Thiotepa versus adriamycin versus cis-platinum in the intravesical prophylaxis of superficial bladder tumors

Superficial bladder cancer: part 2. Management

In the second section of a two-part article, the recent literature is reviewed and the management of nonmuscle-invasive transitional cell carcinoma of the bladder is discussed. Particular attention is given to the indications and timing of intravesical chemotherapy and immunotherapy and the differences in efficacy and side-effect profiles of the available agents. The indications and role of second-look transurethral resection are reviewed. Additionally, the role of bacillus Calmette-Guerin in the management of this disease in terms of definitive treatment and maintenance therapy is discussed. We also offer a review of the literature regarding therapies for bacillus Calmette-Guerin-refractory nonmuscle-invasive transitional cell carcinoma of the bladder and their current place in practice.

Intralymphatic delivery of platinum-based chemotherapeutics is possible: an experimental study

PURPOSE

Systemic chemotherapy regimens with cisplatinum have been associated with several toxicities. Thus, a loco-regional therapy approach may greatly reduce the toxicity. For this purpose, we designed this experimental study to investigate whether local chemotherapeutic injection is superior to systemic cisplatinum injection for retroperitoneal lymph nodes.

METHODS

A total of 48 male Wistar rats were included to the study. Rats were divided into six groups. In the first three groups, systemic applications of cisplatinum, carboplatinum and oxaliplatin were performed, respectively. In the last three, local administration of cisplatinum, carboplatinum and oxaliplatin was performed, respectively. One hour after the chemotherapeutic agent applications, retroperitoneal lymph nodes were dissected and platinum concentrations were analyzed.

RESULTS

When compared with systemic route, achieving higher platinum concentrations in the local chemotherapeutic application groups was the most spectacular result of the study. Serum platinum concentrations were also lower in the local application groups than systemic ones. When we compared local and systemic applications between three chemotherapeutic agents, the most significant concentration difference was seen in carboplatinum group.

CONCLUSION

The results of this study demonstrate that intralymphatic delivery of cisplatinum, carboplatinum and oxaliplatin leads to higher drug concentrations in the retroperitoneal lymph nodes when compared with intravenous administration.

[Baltasar Llopis Mínguez (1934-1990). A pioneer in research on bladder cancer and introduction of computing in Urology]

OBJECTIVE

To recall the figure of a great Valencian urologist, to emphasize his great personality and humanity, and to draw particular attention to his significant contribution to the study of prognostic factors in urology and estimation of individual oncological risk, as well as to introduction of computing in urology.

METHOD

His work, the testimony of colleagues who treated him, and data obtained from his close relatives, as well as our own personal knowledge, are reviewed. Result. Baltasar Llopis was born in Valencia, and obtained his degree and doctorate in Medicine at the Valencia University. He specialized in urology with Dr. Tramoyeres Cases, for whom he acted as assistant surgeon and with whom he shared work at La Fe Hospital, where he carried out his complete urological activity, since its inception. Dr. Llopis opted for oncological research, with a special focus on urothelial tumors. He pioneered diagnosis of these tumors using tumor markers and the study of prognostic factors to assess the individual risk of relapse and to implement a specific chemotherapeutic treatment, which he introduced in clinical practice at La Fe Hospital. He thus demonstrated the two essential components of his personality, his investigative and human sides.

CONCLUSION

A multi-faceted person with great skills and intelligence, Dr. Llopis eagerly devoted himself to research aimed at understanding the biological behavior of cancer, particularly urothelial tumors. In the early 80s he pioneered worldwide the development of specific markers, estimations of individual oncological risk, and prognostic factors useful for planning treatment. He was 20 years ahead of the era of predictive nomograms and their clinical

INTRODUCTION

In addition to being a forerunner of computing applications in Urology, he designed a database for registration of superficial bladder tumors, which allowed him to perform statistical and multivariate analyses using multiple regression models to predict the risk of relapse.

Global problem of drug-induced hearing loss

Clinically used drugs and chemical agents may potentially cause adverse effects to the human auditory and vestibular systems. Many of them, such as aminoglycosides and cisplatin, can play a critical role in the treatment of serious or life-threatening diseases; others, like loop diuretics or salycilates, offer such important therapeutical effects compared to the ototoxic side effects that the ototoxicity risk can be considered to be of minor importance. The problem of ototoxic side effects is more acute in developing countries, where highly effective and low-cost drugs are more easily prescribed without adequate monitoring. Medical awareness of doses, forms of administration, populations at risk, and possible synergism is necessary in order to develop appropriate care in the prescription of drugs with ototoxic side effects. Relatively recent issues such as risk-benefit analysis, patient-informed consent, and quality-of-life considerations, particularly when life expectancy can be low, are also to be considered. At present, a uniform method of monitoring for all potentially ototoxic therapeutics does not seem reasonable or practical. It is recommended, however, that individual auditory function be noted for a particular drug being employed. Protocols and exams should be easy, quick, sensitive, reliable, and as objective as possible. Benefits of audiological monitoring include the opportunity to change the patient's treatment course, improvement of patient and family awareness of the impact of hearing impairment, and timely prescription of amplification devices. Finally, particular attention should be paid to high-risk populations such as neonatal intensive care unit patients.

Current recommendations for the management of bladder cancer. Drug therapy

Superficial transitional cell carcinoma of the bladder is a heterogeneous group of tumours, and prediction of disease outcome in an individual patient is still impossible. In low-risk patients the initial treatment [transurethral resection (TUR)] should be followed by no or only one immediate intravesical instillation with a chemotherapeutic drug to prevent a recurrence due to tumour cell implantation during TUR. Drug efficacy has been clearly demonstrated and adverse effects are very limited. Intermediate-risk patients should receive a course of additional intravesical instillations to reduce the recurrence rate with few adverse effects. All drugs seem to be equally effective, but the long term effects remain a question. In high-risk patients intravesical immunotherapy (BCG) should be given. Although toxicity is more pronounced, it is usually mild and adverse effects disappear after cessation of therapy. BCG (maintenance) therapy seems to be able to improve progression and ultimately tumour-related survival. It is important to know the advantages and disadvantages (adverse effects) of these treatment modalities to be able to individualise treatment as much as possible. The choice is difficult because several intravesical bladder cancer trials have not reached consensus on this. For patients with non-metastasised invasive bladder tumours chemotherapy can be given before (neoadjuvant) or immediately after (adjuvant) surgery or radiotherapy. Both strategies have some advantages and disadvantages. For both, however, efficacy still needs to be proven, and results of ongoing trials are needed. For metastasised or recurrent urothelial cell carcinoma MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) chemotherapy remains the most effective treatment modality. Although initial response rates of between 40% and 70% can be achieved, most patients have a recurrence of their cancer. Moreover, toxicity of these drugs also is considerable and limiting. Leucopenia is responsible for the majority of grade III and IV toxicities and subsequent dose modifications. In case of toxic deaths, a leucopenic sepsis is usually the cause. Most other adverse effects are acceptable or can be treated.

Effects of intravesical instillation of antitumor chemotherapeutic and immunotherapeutic agents on bladder lesion development in rats pretreated with N-butyl-N-(4-hydroxybutyl)nitrosamine

The effects of 12 weeks of intravesical instillation of bleomycin, cisplatinum and picibanyl on development of urinary bladder tumors and preneoplastic lesions were examined in rats pretreated with N-butyl-N-(4-hydroxybutyl)-nitrosamine (BBN) for four weeks. Upon sacrifice at week 36, histopathological examination revealed a significantly reduced incidence of PN hyperplasia and a tendency for decreased papilloma generation in rats given cisplatinum. However, the other treatments were not associated with any effect on carcinogen-induced lesion development. The results demonstrate that cisplatinum has a potential for postinitiation inhibition of rat bladder carcinogenesis.

Approaches to the treatment of bladder cancer at Stanford

The treatment of bladder cancer is one of the most active areas of clinical cancer research. The use of new classes of intravesical agents, such as the interferons, and analogues of effective intravesical chemotherapies, such as epirubicin, the 4-epimer of doxorubicin, show promise of controlling the sequela of this common urologic problem. In metastatic transitional cell carcinoma, the CMV regimen holds promise of palliation for many and or long-term remission for some patients with advanced bladder cancer.

Prevention of human bladder tumor cell implantation in an in vitro assay

The high recurrence rate of bladder tumors can be reduced by prevention of tumor cell reimplantation on denuded urothelium following transurethral resection. This can be achieved by intravesical chemotherapy immediately after the resection of the bladder tumors. We have demonstrated, in an in-vitro system, the process of human bladder tumor cell implantation on a naturally produced extracellular matrix (ECM) which simulates the exposed bladder basement membrane and submucosa. Using this model we examined the efficacy of various cytotoxic agents in preventing tumor cell adhesion to the ECM. Human bladder tumor cell implantation was prevented following exposure of the cells to distilled water, epodyl or mitomycin C, and significantly reduced following one hour incubation in cisplatinum and doxorubicin. The maximal effect for each of these cytotoxic agents was reached within 30 to 60 minutes of treatment. Mitomycin C reached maximal effect within 10 minutes. In contrast, thiotepa did not cause a significant reduction in cell adherence to ECM as compared to untreated control cells.