Primary bladder carcinoma in situ: assessment of early BCG response as a prognostic factor

Prediction models for progression of non-muscle-invasive bladder cancer: A review

An accurate prediction of progression is critically important in the management of non-muscle-invasive bladder cancer. At present, three risk models are widely known for prediction of the risk of tumor recurrence and progression of non-muscle-invasive bladder cancer: the European Organization for Research and Treatment of Cancer, Club Urológico Español de Tratamiento Oncológico, and new European Organization for Research and Treatment of Cancer models. Bladder neck involvement has been shown to be one of the significant predictors for progression in non-muscle-invasive bladder cancer, and a new scoring model (Tokyo Medical and Dental University model) consisting of bladder neck involvement, tumor grade, and stage has been developed and externally validated. However, the predictive abilities of these models are still unsatisfactory, and more precise models are necessary for accurate individual prediction of prognosis. Until now, time-fixed analysis has been used for most studies predicting the prognosis and outcome of non-muscle-invasive bladder cancer patients. In order to predict progression more precisely, time-dependent models should be developed using multiple-event analytical techniques, as non-muscle-invasive bladder cancer often progresses to muscle-invasive bladder cancer after multiple recurrences and changes in tumor characteristics over a long natural history. Integration of molecular markers is also a promising approach. A validated model that accurately predicts the risk of progression would help urologists and patients decide whether and when to choose radical cystectomy on an individual basis.

The predictive value of GSTT1 polymorphisms in predicting the early response to induction BCG therapy in patients with non-muscle invasive bladder cancer

INTRODUCTION

We evaluated the predictive value of glutathione S transferase mu (GSTM1) and theta (GSTT1) polymorphisms in early response to bacillus Calmette-Guérin (BCG) induction therapy in patients with primary non-muscle invasive bladder cancer.

METHODS

GSTM1 and GSTT1 polymorphisms were analyzed by multiplex polymerase chain reaction using blood genomic DNA from 135 patients with primary non-muscle invasive bladder cancer who were being treated with a single induction course of BCG. BCG nonresponsiveness (early BCG failure) was defined as a tumor recurrence or progression within 12 months after BCG induction therapy. The predictive value of GST polymorphisms was evaluated by Kaplan-Meier analysis and multivariate logistic regression models.

RESULTS

Patients carrying a GSTT1-positive genotype demonstrated a higher likelihood of early BCG failure regardless of cigarette smoking. After stratification based on the tumor stage and grade, the high-risk group (T1G3) with a GSTT1-positive genotype showed a 14-fold higher risk of early BCG failure compared with those with a GSTT1-null genotype. In a combined analysis of 2 genes, the GSTT1-positive/GSTM1-null genotype had a higher risk of BCG nonresponsiveness compared with the GSTT1-null/GSTM1-null genotype (odds ratio = 4.17, 95% CI: 1.54-11.26). By multivariate logistic regression analysis, the GSTT1-positive genotype was an independent predictor of early BCG failure (odds ratio = 3.67, 95% CI: 1.61-8.38). Kaplan-Meier estimates revealed a significant difference in disease-free survival depending on the GSTT1 genotype (log rank test, P = 0.038).

CONCLUSIONS

The results of this study suggest that the GSTT1-positive genotype is an independent predictor of early BCG failure. These results can help determine whether patients would benefit from adjuvant BCG treatment or may require more aggressive alternative therapies.

Bacillus Calmette-Guérin in the management of superficial bladder cancer

Intravesical Bacillus Calmette-Guérin (BCG) is the mainstay of superficial bladder cancer treatment. We performed a literature search through Medline/Pubmed using key words 'Bacillus Calmette-Guérin', 'intravesical', 'bladder neoplasm' and 'immunotherapy' for published data in the English language from 1970 to 2007 to review the current status of intravesical therapy and practice recommendations. The exact mechanism of action of intravesical BCG is yet to be elucidated. However, it appears that it is mediated by the local immune response, mainly through T-helper cell response. It reduces the recurrence rate by an average of 40% and progression by more than 20% in papillary tumors over the patients without BCG therapy. However, progression prevention is seen only in series which have used maintenance therapy at least for one year. It is effective in CIS of bladder with a response rate of more than 40% and prevention of progression in one-fourth patients. Most acceptable dose, induction treatment and maintenance therapy protocols are discussed. However, these are yet to be confirmed in large randomized trials. Intravesical BCG is well tolerated in most of the patients with mild to moderate side-effects in induction therapy; however, most patients do not complete maintenance therapy due to side-effects which is the most common concern at the present time.

Current state of immunotherapy for bladder cancer

Bacillus Calmette-Guerin (BCG) has been shown to be the most effective agent for the treatment of superficial bladder cancer since its approval by the US Food and Drug Administration for the treatment of carcinoma in situ of the bladder in 1990. Recently, augmentation of BCG immunotherapy with interferon-alpha2b and other agents is emerging as salvage therapy for those patients who fail initial treatment. This review summarizes the role of various immunotherapeutic agents in the treatment of bladder cancer, with special emphasis on the appropriate administration and schedule of BCG therapy as well as salvage with the combination of BCG with interferon-alpha2b.

Bacillus Calmette-Guerin versus epirubicin for primary, secondary or concurrent carcinoma in situ of the bladder: results of a European Organization for the Research and Treatment of Cancer--Genito-Urinary Group Phase III Trial (30906)

PURPOSE

We compared the efficacy and side effects of intravesical instillations of bacillus Calmette-Guerin (BCG) and epirubicin in patients with carcinoma in situ (CIS) of the bladder.

MATERIALS AND METHODS

Patients with primary, secondary or concurrent CIS of the bladder were randomized to 81 mg BCG-Connaught (6 weekly instillations) or 50 mg epirubicin (8 weekly instillations). When a complete response (CR), defined as no Ta/T1 or CIS on biopsy and negative cytology, was obtained, patients in the 2 groups received maintenance instillations at months 3, 6, 12, 18, 24, 30 and 36. When no complete response was observed, the original treatment was repeated, followed again by cystoscopy and biopsies plus cytology.

RESULTS

A total of 168 patients were randomized between March 1993 and April 1999 to receive BCG (84) or epirubicin (84), while 4 on epirubicin and 3 on BCG were ineligible. The majority (52%) had concurrent CIS. Primary and secondary CIS was found in 23% and 24% of cases, respectively. The overall CR rate was 56% for epirubicin and 65% for BCG (p = 0.21, 90% CI 21.5 to -2.9). When tumor was found following 2 instillation courses, further treatment was left to the investigator (BCG in 29 cases and epirubicin in 37). Time to bladder tumor recurrence after CR was longer in patients treated with BCG vs epirubicin (median 5.1 vs 1.4 years). CIS recurrences were more frequently observed in complete responders to epirubicin (45% vs 16%). No differences in time to progression or duration of survival were observed. Side effects were more frequently seen in patients on BCG with 26 on BCG and 8 on epirubicin stopping treatment due to side effects.

CONCLUSIONS

No significant difference in CR rates could be demonstrated with intravesical instillations of epirubicin or BCG. Time to recurrence was significantly longer in patients treated with BCG after having achieved a CR. More CIS recurrences were found in patients treated with epirubicin. For time to progression and survival longer followup is warranted. Side effects were more frequent in patients on BCG.

Histopathological aspects of transitional cell carcinoma of the bladder: Analysis of 20 years experience

BACKGROUND

In this study we used histopathological examinations performed over a 20-year period to describe the characteristics of newly diagnosed transitional cell carcinoma (TCC) of the bladder in relation to patient age, and to verify changes in the TCC over different periods of observation or in relation to patient age.

METHODS

We reviewed all histopathological examinations performed from January 1979 to December 1998 in patients undergoing surgery who were newly diagnosed with TCC of the bladder. All examinations were performed by the same pathologist and reviewed by two pathologists. In each case analyzed, we evaluated T classification of the tumor, histological grade, size, localization, growth type, multiplicity and carcinoma in situ (CIS).

RESULTS

The study population included 3113 men and 620 women. The mean patient age was 66.31 +/- 10.84 years. A high percentage of Ta (52.2%) and T1 (27.7%) tumors were found. The number of cases observed and, in particular, the percentage of Ta tumors increased significantly and progressively from the first (1979-1983 = 376 cases; Ta = 37.8%) to the last (1994-1998 = 1732 cases; Ta = 56.3%) period of observation (P < 0.001). A significant difference in the distribution of histological grade and T classification in the different age decades was apparent (P < 0.001); in particular, for G1 and Ta tumors there was a trend to decrease, whereas for G3, T1 and T2 tumors there was a tendency to increase with age decades.

CONCLUSION

In our analysis, age of patient and the period of examination significantly influenced different pathological characteristics of newly diagnosed TCC of the bladder.

Immunotherapy for bladder cancer

The primary role of immunotherapy for bladder cancer is to treat superficial transitional cell carcinomas (ie, carcinoma in situ, Ta, and T1). Immunotherapy in the form of bacille Calmette-Guérin (BCG), interferon, bropirimine, keyhole limpet hemocyanin, and gene therapy is intended to treat existing or residual tumor, to prevent recurrence of tumor, to prevent progression of disease, and to prolong survival of patients. Presently, BCG is commonly used and is the most effective immunotherapeutic agent against superficial transitional cell carcinoma. Data support that BCG has a positive impact on tumor recurrence, disease progression, and survival. Proper attention to maintenance schedules, route of administration, dosing, strains, and viability is essential to obtain the maximum benefits of BCG immunotherapy. This review highlights and summarizes the recent advances concerning immunotherapy, with special emphasis on BCG therapy for transitional cell carcinoma.

[Progression and prognosis of in situ carcinoma of the bladder treated with BCG]

OBJECTIVES

In situ carcinoma (isT) of the bladder is a poor prognostic tumour with a natural progressive evolution. Treatment with BCG achieves a significant improvement in survival. This paper analyses our experience in the management of isT patients with endovesical BCG.

MATERIAL AND METHODS

Between 1983 and 1997 the Urology Unit in the Móstoles Hospital saw 636 patients with transitional carcinoma of the bladder. Of these, 498 (78%) were surface tumours, and 138 (22%) were infiltrant. isT: 80 patients (13%), 14 of which were primary (17%), 37 associated to a surface tumour (46%), and 29 to infiltrant tumours (36%). All surface tumours: isT was present in 51 patients (10%) 44 of which were managed with 2 courses of BCG Connaught (81 mg), for 6 weeks each followed by vesical reassessment. Quarterly follow-up was conducted during a 2-year period. Patients not managed with BCG were treated with radical cystectomy. An analysis was made of patients without complete response to BCG, as well as actuarial analysis of disease-free survival (DFS), survival until progression (SUP) and specific survival (SS). All possible prognostic factors are analyzed: sex, focal isT (a single focus) or diffuse isT (more than one focus). Primary or secondary isT and association to G1, G2 or G3 tumours.

RESULTS

In all 44 patients managed with BCG: males 37 (84%), females 7 (16%), primary 14 (32%), focal 22 (50%), diffuse 22 (50%). Six patients died (5 because of the tumour). Mean follow-up of living patients: 3.7 years (0.5-7.5 years). After the 2 BCG courses, 36 (82%) showed complete response. Thirteen patients (30%) had no complete response during follow-up, and 11 (85%) continued to progression. In total 7 patients underwent cystectomy. Of 5 patients directly cystectomized due to persistence of isT or T1G3 tumour at monitoring after BCG, 2 (40%) had infiltrant tumour and one (20%) nodular metastasis. Three patients with persistent isT or T1G3 after BCG were not initially cystectomized: two that were treated with other endovesical therapies because of their age progressed, and the third one underwent a third BCG course and required cystectomy due to tumour persistency. 5-year DFS: 56%, being diffuse isT vs. focal isT (p = 0.0206) was an unfavourable prognostic factor. 5-year SUP: 63%, no significant prognostic factor. 5-year SS: 79%, being a female was an unfavourable prognostic factor (p = 0.0201).

CONCLUSIONS

Based on our results and the analysis of the literature we recommend treatment with 2 BCG courses of all isTs of the bladder that present some of the following factors: Diffuse cancer associated to T1G3, involvement of prostatic urethra or overexpression of p53 over 20%. In the rest of vesical tumours, one BCG course followed by a second one if lack of response to the first. After failure of both BCG courses, cystectomy must be performed in both groups.

Recent perspectives in topical therapy in superficial bladder cancer

With regard to side-effects in intravesical bacillus Calmette-Guérin instillation therapy and the limited efficacy of intravesical chemotherapy, there is still a need for improvement of these standard therapies. Recently, technical adjuvant means or the modification of cytostatic drugs have been undertaken to improve the efficacy of intravesical chemotherapy. Prognostic indicators of the response to bacillus Calmette-Guérin immunotherapy have been identified, but indicators of side-effects are needed in order to improve the benefit-to-risk ratio of bacillus Calmette-Guérin instillation therapy. Many innovative treatment options, however, still require a definition of their clinical value.

Intravesical bacille Calmette-Guérin in the treatment of carcinoma in situ or high-grade superficial bladder carcinoma after radiotherapy for bladder carcinoma

OBJECTIVE

To evaluate the effectiveness and tolerance of endovesical bacille Calmette-Guérin (BCG) after pelvic radiation therapy for bladder cancer in patients with recurrence as carcinoma in situ (CIS) and/or high-grade superficial bladder cancer.

PATIENTS AND METHODS

In a prospective study, 13 patients were treated with weekly instillations of 81 mg BCG Connaught for 6 weeks. for CIS and/or high-grade superficial bladder carcinoma. All had been treated previously with radical radiation therapy for bladder carcinoma.

RESULTS

Five patients had no recurrences and six patients retained their bladders, within a median follow-up of 74.5 months. Five patients progressed; two underwent radical surgery and are alive after 75 months of follow-up, and three died from the disease (two were high-risk surgical patients and one had metastatic disease). Another two patients died from intercurrent disease without bladder cancer. Eight patients were alive at a mean (SD range) follow-up of 85 (12, 65-97) months.

CONCLUSION

Intravesical BCG is useful for controlling CIS and/or high-grade superficial bladder carcinoma in irradiated bladders and has an acceptable local tolerance: more than a third of patients were free of disease and preserved their bladders. This proportion is acceptable in patients currently scheduled for cystectomy.