Adjuvant topical chemotherapy versus immunotherapy in primary superficial transitional cell carcinoma of the bladder

Superficial bladder cancer

Superficial bladder cancer can be resected with minimal morbidity, but the patients are at high risk for tumor recurrence. Tumors can be divided into low-, intermediate-, and high-risk categories based on tumor grade, stage, and pattern of recurrence. Low-risk tumors are best treated with a single instillation of chemotherapy such as thiotepa, doxorubicin, or mitomycin. Intermediate-risk tumors can be treated with chemotherapy, but, similar to high-risk tumors, will often require immunotherapy. High-risk tumors are best treated with intravesical bacille Calmette-Guérin (BCG) using a 3-week maintenance schedule. Side effects of BCG immunotherapy can be reduced by logarithmic reductions in the dosage of BCG. Patients who fail BCG may be rescued with BCG plus interferon-alfa or radical cystectomy.

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).

Immunohistological findings in patients with superficial bladder carcinoma after intravesical instillation of keyhole limpet haemocyanin

OBJECTIVE

To determine whether keyhole limpet haemocyanin (KLH) instilled intravesically improves the local cellular response within the bladder wall of patients suffering from superficial bladder carcinoma.

PATIENTS AND METHODS

Twelve patients (10 men and two women, mean age 67 years, range 42-85) with superficial carcinomas of the bladder were treated for 6 consecutive weeks and then monthly for 1 year with 20 mg KLH in 20 mL saline instilled intravesically after complete resection of the tumours. Biopsies were taken for immunohistochemical examination before treatment and again 6 weeks, 3, 6 and 9 months after treatment. Six patients with no evidence of cystitis or malignant bladder disease acted as a control group. Immunofluorescent staining of the biopsies was performed using monoclonal antibodies to the T-cell markers CD4 and CD8, and to CD14 (monocytes), CDw15 (granulocytes), CD19 B-cells (Pan-B), CD68 (macrophages) and HLA-DR. Anti-KLH antibody-producing plasma cells were detected using a standard technique. A semiquantitative analysis of locally infiltrating cell types was performed.

RESULTS

After treatment with KLH the increase of CD8+ suppressor cells was less pronounced than that of CD4+ helper cells. The T-helper/inducer to T-suppressor/cytotoxic cell ratio thus altered from 0.8:2.0 before treatment to 1.6:2.3 afterwards. Hence, the number of T-helper cells had increased considerably, whereas there was only a moderate increase in the number of T-suppressor cells. This cellular ratio could be detected for 9 months after KLH therapy. The numbers of activated HLA-DR+ immune cells in the submucosa and among urothelial cells also increased after KLH instillation. The degree of mononuclear cell infiltration of the submucosa increased considerably, but granulocyte infiltration was only moderate. Lymph follicles with enhanced B-lymphocyte counts were also detected.

CONCLUSION

Immune-cell infiltration into the urothelium and enhanced activation (expression of class II antigens) suggests distinct processes of cellular antigen recognition, which could be detected for up to 9 months after the beginning of KLH therapy. This may represent a basic functional mechanism of KLH therapy.

Efficacy of local Bacillus Calmette-Guérin treatment in superficial bladder cancer relapsing under Keyhole-Limpet Hemocyanin immunotherapy

The efficacy of local immunotherapy with Keyhole-Limpet Hemocyanin (KLH) and Bacillus Calmette-Guérin (BCG) in preventing recurrence of superficial bladder cancer (stages pTa to pT1; grades 1 to 3) was checked in 96 patients. All tumours were resected and all patients were presumed to be free of malignant disease at initiation of prophylactic KLH instillations. Before starting KLH instillations (20 mg/administration week for 6 weeks, followed by regular (bi)monthly instillations for 3 years altogether) all patients were intracutaneously immunized with 1 mg KLH. Tumour relapse under this therapeutic schedule was the indication for BCG instillations (120 mg BCG-Connaught; administration in analogy to KLH treatment). This study has proved that (1) prophylactic KLH treatment reduced superficial bladder cancer relapse rate after surgical intervention without considerable local/systemic side effects and (2) local BCG-administration was therapeutically effective in relapsing/progressive disease under KLH treatment. There were, however, pronounced side effects.

Carbohydrate content and monosaccharide composition of Rapana thomasiana grosse (Gastropoda) hemocyanin and its structural subunits. Comparison with gastropodan hemocyanins

The hemocyanin of Rapana thomasiana grosse (marine snail, gastropod) is a glycoprotein with a carbohydrate content of 8.9% (w/w) and monosaccharide constituents xylose, fucose, 3-O-methylgalactose, mannose, galactose, N-acetylgalactosamine and N-acetylglucosamine residues. The two structural subunits of this oxygen carrier, RHSS1 and RHSS2, are unevenly glycosylated. On subtracting the carbohydrate contribution from the M(r) values of 250 and 450 kDa attributed to the two subunits, values of 2.18 x 10(5) daltons and 4.30 x 10(5) daltons were calculated for the polypeptide part of the "light" and "heavy" subunits, respectively. Comparison of the monosaccharide compositions of gastropodan hemocyanins revealed qualitative similarities, as well as relationships between the quantities, of the individual monosaccharides: Man > or = 3MeGal > GlcNAc > or = GalNAc and Fuc > or = Xyl.

Immunotherapy with keyhole limpet hemocyanin: efficacy and safety in the MB-49 intravesical murine bladder tumor model

The antitumor activity and potential toxicity of a clinical-grade keyhole limpet hemocyanin preparation (KLH-Immune Activator; KLH-IA) were determined in the MB-49 intravesical murine bladder tumor model. Mice were immunized subcutaneously with KLH-IA two weeks prior to intravesical implantation of MB-49 tumor cells. Treatment consisted of intravesical KLH-IA (10 or 100 micrograms.) 1, 4, 7, 14 and 21 days after implantation. Control animals either were not immunized prior to tumor implantation and KLH-IA treatment, or were immunized with KLH-IA and treated with the vehicle. By 4 weeks after implantation tumor outgrowth in the treated groups was significantly decreased (p < 0.01, Fisher's Exact) relative to the control groups. Prior subcutaneous immunization was required to elicit antitumor activity of KLH-IA; thus, the mechanism of action is immune-mediated and not due to spurious interference with tumor implantation by intravesical instillations. Animals treated with a dissociated form of KLH exhibited decreased tumor outgrowth approaching, but not attaining, significance (p < 0.09, Fisher's Exact). A separate toxicity study in which KLH-IA was given subcutaneously (4 mg./kg.), intraperitoneally (40 mg./kg.), or intravesically (40 mg./kg.) disclosed no significant gross or histopathologic abnormalities except for mild-to-moderate papillary hyperplasia in all catheterized animals. These results establish the efficacy and safety of KLH-IA in mice and suggest that clinical trials for intravesical treatment of superficial bladder cancer may be warranted.