Effect of relative cumulative dose-intensity on survival of patients with urothelial cancer treated with M-VAC

Advanced Bladder Cancer: Changing the Treatment Landscape

Bladder cancer is the 10th most common cancer type in the world. There were more than 573,000 new cases of bladder cancer in 2020. It is the 13th most common cause of cancer death with an estimated more than 212,000 deaths worldwide. Low-grade non-muscle-invasive bladder cancer (NMIBC) is usually successfully managed with transurethral resection (TUR) and overall survival for NMIBC reaches 90% according to some reports. However, long-term survival for muscle-invasive bladder cancer (MIBC) and metastatic bladder cancer remains low. Treatment options for bladder cancer have undergone a rapid change in recent years. Immune checkpoint inhibitors (ICI), targeted therapies, and antibody-drug conjugates are available now. As bladder cancer is genetically heterogeneous, the optimization of patient selection to identify those most likely to benefit from a specific therapy is an urgent issue in the treatment of patients with bladder cancer.

Histone deacetylase 6 inhibition in urothelial cancer as a potential new strategy for cancer treatment

Histone deacetylases (HDACs) are enzymes that remove acetyl groups from histones and have attracted attention as potential targets for cancer therapy. Several small molecule inhibitors have been developed to target HDACs; however, clinical trials of pan-HDAC inhibitors have found these types of inhibitors to be inefficient and to be relatively highly toxic. In the present study, the role of one HDAC isozyme, HDAC6, in urothelial cancer was investigated. Protein expression levels and subcellular localization of HDAC6 was identified in surgically resected bladder tumors using immunohistochemistry. The antitumor effects of 12 small molecule HDAC6 inhibitors were also examined in vitro using cultured urothelial cancer cells. The HDAC6 inhibitors decreased cell viability, with IC₅₀ values in the low µM range, as low as 2.20 µM. HDACi D, E and F had the lowest IC₅₀ values. HDAC6 has been previously reported to regulate programmed death-ligand 1 (PD-L1) and PD-L1 expression was found to be a predictor of decreased overall survival time. There was no association between the protein expression level of HDAC6 and PD-L1 in tumor tissues; however, HDAC6 inhibition by specific small molecule inhibitors resulted in decreased expression levels of membranous PD-L1 in cultured urothelial cancer cell lines. The results suggested that inhibition of HDAC6 could be a promising novel approach for the treatment of urothelial cancer.

Chemotherapy for Metastatic or Unresectable Bladder Cancer

Cisplatin, methotrexate, doxorubicin, and vinblastine (M-VAC) combination chemotherapy has been the historic standard of care in patients with advanced urothelial tumors. Phase III trials have evaluated new combinations such as gemcitabine/cisplatin (GC), carboplatin/paclitaxel, docetaxel/cisplatin, and interferon-alpha/5-fluorouracil/cisplatin. However, these new regimens have failed to demonstrate superiority in terms of overall survival when compared with classic M-VAC. The GC doublet has proved to be a new standard treatment alternative based on an improved toxicity profile and similar survival results. The addition of a third agent (paclitaxel) to this regimen is the focus of a phase III trial. However, long-term follow-up with classical and new regimens (doublets and triplets) still show limited efficacy and emphasize the need to identify more active treatment. For "unfit" patients, ie, those unable to receive cisplatin-based regimens, conventional regimens include methotrexate, carboplatin, and vinblastine (M-CAVI), carboplatin-gemcitabine, carboplatin-paclitaxel, gemcitabine-taxane, or monotherapy with either gemcitabine, carboplatin, or a taxane. New drugs, including pemetrexed and vinflunine, are now being studied for salvage therapy. In addition to new active drug combinations and targeted therapies, chemotherapy optimization using molecular characteristics to predict chemosensitivity is emerging.

Methotrexate, Vinblastine, Doxorubicin, and Cisplatin (MVAC) Regimen for Urothelial Tract Tumors

The increasing complexity of cancer chemotherapy makes it mandatory that pharmacists be familiar with these highly toxic agents. This column focuses on the commercially available and investigational agents used to treat malignant diseases and reviews issues related to the preparation, dispensing, and administration of cancer chemotherapy.

Docetaxel and Cisplatin With Granulocyte Colony-Stimulating Factor (G-CSF) Versus MVAC With G-CSF in Advanced Urothelial Carcinoma: A Multicenter, Randomized, Phase III Study From the Hellenic Cooperative Oncology Group

Purpose

The combination of methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) represents the standard regimen for inoperable or metastatic urothelial cancer, but its toxicity is significant. We previously reported a 52% response rate (RR) using a docetaxel and cisplatin (DC) combination. The toxicity of this regimen compared favorably with that reported for MVAC. We thus designed a randomized phase III trial to compare DC with MVAC.

Patients and Methods

Patients with inoperable or metastatic urothelial carcinoma; adequate bone marrow, renal, liver, and cardiac function; and Eastern Cooperative Oncology Group performance status ≤ 2 were randomly assigned to receive MVAC at standard doses or docetaxel 75 mg/m2 and cisplatin 75 mg/m2 every 3 weeks. All patients received prophylactic granulocyte colony-stimulating factor (G-CSF) support.

Results

Two hundred twenty patients were randomly assigned (MVAC, 109 patients; DC, 111 patients). Treatment with MVAC resulted in superior RR (54.2% v 37.4%; P = .017), median time to progression (TTP; 9.4 v 6.1 months; P = .003) and median survival (14.2 v 9.3 months; P = .026). After adjusting for prognostic factors, difference in TTP remained significant (hazard ratio [HR], 1.61; P = .005), whereas survival difference was nonsignificant at the 5% level (HR, 1.31; P = .089). MVAC caused more frequent grade 3 or 4 neutropenia (35.4% v 19.2%; P = .006), thrombocytopenia (5.7% v 0.9%; P = .046), and neutropenic sepsis (11.6% v 3.8%; P = .001). Toxicity of MVAC was considerably lower than that previously reported for MVAC administered without G-CSF.

Conclusion

MVAC is more effective than DC in advanced urothelial cancer. G-CSF-supported MVAC is well tolerated and could be used instead of classic MVAC as first-line treatment in advanced urothelial carcinoma.

Overview of bladder cancer trials in the European Organization for Research and Treatment

In the 1990s, the European Organization for Research and Treatment of Cancer Genito-Urinary (EORTC GU) Group focused on dose-intensity concepts of the methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) regimen for patents with bladder cancer. In a randomized trial in patients with advanced urothelial cell cancer, standard MVAC was compared with 2-weekly intensified MVAC plus granulocyte-colony stimulating factor (G-CSF) support. Although the dose-intensified therapy resulted in a higher overall and complete response rates, it did not result in a better median survival. In parallel, the Spanish Oncology Genitourinary Group (SOGUG), in collaboration with the EORTC GU Group, conducted Phase I and II trials to investigate the feasibility and efficacy of the incorporation of two new active agents, gemcitabine and paclitaxel, into two-drug or three-drug cisplatin-based or carboplatin-based regimens. The EORTC GU Group currently is conducting randomized studies of combined paclitaxel, cisplatin, and gemcitabine compared with combined gemcitabine plus cisplatin in patients with good performance status and good renal function and studies of combined gemcitabine plus carboplatin compared with combined carboplatin, methotrexate, and vinblastine in patients who are unsuited for cisplatin. In the 1990s, the EORTC coordinated a large Intergroup study of neoadjuvant cisplatin, methotrexate, and vinblastine chemotherapy versus no chemotherapy before definitive treatment. That study included 976 patients and was based on a design to detect at least a 10% absolute improvement in survival. The final results showed a 5.5% survival difference at 3 years in the chemotherapy arm. The EORTC GU Group currently is coordinating an Intergroup study that was designed to detect an improvement of 7% in absolute survival in the adjuvant setting. Cancer 2003;97(8 Suppl):2120-6.

Evaluation of drug delivery and survival impact of dose-intense relative to conventional-dose methotrexate, vinblastine, doxorubicin, and cisplatin chemotherapy in urothelial cancer

The efficacy of dose-intense methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) chemotherapy relative to conventional-dose M-VAC in patients with advanced transitional cell carcinoma is unknown. The outcomes of 33 patients on two successive protocols using dose-intense M-VAC with granulocyte colony-stimulating factor (G-CSF) support were compared with those of 129 patients treated with conventional-dose M-VAC to assess for an impact of dose-intense therapy on long-term survival. The mean relative dose intensity of chemotherapy delivered to the dose-intense cohort was 55% higher than that delivered to the conventional-dose cohort (p = 0.0001). However, no significant differences were observed with regard to response proportion (72% vs. 76%), median survival (13.3 vs. 16.7 months, p = 0.31), or 5-year survival (16% vs. 15%). Growth factor support enabled a statistically significant increase in the delivered dose intensity of M-VAC chemotherapy, but no survival advantage relative to conventional-dose M-VAC was observed.

Exploring sequenced chemotherapy regimens in the treatment of transitional cell carcinoma of the urothelial tract

This phase I trial evaluated the two-drug regimen doxorubicin and gemcitabine (AG) every other week for six cycles followed by ifosfamide, paclitaxel and cisplatin (ITP) every 3 weeks for four cycles in patients with transitional cell carcinoma of the urothelial tract. 15 patients were treated at five AG dose levels ranging up to doxorubicin 50 mg/m(2) and gemcitabine 2000 mg/m(2). The dose and schedule of ITP were constant at ifosfamide 1500 mg/m(2) on days 1-3 and paclitaxel 200 mg/m(2) and cisplatin 70 mg/m(2) on day 1. Granulocyte colony-stimulating factor was self-administered between all cycles of therapy. The trial determined that AG given at alternating weeks at doses of doxorubicin 50 mg/m(2) and gemcitabine 2000 mg/m(2) was feasible. After completion of the AG-ITP sequence, 9 of 14 (64%) evaluable patients had a major response (3 complete responses and 6 partial responses). Phase II investigation at the highest dose level is ongoing.

Phase I evaluation of sequential doxorubicin gemcitabine then ifosfamide paclitaxel cisplatin for patients with unresectable or metastatic transitional-cell carcinoma of the urothelial tract

PURPOSE

This phase I trial sought to evaluate the toxicity of and determine the maximum-tolerated dose (MTD) for the two-drug regimen doxorubicin and gemcitabine (AG) followed by the three-drug regimen of ifosfamide, paclitaxel, and cisplatin (ITP) in patients with unresectable or metastatic transitional-cell carcinoma.

PATIENTS AND METHODS

Patients received AG every other week for six cycles followed by ITP every 3 weeks for four cycles. Five AG dose levels were investigated, up to doxorubicin 50 mg/m(2) and gemcitabine 2, 000 mg/m(2), to determine the MTD of the regimen. The dose and schedule of ITP were constant: ifosfamide 1,500 mg/m(2) (days 1 to 3); paclitaxel 200 mg/m(2) (day 1); and cisplatin 70 mg/m(2) (day 1). Granulocyte colony-stimulating factor was given between all cycles of therapy.

RESULTS

Fifteen patients enrolled onto this phase I trial. AG was well tolerated at all dose levels, with no grade 3 or 4 myelosuppression. Toxicity experienced with ITP included grade 3 and 4 granulocytopenia in four patients and grade 3 nausea/vomiting in three patients. No grade 3 and 4 neurotoxicity was observed. Eight of 14 assessable patients experienced a major response to AG, including five of six patients treated at the two highest AG dose levels. After completion of AG-ITP, nine of 14 assessable patients had a major response (three complete responses and six partial responses).

CONCLUSION

AG is a well-tolerated and active regimen. Sequential chemotherapy with AG-ITP is also well tolerated, and phase II investigation at the highest dose level is ongoing.

High dose chemotherapy for refractory urothelial carcinoma supported by peripheral blood stem cell transplantation

BACKGROUND

Chemotherapy with methotrexate (MTX), vinblastine, doxorubicin, and cisplatin (M-VAC) is reported to be the most effective regimen for urothelial carcinoma. Complete response (CR) is observed in many cases. However, to the authors' knowledge there is no alternative therapy for nonresponders. Thus, the authors attempted high dose chemotherapy (HDC) supported with peripheral blood stem cells (PBSCs) collected after a modified method of mobilization to yield sufficient PBSCs for the HDC regimen employed.

METHODS

PBSCs were collected from ten patients, all of whom had recurrent and/or refractory transitional cell carcinoma. They were treated by modified M-VAC (with pirarubicin in place of doxorubicin) for PBSC harvest. Seven micrograms per kilogram of body weight of granulocyte-colony stimulating factor was injected subcutaneously daily from Day 10 of treatment to the end of the harvest. Harvest was initiated from the day when peripheral leukocyte counts exceeded 10,000/microL and usually continued for 3 consecutive days. Each patient received two courses of HDC. Therefore, 20 courses of HDC comprised of 300 mg/body of MTX, 1500 mg/m(2) of etoposide, and high dose carboplatin (CBDCA) were given to these 10 patients. The dose of CBDCA was determined by the formula of Calvert et al., in which the target area under the concentration versus time curve of CBDCA was adjusted to 21 mg. minute/mL.

RESULTS

Sufficient PBSCs were collected for myeloablative chemotherapy in all patients. No patient responded to the treatment with modified M-VAC. Response to HDC was observed in nine of ten patients. CR was achieved in seven patients and a partial response was noted in two patients. A patient with multiple bone metastases showed no response. All patients rapidly recovered after PBSC transplantation. No patient died of treatment-related toxicity.

CONCLUSIONS

HDC supported by PBSC transplantation was found to have a remarkable response against refractory urothelial carcinoma, for which there was no alternative therapy.

[Chemotherapy for urothelial infiltrating tumors]

Since 1985, the gold standard regimen for metastatic tumours of the urothelial tract is a combination of methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC protocol). Randomised studies have shown the superiority of the M-VAC regimen over cisplatin alone or in combination with cyclophosphamide and doxorubicin. The limited gain in survival shows that, although chemosensitive, metastatic tumours cannot be cured by the available drug combinations. Amongst new cytotoxic drugs in development, paclitaxel and gemcitabine are likely to be involved in the standard regimen of the future. The studies published to date do not support the routine use of chemotherapy in the neo-adjuvant or adjuvant setting for the management of early stage urothelial tumours.

Systemic chemotherapy of transitional cell carcinoma of the urothelium

Although the incidence of bladder cancer has increased in recent years, survival has also improved. Chemotherapy has made a substantial impact on this disease and now is used in patients with advanced or metastatic disease as well as in select patients with high-risk muscle invasive disease. While cisplatin remains the most active single antineoplastic agent, several other agents including methotrexate, vinblastine, and Adriamycin (doxorubicin) have important activity. More recently, paclitaxel and gemcitabine have shown promising activity in bladder cancer. Multidrug combination therapy has provided more frequent and durable responses than single agent therapy. Regimens containing cisplatin and methotrexate have been shown to be most effective in the treatment of advanced disease. Adjuvant chemotherapy regimes typically have included cisplatin or cisplatin and methotrexate combinations. However, studies have been limited and further prospective trials are required to determine the role of adjuvant chemotherapy. Multiple studies have investigated neoadjuvant chemotherapy with cisplatin and methotrexate combinations or anthracycline-based regimens, but study results are mixed. Further trials will be required to define the role of neoadjuvant chemotherapy in bladder cancer.

A phase II trial of cisplatin and interferon alpha 2b in patients with advanced bladder cancer

Twenty-two patients with advanced transitional cell bladder cancer were treated in a phase II trial exploring the possible synergy of cisplatin and interferon alpha 2b. Of the 20 evaluable patients, 7 (35%) had a partial response to the treatment, and only 6 patients were able to complete the full planned six cycles of treatment. Response rates, duration of responses, and overall survival of our patients are not superior to those expected by cisplatin alone.

Comparison between a cisplatin-containing regimen and a carboplatin-containing regimen for recurrent or metastatic bladder cancer patients. A randomized phase II study

BACKGROUND

The aim of this randomized Phase II study was to compare the efficacy and toxicity of a cisplatin-containing regimen with a carboplatin-containing regimen for patients with recurrent or metastatic bladder cancer.

METHODS

Fifty-seven patients with recurrent or metastatic bladder cancer were randomized to receive M-VEC treatment (methotrexate, vinblastine, epirubicin, and cisplatin) (n = 29) or M-VECa treatment (methotrexate, vinblastine, epirubicin, and carboplatin) (n = 28). The chemotherapy was scheduled at 28-day intervals. Recombinant granulocyte-colony stimulating factors were administered daily when the absolute neutrophil count fell below 1000/mm3. The development of ototoxicity was evaluated by measuring auditory brain stem response.

RESULTS

Of the 57 entered patients, 55 were evaluable for response and toxicity. The overall clinical response rate was 71% (with 25% complete responses) in the M-VEC group and 41% (with 11% complete responses) in the M-VECa group (P = 0.04). M-VEC chemotherapy was associated with more pronounced side effects. There was a statistically significant difference between M-VEC and M-VECa in terms of gastrointestinal toxicity (P = 0.04), nephrotoxicity (P = 0.03), and neurotoxicity (P = 0.02) during Cycle 3 of chemotherapy. Leukopenia and neutropenia were worse in the M-VECa arm, but not significantly so (P = 0.4). Ototoxicity was only detected in one of seven examined M-VEC patients after two cycles of chemotherapy.

CONCLUSIONS

M-VECa has a low level of gastrointestinal, renal, neurologic, and otologic toxicity, but is apparently less effective than M-VEC in the treatment of recurrent or metastatic bladder cancer. However, a larger, randomized Phase III trial is needed to confirm these results.

Platinum analogue combination chemotherapy: cisplatin, carboplatin, and methotrexate in patients with metastatic urothelial tract tumors. A phase II trial with evaluation of prognostic factors

BACKGROUND

Cisplatin is one of the single drugs that has shown the best documented effect in treating patients with locally recurrent or metastatic urothelial cancer. To the authors' knowledge, the effect of the combination of different platinum analogues in treating transitional cell carcinoma has not been evaluated previously neither experimentally nor in clinical studies.

METHODS

A Phase II trial of carboplatin (200 mg/m2), cisplatin (100 mg/m2), and methotrexate (250 mg/m2) with folinic acid rescue every 3 weeks was performed on 55 previously untreated patients with metastatic or locally recurrent urothelial cell carcinoma.

RESULTS

A response (complete response and partial response) was achieved in 21 of 51 evaluable patients (41%; 95% confidence limits, 28-56%). Twelve patients had no change, whereas 18 had progressive disease. Eight patients (16%) achieved a complete response, and most of these survived more than 2 years. No patient with poor performance (performance status score > or = 2) or bone metastases achieved a complete response. The median survival for all patients was 8.4 months. Multivariate survival analyses showed that performance status and alkaline phosphatase levels were significant prognostic factors for survival.

CONCLUSION

Combination therapy with cisplatin, carboplatin, and methotrexate is feasible but offers no advantage over other combinations with cisplatin and methotrexate in treating metastatic urothelial cell cancer. It is important to select patients for treatment carefully, and further studies of prognostic factors in these patients are warranted.

Long-term results with M-VAC for advanced urothelial cancer: high relapse rate and low survival in patients with a complete response

OBJECTIVE

To describe the long-term results of treating patients with advanced urothelial cancer using a combination of methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC).

PATIENTS AND METHODS

Fifty-one patients (37 men and 14 women, median age 66 years, range 41-82) with inoperable or metastatic carcinoma of the bladder, ureter or renal pelvis were treated with M-VAC and their responses evaluated for up to 7 years. Relative dose intensity (RDI) was calculated by dividing the actual dose intensity by the projected total dose intensity and related to outcome. Overall survival was assessed from the date of initiation of treatment with M-VAC, using the Kaplan-Meier method.

RESULTS

Of the 51 patients. 10 (20%) had a complete and 18 (35%) had a partial response, giving an overall response rate of 55% (95% CI, 41-68%). There was no significant difference in the median values of RDIs with response to the M-VAC regimen. The median duration of response was 11.9 months for the 10 patients with a complete response and of these, eight relapsed at a median of 10 months after treatment and died at a median of 8.5 months from the time of disease recurrence. Survival of patients with a complete response differed significantly from those with no response at 1 year after the start of treatment, but not subsequently.

CONCLUSION

Long-term follow-up revealed a high relapse rate and poor prognosis in patients with a complete response who received the M-VAC as induction therapy. Therefore, new adjunctive therapies are needed for patients with locally unresectable or metastatic urothelial cancer.

Accelerated cisplatin-based chemotherapy for advanced bladder cancer

The toxicity and efficacy of accelerated cisplatin, vincristine and methotrexate was assessed in patients with advanced urothelial carcinoma. 30 consecutive patients were entered into a phase II trial and treated with cisplatin, vincristine and methotrexate given every 10 days (MOPq10) for four cycles, followed by two further cycles at 21 day intervals. Five complete responses and 14 partial responses were observed (overall response rate 63%; 95% confidence interval 45-78%). The median progression-free survival was 7.5 months (range 1.8-28) and the median overall survival 10.5 months (range 2.36). Toxicity was moderate with no treatment-related deaths. It is concluded that although the overall survival is still disappointing, the toxicity is less with the protocol than reported with methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) or escalated M-VAC (E-MVAC) and the time on treatment is shorter. MOPq10 provided palliative benefit to two-thirds of patients with advanced transitional cell carcinoma including those in their eighth decade.

The status of bladder-preserving therapeutic strategies in the management of patients with muscle-invasive bladder cancer

The recommended treatment for medically fit patients with muscle-invading bladder cancer is usually radical cystectomy. However, transurethral resection of the tumor, partial cystectomy, irradiation and systemic chemotherapy are each effective in some patients. These latter treatments allow bladder preservation and cure as an alternative to radical cystectomy although when used unselectively the survival rates are inferior to those of radical cystectomy. The updated results of conservative surgery, radiation therapy and systemic chemotherapy as monotherapy, as well as strategies of combined modality treatment were reviewed. Based on this review many areas of consensus were reached which include: 1. The primary goal of any treatment for a patient with muscle-invading bladder cancer is survival; bladder preservation in the interest of quality of life is a secondary objective. 2. Only a small proportion of carefully selected patients may be cured by transurethral surgery alone, or by partial cystectomy alone. 3. Radiation therapy is currently the standard bladder-preserving therapy against which all other bladder-preserving methods must be compared. 4. Systemic chemotherapy as monotherapy is inadequate and cannot be recommended. 5. The addition of cisplatin-containing systemic chemotherapy to radiation therapy or conservative surgery appears to improve local control. While no multi-modality therapeutic regimen has yet been shown to be clearly optimal with regard to local efficacy and minimizing toxicity, monotherapy for bladder preservation is probably not desirable as a routine approach. 6. Deferring the patient from immediate cystectomy does not appear to compromise survival, nor does the addition of primary systemic chemotherapy appear to significantly increase the morbidity of cystectomy or radiotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Practical problems in fitting a proportional hazards model to data with updated measurements of the covariates

We review and discuss the practical problems encountered when analysing the effect on survival of covariates which are measured repeatedly over time. Specific issues arise over and above those met with the standard proportional hazards model and concern all stages of data preparation, data analysis and interpretation of the results. Data from a randomized clinical trial of patients with primary biliary cirrhosis, on whom several measurements were taken at regular intervals after entry, are presented as an illustration.

Bladder cancer: advances in biology and treatment

Integrating systemic chemotherapy in the treatment of patients with invasive bladder cancer is essential to improve survival because the majority of deaths are from systemic relapse. However, as experience with invasive tumors evolves, it is clear that treatment recommendations need to be tailored to an individual patient based on metastatic risk and, ideally, sensitivity to treatment. For those with tumors that do not extend through the bladder wall, standard therapy remains radical surgery. Nevertheless, encouraging results are being reported with increasing frequency using strategies designed to preserve bladder function through a variety of means. Crucial to the recommendation of a specific approach for an individual is improving our ability to define prognosis prior to initiating treatment. Patients with a high risk of systemic recurrence generally require chemotherapy, although the optimal route of integration, pre vs. post-operatively, remains controversial. In those patients who require it, chemotherapy can be administered more safely with the concomitant administration of hematopoietic growth factors. These factors alone, however, are unlikely to improve overall survival. Crucial to the latter effort will be the identification of more active agents, improving our understanding of intrinsic and acquired resistance to chemotherapy, and better delivery of the chemotherapeutic agents currently available. Of equal importance, is the enrollment of patients in clinical trials. These can include large scale randomized comparisons with using a survival end-point, as well as new therapies in high risk populations. The latter would include patients with advanced T3b, T4 and N+ disease, with a high risk of metastatic failure, and low complete response proportions to presently available regimens.

The effect of dose intensity on M-VAC therapy for advanced urothelial cancer

M-VAC therapy (methotrexate, vinblastine, Adriamycin, and cisplatin) has improved the treatment results of urothelial cancer patients. However, it is sometimes complicated by drug toxicities, including bone marrow suppression. We analyzed the relative dose intensity in each patient undergoing M-VAC chemotherapy in relation to the chemotherapeutic effect and survival. In addition, the role of granulocyte colony-stimulating factor (G-CSF) in the dose intensity of M-VAC therapy was analyzed. Between June 1988 and March 1993, 29 patients with advanced urothelial cancer were treated with M-VAC therapy in our institution. Of 18 patients with evaluable lesions, 2 (11.1%) showed a complete response (CR) and 7 (38.9%) showed a partial response (PR), and the overall response rate was 50.0%. The median follow-up period for these 18 patients was 14.6 months and the median survival was 8.7 months, with 12 of the 18 patients being alive at the time of analysis. The relative dose intensity (RDI) for these 18 patients was 0.81 for methotrexate, 0.80 for vinblastine, 0.92 for Adriamycin, and 0.91 for cisplatin, for a mean RDI of 0.87. There was no correlation between the chemotherapeutic effect and the RDI. When we calculated the RDI for all 29 patients who underwent M-VAC therapy, G-CSF increased the RDI of Adriamycin significantly. The results of this retrospective study indicate that a dose intensity for M-VAC therapy in the range of 0.61-1.00 is unlikely to correlate with the chemotherapeutic effect, although G-CSF contributes to increasing the RDI of Adriamycin.

Chemioterapia M-VAC intensificata nelle neoplasie uroteliali avanzate

From 1990 to 1992, 15 patients with advanced transitional cell cancer, previously untreated with chemotherapy, were treated with intensified M-VAC: methotrexate 30 mg/m2 day 1 and 15, vinblastine 3 mg/m2 day 2 and 15, adriamycin 30 mg/m2 and cisplatin 100 mg/m2 days 2→5 for a maximum of 4 cycles. Non-responders to the first 2 cycles of therapy were excluded; the partial-responder patients underwent surgical treatment of the residual disease, whenever possible. Three complete responses (20%) and 11 partial responses (73%) were observed. This regimen showed apparent benefit over classic M-VAC.

Selective bladder preservation by combination treatment of invasive bladder cancer

BACKGROUND

For patients with invasive bladder cancer the usual recommended treatment is radical cystectomy, although transurethral resection of the tumor, systemic chemotherapy, and radiotherapy are each effective in some patients. We sought to determine whether these treatments in combination might be as effective as radical cystectomy and thus might allow the bladder to be preserved and the cancer cured.

METHODS

We enrolled 53 consecutive patients with muscle-invading bladder cancer (stages T2 through T4, NXM0) in a trial of transurethral surgery, combination chemotherapy, and irradiation (4000 cGy) with concurrent cisplatin administration. Urologic evaluation of the tumor response directed further therapy: radical cystectomy in the 8 patients who had incomplete responses, additional chemotherapy and radiotherapy (6480 cGy) in the 34 patients who had complete responses or who were unsuited for cystectomy, and alternative care in the 11 patients who could not tolerate either irradiation or chemotherapy.

RESULTS

After a median follow-up of 48 months, 24 of the 53 patients (45 percent) were alive and free of detectable tumor. In 31 patients (58 percent) the bladder was free of invasive tumor and functioning well, even though in 9 (17 percent) a superficial tumor recurred and required further transurethral surgery and intravesical drug therapy. Of the 28 patients who had complete responses after initial treatment, 89 percent had functioning tumor-free bladders.

CONCLUSIONS

Conservative combination treatment may be an acceptable alternative to immediate cystectomy in selected patients with bladder cancer, although a randomized clinical trial that included a group for simultaneous comparison would be required to produce definitive results.