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Andruska N, Waters MR, Fischer-Valuck BW, Smith ZL, Kim EH, Reimers M, Brenneman R, Gay HA, Patel SA, Michalski JM, Delacroix SE, Efstathiou JA, Baumann BC. Does Chemo-Radiotherapy Improve Survival Outcomes vs. Radiotherapy Alone for High-Grade cT1 Urothelial Carcinoma of the Bladder? Clin Genitourin Cancer 2023; 21:653-659.e1. [PMID: 37704483 DOI: 10.1016/j.clgc.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Non-muscle invasive bladder cancer (non-MIBC) that is high-grade and confined to the lamina propria (HGT1) often has an aggressive clinical course. Currently, there is limited data on the comparative effectiveness of RT vs. CRT for HGT1 non-MIBC. We hypothesized that CRT would be associated with improved overall survival (OS) vs. RT in HGT1 bladder cancer. METHODS Patients diagnosed with HGT1 non-MIBC, and treated with transurethral resection of bladder tumor followed by either treatment with RT alone or CRT, were identified in the National Cancer Database. Inverse probability of treatment weighting (IPTW) was employed and weight-adjusted multivariable analysis (MVA) using Cox regression modeling was used to compare overall survival (OS) hazard ratios. OS was the primary endpoint, and was estimated using the Kaplan-Meier method and log-rank tests. RESULTS A total of 259 patients with HGT1 UC were treated with: (i) RT alone (n = 123) or (ii) CRT (n = 136). Propensity-weighted MVA showed that combined modality treatment with CRT was associated with improved OS relative to radiation alone (Hazard Ratio [HR]: 0.62, 95% Confidence Interval (95% CI): 0.44-0.88, P = .007). Four-year OS for the CRT vs. RT alone was 36% and 19%, respectively (log-rank P <.008). CONCLUSION For patients with HGT1 bladder cancer, concurrent CRT was associated with improved OS compared with radiation alone in a retrospective cohort. These results are hypothesis-generating. The NRG is currently developing a phase II randomized clinical trial comparing CRT to other novel, bladder preservation strategies.
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Affiliation(s)
- Neal Andruska
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | - Michael R Waters
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | | | - Zachary L Smith
- Division of Urology, Washington University School of Medicine, St Louis, MO
| | - Eric H Kim
- Division of Urology, Washington University School of Medicine, St Louis, MO
| | - Melissa Reimers
- Division of Medical Oncology, Washington University School of Medicine, St Louis, MO
| | - Randall Brenneman
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | - Hiram A Gay
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | - Sagar A Patel
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO
| | - Scott E Delacroix
- Department of Urology, Louisiana State University School of Medicine, New Orleans, LA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Harvard University School of Medicine, Boston, MA
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, MO; Department of Radiation Oncology, Springfield Clinic, Springfield, IL.
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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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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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4
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Prediction of BCG responses in non-muscle-invasive bladder cancer in the era of novel immunotherapeutics. Int Urol Nephrol 2019; 51:1089-1099. [DOI: 10.1007/s11255-019-02183-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 05/26/2019] [Indexed: 01/05/2023]
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5
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Hori S, Miyake M, Tatsumi Y, Onishi S, Morizawa Y, Nakai Y, Tanaka N, Fujimoto K. Topical and systemic immunoreaction triggered by intravesical chemotherapy in an N-butyl-N-(4-hydroxybutyl) nitorosamine induced bladder cancer mouse model. PLoS One 2017; 12:e0175494. [PMID: 28406993 PMCID: PMC5391151 DOI: 10.1371/journal.pone.0175494] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/27/2017] [Indexed: 11/19/2022] Open
Abstract
Intravesical bacillus Calmette-Guerin (BCG) treatment is the most common therapy to prevent progression and recurrence of non-muscle invasive bladder cancer (NMIBC). Although the immunoreaction elicited by BCG treatment is well documented, those induced by intravesical treatment with chemotherapeutic agents are much less known. We investigated the immunological profiles caused by mitomycin C, gemcitabine, adriamycin and docetaxel in the N-butyl-N-(4-hydroxybutyl) nitrosamine (BBN)-induced orthotopic bladder cancer mouse model. Ninety mice bearing orthotopic bladder cancer induced by BBN were randomly divided into six groups and treated with chemotherapeutic agents once a week for four weeks. After last treatment, bladder and serum samples were analyzed for cell surface and immunological markers (CD4, CD8, CD56, CD204, Foxp3, and PD-L1) using immunohistochemistry staining. Serum and urine cytokine levels were evaluated by ELISA. All chemotherapeutic agents presented anti-tumor properties similar to those of BCG. These included changes in immune cells that resulted in fewer M2 macrophages and regulatory T cells around tumors. This result was compatible with those in human samples. Intravesical chemotherapy also induced systemic changes in cytokines, especially urinary interleukin (IL)-17A and granulocyte colony stimulating factor (G-CSF), as well as in the distribution of blood neutrophils, lymphocytes, and monocytes. Our findings suggest that intravesical treatment with mitomycin C and adriamycin suppresses protumoral immunity while enhancing anti-tumor immunity, possibly through the action of specific cytokines. A better understanding of the immunoreaction induced by chemotherapeutic agents can lead to improved outcomes and fewer side effects in intravesical chemotherapy against NMIBC.
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Affiliation(s)
- Shunta Hori
- Departments of Urology, Nara Medical University, Nara, Japan
| | - Makito Miyake
- Departments of Urology, Nara Medical University, Nara, Japan
| | | | - Sayuri Onishi
- Departments of Urology, Nara Medical University, Nara, Japan
| | - Yosuke Morizawa
- Departments of Urology, Nara Medical University, Nara, Japan
| | - Yasushi Nakai
- Departments of Urology, Nara Medical University, Nara, Japan
| | | | - Kiyohide Fujimoto
- Departments of Urology, Nara Medical University, Nara, Japan
- * E-mail:
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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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Hori S, Miyake M, Onishi S, Tatsumi Y, Morizawa Y, Nakai Y, Anai S, Tanaka N, Fujimoto K. Clinical significance of α‑ and β‑Klotho in urothelial carcinoma of the bladder. Oncol Rep 2016; 36:2117-25. [PMID: 27573985 DOI: 10.3892/or.2016.5053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/05/2016] [Indexed: 11/06/2022] Open
Abstract
Non-muscle invasive bladder cancer (NMIBC) accounts for ~70% of all bladder cancers. One of the serious clinical issues related to the management of NMIBC is that it has significant potential to progress to muscle invasive bladder cancer (MIBC) after initial treatments. α‑Klotho (KLα), originally identified as an anti‑aging gene, has recently been reported to have antitumor effects in various malignancies. In contrast, β‑Klotho (KLβ) has been reported to have protumoral functions. However, the associations between KLα/KLβ and the biological behavior of urothelial carcinoma remain unclear. In the present study, we evaluated the association between clinicopathological background factors of NMIBC and the expression levels of KLα or KLβ. A high expression level of KLβ, but not KLα, was an independent predictive factor of short progression‑free survival for NMIBC. An elevated level of KLβ correlated with a higher incidence of lymphovascular invasion (LVI). We added in vitro assays using human bladder cancer cell lines to investigate the role of KLβ. Treatment with exogenous KLβ protein increased the proliferation, migration, transendothelial migration abilities and anchorage‑independent growth of the cell lines. In addition, the KLβ concentration in voided urine samples obtained before initial transurethral surgery was quantitated with enzyme‑linked immunosorbent assay (ELISA). The urine KLβ concentration was found to be higher in patients with bladder cancer than that in healthy volunteers. Our results suggest that KLβ plays important roles in tumor invasion and progression, and its concentration may be a valuable urine‑based marker for the detection of bladder cancer.
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Affiliation(s)
- Shunta Hori
- Department of Urology, Nara Medical University, Kashihara, Nara 634‑8522, Japan
| | - Makito Miyake
- Department of Urology, Nara Medical University, Kashihara, Nara 634‑8522, Japan
| | - Sayuri Onishi
- Department of Urology, Nara Medical University, Kashihara, Nara 634‑8522, Japan
| | - Yoshihiro Tatsumi
- Department of Urology, Nara Medical University, Kashihara, Nara 634‑8522, Japan
| | - Yosuke Morizawa
- Department of Urology, Nara Medical University, Kashihara, Nara 634‑8522, Japan
| | - Yasushi Nakai
- Department of Urology, Nara Medical University, Kashihara, Nara 634‑8522, Japan
| | - Satoshi Anai
- Department of Urology, Nara Medical University, Kashihara, Nara 634‑8522, Japan
| | - Nobumichi Tanaka
- Department of Urology, Nara Medical University, Kashihara, Nara 634‑8522, Japan
| | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, Kashihara, Nara 634‑8522, Japan
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8
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Poor prognostic value of lymphovascular invasion for pT1 urothelial carcinoma with squamous differentiation in bladder cancer. Sci Rep 2016; 6:27586. [PMID: 27279531 PMCID: PMC4899777 DOI: 10.1038/srep27586] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/20/2016] [Indexed: 11/30/2022] Open
Abstract
Lymphovascular invasion (LVI) is the primary and essential step in the systemic dissemination of cancer cells. The aim of our study was to assess the independent prognostic role of LVI for pT1 urothelial carcinoma with squamous differentiation in bladder cancer. We retrospectively analyzed the clinical and pathological information of 206 patients diagnosed pT1 urothelial carcinoma with squamous differentiation. Of the 206 patients, LVI was detected in 57 (27.6%) patients. The 5 year cancer specific survival (CSS) rates were 87.2% in LVI (−) and 52.4% in LVI (+) (p < 0.001). According to univariate analysis, tumor multiplicity, tumor size, recurrence and LVI were the prognostic factors associated with CSS. Additionally, tumor size and LVI significantly influenced the CSS in multivariate analysis. TURBT had shorter median CSS than RC in recurred patients with LVI (+). Our study suggested that LVI is an important predictor for survival of pT1 urothelial carcinoma with squamous differentiation. LVI positive status and tumor size ≥3 cm led to a higher risk of death. RC should be routinely performed in recurred LVI (+) bladder cancer patients of pT1 urothelial carcinoma with squamous differentiation.
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9
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Steinberg RL, Thomas LJ, O'Donnell MA. Bacillus Calmette-Guérin (BCG) Treatment Failures in Non-Muscle Invasive Bladder Cancer: What Truly Constitutes Unresponsive Disease. Bladder Cancer 2015; 1:105-116. [PMID: 27376112 PMCID: PMC4927833 DOI: 10.3233/blc-150015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
| | - Lewis J Thomas
- University of Iowa Department of Urology, Iowa City, IA, USA
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10
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Gakis G, Todenhöfer T, Braun M, Fend F, Stenzl A, Perner S. Immunohistochemical assessment of lymphatic and blood vessel invasion in T1 urothelial carcinoma of the bladder. Scand J Urol 2015; 49:382-7. [PMID: 25921278 DOI: 10.3109/21681805.2015.1040449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was evaluate the incidence and significance of immunohistochemically assessed lymphatic (LVI) and blood vessel invasion (BVI) in primary T1 urothelial carcinoma of the bladder (UCB) treated with radical cystectomy (RC). MATERIALS AND METHODS Thirty-two patients with T1 UCB at primary diagnosis were identified who underwent radical cystectomy (RC) subsequently. Of these, 16 (50%) had pT1N0M0 (group I) and 16 (50%) ≥ pT2aN0-3M0 UCB (group II) at RC. The presence of LVI and BVI in transurethral resection of bladder tumor (TURBT) and corresponding RC specimens was assessed using hematoxylin & eosin (H&E) and immunohistochemical (IHC) staining against the lymphatic (D2-40) and vascular endothelium (CD31). RESULTS At TURBT and RC, none of the patients in group I showed LVI or BVI on H&E and IHC sections. In group II, at TURBT, LVI and BVI were negative on H&E staining in all patients, but detectable by IHC in two patients (13%) and one patient (6%), respectively (p = 0.48 and p = 0.99 compared to group I). At RC, LVI and BVI were detected by IHC in eight (50%) and five (31%) of the 16 patients, respectively (p = 0.002 and p = 0.021 compared to group I). Of these eight and five patients, detection of LVI and BVI was only possible with IHC in six (75%) and three (60%), respectively. CONCLUSIONS Although this hypothesis-generating study did not show a high degree of concordance between TURBT and RC specimens, IHC assessment on a regular basis may increase the detection rates of LVI and BVI at initial diagnosis and improve the selection of those T1 patients who should be offered early radical treatment.
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Affiliation(s)
- Georgios Gakis
- a 1 Department of Urology, University Hospital Tübingen , Tübingen, Germany
| | - Tilman Todenhöfer
- a 1 Department of Urology, University Hospital Tübingen , Tübingen, Germany
| | - Martin Braun
- b 2 Institute of Pathology, Department of Prostate Cancer Research , Bonn, Germany , and
| | - Falko Fend
- c 3 Institute of Pathology, Eberhard-Karls University , Tübingen, Germany
| | - Arnulf Stenzl
- a 1 Department of Urology, University Hospital Tübingen , Tübingen, Germany
| | - Sven Perner
- b 2 Institute of Pathology, Department of Prostate Cancer Research , Bonn, Germany , and
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11
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Kitamura H, Kakehi Y. Treatment and management of high-grade T1 bladder cancer: what should we do after second TUR? Jpn J Clin Oncol 2015; 45:315-22. [PMID: 25583419 DOI: 10.1093/jjco/hyu219] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Most T1 bladder cancers are high grade and have the potential to progress to muscle invasion and extravesical dissemination. Many studies reported that ∼50% of patients displayed residual tumors when a second transurethral resection was performed 2-6 weeks after the initial resection for patients who were diagnosed with T1 bladder cancer. Furthermore, muscle-invasive disease was detected by the second transurethral resection in 10-25% of those patients. Therefore, a second transurethral resection is strongly recommended for patients newly diagnosed with high-grade T1 bladder cancer in various guidelines. T1 bladder cancers are heterogeneous in terms of progression and prognosis after the second transurethral resection. Optimal management and treatment should be considered for patients with T1 bladder cancer based on the pathological findings for the second transurethral resection specimen. If the second transurethral resection reveals residual tumors, aggressive treatments based on the pathological findings should be performed. Conversely, overtreatment with respect to the tumor status should be avoided. Since the evidence of pathological diagnosis at the second transurethral resection is insufficient and many retrospective studies were carried out before the second transurethral resection era, prospective randomized studies should be conducted.
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Affiliation(s)
- Hiroshi Kitamura
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo
| | - Yoshiyuki Kakehi
- Department of Urology, Kagawa University Faculty of Medicine, Kagawa, Japan
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12
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Farah NB, Ghanem R, Amr M. Treatment efficacy and tolerability of intravesical bacillus Calmette-Guerin (BCG)-RIVM strain: induction and maintenance protocol in high grade and recurrent low grade non-muscle invasive bladder cancer (NMIBC). BMC Urol 2014; 14:11. [PMID: 24468269 PMCID: PMC3909512 DOI: 10.1186/1471-2490-14-11] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/06/2014] [Indexed: 12/01/2022] Open
Abstract
Background BCG-RIVM strain was used in many treatment protocols for non-muscle invasive bladder cancer only as induction courses. Cho et al. (Anticancer Res 2012) compared BCG-RIVM induction and 'standard' maintenance (Lamm et al., J Urol. 2000) to mitomycin C. They found no statistically significant differences regarding disease recurrence and progression. The purpose of our study was to determine the efficacy & tolerability of this specific BCG RIVM strain, using six-weekly, induction course and single monthly instillations as maintenance for one year, in high risk recurrent, multifocal low grade and multifocal high grade pTa/pT1, CIS transitional cell carcinoma of bladder. Methods From 2003 - 2012, BCG-naive patients treated with intravesical BCG-RIVM for high-risk multifocal NMIBC were identified. Transurethral resection of bladder tumor (TURBT) and re-staging TURBT within six weeks, was done for accurate staging and complete elimination of disease. A six-weekly induction course, started 2-3 weeks after the last TURBT, followed by monthly maintenance protocol for one year. Recurrence, progression, cystectomy free survivals, cancer specific and over-all survival were determined. Results Sixty evaluable patients - median age 63, median follow-up 3.98 years. Forty-two patients (70%) completed BCG-RIVM treatment as planned. BCG termination was necessary in 18 patients (30%). Recurrence occurred in 16 patients (26.7%) at a median follow-up of 24.2 months while progression occurred in five patients (8.3%) at a median follow-up of 33 months. Recurrence-free survival and progression-free survival rates were 73% and 92% respectively. Cystectomy was performed in seven patients (12%) with a cystectomy-free survival of 88%. There were no cancer specific deaths. Two patients died of other causes (3.3%). The overall survival rate was 97%. Conclusions Our study is the first to show the clinical efficacy and tolerability of BCG-RIVM strain in the management of high risk NMIBC when given in a schedule of six-weekly induction with monthly maintenance for one year. Our maintenance protocol, achieved equivalent recurrence-free, progression-free, disease specific survival and overall survival to the reported literature and the more intense three-years South West Oncology Group (SWOG) protocol.
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Affiliation(s)
- Naim B Farah
- From the department of surgery, section of Uro-oncology, King Hussein Cancer Center, Amman, Jordan.
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13
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Metwalli AR, Kamat AM. Controversial issues and optimal management of stage T1G3 bladder cancer. Expert Rev Anticancer Ther 2014; 6:1283-94. [PMID: 16925494 DOI: 10.1586/14737140.6.8.1283] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Adam R Metwalli
- The University of Texas MD Anderson Cancer Center, Department of Urology, Unit 1373, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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14
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Kunieda F, Kitamura H, Niwakawa M, Kuroiwa K, Shinohara N, Tobisu K, Nakamura K, Shibata T, Tsuzuki T, Tsukamoto T, Kakehi Y. Watchful waiting versus intravesical BCG therapy for high-grade pT1 bladder cancer with pT0 histology after second transurethral resection: Japan Clinical Oncology Group Study JCOG1019. Jpn J Clin Oncol 2012; 42:1094-8. [PMID: 22952293 DOI: 10.1093/jjco/hys143] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A Phase III clinical trial has been started in Japan to determine the optimal treatment strategy for patients with high-grade pT1 bladder cancer who have pT0 histology after second transurethral resection. The aim of this trial is to demonstrate the non-inferiority of relapse-free survival (excluding Tis or Ta intravesical recurrence) for watchful waiting compared with intravesical bacillus Calmette-Guérin therapy for pT0 after second transurethral resection. Patients with high-grade pT1 bladder cancer at the first registration and pT0 after second transurethral resection at the second registration are randomized to either a watchful waiting arm or an intravesical bacillus Calmette-Guérin therapy arm. A total of 575 patients at the first registration and 260 patients at the second registration will be accrued for this study from 38 institutions over 5 years. The primary endpoint is relapse-free survival (excluding Tis or Ta intravesical recurrence), and the secondary endpoints are overall survival, metastasis-free survival with bladder preserved, annual proportion of intravesical relapse-free survival, annual proportion of T2 or deeper relapse-free survival, adverse events and serious adverse events.
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Affiliation(s)
- Futoshi Kunieda
- Japan Clinical Oncology Group Data Center/Operations Office, Multi-institutional Clinical Trial Support Center, National Cancer Center, Tokyo, Japan
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15
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Predictive biomarkers of bacillus calmette-guérin immunotherapy response in bladder cancer: where are we now? Adv Urol 2012; 2012:232609. [PMID: 22919375 PMCID: PMC3420223 DOI: 10.1155/2012/232609] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 05/29/2012] [Accepted: 06/16/2012] [Indexed: 01/01/2023] Open
Abstract
The most effective therapeutic option for managing nonmuscle invasive bladder cancer (NMIBC), over the last 30 years, consists of intravesical instillations with the attenuated strain Bacillus Calmette-Guérin (the BCG vaccine). This has been performed as an adjuvant therapeutic to transurethral resection of bladder tumour (TURBT) and mostly directed towards patients with high-grade tumours, T1 tumours, and in situ carcinomas. However, from 20% to 40% of the patients do not respond and frequently present tumour progression. Since BCG effectiveness is unpredictable, it is important to find consistent biomarkers that can aid either in the prediction of the outcome and/or side effects development. Accordingly, we conducted a systematic critical review to identify the most preeminent predictive molecular markers associated with BCG response. To the best of our knowledge, this is the first review exclusively focusing on predictive biomarkers for BCG treatment outcome. Using a specific query, 1324 abstracts were gathered, then inclusion/exclusion criteria were applied, and finally 87 manuscripts were included. Several molecules, including CD68 and genetic polymorphisms, have been identified as promising surrogate biomarkers. Combinatory analysis of the candidate predictive markers is a crucial step to create a predictive profile of treatment response.
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16
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Mohanty NK, Nayak RL, Vasudeva P, Arora RP. Management of BCG non-responders with fixed dose intravesical gemcitabine in superficial transitional cell carcinoma of urinary bladder. Indian J Urol 2011; 24:44-7. [PMID: 19468358 PMCID: PMC2684230 DOI: 10.4103/0970-1591.35759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aims and Objectives: The incidence of bladder malignancy is increasing worldwide and the projected rise is 28% by 2010 for both sexes (WHO). Though intravesical adjuvant therapy with BCG is superior to any other immunotherapeutic/chemotherapeutic agent in reducing tumor recurrences and disease progression, its real efficacy remains controversial as one-third of the patients will soon become BCG failure. Hence there is a need for an alternative intravesical agent for treatment of BCG failure. Our aim was to study the efficacy, tolerability and safety of intravesical Gemcitabine in managing BCG-refractory superficial bladder malignancy. Materials and Methods: Thirty-five BCG failure patients, 26 males and nine females between 20-72 years of age were instilled with 2000 mg of Gemcitabine in 50 ml of normal saline intravesically two weeks post tumor resection, for six consecutive weeks. Mean follow-up was for 18 months with cystoscopies. Results: Twenty-one patients (60%) showed no recurrences, 11 patients (31.4%) had superficial recurrences while three patients (8.6%) progressed to muscle invasiveness. Average time to first recurrence was 12 months and to disease progression was 16 months. Adverse event was low and mild. Therapy was well tolerated. Conclusion: Gemcitabine fulfils all requirements as an alternative agent, in treating BCG failure patients with low adverse events, is well tolerated and highly effective in reducing tumor recurrences.
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Affiliation(s)
- N K Mohanty
- Department of Urology, VM Medical College and Safdarjung Hospital, New Delhi, India
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17
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Prognostic significance of tumor location in high-grade non-muscle-invasive bladder cancer. Med Oncol 2011; 29:1916-20. [DOI: 10.1007/s12032-011-9999-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 05/27/2011] [Indexed: 11/25/2022]
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18
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Kamel MH, Bailey SL, Moore JT, Heshmat SM, Bissada NK. Definition of BCG Failure in Non-Muscle Invasive Bladder Cancer in Major Urological Guidelines. ACTA ACUST UNITED AC 2011. [DOI: 10.3834/uij.1944-5784.2011.12.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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Intravesical gemcitabine for treatment of superficial bladder cancer not responding to Bacillus Calmette-Guérin vaccine. AFRICAN JOURNAL OF UROLOGY 2010. [DOI: 10.1007/s12301-010-0024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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20
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Long-term outcomes of intravesical therapy for non-muscle invasive bladder cancer. World J Urol 2010; 29:59-71. [DOI: 10.1007/s00345-010-0617-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 11/09/2010] [Indexed: 11/26/2022] Open
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21
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Kakiashvili DM, van Rhijn BWG, Trottier G, Jewett MAS, Fleshner NE, Finelli A, Azuero J, Bangma CH, Vajpeyi R, Alkhateeb S, Hanna S, Kostynsky A, Kuk C, Van Der Kwast TH, Zlotta AR. Long-term follow-up of T1 high-grade bladder cancer after intravesical bacille Calmette-Guérin treatment. BJU Int 2010; 107:540-6. [PMID: 21276177 DOI: 10.1111/j.1464-410x.2010.09572.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To report the long-term results of bacille Calmette-Guérin (BCG) intravesical therapy in relation to disease progression and recurrence in primary T1 high-grade (HG) bladder cancer (BC) confirmed by central pathological review. PATIENTS AND METHODS In all, 136 patients from two university centres (Rotterdam, n = 49; Toronto, n = 87) were diagnosed with primary T1HG BC. One experienced uro-pathologist reviewed all slides, ensuring all cases were indeed HG and that muscle was present in all specimens. Patients were treated with BCG induction (six instillations) after transurethral resection (TUR) of the tumour and followed with cystoscopy and urinary cytology. Predictors for recurrence, progression and survival were assessed with multivariable Cox regression models. RESULTS Mean (range) follow-up was 6.5 (0.3-21.6) years. There were no significant differences for recurrence (P = 0.52), progression (P = 0.35) and disease-specific survival (DSS) (P = 0.69) between the two centres. Among the cohort, 47 patients (35%) recurred and 42 (30.9%) progressed with a median time to progression of 2.1 years; 16 (38%) of these progressions occurred ≥ 3 years after the initial BCG course; 22 (16%) patients who progressed died from BC. Overall, 96 (71%) patients had no evidence of disease at the last follow-up. Carcinoma in situ was the only independent predictor for recurrence in multivariate analysis (P = 0.011). No independent predictors were found for progression. CONCLUSIONS Conservative treatment with BCG is a valid option in primary T1HG BC. Nevertheless, the aggressive nature of T1HG BC is evident in the fact that 30% progressed, with a high proportion of these progression events occurring ≥ 3 years after BCG. Caution should be exercised when relying on the long-term effects of BCG, and close follow-up of these patients should not be neglected.
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Affiliation(s)
- David M Kakiashvili
- Department of Surgical Oncology (Division of Urology), Princess Margaret Hospital, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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22
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Kulkarni GS, Hakenberg OW, Gschwend JE, Thalmann G, Kassouf W, Kamat A, Zlotta A. An Updated Critical Analysis of the Treatment Strategy for Newly Diagnosed High-grade T1 (Previously T1G3) Bladder Cancer. Eur Urol 2010; 57:60-70. [DOI: 10.1016/j.eururo.2009.08.024] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 08/26/2009] [Indexed: 11/16/2022]
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23
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Stein JP, Penson DF. Invasive T1 bladder cancer: indications and rationale for radical cystectomy. BJU Int 2008; 102:270-5. [DOI: 10.1111/j.1464-410x.2008.07743.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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24
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Stein JP, Penson DF. The invasive T1 bladder tumor: Contemporary issues and rationale for radical cystectomy. Curr Urol Rep 2008; 9:179-81. [DOI: 10.1007/s11934-008-0031-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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25
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Mohanty NK, Nayak RL, Vasudeva P, Arora RP. Intravesicle gemcitabine in management of BCG refractory superficial TCC of urinary bladder-our experience. Urol Oncol 2008; 26:616-9. [PMID: 18367121 DOI: 10.1016/j.urolonc.2007.10.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 10/23/2007] [Accepted: 10/29/2007] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The incidence of bladder malignancy is increasing worldwide and the projected rise is 28% by 2010 for both sexes (according to the WHO). Though intravesical adjuvant therapy with bacillus Calmette-Guérin (BCG) is superior to any other immunotherapeutic/chemotherapeutic agent in reducing tumor recurrences and disease progression, its real efficacy remains controversial as one-third of the patients will soon develop BCG failure. Hence, there is a need for an alternative intravesical agent for treatment of BCG failure. Our aim is to study the efficacy, tolerability, and safety of intravesical gemcitabine in managing BCG refractory superficial bladder malignancy. MATERIAL AND METHODS Thirty-five BCG failure patients, 26 males and 9 females between 20 and 72 years of age were instilled 2000 mg of gemcitabine in 50 ml of normal saline intravesically 2 weeks post-tumor resection, for 6 consecutive weeks. Mean follow-up for 18 months with cystoscopy was done. RESULT Twenty-one patients (60%) showed no recurrences, 11 patients (31.4%) had superficial recurrences, while 3 patients (8.75%) progressed to muscle invasiveness. Average time to first recurrence was 12 months and to disease progression was 16 months. Adverse event was low and mild. Therapy was well tolerated. CONCLUSION Gemcitabine fulfills all requirements as an alternative agent in treating BCG failure patients with low adverse events, well tolerated, and highly effective in reducing tumor recurrences.
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Affiliation(s)
- Nayan Kumar Mohanty
- Department of Urology, V.M. Medical College and Safdarjang Hospital, New Delhi, India.
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Gofrit ON, Pode D, Shapiro A, Zorn KC, Pizov G. Significance of inflammatory pseudotumors in patients with a history of bladder cancer. Urology 2007; 69:1064-7. [PMID: 17572187 DOI: 10.1016/j.urology.2007.01.101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Revised: 12/19/2006] [Accepted: 01/30/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To study the significance of inflammatory pseudotumor (IPT) in patients with a history of bladder cancer. METHODS We surveyed our hospital database for patients who developed IPT during follow-up of bladder cancer. The original histologic blocks were reviewed and immunostained for vimentin, anaplastic large cell lymphoma (ALK), and pancytokeratin. RESULTS Between the years 1988 and 2005, a total of 809 patients were registered in the database, and 16 patients (2%) developed IPT during follow-up. All patients had initial high-grade tumor. Immunostaining for vimentin was positive in all patients, ALK was negative in all patients, and pancytokeratin positive in only 2 patients. During follow-up, 12 patients (75%) developed tumor recurrence, 9 patients (56%) tumor progression, and 6 patients (37.5%) died of bladder cancer. Median period from the finding of IPT to tumor recurrence was 16 months, to progression 7 months, and to mortality 26 months. CONCLUSIONS The finding of IPT in a patient with a history of bladder cancer is associated with a high risk of tumor recurrence, progression, and cancer-related mortality. Second- and possibly third-look bladder biopsies should be considered. The unique characteristics of IPT in patients with a history of bladder cancer suggest that this is a separate disease entity.
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Affiliation(s)
- Ofer N Gofrit
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
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28
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Sighinolfi MC, Micali S, De Stefani S, Mofferdin A, Ferrari N, Giacometti M, Bianchi G. Bacille Calmette-Guérin intravesical instillation and erectile function: is there a concern? Andrologia 2007; 39:51-4. [PMID: 17430423 DOI: 10.1111/j.1439-0272.2007.00762.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of our study was to evaluate the effect of bacille Calmette-Guérin (BCG) therapy on erectile function in a cohort of male patients affected by non-muscle invasive bladder cancer. Thirty male patients undergoing BCG treatment for non-muscle invasive bladder cancer were enrolled in the study. Their mean age was 60.4 years. None of the patients had risk factors for erectile dysfunction (ED). All subjects underwent a BCG standard schedule therapy (once weekly instillation for 6 weeks). International Index of Erectile Function (IIEF-5) and International Prostate Symptom score (I-PSS) were addressed to the patients during the treatment schedule (at fourth or fifth instillation) and 1 month after the last instillation. The mean IIEF-5 score was 17.6 +/- 6.7 during therapy and 21.7 +/- 2.92 a month after the last instillation (P=0.008). Baseline ED and the association with lower urinary tract symptoms are variables significantly connected with post-treatment results (P=0.016 and 0.00 respectively) whereas the age seems not to be related to ED (P=0.256). No major side effects were recorded. It is concluded that BCG treatment is effective for prophylaxis of non-muscle invasive bladder cancer; however, it may induce a high incidence of ED. Although this effect is transient and reversible, erectile failure is another source of psychological distress that adversely affects the quality of life of men undergoing BCG treatment.
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Affiliation(s)
- M C Sighinolfi
- Department of Urology, University of Modena, Modena, Italy.
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29
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Margel D, Tal R, Golan S, Kedar D, Engelstein D, Baniel J. Long-Term Follow-up of Patients with Stage T1 High-Grade Transitional Cell Carcinoma Managed by Bacille Calmette-Guérin Immunotherapy. Urology 2007; 69:78-82. [PMID: 17270621 DOI: 10.1016/j.urology.2006.09.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Revised: 06/12/2006] [Accepted: 09/08/2006] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To report the long-term outcome of patients with Stage T1 high-grade transitional cell carcinoma of the bladder treated initially by transurethral resection and adjuvant intravesical bacille Calmette-Guérin. METHODS From June 1984 to November 1995, 78 consecutive patients with Stage T1 high-grade bladder cancer underwent transurethral resection and adjuvant intravesical bacille Calmette-Guérin therapy. The results at the interim follow-up (median 56 months) were reported in 1998. The median duration of follow-up for the present study was 107 months (range 16 to 238). The endpoints were tumor recurrence (Stage Ta, T1, or Tis), tumor progression (to T2 or greater), and disease-specific survival. RESULTS Of the 78 patients, 34 (44%) were alive for the present analysis and 44 (56%) had died, 12 (16%) of transitional cell carcinoma and 32 (72%) of other causes. Recurrence was documented in 27 patients (35%) at a median of 8.5 months (range 5 to 129) after treatment, and progression in 14 patients (18%) at a median of 31.4 months (range 5 to 88) after treatment. The 2, 5, and 10-year recurrence-free survival and progression-free survival rates were 76%, 72%, and 62% and 92%, 82%, and 80%, respectively. The corresponding disease-free survival rates were 99%, 90%, and 85%. Disease progression occurred in 10 (37%) of 27 patients with recurrence, of whom 9 died. Of the 14 patients with disease progression, 12 died of their disease. CONCLUSIONS Bacille Calmette-Guérin is an effective conservative treatment for patients with Stage T1 high-grade bladder cancer. More than one half the recurrences appeared within the first year, but a small risk remains throughout the patient's life. Progression during follow-up appears to carry a high risk of cancer-specific death.
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Affiliation(s)
- David Margel
- Institute of Urology, Rabin Medical Center, Beilinson Campus, Petah Tiqwa, Israel.
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Gontero P, Frea B. Actual experience and future development of gemcitabine in superficial bladder cancer. Ann Oncol 2006; 17 Suppl 5:v123-8. [PMID: 16807439 DOI: 10.1093/annonc/mdj966] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Gemcitabine has a molecular weight of 299 D, lower than that of commonly-used intravesical chemotherapeutic agents such as mitomycin C (389 D) and doxorubicin (589 D). This may enable gemcitabine to penetrate the bladder mucosa with beneficial effects in the treatment of early invasive bladder cancer (T1 disease). At the same time the molecular weight is high enough to prevent significant systemic absorption in an intact bladder. Based on the results of phase I studies, it appears that the 2000 mg dose of gemcitabine in 50/100 ml normal saline when administered intravesically for up to 2 h once a week for 6 weeks has unremarkable systemic and local side effects and therefore should be considered the most convenient schedule. The currently available phase II studies have assessed the activity of intravesical gemcitabine on a marker lesion in intermediate risk superficial bladder cancers (SBC), showing complete responses in up to 56% of cases. Few attempts have been made to test the activity of intravesical gemcitabine in high risk SBC achieving unexpected complete responses in BCG refractory CIS. Gemcitabine seems to have fulfilled the requirements to be a promising new candidate for standard intravesical therapy in SBC so far. Further phase II trials exploring the activity of gemcitabine on highly-recurrent intermediate risk or high risk SBC would provide additional information to foresee its efficacy in clinical practice and thus constitute the framework for large comparative phase III trials.
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Affiliation(s)
- P Gontero
- Clinica Urologica, Università Piemonte Orientale, Novara, Italy.
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Nieder AM, Simon MA, Kim SS, Manoharan M, Soloway MS. Radical cystectomy after bacillus Calmette-Guérin for high-risk Ta, T1, and carcinoma in situ: Defining the risk of initial bladder preservation. Urology 2006; 67:737-41. [PMID: 16618564 DOI: 10.1016/j.urology.2005.10.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2005] [Revised: 09/14/2005] [Accepted: 10/07/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To critically evaluate the survival of patients with high-grade Ta or T1 urothelial cancer (UC) or carcinoma in situ of the bladder who have received bacillus Calmette-Guérin (BCG) and who have undergone radical cystectomy. METHODS We retrospectively reviewed our single-surgeon database of those patients who underwent cystectomy and previously received BCG. We evaluated the baseline characteristics, pathologic outcomes, and survival data. RESULTS Of 313 patients who underwent cystectomy between January 1992 and March 2004, 90 (29%) received BCG before bladder removal. The mean time from the first BCG course to the date of cystectomy was 27.9 months. The mean duration of follow-up from cystectomy was 32.1 months. The risk of progression to muscle invasion for those who underwent cystectomy less than or more than 1 year from the time of their first BCG dose was 59% and 36%, respectively (P = 0.05). The disease-specific survival rate was 81% versus 80% for those who underwent early versus delayed cystectomy (P = 0.9). CONCLUSIONS Patients with high-grade UC are at risk of dying from this cancer, even if they ultimately undergo cystectomy. Patients who receive BCG should be appropriately counseled that they remain at risk for disease progression and death from UC. It is difficult to ascertain the proper time to proceed with cystectomy if an initial bladder conservation approach is used.
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Affiliation(s)
- Alan M Nieder
- Department of Urology, University of Miami Miller School of Medicine, Miami, Florida 33140, USA.
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Nieder AM, Brausi M, Lamm D, O'Donnell M, Tomita K, Woo H, Jewett MAS. Management of stage T1 tumors of the bladder: International Consensus Panel. Urology 2006; 66:108-25. [PMID: 16399419 DOI: 10.1016/j.urology.2005.08.066] [Citation(s) in RCA: 167] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2005] [Accepted: 08/12/2005] [Indexed: 11/25/2022]
Abstract
The International Consensus Panel on T1 bladder tumors markers reviewed the subject from a clinical perspective. From diagnosis to treatment decisions, what are the important issues in the management of a new patient? The assessment of prognostic factors for progression requires optimal resection and documentation. The role of immediate adjuvant intravesical chemotherapy after resection remains controversial. How often should the upper tract be assessed for tumor recurrence? The decision on whether to attempt bladder conservation with intravesical therapy or to perform a cystectomy is the most difficult issue in the management of superficial bladder cancer today. Finally, what therapies exist if initial intravesical bacille Calmette-Guérin fails to eradicate the disease or prevent recurrence? The panel thoroughly explored all these subjects and has made recommendations with supporting evidence.
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Affiliation(s)
- Alan M Nieder
- Department of Urology, State University New York, Stony Brook, New York, USA
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Gontero P, Marini L, Frea B. Intravesical gemcitabine for superficial bladder cancer: rationale for a new treatment option. BJU Int 2005; 96:970-6. [PMID: 16225511 DOI: 10.1111/j.1464-410x.2005.05739.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Paolo Gontero
- Clinica Urologica, University of Piemonte Orientale, Novara, Italy.
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Abstract
TIG3 transitional cell carcinoma of the bladder represents a highly malignant tumor with a variable and unpredictable biologic potential. The most critical aspect of management requires a detailed discussion with the patient regarding the treatment options. Both the physician and the patient should be willing to reconsider the treatment options as the disease continues to evolve. In most cases initial management involves complete resection of the tumor, accurate staging of the disease, and intravesical immunotherapy or chemotherapy. Rigorous surveillance with long-term follow-up is crucial for managing these cases. In selected cases with adverse prognostic factors immediate cystectomy should be considered. The choice and timing of the decision to abandon bladder preservation and proceed with cystectomy should be continuously reconsidered on an individual patient basis, in concordance with the evolution of the disease (Fig. 1). The goal is to spare the bladder when possible but not at the risk of death from metastatic disease. Radical cystectomy in high-grade stage T1 transitional cell carcinoma offers excellent results in regard to the prevention of recurrence and progression and survival. Improvements in urinary diversion and nerve-sparing techniques have decreased the magnitude of social implications related to cystectomy in most patients regardless of gender. The discovery of reliable markers may contribute to better selection of patients for bladder sparing. Until then, the optimal treatment for the T1G3 tumor remains controversial.
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Affiliation(s)
- Murugesan Manoharan
- Department of Urology, University of Miami School of Medicine, 1400 NW 10th Avenue, # 506, Miami, FL 33136, USA
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Abstract
PURPOSE OF REVIEW This article reviews recent advances in the diagnosis and management of bladder cancer. RECENT FINDINGS Bladder cancer is a significant cause of morbidity and mortality. Recent research has attempted to improve the care of patients with this disease. Evidence suggests that bacillus Calmette-Guerin is the most effective intravesical therapy for the treatment of superficial bladder cancer and that maintenance therapy is superior to an induction course alone. In patients with muscle-invasive disease, nodal status and extent of lymphadenectomy have been shown to correlate with survival after radical cystectomy. The role of chemotherapy in the treatment of bladder cancer continues to evolve as well. Neoadjuvant chemotherapy has recently demonstrated a survival benefit, and trials are ongoing to define the optimal regimen of chemotherapy for urothelial carcinoma. SUMMARY Improved understanding and advancements in the management of all stages of bladder cancer continue to improve the care of patients with this disease.
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Affiliation(s)
- Lester S Borden
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Abstract
Physicians have, for over a century, attempted to harness the potential therapeutic power of the immune system to treat patients with cancer. The discovery that cancer regression can be achieved by immune rejection of tumour antigens theoretically allows the eradication of neoplastic cells without toxicity to normal tissues. An understanding of the mode of presentation of tumour antigens, including those complexed to heat shock proteins by major histocompatibility complex (MHC) class I and class II molecules, and their recognition by CD8(+) and CD4(+) T cells, respectively, has further delineated the potential cancer rejection pathways involved. This also enables the sustained induction and expansion of specific anti-tumour T cells with cytolytic activity.
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Affiliation(s)
- Justin Stebbing
- The Department of Immunology, Division of Investigative Science, Faculty of Medicine, Imperial College of Science, Technology and Medicine, The Chelsea and Westminster Hospital, 369 Fulham Road, London, UK SW10 9NH
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