette-Guerin for transitional cell carcinoma of the bladder. We also investigated the impact of ofloxacin on bacillus Calmette-Guerin antitumor efficacy. MATERIALS AND METHODS In this randomized, double-blind, multicenter study 115 patients with primary or recurrent superficial bladder cancer (Ta/T1, CIS, G1-G3) and no prior bacillus Calmette-Guerin treatment were randomized to induction treatment with intravesical bacillus Calmette-Guerin (6 plus 3 instillations) plus 200 mg ofloxacin in group 1 or plus placebo in group 2. Adverse events were assessed using a detailed grid of classification for bacillus Calmette-Guerin related adverse events. Mean patient age +/- SD was 65.6 +/- 10.4 years in the 57 group 1 patients and 65.7 +/- 8.7 years in the 58 in group 2. Median followup was 369 and 374 days in groups 1 and 2, respectively. RESULTS Ofloxacin significantly decreased by 18.5% the incidence of class II or higher moderate and severe adverse events between instillations 4 and 6. The percent of class III adverse events was significantly decreased by ofloxacin between instillations 1 and 9. Although ofloxacin decreased adverse events involving the lower urinary tract, it did not prevent class I adverse events. Compliance with full bacillus Calmette-Guerin treatment was also improved. Of patients in group 1, 80.7% received 9 instillations compared with 65.5% in group 2 (p = 0.092). At 12 months recurrence and progression rates in group 1 and 2 were 12.7% and 17.2%, and 5.5% and 1.7%, respectively. CONCLUSIONS Prophylactic ofloxacin decreased the incidence of moderate to severe adverse events associated with bacillus Calmette-Guerin intravesical therapy, particularly class III events, which are primarily associated with patient dropout. Compliance with induction and maintenance therapy may be improved by adjuvant ofloxacin therapy. However, long-term comparative studies with other preventive strategies must be done to confirm these initial findings with compliance and recurrence-free survival as the primary end points.
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Affiliation(s)
- Marc Colombel
- Service d'Urologie et Chirurgie de la Transplantation, Hôpital Edouard Herriot, Université Claude Bernard, 5. Place d'Arsonval, 69437 Lyon Cedex 03, France.
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Gasión JPB, Cruz JFJ. Improving Efficacy of Intravesical Chemotherapy. Eur Urol 2006; 50:225-34. [PMID: 16793196 DOI: 10.1016/j.eururo.2006.05.035] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Accepted: 05/18/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This paper reviews the most relevant findings published recently on intravesical chemotherapy for superficial bladder tumours and provides recommendations based on documented research. METHODS The evidence was categorised according to the North of England Evidence Based Guideline Development Project. Levels of evidence were based on the source of the information, meta-analyses, systematic reviews, well-designed randomised or nonrandomised controlled clinical trials, and uncontrolled studies or consensus. Three levels of recommendations were assigned to the evidence obtained. RESULTS Despite intravesical chemotherapy being used prophylactically after endoscopic resection of superficial bladder tumours, the recurrence rate is still 36-44%. Researchers have focused on improving the effectiveness of intravesical chemotherapy, each adopting a different strategy. Some have aimed to identify the optimum timing for instillations and others to improve the pharmacokinetics of agents by avoiding their dilution, increasing their stability, or improving the absorption of the drug by bladder mucosa. Some researchers are looking into new, single chemotherapeutic agents or combinations for intravesical use and others into avoiding chemoresistance with resistance-reverting agents (modulating agents) or by using in vitro chemosensitivity tests to identify the most sensitive drug. CONCLUSION Progress has been made in optimising intravesical chemotherapy for timing of instillations and pharmacokinetic interventions. Simple and inexpensive approaches may have a widespread, practical acceptance by urologists, but it is more difficult to extend new techniques requiring more complex and sometimes expensive instrumentation to the urologic community. Further research into finding more effective cytotoxic drugs, combinations, or modulating agents should be encouraged.
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Improving Compliance of BCG Immunotherapy: Practical Approaches to Managing Side-Effects. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.eursup.2006.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Burgués Gasión JP, Pontones Moreno JL, Vera Donoso CD, Jiménez Cruz JF, Ozonas Moragues M. [Cell cycle and apoptosis mechanisms implicated in intravesical chemotherapy resistances in superficial bladder cancer]. Actas Urol Esp 2005; 29:846-59. [PMID: 16353771 DOI: 10.1016/s0210-4806(05)73356-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
It is well documented the effectiveness of intravesical chemotherapy following transurethral resection to prevent recurrences of superficial bladder cancer. But it is also known that efficacy may be limited by tumour cell resistance to one or several of the drugs available for instillation. In addition to the genetically determined unicellular mechanisms classically described in the literature such as glycoprotein P-170 expression (mdr-1), overexpression of Bcl-2 or glutation S-transferase activity, it has been recently shown that multicellular mechanisms may also be involved in drug resistance. Multicellular resistance can only be demonstrated in three-dimensional cultures and fails to be shown in monolayers or cell suspensions. This is explained by the fact that cell-to-cell and cell-to-stroma adhesion limits drug penetration and by the variable susceptibility to cytotoxicity determined by oxygen and tissue proliferation gradients. A better understanding of the molecular mechanisms involved in drug resistance is necessary to increase intravesical chemotherapy effectiveness. Current research includes improving drug penetration, searching resistance reversing agents and developing in vitro chemosensitivity tests to identify drug resistance.
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Affiliation(s)
- J P Burgués Gasión
- Servicio de Urologia, Hospital Universitario Son Dureta Palma de Mallorca, Hospital Universitario La Fe, Valencia.
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