[EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder, the 2011 update]

CONTEXT AND OBJECTIVE

To present the 2011 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer (NMIBC).

EVIDENCE ACQUISITION

Literature published between 2004 and 2010 on the diagnosis and treatment of NMIBC was systematically reviewed. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned.

EVIDENCE SYNTHESIS

Tumours staged as Ta, T1, or carcinoma in situ (CIS) are grouped as NMIBC. Diagnosis depends on cystoscopy and histologic evaluation of the tissue obtained by transurethral resection (TUR) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TUR is essential for the patient's prognosis. Where the initial resection is incomplete or where a high-grade or T1 tumour is detected, a second TUR should be performed within 2-6 wk. In papillary tumours, the risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients into low-, intermediate-, and high-risk groups (separately for recurrence and progression) is pivotal to recommending adjuvant treatment. For patients with a low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is recommended. Patients with an intermediate or high risk of recurrence and an intermediate risk of progression should receive one immediate instillation of chemotherapy followed by a minimum of 1 yr of bacillus Calmette-Guérin (BCG) intravesical immunotherapy or further instillations of chemotherapy. Papillary tumours with a high risk of progression and CIS should receive intravesical BCG for 1 yr. Cystectomy may be offered to the highest risk patients, and it is at least recommended in BCG failure patients.

CONCLUSIONS

These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice.

Wirkmechanismen der intravesikalen BCG-Immuntherapie des oberflächlichen Harnblasenkarzinoms

Immunotherapy for treatment of solid cancer mostly is an experimental treatment. In contrast, intravesical immunotherapy of superficial bladder cancer with bacille Calmette-Guérin (BCG) is clinically well established and accepted worldwide because of better results compared to topical chemotherapy. BCG is currently regarded as the most successful immunotherapy of cancer. Unfortunately the mechanism of action has not yet been fully clarified. This article gives an overview on the complex research on the mechanisms of actionhighly successful therapy.

Studienteilnahme in der urologischen Facharztpraxis

In the past, participation of practicing urologists in clinical trials has been very rare. The reasons for this have been influenced in different ways over the last 10 years, so that the situation has now changed. In this paper, the current motivation for the participation of practicing urologists in research studies is discussed. Moreover, we discuss the ways in which the Association of Urological Oncology (AUO) of the German Cancer Association promotes the participation of colleagues in AUO studies and how the AUO meets the needs of urologists in practice.

Studienlandschaft Blasenkarzinom

The urothelial cancer section of the Association of Urogenital Oncology (AUO) of the German Cancer Society has successfully performed and published clinical trials on treatment of urothelial neoplasia. During the last decade, around 770 patients have been recruited for several phase I, II and III trials. The majority of trials had been conceived for advanced inoperable stages, but the AUO has also been particularly successful in recruiting large trials on adjuvant chemotherapy after radical cystectomy for locally advanced bladder cancer. Future goals address extending the number of active centers in Germany as well as seeking international collaborations in order to enable timely recruitment of trials that demand an extensive sample size.

Ki-67-directed antisense therapy in an orthotopic renal cell carcinoma model

PURPOSE

The Ki-67 antigen is only present in proliferating cells. We have shown previously that phosphorothioate-modified antisense oligonucleotides (ON) against this antigen are potent antitumoral agents in bladder and prostate cancer-derived cells. Since ON are known to accumulate in vivo in the kidney, high local effectivity may be expected. Here, we evaluated and characterized antitumoral effects in an orthotopic renal cell cancer (RENCA) model.

MATERIAL AND METHODS

RENCA cells were incubated with antisense and control ON in the presence of a cationic lipid. Uptake studies were performed with FITC-labeled ON. Ki-67 protein analysis after ON treatment was performed by immunohistochemical staining. For animal studies, 1 x 10(5) RENCA cells were implanted under the renal capsule of Balb/c mice. Antisense and control ON were injected intraperitoneally daily for 14 days. Tumor weights and status of metastasis were documented after sacrifice. Furthermore, vessel density in tumor tissues was determined by CD31 immunolabeling.

RESULTS

Antisense treatment of RENCA cells resulted in specific reduction of the Ki-67 protein and inhibition of cell growth. A substantial cellular uptake of labeled ON was noted in vitro and in vivo. The growth of orthotopically implantated syngeneic kidney tumors in immunocompetent mice was significantly inhibited in antisense-treated animals (p < 0.05). Furthermore, lung metastases were noted in 10% of antisense-treated animals compared to 30-40% in control groups. Immunohistochemical staining of the vessel density showed no significant difference among treatment groups.

CONCLUSIONS

The results demonstrate that Ki-67-directed antisense oligonucleotides are potent inhibitors of target protein expression and proliferation of tumor cells in vitro, and of tumor growth and lung metastasis formation in murine renal cell carcinoma whereas tumor vascularization is not significantly affected.

[Experimental investigations of the optimal therapy of systemic BCG infection in vivo]

PURPOSE

Hematogenous spread of BCG after intravesical instillation against bladder cancer is rare, but may result in systemic infection and hypersensitivity reaction. We investigated fluoroquinolones and steroids in an animal model to improve the therapeutic options in local and systemic BCG infection. Furthermore, we tested the antitumor effectiveness of intravesical BCG with simultaneous application of fluoroquinolones and/or steroids.

METHODS

After systemic BCG infection, experiments were performed with quinolones as antimicrobial agent. Trimethoprim/sulfamethoxazole (TMS) was also tested in comparison to quinolones as a non-specific antimicrobial agent. To evaluate the hyperergic reaction after repeated BCG infection (hypersensitivity model), re-infection was performed seven days after primary infection with accompanying oral antimicrobial therapy with and without steroids. Intravesical tumor therapy was carried out with BCG in orthotopic murine bladder tumor model MB 49 together with simultaneous antimicrobial therapy.

RESULTS

After primary infection, quinolones led to a significant prolonged survival independent of steroid administration. Steroids alone after primary BCG infection reduced the survival. In contrast to these experiments, only steroid-treated mice had a significant improvement in survival after a second challenge with BCG. Therapeutic efficacy of BCG was not affected by antibacterial therapy with quinolones. Steroids alone induced a significantly increased death rate during intravesical BCG therapy.

CONCLUSION

Quinolones have a positive effect on survival in acute systemic BCG infection in mice. Re-infection with BCG led to severe hyperergic reaction that can only be influenced by steroids. Thus, quinolones can be used in primary systemic BCG infection after topical application as a sufficient alternative to common tuberculostatics. Repeated BCG instillation may lead to hyperergic reaction, making additional administration of steroids essential. In this animal model, therapeutic efficacy of BCG obviously was not affected by additional administration of antimicrobials.

Prognostic significance of a grading system considering tumor heterogeneity in muscle-invasive urothelial carcinoma of the urinary bladder

The fact that urothelial carcinomas (UC) often contain areas with different histologic grades has been recently shown to bear some prognostic relevance. Here we examined the prognostic significance of a grading system considering tumor heterogeneity in muscle-invasive bladder carcinomas. 151 UC treated by radical cystectomy were included. According to the World Health Organization/International Society of Urological Pathology (WHO/ISUP) classification, histologic grade was low-grade (LG) in 8 and high-grade (HG) in 143 cases. 65 HG tumors which focally harbored LG areas were assigned to mixed-type (MT) carcinomas. Mean follow-up was 50 months. While the WHO/ISUP classification showed no significant correlation with disease-specific survival (p = 0.3995 by log-rank test), stratification into LG/MT and HG tumors had a significant prognostic relevance (p = 0.0404). Nodal status was identified as the only independent prognostic factor (p = 0.0001 by multivariate analysis). In this respect, stratification into LG/MT and HG tumors missed the level of statistical significance by a norrow margin (p = 0.07 by multivariate analysis), but it turned out better than tumor category (p = 0.08). In conclusion, a grading system considering tumor heterogeneity may improve the predictive power of the WHO/ISUP classification in muscle-invasive UC of the urinary bladder. Although the two-tired grading system proposed in this study was not identified as an independent prognostic factor, it may help to obtain additional prognostic information on patients with advanced bladder cancer treated by radical cystectomy.

EAU Guidelines on Diagnosis and Treatment of Upper Urinary Tract Transitional Cell Carcinoma

OBJECTIVES

On behalf of the European Association of Urology (EAU) guidelines for diagnosis, therapy and follow-up of upper urinary tract transitional cell carcinoma (UUTT) patients were established. Criteria for recommendations are based of level 2 only, as large randomised clinical trials have not been performed in this type of disease.

METHOD

A systematic literature research using Medline Services was conducted. References were weighted by a panel of experts.

RESULTS

TNM classification 2002 is recommended. Recommendations are developed for diagnosis, radical and conservative treatment and for local chemo-immunotherapy. Prognostic factors are defined. Recommendations for follow-up after different types of treatment are given.

Intravesical bacille calmette-guérin versus mitomycin c in superficial bladder cancer: formal meta-analysis of comparative studies on tumor progression

OBJECTIVES

To compare the therapeutic efficacy of intravesical bacille Calmette-Guérin (BCG) with mitomycin C (MMC) on progression of Stage Ta and T1 bladder carcinoma.

METHODS

Combined published and unpublished data from comparative studies on BCG versus MMC in superficial bladder carcinoma were analyzed, considering possible confounding factors. Odds ratios (ORs) and 95% confidence intervals (CIs) were used as the primary effect size estimate. Tumor progression was defined as progression to a higher tumor stage or the development of metastatic disease.

RESULTS

In nine eligible clinical trials, 1277 patients were treated with BCG and 1133 with MMC. Within the overall median follow-up of 26 months, 7.67% of the patients in the BCG group and 9.44% of the patients in the MMC group developed tumor progression. In all nine individual studies and in the combined results, no statistically significant difference in the ORs for progression between the BCG and MMC-treated groups was found (combined OR = 0.77; 95% CI 0.57 to 1.03; P = 0.081). In the subgroup with BCG maintenance, the combined result of the five individual studies showed a statistically significant superiority of BCG over MMC (OR = 0.66; 95% CI 0.47 to 0.94; P = 0.02). In the four studies without BCG maintenance, the combined result indicated no statistically significant difference between the two treatments (OR = 1.16; 95% CI 0.65 to 2.07; P = 0.612). Potential confounders, such as tumor risk status, duration of follow-up, BCG strain, BCG and MMC treatment regimen, and year of publication did not significantly influence these results.

CONCLUSIONS

The results demonstrated statistically significant superiority for BCG compared with MMC for the prevention of tumor progression only if BCG maintenance therapy was provided.

Elevation of CA 19-9 in giant hydronephrosis induced by a renal calculus

CA 19-9 is a tumor marker of pancreatic and gastrointestinal cancer. Elevation in nonmalignant disease is rare. The case of a patient with a partial staghorn calculus, giant hydronephrosis, and elevated CA 19-9 serum levels is presented. Open transperitoneal right-sided nephrectomy was performed. In immunohistochemical analysis, CA 19-9 was expressed in the renal tubular epithelium and the renal pelvis. During postoperative follow-up, the CA 19-9 levels returned to normal. Hydronephrosis might cause false-positive results when CA 19-9 measurement is used to screen for malignant disease. Posttreatment CA 19-9 levels of patients with hydronephrosis have to be monitored closely to safely exclude malignant disease.

[Basics of antisense oligonucleotide therapy and current therapeutical strategies in urology]

Antisense oligonucleotides are short DNA sequences designed to modulate the information transfer from gene to protein. Sequence-related hybridisation with the mRNA of a specific protein results in selective inhibition of gene expression and downregulation of protein expression. This allows the study of gene function and therapy on a molecular level. Antisense oligonucleotide inhibitors can be designed directly from genomic sequence information by simply making the reversed complement of the desired sequence. In this review, we focus on the mechanisms of action of antisense oligonucleotides and summarize the progress in urological antisense therapy. The ability to inhibit individual gene expression with antisense oligonucleotides has been promising in preclinical cancer models. Current clinical studies test antisense compounds targeted against various cancer related genes. Although some of these studies comprise patients with urological tumors, such as advanced prostate cancer, experimental antisense therapy in urology is still in its infancy.

[Non-invasive urinary diagnosis of bladder cancer. What do we know?]

Although the current system of classifying bladder cancer by stage and histological grade is very useful, it is still difficult to predict the natural progression of the disease either with or without therapy. Cystoscopy and urine cytology are currently the gold standards in the monitoring and diagnosis of bladder cancer. Classical urine cytology is, however, at least in the diagnosis of G1-tumors, characterized by a relatively low sensitivity. In the last few years, the molecular biological investigation of the basic mechanisms involved in carcinogenesis has provided a host of markers which are of potential diagnostic value for bladder cancer. We provide a current, comprehensive review of the literature on bladder tumor markers and summarize their diagnostic and prognostic potential. At present, no diagnostic marker with a comparable sensitivity and specificity to cystoscopy exists, given that cystoscopy has never been evaluated. The combined analysis of several tumor markers seems to be the most promising approach as an adjunct to cystoscopy. Moreover, the increasing simplification of test systems will increase their acceptance by clinicians.

Intravesical bacillus Calmette-Guerin versus mitomycin C for superficial bladder cancer: a formal meta-analysis of comparative studies on recurrence and toxicity

PURPOSE

We compare the therapeutic efficacy and toxicity of intravesical bacillus Calmette-Guerin (BCG) with mitomycin C on recurrence of stages Ta and T1 bladder carcinoma.

MATERIALS AND METHODS

Combined published and unpublished data from comparative studies on BCG versus mitomycin C for superficial bladder carcinoma considering possible confounding factors were analyzed. Odds ratio (OR) and its 95% CI were used as primary effect size estimate. Toxicity data were evaluated descriptively.

RESULTS

In 11 eligible clinical trials 1,421 patients were treated with BCG and 1,328 were treated with mitomycin C. Within the overall median followup time of 26 months 38.6% of the patients in the BCG group and 46.4% of those in the mitomycin C group had tumor recurrence. In 7 of 11 studies BCG was significantly superior to mitomycin C, in 3 studies no significant difference was found, while in 1 study mitomycin C was significantly superior to BCG. An overall statistically significant superiority of BCG versus mitomycin C efficacy in reducing tumor recurrence was detected (OR 0.56, 95% CI 0.38 to 0.84, p = 0.005). In the subgroup treated with BCG maintenance all 6 individual studies showed a significant superiority of BCG over mitomycin C (OR 0.43, 95% CI 0.35 to 0.53, p <0.001). In 4 of the 5 studies with reported data on toxicity BCG associated cystitis was significantly more frequent than in the mitomycin C group (53.8% versus 39.2%). The combined cystitis OR was 1.81 (95% CI 1.48 to 2.23, p <0.001). The OR for cystitis in the BCG maintenance group did not significantly differ from that in the nonmaintenance therapy group.

CONCLUSIONS

The results suggest superiority of BCG over mitomycin C for prevention of tumor recurrences in the combined data and particularly in the BCG maintenance treatment subgroup, irrespective of the actual (intermediate or high) tumor risk status. The toxicity with BCG is higher but does not differ between BCG maintenance and nonmaintenance groups.

Intravesical bacillus Calmette-Guerin versus mitomycin C for superficial bladder cancer: a formal meta-analysis of comparative studies on recurrence and toxicity

PURPOSE

We compare the therapeutic efficacy and toxicity of intravesical bacillus Calmette-Guerin (BCG) with mitomycin C on recurrence of stages Ta and T1 bladder carcinoma.

MATERIALS AND METHODS

Combined published and unpublished data from comparative studies on BCG versus mitomycin C for superficial bladder carcinoma considering possible confounding factors were analyzed. Odds ratio (OR) and its 95% CI were used as primary effect size estimate. Toxicity data were evaluated descriptively.

RESULTS

In 11 eligible clinical trials 1,421 patients were treated with BCG and 1,328 were treated with mitomycin C. Within the overall median followup time of 26 months 38.6% of the patients in the BCG group and 46.4% of those in the mitomycin C group had tumor recurrence. In 7 of 11 studies BCG was significantly superior to mitomycin C, in 3 studies no significant difference was found, while in 1 study mitomycin C was significantly superior to BCG. An overall statistically significant superiority of BCG versus mitomycin C efficacy in reducing tumor recurrence was detected (OR 0.56, 95% CI 0.38 to 0.84, p = 0.005). In the subgroup treated with BCG maintenance all 6 individual studies showed a significant superiority of BCG over mitomycin C (OR 0.43, 95% CI 0.35 to 0.53, p <0.001). In 4 of the 5 studies with reported data on toxicity BCG associated cystitis was significantly more frequent than in the mitomycin C group (53.8% versus 39.2%). The combined cystitis OR was 1.81 (95% CI 1.48 to 2.23, p <0.001). The OR for cystitis in the BCG maintenance group did not significantly differ from that in the nonmaintenance therapy group.

CONCLUSIONS

The results suggest superiority of BCG over mitomycin C for prevention of tumor recurrences in the combined data and particularly in the BCG maintenance treatment subgroup, irrespective of the actual (intermediate or high) tumor risk status. The toxicity with BCG is higher but does not differ between BCG maintenance and nonmaintenance groups.

Antisense oligonucleotide therapy in urology

PURPOSE

Antisense oligonucleotides are short modified DNA or RNA molecules designed to bind selectively messenger RNA and inhibit synthesis of the encoded protein. In the last 20 years antisense technology has emerged as an exciting and promising strategy, especially for treating cancer. We provide urologists with a contemporary review of relevant background information and outline current treatment strategies and clinical trials of antisense oligonucleotide therapy for urological tumors.

MATERIALS AND METHODS

We comprehensively reviewed the literature, including PubMed and recent abstract proceedings from international meetings, on preclinical and clinical studies of antisense oligonucleotide therapy in urology.

RESULTS

Current preclinical antisense strategies in urological cancer research include the inhibition of proliferation and induction of tumor cell differentiation, reversal of immunosuppression by tumor secreted molecules and induction of apoptosis. The use of phosphorothioate oligonucleotides as antisense agents has shown promising results in various preclinical cancer models. In recent and current clinical trials in patients with urological tumors antisense agents targeted against c-raf kinase, protein kinase C-alpha, protein kinase A and bcl-2 are being evaluated.

CONCLUSIONS

Many compounds have achieved convincing in vitro reduction of target messengerRNA and protein expression. Early clinical trials show safety and mild toxicity at the given doses. Overall the current state of antisense oligonucleotide research described promises a highly productive future for this technology. However, for most medical applications of antisense compounds many obstacles related to nuclease stability, affinity, cellular delivery and specificity remain to be clarified.

Inhibition of bladder carcinoma cell adhesion by oligopeptide combinations in vitro and in vivo

PURPOSE

A presumed reason for the high recurrence rate of superficial bladder cancer after transurethral tumor resection is the reimplantation of tumor cells. Because tumor cell adhesion to the extracellular matrix is mediated by integrin molecules, we tested specific integrin receptor blocking oligopeptides to prevent this mechanism.

MATERIALS AND METHODS

An in vitro cell adherence assay with various bladder cancer cell lines and extracellular matrices, including fibronectin, collagen type I, laminin and combinations, was used to analyze the inhibition of tumor cell adhesion by the matrix specific oligopeptides GRGDS, DGEA and EILDV. In therapeutic in vivo experiments the orthotopic murine bladder tumor model MB49 was used. The ability of oligopeptides to interfere with tumor cell adhesion and consecutive tumor outgrowth was evaluated and compared with that of nonspecific peptides, commercially available irrigation fluid and single dose epirubicin chemotherapy.

RESULTS

In vitro fibronectin specific oligopeptides showed a concentration dependent inhibition of tumor cell adherence to fibronectin, whereas adhesion to laminin, collagen and combined matrices was not inhibited. In contrast, combinations of integrin receptor blocking oligopeptides were highly active. In vivo local tumor take was not affected by irrigation fluid, nonspecific peptides or monospecific oligopeptides alone, whereas the combination of the 3 oligopeptides effectively inhibited tumor outgrowth.

CONCLUSIONS

Combining oligopeptides with various specificities significantly inhibited tumor cell adhesion and tumor outgrowth. Application of this principle in a clinical setting may be an effective method for reducing the recurrence rate of superficial bladder cancer.

IFN-gamma and IL-12 but not IL-10 are required for local tumour surveillance in a syngeneic model of orthotopic bladder cancer

In recent studies, a crucial role for IFN-gamma in immunosurveillance of tumours and in IL-12 immunotherapy has been suggested. Nevertheless, little is known about the relevance of IFN-gamma and IL-12 for tumour surveillance in noncytokine immunotherapy. Adjuvant immunotherapy with viable BCG (Bacillus Calmette--Guérin) is considered to be the most powerful clinical treatment regimen of bladder cancer and is known to induce a variety of proinflammatory cytokines. Consequently, we analysed the antitumour response of IFN-gamma knockout (KO), IL-12 KO and IL-10 KO mice in the absence and presence of BCG immunotherapy in a syngeneic orthotopic model of bladder cancer. IFN-gamma KO and IL-12 KO mice died much earlier and by far smaller tumour inocula compared to wildtype mice, while this intrinsic antitumour response was not altered in IL-10 KO mice. BCG immunotherapy was effective in wildtype mice, but totally ineffective in IFN-gamma KO and IL-12 KO mice. BCG induced a massive local immune response in the bladder of treated animals. This response was markedly increased in IL-10 KO mice, which coincides with increased therapeutic efficacy in this mouse strain compared with wildtype mice. Our data establish a crucial role for a Th1 type immune response in the intrinsic and immunotherapeutic control of local orthotopic bladder cancer.

Molecular aspects of bladder cancer III. Prognostic markers of bladder cancer

The current pathological and clinical parameters provide important prognostic information, yet still have limited ability to predict the true malignant potential of most bladder tumors. In the last years, investigation of the basic mechanisms involved in carcinogenesis and tumor progression by molecular biology has provided a host of markers which are of potential diagnostic or prognostic value for bladder carcinoma. These markers may serve as tools for early and accurate prediction of tumor recurrence, progression and development of metastases and for prediction of response to therapy. The precise prediction of tumor biological behavior would facilitate treatment selection for patients who may benefit from radical surgical treatment or adjuvant therapy. We provide a current, comprehensive review of the literature on bladder tumor markers with a special emphasis on their prognostic potential. The literature suggests that currently no single marker is able to accurately predict the clinical course of bladder tumors and thus would serve as a reliable prognosticator. A combination of prognostic markers could predict which superficial tumors need an aggressive form of therapy and which invasive tumors require adjuvant therapy. Altogether, the most promising markers are, at this point, Ki-67 and p53 expression as well as matrixmetalloproteinase complex and angiogenesis.

[Radiotherapy of urothelial carcinomas of the urinary bladder]

Radiotherapy of bladder cancer is a locally effective therapeutic approach. It is increasingly becoming part of the multimodal protocols aimed at the preservation of both organ and organ function. In this context, it is an alternative to cystectomy. The addition of chemotherapy to radiotherapy enhances the curative potential of this non-surgical approach and may be useful especially in older, multimorbid patients. If chemotherapy can not be applied, the use of radiotherapy alone is reasonable, although in advanced tumors the results are disappointing. After the transurethral resection of bladder cancer, postoperative radiotherapy should be considered in muscle-invasive cancer as well as when other negative prognostic factors occur. The prerequisites for an effective, minimally toxic, state of the art radiotherapy are a subtle treatment-planning procedure and an accurate delivery of the radiation.

[Radiochemotherapy of urothelial carcinoma]

Radical cystectomy is the current standard therapy for muscle invasive or locally advanced transitional cell carcinoma of the bladder. Organ-preserving monotherapeutic alternatives (e.g. transurethral resection, radiotherapy) do not lead to similar cure rates. In selected cases, a trimodal approach using transurethral resection and combined radio- and chemotherapy can be as efficient as cystectomy.

NK cells are essential for effective BCG immunotherapy

Adjuvant intravesical bacillus Calmette-Guérin (BCG) therapy is a well-established and successful adjuvant immunotherapy in the treatment of superficial bladder cancer. Although the function of natural killer (NK) cells in other immunotherapeutic regimens (e.g., lymphokine-activated killer [LAK] cell or interleukin-2 [IL-2] therapy) has been established, the contribution of NK cells to effective BCG immunotherapy is not clear. We used a human in vitro system to analyze the role of NK cells in BCG-induced cellular cytotoxicity. After stimulation of mononuclear cells with BCG for 7 days, these BCG-activated killer (BAK) cells displayed substantial cytotoxicity against bladder tumor cells. Magnetic depletion experiments and fluorescence activated cell sorting revealed that NK cells were the major effector cell population. To address NK cell function in vivo, we studied a syngeneic orthotopic murine bladder cancer model and compared BCG immunotherapy in C57BL/6 wild-type mice, NK-deficient beige mice and mice treated with anti-NK1.1 monoclonal antibody. Four weekly instillations of viable BCG significantly prolonged survival in wild-type mice compared with control mice treated with solvent alone. In contrast, BCG therapy was completely ineffective in NK-deficient beige mice and in mice treated with anti-NK1.1 monoclonal antibody. These findings suggest a key role for NK cells during BCG immunotherapy.

Bladder cancer. I. Molecular and genetic basis of carcinogenesis

The transformation of a normal into a malignant cell is a multistep mechanism, which involves various alterations on the molecular and genetic level. These molecular alterations occur spontaneously or are induced by carcinogens (e.g. naphthylamine--a component of cigarette smoke and one of the most important carcinogens leading to bladder tumor carcinogenesis). This report summarizes some of the most important molecular and genetic alterations in bladder cancer. As in most other malignancies the generation of bladder cancer is caused by the accumulation of various molecular changes. The expression of oncogenes (ras, erbB-2 and EGF receptor), tumor-suppressor genes (Rb, p53), cell-cycle genes (p15, p16) and DNA-repair genes is altered mostly by mutation or chromosomal aberration. Loss of heterozygosity of chromosome 9p and 9q has been shown to be a crucial event in the transition of normal urothelium to papillary transitional cell carcinoma while p53 is primarily involved in the development of carcinoma in situ.

The fate of bacillus Calmette-Guerin after intravesical instillation

PURPOSE

Long-term activation of immunocompetent cells of the bladder wall as well as case reports of systemic infections some months or years after intravesical bacillus Calmette-Guerin (BCG) therapy imply that mycobacteria may persist in the body. Therefore. we investigated the fate of BCG in patients after uncomplicated intravesical instillation therapy.

MATERIAL AND METHODS

A total of 49 patients were included in the study, from whom various numbers of specimens were used for mycobacterial culture and molecular biological detection techniques. In 23 patients who received a total of 128 instillations urine, sputum, venous blood and bladder biopsies were screened for BCG by acid-fast staining and culture at different times before and after instillation. From 16 of the 23 patients and from an additional 26 a total of 180 bladder biopsies obtained at intervals 3 to 30 months after instillation were screened for mycobacterial 16S ribosomal DNA by a nested polymerase chain reaction protocol.

RESULTS

No viable BCG was found in venous blood or in 127 of 128 sputum specimens before and 2 hours after instillation. Two of 56 bladder biopsies were culture positive. In urine BCG was detected in 96.4% of the specimens after 2 hours and in 67.9% after 24 hours after instillation. The number of positive specimens decreased and it was 27.1% on day 7 immediately before the next instillation. In 14 of 44 bladder biopsies (31.8%) mycobacterial ribosomal DNA was found within 1 week after the sixth instillation. A positive polymerase chain reaction was evident up to 24 months in between 4.2% and 37.5% of the investigated biopsies. After 30 months no ribosomal DNA was evident in the 6 samples available for testing.

CONCLUSIONS

Nontraumatic intravesical instillation of BCG is not accompanied by systemic mycobacterial spread. Local persistence during the instillation course is evident since viable BCG is commonly found in the urine. Long lasting and persistent BCG DNA in the bladder wall may account for long-term immuno-activation. However, the remaining BCG may be a possible source of late systemic infections.

Activation of natural killer cells by Bacillus Calmette-Guérin

OBJECTIVES

Using a human in vitro model we have previously identified so-called bacillus Calmette-Guérin (BCG)-activated killer (BAK) cells as potential effector cells in BCG immunotherapy. This study was designed to prove the hypothesis that BAK cells are a subpopulation of natural killer (NK) cells and to analyze the role of NK cells during BCG immunotherapy in vivo.

METHODS

After stimulation of mononuclear cells (MNCs) with BCG for 7 days CD3+ and CD56+ lymphocytes were depleted by magnetic cell separation. Subsequently, the cytotoxicity of the marker-negative cell population was tested in a radioactive release assay. Coexpression of CD56/CD16 and CD56/perforin was assessed by flow cytometry. The importance of NK cells for effective BCG immunotherapy in vivo was analyzed by comparing BCG treatment of bladder tumors bearing 'wild-type' C57BL/6 and NK-deficient beige mice.

RESULTS

BAK cells were shown to have a CD3-/CD56+ NK cell phenotype. They expressed high amounts of perforin and low amounts of CD16, both of which are characteristic features of (activated) NK cells. BCG immunotherapy significantly prolonged survival in tumor-bearing C57BL/6 mice but was ineffective in NK-deficient beige mice. However, BCG treatment did not influence the frequency of pulmonary metastases in both mouse strains.

CONCLUSIONS

Our data clearly indicate that stimulation of human MNCs with BCG leads to the activation of cytotoxic lymphocytes with NK cell phenotype. These killer cells express perforin and CD16, two molecules involved in NK cell cytotoxicity. Finally, ineffective BCG treatment of beige mice suggests a key role for NK cells during BCG immunotherapy in vivo.

Bladder cancer. II. Molecular aspects and diagnosis

The current system used to classify bladder carcinoma by stage and histological grade is very useful, yet still has limited ability to predict the natural history, or treated natural history, of a bladder tumor. Cystoscopy and urine cytology are currently the gold standard in the diagnosis and follow-up of bladder cancer. Classical urine cytology, however, at least in the diagnosis of G1 tumors, is definitely characterized by a relative low sensitivity. The low sensitivity and subjective interpretation of cytology led to the development of several tests to detect bladder cancer in urine. We provide a current, comprehensive review of the literature on bladder tumor markers and summarize their diagnostic potential. In conclusion, under the premise that cystoscopy has never been subjected to evaluation, no diagnostic marker with a sensitivity and specificity comparable to cystoscopy currently exists. The combined analysis of several tumor markers, as in the Immunocyt test, seems to be the most promising approach. In the future, rather highly sensitive tests may be able to replace cystoscopy or prolong the intervals of cystoscopies in the follow-up of selected patients.

Burn-out of urologists in the county of Schleswig-Holstein, Germany: a comparison of hospital and private practice urologists

PURPOSE

Mental and physical burden of physicians, especially surgeons, is high. The degree of burn-out was estimated among urologists in the German federal county of Schleswig-Holstein, with special emphasis on differences related to age, qualification and hospital versus private practice.

MATERIALS AND METHODS

The Maslach Burnout Inventory was mailed to all urologists and urologists in training registered in the county of Schleswig-Holstein to determine the frequency and intensity of the 3 burn-out subscales of emotional exhaustion, depersonalization and low personal accomplishment, together with a questionnaire covering demographic data.

RESULTS

Of 128 urologists 75 (58.6%) replied. Levels of burn-out in the subscales of emotional exhaustion and depersonalization were increased among hospital urologists, urologists in training and urologists younger than 45 years. Urologists in private practices, fully trained urological specialists and urologists older than 45 years showed a low degree of burn-out, corresponding to normal values, whereas young urologists in training and working in hospitals had the highest risk of burn-out. The personal accomplishment level was generally high in all groups.

CONCLUSIONS

The constellation of being a urologist in private practice and older than 45 years appears to provide some protection against burn-out that might be due to a more personal relationship to the patients, lesser hierarchical situation and workload related income. In times of increasing pressure on the health care system, the personal situation of physicians in training should not be overlooked.

Primary treatment of condylomata acuminata with viable bacillus Calmette-Guerin

PURPOSE

Condylomata acuminata or genital warts are caused by human papillomavirus. Prevalence data show that infection rates are increasing. To our knowledge we report the first successful primary treatment of genital warts with topical bacillus Calmette-Guerin (BCG) and provide long-term followup in a group of adjuvant treated patients with recurrent condylomata acuminata.

MATERIALS AND METHODS

In 10 consecutive men viable BCG was directly applied to the condylomata acuminata lesions once weekly for 6 weeks. In nonresponding patients another course of 9 applications was administered for 3 weeks.

RESULTS

A complete response was achieved in 6 of the 10 men after 1 or 2 treatment cycles. All responding patients are disease-free at a median followup of 9.2 months (range 4 to 12). One patient achieved partial regression of the lesions and in 3 the condylomata did not disappear. Side effects were rare and mild. Long-term followup in 6 adjuvant treated patients with rapidly recurrent condylomata acuminata showed no further recurrence after topical BCG in 5 at a median of 30.8 months (range 29 to 50).

CONCLUSIONS

Topical application of viable BCG has therapeutic activity as adjuvant and primary treatment for penile condylomata acuminata with negligible side effects. Long-term followup implies the prevention of recurrent disease.

In vitro generation of bacillus Calmette-Guérin-activated killer cells

Tumor regression induced in cancer patients by local instillation of bacillus Calmette-Guérin (BCG) into the bladder is considered to be mediated by cellular immune and inflammatory reactions. In an attempt to elucidate which of these effects are relevant to tumoricidal activity, an in vitro system was employed in which the immunostimulatory effects of BCG could be studied. This report describes the induction of BCG-activated killer (BAK) cells, which effectively lyse bladder tumor cells. Human peripheral blood mononuclear cells (PBMC) were stimulated with viable and sonicated BCG (v-BCG and s-BCG, respectively) to generate BAK cells. Cytotoxicity of BAK cells was comparable with the cytotoxicity exerted by lymphokine-activated killer (LAK) cells generated by interferon (IFN)-gamma but did not reach the level of interleukin-2 (IL-2)-generated LAK cells. Induction of BAK cells was possible only with v-BCG and not with s-BCG. By depletion and enrichment of defined cell populations, the cytotoxic potential of BAK cells could be attributed to a population of CD8(+) and CD56(+) double-positive lymphocytes. Macrophages and CD4(+) cells were required for the induction of killing activity but had no such activity by themselves. Furthermore, the presence of IFN-gamma and IL-2 in the supernatants harvested during the generation of BAK cells was demonstrated. Monoclonal antibodies neutralizing these cytokines abolished BCG-mediated cytotoxicity. From these results, it is concluded that the known beneficial effect of local instillation of BCG on maintenance of the relapse-free state in superficial bladder cancer may be due to local generation of BAK cells.

Perforin-mediated lysis of tumor cells by Mycobacterium bovis Bacillus Calmette-Guérin-activated killer cells

Immunotherapy with Bacillus Calmette-Guérin (BCG) is clinically established in the treatment of superficial bladder cancer. In our attempt to clarify the underlying immunological mechanism, we could previously show that stimulation of PBMC with BCG leads to the generation of cytotoxic BCG-activated killer (BAK) cells. Among others, these BAK cells as well as lymphokine-activated killer (LAK) cells have been suggested as possible effector cells during BCG therapy. To understand BCG-induced activation of effector lymphocytes more precisely, we investigated the lytic pathways of human BAK cells and compared BAK cell cytotoxicity with LAK cell cytotoxicity. Perforin and Fas ligand (FasL) are the major cytolytic molecules of cytotoxic lymphocytes. Our results demonstrate that BAK and LAK cells showed an increased expression of perforin and FasL as compared with unstimulated controls. Killing of T-24 bladder tumor as well as Jurkat cells by BAK and LAK cells was predominantly mediated via perforin as demonstrated by a drastically reduced lysis in the presence of concanamycin A and EGTA/MgCl2, respectively. In contrast, lysis (radioactive release assay) and membrane disintegration (Annexin V binding) of both targets by BAK and LAK cells could not be blocked with an inhibitory anti-FasL monoclonal antibody (NOK-1). Nevertheless, T-24 and Jurkat were susceptible to killing by recombinant soluble FasL and by Chinese hamster ovary cells expressing membrane-bound FasL. We conclude that cellular mediators of BCG effector mechanisms, such as BAK and LAK cells, kill their targets via perforin and independent of the FasL pathway. Because we also found increased numbers of perforin-expressing lymphocytes in patients after BCG therapy, our findings have potential clinical relevance because BCG therapy would not be impaired by FasL resistance of target cells, which recently has been described for some tumors.

Reduction of side effects of intravesical therapy with bacille Calmette-Guérin by pentoxifylline?--an in vitro approach

Immunotherapy with intravesical bacille Calmette-Guérin (BCG) is the treatment of choice against superficial bladder cancer recurrences. However, this therapy is associated with side effects that are considered to be the result of inflammatory cytokines. Since pentoxifylline is known to interfere with the production of cytokines, this drug was tested in vitro with regard to a later clinical application in BCG-treated patients. The cytokine release and the cytotoxicity of interleukin-2 or BCG-stimulated mononuclear cells were analyzed, and the growth of BCG under the influence of pentoxifylline was assayed. The results showed an inhibition of cytokine release of stimulated mononuclear cells. The cytotoxicity of BCG-stimulated mononuclear cells but not of lymphokine-stimulated mononuclear cells against bladder carcinoma cells was significantly inhibited. Restimulation with fresh BCG restored cytotoxicity. Direct coincubation of BCG and pentoxifylline resulted in a reduction of mycobacterial metabolism. From these data, we conclude that the use of pentoxifylline to reduce BCG-related side effects should be tested further in a clinical study.