Current perspectives on diagnosis and treatment of superficial bladder cancer

From the battlefield to the bladder: The development of thioTEPA

Effective medications for the treatment of cancer were nonexistent in the early twentieth century. Ironically the widespread use of toxic chemical weapons, chlorine and sulfur mustard gas, during the “Great War” led to the first successful chemotherapeutic treatment of cancer patients. Soon after the introduction of poisonous gas on the battlefield, reports of the resulting pancytopenia in exposed combatants appeared in the medical literature. The biologic effect of chemical weaponry on rapidly dividing cells eventually was recognized for its salutary potential in the treatment of cancer. Once this potential was appreciated, hundreds of similar compounds were synthesized and evaluated as chemotherapeutic agents. One such compound, thioTEPA, would eventually open the era of intravesical treatment of urothelial cancer.

A Comparison Between ThinPrep Monolayer and Cytospin Cytology for the Detection of Bladder Cancer

Purpose

The sensitivity of urine cytology is higher for carcinoma in situ and poorly differentiated tumors in bladder cancer, while being fairly low for low-grade or well-differentiated tumors. Development of a sensitive diagnostic test to detect bladder carcinoma would significantly facilitate patient management and allow earlier treatment of this disease. This study compared ThinPrep urine cytology (Cytyc Co.) and conventional Cytospin urine cytology (Shandon Scientific Ltd.) in the diagnosis of bladder cancer.

Materials and Methods

From January 2002 to December 2010, ThinPrep cytology and conventional urine Cytospin cytologic examination of bladder washings were performed in 3,085 subjects suspected of having bladder cancer and in 379 patients with follow-up after transurethral resection of bladder tumor (TUR-BT). The sensitivity and specificity of the urine ThinPrep test was compared with that of conventional Cytospin cytology according to tumor number, size, pathological stage, grade, and recurrence.

Results

Of 3,085 subjects, bladder cancer was confirmed by TUR-BT in 379 subjects. The overall sensitivity of ThinPrep and Cytospin cytology was 60.9% and 59.9% in patients suspected of having bladder cancer, respectively. The overall specificity of ThinPrep and Cytospin cytology was 94.8% and 95.3% in patients suspected of having bladder cancer, respectively. The sensitivity of ThinPrep and Cytospin cytology was increased with increasing number, size, pathological stage, and grade, but there was no significant difference between the two tests.

Conclusions

These results suggest that ThinPrep cytology has no advantage in the diagnosis of bladder cancer of a low grade or low stage.

Immunostimulation in the urinary bladder by local application of Nocardia rubra cell-wall skeletons (Rubratin) and bacillus Calmette-Guérin as therapy for superficial bladder cancer: a comparative study

Twelve patients with superficial bladder cancer were treated with intravesical instillations of Rubratin (ASTA Pharma AG, Frankfurt, Germany), a cell-wall preparation of Nocardia rubra. The objective was to compare the immunostimulating effect of Rubratin with that of bacillus Calmette-Guérin (BCG). Local immunostimulation was determined by cytokine induction in serially collected urine samples during the first 24 h after each instillation, leukocyte influx into the urine, and phenotypic analysis of the lymphocyte fraction. Levels of Rubratin-induced interleukin (IL)-1 beta, IL-6, and tumor necrosis factor-alpha were significantly elevated compared with pretherapy levels. Rubratin induced leukocyte influx into the urine. T-cell activation (IL-2 receptor and human leukocyte antigen-DR expression) can be induced, and CD4:CD8 cell ratios can be increased. All parameters indicated that Rubratin-induced immunostimulation was less than that associated with BCG. In conclusion, although local Rubratin-induced immunostimulation occurs in a limited number of patients, the amount of immunocompetent cells attracted to the bladder seems to be less than that associated with BCG therapy, thus resulting in lower levels of cytokine production (which may reflect less clinical efficacy).

Prospective phase II trial of alternating intravesical Bacillus Calmette-Guérin (BCG) and interferon alpha IIB in the treatment and prevention of superficial transitional cell carcinoma of the urinary bladder: preliminary results

BACKGROUND AND OBJECTIVE

Evaluate the efficacy and toxicity of alternating intravesical instillation of Bacillus Calmette-Guerin(BCG) and Interferon alpha2-b (IFN) in the treatment and prevention of recurrence of superficial transitional cell carcinoma (TCC) of the urinary bladder.

METHODS

Patients with Ta, T1 tumors and carcinoma in situ, either recurrent (TaG1, T1G1) or primary/recurrent TaG2 TaG3, T1G2, T1G3 and Tis (T: Tumor stage, G: grade) are eligible. All patients received intravesical BCG 81 mg on Weeks 1, 3, 5 and 7 and IFN 100 million units on Weeks 2, 4, 6 and 8. Cystoscopy performed 4 weeks after completion of therapy, and every 3 months thereafter.

RESULTS

There was a total of 37 patients. Thirteen had TaG2, 13 T1G2, 1 T1G1, 4 TaG1, 1 TaG3, 3 T1G3 and 7 Tis (5 concurrent with other above tumors). Index lesion cleared in 7/10 patients. With a median follow-up of 26.2 month, 22 patients (59%) failed above therapy. Median time to treatment failure was 7 months. Seven, 6 and 9 patients recurred at a higher, lower and same stage or grade respectively. No grade 3 or 4 toxicity was encountered.

CONCLUSIONS

Alternating intravesical BCG and IFN is effective and well tolerated therapy for superficial TCC of urinary bladder.

Upper urinary tract tumors developing after treatment of superficial bladder cancer: 7-year follow-up of 591 consecutive patients

OBJECTIVES

To evaluate upper urinary tract tumor (UUTT) incidence and characteristics in 591 consecutive patients with low-, intermediate-, or high-risk superficial bladder cancer, who were followed up for at least 5 years or until death.

METHODS

From 1986 to 1992, 591 patients were treated for superficial bladder cancer: 216 patients with primary, solitary, low-grade (G1-G2), and low-stage (Ta-T1) superficial bladder cancer were considered at low risk of disease recurrence and treated with transurethral resection (TUR) alone; 182 patients with recurrent or multifocal superficial bladder cancer were considered at intermediate risk of disease recurrence or progression and treated with intravesical chemotherapy after TUR; 193 patients with carcinoma in situ, high-grade (G3) superficial bladder tumor, or intravesical chemotherapy failure were considered at high risk of disease recurrence or progression and treated with bacille Calmette-Guérin (BCG).

RESULTS

After a median follow-up of 86 months (range 20 to 143), 2 (0.9%) of 216 patients at low risk, 4 (2.2%) of 182 patients at intermediate risk, and 19 (9.8%) of 193 patients at high risk developed UUTTs. The incidence of UUTTs is significantly higher in patients at high risk than in those at low risk (P = 0.0004, odds ratio = 11.6, 95% confidence interval [CI] 2.5 to 40.7) or at intermediate risk (P = 0.004, odds ratio = 4.8, 95% CI 1.5 to 17.2), or both (P = 0.000006, odds ratio = 7.3, 95% CI 2.6 to 20.3). The difference between patients at low risk and those at intermediate risk was not statistically significant (P = 0.5, odds ratio = 0.4, 95% CI 0.02 to 2.6). After a median time of 36 months (range 9 to 119) from UUTT diagnosis, 5 (20%) of 25 patients have died of the disease.

CONCLUSIONS

The incidence of metachronous UUTTs is low in patients with superficial bladder cancer at low or intermediate risk of disease recurrence or progression and significantly higher for patients at high risk. Because UUTT is often asymptomatic, and mortality is high, frequent and lifelong examination of the upper urinary tract is suggested, with an annual intravenous urogram and urinary cytologic analysis every 4 months in patients with superficial bladder cancer at high risk of disease recurrence or progression.

Systemic immune response after intravesical instillation of bacille Calmette-Guérin (BCG) for superficial bladder cancer

The mechanism of anti-tumour activity by BCG is not known clearly. However, many studies suggest that immunological response is related to effectiveness of intravesical instillation of BCG in the therapy for superficial bladder carcinoma. Peripheral blood mononuclear cells (PBMC), urine and serum were obtained from patients with superficial carcinoma at various times during the course of BCG instillation. Urine of patients showed increased levels of IL-1beta, IL-2, IL-6, tumour necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma) and macrophage colony-stimulating factor (M-CSF) after BCG instillation. Levels of IL-2 and IFN-gamma in the serum also increased after BCG instillation, but IL-1beta, IL-6, TNF-alpha and M-CSF were not detectable. Maximal levels of IL-2 and IFN-gamma in the urine or serum were shown after the fourth instillation. BCG-induced killer cell activity in PBMC increased significantly after the third BCG instillation. These results suggest that BCG instillation involved not only local immunological efforts but also systemic immune responses. Tumour-free patients produced higher BCG-induced killer cell activity than tumour recurrence patients. BCG-induced killer cell activity may be useful for monitoring the effectiveness of intravesical BCG instillation.

Prognostic markers of intravesical bacillus Calmette-Guérin therapy for multiple, high-grade, stage T1 bladder cancers

BACKGROUND

Prediction of a response to intravesical bacillus Calmette-Guérin (BCG) therapy for bladder cancer is clinically important. We determined whether several molecular markers have prognostic value in intravesical BCG therapy for multiple, high-grade, stage T1 bladder cancers.

METHODS

The expressions of p53 (clone D07), bcl-2 (100-D5), cathepsin-D (C5), c-myc(9E11), c-erbB-2 (CB11) and Ki-67 (MM1) were determined by immunohistochemistry in paraffin-embedded tissues from 32 multiple, T1, grade II-III bladder cancer patients (15 BCG responders, 17 nonresponders) who had undergone a single course of BCG therapy (Pasteur strain, 5 x 10(8) CFU weekly for 6 weeks) after complete removal of the tumors. The association between the expression of these markers and the response to BCG was assessed by univariate and multivariate analyses.

RESULTS

There was no difference in patient and tumor characteristics between the 2 groups. Using multivariate analysis, the only useful marker was p53, with the overexpression of the p53 protein inversely related to the response to BCG therapy (P = 0.0182).

CONCLUSION

Our results suggest that the status of p53 expression offers significant clinical information and may be a useful tool in the selection of suitable candidates for BCG therapy in multiple, high-grade stage T1 bladder cancer patients.

Biologic response modifiers in the management of superficial bladder cancer

For the treatment of existing transitional-cell carcinoma or for prophylaxis of recurrent disease, intravesical therapy should be chosen according to stage. Papillary disease (stages Ta, Tl) may be treated effectively either with an alkylating agent or with bacillus Calmette-Guérin (BCG). BCG is the agent of choice for the treatment of Hat carcinoma in situ (Tis), with the recommended treatment course comprising 12 weekly and 12 monthly instillations. Intravesical interferon and many of the other biologic response modifiers mentioned herein may be effective for patients with Ta disease who have failed BCG therapy.

Immunostimulation in the urinary bladder by local application of Nocardia rubra cell wall skeleton preparation (Rubratin) for superficial bladder cancer immunotherapy--a phase I/II study

OBJECTIVES

Twelve patients with superficial papillary transitional cell carcinoma of the bladder (pTa, pT1) were treated with six consecutive weekly intravesical instillations of Rubratin (in a dose of 1.5, 3.0, or 4.5 mg), a cell wall skeleton preparation of Nocardia rubra (NCW). The main objective of this study was to look for local immunomodulating effects of NCW and in the first four patients the effect on a marker lesion was also investigated.

METHODS

Local immunostimulation in all 12 patients was determined by (1) measurement of cytokine induction [interleukin 1 beta (IL1 beta), IL2, IL6, and tumor necrosis factor alpha (TNF alpha)], (2) leukocyte influx into the urine, and (3) phenotypic analysis of the lymphocyte fraction of these leukocytes.

RESULTS

Significantly elevated levels of Rubratin-induced IL1 beta (P < 0.001), IL2 (P < 0.001), IL6 (P < 0.01), and TNF alpha (P < 0.001) were found compared to control pretherapy levels. Rubratin also induced leukocyte influx into the urine. Fluorescence-activated cell sorter (FACS) analysis of the urinary leukocytes indicated T-cell activation (IL2 receptor and HLA-DR expression), while in two out of five patients the CD4/CD8 ratios were increased. Urinary cytokine induction by Rubratin was comparable with cytokine induction observed in nonresponding bacillus Calmette-Guérin (BCG) patients (recurrent tumor within 6 months), but less compared with responding BCG patients (no recurrent tumor within 6 months). Clinical results showed no response on the marker lesion and in five out of eight patients early recurrence was found after complete transurethral resection (TUR) of the bladder tumors. This biological response modifier caused no local or systemic side effects at the doses used.

CONCLUSION

Although local immunostimulation by intravesical Rubratin administration can be induced, the amount of immunocompetent cells attracted to the bladder is not as high as observed in BCG-responding patients, resulting in lower amounts of cytokines produced. This could also explain the lack of clinical efficacy.

Prophylactic intracavitary treatment with interferon alpha increases interferon gamma production by peripheral blood mononuclear cells in patients with superficial transitional cell carcinoma of the bladder

The immunomodulatory effect of prophylactic intravesical instillations of interferon alpha 2b (IFN-alpha-2b) on interferon gamma (IFN-gamma) and interleukin 4 (IL-4) production by peripheral blood mononuclear cells (PBMCs) from patients with superficial transitional cell carcinoma (STCC) of the bladder has been analysed. There were no significant differences in the production of IFN-gamma and IL-4 by PBMCs from untreated patients and healthy control subjects after 24 h of phytohaemagglutinin (PHA) stimulation. However, between 3 and 6 months after finishing the prophylactic intracavitary treatment with IFN-alpha-2b, PHA-stimulated PBMCs from patients with STCC of the bladder showed a significantly enhanced production of IFN-gamma and a significantly decreased production of IL-4. Both IFN-gamma and IL-4 returned to pretreatment levels 1 year after ending the treatment. In conclusion, prophylactic intravesical instillations of IFN-alpha-2b in patients with STCC of the bladder have an immunoregulatory effect on the production of IFN-gamma and IL-4 by PBMCs.

Intracavitary prophylactic treatment with interferon alpha 2b of patients with superficial bladder cancer is associated with a systemic T-cell activation

The activation and proliferation of peripheral blood mononuclear cells (PBMNCs) are complex processes involving several surface molecules, cell secretion and response to cytokines. This paper investigates the immunomodulatory effect of prophylactic treatment with interferon alpha 2b (IFN-alpha 2b) upon the blastogenic response of PBMNCs from patients with superficial transitional cell carcinoma (STCC) of the bladder to mitogenic signals that interact with surface molecules [phytohaemagglutinin, PHA and anti-CD3 monoclonal antibodies, (MAbs)]. PBMNCs from the patients were studied prior to the transurethral resection (TUR) of the tumour, during the second month of prophylactic intravesical instillation of IFN-alpha 2b and 3 and 6 months after finishing the instillation treatment. The [3H]thymidine uptake of PBMNCs from 17 patients with STCC of the bladder after 5 days of PHA and anti-CD3 MAb stimulus was found to be significantly lower than that of healthy controls (P < 0.05). The addition of interleukin 2 (IL-2) to the culture medium did not correct this defective proliferative response to PHA and the anti-CD3 MAb. There were no significant differences between IL-2 production in PBMNCs from STCC patients after stimulation with PHA and in PBMNCs from healthy controls (P > 0.05). Patients without evidence of recurrence showed a significantly enhanced proliferative response in PBMNC to PHA and anti-CD3 MAb after intravesical prophylactic treatment with interferon-alpha 2b in the follow-up examinations 3 and 6 months after treatment (P < 0.01). However, three patients had evidence of tumour recurrence, and they showed no enhancement of the PBMNC proliferative response to these mitogens in the same examinations. In conclusion, the prophylactic intracavitary treatment of STCC with IFN-alpha 2b may induce a systemic immunomodulatory effect which is associated to the clinical evolution of the disease.

Intravesical bacillus Calmette-Guerin for superficial bladder cancer: experience with Danish 1331 strain

A total of 95 patients with stage Ta/T1 superficial bladder cancer was eligible for intravesical bacillus Calmette-Guerin (BCG) immunoprophylaxis according to the standard high risk criteria for tumor recurrence and progression. Of these patients 50 agreed to undergo treatment while the remaining 45 refused any intravesical therapy and served as concurrent nonrandomized controls. The patient and tumor characteristics in the 2 groups of patients were identical. All patients underwent complete transurethral resection of the bladder tumor. Therapy consisted of 120 mg. weekly instillations of BCG (Danish 1331 strain) for 6 weeks. Among the 50 patients 33 received BCG initially while 17 received it after failure of intravesical chemotherapy. Responses were evaluated according to standard criteria. Recurrence was noted in 24 patients (48%) in the BCG group compared to 38 (84.4%) in the control group. The recurrence rates per year and per 100 patient-months were significantly reduced in the BCG arm compared to the control arm. The mean interval to first recurrence and the mean recurrence interval were significantly increased in the BCG arm compared to the control arm. The relative risk of recurrence in the BCG group was 0.62 versus 1.63 in the control group. Subgroup analysis showed significant benefit of BCG for patients with single as well as multiple, stages Ta and T1, and grades II and III tumors. Comparison with pretreatment controls in the BCG group revealed a significant reduction in the recurrence rate in those patients after treatment with BCG, which was not seen in the control group. The benefit of BCG was seen in those who received BCG initially as well as in those who received it after failure of intravesical chemotherapy. Multivariate analysis of prognostic factors showed that this benefit in the BCG group was related only to the treatment, while other prognostic parameters, such as tumor stage, grade, number and so forth were not independent prognostic variables. The rate of progression to muscle invasion was not significantly different in the 2 treatment groups. The relapse-free survival in the BCG group was 35.4% at 60 months compared to 11.2% in the control group (p < 0.001). The side effects of BCG therapy were mild, brief and easily controlled with conservative measures.

Multiple bladder biopsies under intravesical lignocaine anaesthesia

OBJECTIVE

To study biopsy quality, complications and patient acceptance when urinary bladder biopsies were taken under local anaesthesia.

PATIENTS AND METHODS

Multiple large cold-cup urinary bladder biopsies were taken under topical lignocaine anaesthesia in 20 patients who had previously undergone transurethral resection for superficial bladder cancer.

RESULTS

The procedures were carried out at the outpatient clinic with 0.5-2 h post-operative observation. Patient acceptance was very high and complications were minimal. The quality of the biopsies was consistently high and influenced treatment in the majority of the patients.

CONCLUSION

In our department multiple bladder biopsies (mapping) have previously always been performed as a transurethral resection under general or spinal anaesthesia. Operation under intravesical lignocaine anaesthesia with 2 h post-operative observation reduced the costs by 70%.

BCG in the treatment of superficial cancer of the bladder: a review

Superficial Bladder Cancer can be treated in several ways. During the last decades, intravesical instillation of Bacillus Calmette Guerin (BCG) has emerged as an effective therapy. The history of how BCG became an antitumoral treatment is long and intriguing, and the theoretical background is fragile. In numerous studies, involving over 3,000 patients, intravesical instillation of BCG has been shown to be an effective treatment for superficial cancer of the urinary bladder in humans. Temporarily, BCG can eradicate residual disease after surgery, it can prevent local recurrence, and it can halt deterioration of malignancy in recurrences. However, its effect on survival is uncertain. For patients, treatment with BCG is prolonged, expensive, associated with side-effects, and may even be harmful. The mode of action is obscure. The theoretical framework on which this therapy is based is purely speculative, if existing at all. Although BCG has been classified as a biological response modifier, and the treatment is termed immunotherapy, proof is still lacking that the mechanism is immunological.

Natural history of early bladder cancer

Non-invasive transitional cell carcinoma (TCC) occurs as two distinct growth patterns, papillary and non-papillary (flat), which display significant differences in biologic potential. Papillary carcinoma usually presents as a low-grade lesion which frequently recurs multiple times prior to invasion; conversely, non-papillary (flat) carcinoma in situ is usually high-grade at presentation (carcinoma in situ) and frequently associated with invasion. These lesions may occur together, although papillary cancer is more easily visualized cystoscopically due to its exophytic growth; flat carcinoma in situ is often cystoscopically invisible. This report reviews existing data concerning the prognostic value of pathologic grading and staging of non-invasive and early invasive TCC. Emphasis is placed on those studies reporting surgical treatment rather than other forms of treatment.