A controlled trial of single dose intravesical adriamycin in superficial bladder tumours

Tackling non-muscle invasive bladder cancer in the clinic

INTRODUCTION

Non-muscle invasive bladder cancer (NMIBC) is a common disease process with a high propensity for recurrence and risk of progression to muscle-invasive or systemic disease. Optimal management of NMIBC depends on appropriate resection and staging, risk-based use of intravesical therapy and tailored surveillance. Current challenges include compliance with guideline recommendations and cancers which are refractory to standard therapies. Areas covered: This review summarizes the conventional management of NMIBC - which relies on strict cystoscopic surveillance and intravesical therapies with chemotherapy and/or immunotherapy in the form of bacillus Calmette-Guerin (BCG). As many patients will be resistant to conventional treatment, investigational therapies and novel prognostic models will also be discussed. Expert commentary: For decades, the management of NMIBC has been predicated on intravesical therapies, most often through the instillation of BCG which has proven clinical efficacy over transurethral resection alone. Despite this, many patients will recur or progress after BCG therapy. While radical cystectomy remains the standard for such patients, suitable alternatives are being actively investigated. An increased interest in immunotherapy for malignancy has reinvigorated this field and on-going advances in disease prognostication are likely to improve upon the existing treatment paradigms for NMIBC.

Single early instillation of mitomycin C and urinary alkalinization in low-risk non-muscle-invasive bladder cancer: a preliminary study

Background

The purpose of this study was to determine the effectiveness of a single early instillation of mitomycin C (MMC) after transurethral resection of bladder tumor (TURBT) together with urinary alkalinization in patients with low-risk non-muscle-invasive bladder cancer (NMIBC).

Methods

Between February 2006 and November 2010, patients diagnosed as having a primary bladder tumor were randomized into standard and optimized treatment groups. The treatment groups were formed prospectively from patients with NMIBC according to results of pathological examination postoperatively, whereas the control group was formed retrospectively. Patients in the standard group (n = 11) were given intravesical MMC 40 mg in the first 6 hours after TURBT, while the patients in the optimized group (n = 15) underwent urinary alkalinization prior to MMC. In the control group (n = 23), no drug treatment was given. The patients were followed after surgery at months 3 and 12, and then annually for the first 5 years using cystoscopy and ultrasound. Time to recurrence and recurrence-free survival rates were calculated.

Results

There were no statistically significant differences between the standard and optimized groups, between the control and optimized groups, or between the control and standard groups in terms of mean recurrence-free survival rates (P = 0.132, 0.645, and 0.173, respectively). The mean time to recurrence was 34.8 (range 28.5–41.1) months in the optimized group and 51.8 (range 44.3–59.2) months in the control group. There was no recurrence during the follow-up period in the standard group.

Conclusion

The results of this preliminary study could not demonstrate the efficacy of urinary alkalinization before a single dose of early MMC following TURBT to increase the effectiveness of the MMC, so we did not continue the study further.

The Direct Anti-Cancer Effect of a Single Instillation of Epirubicin after Transurethral Resection of Bladder Tumor for Non-Muscle-Invasive Bladder Cancer

Purpose

To evaluate the direct anti-cancer effect of a single instillation of epirubicin (SIE) after transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC) by analysis of immediate urine cytology (IUC).

Materials and Methods

We reviewed the records of 158 patients who had IUC after TURBT for NMIBC. Fifty-six patients were treated with SIE after TURBT and 102 patients were not treated with SIE. The direct anti-cancer effect of SIE was compared in the two groups according to the result of IUC. The relationship between SIE and IUC in NMIBC was analyzed by use of multivariate Cox proportional hazards regression models.

Results

The IUC-positive rate was 33.9% in the SIE group and 42.1% in the non-SIE group (p=0.005). The IUC-positive rate was lower in the SIE group than in the non-SIE group for each factor, including tumor stage, tumor grade, tumor size, tumor multiplicity, and preoperative urine cytology. Multivariate Cox proportional hazards regression analysis revealed that SIE was significantly associated with a negative IUC result in patients with NMIBC (HR, 0.163) (p<0.001).

Conclusions

These results indicate the direct anti-cancer effect of SIE in patients who undergo TURBT for NMIBC.

Should all patients with non-muscle-invasive bladder cancer receive early intravesical chemotherapy after transurethral resection? The results of a prospective randomised multicentre study

BACKGROUND

To decrease recurrences in non-muscle-invasive bladder cancer (NMIBC), the European Association of Urology (EAU) guidelines recommend immediate, intravesical chemotherapy after transurethral resection (TUR) for all patients with Ta/T1 tumours.

OBJECTIVE

To study the benefits of a single, early, intravesical instillation of epirubicin after TUR in patients with low- to intermediate-risk NMIBC.

DESIGN, SETTING, AND PARTICIPANTS

In this prospective randomised multicentre trial, 305 patients with primary as well as recurrent low- to intermediate-risk (Ta/T1, G1/G2) tumours were enrolled between 1997 and 2004. Patients were randomly allocated to receive 80 mg of epirubicin in 50 ml of saline intravesically within 24 h of TUR or no further treatment after TUR.

MEASUREMENTS

The primary end point was time to first recurrence.

RESULTS AND LIMITATIONS

A total of 219 patients remained for analysis after exclusions. The median follow-up time was 3.9 yr. During the study period, 62% (63 of 102) of the patients in the epirubicin group and 77% (90 of 117) in the control group experienced recurrence (p=0.016). In a multivariate model, the hazard ratio (HR) for recurrence was 0.56 (p=0.002) for early instillation of epirubicin versus no treatment. In a subgroup analysis, the treatment had a profound recurrence-reducing effect on patients with primary, solitary tumours, whereas it provided no benefits in patients with recurrent or multiple tumours. Furthermore, patients with a modified European Organisation for Research and Treatment of Cancer (EORTC) risk score of 0-2 with and without single instillation had recurrence rates of 41% and 69%, respectively (p=0.003), whereas the corresponding rates for those with a risk score of > or = 3 were 81% and 85%, respectively (p=0.35).

CONCLUSIONS

A single, early instillation of epirubicin after TUR for NMIBC reduces the likelihood of tumour recurrence; however, the benefit seems to be minimal in patients at intermediate or high risk of recurrence. Future trials will determine the value of early instillation in addition to serial instillations in NMIBC.

A single instillation of epirubicin after transurethral resection of bladder tumors prevents only small recurrences

PURPOSE

We studied whether a single instillation of epirubicin after transurethral bladder tumor resection would influence the interval to and size of the first recurrence.

MATERIALS AND METHODS

A total of 404 patients from 13 hospitals were randomized to 1 instillation of 50 mg epirubicin or placebo within 6 hours after transurethral resection of bladder tumors.

RESULTS

Of 155 evaluable patients in the epirubicin group 79 (51.0%) had recurrence compared to 95 of 152 (62.5%) in the placebo group (p = 0.04). Of the recurrences 63.3% were small (1 to 5 mm). Tumor size was unknown in 5 patients. Of 79 patients with recurrence in the epirubicin arm 33 (42.9%) vs 29 (31.5%) of 95 in the placebo arm had larger (more than 5 mm) first recurrences (p = 0.12). Approximately half of the patients with first recurrences were treated as outpatients and the other half spent a total of 145 days in the hospital with no difference between the groups.

CONCLUSIONS

We confirmed the results of previous studies showing that 8.5 patients must be treated with a single instillation to prevent 1 recurrence. Furthermore, our data may indicate that only small recurrences are prevented, which could easily be fulgurated using local anesthesia at followup cystoscopy. The benefit of single instillations can be questioned if this finding is confirmed by others.

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.

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.

A SINGLE IMMEDIATE POSTOPERATIVE INSTILLATION OF CHEMOTHERAPY DECREASES THE RISK OF RECURRENCE IN PATIENTS WITH STAGE Ta T1 BLADDER CANCER: A META-ANALYSIS OF PUBLISHED RESULTS OF RANDOMIZED CLINICAL TRIALS

PURPOSE

We determined if 1 immediate instillation of chemotherapy after transurethral resection (TUR) decreases the risk of recurrence in patients with stage Ta T1 single and multiple bladder cancer overall and separately.

MATERIALS AND METHODS

A meta-analysis was performed of the published results of randomized clinical trials comparing TUR alone to TUR plus 1 immediate instillation of chemotherapy.

RESULTS

Our study included 7 randomized trials with recurrence information on 1476 patients. Based on a median followup of 3.4 years and a maximum of 14.5 years, 267 of 728 patients (36.7%) receiving 1 postoperative instillation of epirubicin, mitomycin C, thiotepa or (2'R)-4'-O-tetrahydropyranyl-doxorubicin (pirarubicin) had recurrence compared to 362 of 748 patients (48.4%) with TUR alone, a decrease of 39% in the odds of recurrence with chemotherapy (OR 0.61, p <0.0001). Patients with a single tumor (OR 0.61) and those with multiple tumors (OR 0.44) benefited. However, after 1 instillation 65.2% of patients with multiple tumors had recurrence compared to 35.8% of patients with single tumors, showing that 1 instillation alone is insufficient treatment for patients with multiple tumors.

CONCLUSIONS

One immediate intravesical instillation of chemotherapy significantly decreases the risk of recurrence after TUR in patients with stage Ta T1 single and multiple bladder cancer. It is the treatment of choice in patients with a single, low risk papillary tumor and is recommended as the initial treatment after TUR in patients with higher risk 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.

Perioperative single dose instillation of epirubicin or interferon-alpha after transurethral resection for the prophylaxis of primary superficial bladder cancer recurrence: a prospective randomized multicenter study--FinnBladder III long-term results

PURPOSE

We evaluated the long-term efficacy of a single dose of interferon or epirubicin administered immediately after transurethral resection compared with transurethral resection alone for primary superficial bladder cancer recurrence.

MATERIAL AND METHODS

A total of 200 patients with primary superficial stages Ta to T1, grades 1 to 3 bladder cancer were randomized into 3 treatment groups, including transurethral resection alone, transurethral resection plus 50 milliunits interferon-alpha2b and transurethral resection plus 100 mg. epirubicin. The primary end point was time to first recurrence.

RESULTS

At a median followup of 72 months we observed a sustained effect of a single epirubicin instillation compared with other treatments. To date only 46% of the patients in group 3 have experienced recurrence in contrast to 73% and 68% in groups 1 and 2, respectively (p = 0.002). At 72 months the Kaplan-Meier disease-free estimates were 24%, 31% and 51% in groups 1 to 3, respectively (p = 0.002). The Cox multivariate model revealed a more than 2-fold relative risk of recurrence in group 1 versus group 3 (p <0.001). Other significant variables predicting recurrence were grade and the number of tumors.

CONCLUSIONS

A single perioperative instillation of 100 mg. epirubicin causes a significant and sustained decrease in primary superficial bladder cancer recurrence, whereas a single dose of 50 milliunits interferon-alpha2b is ineffective for prophylaxis.

Factors explaining recurrence in patients undergoing chemoimmunotherapy regimens for frequently recurring superficial bladder carcinoma

OBJECTIVES

To study the factors determining new recurrences in patients with frequently recurring superficial bladder tumors.

METHODS

Of all 205 eligible patients, each received 5 weekly intravesical instillations of mitomycin C (MMC), with the first instillation given perioperatively. This was followed, according to randomization, by BCG instillations alone or by alternating instillations of interferon-alpha and BCG monthly for up to 1 year. Impact of 12 variables on time to first recurrence was retrospectively studied with the Cox multiple hazards regression and Kaplan-Meier analysis.

RESULTS

Type of regimen was the most significant factor determining new recurrences, with preceding recurrence rate being the most important prognostic factor. Timing of the first MMC was the third significant predictor in the main multivariate analysis, with more than a two-fold relative risk for a new recurrence if the first MMC instillation was given later than on day 0.

CONCLUSION

Preceding recurrence rate, most accurately reflects, in patients with frequently recurring tumors, the inherent risk for new recurrences. This risk can be considerably reduced by use of an effective chemoimmunotherapy regimen, and in addition, by inclusion of an early perioperative chemotherapy instillation in such a regimen.

Transurethral resection with perioperative instilation on interferon-alpha or epirubicin for the prophylaxis of recurrent primary superficial bladder cancer: a prospective randomized multicenter study--Finnbladder III

PURPOSE

We evaluated the efficacy of single dose of interferon or epirubicin administered immediately after transurethral resection compared with transurethral resection only on the recurrence of primary (not recurrent) superficial bladder cancer.

MATERIALS AND METHODS

A total of 283 patients with stages Ta to T1 primary superficial, grades 1 to 3 bladder cancer was randomized into study groups 1-transurethral resection only, 2-transurethral resection plus 50 million units interferon-a2b and 3-transurethral resection plus 100 mg. epirubicin. Eligible for final analysis were 200 patients, including 66 in group 1, 66 in group 2 and 68 in group 3. Patients were followed with cystoscopy every 3 months for 2 years or until the initial recurrence.

RESULTS

Group 3 had the most favorable outcome, since 45 of the 68 patients (66%) were without recurrence after 2 years compared to 24 of the 66 (37%) in group 2 and 26 of the 66 (40%) in group 1 (log rank test p <0.001). Side effects were mostly mild and transient, and no differences were found among the groups.

CONCLUSIONS

A single 100 mg. dose of epirubicin given intravesically immediately after transurethral resection is safe, and significantly decreases the recurrence of primary superficial bladder cancer. A 50 million unit dose of interferon-alpha2b is well tolerated but it has no effect on recurrence as a single dose. The long-term effect of this treatment remains to be studied.

A prospective European Organization for Research and Treatment of Cancer Genitourinary Group randomized trial comparing transurethral resection followed by a single intravesical instillation of epirubicin or water in single stage Ta, T1 papillary carcinoma of the bladder

A total of 431 eligible patients with solitary, primary or recurrent stages Ta and T1 transitional cell carcinoma of the bladder was included in a randomized multicenter trial to compare a single intravesical instillation of 80 mg. epirubicin with water given immediately after resection, with respect to the disease-free interval and recurrence rate. The interval to initial recurrence was significantly better in favor of the epirubicin group. After a mean followup of 2 years it became evident that the recurrence rate after a single epirubicin instillation was decreased by nearly half with the same trend being found in all subgroups examined. Toxicity was mainly restricted to bladder irritation in plus or minus 10% of the cases. Pathology review brought considerable changes in T category from stages T1 to Ta (53%). Changes in grade were less pronounced but nevertheless important.

Natural history and treatment of low and high risk superficial bladder tumors

Since 1979 a prospective randomized trial was done to examine the efficacy of intravesical doxorubicin as prophylaxis against recurrence. After complete transurethral resection of the tumor, patients were divided into 3 groups at random: group 1-no further treatment after transurethral resection, group 2-doxorubicin twice weekly for 6 weeks and group 3-doxorubicin for 1 year. A total of 268 patients entered the study. Neither frequency of recurrences, tumor progression nor survival rate was improved significantly by the adjuvant treatment, so that only a limited number of patients will profit by instillation therapy. Analysis of previously reported data suggests that patients with superficial bladder tumors can be stratified into groups with appreciable differences in risk of progression. With regard to these results a differentiated use of a "wait and see" adjuvant intravesical therapy and more aggressive treatment after transurethral resection of superficial bladder tumors seems to be indicated rather than a general practice of chemoprophylaxis.

The effect of intravesical thiotepa on the recurrence rate of newly diagnosed superficial bladder cancer. An MRC Study. MRC Working Party on Urological Cancer

Four hundred and seventeen patients with newly diagnosed superficial bladder tumours (Ta or T1) were treated with complete transurethral resection and then randomised between three groups. Group 1 had an instillation of 30 mg thiotepa at the time of primary treatment. Group 2 had instillations of thiotepa at 3-monthly intervals for a year. Group 3 was given no instillation. Regular check cystoscopies revealed no significant difference in the rate at which tumours recurred in the three groups (p = 0.4 and P = 0.7 for control vs thiotepa given once and five times respectively). It was concluded that neither thiotepa regimen produced sufficient improvement to justify its use in this group of patients.

Intravesical doxorubicin for the prophylaxis of superficial bladder tumors. A multicenter study. Blinst Italian Cooperative Group

A multicenter trial was carried out with patients with superficial Ta-T1 bladder tumors in 37 urology centers throughout Italy. After transurethral resection (TUR) patients were given intravesical doxorubicin instillations at the mean dose of 50 mg per instillation diluted in 50 ml of distilled water or physiologic saline. Chemoprophylaxis was performed at weekly intervals for the first 4 weeks and then monthly. Cystoscopies were taken every 3 months during the first year, every 4 months during the second year, and every 6 months thereafter. A total of 435 patients, with a median follow-up time of 436 days, were considered eligible for the evaluation of activity. The lowest recurrence rate and the longest disease-free interval was observed in the group of patients with primary or single tumor. Treatment was well tolerated; 119 patients (22.7%) complained of local adverse reactions, and 10 (1.9%) of systemic adverse reactions. In 34 of the patients (6.5%) treatment had to be discontinued.

Intravesical high dose 5-fluorouracil instillations combined with allopurinol--a therapeutic alternative in the treatment of multiple bladder tumors

Chemical cystitis and systemic toxic effects limit the therapeutic use of intravesical cytotoxic agents against bladder tumors. In our series 1,000 mg. 5-fluorouracil could be instilled 2 hours daily, 5 days per week for 5 weeks if 100 mg. allopurinol were given 3 times daily simultaneously. After 6 weeks all patients were macroscopically free of tumors. Another instillation was performed because of recurrences within 6 months in 3 patients. This preliminary report of 5 patients with multiple superficial transitional cell bladder tumors shows that a combined treatment of high dose 5-fluorouracil instillation and simultaneous oral allopurinol will abolish temporarily all tumor tissue without signs of general absorption or chemical cystitis. The observation time is too short to predict definitive cure.

Prognostic factors in non-infiltrating carcinoma of the bladder: a preliminary report

We have reviewed 111 patients with papillary transitional cell carcinoma of the bladder, category Ta and T1, admitted between 1975 and 1980. Histological grade and the presence of multiple tumours at presentation were the most useful prognostic features in terms of recurrence and mortality from either locally invasive or metastatic disease.