Prognostic markers of intravesical bacillus Calmette-Guérin therapy for multiple, high-grade, stage T1 bladder cancers

Predictive biomarkers of response to bacillus Calmette‐Guérin immunotherapy and bacillus Calmette‐Guérin failure for non‐muscle invasive bladder cancer

Within the heterogeneous population of patients with bacillus Calmette‐Guérin failure, there are clear differences in prognosis and therapy with regard to the timeline when bacillus Calmette‐Guérin failure occurred. There are a variety of classifications which include bacillus Calmette‐Guérin refractory disease, relapsing, unresponsive, and intolerant. Further profiling of these patients may help to shed light on other forms of therapy that are less radical. We hereby summarize the different biomarkers that predicts for response to bacillus Calmette‐Guérin immunotherapy and bacillus Calmette‐Guérin failure for non‐muscle invasive bladder cancer.

Biomarkers predicting oncological outcomes of high-risk non-muscle-invasive bladder cancer

INTRODUCTION

The European Organization for Research and Treatment of Cancer (EORTC) and the Spanish Urological Club for Oncological Treatment (CUETO) scoring systems show limited accuracy for the prediction of disease recurrence and progression of non-muscle-invasive bladder cancer (NMIBC). This aspect is even more relevant in the category of HR NMIBC. Biomarkers might potentially help to further categorize the outcomes of these patients. Therefore, we sought to review the evidence available on tissue-based, urinary, and serum biomarkers for the prediction of recurrence, progression, and survival in HR NMIBC.

EVIDENCE ACQUISITION

A systematic literature review without time restrictions was performed using PubMed/EMBASE, Web of Science, SCOPUS, and the Cochrane Libraries. The search was filtered for articles in the English, Italian, German, French, and Spanish languages, involving patients with more than 18 years of age. Relevant papers on tissue-based, serum and urinary biomarkers related to the prediction of oncological outcomes for high-risk bladder cancer patients were included in the analyses.

EVIDENCE SYNTHESIS

Overall, 71 studies were eligible for inclusion in this review. The majority of the investigations performed so far focused on immunohistochemical analyses on tumoral tissue. Overall, p53 was the most studied biomarker, but results regarding its prognostic and predictive role were contradictory. Ki67 seems to be a promising biomarker in the prediction of recurrence. Recently, PD-L1 has been associated with the prediction of recurrence free survival and of treatment-refractory disease. Markers developed un urine samples are focused on commercially available kits, which currently do not unequivocally show strongly superior levels of accuracy to cytology. However, they have demonstrated to be potentially helpful in the prediction of recurrence. Blood-based biomarkers represent an emerging reality with promising future applications.

CONCLUSIONS

Despite a long history of attempts to discover accurate biomarkers predicting oncological outcomes for HR NMIBC, contradictory or uncertain findings render the adoption of this ancillary techniques in clinical practice still unlikely. Future attempts should be directed to the development of prospective trials and the definition of standardized cut-off levels to render findings worthy of comparison.

Prognostic value of ki67 in BCG-treated non-muscle invasive bladder cancer: a meta-analysis and systematic review

OBJECTIVES

The aim of this study was to explore the prognostic value of ki67 as a marker in patients with non-muscle invasive bladder cancer (NMIBC) treated with BCG.

METHODS

Studies were systematically retrieved from the relevant databases (Web of Science, PubMed, Cochrane Library and Embase), and the expiry date was May 2017. The research steps referred to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement.

RESULTS

A total of 11 studies that complied with the inclusion criteria were included. The expression of ki67 was not statistically significantly associated with recurrence-free survival (RFS) (HR 1.331; 95% CI 0.980 to 1.809). No significant heterogeneity was found among all included studies (I² =36.7%, p=0.148). The expression of ki67 was statistically significantly associated with progression-free survival (PFS) (HR 2.567; 95% CI 1.562 to 4.219), and the overexpression of ki67 was the risk factor for PFS. Significant heterogeneity was noted among all the included studies (I² =55.6%, p=0.021). The studies that might cause heterogeneity were excluded using the Galbraith plot, and then the meta-analysis was performed again. The results showed that the expression of ki67 was still associated with PFS (HR 2.922; 95% CI 2.002 to 4.266).

CONCLUSIONS

The overexpression of ki67 was the risk factor for PFS, and the relationship between the expression of ki67 and RFS was not statistically significant in patients with NMIBC treated with BCG intravesical immunotherapy. Well-designed, prospective, with a large sample size are still needed to validate the findings.

Significance of Ki-67 in non-muscle invasive bladder cancer patients: a systematic review and meta-analysis

Purpose

This meta-analysis evaluated the prognostic significance of Ki-67 in non-muscle invasive bladder cancer (NMIBC).

Materials and Methods

We selected 39 articles including 5,229 patients from Embase, Scopus, and PubMed searches. The primary outcomes, recurrence-free survival (RFS), progression-free survival (PFS), disease-specific survival (DSS), and overall survival (OS) were determined using time-to event hazard ratios (HRs) with 95% confidence intervals (CIs). Study heterogeneity was tested by chi-square and I² statistics. Heterogeneity sources were identified by subgroup meta-regression analysis.

Results

Two studies were prospective; 37 were retrospective. Immunohistochemistry was performed in tissue microarrays or serial sections. A wide range of antibody dilutions and Ki-67 positivity thresholds were used. Study heterogeneity was attributed to analysis results in studies of RFS (p < 0.0001). Meta-regression analysis revealed that region and analysis results accounted for heterogeneity in PFS studies (p = 0.00471, p < 0.0001). High Ki-67 expression was associated with poor RFS (pooled HR, 1.78; 95% CI, 1.48–2.15), poor PFS (pooled HR, 1.28; 95% CI, 1.13–2.15), poor DSS (pooled HR, 2.24; 95% CI, 1.47–2.15), and worse OS (pooled HR, 2.29; 95% CI, 1.24–4.22).

Conclusions

The meta-analysis found that current evidence supports the prognostic value of Ki-67 in NMIBC patients.

p53 Status correlates with the risk of recurrence in non-muscle invasive bladder cancers treated with Bacillus Calmette-Guérin: a meta-analysis

Objective

Published studies have yielded inconsistent results on the relationship between p53 status and the prognosis of non-muscle invasive bladder cancer (NMIBC) treated with Bacillus Calmette–Guérin (BCG) intravesical therapy. Therefore, we performed a meta-analysis to evaluate the prognostic value of p53 in NMIBC treated with BCG.

Methods

We systematically searched for relevant literature in PubMed, EMBASE, CNKI, and Chinese Wanfang databases. Hazard ratios (HRs) with 95% confidence intervals (CIs) were combined as the effect size (ES) across studies for recurrence-free survival (RFS) and progression-free survival (PFS).

Results

A total of 11 studies, consisting of 1,049 participants, met the criteria. Overall, there was no clear relationship between p53 status and RFS or PFS for NMIBC patients treated with BCG (HR: 1.40, 95% CI: 0.91-2.16; HR: 1.37, 95% CI: 0.90-2.09, respectively). Obvious heterogeneity was observed across the studies (I² = 69.5%, P = 0.001; I² = 44.7%, P = 0.081, respectively). In stratified analysis by region, p53 overexpression was a predictor of poor RFS in Asian populations (HR: 1.57, 95% CI: 1.08-2.27). In addition, after excluding the studies that possibly contributed to the heterogeneity by the Galbraith plot, the overall association for RFS became statistically significant (HR: 1.38 95% CI: 1.08-1.77) without evidence of heterogeneity (I² = 0.0%, P = 0.499).

Conclusion

This meta-analysis suggests that p53 overexpression in NMIBC patients treated with BCG may be associated with RFS, especially in Asian populations. Because of the heterogeneity and other limitations, further studies with rigid criteria and large populations are still warranted to confirm our findings.

Predictive biomarkers of bacillus calmette-guérin immunotherapy response in bladder cancer: where are we now?

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.

Prognostic value of p53, Ki-67, microstaging and microvessel density in pT1G3 bladder tumors: Creation of risk groups for progression

OBJECTIVE

New predictive factors for bladder tumor progression have been analyzed in many publications, often with contradictory results. Very few papers have referred specifically to T1G3 tumors. Our objective was to find new, clinically useful markers which either alone or in association with classical prognostic factors would allow the early selection of the correct therapeutic approach.

MATERIAL AND METHODS

This was a retrospective study of 83 patients with T1G3 bladder tumors who were initially treated with transurethral resection + bacillus Calmette-Guérin therapy, with a minimum follow-up period of 3 years. We analyzed eight variables. New factors considered were: the level of submucosal invasion; microvessel density; and immunostaining for Ki-67 and p53. Independent prognostic variables for progression were established using logistic regression analysis, and risk groups were created from mathematical models.

RESULTS

Five variables were determined as unfavorable: tumor multiplicity; tumor size >3 cm; carcinoma in situ; T1b substage; and p53 positivity. The first three factors predicted progression in only 32% of cases, while the addition of the new prognostic factors (T1b substage and p53 positivity) increased this rate to 65%. We established four risk groups, with rates of progression of 67% and 100% in the high-risk and very high-risk groups, respectively. For inclusion in these groups, both new predictive factors had to be unfavorable; if either one were absent then the three classical factors had to be present.

CONCLUSIONS

Microstaging and p53 positivity have a prognostic value for predicting progression in T1G3 tumors, providing 33% more information than that obtained with classical prognostic factors alone. The application of mathematical models identifies risk groups and allows the use of an early and more aggressive treatment.

Expression and prognostic significance of Livin in the progression of bladder cancer

It has been suggested that progression of bladder transitional cell cancer (BTCC) may be regulated at the molecular level by a typical pattern of expression of genes involved in apoptosis. Recently Livin, belonging to the inhibitors of apoptosis (IAP) family, has been found to be expressed in most solid tumors, where its expression is suggested to have clinical significance. In order to explore the significance of Livin expression in the development of BTCC, immunohistochemistry and RT-QPCR were used to detect the expression of Livin mRNA in tumor tissues and adjacent normal tissues of 30 cases of BTCC. The results showed that the positive rate of Livin expression in adjacent normal tissues and tumor tissues was 0 and 60% (18/30) respectively. The-Delta Delta CT value of Livin in BTCC tissues was 8.0454 (7.4264-8.6644) times of that in adjacent normal tissues. The expression of Livin mRNA had no correlation with tumor pathological grades and clinical stages. It was suggested that there was weak expression of Livin mRNA in adjacent normal tissues, but strong in tumor tissues.

P53 as a prognostic marker for bladder cancer: a meta-analysis and review

BACKGROUND

P53 is the most widely investigated molecular marker in bladder cancer. We aimed to review comprehensively the evidence for use of changes in P53 to predict bladder-cancer recurrence, progression, and mortality.

METHODS

We reviewed 168 publications from 117 studies. Estimates of significance were extracted from association tests, and hazard ratios with 95% CI from actuarial curves and Cox regression analyses. A meta-analysis was done on the studies that applied Cox models.

FINDINGS

The methods used to assess significance varied widely between studies. 27% (nine of 34) of studies that assessed the prognostic value of P53 overexpression in recurrence by use of multivariate tests showed a significant association. The corresponding values for progression and mortality were 50% (12 of 24) and 29% (ten of 35), respectively. In the studies that used Cox models, the overall risk of recurrence was 1.6 (95% CI 1.2-2.1), of progression was 3.1 (1.9-4.9), and of mortality was 1.4 (1.2-1.7). These findings could be overestimates because of publication and reporting bias.

INTERPRETATION

After 10 years of research, evidence is not sufficient to conclude whether changes in P53 act as markers of outcome in patients with bladder cancer.

Valor pronóstico de progresión de las moléculas reguladoras del ciclo celular en tumores vesicales T1G3

INTRODUCTION AND OBJECTIVE

Bladder tumor T1G3 constitutes the group of superficial tumors more aggressive. New prognostic factors in the field of the cytogenetics and molecular biology have been analyzed, with often contradictory results, being little the specific works in tumors T1G3. Our objective is to determine if in this group of tumors the immunohistochemical markers present predictive value of clinically useful progression, and therefore with validity to indicate more suitable a precocious therapeutic attitude.

MATERIAL AND METHODS

Retrospective study of a series of 83 patients affected of bladder tumor T1G3, on which we analyzed a total of 14 variables; between the new predictive factors: the immunohistochemical determination of regulating proteins of the cellular cycle: p53, p21 and bcl-2, as well as the Ki-67 protein like marker of cellular proliferation. By means of logistic regression analysis we establish the independent prognostic variables for tumorlike progression.

RESULTS

The cut point established for Ki67 and p53 was 40% of inmmunomarked cells, 20% for p21 and 10% for Bcl-2. The univariant analysis showed different rates from progression and free times of progression based on the immunohistochemistry of Ki67 and p53: nevertheless, the logistic regression demonstrated that single the immunohistochemistry of p53 presented independent predictive value.

CONCLUSIONS

The determination of p53 presents predictive value of clinically useful progression in bledder tumors T1G3, so that its determination can constitute a essential factor in the strategies of treatment of these tumors.

Intravesical therapy of superficial bladder cancer

The aim of treatment of superficial bladder cancer with intravesical therapy is threefold: (1) Eradicate existing disease. (2) Prevention of recurrence. (3) Prevention of tumor progression. The prognostic factors allow differentiation in different risk groups and this is useful in planning treatment. Studies on pharmacokinetics have proved the efficacy of optimized drug delivery. Comparing resection with and without intravesical chemotherapy a short term approximately 15% decrease in tumor recurrence with chemotherapy can be obtained but no effect on progression was proven. No agent has proved more effective than the other. Single, early instillation of chemotherapy has proven effective but the role of maintenance therapy has been controversial. Immunotherapy in the form of Bacillus Calmette-Guerin generally have proven more efficacious than chemotherapy. The results in comparison to mitomycin C have not been as conclusive. Several new approaches are explored to improve the efficacy of this therapy.

Proapoptotic genes BAX and CD40L are predictors of survival in transitional cell carcinoma of the bladder

The purpose of the study was to investigate the effects of expression of a range of genes involved in apoptosis on outcome in bladder cancer. Immunohistochemistry was used to examine expression of BCL2, BAX, P53, CD40 and CD40L in archival tissues of patients included in various treatment trials for transitional cell carcinoma (TCC) of the bladder. Data were collected on 94 patients who first presented with either invasive or superficial bladder cancer. Median follow-up for alive patients was 83 months (m) (range 12-195 m). Median survival was 80 m (95% CI=56-128 m). Median survivals for the various markers were as follows: BAX-positive patients 110 m vs BAX-negative patients 18 m (P=0.0002); CD40L-positive patients 95 m vs CD40L-negative patients 45 m (P=0.04); BCL2-positive patients 44 m and BCL2-negative patients 74 m, (P=0.64); CD40-positive patients 110 m and CD40 negative patients 45 m (P=0.12); and P53 positive patients 80 m and P53 negative patients 45 m (P=0.58). In conclusion, it was seen that overexpressions of BAX and CD40L are prognostic of better survival in TCC of the bladder. Our results also raise the possibility of the future development of CD40- and CD40 ligand-based immunotherapy for bladder cancer. This study links proapoptotic and antiapoptotic markers to overall survival.

Expression and prognostic significance of LIVIN, SURVIVIN and other apoptosis-related genes in the progression of superficial bladder cancer

BACKGROUND

It has been suggested that progression of superficial bladder cancer may be regulated at the molecular level by a typical pattern of expression of genes involved in apoptosis. Recently LIVIN, belonging to the inhibitors of apoptosis (IAP) family, has been found to be expressed in most solid tumors, where its expression is suggested to have prognostic significance. No data are available concerning the significance of LIVIN in the progression of bladder tumors.

PATIENTS AND METHODS

In the present paper we used RT-PCR to investigate the expression of LIVIN isoforms alpha and beta, SURVIVIN, BCL-X and BCL-2/BAX expression ratio both in normal and tumoral bladder tissues, and correlated their expression with the emergence of early relapses in a follow-up of 4 years. This study shows that only the alpha isoform of LIVIN, which is not expressed in normal bladder tissue, is expressed in a proportion of tumors with a high risk of relapse.

RESULTS

LIVIN was found in 7/30 patients (23%), SURVIVIN in 9/30 (30%), BCL-2/BAX ratio >1 in 16/30 (53%), BCL-2/BAX expression ratio <1 in 14/30 (46.6%) and BCL-X, only in isoform BCL-X(L), in 11/30 (36.6%). When we evaluated the dependence between each gene expression and relapse free time of patients, we found that LIVIN, high BCL-2/BAX ratio and BCL-X(L), but not SURVIVIN, reached statistical significance in order to predict relapses.

CONCLUSIONS

Our findings suggest that LIVIN may be involved in the progression of superficial bladder cancer and used as a marker of early recurrence; while the expression of SURVIVIN cannot be used to identify patients with high risk of relapse.

Prognostic value of p53 overexpression in bladder tumors treated with Bacillus Calmette-Guerin

Bacillus Calmette-Guerin intravesical therapy is the standard treatment of superficial bladder tumors at high risk of recurrence and progression to muscle-invasion disease. To date, there is no well established predictive factor of response to Bacillus Calmette-Guerin intravesical therapy. The prognostic value of p53 overexpression in bladder tumors is controversial. Most investigators have found no correlation between p53 status assessed before Bacillus Calmette-Guerin intravesical therapy and patient outcome. On the other hand, it is acknowledged that the persistence of p53 overexpression after Bacillus Calmette-Guerin intravesical therapy is predictive of progression in patients treated for carcinoma in situ. Since conflicting data have been reported, further evaluation of the impact of p53 overexpression in patients treated with Bacillus Calmette-Guerin intravesical therapy for bladder carcinoma is required.

Therapeutic potential of mycobacterial cell wall-DNA complexes

Cell wall skeletons isolated from many bacteria have been shown to possess anticancer activity. The anticancer activities of such preparations have been attributed to the activation of immune effector cells and not to a direct effect on cancer cell division. A cell wall extract from Mycobacterium phlei, wherein mycobacterial DNA in the form of short oligonulceotides is preserved to the cell wall, has anticancer activity against a wide range of cancer cells. Mycobacterial cell wall-DNA complexes (MCC) exert their anticancer activity by a dual mechanism of action: an indirect effect via the induction of anticancer cytokines and a direct effect on cancer cell division mediated by the induction of apoptosis. In this review, the immunomodulatory and the pro-apoptotic mechanisms of action of MCC will be explored. The identification of the active component in MCC will be discussed, as well as the composition differences with cell wall skeletons and live mycobacteria. Finally, the use of MCC against bladder and prostate cancers will be discussed and compared to standard therapies, particularly therapy using mycobacteria and mycobacteria-derived products.

[DNA ploidy determination with flow cytometry, Ki-67 index and overexpression of p53 protein in 121 T1 superficial bladder carcinomas. Retrospective studies. Part II: Prognostic value and usefulness in the indication for prophylactic treatment with BCG]

OBJECTIVE

Evaluate the utility of Ki-67 label index, p53 expression and flow cytometry-DNA ploidy in the selection of groups to be treated with prophylactic BCG and the prognostic value compared with the classic variables (grade, lymphatic permeation, multiplicity, volume, primary).

MATERIAL & METHOD

121 superficial bladder tumors T1. 10% Cut-off level for Ki-67 and p53. Aneuplody is defined as a tumor with DNA index different of 1 or more than 20% in G2-M phase. 71 (58.7%) received BCG.

RESULTS

In uni and multivariate analysis positivity to Ki-67 is correlated with recurrence. Progression is correlated with lymphatic permeation (p .0003), volume (p .016), ploidy (p .022) and positivity to p53 (p .007). In multivariate analysis, volume and positivity to p53 are independent variables. None were of utility to prevent recurrence, but Ki-67 positive or aneuploid treated tumors had less progression (p .025 and p .009 respectively). The p53 negative treated tumors had less progression too.

CONCLUSIONS

Only Ki-67 is correlated with tumoral recurrence. P53 and tumor volume are correlated with stage progression. If the results are confirmed with bigger series, the Ki-67 positive and/or aneuploid tumors would obtain benefits of prophylactic treatment with BCG.

Functional foods: the US perspective

Widespread interest in the possibility that selected foods might promote health has resulted in the coining of the term functional food, although agreement about what is and what is not a functional food is lacking. Public interest in functional foods is increasing because of higher health care costs; the passage of federal legislation affecting many food categories, including the expanded category of dietary supplements; and recent scientific discoveries linking dietary habits with the development of many diseases, including coronary heart disease and some cancers. A variety of foods have been proposed as providing health benefits by altering one or more physiologic processes. Biomarkers are needed to assess the ability of functional foods or their bioactive components to modify disease and to evaluate the ability of these foods to promote health, growth, and well-being. Evidence suggests that several biomarkers may be useful for distinguishing between diseased and nondiseased states and even for predicting future susceptibility to disease. A variety of biomarkers will probably be needed to develop a profile for an individual that reflects the impact of diet on performance and health. Another area of interest is the interaction of nutrients and their association with genetics. These interactions may account for the inconsistent interrelations observed between specific dietary constituents and the incidence of disease. Greater understanding of how diet influences a person's genetic potential, overall performance, and susceptibility to disease can have enormous implications for society. As new discoveries are made in this area, consumers will need access to this information so that they can make informed decisions.

Bcl-2 expression identifies patients with advanced bladder cancer treated by radiotherapy who benefit from neoadjuvant chemotherapy

OBJECTIVE

To assess the prognostic significance of Bcl-2 expression on the clinical outcome after radiotherapy for muscle-invasive bladder cancer, and to determine if it is possible to identify a subgroup of patients to whom neoadjuvant chemotherapy can be targeted to improve survival.

PATIENTS AND METHODS

Immunohistochemical staining for Bcl-2 and p53 was performed on the tumours of 51 patients with stage T2-T4a NXM0 transitional cell carcinoma of the bladder who had been included in a randomized clinical trial of radiotherapy with or without neoadjuvant cisplatin. The association between positive staining and salvage cystectomy rate and overall survival was examined, with a median follow-up of 12 years.

RESULTS

Bcl-2 and p53 expression was positive in 31 (61%) and 39 (76%) of the tumours, with no association between either, or with tumour stage or grade. There was no difference according to Bcl-2 positivity in the salvage cystectomy rate (P = 0.83) or survival (P = 0.68) for the 51 patients as a whole, but Bcl-2-negative patients receiving neoadjuvant cisplatin had a significantly better prognosis, with a median survival of 72 months compared to 17 months in Bcl-2-positive patients, and a 5-year survival rate of 55% (P = 0.03).

CONCLUSIONS

Quantifying Bcl-2 in patients undergoing radiotherapy for advanced bladder cancer identifies those who may benefit from neoadjuvant chemotherapy. Further studies of other members of the Bcl-2 family and other proteins controlling both cell proliferation and apoptosis are warranted, to define the roles and the interactions between them that may contribute to oncogenesis and resistance to standard treatments. This may allow the targeting of specific treatments to patients known to be sensitive to them, and aid the future development of novel therapies for bladder cancer.

Biological markers in superficial bladder tumors and their prognostic significance

This article reviews the literature on some of the available biomarkers such as p53 and its down-stream effector p21 on superficial bladder tumor biology and their prognostic significance. The role of p53 tumor suppressor gene is controversial in superficial bladder cancer, possibly because analyzing one single effector of a pathway might hide the role of downstream effectors. The aggressiveness of this condition is related to proliferative activity as measured by Ki-67. Further studies are still necessary to draw definitive conclusions about the role of these different biological markers in superficial bladder cancer.