A Randomized Controlled Trial of Short-Term Versus Long-Term Prophylactic Intravesical Instillation Chemotherapy for Recurrence After Transurethral Resection of Ta/T1 Transitional Cell Carcinoma of the Bladder

Anti-Proliferative Effects of Lidocaine as an Autophagy Inducer in Bladder Cancer via Intravesical Instillation: In Vitro and Xenograft Mouse Model Experiments

Lidocaine exerts potential anti-tumor effects on various cancer cell lines, and its intravesical instillation is considered safer than intravenous administration for bladder cancer. However, the mechanisms underlying its anti-tumor effects have not been fully elucidated. Here, we aimed to elucidate the anti-tumor molecular mechanisms of lidocaine in bladder cancer cells and a xenograft model to substantiate the efficacy of its intravesical administration. We investigated the anti-proliferative and autophagyinducing activities of lidocaine in Nara Bladder Tumor No. 2 (NBT-II) rat bladder carcinoma cells using cell viability, flow cytometry, a wound healing assay, and western blotting. We also established a xenograft mouse model of bladder cancer, and cancer growth was examined using in vivo bioluminescence imaging. Lidocaine decreased cell viability, induced G0/G1 phase cell cycle arrest, and inhibited cell migration partially via glycogen synthase kinase (GSK) 3β phosphorylation. Moreover, a combination of lidocaine and SB216763 (a GSK3β inhibitor) suppressed autophagy-related protein expression. Bafilomycin-A1 with lidocaine significantly enhanced microtubule-associated protein 1A/1B-light chain (LC3B) expression; however, it decreased LC3B expression in combination with 3-methyladenine compared to lidocaine alone. In the xenograft mouse model, the bladder cancer volume was reduced by lidocaine. Overall, lidocaine exerts anti-proliferative effects on bladder cancer via an autophagy-inducing mechanism.

The optimal intravesical maintenance chemotherapy scheme for the intermediate-risk group non-muscle-invasive bladder cancer

OBJECTIVE

Although the current European Association of Urology(EAU) guideline recommends that patients with intermediate-risk non-muscle-invasive bladder cancer (NMIBC) should accept intravesical chemotherapy or Calmette-Guerin (BCG) for no more than one year after transurethral resection of bladder tumor(TURBT), there is no consensus on the optimal duration of chemotherapy. Hence, we explored the optimal duration of maintenance intravesical chemotherapy in patients with intermediate-risk NMIBC.

SUBJECTS AND METHODS

This was a real-world single-center retrospective cohort study. In total 158 patients with pathologically confirmed intermediate-risk NMIBC were included, who were divided into 4 subgroups based on the number of instillations given. We used Cox regression analysis and survival analysis chart to explore the 3-yr recurrence outcomes of tumor.The optimal duration was determined by receive operating characteristic curve (ROC).

RESULTS

The median follow-up was 5.2 years. Compared with instillation for 1-2 months, the Hazard Ratios(HR) values of instillation for less than 1 month, maintenance instillation for 3-6 months and > 6 months were 3.57、1.57 and 0.22(95% CI 1.27-12.41;0.26-9.28;0.07-0.80, P = 0.03;0.62;0.02, respectively). We found a significant improvement in 3-yr relapse-free survival in intermediate-risk NMIBC patients who maintained intravesical instillation chemotherapy for longer than 6 months, and the best benefit was achieved with 10.5 months of maintenance chemotherapy by ROC.

CONCLUSIONS

In our scheme, the optimal duration of intravesical instillation with pirrubicin is 10.5 months. This new understanding provides valuable experience for the precise medical treatment model of intermediate-risk NMIBC.

French AFU Cancer Committee Guidelines - Update 2022-2024: Non-muscle-invasive bladder cancer (NMIBC)

OBJECTIVE

To update the ccAFU recommendations for the management of bladder tumours that do not infiltrate the bladder muscle (NBMIC).

METHODS

A systematic review (Medline) of the literature from 2020 to 2022 was performed, taking account of the diagnosis, treatment options and surveillance of NMIBC, while evaluating the references with their levels of evidence.

RESULTS

The diagnosis of NMIBC (Ta, T1, CIS) is made after complete full-thickness tumour resection. The use of bladder fluorescence and the indication of a second look (4-6 weeks) help to improve the initial diagnosis. The EORTC score is used to assess the risk of recurrence and/or tumour progression. Through the stratification of patients in low, intermediate and high-risk categories, adjuvant treatment can be proposed: intravesical chemotherapy (immediate postoperative, initiation regimen) or BCG (initiation and maintenance regimen) instillations, or even the indication of cystectomy for BCG-resistant patients.

CONCLUSION

Updating the ccAFU recommendations should contribute to improving patient management, as well as the diagnosis and treatment of NMIBC.

[French ccAFU guidelines - update 2020-2022: bladder cancer]

OBJECTIVE

- To update French guidelines for the management of bladder cancer specifically non-muscle invasive (NMIBC) and muscle-invasive bladder cancers (MIBC).

METHODS

- A Medline search was achieved between 2018 and 2020, notably regarding diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

RESULTS

- Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS <1) and renal function (creatinine clearance >60 mL/min) allow it (only in 50% of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

CONCLUSION

- These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment of patients diagnosed with NMIBC and MIBC.

Systematic Review on the Utilization of Maintenance Intravesical Chemotherapy in the Management of Non-muscle-invasive Bladder Cancer

CONTEXT

Current guidelines remain ill-defined regarding the optimal intravesical chemotherapy type and regimen for the treatment of non-muscle-invasive bladder cancer (NMIBC). Although maintenance therapy is a standard part of bacillus Calmette-Guerin (BCG) therapy, its role in the context of chemotherapy remains debatable.

OBJECTIVE

We reviewed the literature regarding the utilization of intravesical maintenance chemotherapy in the treatment of NMIBC to determine its impact on recurrence, progression, and survival.

EVIDENCE ACQUISITION

A systematic search was conducted using Ovid and Medline according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2018 reporting on the utilization of maintenance intravesical chemotherapy. Only randomized controlled trials (RCTs) that included a comparison between an induction regimen and an induction plus maintenance regimen were included.

EVIDENCE SYNTHESIS

Sixteen RCTs were included in the final analysis. The most commonly studied intravesical chemotherapy agents used in maintenance regimens were epirubicin, doxorubicin, and mitomycin C. Several maintenance schedules were utilized, some as short as 3mo and others as long as 3 yr, while the most common maintenance regimen utilized was monthly instillation for 1 yr. Of the 16 trials, 13 reported no significant improvement in recurrence for patients receiving maintenance compared with no maintenance, and none of the trials demonstrated a significant impact on progression or survival.

CONCLUSIONS

Intermediate length maintenance regimens lasting 7-12mo were the most common maintenance regimens utilized. There was considerable heterogeneity between trial design and duration of follow-up, making direct comparisons for recurrence, progression, and survival outcomes between trials challenging. Although maintenance intravesical chemotherapy is suggested as a treatment option for patients with NMIBC by some guidelines, the majority of evidence suggested that it provided no significant advantage over induction therapy alone with respect to recurrence, progression, or survival.

PATIENT SUMMARY

In this review, we reviewed prior clinical trials to determine whether prolonged intravesical chemotherapy ("maintenance therapy") improved the rates of recurrence, progression, and survival. Where differences were found in favor of maintenance therapy, there was no statistical significance demonstrated, possibly due to the underpowered nature of the study design. While there was no consensus on an optimal agent or maintenance schedule, we found no evidence to suggest that maintenance therapy would improve recurrence, progression, or survival.

Lidocaine enhances the effects of chemotherapeutic drugs against bladder cancer

This study aimed to investigate whether lidocaine, alone or in combination with other chemotherapeutic agents, inhibits the growth of human bladder cancer cells in vitro and orthotopically transplanted bladder tumors in vivo. The effects of lidocaine (1.25, 2.5 or 5 mg/mL), mitomycin C (MMC, 0.66 mg/mL), pirarubicin (0.75 mg/mL) and Su Fu’ning lotion (SFN, 0.0625 mg/mL) on the proliferation of human bladder cancer (BIU-87) cells were studied using the MTT assay. A Balb/c nude mouse model of bladder cancer was developed by orthotopic transplantation of BIU-87 cells, and the effects of intravesical instillation of lidocaine and MMC on bladder wet weight (a measure of tumor size) and survival (over 60 days) were studied. Lidocaine inhibited proliferation of BIU-87 cells in a concentration-dependent manner and (when given in combination) enhanced the actions of each of the other antiproliferative agents. In tumor-bearing mice, MMC alone had no effect on mean survival or bladder wet weight. However, the combination of 0.66 mg/mL MMC and 5 mg/mL lidocaine prolonged survival (from 34.62 ± 6.49 to 49.30 ± 6.72 days; n = 8, P < 0.05) and reduced bladder wet weight (from 68.94 ± 53.61 to 20.26 ± 6.07; n = 8, P < 0.05). Intravesical instillation of lidocaine combined with other chemotherapeutic agents potentially could be an effective therapy for bladder cancer.

Evaluation of Su Fu'ning Lotion's Inhibitory Effects on Bladder Cancer Cells In Vitro and In Vivo by Intravesical Instillation

BACKGROUND

Bladder cancer is a common malignant tumor with a very high recurrence rate after surgery. Intravesical instillation can help clear up the residual tumor cells after surgery and thereby reduce the recurrence rate.

OBJECTIVE

To establish a bladder tumor transplantation animal model and to evaluate the inhibitory effects of a novel perfusate, Su Fu'ning Lotion (SFN), on bladder tumor.

METHODS

SFN was compared with several commonly used chemotherapy drugs, including mitomycin (MMC) and pirarubicin (THP) for anticancer effects on the bladder cancer cell lines T24, BTT, and BIU-87 and SFN half inhibitory concentrations (IC50) were determined after 48 hours of treatment. In addition, bladder cancer orthotopic transplantation tumor models were established in BALB/C nude mice and T739 mice, and SFN anticancer effects were assessed in vivo, with normal saline and MMC as negative and positive controls, respectively.

RESULTS

SFN, MMC, and THP were all lethal to bladder cancer cells, in vitro, with SFN and THP significantly superior to MMC. IC50 values for SFN were 13.22, 11.22, and 12.5 µg/mL on T24, BTT, and BIU-87 cells, respectively. In vivo, SFN significantly reduced the mouse bladder wet weight and prolonged the animal survival compared with controls (P < .05), suggesting that SFN significantly inhibited T24/BTT cell growth in mice.

CONCLUSION

SFN inhibited the bladder cancer cell proliferation in vitro and in vivo and significantly prolonged the survival of mice with bladder cancer xenografts, indicating that SFN could be used as a perfusate after surgery for removal of residual bladder cancers cells.

Analysis of Japanese Patients Treated with or without Long-Term Epirubicin Plus Ara-C Intravesical Instillation Therapy for Low-Grade Superficial Bladder Cancer

The high incidence of tumor recurrence following transurethral resection (TUR) represents a major problem encountered in the management of bladder cancer. This study examined the efficacy of intravesical chemotherapy in superficial bladder cancer. We retrospectively analyzed 90 Japanese cases with low-grade superficial transitional cell carcinoma (stage T1, grades 1 and 2) who were rendered tumor-free by TURBT (TUR of bladder tumor) and who thereafter were treated with or without intravesical chemotherapy. Among them, instillation was terminated in 2 patients due to adverse effects (severe but reversible chemical cystitis). Remaining 88 patients were divided into 2 groups according to therapy: the TURBT-only group (n = 46), defined as patients treated with TURBT alone, and the Instillation group (n = 42), defined as patients treated with weekly intravesical instillation therapies using epirubicin plus Ara-C. Recurrence-free rate was significantly higher in the Instillation group than in the TURBT-only group (p = 0.02, HR = 0.457). The 5-year recurrence-free rate was 58.5% for the Instillation group and 38.6% for the TURBT-only group. Our instillation schedule represents the most intensive regimen among previously reported therapies and resulted in a 54.3% decrease in incidence of tumor recurrence. We believe that the results of this study could provide useful information on management of bladder cancer.

Long-term versus short-term introvesical chemotherapy in patients with non-muscle-invasive bladder cancer: a systematic review and meta-analysis of the published results of randomized clinical trials

In order to assess the effect of long-term versus short-term intravesical chemotherapy in preventing the recurrence of patients with non-muscle-invasive bladder cancer, we searched several databases with words as mesh terms and free text words to find all eligible randomized clinical trials (RCTs) for the comparison of the two strategies of instillation durations. "Observed-Expected events research (O-E)" and "Variance (V)" for calculating hazard ratio (HR) were used in Revman 5.2 software recommended by Cochrane Collabration for data analysis. Sensitivity and subgroup analysis were selected to minish heterogeneity. GRADEpro 3.6 profile recommended by Cochrane Collabration was employed for quality assessment of analyses. Finally, 13 eligible RCTs with 4216 patients were included in this review and 16 comparisons from 13 trials were involved for analysis. The pooled analysis revealed no significant difference between long-term and short-term duration [HR=0.99, 95% CI (0.89, 1.11), P=0.89]. Within the subgroup analysis, patients benefited from long-term instillations with a start regimen of one immediate instillation [HR=0.83, 95% CI (0.69, 1.00), P=0.05]. But patients were not suitable to receive long-term instillations with epirubicin (EPI) [HR=1.01, 95% CI (0.91, 1.13), P=0.78]. The progression rate was not reduced after long-term instillations [HR=0.96, 95% CI (0.66, 1.39), P=0.82]. From our results, patients should not receive introvesical chemotherapy more than half a year. In contrast, patients with one immediate instillation are preferred to have a long-term duration at least one year. Long-term instillations can not reduce the progression rate.

[Endovesical treatment as an alternative to BCG for intermediate or high-risk NMI bladder cancer]

A shortage of BCG is foreseen till the end of 2013. Which will be the management of intermediate and high-risk NMI-BC if BCG will not be available? In patients harboring high-risk NMI tumors, particularly T1G3 and Tis, the first therapeutic choice is radical cystectomy. Device-assisted therapies, although showing promising results, should be considered only for selected patients. In intermediate risk patients, intravesical chemotherapy remains a legitimate option even if BCG is available. Thus, in a period of BCG shortage, intravesical chemotherapy should be offered, preferably preceded by early instillation, according to the EAU guidelines.

[The intravesical recurrence after 3-day consecutive intravesical instillation of pirarubicine hydrochloride (THP) following transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer]

PURPOSE

We estimated the results of 3-day consecutive intravesical instillation of pirarubicine hydrochloride (THP) following transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer retrospectively.

PATIENTS AND METHODS

Through March 1995 to April 2009, a total of 184 patients were instilled 3-day consecutive intravesical instillation of pirarubicine hydrochloride (THP) (30 mg/40 ml in disinfected distilled water) started within a few hours after TURBT. 184 patients were diagnosed as untreated fresh non-muscle-invasive urothelial bladder cancer with no concomitant carcinoma in situ (CIS), no concurrent upper urinary tract urothelial cancer and no past history of upper urinary tract urothelial cancer. Number of tumors, tumor size, tumor grade and clinical tumor stage were analyzed in relation to tumor recurrence by univariate and multivariate analyses. Median follow-up were 55.1 months.

RESULTS

Using EAU guideline on non-muscle invasive urothelial carcinoma of the bladder, 168 patients were classified at intermediate risk of tumor recurrence, 14 patients were at low risk of tumor recurrence and 2 patients were at high risk of tumor recurrence. The shape of non-recurrence rate curve showed two phase decrease pattern, namely, early hasty decrease within 1.5 or two years and late gentle decrease thereafter. The 1, 2, 3, 5-year non-recurrence rate were 82.7%, 75.3%, 72.3% and 67.4% respectively. The 3-year non-recurrence rate of low score group (recurrence score 1-3) at intermediate risk of tumor recurrence was 85.3%. Univariate analysis revealed that number of tumors, tumor grade and clinical tumor stage were related to tumor recurrence (p<0.05). By multivariate analysis, number of tumors and clinical tumor stage were related to tumor recurrence (p<0.05).

CONCLUSIONS

In patients of low score group at intermediate risk of tumor recurrence without grade 3 urothelial carcinoma and concomitant bladder CIS, 3-day consecutive intravesical instillation of pirarubicine hyorochloride (THP) following TURBT for non-muscle-invasive bladder cancer would be a significant adjuvant therapy. But in patients of high score group at intermediate risk of tumor recurrence, it seemed better to do additional maintenance intravesical chemotherapy or intravesical BCG therapy.

2-micrometer continuous wave laser treatment for multiple non-muscle-invasive bladder cancer with intravesical instillation of epirubicin

BACKGROUND AND OBJECTIVES

We have reported the efficacy and safety of 2-micrometer continuous wave laser resection of non-muscle-invasive bladder tumor (NMIVBC) (World J Urology 2010;28:157-161). In this study, we evaluated the use of 2-micrometer continuous wave laser resection in combination with intravesical instillation of epirubicin for the treatment of multiple NMIVBC.

MATERIALS AND METHODS

From September 2007 to April 2008, sixty patients with multiple NMIVBC were included in this study (44 cases of low grade papillary urothelial carcinoma, 10 cases of high grade papillary urothelial carcinoma, and six cases of papillary urothelial neoplasm with low malignant potential). Imaging examinations including pelvic computer tomography (CT) and intravenous urography showed no extravesical extension, lymphatic metastasis or any lesions of upper urinary tract. All patients received 2-micrometer continuous wave laser therapy under continuous epidural anesthesia, and intravesical chemotherapy with epirubicin 1 week later (intravesical instillation weekly for 8 weeks, followed by monthly maintenance to 12 months).

RESULTS

Totally 211 tumors in 60 patients were successfully removed with 2-micrometer continuous wave laser. The mean operation time was 48 minutes per patient (ranged 20-90 minutes) and 13.6 minutes per tumor (range 5-25 minutes). No obturator nerve reflection or bladder perforation occurred during the procedure. All patients finished 12 months of intravesical chemotherapy without severe complications. The mean followed-up time was 23 months. Tumor recurrences were found in 13 patients (22%).

CONCLUSIONS

The combination of 2-micrometer continuous wave laser and intravesical chemotherapy is feasible, safe, and efficacious for the treatment of multiple NMIVBC.

Intravesical Bacillus Calmette-Guérin versus epirubicin for Ta and T1 bladder cancer

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.

Overexpression of Eg5 predicts unfavorable prognosis in non-muscle invasive bladder urothelial carcinoma

OBJECTIVE

To investigate the relationship between Eg5 expression and prognosis of patients with non-muscle invasive bladder urothelial carcinoma.

METHODS

Eg5 expression was examined by immunohistochemistry in non-muscle invasive urothelial carcinoma specimens (grade: G1, 32 cases; G2, 92 cases; and G3, 39 cases. Stage: pTa, 49 cases and pT1, 114 cases). The correlation between clinicopathological characteristics and Eg5 expression was evaluated. The prognostic significance of Eg5 immunoreactivity was analyzed through survival analysis in 163 non-muscle invasive cases that were treated with transurethral resection and adjuvant intravesical instillations.

RESULTS

The expression of Eg5 was significantly associated with tumor grade (P = 0.006), with a trend towards significant association with stage (P = 0.057). The 163 patients with non-muscle invasive tumors were regularly followed with the mean of 32.52 (from 6 to 72) months. Univariate analysis showed Eg5 overexpression exhibited a significant unfavorable influence on intravesical recurrence (P = 0.012) while having only a marginal correlation with disease progression (P = 0.070). Subsequent Cox hazard multivariate analysis showed that both grade (P = 0.045) and Eg5 expression (P = 0.029) were independent predictors for early intravesical recurrence.

CONCLUSIONS

Overexpression of Eg5 correlates with poor differentiation of bladder cancer, and it represents an independent prognostic factor in predicting early intravesical recurrence in non-muscle invasive bladder carcinoma patients.

Intravesical therapy for urothelial carcinoma of the urinary bladder: a critical review

The management of non-muscle-invasive urothelial carcinoma of the bladder (UCB) is a challenge for physicians and patients alike. This is largely due to the heterogeneous natural history of this disease, in which tumors range from indolent to rapidly progressive and eventually fatal. Moreover, the high rate of recurrence and progression cause significant morbidity, expense, and detriment to quality of life. The advent of effective and safe intravesical therapies has improved the management of non-muscle-invasive UCB. Nevertheless, despite over 30 years of research and clinical experience, the mechanism, risks, benefits, and optimal regimens and treatment algorithms remain unclear. Although immunotherapy with bacillus Calmette-Guerin (BCG) has been the mainstay of intravesical treatment and represents a significant advance in the interaction of immunology and oncology, its clinical effectiveness is accompanied by a wide range of adverse events. Here, we review the literature on intravesical immunotherapy and chemotherapy with the aim of evaluating the clinical utility of the different treatments and providing recommendations. Many studies over the years have compared efficacy and toxicities of different agents and regimens, and certain conclusions are now well supported by high-level evidence. Future perspectives and promising advances in drug development are discussed and areas of improvement are identified in order to promote better cancer control and decrease the rate and severity of side-effects.

Update on intravesical agents for non-muscle-invasive bladder cancer

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.

New Italian guidelines on bladder cancer, based on the World Health Organization 2004 classification

OBJECTIVE To provide evidence-based recommendations on bladder cancer management METHODS A multidisciplinary guideline panel composed of urologists, medical oncologists, radiotherapists, general practitioners, radiologists, epidemiologists and methodologists conducted a structured review of previous reports, searching the Medline database from 1 January 2004 to 31 December 2008. The milestone papers published before January 2004 were accepted for analysis. The level of evidence and the grade of the recommendations were established using the GRADE system. RESULTS In all, 15 806 references were identified, 1940 retrieved, 1712 eliminated (specifying the reason for their elimination) and 971 included in the analysis, as well as 241 milestone reports. A consensus conference held to discuss the discrepancies between the scientific evidence and the clinical practice was then attended by 122 delegates of various specialities. CONCLUSION Recommendations on bladder cancer management are provided.

Results at 48 Months of a Randomized Trial on Maintenance after Early Adjuvant

Introduction and objectives

The role of maintenance regimen following early intravesical chemotherapy after TUR of intermediate risk non-muscle invasive bladder cancer (NMI-BC) is still debated. Only few studies have been published on this topic, rarely dealing with patients receiving an early treatment. The aim of the present study is to evaluate the efficacy of one-year maintenance after a 6-week cycle of early intravesical chemotherapy.

Methods

Between May 2002 and August 2003, 482 patients with intermediate risk NMI-BC after TUR and early intravesical chemotherapy (epirubicin, 80mg/50mL) were randomized between 6-week induction cycle and induction plus maintenance with 10 monthly instillations. A written informed consent was obtained. All patients underwent cytology and cystoscopy 3-monthly for 2 years and 6-monthly thereafter.

Results

Treatment interruption for toxicity was required in 39 patients. Median follow-up was 48 months. Ten patients (2.5%) progressed and 117 patients (29.6%) recurred. The tumor characteristics were equally distributed between the two arms. No statistically significant difference in recurrence free survival (RFS) was detected between the two arms (p=0.43). An advantage in terms of recurrence free rate (RFR) in favor of the maintenance arm was evident only until 18 months after TUR (p=0.03). A trend for a higher benefit from maintenance in primary and multiple tumors was detected.

Conclusions

The risk of tumor recurrence is significantly reduced by one-year maintenance only for 18 months after TUR in comparison with patients receiving a 6-week cycle of early intravesical chemotherapy. The disadvantages of prolonged intravesical chemotherapy should be taken into account.

Prevention of recurrence with epirubicin and lactobacillus casei after transurethral resection of bladder cancer

PURPOSE

A prospective, randomized, controlled trial was done to evaluate whether oral administration of a preparation of the probiotic agent Lactobacillus casei (Yakult Honsha, Tokyo, Japan) could enhance the prevention of recurrence by intravesical instillation of epirubicin after transurethral resection for superficial bladder cancer.

MATERIALS AND METHODS

Between August 1999 and December 2002, 207 patients clinically diagnosed with superficial bladder cancer were included as study candidates and underwent transurethral resection, followed by intravesical instillation of 30 mg epirubicin/30 ml saline twice during 1 week. After histological confirmation of superficial bladder cancer they were again included as study participants with 102 randomized to receive treatment with 6 additional intravesical instillations of epirubicin during the 3-month period after transurethral resection (epirubicin group) and 100 randomized to intravesical chemotherapy on the same schedule as the epirubicin group plus oral administration of 3 gm Lactobacillus casei preparation per day for 1 year (epirubicin plus Lactobacillus casei group). Patients were evaluated for intravesical recurrence, disease progression, prognosis and adverse drug reactions.

RESULTS

The 3-year recurrence-free survival rate was significantly higher in the epirubicin plus Lactobacillus casei group than in the epirubicin group (74.6% vs 59.9%, p = 0.0234), although neither progression-free nor overall survival differed between the groups. The incidence of adverse drug reactions did not significantly differ between the groups and there were no serious adverse drug reactions.

CONCLUSIONS

Intravesical instillation of epirubicin plus oral administration of Lactobacillus casei preparation is a novel, promising treatment for preventing recurrence after transurethral resection for superficial bladder cancer.

The schedule and duration of intravesical chemotherapy in patients with non-muscle-invasive bladder cancer: a systematic review of the published results of randomized clinical trials

OBJECTIVES

Intravesical chemotherapy has been studied in randomized clinical trials for >30 yr; however, the optimal schedule and duration of treatment are unknown. The objective is to determine the effect of schedule and duration of intravesical chemotherapy on recurrence in patients with stage Ta T1 bladder cancer.

METHODS

A systematic review was conducted of the published results of randomized clinical trials that compared intravesical instillations with respect to their number, frequency, timing, duration, dose, or dose intensity.

RESULTS

One immediate instillation after transurethral resection (TUR) is recommended in all patients. In low-risk patients, no further treatment is recommended before recurrence. In patients with multiple tumors, one immediate instillation is insufficient treatment. Additional instillations may further reduce the recurrence rate; however, no recommendations can be made concerning their optimal duration. A short intensive schedule of instillations within the first 3-4 mo after an immediate instillation may be as effective as longer-term treatment schedules (grade C). Instillations during > or =1 yr in intermediate-risk patients seem advisable only when an immediate instillation has not been given (grade C). Higher drug concentrations and optimization of the drug's concentration in the bladder may provide better results (grade C).

CONCLUSIONS

The optimal schedule and duration of intravesical chemotherapy after an immediate instillation remain unknown. Future studies should focus on the eradication of residual disease after TUR and the prevention of late recurrences.

Superficial and Muscle-Invasive Bladder Cancer: Principles of Management for Outcomes Assessments

Bladder cancer is a heterogeneous disease. Non–muscle-invasive bladder cancer embraces a spectrum of tumors with varying degrees of clinical behavior. Transurethral resection remains the surgical mainstay for the treatment of non–muscle-invasive bladder cancer. In an attempt to decrease the recurrence or progression rate, intravesical chemotherapy or immunotherapy is also used. Radical cystectomy with bilateral pelvic lymph node dissection remains the gold standard for treating muscle-invasive bladder cancer. Over the last decade, the orthotopic neobladder has gained widespread popularity as the preferred mode of urinary diversion in both males and females with similar oncologic and functional outcomes. Well-designed trials with effective chemotherapy have shown a beneficial role for neoadjuvant chemotherapy.

Phase II trial of intravesical gemcitabine in bacille Calmette-Guérin-refractory transitional cell carcinoma of the bladder

PURPOSE

The aim of this phase II study was to determine the efficacy of gemcitabine administered as an intravesical agent in patients with bacille Calmette-Guérin (BCG) -refractory transitional cell carcinoma of the bladder.

PATIENTS AND METHODS

Patients with superficial bladder cancer refractory or intolerant to intravesical BCG therapy and refusing a cystectomy were considered eligible for the trial. Eligible patients received two courses of intravesical gemcitabine twice weekly at a dose of 2,000 mg/100 mL for 3 consecutive weeks, with each course separated by 1 week of rest. Patients were evaluated for response at 8 weeks, then every 3 months to 1 year.

RESULTS

Thirty eligible patients were included on study. The median follow-up for all the patients was 19 months (range, 0 to 35 months). Of the 30 patients, 15 (50%; 95% CI, 32% to 68%) achieved a complete response (CR). Twelve patients had tumor recurrence with a median recurrence-free survival time of 3.6 months (95% CI, 2.9 to 11.0 months). Two patients maintained a CR at 23 and 29 months, respectively. The 1-year recurrence-free survival rate for patients with a CR was 21% (95% CI, 0% to 43%). Two patients progressed to a higher stage while receiving gemcitabine treatment. The median follow-up for patients who did not have a progression or a cystectomy was 19 months (range, 2 to 35 months). Eleven patients (37%) underwent a cystectomy subsequent to gemcitabine therapy.

CONCLUSION

Gemcitabine has activity in a high-risk patient population and remains a viable option for some patients who refuse cystectomy.

Early bladder cancer: concept, diagnosis, and management

Recent evidence on molecular pathways helps us to understand the pathogenesis of bladder cancer. However, the molecular mechanisms of recurrence of the disease and progression into muscle-invasive disease are not fully understood. The diagnostic accuracy and specificity of innovative markers for detection of the disease currently available in the clinical setting are still far from the level where cystoscopy would not be needed. Although risk factors for progression to muscle-invasive disease have been identified, we still cannot predict accurately the clinical behavior of superficial bladder cancer. In this review article, we summarize recent evidence on molecular pathogenesis, risk factors for recurrence and progression, urine markers for detection, and treatments in superficial bladder cancer.

Low-grade Ta (noninvasive) urothelial carcinoma of the bladder

This article discusses the development of international guidelines for the diagnosis, treatment, follow-up, and prevention of low-grade Ta urothelial carcinoma of the bladder. The authors, who are experts in this field from 3 continents and 7 countries, reviewed the English language literature through September 2004. The results of the authors' deliberations are presented here as a consensus document. The objective of this study was to determine the optimal diagnostic workup, treatment, follow-up, and prevention of low-grade, Ta urothelial carcinoma of the bladder. A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) met to critically review the literature on the diagnosis and treatment of low-grade Ta urothelial carcinoma of the bladder. Research was conducted using Medline; this search engine also was used to identify additional works not detected at the initial search. Evidence-based recommendations for diagnosis and management of the disease were made with reference to a 4-point scale. Low-grade Ta urothelial carcinoma of the bladder is a well-studied subject with many level 1 and 2 evidence references that support clinical practice. Findings from 135 reviewed citations are summarized. Many grade A and B recommendations on the diagnostic workup and management of this disease can be given with level 1 and 2 evidence based on prospective randomized clinical trials of sufficient statistical power. This should improve the quality of the treatment of this disease.

Superficial Bladder Cancer Therapy: A Review

Most bladder cancers present as a superficial disease, confined to the bladder mucosa or submucosal layer, without muscle invasion. Most superficial tumors have a propensity for recurrence after transurethral resection; some have a high risk for progression to muscle invasion. The treatment aim in superficial bladder cancer with intravesical therapy is three-fold: (1) eradicate existing disease, (2) prevention of recurrence, (3) prevention of tumor progression. The prognostic factors (tumor stage, grade, size, number and recurrence pattern) allow the stratification of tumors in different risk groups to plan treatment. Studies on pharmacokinetics have proved the efficacy of optimized drug delivery. Comparing resection with and without intravesical chemotherapy, a short-term reduction, approximately 15%, in tumor recurrence with chemotherapy can be obtained, but no effect on progression was proven. No agent has proved to be more effective than the others. A single instillation of chemotherapy immediately after transurethral resection has proven to be effective, but the role of maintenance therapy is controversial. Immunotherapy, in the form of Bacillus Calmette-Guerin, is generally shown to be more effective than chemotherapy, even if the results in comparison to mitomycin C do not result conclusive. Several new approaches are being explored to improve the efficacy of this therapy.

The nuclear membrane in multidrug resistance: microinjection of epirubicin into bladder cancer cell lines

OBJECTIVE

To assess whether microinjecting epirubicin into cells showing multidrug resistance (MDR, common to many cancers, including bladder cancer, with resistance to, e.g. anthracyclines and mitomycin C) spares the nucleus, as when these drugs accumulate, distribution in MDR cells characteristically spares the nucleus, suggesting that the nuclear membrane is responsible for excluding cytotoxic drugs from MDR nuclei.

MATERIALS AND METHODS

Nuclear exclusion of drugs is an important feature of resistance in MDR cells, as many MDR-susceptible drugs have cytotoxic actions within the nucleus. Drug accumulation in 'classical' P-glycoprotein-mediated MDR cells is greatly reduced by efflux. Microinjection of epirubicin into the cytoplasm of MDR cells bypasses the P-glycoprotein efflux pump on the plasma membrane. Nuclear sparing would directly implicate the nuclear membrane in this phenomenon. Because of their fluorescence properties, which allow study by confocal microscopy and flow cytometry, anthracyclines have also been used extensively to investigate MDR. Thus sensitive (MGH-U1 and RT112) and MDR (MGH-U1R and MGH-U1-MMC) bladder cancer cell lines were used. Adherent cells from each cell line were individually microinjected with epirubicin (0.5 mg/mL) and a 77 kDa fluorescein isothiocyanate (FITC)-dextran (0.5 mg/mL). The pattern of nuclear epirubicin uptake in injected cells was then evaluated by confocal microscopy. The 77 kDa FITC-dextran allowed easier identification of injected cells and was also excluded from their nuclei.

RESULTS

Sensitive bladder cancer cell lines all showed a nuclear accumulation pattern of epirubicin, consistent with their normal uptake after exposure to epirubicin. The MDR cell lines showed the characteristic nuclear-sparing pattern of epirubicin uptake, similar to the normal uptake pattern after epirubicin exposure. The 77 kDa FITC-dextran showed clearly which cells had been microinjected, and was excluded from the nuclei of all injected cells. Cell viability was confirmed by acridine-orange staining after initial visualization of injected cells.

CONCLUSION

The nuclear membrane is responsible for the nuclear exclusion of epirubicin in MDR cells. Further work is necessary to determine the mechanisms involved.

Practical Applications of Intravesical Chemotherapy and Immunotherapy in High-risk Patients with Superficial Bladder Cancer

The following steps are practical in the treatment of intermediate-to-high risk patients with superficial bladder cancer: Resect all visible tumor at the time of first TUR of bladder tumor. Strongly consider re-resection, especially for high-risk, large, multifocal, stage T1 tumors. Apply one dose of cytotoxic chemotherapy perioperatively within 6 hours of TUR (ideally immediately). Once histopathology is available, consider intravesical induction chemotherapy for intermediate-risk patients and BCG for intermediate- or high-risk patients and those having failed prior chemotherapy. At least 1 year of maintenance therapy should be planned for all intermediate-to-high risk BCG-treated patients. Chemotherapy maintenance may be useful if perioperative chemotherapy was omitted. For patients failing standard therapy, a thorough discussion of the risks (including progression and metastasis) and expected benefits should take place before the initiation of salvage therapy. The radical cystectomy option should be openly entertained. Consider BCG plus interferon or gemcitabine-based salvage programs if appropriate. Explore clinical trial options. Contact urologic cancer experts for guidance and advice.

Phase II Study to Investigate the Ablative Efficacy of Intravesical Administration of Gemcitabine in Intermediate-Risk Superficial Bladder Cancer (SBC)

OBJECTIVE

Phase I studies have so far demonstrated that intravesical Gemcitabine up to a 40 mg/ml concentration is well tolerated and has a substantial ablative activity on high-risk BCG refractory SBC. New treatment options are needed for intermediate-risk SBC recurring after conventional intravesical treatments. The purpose of the present study was to investigate the ablative efficacy of intravesical Gemcitabine on intermediate-risk SBC.

METHODS

The study was designed as a two-stage phase II trial, with a sample size of 39 patients. The efficacy of intravesical Gemcitabine at a concentration of 40 mg/ml (2000 mg in 50 ml saline solution) administered weekly for 6 weeks was assessed on a single marker tumour left in the bladder after a complete TUR of all other lesions. Patients underwent TUR or biopsy at the site of the marker lesion 2 weeks after completion of the treatment.

RESULTS

Complete response was observed in 22 out of 39 patients (56%). No progression was observed among the 17 non-responders. Neither systemic nor local side effects generally exceeded grade I toxicity.

CONCLUSION

The ablative effect of Gemcitabine produced a higher number of responses than the minimum required by the protocol to indicate a significant probability of drug efficacy. It is worth testing the drug in phase III trials to assess for durability of response.