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Hartert M, Deppe C, Fink L, Kappes J. Chest wall tumor following intravesical BCG instillation for non-muscle invasive bladder cancer. J Clin Tuberc Other Mycobact Dis 2024; 35:100438. [PMID: 38623461 PMCID: PMC11017275 DOI: 10.1016/j.jctube.2024.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Mycobacterium bovis bacille Calmette-Guérin (BCG) is the most effective intravesical immunotherapy for non-muscle invasive bladder cancer (NMIBC), administered after its transurethral resection. Although its instillation is generally well tolerated, BCG-related infectious complications may occur in up to 5% of patients. Clinical manifestations may arise in conjunction with initial BCG instillation or develop months or years after the last BCG instillation. The range of presentations and potential severity pose an imminent challenge for clinicians. We present a case of an isolated subcutaneous chest wall abscess in an immunocompetent 52-year-old patient nearly two years after intravesical BCG instillation for NMIBC, an absolute rarity. As the enlarging chest wall tumor may be misinterpreted as malignancy, its expedient diagnosis and prompt treatment are of critical importance.
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Affiliation(s)
- Marc Hartert
- Department of Thoracic Surgery, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Claudia Deppe
- Department of Internal Medicine and Pneumology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | - Ludger Fink
- Institute of Pathology, Cytopathology, and Molecular Pathology, Supraregional Joint Practice for Pathology, Member of the German Center for Lung Research, Wetzlar, Germany
| | - Jutta Kappes
- Department of Internal Medicine and Pneumology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
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P. van Valenberg FJ, van der Heijden AG, Cutie CJ, Bhanvadia S, Keegan KA, Hampras S, Sweiti H, Maffeo JC, Jin S, Chau A, Reynolds DL, Iarossi C, Kelley A, Li X, Stromberg KA, Michiel Sedelaar J, Steenbruggen JJ, Somford DM, Alfred Witjes J. The Safety, Tolerability, and Preliminary Efficacy of a Gemcitabine-releasing Intravesical System (TAR-200) in American Urological Association-defined Intermediate-risk Non-muscle-invasive Bladder Cancer Patients: A Phase 1b Study. EUR UROL SUPPL 2024; 62:8-15. [PMID: 38585206 PMCID: PMC10998271 DOI: 10.1016/j.euros.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 04/09/2024] Open
Abstract
Background and objective Patients with intermediate-risk non-muscle-invasive bladder cancer (IR NMIBC) have a high risk of recurrence and need effective therapies to reduce the risk of disease recurrence or progression. This phase 1b study (NCT02720367) assessed the safety and tolerability of TAR-200, an intravesical drug delivery system, in participants with IR NMIBC. Methods Participants with recurrent IR NMIBC were eligible. Participants received either two 7-d or two 21-d TAR-200 dosing cycles over a 4-6-wk period in a marker lesion/ablation design. TAR-200 was placed in the window between the cystoscopy showing recurrent papillary disease and the subsequent complete transurethral resection of the bladder tumour. The primary endpoint was TAR-200 safety. The secondary endpoints included TAR-200 tolerability, pharmacokinetics, and preliminary efficacy. Key findings and limitations Twelve participants received TAR-200 treatment. No TAR-200-related serious or grade ≥ 3 treatment-emergent adverse events (TEAEs) occurred. Nine participants had grade ≤ 2 TAR-200-related TEAEs, with urgency, dysuria, and haematuria being most common. Two participants refused a second dosing cycle due to urinary urgency and frequency. Insertion and removal of TAR-200 was successful in all cases. Plasma gemcitabine concentrations remained below the lower limit of detection. Five participants (42%) had complete response (CR): four had pathological CR and one had CR based on visual assessment. Conclusions and clinical implications TAR-200 appears to be safe and well tolerated, with encouraging preliminary efficacy in participants with IR NMIBC. This study lays the groundwork for the multiple phase 2 and 3 global studies that are currently on-going for TAR-200. Patient summary In this study, researchers evaluated the safety of the novel drug delivery system TAR-200 in participants with intermediate-risk non-muscle-invasive bladder cancer. They concluded that TAR-200 was safe and well tolerated with promising antitumour activity.
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Affiliation(s)
- F. Johannes P. van Valenberg
- Department of Urology, Radboudumc, Nijmegen, The Netherlands
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | | | | | - Kirk A. Keegan
- Janssen Research & Development, Lexington, MA, USA
- Department of Urology, Vanderbilt University, Nashville, TN, USA
| | | | | | | | - Shu Jin
- Janssen Research & Development, Lexington, MA, USA
| | | | | | | | - April Kelley
- Janssen Research & Development, Lexington, MA, USA
| | - Xiang Li
- Janssen Research & Development, Raritan, NJ, USA
| | | | | | | | - Diederik M. Somford
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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Lone Z, Benidir T, Wood A, Campbell RA, Alaghehbandan R, Li J, Haber GP, Eltemamy M, Haywood SC, Weight CJ, Lee BH, Almassi N. Oncologic outcomes of intravesical therapy in the management of nonmuscle invasive bladder cancer with variant histology. Urol Oncol 2024; 42:71.e1-71.e7. [PMID: 38135626 DOI: 10.1016/j.urolonc.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 11/10/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE There is limited data on oncologic outcomes in nonmuscle invasive bladder cancer (NMIBC) with variant histology (VH) managed with intravesical therapy. We sought to evaluate oncologic outcomes for this cohort at a high-volume center. MATERIALS AND METHODS A retrospective review of an IRB-approved bladder cancer database was performed. Patients with a history of NMIBC with VH present on transurethral resection of bladder tumor (TURBT) treated with intravesical therapy (BCG or chemotherapy) were identified. Outcomes of interest included recurrence within the bladder, progression to muscle-invasive bladder cancer (MIBC), metastatic progression, cancer-specific, and overall survival. Survival time was computed from the date of initiation of intravesical therapy to the date of event or censoring. For patients who underwent radical cystectomy, recurrence-free, cancer-specific, and overall survival were also computed. The Kaplan-Meier method with log rank was utilized to compare survival time between VH sub-groups. RESULTS Ninety patients were included in the final cohort with a median follow-up of 38 months. The majority of patients had T1 disease (72%) and received intravesical BCG (83%) as their only form of intravesical therapy. The most commonly represented VH in this series were glandular and squamous differentiation (26%). Forty-eight patients (53%) experienced recurrence within the bladder with a median recurrence-free survival of 24 months (95% Confidence Interval [CI]: 2-46 months). Five-year rates of progression to MIBC and distant metastasis were both 14% respectively. Twenty-six patients (28%) eventually required cystectomy. When stratifying by VH, patients with sarcomatoid, plasmacytoid, and micropapillary had significantly worse oncologic outcomes. CONCLUSION In this series of highly-selected patients with NMIBC and VH, bladder-sparing treatment with intravesical therapy demonstrated acceptable oncologic outcomes for most VHs. This may be an acceptable treatment option for patients without plasmacytoid, sarcomatoid, or micropapillary features who are not suitable cystectomy candidates or who prioritize bladder-sparing treatment.
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Affiliation(s)
- Zaeem Lone
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.
| | - Tarik Benidir
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Andrew Wood
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Rebecca A Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Reza Alaghehbandan
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Jianbo Li
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | | | - Mohammed Eltemamy
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Samuel C Haywood
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | - Byron H Lee
- Department of Urology, MD Anderson Cancer Center, Houston, TX
| | - Nima Almassi
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
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Yim K, Melnick K, Mott SL, Carvalho FLF, Zafar A, Clinton TN, Mossanen M, Steele GS, Hirsch M, Rizzo N, Wu CL, Mouw KW, Wszolek M, Salari K, Feldman A, Kibel AS, O'Donnell MA, Preston MA. Sequential intravesical gemcitabine/docetaxel provides a durable remission in recurrent high-risk NMIBC following BCG therapy. Urol Oncol 2023; 41:458.e1-458.e7. [PMID: 37690933 DOI: 10.1016/j.urolonc.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Bacillus Calmette-Guerin (BCG) is the standard of care for high-risk nonmuscle invasive bladder cancer (NMIBC), but half of patients develop disease recurrence. Intravesical regimens for BCG unresponsive NMIBC are limited. We report the safety, efficacy, and differential response of sequential gemcitabine/docetaxel (gem/doce) depending on BCG failure classification. METHODS Multi-institutional retrospective analysis of patients treated with induction intravesical gem/doce (≥5/6 instillations) for recurrent high-risk NMIBC after BCG therapy from May 2018 to December 2021. Maintenance therapy was provided to those without high-grade (HG) recurrence on surveillance cystoscopy. Kaplan-Meier curves and Cox regression analyses were utilized to assess survival and risk factors for disease recurrence. RESULTS Our cohort included 102 patients with BCG-unresponsive NMIBC. Median age was 72 years and median follow-up was 18 months. Six-, 12-, and 24-month high-grade recurrence-free survival was 78%, 65%, and 49%, respectively. Twenty patients underwent radical cystectomy (median 15.5 months from induction). Six patients progressed to muscle invasive disease. Fifty-seven percent of patients experienced mild/moderate adverse effects (AE), but only 6.9% experienced a delay in treatment schedule. Most common AE were urinary frequency/urgency (41%) and dysuria (21%). Patients with BCG refractory disease were more likely to develop HG recurrence when compared to patients with BCG relapsing disease (HR 2.14; 95% CI 1.02-4.49). CONCLUSIONS In patients with recurrence after BCG therapy, sequential intravesical gem/doce is an effective and well-tolerated alternative to early cystectomy. Patients with BCG relapsing disease are more likely to respond to additional intravesical gem/doce. Further investigation with a prospective trial is imperative.
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Affiliation(s)
- Kendrick Yim
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | - Kevin Melnick
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | - Sarah L Mott
- Department of Urology, University of Iowa, Iowa City, IA
| | | | - Affan Zafar
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | | | | | - Graeme S Steele
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | - Michelle Hirsch
- Department of Pathology, Brigham and Women's Hospital, Boston MA
| | - Natalie Rizzo
- Department of Pathology, Brigham and Women's Hospital, Boston MA
| | - Chin-Lee Wu
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Kent W Mouw
- Department of Radiation Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Matthew Wszolek
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | - Keyan Salari
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | - Adam Feldman
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | - Adam S Kibel
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | | | - Mark A Preston
- Division of Urology, Brigham and Women's Hospital, Boston, MA.
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Smelser WW, Wang J, Ogden KM, Chang SS, Kirschner AN. Intravesical oncolytic virotherapy and immunotherapy for non-muscle-invasive bladder cancer mouse model. BJU Int 2023; 132:298-306. [PMID: 36961272 PMCID: PMC10518025 DOI: 10.1111/bju.16012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
OBJECTIVES To test if intravesical instillation of both an anti-programmed cell death protein 1 (PD-1) inhibitor and an oncolytic reovirus would demonstrate a greater effect than either treatment alone, as non-muscle-invasive bladder cancer that is refractory to intravesical bacillus Calmette-Guérin can be treated by systemic anti-PD-1 immunotherapy and we previously demonstrated improved overall survival (OS) with six once-weekly instillations of intravesical anti-PD-1 in a murine model. MATERIALS AND METHODS Using an orthotopic syngeneic C3H murine model of MBT2 urothelial bladder cancer, groups of 10 mice were compared between no treatment, intravesical anti-PD-1, intravesical oncolytic reovirus, or intravesical reovirus + anti-PD-1. A single intravesical treatment session was given. The primary outcome was OS, and the secondary outcomes included long-term immunity and tumour-immune profile. RESULTS With a median follow-up of 9 months, all mice that received no treatment died with a median survival of 41 days, while the comparison median OS was not reached for reovirus (hazard ratio [HR] 14.4, 95% confidence interval [CI] 3.9-32.6; P < 0.001), anti-PD-1 (HR 28.4, 95% CI 7.0-115.9; P < 0.001), and reovirus + anti-PD-1 (HR 28.4, 95% CI 7.0-115.9; P < 0.001). Monotherapy with anti-PD-1 or reovirus demonstrated no significant differences in survival (P = 0.067). Mass cytometry showed that reovirus + anti-PD-1 treatment enriched monocytes and decreased myeloid-derived suppressor cells, generating an immuno-responsive tumour microenvironment. Depletion of CD8+ T cells eliminated the survival advantage provided by the intravesical treatment. CONCLUSIONS Treatment of murine orthotopic bladder tumours with a single instillation of intravesical reovirus, anti-PD-1 antibody, or the combination confers superior survival compared to controls. Tumour-immune microenvironment differences indicated myeloid-derived suppressor cells and CD8+ T cells mediate the treatment response.
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Affiliation(s)
- Woodson W. Smelser
- Department of Surgery, Division of Urology, Washington University in St. Louis, St. Louis, MI, Nashville, TN, USA
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jian Wang
- Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kristen M. Ogden
- Department of Pediatrics, Immunology, Nashville, TN, USA
- Pathology, Microbiology, and Immunology, Nashville, TN, USA
| | - Sam S. Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Austin N. Kirschner
- Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
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Madan R, Radoiu C, Liaw A, Lucas S, Hamada A, Dhar N. Early three-month report of amniotic bladder therapy in patients with interstitial cystitis/bladder pain syndrome. Int Urol Nephrol 2023:10.1007/s11255-023-03652-8. [PMID: 37273012 DOI: 10.1007/s11255-023-03652-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/25/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Interstitial cystitis/bladder pain syndrome (IC/BPS) is characterized by symptomatic frequency and urgency, as well as chronic pelvic pain. Disruption of the urothelial barrier is closely associated with IC/BPS. As amniotic membranes (AM) offer capabilities of wound healing in many other fields of medicine, likewise amniotic bladder therapy (ABT) may offer capability of urothelial healing in IC/BPS. METHODS Under general anesthesia, 10 consecutive IC/BPS patients received intra-detrusor injections of 100 mg micronized AM (Clarix Flo) diluted in 10 ml 0.9% preservative-free sodium chloride. Clinical evaluation and questionnaires (Interstitial Cystitis Symptom Index (ICSI), Interstitial Cystitis Problem Index (ICPI), Bladder Pain/ Interstitial Cystitis Symptom Score (BPIC-SS), Overactive Bladder Assessment Tool, and SF-12 Health Survey) were repeated at pre-op and 2, 4, 8 and 12 weeks post-op. RESULTS Ten females (47.4 ± 14.4 years) who had recalcitrant IC/BPS for 7.8 years (5.2-12.1 years) received injection of micronized AM uneventful in all cases. After treatment, voiding symptoms and bladder pain significantly improved from pre-injection to 3 months. BPIC-SS significantly decreased from 37.4 ± 0.70 at baseline to 12.2 ± 2.90 at 3 months (p < 0.001). This corresponded to a significant improvement in their overall physical and mental quality of life. No adverse events occurred related to micronized AM injections, such as UTIs or acute urinary retention. CONCLUSION ABT could be an innovative treatment option for IC/BPS patients in terms of improving clinical symptoms based on preliminary outcomes at 3 months. Further studies are warranted to confirm the usefulness of ABT in patients with IC/BPS and to determine the duration of the effect.
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Affiliation(s)
- Raghav Madan
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Codrut Radoiu
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Aron Liaw
- Wayne State University School of Medicine, Detroit, MI, USA
- John D. Dingell VA Medical Center, 4646 John R Street, Detroit, MI, 48201, USA
| | - Steven Lucas
- Wayne State University School of Medicine, Detroit, MI, USA
- John D. Dingell VA Medical Center, 4646 John R Street, Detroit, MI, 48201, USA
| | - Alaa Hamada
- John D. Dingell VA Medical Center, 4646 John R Street, Detroit, MI, 48201, USA
| | - Nivedita Dhar
- John D. Dingell VA Medical Center, 4646 John R Street, Detroit, MI, 48201, USA.
- Detroit Medical Center, Detroit, MI, USA.
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Chung R, Moran GW, Movassaghi M, Pohl D, Ingram J, Lenis AT, McKiernan JM, Anderson CB, Faiena I. Survival outcomes in patients with muscle invasive bladder cancer undergoing radical vs. partial cystectomy. Urol Oncol 2023:S1078-1439(23)00137-0. [PMID: 37210247 DOI: 10.1016/j.urolonc.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 04/03/2023] [Accepted: 04/22/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE While radical cystectomy (RC) is the standard of care for muscle invasive bladder cancer (MIBC), partial cystectomy (PC) is an effective alternative in select patients. We sought to examine differences in survival for RC and PC in a hospital-based registry. MATERIAL AND METHODS We identified patients diagnosed with cT2-4 bladder cancer who underwent RC or PC from 2003 to 2015 in the National Cancer Database (NCDB). Using inverse probability treatment weighting (IPTW) to control for known confounders, we compared the primary outcome of overall survival (OS) in patients who underwent RC vs. PC. Kaplan-Meier survival analysis, univariable and multivariable Cox proportional hazards modeling were used. We performed a secondary survival analysis for a subcohort of patients with cT2, cN0, tumor size ≤5 cm, and no concurrent carcinoma in situ (CIS), who may be optimal candidates for PC. RESULTS A total of 22,534 patients met inclusion criteria, of which 6.9% (1,457) underwent PC. RC had longer median OS than PC (67.8 vs. 54.1 months) and on Cox regression analysis (HR 0.88, 95% CI, 0.80-0.95, P = 0.002). However, in our subcohort, there was no difference in OS between RC and PC (HR 1.02, 95% CI, 0.9-1.2, P = 0.74). PC was associated with increased time from surgery to any systemic therapy or death in the subcohort. CONCLUSIONS Among patients with clinically organ-confined MIBC, PC appears to afford similar survival outcomes to RC in a large national data set. The safety and tolerability of PC may warrant consideration in highly selected patients.
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Affiliation(s)
- Rainjade Chung
- Department of Urology, Columbia University Medical Center, New York, NY
| | - George W Moran
- Department of Urology, Columbia University Medical Center, New York, NY
| | - Miyad Movassaghi
- Department of Urology, Columbia University Medical Center, New York, NY
| | - Daniel Pohl
- Department of Urology, Columbia University Medical Center, New York, NY
| | - Justin Ingram
- Department of Urology, Columbia University Medical Center, New York, NY
| | - Andrew T Lenis
- Department of Urology, Columbia University Medical Center, New York, NY
| | - James M McKiernan
- Department of Urology, Columbia University Medical Center, New York, NY
| | | | - Izak Faiena
- Department of Urology, Columbia University Medical Center, New York, NY.
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Zhang P, Wu G, Zhang D, Lai WF. Mechanisms and strategies to enhance penetration during intravesical drug therapy for bladder cancer. J Control Release 2023; 354:69-79. [PMID: 36603810 DOI: 10.1016/j.jconrel.2023.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/30/2022] [Accepted: 01/01/2023] [Indexed: 01/05/2023]
Abstract
Bladder cancer (BCa) is one of the most prevalent cancers worldwide. The effectiveness of intravesical therapy for bladder cancer, however, is limited due to the short dwell time and the presence of permeation barriers. Considering the histopathological features of BCa, the permeation barriers for drugs to transport across consist of a mucus layer and a nether tumor physiological barrier. Mucoadhesive delivery systems or mucus-penetrating delivery systems are developed to enhance their retention in or penetration across the mucus layer, but delivery systems that are capable of mucoadhesion-to-mucopenetration transition are more efficient to deliver drugs across the mucus layer. For the tumor physiological barrier, delivery systems mainly rely on four types of penetration mechanisms to cross it. This review summarizes the classical and latest approaches to intravesical drug delivery systems to penetrate BCa.
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Affiliation(s)
- Pu Zhang
- Urology & Nephrology Center, Department of Urology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
| | - Guoqing Wu
- Urology & Nephrology Center, Department of Urology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China
| | - Dahong Zhang
- Urology & Nephrology Center, Department of Urology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China.
| | - Wing-Fu Lai
- Urology & Nephrology Center, Department of Urology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang 310014, China; Department of Food Science and Nutrition, Hong Kong Polytechnic University, Hong Kong, China.
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Chung R, Moran GW, Wang C, McKiernan JM, Anderson CB. Partial cystectomy: Review of a single center experience from 2004 to 2019. Urol Oncol 2022; 40:538.e1-5. [PMID: 36216663 DOI: 10.1016/j.urolonc.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/30/2022] [Accepted: 09/06/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE Partial cystectomy (PC) is a bladder sparing option to treat bladder cancer in a carefully selected group of patients. We sought to analyze outcomes of partial cystectomy (PC) in a contemporary cohort of patients at a single institution. MATERIAL AND METHODS Records were reviewed for 43 patients with a primary urothelial carcinoma (UC) who had a partial cystectomy with curative intent at Columbia University Medical Center from 2004 to 2019. Endpoints of interest were noninvasive recurrence (defined as any recurrent nonmuscle invasive disease), advanced recurrence (defined as a muscle invasive recurrence or metastasis), and death. We used unadjusted Cox proportional hazards regressions and log rank tests to estimate the association between clinical characteristics and endpoints of interest. RESULTS Among 43 patients with bladder cancer treated with partial cystectomy, median patient age was 73 years (interquartile range 67-77.5) and 86% were male. Twenty-three percent of patients received preoperative neoadjuvant chemotherapy (NAC) and 49% of patients were given perioperative intravesical chemotherapy at the time of PC. Pathologic stage was <T2 for 23 (53%) patients and ≥T2 for 20 (47%) patients. Pathology showed 14% of patients had lymph node involvement, and 9% had positive surgical margins. Mean follow-up was 51 months (range 1-176). Five-year overall survival was 78%. Of 43 patients, 23 patients (53%) had no recurrence, 9 patients (21%) experienced noninvasive intravesical recurrence, and 11 patients (26%) experienced advanced recurrences. Two patients (5%) required salvage radical cystectomy and 8 patients (19%) died of bladder cancer. On univariate analysis, lymphovascular invasion (hazard ratio [HR] 4.4, confidence interval [CI] 1.3-14.3), pathological stage (HR 5.9, CI 1.3-27.4), and NAC (HR 6.5, CI 1.9-22.7) were associated with advanced recurrence. Noninvasive recurrence was associated with not receiving perioperative intravesical chemotherapy (HR 0.7, CI 0.1-6.0). CONCLUSIONS In well-selected patients, partial cystectomy offers adequate local control of bladder cancer. The risk of systemic progression is similar to reported case series of RC.
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Yong C, Mott SL, Steinberg RL, Packiam VT, O'Donnell MA. A longitudinal single center analysis of T1HG bladder cancer: An 18 year experience. Urol Oncol 2022; 40:491.e1-491.e9. [PMID: 35831215 DOI: 10.1016/j.urolonc.2022.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/06/2022] [Accepted: 06/12/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To re-evaluate the treatment of T1HG bladder cancer by analyzing our experience over 18 years. METHODS AND MATERIALS An IRB-approved, single-institution retrospective review was performed of all patients with T1HG bladder cancer between August 1999 and July 2017. We assessed clinicopathologic characteristics, treatment history (including intravesical therapy, cystectomy, systemic chemotherapy, and radiation), and oncologic outcomes. RESULTS We identified 191 patients with T1HG. Five patients underwent cystectomy at diagnosis. The five-year recurrence-free survival (RFS) for the 186 patients who initially underwent bladder sparing treatments was 50% (95% CI: 41%-58%). There were 83 patients (45%) with disease recurrence; median time to recurrence was 6.7 months (IQR: 4.9-17.5). Disease characteristics at initial recurrence was T2 or greater in 8 patients (10%), T1HG in 19 (23%), CIS in 30 (36%), TaHG in 10 (12%), T1 low-grade (LG) in 1 (1%), and TaLG in 15 (18%). For patients with no prior recurrences, neither re-resection (P = 0.12), receipt of induction therapy (P = 0.81), prostatic urethra positivity (P = 0.51), or age (P = 0.34) were significantly associated with risk of recurrence. Similarly, patients with a single recurrence also fared well without identifiable risk factors. In fact, baseline hazard function analysis demonstrated no differences in RFS comparing patients stratified by 0, 1, and 2+ prior recurrences (P = 0.46). The five-year overall survival (OS) was 76% (95% CI: 68%-82%), and median OS was 127 months. The five-year cancer-specific survival was 86% (95% CI: 78%-91%) for the overall cohort. Five-year cystectomy-free survival for patients with BCG responsive disease and unresponsive disease was 95% (95% CI: 85%-98%) and 72% (95% CI: 52%-84%), respectively. CONCLUSION For patients who recurred after intravesical therapy, including those with recurrent T1 disease, additional induction courses of intravesical therapy did not negatively affect oncologic outcomes. Pathology of initial recurrence was not found to be a statistically significant risk factor for future recurrence. These findings suggest that BCG-unresponsive disease does not necessarily require immediate cystectomy. A multicenter, pragmatically designed evaluation in a contemporary cohort would more validly interrogate this important patient population.
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Affiliation(s)
- Courtney Yong
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Sarah L Mott
- Holden Comprehensive Cancer Center Biostatistics, College of Public Health Building, Iowa City, IA
| | - Ryan L Steinberg
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Vignesh T Packiam
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael A O'Donnell
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA.
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11
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Ourfali S, Matillon X, Ricci E, Fassi-Fehri H, Benoit-Janin M, Badet L, Colombel M. Prognostic Implications of Treatment Delays for Patients with Non-muscle-invasive Bladder Cancer. Eur Urol Focus 2022; 8:1226-1237. [PMID: 34172421 DOI: 10.1016/j.euf.2021.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/13/2021] [Accepted: 06/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delay in treatment is a prognostic factor in muscle-invasive bladder cancer. OBJECTIVE To evaluate clinical outcomes associated with delays in diagnosis and treatment for patients with non-muscle invasive bladder cancer (NMIBC). DESIGN, SETTING, AND PARTICIPANTS In this retrospective study we analyzed data for patients treated at our center between November 2008 and December 2016 for intermediate risk (IR) or high risk (HR) NMIBC with an additional intravesical treatment. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Time delays from diagnosis to first transurethral resection (TT-TUR), from resection to restaging resection (TT-reTUR), and from the last resection to first instillation (TT-INST) of bacillus Calmette-Guérin (BCG) or mitomycin C (MMC) were documented. To identify the interval of time from which recurrence rates significantly increased, we used nonparametric series regression. Recurrence-free survival (RFS) and progression-free survival for patients in each time delay category were compared using the Kaplan-Meier method. Factors associated with tumor recurrence were analyzed in a multivariable model. RESULTS AND LIMITATIONS A total of 434 patients were included, of whom 168 (38.7%) had IR and 266 (61.3%) had HR NMIBC. Among the patients, 34.6% had reTUR, 63.6% received BCG, and 36.4% received MMC. The median TT-TUR, TT-reTUR, and TT-INST was 4.0 wk, 6.5 wk, and 7.0 wk, respectively. At 40 mo the rate of recurrence was 28.4% and the rate of progression was 7.3%. Nonparametric analysis revealed that each week in delay increased the risk of recurrence, starting from week 6 for TT-TUR for IR and HR cases, and starting from week 7 for TT-INST for IR cases. RFS was significantly lower with TT-TUR > 6 wk among patients in the IR (p < 0.001) and HR (p = 0.04) groups, and with TT-INST >7 wk for patients in the IR group (p = 0.001). TT-reTUR >7 wk had a significant negative impact on progression (p < 0.017). Multivariable analysis revealed that for IR and HR cases, multifocality (p = 0.02 and p = 0.007) and TT-TUR >6 wk (p = 0.001 and p = 0.03) were independent predictors of recurrence, while TT-INST >7 wk predicted recurrence (p = 0.04) for IR NMIBC. CONCLUSIONS Our results suggest that delays of >6 wk to first TUR in IR and HR NMIBC, and >7 wk to first instillation in IR cases are associated with increases in the risk of recurrence. TT-reTUR of >7 wk is also associated with higher risk of progression. PATIENT SUMMARY We evaluated the impact of treatment delays on outcomes for patients with intermediate- and high-risk bladder cancer not invading the bladder wall muscle. We found that delays from diagnosis to first bladder resection, from first resection to repeat resection, and from last resection to bladder instillation treatment increase the rates of cancer recurrence and progression. The medical team should avoid delays in treatment, even for low-grade bladder cancer.
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Affiliation(s)
- Said Ourfali
- Service d'Urologie et Chirurgie de la Transplantation, Hospices Civils de Lyon, Lyon, France; Université Claude Bernard-Lyon 1, Lyon, France.
| | - Xavier Matillon
- Service d'Urologie et Chirurgie de la Transplantation, Hospices Civils de Lyon, Lyon, France; Université Claude Bernard-Lyon 1, Lyon, France
| | - Estelle Ricci
- Service d'Urologie et Chirurgie de la Transplantation, Hospices Civils de Lyon, Lyon, France
| | - Hakim Fassi-Fehri
- Service d'Urologie et Chirurgie de la Transplantation, Hospices Civils de Lyon, Lyon, France
| | - Mélanie Benoit-Janin
- Service d'Anatomo-Cyto-Pathologie, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Lionel Badet
- Service d'Urologie et Chirurgie de la Transplantation, Hospices Civils de Lyon, Lyon, France; Université Claude Bernard-Lyon 1, Lyon, France
| | - Marc Colombel
- Service d'Urologie et Chirurgie de la Transplantation, Hospices Civils de Lyon, Lyon, France; Université Claude Bernard-Lyon 1, Lyon, France
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12
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Roumiguié M, Kamat AM, Bivalacqua TJ, Lerner SP, Kassouf W, Böhle A, Brausi M, Buckley R, Persad R, Colombel M, Lamm D, Palou-Redorta J, Soloway M, Brothers K, Steinberg G, Lotan Y, Sylvester R, Alfred Witjes J, Black PC. International Bladder Cancer Group Consensus Statement on Clinical Trial Design for Patients with Bacillus Calmette-Guérin-exposed High-risk Non-muscle-invasive Bladder Cancer. Eur Urol 2022; 82:34-46. [PMID: 34955291 DOI: 10.1016/j.eururo.2021.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/22/2021] [Accepted: 12/03/2021] [Indexed: 11/21/2022]
Abstract
CONTEXT A large proportion of patients with non-muscle-invasive bladder cancer (NMIBC) fall in the gap between bacillus Calmette-Guérin (BCG)-naïve and BCG-unresponsive disease. As multiple therapeutic agents move into this gray area, there is a critical need to define the disease state and establish recommendations for optimal trial design. OBJECTIVE To develop a consensus on optimal trial design for patients with BCG-exposed NMIBC, defined as high-grade recurrence after BCG treatment that does not meet the criteria for BCG-unresponsive disease. EVIDENCE ACQUISITION We conducted a literature review using the Cochrane Library, Medline, and Embase and a review of clinical trials in ClinicalTrials.gov as a basis to generate consensus recommendations for clinical trial design in BCG-exposed NMIBC. EVIDENCE SYNTHESIS BCG-exposed NMIBC encompasses BCG resistance (presence of high-grade Ta or carcinoma in situ [CIS] at 3-mo evaluation after induction BCG) and delayed relapse. Randomized controlled trials are required to compare experimental therapies to a control arm receiving additional BCG, although ongoing BCG shortages may impact our ability to follow an optimal trial design. A placebo should be used in combination with BCG if the treatment arm includes BCG plus a study drug. Trials will either need to separate patients with and without CIS into two cohorts, or stratify by the presence of CIS at the time of randomization. If two cohorts are used, the primary endpoint for CIS patients should be complete response within a predetermined time. The primary endpoint in a cohort with Ta/T1 only, or if a single combined cohort is used, should be the duration of event-free survival. Suggested efficacy thresholds and corresponding sample sizes are provided. CONCLUSIONS The International Bladder Cancer Group has developed recommendations regarding definitions, endpoints, and clinical trial design for BCG-exposed NMIBC to encourage uniformity among studies in this disease state. PATIENT SUMMARY Our consensus provides a precise definition of the disease state for bladder cancer not invading the bladder muscle and exposed to bacillus Calmette-Guérin (BCG) treatment. Clear guidance for conducting optimal clinical trials in this disease setting was established and we believe that this will promote further progress in this field.
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Affiliation(s)
- Mathieu Roumiguié
- Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada; Department of Urology, Toulouse Cancer Institute and Toulouse University Hospital, Toulouse, France
| | - Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Trinity J Bivalacqua
- Perelman Center for Advanced Medicine, University of Pennsylvania, Division of Urology, Department of Surgery, Philadelphia, PA.
| | - Seth P Lerner
- Scott Department of Urology, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Wassim Kassouf
- Department of Surgery (Urology), Faculty of Medicine, McGill University, Montreal, Canada
| | - Andreas Böhle
- Departments of Urology, University of Lübeck, Lübeck, Germany; HELIOS Agnes-Karll-Krankenhaus, Bad Schwartau, Germany
| | | | - Roger Buckley
- North York General Hospital, Toronto, Ontario, Canada
| | - Raj Persad
- Department of Urology, Southmead Hospital, North Bristol Hospitals Trust, Bristol, UK
| | - Marc Colombel
- Claude Bernard University, Hôpital Edouard Herriot, Lyon, France
| | - Donald Lamm
- University of Arizona and BCG Oncology, Phoenix, AZ, USA
| | - Juan Palou-Redorta
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mark Soloway
- Division of Urology, Memorial Cancer Institute, Memorial Hospital, Hollywood, FL, USA
| | - Ken Brothers
- Patient Advocate, National Cancer Institute Bladder Cancer Task Force, Snowbasin, UT, USA
| | - Gary Steinberg
- Department of Urology, NYU Langone Health, New York, NY, USA
| | - Yair Lotan
- Department of Urology, UT Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Richard Sylvester
- European Association of Urology Guidelines Office, Brussels, Belgium
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter C Black
- Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada.
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13
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Huo F, Zhang Y, Li Y, Bu H, Zhang Y, Li W, Guo Y, Wang L, Jia R, Huang T, Zhang W, Li P, Ding L, Yan C. Mannose-targeting Concanavalin A-Epirubicin Conjugate for Targeted Intravesical Chemotherapy of Bladder Cancer. Chem Asian J 2022; 17:e202200342. [PMID: 35713953 DOI: 10.1002/asia.202200342] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/10/2022] [Indexed: 12/26/2022]
Abstract
Intravesical instillation of chemotherapeutic drugs such as epirubicin (EPI) is routinely used to prevent tumor recurrence and progression after transurethral resection of bladder tumor. However, the lack of tumor selectivity often causes severe damage to normal bladder urothelium leading to intolerable side effects. Here, we analyzed abnormal changes in glycosylation in bladder cancer and identified mannose as the most aberrantly expressed glycan on the surface of bladder cancer cell lines and human bladder tumor tissues. We then constructed a lectin-drug conjugate by linking concanavalin A (ConA) - a lectin that specifically binds to mannose, with EPI through a pH-sensitive linker. This ConA-EPI conjugate conferred EPI with mannose-targeting ability and selectively internalized cancer cells in vitro. This conjugate showed selective cytotoxicity to cancer cells in vitro and better antitumor activity in an orthotopic mouse model of bladder cancer. Our lectin-drug conjugation strategy makes targeted intravesical chemotherapy of bladder cancer possible.
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Affiliation(s)
- Fan Huo
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, Jiangsu, 210023, P. R. China
| | - Yang Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, Jiangsu, 210023, P. R. China
| | - Yiran Li
- State Key Laboratory of Analytical Chemistry for Life Science, School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, P. R. China
| | - Huagang Bu
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, Jiangsu, 210023, P. R. China
| | - Yaliang Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, Jiangsu, 210023, P. R. China
| | - Wei Li
- State Key Laboratory of Analytical Chemistry for Life Science, School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, P. R. China
| | - Yuna Guo
- State Key Laboratory of Analytical Chemistry for Life Science, School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, P. R. China
| | - Lan Wang
- State Key Laboratory of Analytical Chemistry for Life Science, School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, P. R. China
| | - Ru Jia
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, Jiangsu, 210023, P. R. China
| | - Tengfei Huang
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, Jiangsu, 210023, P. R. China
| | - Weiyi Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, Jiangsu, 210023, P. R. China
| | - Pengchao Li
- Department of Urology, the First Affiliated Hospital with Nanjing Medical University, Jiangsu Province Hospital), Nanjing, Jiangsu, 210023, P. R. China
| | - Lin Ding
- State Key Laboratory of Analytical Chemistry for Life Science, School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, 210023, P. R. China.,Chemistry and Biomedicine Innovation Center (ChemBIC), Nanjing University, Nanjing, Jiangsu, 210023, P. R. China
| | - Chao Yan
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, Jiangsu, 210023, P. R. China.,Chemistry and Biomedicine Innovation Center (ChemBIC), Nanjing University, Nanjing, Jiangsu, 210023, P. R. China.,Engineering Research Center of Protein and Peptide Medicine, Ministry of Education, P. R. China
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14
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[Expert consensus on intravesical therapy for non-muscle invasive bladder cancer (2021 edition)]. Zhonghua Zhong Liu Za Zhi 2021; 43:1027-1033. [PMID: 34695892 DOI: 10.3760/cma.j.cn112152-20210811-00605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bladder cancer is one of the common malignant tumors in China, with 75% of bladder cancer being non-muscle invasion with a high recurrence rate after surgery. Intravesical therapy is an useful methods to either directly kill tumor cells by infusing cytotoxic drugs into the bladder or directly or indirectly induce local immune responses of the body through infusing immune agents, such as bacillus calmette guerin, and thus reduce the risk of tumor recurrence and progression. In 2019, the Urological Chinese Oncology Group issued the "Expert consensus on intravesical therapy on non-muscle invasive bladder cancer" . Recently, great progress in the clinical diagnosis and treatment of non-muscle invasive bladder cancer has been achieved domestically and abroad, including the risk assessment of non-muscle invasive bladder cancer, the therapeutic choice of intravesical drugs, the adverse reactions and treatment experience of intravesical therapy, and clinical research on new types of intravesical drugs. This consensus is made according to domestic and overseas evidence-based medicine in combination with current clinical practice and experience of intravesical therapy for non-muscle invasive bladder cancer in China. It is an update of the 2019 expert consensus, with the wish to provide a guidance for domestic clinical standardized intravesical therapy for non-muscle invasive bladder cancer.
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15
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Abstract
PURPOSE OF REVIEW Non-muscle-invasive bladder cancer (NMIBC) is a heterogenous malignancy with high recurrence and progression rates, which necessitate uniform recommendations for diagnosis and management. Herein, we review the literature, with an emphasis on guidelines and contemporary diagnostic techniques and interventions. RECENT FINDINGS Guidelines around the world have adopted a schema which risk-stratify cases at diagnosis, to offer evidence-based treatment and surveillance recommendations. Enhanced endoscopic technologies can improve detection of NMIBC and reduce recurrence. The present Bacillus Calmette-Guerin (BCG) shortage in the USA has led to new strategies to prioritize the most high-risk cases. The entity of BCG-unresponsive high-risk NMIBC remains a challenge to manage, with multiple novel treatments under investigation; fortunately, new therapies have been approved, such as immune checkpoint inhibitors, and others are showing tremendous promise. The standardization of NMIBC management, with evolving detection techniques and therapeutics, offers great potential to improve patient outcomes and survivorship.
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Affiliation(s)
- Hannah Slovacek
- Loyola University Chicago Stritch School of Medicine, Chicago, IL, USA
| | - Jerry Zhuo
- Department of Urology, Baylor College of Medicine, 7200 Cambridge St, Ste 10B, Houston, TX, 77030, USA
| | - Jennifer M Taylor
- Department of Urology, Baylor College of Medicine, 7200 Cambridge St, Ste 10B, Houston, TX, 77030, USA.
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16
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Pfail JL, Small AC, Cumarasamy S, Galsky MD. Real World Outcomes of Patients with Bladder Cancer: Effectiveness Versus Efficacy of Modern Treatment Paradigms. Hematol Oncol Clin North Am 2021; 35:597-612. [PMID: 33958153 DOI: 10.1016/j.hoc.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Bladder cancer remains a common and insidious disease in the United States. There have been several advances in the understanding of the biology of bladder cancer, novel diagnostic tools, improvements in multidisciplinary care pathways, and new therapeutics for advanced disease over the past few decades. Clinical trials have demonstrated efficacy for new treatments in each disease state, but additional work is needed to advance the effectiveness of bladder cancer care. Real world data provide critical information regarding patterns of care, adverse events, and outcomes helping to bridge the efficacy versus effectiveness gap.
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Laukhtina E, Abufaraj M, Al-Ani A, Ali MR, Mori K, Moschini M, Quhal F, Sari Motlagh R, Pradere B, Schuettfort VM, Mostafaei H, Katayama S, Grossmann NC, Fajkovic H, Soria F, Enikeev D, Shariat SF. Intravesical Therapy in Patients with Intermediate-risk Non-muscle-invasive Bladder Cancer: A Systematic Review and Network Meta-analysis of Disease Recurrence. Eur Urol Focus 2021; 8:447-456. [PMID: 33762203 DOI: 10.1016/j.euf.2021.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/11/2021] [Accepted: 03/10/2021] [Indexed: 12/09/2022]
Abstract
CONTEXT Patients with intermediate-risk non-muscle-invasive bladder cancer (NMIBC) may pose a clinical dilemma without an agreed evidence-based decision tree for personalized treatment. OBJECTIVE To perform a systematic review and network meta-analysis (NMA) to summarize available evidence on the oncologic outcomes of intravesical therapy in patients with intermediate-risk NMIBC. EVIDENCE ACQUISITION The MEDLINE, EMBASE, and ClinicalTrials.gov databases were searched in October 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Studies were deemed eligible if they reported on oncologic outcomes in patients with intermediate-risk NMIBC treated with transurethral resection of bladder tumor with and without intravesical chemotherapy or bacillus Calmette-Guérin (BCG) immunotherapy. EVIDENCE SYNTHESIS Twelve studies were included in a qualitative synthesis (systematic review); three were deemed eligible for a quantitative synthesis (NMA). An NMA of five different regimens was conducted for the association of treatment with the 5-yr recurrence risk. Chemotherapy with maintenance was associated with a lower likelihood of 5-yr recurrence than chemotherapy without maintenance (odds ratio [OR] 0.51, 95% credible interval [CI] 0.26-1.03). Immunotherapy, regardless of whether a full- or reduced-dose regimen, was not associated with a significantly lower likelihood of 5-yr recurrence when compared with chemotherapy without maintenance (OR 0.90, 95% CI 0.39-2.11 vs OR 0.93, 95% CI 0.40-2.19). Analysis of the treatment ranking revealed that chemotherapy with maintenance had the lowest 5-yr recurrence risk (P score 0.9666). CONCLUSIONS Our analysis indicates that chemotherapy with a maintenance regimen confers a superior oncologic benefit in terms of 5-yr recurrence risk compared to chemotherapy without maintenance in patients with intermediate-risk NMIBC. Regardless of the dose regimen, immunotherapy with BCG does not appear to be superior to chemotherapy in patients with intermediate-risk NMIBC in term of disease recurrence. However, owing to the lack of comparative studies, there is an unmet need for well-designed, large-scale trials to validate our findings and generate robust evidence on disease recurrence and progression. PATIENT SUMMARY A maintenance schedule of chemotherapy reduces the rate of long-term recurrence of bladder cancer that has not invaded the bladder muscle. Chemotherapy inserted directly into the bladder and immunotherapy without maintenance schedules seem to have limited benefit in preventing cancer recurrence.
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Affiliation(s)
- Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Mohammad Abufaraj
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Abdallah Al-Ani
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Mustafa Rami Ali
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Keiichiro Mori
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Marco Moschini
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Urology and Division of Experimental Oncology, Urological Research Institute, Vita-Salute San Raffaele, Milan, Italy
| | - Fahad Quhal
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Reza Sari Motlagh
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Victor M Schuettfort
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hadi Mostafaei
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Satoshi Katayama
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nico C Grossmann
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Harun Fajkovic
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
| | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
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Miyake M, Iida K, Nishimura N, Miyamoto T, Fujimoto K, Tomida R, Matsumoto K, Numakura K, Inokuchi J, Morizane S, Yoneyama T, Matsumura Y, Abe T, Inoue M, Yamada T, Terada N, Hirao S, Uemura M, Matsushita Y, Taoka R, Kobayashi T, Kojima T, Matsui Y, Kitamura H, Nishiyama H; Japanese Urological Oncology Group. Non-maintenance intravesical Bacillus Calmette-Guérin induction therapy with eight doses in patients with high- or highest-risk non-muscle invasive bladder cancer: a retrospective non-randomized comparative study. BMC Cancer 2021; 21:266. [PMID: 33706705 DOI: 10.1186/s12885-021-07966-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/22/2021] [Indexed: 12/11/2022] Open
Abstract
Background To explore possible solutions to overcome chronic Bacillus Calmette–Guérin (BCG) shortage affecting seriously the management of non-muscle invasive bladder cancer (NMIBC) in Europe and throughout the world, we investigated whether non-maintenance eight-dose induction BCG (iBCG) was comparable to six-dose iBCG plus maintenance BCG (mBCG). Methods This observational study evaluated 2669 patients with high- or highest-risk NMIBC who treated with iBCG with or without mBCG during 2000–2019. The patients were classified into five groups according to treatment pattern: 874 (33%) received non-maintenance six-dose iBCG (Group A), 405 (15%) received six-dose iBCG plus mBCG (Group B), 1189 (44%) received non-maintenance seven−/eight-dose iBCG (Group C), 60 (2.2%) received seven−/eight-dose iBCG plus mBCG, and 141 (5.3%) received only ≤5-dose iBCG. Recurrence-free survival (RFS), progression-free survival, and cancer-specific survival were estimated and compared using Kaplan–Meier analysis and the log-rank test, respectively. Propensity score-based one-to-one matching was performed using a multivariable logistic regression model based on covariates to obtain balanced groups. To eliminate possible immortal bias, 6-, 12-, 18-, and 24-month conditional landmark analyses of RFS were performed. Results RFS comparison confirmed that mBCG yielded significant benefit following six-dose iBCG (Group B) in recurrence risk reduction compared to iBCG alone (groups A and C) before (P < 0.001 and P = 0.0016, respectively) and after propensity score matching (P = 0.001 and P = 0.0074, respectively). Propensity score-matched sequential landmark analyses revealed no significant differences between groups B and C at 12, 18, and 24 months, whereas landmark analyses at 6 and 12 months showed a benefit of mBCG following six-dose iBCG compared to non-maintenance six-dose iBCG (P = 0.0055 and P = 0.032, respectively). There were no significant differences in the risks of progression and cancer-specific death in all comparisons of the matched cohorts. Conclusions Although non-maintenance eight-dose iBCG was inferior to six-dose iBCG plus mBCG, the former might be an alternative remedy in the BCG shortage era. To overcome this challenge, further investigation is warranted to confirm the real clinical value of non-maintenance eight-dose iBCG. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-07966-7.
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Abstract
OBJECTIVE This literature review provides an overview of non-muscle-invasive bladder cancer diagnosis (NMIBC), treatment, and surveillance. Existing evidence is reviewed to identify the NMIBC patient pathway, highlight its effect on quality of life, and identify supportive care needs of this patient group. A framework to guide nurses in the care of this underserved population is proposed. DATA SOURCES Electronic databases including CINAHL, Medline, PsychInfo, Cochrane, and Google Scholar were searched. CONCLUSION NMIBC is a chronic disease with high recurrence and progression rates with most patients requiring invasive treatment and burdensome surveillance schedules with frequent hospital visits. Treatment-related side effects may interrupt therapy and possibly result in its discontinuation. Patients' quality of life can be negatively affected at various stages of the cancer trajectory. Specialist nurses provide holistic care throughout all stages of the patient journey to optimize supportive care, information provision, and delivery of appropriate treatment and surveillance protocols. NMIBC research is historically underfunded with a paucity of evidence identifying the supportive care needs of this population. Further research is urgently required to fill the gaps identified. IMPLICATIONS FOR NURSING PRACTICE This timely paper raises the profile of unmet supportive care needs in an underserved research cancer population. Suggestions are proposed to improve the quality of nursing care through standardized practices and the development and integration of patient pathways. Evidence of the effect of NMIBC on family members or carers is absent from the literature. Future research implications and directions are proposed.
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Hurle R, Contieri R, Casale P, Morenghi E, Saita A, Buffi N, Lughezzani G, Colombo P, Frego N, Fasulo V, Paciotti M, Guazzoni G, Lazzeri M. Midterm follow-up (3 years) confirms and extends short-term results of intravesical gemcitabine as bladder-preserving treatment for non-muscle-invasive bladder cancer after BCG failure. Urol Oncol 2020; 39:195.e7-195.e13. [PMID: 33268275 DOI: 10.1016/j.urolonc.2020.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/23/2020] [Accepted: 09/19/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is a high demand for bladder sparing therapies in patients who do not respond to bacillus Calmette-Guérin (BCG). OBJECTIVE To report the mid-term results of intravesical gemcitabine in non-muscle-invasive bladder cancer (NMIBC) patients, who failed BCG and who were unwilling to undergo radical cystectomy (RC). MATERIAL & METHODS This is an extended confirmatory open-label, single-arm study, which enrolled consecutive patients who failed BCG or were BCG intolerant and unwilling to undergo the RC (histologically confirmed Tis (CIS), T1 high grade or multifocal Ta high grade of the urinary bladder). Intravesical gemcitabine was administered once a week for 6 consecutive weeks and once a month for 12 months. The primary outcome was disease-free survival (DFS) defined as the lack of tumor on cystoscopy and negative urine cytology. The secondary endpoint was safety, defined according a grading of side effects. overall survival, progression-free survival and DFS were described with Kaplan-Meier method at 12, 24, and 36 months. RESULTS AND LIMITATIONS Overall 46 patients were enrolled. The mean follow-up was 40 months. The DFS was 69.05% at the end of induction phase and 32.69% at 36 months. The progression-free survival at 36 months was 65.38%. The overall survival and cancer specific survival were 66.97% (95% confidence interval 47.25%-80.70%) and 78.71% (95% confidence interval 59.16%-89.66%), respectively. There was no life-threatening event or treatment related death (grade 4 or 5). The most common mild and moderate adverse events reported were urinary symptoms (lower urinary tract symptoms) and fatigue (G1-G2). CONCLUSION Intravesical gemcitabine seemed to represent a valid and safe alternative at 3 years follow-up for patients who failed BCG and were unwilling to undergo RC.
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Affiliation(s)
- Rodolfo Hurle
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Roberto Contieri
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Paolo Casale
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Emanuela Morenghi
- Department of Medical Statistic, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Alberto Saita
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Nicolòmaria Buffi
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy; Department of Medical Statistic, Humanitas Clinical and Research Center - IRCCS, Milan, Italy; Department of Urology, Department of Biomedical Sciences, Pieve Emanuele - Milano, Italy
| | - Giovanni Lughezzani
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy; Department of Urology, Department of Biomedical Sciences, Pieve Emanuele - Milano, Italy
| | - Piergiuseppe Colombo
- Department of Pathology, Humanitas Clinical and Research Center - IRCCS, (Milan), Italy
| | - Nicola Frego
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Vittorio Fasulo
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Marco Paciotti
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Giorgio Guazzoni
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy; Department of Urology, Department of Biomedical Sciences, Pieve Emanuele - Milano, Italy
| | - Massimo Lazzeri
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy.
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Santoni N, Cottrell L, Talia Jones JE, Bekarma HJ. Multifocal nephrogenic adenoma treated by intravesical sodium hyaluronate. Urol Ann 2020; 12:187-189. [PMID: 32565661 PMCID: PMC7292422 DOI: 10.4103/ua.ua_74_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 12/31/2019] [Indexed: 12/27/2022] Open
Abstract
Nephrogenic adenoma is a rare benign urinary tract lesion. There are pediatric cases that have been managed with intravesical sodium hyaluronate, but there are no published adult cases. We present the first case of an adult successfully treated with intravesical sodium hyaluronate without resection. A 77-year-old man was investigated with cystoscopy for lower urinary tract symptoms (LUTS) unresponsive to medical therapy. This revealed multifocal flat black bladder lesions. Biopsy showed the lesions to be nephrogenic adenoma. His LUTS were treated with 6 weeks of intravesical sodium hyaluronate. He returned 6 weeks later for resection of his bladder lesions. However, resection was abandoned as the bladder lesions had entirely resolved. The resolution of the bladder lesions following intravesical sodium hyaluronate was unexpected but does agree with existing literature. The two reported pediatric cases also suggest that intravesical sodium hyaluronate is therapeutic for nephrogenic adenoma.
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Affiliation(s)
- Nicola Santoni
- Department of Urology, University Hospital Ayr, Ayr, United Kingdom
| | - Lorna Cottrell
- Department of Pathology, Crosshouse Hospital, Kilmarnock, United Kingdom
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Jeglinschi S, Schirmann A, Durand M, Sanchez S, Larré S, Léon P. Factors affecting guideline adherence in the initial treatment of non-muscle invasive bladder cancer: Retrospective study in a French peripheral hospital. Prog Urol 2019; 30:26-34. [PMID: 31813714 DOI: 10.1016/j.purol.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/10/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To assess whether the initial treatment of non-muscle invasive bladder cancer (NMIBC) was performed according to the guidelines, and to determine the reasons why initial treatment was not provided in nonadherence cases. MATERIALS AND METHODS We retrospectively reviewed all patients with NMIBC who underwent their first transurethral resection of bladder tumor (TURBT) at a peripheral hospital, between 2007 and 2016. The treatment offered to the patient was compared to the European Association of Urology guidelines according to risk stratification. For each patient who did not receive the treatment according to the guidelines, one of the following reasons was identified: poor patient compliance, poor patient general health status, urologist's decision, lack of resources. RESULTS One hundred fifty-nine patients were included with a mean age of 72.2 years at the time of NMIBC diagnosis. The low-risk patients were strictly treated according to the guidelines. Among the intermediate-risk patients, 14% received mitomycin C. Among the high-risk patients, 39% received intravesical Bacillus Calmette-Guerin. In the nonadherence cases (61%), the reasons were related to the patient in 44% of cases (poor compliance, 21%; poor patient general health status, 23%), urologist's decision in 54% of cases, and lack of resources in 2% of cases. Thirty-seven percent of the high-risk patients underwent re-resection. CONCLUSIONS Overall, adherence to NMIBC guidelines was low in all treatment types (intravesical therapy, re-resection, or cystectomy for very high-risk patients), but this finding was similar to that in previous studies. Reasons were mainly related to the urologist's decision or to the patient condition (poor compliance or poor general health status). LEVEL OF EVIDENCE 3.
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Affiliation(s)
- S Jeglinschi
- Service d'urologie, CHU Nice, 06000 Nice, France; Service d'urologie, CHU Reims, 51100 Reims, France.
| | - A Schirmann
- Service d'urologie, CHU Reims, 51100 Reims, France
| | - M Durand
- Service d'urologie, CHU Nice, 06000 Nice, France
| | - S Sanchez
- Départment d'information médicale, centre hospitalier, 10000 Troyes, France
| | - S Larré
- Service d'urologie, CHU Reims, 51100 Reims, France
| | - P Léon
- Service d'urologie, CHU Reims, 51100 Reims, France; Service d'urologie, clinique Pasteur, 17200 Royan, France
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23
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Abstract
Bacillus Calmette-Guerin (BCG)-refractory high-grade non-muscle-invasive bladder cancer remains a challenging problem. Radical cystectomy is standard of care, but carries significant morbidity. Therefore, there is a need for effective treatments. Previous salvage intravesical therapies have had disappointing results with long-term follow-up; however, a wide array of novel agents is currently under investigation. These include novel combinations of existing intravesical agents, novel modes of delivery such as hyperthermia, viral mediated therapies, and immunotherapy. We review the need for novel treatment with existing agents and their long-term results, and discuss novel intravesical therapies and the data currently available on these therapies.
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Affiliation(s)
- Dunia Khaled
- Department of Urology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 3016, Kansas City, KS 66160, USA
| | - John Taylor
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jeffrey Holzbeierlein
- Department of Urology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 3016, Kansas City, KS 66160, USA.
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24
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Abstract
After Bacillus Calmette-Guerin (BCG) failure, there is likely a 6- to 24-month window whereby salvage intravesical therapy might allow for preservation of the bladder without disease worsening. Combination intravesical, salvage therapy for nonmuscle invasive bladder cancer represents a promising avenue for treatment in patients unfit or unwilling to undergo cystectomy. BCG with concomitant immune stimulating agents or immune checkpoint inhibitors, combination chemotherapy regimens, such as gemcitabine and docetaxol, and novel agents currently in clinical trials provide hope for a bladder-sparing alternative for patients after BCG failure.
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Affiliation(s)
- Nathan A Brooks
- Department of Urology, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, USA
| | - Michael A O'Donnell
- Department of Urology, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, USA.
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Becker REN, Kates MR, Bivalacqua TJ. Identification of Candidates for Salvage Therapy: The Past, Present, and Future of Defining Bacillus Calmette-Guérin Failure. Urol Clin North Am 2019; 47:15-21. [PMID: 31757296 DOI: 10.1016/j.ucl.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Disease progression and recurrence are common among patients on Bacillus Calmette-Guérin (BCG) therapy, and options for bladder-preserving subsequent therapy remain limited. Ongoing efforts to develop better second-line bladder-sparing therapies rely on clinical trials of patients deemed to have failed management with BCG. This article describes historical definitions of BCG failure, as well as recent efforts to better delineate and refine the clinical criteria for identifying individual patients who will not benefit from further intravesical BCG therapy. It also reviews guidance from the most recent expert consensus panels and professional association guidelines regarding which patients should not receive additional BCG therapy.
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Affiliation(s)
- Russell E N Becker
- The James Buchanan Brady Urological Institute and Greenberg Bladder Cancer Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Max R Kates
- The James Buchanan Brady Urological Institute and Greenberg Bladder Cancer Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute and Greenberg Bladder Cancer Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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26
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Abstract
Despite the 40-year reign of bacillus Calmette-Guérin (BCG) as the most effective immunotherapy in urologic cancers, a lack of clinical tools to predict treatment response has hampered progress in the field. Acting as an immunostimulatory agent against a multitude of phenotypically diverse non-muscle-invasive bladder cancers, response to BCG likely depends on both tumor characteristics as well as host factors. With a deeper understanding of the tumor biology as well as the mechanism of action underpinning immunotherapy, newer and more effective clinical tools are being constructed to improve patient selection.
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Affiliation(s)
- Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1373, Houston, TX 77030, USA.
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Wang TW, Yuan H, Diao WL, Yang R, Zhao XZ, Guo HQ. Comparison of gemcitabine and anthracycline antibiotics in prevention of superficial bladder cancer recurrence. BMC Urol 2019; 19:90. [PMID: 31615492 PMCID: PMC6794870 DOI: 10.1186/s12894-019-0530-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 09/27/2019] [Indexed: 12/20/2022] Open
Abstract
Background Because of the failure, shortage and related toxicities of Bacillus Calmette-Guérin (BCG), the other intravesical chemotherapy drugs are also widely used in clinical application. Gemcitabine and anthracycline antibiotics (epirubicin and pirarubicin) are widely used as first-line or salvage therapy, but which drug is better is less discussed. Methods A total of 124 primary NMIBC patients administered intravesical therapy after transurethral resection of bladder tumor (TURBT) at Nanjing Drum Tower hospital from January 1996 to July 2018. After TURBT, all patients accepted standard intravesical chemotherapy. Recurrence was defined as the occurrence of a new tumor in the bladder. Progression was defined as confirmed tumor invading muscular layer. Treatment failure was defined as need for radical cystectomy (RC), systemic chemotherapy and radiation therapy. Results Of the 124 patients who underwent intravesical chemotherapy, 84 patients were given gemcitabine, 40 patients were given epirubicin or pirarubicin, with mean follow-up times (mean ± SD) of (34.8 ± 17.9) and (35.9 ± 22.1) months respectively. The clinical and pathological features of patients show no difference between two groups. Recurrence rate of patients given gemcitabine was 8.33% (7 out of 84), the recurrence rate was 45% (18 out of 40) for epirubicin or pirarubicin (P < 0.0001). The progression rates of gemcitabine, anthracycline antibiotics groups were 2.38% (2 out of 84) and 20% (8 out of 40), respectively (P < 0.001). The rate of treatment failure is 8.33% (7 out of 84) and 25% (10 out of 40), respectively (P = 0.012). Gemcitabine intravesical chemotherapy group was significantly related to a lower rate of recurrence (HR = 0.165, 95% CI 0.069–0.397, P = 0.000), progression (HR = 0.160, 95% CI 0.032–0.799, P = 0.026) and treatment failure (HR = 0.260, 95% CI 0.078–0.867, P = 0.028). Conclusion In conclusion, gemcitabine intravesical chemotherapy group was significantly related to a lower rate of recurrence, progression and treatment failure. Gemcitabine could be considered as a choice for these patients who are not suitable for BCG.
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Affiliation(s)
- Tian-Wei Wang
- Nanjing Medical University, 101 Longmian Rd, Nanjing, 211166, China
| | - Hui Yuan
- Department of Urology, Nanjing Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, China
| | - Wen-Li Diao
- Department of Urology, Nanjing Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, China
| | - Rong Yang
- Department of Urology, Nanjing Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, China
| | - Xiao-Zhi Zhao
- Department of Urology, Nanjing Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, China
| | - Hong-Qian Guo
- Department of Urology, Nanjing Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, China.
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Shariat S, Gontero P, Catto JWF. How to Treat a Patient with T1 High-grade Disease and No Tumour on Repeat Transurethral Resection of the Bladder? Eur Urol Oncol 2021; 4:663-9. [PMID: 31481345 DOI: 10.1016/j.euo.2019.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/20/2019] [Accepted: 07/10/2019] [Indexed: 11/22/2022]
Abstract
A relatively young (64-yr old) long-term heavy smoker but otherwise very healthy man is diagnosed with a primary unifocal left-side tumour (urothelial, T1 high grade), but no lymphovascular invasion and no variant histology. We discuss whether treatment with intravesical bacillus Calmette-Guérin vaccine will be sufficient or early radical cystectomy is at least equally preferred regarding patient benefit, safety, and quality of life. PATIENT SUMMARY: A patient with a single high-grade T1 bladder tumour without aggressive features (eg, lymphovascular invasion or variant tumour aspects) will be adequately treated with bacillus Calmette-Guérin intravesical therapy delivered into the bladder, followed by 3 yr of maintenance. However, all decisions should be taken with the patient in a shared decision-making process, including a discussion regarding removal of the bladder.
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Peyton CC, Chipollini J, Azizi M, Kamat AM, Gilbert SM, Spiess PE. Updates on the use of intravesical therapies for non-muscle invasive bladder cancer: how, when and what. World J Urol 2019; 37:2017-29. [PMID: 30535583 DOI: 10.1007/s00345-018-2591-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Intravesical therapy has been an important aspect of the management of non-muscle invasive bladder cancer (NMIBC) for 40 years. Bacillus Calmette-Guerin (BCG) is considered standard of care for intermediate and high-grade non-invasive disease, yet understanding the nuances of subsequent intravesical therapy is important for any provider managing bladder cancer. Herein, we review the literature and describe optimal use of intravesical therapies for NMIBC. METHODS A comprehensive search of the medical literature was performed and highlighted in this review of intravesical therapy for NMIBC. RESULTS Post-resection intravesical Mitomycin C therapy for low-risk disease remains an important component of care, and gemcitabine now has level-one evidence demonstrating efficacy in this setting but is not yet a guideline recommendation. BCG intravesical therapy remains the most effective therapy preventing recurrence and progression of intermediate and high-risk NMIBC. Adequately characterizing BCG-failure is critical in determining the next step in management which includes radical cystectomy, additional intravesical immunotherapy, chemotherapy with intravesical gemcitabine ± docetaxel and clinical trials. CONCLUSIONS Intravesical therapy remains the mainstay of treatment for NMIBC and bladder preservation. Intravesical induction BCG followed by maintenance therapy remains standard of care for intermediate and high-risk patients. Detailing the timing and characteristics of recurrence after intravesical therapy is crucial in determining subsequent treatment recommendations. Current clinical trials focus on systemic immunotherapy and enhancing the intravesical immune response by augmenting the delivery mechanism.
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Wang Z, Xiao H, Wei G, Zhang N, Wei M, Chen Z, Peng Z, Peng S, Qiu S, Li H, Long J. Low-dose Bacillus Calmette-Guerin versus full-dose for intermediate and high-risk of non-muscle invasive bladder cancer: a Markov model. BMC Cancer 2018; 18:1108. [PMID: 30419836 PMCID: PMC6233591 DOI: 10.1186/s12885-018-4988-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 10/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the efficacy of low dose (27 mg) Bacillus Calmette-Guérin (BCG) and a full dose (81 mg) BCG immunotherapy for patients with intermediate and high-risk non-muscle invasive bladder cancer (NMIBC) after a typical transurethral bladder resection. METHODS We constructed a Markov model for a 20-year simulation of the disease to compare the overall survival of patients with intermediate and high-risk of NMIBC between the full-dose therapy (FD group) and the low-dose therapy (LD group). Base case analysis, one-way and two-way sensitivity analysis and a second-order Monte Carlo analysis were performed based on data from 15 published articles. RESULTS The expected overall survivals were 9.56 (9.55-9.57) years for FD group and 9.63 (9.61-9.64) years for LD group(P < 0.001). The estimated mortality in the FD group at 5, 10, and 20 years were 34.23%, 57.51% and 83.14%, respectively. The corresponding values in the LD group were 34.11%, 57.17%, 82.16%, respectively. Age-specific mortality and metastatic rate after undergoing radical cystectomy (RC) were the most two sensitive parameters in both groups. The rate of disease recurrence with disease worsening is the determining factor when choosing the optimal dose of BCG treatment. CONCLUSIONS A low-dose BCG treatment may act slightly better than a full-dose BCG treatment for patients with intermediate and high-risk of NMIBC. This finding will require further high-quality studies to validate.
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Affiliation(s)
- Zongren Wang
- Department of Urology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Han Xiao
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Guangyan Wei
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ning Zhang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Mengchao Wei
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zebin Chen
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhenwei Peng
- Department of Clinical Trials Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
- Department of Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Sui Peng
- Department of Clinical Trials Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Shaopeng Qiu
- Department of Urology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Heping Li
- Department of Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Jianting Long
- Department of Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
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Abstract
PURPOSE OF REVIEW The optimal management of high-grade T1 (HGT1) urothelial carcinoma (UC) is complex given its high rate of recurrence, progression, and cancer-specific mortality as well as its clinical variability. Our current treatment paradigm has been supplemented by recent data describing the expanding options for salvage intravesical therapy, bladder preservation, and the promising role of molecular epidemiology. In the current review, we attempt to summarize and critically analyze these studies. RECENT FINDINGS Evidence describing new intravesical therapies has demonstrated an adequate safety profile and some efficacy in BCG-unresponsive patients who desire bladder preservation. However, response rates are still poor in this high-risk patient population, and it is important to keep these data in perspective when counseling patients. Concomitantly, the continued molecular characterization of non-muscle-invasive bladder cancer may suggest potential therapeutic targets as well as predictors of treatment response in the future. The integration of new intravesical therapies and molecular data into the current treatment paradigm for HGT1 urothelial carcinoma will be critical to improving oncologic outcomes in this particularly high-risk population.
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Affiliation(s)
- Peter A Reisz
- Department of Urology, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN, 37232, USA.
| | - Aaron A Laviana
- Department of Urology, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN, 37232, USA
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN, 37232, USA
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Li R, Tabayoyong WB, Guo CC, González GMN, Navai N, Grossman HB, Dinney CP, Kamat AM. Prognostic Implication of the United States Food and Drug Administration-defined BCG-unresponsive Disease. Eur Urol 2018; 75:8-10. [PMID: 30301695 DOI: 10.1016/j.eururo.2018.09.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/14/2018] [Indexed: 10/28/2022]
Abstract
The category "BCG-unresponsive disease", formulated by experts at the request of the United States Food and Drug Administration, denotes a group of patients with recurrent non-muscle-invasive bladder cancer for whom continued BCG treatment is unlikely to provide benefit. Although quickly adopted for trial design, many of the nuances within the definition lack validation. In this study, we evaluated the prognostic value of BCG unresponsive designation (i.e. recurrence after induction plus at least 1 maintenance course of BCG) by comparing the oncologic outcomes of these patients with those recurring after induction BCG alone. We confirm that appropriately defined, BCG-unresponsive patients are more likely to require salvage radical cystectomy (54.5% vs 17.9%, p=0.002). Moreover, those opting for second-line bladder-sparing therapies are less likely to remain free of tumor recurrence (23% vs 69.2%, p=0.003). On multivariate analysis, BCG-unresponsive disease independently predicts inferior high-grade recurrence-free survival (hazard ratio [HR]: 6.25, 95% confidence interval [CI]: 2.27-16.67; p<0.001) and cystectomy-free survival (HR: 3.85, 95% CI: 1.49-10.0; p=0.006). Our data confirm the prognostic implication of the BCG unresponsive definition i.e. recurrence of high grade disease after induction and one course of maintenance BCG, and support its use in counseling and risk stratification of patients with tumor recurrence after BCG. Patient summary: Patients who have BCG-unresponsive disease, that is, high-grade non-muscle-invasive bladder cancer recurring after BCG induction and maintenance, have a low likelihood to respond to further BCG treatment and should consider radical cystectomy or clinical trial enrollment.
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Affiliation(s)
- Roger Li
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William B Tabayoyong
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles C Guo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Neema Navai
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - H Barton Grossman
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Colin P Dinney
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Yuen JWM, Mak DSY, Chan ES, Gohel MDI, Ng CF. Tumor inhibitory effects of intravesical Ganoderma lucidum instillation in the syngeneic orthotopic MB49/C57 bladder cancer mice model. J Ethnopharmacol 2018; 223:113-121. [PMID: 29783018 DOI: 10.1016/j.jep.2018.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/14/2018] [Accepted: 05/17/2018] [Indexed: 06/08/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Ganoderma lucidum (GL) has been traditionally used in oriental medicine as superior health tonic, and there are numerous scientific evidences of its antitumorigenic activities. AIM OF THE STUDY To evaluate the intravesical chemopreventive effects of ethanol extract of GL (GLe) on bladder cancer. MATERIALS AND METHODS Intravesical therapy is defined as the direct instillation of a liquid drug into bladder through a catheter. Bacille Calmette-Guerin(BCG) solution is applied intravesically as a conventional immunotherapy for preventing recurrence of bladder cancer. By adopting the MB49/C57 bladder cancer mice model, an overall 60 MB49-implanted mice were randomized into 3 groups and treated according to 3 treatment arms, including GLe, BCG and PBS. Additionally, wild-type mice without MB49 cell inoculation and treated with PBS were used as the negative control group. Testing agents were instilled intravesically for 2 h and repeated after one week for evaluating the effects on preventing the tumor formation and growth. The treated-mice were closely monitored for major adverse effects. RESULTS GLe demonstrated more potent cytotoxic effects than BCG on MB49 cells, although both in dose-dependent manner. In the MB49-implanted mice, 80 µg/ml GLe was shown to delay the tumor formation by one week, whereas the averaged tumor volume measured at endpoint was 3.6-fold and 4.6-fold smaller than that of the BCG or PBS, respectively. However, no significant effects were observed on body weight and hematuria. CONCLUSION Current findings in mice suggested intravesical GLe therapy as an effective and safe chemopreventive strategy for inhibiting bladder tumor formation.
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Affiliation(s)
- J W M Yuen
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China.
| | - D S Y Mak
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China.
| | - E S Chan
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Sha Tin, N.T., Hong Kong, China.
| | - M D I Gohel
- School of Medical and Health Science, Tung Wah College, Homantin, Kowloon, Hong Kong, China.
| | - C F Ng
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Sha Tin, N.T., Hong Kong, China.
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Li R, Metcalfe MJ, Tabayoyong WB, Guo CC, Nogueras González GM, Navai N, Grossman HB, Dinney CP, Kamat AM. Using Grade of Recurrent Tumor to Guide Further Therapy While on Bacillus Calmette-Guerin: Low-grade Recurrences Are not Benign. Eur Urol Oncol 2018; 2:286-293. [PMID: 31200843 DOI: 10.1016/j.euo.2018.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/04/2018] [Accepted: 08/16/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Tumors that recur after bacillus Calmette-Guerin (BCG) therapy are considered to be of very high risk, and patients are often recommended to undergo radical cystectomy (RC). However, the nuances associated with the grade of tumor recurrence after BCG treatment are not well understood. OBJECTIVE To characterize the pattern of bladder cancer progression and cancer-specific survival (CSS) in patients with recurrences dichotomized by low grade (LG) versus high grade (HG) after intravesical BCG treatment, and to assess the safety of continued bladder-sparing therapy in these patients. DESIGN, SETTING, AND PARTICIPANTS We performed an Institutional Review Board-approved review of our bladder cancer database. Overall, 146 non-muscle-invasive bladder cancer (NMIBC) patients were found to have NMIBC recurrence while on BCG therapy; this recurrence was LG in 38 and HG in 108. Baseline clinicopathologic characteristics including age, gender, primary tumor grade, stage, size, multiplicity, and concurrent carcinoma in situ were also evaluated. The primary endpoint was progression-free survival (PFS), with progression defined as the development of muscle-invasive bladder cancer (MIBC)/distant metastasis. In addition, recurrence-free survival (RFS), HG RFS, cystectomy-free survival (CFS), and CSS were also compared. Multivariable analysis was performed using the Cox regression model. All tests were two sided, and p<0.05 was considered statistically significant. INTERVENTION Further intravesical therapy versus salvage RC. RESULTS AND LIMITATIONS Overall, estimated 5-yr PFS was 72.4% (95% confidence interval [CI] 60.4-81.3%). As dichotomized by grade of recurrent tumor, PFS was greater for patients with LG recurrences (85.6%, 95% CI 60.8-95.2%) than for those with HG recurrence (67.9%, 95% CI 54.1-78.4%; p=0.010). Furthermore, patients whose initial recurrence on BCG therapy was LG had improved subsequent RFS (median 62 vs 34mo, p=0.007), HG RFS (median 112 vs 36mo, p<0.001), and CFS (estimated 5-yr CFS 80.8% vs 49.8%, p<0.001) compared with those who had HG initial recurrence. On univariate and multivariate analyses, grade of tumor recurrence after BCG was an independent predictor of time to progression to MIBC/distant metastasis (hazard ratio 3.60, 95% CI 1.18-10.94, p=0.024). CONCLUSIONS Grade of tumor recurrence after intravesical BCG is an important predictor of bladder cancer progression to MIBC/metastatic urothelial carcinoma. While, patients with LG recurrences have less than half the progression events compared with those with HG recurrences, their estimated 5-yr progression rate is still 14.4%. Hence all patients should be carefully counseled on bladder-sparing therapy. This also has implications for clinical trial design. PATIENT SUMMARY If bladder cancer recurs after bacillus Calmette-Guerin treatment, there are many factors that determine the further clinical outcome. Although low-grade recurrent tumors confer a less aggressive course, disease progression can still occur, and hence continued vigilance is important.
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Affiliation(s)
- Roger Li
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Metcalfe
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William B Tabayoyong
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles C Guo
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Neema Navai
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - H Barton Grossman
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Colin P Dinney
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Alameddine M, Kineish O, Ritch C. Predicting Response to Intravesical Therapy in Non-muscle-invasive Bladder Cancer. Eur Urol Focus 2018; 4:494-502. [PMID: 30098938 DOI: 10.1016/j.euf.2018.07.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/11/2018] [Accepted: 07/20/2018] [Indexed: 11/20/2022]
Abstract
CONTEXT The ability to predict response to intravesical therapy (IVT) following transurethral resection in non-muscle-invasive bladder cancer holds important prognostic information. However, few predictive tools are available to guide urologists. OBJECTIVE We reviewed the most recent studies investigating the predictors of response to IVT. EVIDENCE ACQUISITION A literature search was conducted using PubMed database from January 1, 2013 to April 1, 2018 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. For our search strategy, we used the combination of the MeSH terms of "Administration, Intravesical" and "Urinary Bladder Neoplasms" with any of the following words: "Biomarkers," "Predictive Value of Tests," "response," "recurrence," and "progression." We limited our search to the English language. EVIDENCE SYNTHESIS Risk stratification models utilizing clinicopathological features are the most cost-effective and widely used tools currently available to predict response to IVT. Additionally, urinary fluorescence in situ hybridization testing and urinary cytokine-based nomograms (Cytokine Panel for Response to Intravesical Therapy) may enhance predictive ability. Protein-based biomarkers have been associated with predicting recurrence. Several gene-based biomarkers quantifying mutations in DNA damage repair genes may have predictive ability. However, genomic data are relatively new and lack validation. CONCLUSIONS Clinicopathological criteria remain the most widely utilized tool for predicting IVT response. Further research to validate protein- and genomic-based biomarkers are needed before adoption in clinical practice. PATIENT SUMMARY We reviewed contemporary studies that investigated how to predict response to medication instilled in the bladder (intravesical therapy) for bladder cancer. We found that most predictive tools use clinical data, such as tumor stage and grade, to determine the outcome. Newer biological (gene, protein, cytokines) marker tests are being studied. We concluded that the combination of clinical data with levels of certain experimental markers (fluorescence in situ hybridization test or urinary cytokines) may improve predictive ability. Genetic testing methods may also yield additional predictive markers in the future, but this needs more validation.
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Kayama E, Kikuchi E, Fukumoto K, Shirotake S, Miyazaki Y, Hakozaki K, Kaneko G, Yoshimine S, Tanaka N, Takahiro M, Kanai K, Oyama M, Nakajima Y, Hara S, Monma T, Oya M. History of Non-Muscle-Invasive Bladder Cancer May Have a Worse Prognostic Impact in cT2-4aN0M0 Bladder Cancer Patients Treated With Radical Cystectomy. Clin Genitourin Cancer 2018; 16:e969-e976. [PMID: 29778322 DOI: 10.1016/j.clgc.2018.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/21/2018] [Accepted: 04/20/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To investigate whether a history of non-muscle-invasive bladder cancer (NMIBC) plays a prognostic role in patients with muscle-invasive bladder cancer (MIBC) treated with radical cystectomy in the era when neoadjuvant chemotherapy was established as standard therapy for MIBC. PATIENTS AND METHODS A total of 282 patients who were diagnosed with cT2-T4aN0M0 bladder cancer treated with open radical cystectomy at our institutions were included. Initially diagnosed MIBC without a history of NMIBC was defined as primary MIBC group (n = 231), and MIBC that progressed from NMIBC was defined as progressive MIBC (n = 51). RESULTS The rate of cT3/4a tumors was significantly higher in the primary MIBC group than in the progressive MIBC group (P = .004). Five-year recurrence-free survival and cancer-specific survival (CSS) rates for the primary MIBC group versus progressive MIBC group were 68.2% versus 55.9% (P = .039) and 76.1% versus 61.6% (P = .005), respectively. Progressive MIBC (hazard ratio, 2.170; P = .008) was independently associated with cancer death. In the primary MIBC group, the 5-year CSS rate in patients treated with neoadjuvant chemotherapy was 85.4%, which was significantly higher than that in patients without (71.5%, P = .023). In the progressive MIBC group, no significant differences were observed in CSS between patients treated with and without neoadjuvant chemotherapy. CONCLUSION MIBC that progressed from NMIBC had a significantly worse clinical outcome than MIBC without a history of NMIBC and may not respond as well to neoadjuvant chemotherapy. These results are informative, even for NMIBC patients treated with conservative intravesical therapy.
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Affiliation(s)
- Emina Kayama
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Eiji Kikuchi
- Department of Urology, Keio University School of Medicine, Tokyo, Japan.
| | - Keishiro Fukumoto
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Suguru Shirotake
- Department of Urology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yasumasa Miyazaki
- Department of Urology, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Kyohei Hakozaki
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Gou Kaneko
- Department of Urology, Kawasaki Municipal Hospital, Kanagawa, Japan
| | | | - Nobuyuki Tanaka
- Department of Urology, Saitama City Hospital, Saitama, Japan
| | - Maeda Takahiro
- Department of Urology, Saiseikai Central Hospital, Tokyo, Japan
| | - Kunimitsu Kanai
- Department of Urology, National Hospital Organization, Saitama National Hospital, Saitama, Japan
| | - Masafumi Oyama
- Department of Urology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yosuke Nakajima
- Department of Urology, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Satoshi Hara
- Department of Urology, Kawasaki Municipal Hospital, Kanagawa, Japan
| | - Tetsuo Monma
- Department of Urology, National Hospital Organization, Saitama National Hospital, Saitama, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
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Packiam VT, Lamm DL, Barocas DA, Trainer A, Fand B, Davis RL, Clark W, Kroeger M, Dumbadze I, Chamie K, Kader AK, Curran D, Gutheil J, Kuan A, Yeung AW, Steinberg GD. An open label, single-arm, phase II multicenter study of the safety and efficacy of CG0070 oncolytic vector regimen in patients with BCG-unresponsive non-muscle-invasive bladder cancer: Interim results. Urol Oncol 2017; 36:440-447. [PMID: 28755959 DOI: 10.1016/j.urolonc.2017.07.005] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/14/2017] [Accepted: 07/01/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES CG0070 is a replication-competent oncolytic adenovirus that targets bladder tumor cells through their defective retinoblastoma pathway. Prior reports of intravesical CG0070 have shown promising activity in patients with high-grade non-muscle invasive bladder cancer (NMIBC) who previously did not respond to bacillus Calmette-Guérin (BCG). However, limited accrual has hindered analysis of efficacy, particularly for pathologic subsets. We evaluated interim results of a phase II trial for intravesical CG0070 in patients with BCG-unresponsive NMIBC who refused cystectomy. PATIENTS AND METHODS At interim analysis (April 2017), 45 patients with residual high-grade Ta, T1, or carcinoma-in-situ (CIS) ± Ta/T1 had evaluable 6-month follow-up in this phase II single-arm multicenter trial (NCT02365818). All patients received at least 2 prior courses of intravesical therapy for CIS, with at least 1 being a course of BCG. Patients had either failed BCG induction therapy within 6 months or had been successfully treated with BCG with subsequent recurrence. Complete response (CR) at 6 months was defined as absence of disease on cytology, cystoscopy, and random biopsies. RESULTS Of 45 patients, there were 24 pure CIS, 8 CIS + Ta, 4 CIS + T1, 6 Ta, 3 T1. Overall 6-month CR (95% CI) was 47% (32%-62%). Considering 6-month CR for pathologic subsets, pure CIS was 58% (37%-78%), CIS ± Ta/T1 50% (33%-67%), and pure Ta/T1 33% (8%-70%). At 6 months, the single patient that progressed to muscle-invasive disease had Ta and T1 tumors at baseline. No patients with pure T1 had 6-month CR. Treatment-related adverse events (AEs) at 6 months were most commonly urinary bladder spasms (36%), hematuria (28%), dysuria (25%), and urgency (22%). Immunologic treatment-related AEs included flu-like symptoms (12%) and fatigue (6%). Grade III treatment-related AEs included dysuria (3%) and hypotension (1.5%). There were no Grade IV/V treatment-related AEs. CONCLUSIONS This phase II study demonstrates that intravesical CG0070 yielded an overall 47% CR rate at 6 months for all patients and 50% for patients with CIS, with an acceptable level of toxicity for patients with high-risk BCG-unresponsive NMIBC. There is a particularly strong response and limited progression in patients with pure CIS.
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Affiliation(s)
- Vignesh T Packiam
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL.
| | | | - Daniel A Barocas
- Department of Urologic Oncology, Vanderbilt University, Nashville, TN
| | - Andrew Trainer
- Adult Pediatric Urology & Urogynecology, P.C., Omaha, NE
| | | | - Ronald L Davis
- Department of Urology, Wake Forest University, Winston-Salem, NC
| | | | | | | | - Karim Chamie
- Department of Urology, University of California Los Angeles, Los Angeles, CA
| | - A Karim Kader
- Department of Urology, University of California San Diego, San Diego, CA
| | | | | | | | | | - Gary D Steinberg
- Section of Urology, Department of Surgery, University of Chicago, Chicago, IL
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Singla N, Haddad AQ, Passoni NM, Meissner M, Lotan Y. Anti-inflammatory use may not negatively impact oncologic outcomes following intravesical BCG for high-grade non-muscle-invasive bladder cancer. World J Urol 2017; 35:105-11. [PMID: 27194044 DOI: 10.1007/s00345-016-1853-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 05/10/2016] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To evaluate whether anti-inflammatory agents affect outcomes in patients receiving intravesical BCG therapy for high-grade (HG) non-muscle-invasive bladder cancer (NMIBC). METHODS We reviewed the records of 203 patients in a prospective database of HG NMIBC from 2006 to 2012 at a single institution. Patients who had muscle-invasive disease (n = 32), low-grade pathology (n = 4), underwent early cystectomy within 3 months (n = 25), had <3 months of follow-up (n = 11), or did not receive an induction course of intravesical BCG (n = 32) were excluded. Clinicopathologic data were tabulated including demographics, comorbidities, pathologic stage and grades, intravesical therapy, and concomitant use of aspirin, NSAIDs, COX inhibitors, and statins. Multivariate Cox regression analysis explored predictive factors for recurrence, progression (stage progression or progression to cystectomy), cancer-specific survival (CSS), and overall survival (OS). RESULTS Ninety-nine patients with HG NMIBC who received at least one induction course of intravesical BCG were identified, with median follow-up of 31.4 months. There were 20 (20.2 %) deaths, including 6 (6.1 %) patients with bladder cancer-related mortality. 13 % patients experienced tumor progression and 27 % underwent cystectomy following failure of intravesical therapy. Anti-inflammatory use included statins (65 %), aspirin (63 %), or non-aspirin NSAIDs/COX inhibitors (26 %). Anti-inflammatory use was not significantly predictive of recurrence, progression, or mortality outcomes on Cox regression. CIS stage was associated with higher progression, while age, BMI, and Charlson score were independent predictors of overall mortality. CONCLUSION Despite speculation of inhibitory effects on BCG immunomodulation there was no evidence that anti-inflammatory agents impacted oncologic outcomes in patients receiving BCG for HG NMIBC.
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Fernández-Gómez J, Carballido-Rodríguez J, Cozar-Olmo J, Palou-Redorta J, Solsona-Narbón E, Unda-Urzaiz J. Treatment of non muscle invasive bladder tumor related to the problem of bacillus Calmette-Guerin availability. Consensus of a Spanish expert's panel. Spanish Association of Urology. Actas Urol Esp 2013; 37:387-94. [PMID: 23773824 DOI: 10.1016/j.acuro.2013.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 04/11/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT Since June 2012, the has been a worldwide lack of available of the Connaught strain. In December 2012, a group of experts met in the Spanish Association of Urology to analyze this situation and propose alternatives. OBJECTIVE To present the work performed by said committee and the resulting recommendations. ACQUISITION OF EVIDENCE An update has been made of the principal existing evidence in the treatment of middle and high risk tumors. Special mention has been made regarding the those related with the use of BCG and their possible alternative due to the different availability of BCG. EVIDENCE SYNTHESIS In tumors with high risk of progression, immediate cystectomy should be considered when BCG is not available, with dose reduction or alternating with chemotherapy as methods to economize on the use of BCG when availability is reduced. In tumors having middle risk of progression, chemotherapy can be used, although when it is associated to a high risk of relapse, BCG would be indicated if available with the mentioned savings guidelines. BCG requires maintenance to maintain its effectiveness, it being necessary to optimize the application of endovesical chemotherapy and to use systems that increase its penetration into the bladder wall (EMDA) if they are available. CONCLUSIONS Due to the scarcity of BCG, it has been necessary to agree on a series of recommendations that have been published on the web page of the Spanish Association of Urology.
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Lamm D, Brausi M, O'Donnell MA, Witjes JA. Interferon alfa in the treatment paradigm for non-muscle-invasive bladder cancer. Urol Oncol 2013; 32:35.e21-30. [PMID: 23628309 DOI: 10.1016/j.urolonc.2013.02.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/05/2013] [Accepted: 02/06/2013] [Indexed: 01/01/2023]
Abstract
OBJECTIVES In this article, we review the various options for and the potential role of interferon alfa (IFN-α) in the treatment of non-muscle-invasive bladder cancer (NMIBC). METHODS PubMed was searched for journal articles on IFN-α use in treating bladder cancer. The references listed in the National Comprehensive Cancer Network guidelines were used as a guide to identify relevant publications on treatments for NMIBC. RESULTS Transurethral resection with adjuvant intravesical chemotherapy or immunotherapy is the standard treatment option for NMIBC. Adjuvant IFN-α therapy has limited efficacy in preventing recurrences in intermediate-risk and high-risk patients; bacillus Calmette-Guérin (BCG) monotherapy is the recommended first-line treatment in these patients. Unfortunately, cancer progression or recurrence is a common outcome; radical cystectomy, which is often the lifesaving approach in such a scenario, is associated with significant morbidity, mortality, and decreased quality of life. Current alternatives to cystectomy include repeat intravesical immunotherapy, conventional instillation chemotherapy, and device-assisted intravesical chemotherapy. The efficacy of any chemotherapy after BCG failure, either conventional or device assisted, has not been established. BCG and IFN-α combination intravesical therapy has not been investigated thoroughly; based on available data, combination therapy appears to be most effective in patients with carcinoma in situ and may be preferentially considered as an alternative to radical cystectomy for patients with intermediate-risk or high-risk NMIBC who do not tolerate the standard BCG dose or experience BCG failure after 1 year of therapy. However, this approach requires close follow-up and should only be chosen after careful consideration of all risk factors. CONCLUSIONS There is a lack of efficacious treatment options for patients with NMIBC recurrence or progression after initial BCG treatment. There is a need for well-designed clinical trials investigating the safety and efficacy of available therapies, including BCG and IFN-α2b combination therapy.
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Affiliation(s)
| | | | | | - J Alfred Witjes
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Rao MV, Ellimoottil C, Sondej T, Flanigan RC, Quek ML. Intravesical bacillus Calmette-Guerin immunotherapy after previous prostate radiotherapy for high-grade non-muscle-invasive bladder cancer. Urol Oncol 2013; 31:857-61. [PMID: 21868262 DOI: 10.1016/j.urolonc.2011.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 06/14/2011] [Accepted: 07/07/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Intravesical bacillus Calmette-Guerin (BCG) immunotherapy is a standard treatment for high-grade non-muscle-invasive bladder cancer (NMIBC). We evaluated outcomes of BCG therapy for NMIBC in patients with a previous history of prostate cancer (CaP) radiotherapy (RT). MATERIALS AND METHODS A retrospective review of patients with a history of CaP RT who subsequently underwent treatment with intravesical BCG for high-grade NMIBC was performed. Patients were categorized as "BCG success" or "BCG failure" (defined as stage progression or recurrent/persistent disease). We evaluated factors related to the radiotherapy (type, interval to BCG), bladder cancer (clinical stage, immunotherapy type, and course), and patient comorbidities, to identify factors associated with BCG failure. RESULTS From 1996 to 2008, 26 patients with high-grade NMIBC received intravesical BCG immunotherapy after CaP RT. At a mean follow-up of nearly 5 years, 13 patients (50%) were successfully managed with one or more induction courses of BCG with or without the addition of interferon alpha. Twelve (46%) eventually required cystectomy for disease recurrence or progression, of which half had pathologically advanced disease (≥pT3). Clinical stage was similar between BCG success and failure patients (P = 0.40). Those who failed immunotherapy were more likely to have had a longer interval between RT and BCG induction (5.8 vs. 2.4 years, P = 0.02). CONCLUSION Approximately 50% of patients with NMIBC who were previously exposed to prostate radiation had a durable response to intravesical BCG. For non-responders, extravesical progression was common.
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Kaufman J, Tyagi V, Anthony M, Chancellor MB, Tyagi P. State of the art in intravesical therapy for lower urinary tract symptoms. Rev Urol 2010; 12:e181-e189. [PMID: 21234261 PMCID: PMC3020280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Intravesical therapy is the routine first-line treatment for effectively delaying or preventing the recurrence of bladder cancer. This route of drug administration has also shown tremendous promise in the treatment of interstitial cystitis/painful bladder syndrome (IC/PBS) and potentially overactive bladder to justify investments for further improvements. This review takes a bird's eye view into the current status of intravesical therapy, with emphasis on liposomal nanoparticles, in diseases associated with lower urinary tract symptoms (LUTS). Ongoing efforts to advance the field of intravesical drug delivery include development of sustained-release drug implants and efforts to improve delivery of biotechnological products including large protein acting as neurotoxins and small interfering RNAs.
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Stein JP. Best of the 2007 AUA Annual Meeting (2): Bladder Cancer Highlights from the 2007 Annual Meeting of the American Urological Association, May 19-24, 2007, Anaheim, CA. Rev Urol 2007; 9:220-34. [PMID: 18231619 PMCID: PMC2199499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- John P Stein
- Keck School of Medicine, University of Southern California Los Angeles, CA
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