Bacillus Calmette-Guérin therapy in stage Ta/T1 bladder cancer: prognostic factors for time to recurrence and progression

Fremantle protocol: Multicenter clinical outcomes for a pragmatic protocol for intravesical bacillus Calmette-Guerin

OBJECTIVES

To examine the utility and efficacy of a multifaceted protocol for the administration of intravesical bacillus Calmette-Guerin (BCG) for non-muscle-invasive bladder cancer (NMIBC).

SUBJECTS AND METHODS

A multicenter retrospective review was conducted among 83 patients undergoing Fremantle protocol intravesical BCG for NMIBC within 4 major hospitals in Western Australia between January 2016 and December 2018. The Fremantle protocol consists of weekly BCG instillations for 6 weeks during the induction phase, followed by monthly BCG instillations for 10 months during the maintenance phase with integrated clearance-to-proceed algorithms for urine MSU checks, flexible cystoscopies performed at 3 monthly intervals during maintenance BCG, and repeat GA cystoscopies with four quadrant bladder biopsies routinely obtained following the completion of induction and maintenance treatment.

RESULTS

For patients undergoing Fremantle protocol BCG, 98.8% (82/83) and 75.9% (63/83) of patients completed their induction and maintenance courses of BCG, respectively. Induction BCG was delivered over a median duration of 35 days (range 34-84 days), and maintenance BCG was delivered over a median duration of 266 days (range 1-682 days). The tumor recurrence rate was 10.8% (9/83) at the time of post-induction biopsies, 2.4% (2/83) during maintenance treatment, 0% (0/60) at the time of post-maintenance biopsies, and 8.8% (5/57) after a median further follow-up of 16 months (range 0-51 months).

CONCLUSION

The Fremantle protocol appears to be a safe and effective BCG regimen with several advantages over other BCG protocols, including high completion rates, low recurrence rates, and being highly pragmatic.

Highlights into historical and current immune interventions for cancer

Immunotherapy is an additional pillar when combined with traditional standards of care such as chemotherapy, radiotherapy, and surgery for cancer patients. It has revolutionized cancer treatment and rejuvenated the field of tumor immunology. Several types of immunotherapies, including adoptive cellular therapy (ACT) and checkpoint inhibitors (CPIs), can induce durable clinical responses. However, their efficacies vary, and only subsets of cancer patients benefit from their use. In this review, we address three goals: to provide insight into the history of these approaches, broaden our understanding of immune interventions, and discuss current and future approaches. We highlight how cancer immunotherapy has evolved and discuss how personalization of immune intervention may address present limitations. Cancer immunotherapy is considered a recent medical achievement and in 2013 was selected as the "Breakthrough of the Year" by Science. While the breadth of immunotherapeutics has been rapidly expanding, to include the use of chimeric antigen receptor (CAR) T-cell therapy and immune checkpoint inhibitor (ICI) therapy, immunotherapy dates back over 3000 years. The expansive history of immunotherapy, and related observations, have resulted in several approved immune therapeutics beyond the recent emphasis on CAR-T and ICI therapies. In addition to other classical forms of immune intervention, including human papillomavirus (HPV), hepatitis B, and the Mycobacterium bovis Bacillus Calmette-Guérin (BCG) tuberculosis vaccines, immunotherapies have had a broad and durable impact on cancer therapy and prevention. One classic example of immunotherapy was identified in 1976 with the use of intravesical administration of BCG in patients with bladder cancer; resulting in a 70 % eradication rate and is now standard of care. However, a greater impact from the use of immunotherapy is documented by the prevention of HPV infections that are responsible for 98 % of cervical cancer cases. In 2020, the World Health Organization (WHO) estimated that 341,831 women died from cervical cancer [1]. However, administration of a single dose of a bivalent HPV vaccine was shown to be 97.5 % effective in preventing HPV infections. These vaccines not only prevent cervical squamous cell carcinoma and adenocarcinoma, but also oropharyngeal, anal, vulvar, vaginal, and penile squamous cell carcinomas. The breadth, response and durability of these vaccines can be contrasted with CAR-T-cell therapies, which have significant barriers to their widespread use including logistics, manufacturing limitations, toxicity concerns, financial burden and lasting remissions observed in only 30 to 40 % of responding patients. Another, recent immunotherapy focus are ICIs. ICIs are a class of antibodies that can increase the immune responses against cancer cells in patients. However, ICIs are only effective against tumors with a high mutational burden and are associated with a broad spectrum of toxicities requiring interruption of administration and/or administration corticosteroids; both of which limit immune therapy. In summary, immune therapeutics have a broad impact worldwide, utilizing numerous mechanisms of action and when considered in their totality are more effective against a broader range of tumors than initially considered. These new cancer interventions have tremendous potential notability when multiple mechanisms of immune intervention are combined as well as with standard of care modalities.

Oncologic outcomes of Bacillus Calmette-Guérin therapy in elderly patients with non-muscle-invasive bladder cancer: A meta-analysis

Introduction

There is a challenge on the medical efficacy of intravesical Bacillus Calmette-Guérin (BCG) therapy and the power of the immune system boosting, which can be influenced by the age of the non-muscle-invasive bladder cancer (NMIBC) patients. This meta-analysis evaluates the efficacy of BCG therapy among aged (>70) and younger patients with non-muscle-invasive bladder cancer (NMIBC).

Methods

The central database of PubMed, Scopus, and Web of Science were queried until August 4, 2021, by using "BCG," "Bladder Cancer," "AGE," and "efficacy" keywords. After excluding duplicated results, titles and abstracts were evaluated by two independent reviewers. The exclusion criteria included non-English studies, conference abstracts, reviews, editorials, letters, and comments. Three main outcomes, disease-free survival (DFS), progression-free survival (PFS), and cancer-specific survival (CSS), were considered. The statistical analysis was performed using STATA (version 14; Stata Corp, College Station, Texas, USA).

Results

From 1115 found documents, the 24 research articles were recruited in the systematic review, and 10 were the candidate for meta-analysis. The overall estimate of H.R. revealed that BCG therapy in those over age 70 is significantly associated with an improved risk of progression and cancer-specific death in studied patients. However, this association was not statistically significant for DFS (1.04 (95% CI: 0.85,1.26)).

Conclusion

The BCG maintenance therapy improved CSS and PFS oncological outcomes in elderly patients with NMIBC. BCG therapy did not significantly change the DSF.

Spinal Tuberculosis Secondary to Intravesical Bacille Calmette-Guerin Treatment for Bladder Cancer

Intravesical administration of bacille Calmette-Guérin (BCG) is an important component of the gold standard in treating non-muscle invasive bladder cancer (NMIBC). However, complications of this treatment include infections caused by the dissemination of Mycobacterium bovis. We present a case of a 62-year-old man who had been treated with intravesical BCG for bladder cancer and developed an M. bovis infection of his vertebral column. About four months after completing the BCG treatment, he developed an acute onset of severe upper thoracic radicular back pain, with radiation anteriorly to his sternum. Examination revealed the presence of early myelopathy. After other causes were ruled out, he was diagnosed with the infection four months later. He was investigated for the pain, with resulting imaging identifying an erosive ventral epidural mass at the T4-T5 levels causing cord compression. The patient underwent a transthoracic procedure to evacuate the paraspinal mass lesion and obtain a diagnostic biopsy, followed by a posterolateral decompression of the lesion and posterior instrumented stabilization. Pathology resulted in the identification of a granuloma with a single acid-fast bacillus (AFB) from the paraspinal abscess, thus being diagnostic of a mycobacterial granuloma with paraspinal involvement. We subsequently performed an extensive review of current literature, looking at articles on spinal osteomyelitis following intravesical BCG treatment of bladder cancer. We identified 26 documented cases in English literature. We present our case report with a good outcome at 24 months, resolving with appropriate chemotherapy. Additionally, we completed a systematic review of the literature and discuss this infrequent iatrogenic pathology. Our report reveals the good response to targeted therapy in the case of osteomyelitis at other skeletal sites and that practitioners caring for these patients maintain a high degree of suspicion in the workup of these patients. Early identification and treatment can appropriately treat osteomyelitis with good long-term outcomes.

Bacillus Calmette-Guérin immunotherapy for bladder cancer: a review of immunological aspects, clinical effects and BCG infections

Bacillus Calmette-Guérin (BCG) immunotherapy for bladder cancer has been used since 1976 when the first evidence of its ability to lower recurrence and progression rates was published. Today, BCG immunotherapy is the choice of care for high-grade non-muscle invasive bladder cancer (NMIBC) after transurethral resection. This article presents indications and procedure of BCG instillations, and outlines the effects on recurrence and progression of NMIBC. The BCG-induced immunity in NMIBC is not yet fully understood. Animal studies point towards BCG inducing specific tumour immunity. We describe the current knowledge of how this immunity is induced, from internalization of BCG bacilli in urothelial cells, to cytokine- and chemokine-mediated recruitment of neutrophils, monocytes, macrophages, T cells, B cells and natural killer cells. In addition, we describe the process of trained immunity, the non-specific protective effects of BCG. Recent studies also indicate that dysbiosis of the urinary microbiome may cause lower urinary tract dysfunction. Side effects of BCG bladder instillations range from common, mild and transient symptoms, such as dysuria and flu-like symptoms, to more severe and rarely occurring life-threatening complications. We review the literature and give an overview of reported incidences and management of BCG infections after intravesical instillation.

Maintenance versus non-maintenance intravesical Bacillus Calmette-Guerin instillation for non-muscle invasive bladder cancer: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

It is not clear whether maintenance Bacillus Calmette-Guerin (BCG) is necessary for intermediate- or high-risk non-muscle-invasive bladder cancer (NMIBC). This systematic review and meta-analysis aimed to illustrate the effects of maintenance BCG for intermediate- or high-risk NMIBC.

METHODS

A comprehensive literature search of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov databases and International Clinical Trials Register (ICTRP) Search was conducted to identify relevant randomized controlled trials (RCTs) that have assessed the efficacy of maintenance or non-maintenance BCG therapy for patients with NMIBC. The maintenance group first received induction BCG instillations, and subsequently received BCG intravesical instillations regularly for at least 1 year, while the control group only received induction BCG instillations. Systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis Criteria.

RESULTS

Ten RCTs were eligible in this systematic review. The meta-analysis showed that induction BCG followed by maintenance BCG instillation after transurethral resection (TUR) could reduce the risk ratios of tumor recurrence by 21% (RR = 0.79; 95% CI 0.70-0.89; P < 0.0001) and prolong recurrence-free survival (RFS) by 33% (HR: 0.67; 95% CI, 0.54-0.82; P < 0.001), compared with non-maintenance BCG. It could also reduce the risk ratios of tumor progression (RR = 0.81; 95% CI 0.68-0.97; P = 0.02). However, these pooled results should be considered with caution since the quality of evidences for outcomes ranged low. Subgroup analysis implied that different durations of maintenance BCG instillations might be one of the sources of potential clinical heterogeneity of included studies. Begg's funnel plot and Egger's test did not reveal any evidence of publication bias in this meta-analysis.

CONCLUSIONS

Induction BCG followed by maintenance BCG instillation after TUR, compared with induction BCG along, can reduce the risk ratios of tumor recurrence and tumor progression, and prolong RFS. However, these results with a lower level of evidence should be treated with caution. The optimal maintenance schedule has yet to be determined and a large multi-institutional study in intermediate- and high-risk patients is also needed to determine the optimal maintenance schedule.

Dynamics of Immune Checkpoints, Immune System, and BCG in the Treatment of Superficial Bladder Cancer

This paper aims to study the dynamics of immune suppressors/checkpoints, immune system, and BCG in the treatment of superficial bladder cancer. Programmed cell death protein-1 (PD-1), cytotoxic T-lymphocyte-associated antigen 4 (CTLA4), and transforming growth factor-beta (TGF-β) are some of the examples of immune suppressors/checkpoints. They are responsible for deactivating the immune system and enhancing immunological tolerance. Moreover, they categorically downregulate and suppress the immune system by preventing and blocking the activation of T-cells, which in turn decreases autoimmunity and enhances self-tolerance. In cancer immunotherapy, the immune checkpoints/suppressors prevent and block the immune cells from attacking, spreading, and killing the cancer cells, which leads to cancer growth and development. We formulate a mathematical model that studies three possible dynamics of the treatment and establish the effects of the immune checkpoints on the immune system and the treatment at large. Although the effect cannot be seen explicitly in the analysis of the model, we show it by numerical simulations.

Natural course of asymptomatic abnormal prostate findings incidentally detected by CT after intravesical BCG therapy

BACKGROUND

Detailed information is not currently available on the incidence, natural course, and management of asymptomatic abnormal prostate findings incidentally detected by radiologic evaluations after BCG therapy for non-muscle-invasive bladder cancer patients.

METHODS

We identified 38 patients who were evaluated by contrast-enhanced CT scans before TUR-BT and after BCG therapy between 2006 and 2012. We evaluated the clinical courses of patients with abnormal radiologic findings of the prostate gland after BCG therapy.

RESULTS

Abnormal findings on CT scans were found in the prostate glands of 11 of the 38 patients examined (28.9%), none of whom exhibited any sign or symptom associated with prostatitis. Abnormal findings included a low attenuation area (n = 6, 15.8%), contrast enhancement (n = 3, 7.9%), and a low attenuation area and contrast enhancement in the prostate gland (n = 2, 5.3%). During the follow-up, abnormal prostate findings disappeared spontaneously in most cases without any anti-bacterial or anti-tuberculous drug treatments. No significant differences were observed in patient clinical backgrounds, with the exception of post-BCG prostate volumes, between patients with and without abnormal CT findings. Furthermore, no significant differences were noted in the incidence of the adverse effects of BCG therapy, tumor recurrence rates, or progression rates between patients with and without abnormal CT findings of the prostate gland after BCG therapy.

CONCLUSIONS

Asymptomatic abnormal prostate findings incidentally detected by CT after BCG therapy are not rare, and these disappear over time during the follow-up period without any treatment.

Prognostic impact of Bacillus Calmette-Guérin interruption at the time of induction and consolidation

Context

Intravesical Bacillus Calmette-Guérin (BCG) is a cause of bladder and systemic toxicity that is difficult to prevent and is responsible for treatment drop out in bladder cancer patients. More recently, BCG shortage has become the main cause of incomplete treatment.

Aims

The aim of this study was to examine the impact on long-term prognosis of bladder cancer patients following discontinuation of BCG instillations.

Settings and Design

In this retrospective study, data were examined from 333 consecutive nonmuscle invasive bladder cancer patients treated from 2005 to 2015 by transurethral resection (TUR) and had undergone adjuvant BCG therapy after TUR.

Subjects and Methods

Rate of complete cure, the reason for the interruption, toxicity, and the associations between discontinuance of BCG therapy, tumor characteristics, association with carcinoma in situ and tumor recurrence or progression were analyzed.

Statistical Analysis Used

Recurrence and progression-free survival rate curves were estimated using the Kaplan-Meier method and were compared using the log-rank test. Univariate and multivariate analyses were performed using the Cox proportional hazards model. Differences among groups were considered as statistically significant when P < 0.05.

Results

Overall, 303 patients were eligible for analysis. Median follow up was 36 (confidence interval: 7-120) months. A total of 55 (18.1%) had <6 installations (Group I); 87 (28.7%) completed induction and 1-year maintenance (Group III); and 161 (53.1%) completed the induction course, but not the 1-year maintenance (Group II). Grade III-IV toxicity rates were significantly higher in Group I than Group II and III. Interruption for BCG shortage was the main cause of interrupting BCG in Group II. Multivariate analysis showed that discontinuation of BCG induction therapy was an independent predictor for tumor recurrence (P < 0.001) and 1-year BCG maintenance therapy for tumor progression (P = 0.005).

Conclusions

Discontinuation of BCG therapy has a significantly deleterious effect on tumor recurrence and progression rates. Although BCG toxicity is a major cause of drop out, BCG shortage became a major cause of discontinuation. All effort must be done today to restore normal production of BCG worldwide.

Construction of predictive models for cancer-specific survival of patients with non-muscle-invasive bladder cancer treated with bacillus Calmette-Guérin: results from a multicenter retrospective study

OBJECTIVE

The aims of this study were to clarify the prognostic factors and to validate the bacillus Calmette-Guérin failure classification advocated by Nieder et al. in patients with non-muscle-invasive bladder cancer who had intravesical recurrence after bacillus Calmette-Guérin therapy.

METHODS

Data from 402 patients who received intravesical bacillus Calmette-Guérin therapy between January 1990 and November 2011 were collected from 10 institutes. Among these patients, 187 with bacillus Calmette-Guérin failure were analyzed for this study.

RESULTS

Twenty-nine patients (15.5%) were diagnosed with progression at the first recurrence after bacillus Calmette-Guérin therapy. Eighteen (62.1%) of them died of bladder cancer. A total of 158 patients were diagnosed with non-muscle-invasive bladder cancer at the first recurrence after bacillus Calmette-Guérin therapy. Of them, 23 (14.6%) underwent radical cystectomy. No patients who underwent radical cystectomy died of bladder cancer during the follow-up. On multivariate analysis of the 135 patients with bladder preservation, the independent prognostic factors for cancer-specific survival were age (≥70 [P = 0.002]), tumor size (≥3 cm [P = 0.015]) and the Nieder classification (bacillus Calmette-Guérin refractory [P < 0.001]). In a subgroup analysis, the estimated 5-year cancer-specific survival rates in the groups with no positive, one positive and two to three positive factors were 100, 93.4 and 56.8%, respectively (P < 0.001).

CONCLUSIONS

Patients with stage progression at the first recurrence after bacillus Calmette-Guérin therapy had poor prognoses. Three prognostic factors for predicting survival were identified and used to categorize patients with non-muscle-invasive bladder cancer treated with bacillus Calmette-Guérin into three risk groups based on the number of prognostic factors in each one.

Salvage combination intravesical immunotherapy with Bacillus Calmette-Guérin and interferon-α2B: impact on recurrence, progression, and survival

BACKGROUND

The population of patients with bladder cancer who have recurrence following an initial instillation of Bacillus Calmette-Guérin (BCG) is critical to study, as treatment delay with repeated courses of intravesical therapy may yield poor prognosis in patients with disease progression.

OBJECTIVE

To evaluate our institution's experience with use of BCG alone and in combination with interferon (INF)-α2B in regard to the rates of bladder cancer recurrence, disease progression, need for eventual cystectomy, and survival in patients with initial BCG failure.

STUDY DESIGN

We identified a combined series of 139 patients who had undergone intravesical instillations of BCG alone (n = 114) or in combination with INF-α2B (n = 25) performed at Brigham and Women's Hospital, Boston, between 2002 and 2007. All patients previously received an initial 6-week course of BCG therapy and subsequently had BCG failure on follow-up cystoscopy. Study outcome measures included: time to cancer recurrence in patients, progression of disease, eventual cystectomy, and patient mortality.

RESULTS

At a median follow-up of 64.7 months from initial BCG administration, 84% of patients treated with BCG + INF-α2B had disease recurrence. The average time to recurrence was < 1 year, and 63% of patients had recurrence on the first post-treatment biopsy. Among patients with a positive first biopsy, 52% had disease progression on initial surveillance. Overall, disease progression was seen in 48% of patients receiving BCG + INF-α2B therapy, and 28% of all patients eventually underwent radical cystectomy. All outcomes occurred more frequently in patients undergoing combination intravesical therapy compared with patients given BCG monotherapy.

CONCLUSIONS

Patients with bladder cancer undergoing salvage intravesical BCG + INF-α2B at our institution had a > 50% chance of disease recurrence and progression, and > 25% of patients eventually proceeded to radical cystectomy. Randomized trials are needed to clarify the issues present in our findings and to determine the appropriate role for concomitant INF therapy in patients when BCG monotherapy has failed.

Optimal schedule of bacillus calmette-guerin for non-muscle-invasive bladder cancer: a meta-analysis of comparative studies

Background

To explore the necessity of maintenance, efficacy of low-dose and superiority of various combination therapies of Bacillus Calmette-Guérin (BCG) in treatment of superficial bladder cancer (BCa).

Methods

Comprehensive searches of electronic databases (PubMed, Embase, and the Cochrane Library) were performed, then a systematic review and cumulative meta-analysis of 21 randomized controlled trials (RCTs) and 9 retrospective comparative studies were carried out according to predefined inclusion criteria.

Results

Significantly better recurrence-free survivals (RFS) were observed respectively in patients who received BCG maintenance, standard-dose and BCG plus epirubicin therapy comparing to those received induction, low-dose and BCG alone. BCG maintenance therapy was also associated with significantly better progression-free survival (PFS), but there were more incidences of adverse events. Pooled results showed no remarkable advantage of BCG combined with Mitomycin C or with interferon α-2b in improving oncologic outcomes. Sensitivity-analyses stratified by study-design and tumor stage led to very similar overall results and often to a decrease of the between-study heterogeneity. Our data confirmed that non-RCT only affected strength rather than direction of the overall results.

Conclusions

All patients with superficial BCa should be encouraged to accept BCG maintenance therapy with standard-dose if well tolerated. Patients can benefit from BCG combined with epirubicin but not from BCG combined with Mitomycin C or interferon α-2b.

MDM2 SNP309 promoter polymorphism and p53 mutations in urinary bladder carcinoma stage T1

Background

Urinary bladder carcinoma stage T1 is an unpredictable disease that in some cases has a good prognosis with only local or no recurrence, but in others can appear as a more aggressive tumor with progression to more advanced stages. The aim here was to investigate stage T1 tumors regarding MDM2 promoter SNP309 polymorphism, mutations in the p53 gene, and expression of p53 and p16 measured by immunohistochemistry, and subsequently relate these changes to tumor recurrence and progression. We examined a cohort of patients with primary stage T1 urothelial carcinoma of the bladder and their tumors.

Methods

After re-evaluation of the original slides and exclusions, the study population comprised 141 patients, all with primary stage T1 urothelial carcinoma of the bladder. The hospital records were screened for clinical parameters and information concerning presence of histologically proven recurrence and progression. The paraffin-embedded tumor material was evaluated by immunohistochemistry. Any mutations found in the p53 gene were studied by single-strand conformation analysis and Sanger sequencing. The MDM2 SNP309 polymorphism was investigated by pyrosequencing. Multivariate analyses concerning association with prognosis were performed, and Kaplan-Meier analysis was conducted for a combination of changes and time to progression.

Results

Of the 141 patients, 82 had at least one MDM2 SNP309 G allele, and 53 had a mutation in the p53 gene, but neither of those anomalies was associated with a worse prognosis. A mutation in the p53 gene was associated with immunohistochemically visualized p53 protein expression at a cut-off value of 50%. In the group with p53 mutation Kaplan-Meier analysis showed higher rate of progression and shorter time to progression in patients with immunohistochemically abnormal p16 expression compared to them with normal p16 expression (p = 0.038).

Conclusions

MDM2 SNP309 promoter polymorphism and mutations in p53 were not associated with worse prognosis in this cohort of patients with primary stage T1 urinary bladder carcinoma. However, patients with abnormal p16 expression and a mutated p53 gene had a higher rate of and a shorter time to progression, and p53 gene mutation was associated with an abnormal immunohistochemistry for p53 at a cut-off of 50%.

A 2-week maintenance regimen of intravesical instillation of bacillus Calmette-Guerin is safe, adherent and effective in patients with non-muscle-invasive bladder cancer: a prospective, multicenter phase II clinical trial

OBJECTIVE

To investigate the safety and efficacy of a maintenance regimen of bacillus Calmette-Guérin therapy including 6-week induction and 2-week maintenance instillation for patients with recurrent or multiple Ta, T1 tumors or carcinoma in situ of the urinary bladder.

METHODS

This study was performed as single-arm multi-institutional study. The enrolled patients had been diagnosed with urothelial carcinoma of the bladder, including the presence of at least two bladder tumors, single tumors recurring within 12 months of follow-up, any Grade 3 Stage Ta or T1 tumor, and primary or recurrent biopsy proven carcinoma in situ. Patients received 81 mg intravesical bacillus Calmette-Guérin (Connaught strain). The instillation was repeated once a week for another 5 weeks, followed by once a week for 2 weeks at months 3, 6, 12, 18, 24, 30 and 36, for a total of 20 instillations in 3 years.

RESULTS

From 28 hospitals, 202 patients were registered. A total of 186 patients matched the inclusion criteria: 139 patients in the Ta/T1group and 47 patients in the carcinoma in situ group. At the 4-year median point of follow-up, recurrence-free survival rates in the Ta/T1 group and the carcinoma in situ group were 76.7 and 77.7%, respectively. Completion rates for maintenance therapy in both groups at months 3, 6, 12, 24 and 36 were 81.7, 68.9, 58.1, 42.5 and 35.0%, respectively. Common toxicities were pain on urination, urinary frequency and gross hematuria. There was no treatment-related death.

CONCLUSIONS

This regimen may be feasible in patients with Ta/T1 tumor or carcinoma in situ; however, future Phase III randomized study is needed to determine whether this regimen would be truly safe and effective compared with 3-week maintenance regimen.

HER2 status in primary stage T1 urothelial cell carcinoma of the urinary bladder

OBJECTIVE

The HER2 receptor is involved in pathways essential for cell proliferation, and is an important predictive and prognostic factor in breast cancer. HER2 probably plays a critical role in many types of cancer, including urothelial carcinoma of the bladder (UCB). Stage T1 UCB exhibits heterogeneous clinical behaviour, and the frequency of HER2 expression in such disease has not been thoroughly examined. The aim of this study was to use an immunohistochemical technique to evaluate the frequency of HER2 expression in a defined population-based cohort of patients registered as having primary stage T1 UCB.

MATERIAL AND METHODS

The initial study population comprised 285 patients registered as having primary stage T1 UCB. The original histological specimens were re-evaluated with regard to T stage and World Health Organization grade. Hospital records provided information on tumour size, multiplicity, possible presence of histologically proven recurrence and progression. The patients were followed for at least 5 years or until death. In tumours still considered stage T1 after re-evaluation, HER2 was investigated by immunohistochemistry of paraffin-embedded material and scored according to the guidelines used in breast cancer.

RESULTS

After histopathological re-evaluation, 201 patients were still T1 UCB and could be investigated regarding HER2 expression. HER2 overexpression was observed in 25 of those patients (12.4%). HER2 status was not significantly associated with recurrence or progression.

CONCLUSIONS

HER2 was overexpressed in 12.4% of the present cohort of patients with primary stage T1 UCB. There was no significant association between tumour HER2 status and prognosis.

Early Re-Resection for T1 Transitional Cell Carcinoma of the Bladder—A Study of Current Practice in the South West of England

Objective:

To evaluate resection and re-resection practice in the South West region of England in patients with newly diagnosed T1 bladder cancer.

Patients and methods:

All patients diagnosed with T1 disease between 2005 and 2008 were identified. Patients with incomplete primary resections were excluded.

Results:

Of 344 patients identified, the primary resection specimen did not contain deep muscle in 110 (32%). In total, 76 patients (22%) underwent a planned re-resection within 8 weeks of their primary resection. In 225 patients, a routine check cystoscopy was performed at an interval of 3 months or greater. The remainder had no further cystoscopy. Residual disease was present in 38 (50%) patients undergoing early re-resection and 89 (40%) patients in the routine check cystoscopy group. Upstaging of tumours from T1 to T2 was demonstrated in 7% and 5% of patients within these respective groups. Grade of operating surgeon was not a predictor of adequacy of resection or tumour persistence/recurrence.

Conclusions:

Primary transurethral resection remains an area for improvement in contemporary practice. Early re-resection should be performed in patients with newly diagnosed T1 bladder cancer unless precluded by co-morbidity to ensure complete resection, accurate staging and facilitate risk stratification. Selective approaches to re-resection risk delayed treatment of significant residual disease.

Completeness and correctness of registration of renal pelvic and ureteral cancer in the Swedish Cancer Registry

OBJECTIVE

To study the completeness and correctness of the Swedish Cancer Registry (SCR) for renal pelvic and ureteral carcinomas diagnosed in western Sweden.

MATERIAL AND METHODS

We performed a retrospective clinical and histopathological study of 939 patients in the SCR with a diagnosis of a renal pelvic or ureteral carcinoma between 1971 and 1998 and of 54 patients with a diagnosis of tumors in multiple locations in the urinary tract. In addition, we reviewed our earlier bladder cancer studies to assess whether patients with upper urinary tract tumors had been notified to the SCR.

RESULTS

There were 68 false-positive patients (7.2%) out of 939 in the SCR. The commonest diagnoses were other urological malignancies (n=46) and no malignancy at all (n=15). There were five false-positives (9.3%) out of 54 patients in the file with tumors in multiple locations. Twenty-eight patients with renal pelvic or ureteral carcinoma were identified in our earlier studies but not found in the SCR. Most discrepancies were attributable to inadequate or missing notification by the urologist and registration errors.

CONCLUSIONS

The completeness and correctness of the registration of renal pelvic and ureteral carcinomas are unsatisfactory but in line with registries for some other primary sites. The notification of upper urinary tract tumors among patients with a history of bladder cancer was poor, in particular in patients not treated with surgery. Improved communication between reporting sources and the registry is needed. Clinical and histopathological reviews seem necessary in studies based on the SCR.

Urinary fibronectin as a predictor of a residual tumour load after transurethral resection of bladder transitional cell carcinoma

OBJECTIVE

To determine whether the level of urinary fibronectin predicts the residual tumour load after transurethral resection (TUR) of bladder transitional cell carcinoma (TCC).

PATIENTS AND METHODS

Urine samples were collected from 167 consecutive patients with suspected bladder cancer admitted for TUR. Samples were taken both before and after surgery. Bladder tumour fibronectin (BTF) was analysed using a solid-phase chemiluminescent immunometric test. Creatinine in urine was also determined and the BTF/creatinine ratio calculated.

RESULTS

Patients were divided into a control group of 41 whose previous diagnosis was negative for BT and another of 126 with a positive diagnosis for BT, which was further subdivided into those with and without residual tumour, according to findings from specimens obtained during the second procedure (repeat TUR or cystectomy). After the second procedure, 68 patients (56%) had no residual tumour, whereas 54 (44%) did. Four patients with BT who did not have the second procedure were excluded from the study. The median BTF and BTF/creatinine value in the control group was 33.2 microg/L and 51.4 microg/g, respectively, before the first TUR, and 29.6 microg/L and 46.7 microg/g, respectively, after the first TUR. There were no statistically significant changes in BTF and BTF/creatinine ratio (P = 0.61 and 0.79, respectively). In the group with TCC, the BTF decreased from 211.9 to 97.3 microg/L (P = 0.02) and the BTF/creatinine ratio from 281.6 to 146.5 microg/g (P = 0.009) for those with residual tumour, while it decreased from 195.1 to 34.0 microg/L (P = 0.007) and the BTF/creatinine ratio decreased from 249.1 to 53.7 microg/g (P = 0.003) for those with no residual tumour. After initial TUR, the patients with residual tumour had significantly greater levels of BTF and BTF/creatinine than did those with no residual tumour (P = 0.004 and 0.006, respectively). The receiver operating characteristic curves showed an optimum threshold of 67.8 microg/L and 81.3 microg/g for BTF and the BTF/creatinine in detecting residual tumour, respectively, with a sensitivity of 91.4% and 89.0%, respectively, and a specificity of 87.8% and 85.6%, respectively.

CONCLUSION

Urinary fibronectin, in addition to being one of the best markers for diagnosing bladder carcinoma, can be used to determine the presence of residual tumour load after TUR of bladder TCC.

Bacille Calmette-Guérin intravesical instillation and erectile function: is there a concern?

The aim of our study was to evaluate the effect of bacille Calmette-Guérin (BCG) therapy on erectile function in a cohort of male patients affected by non-muscle invasive bladder cancer. Thirty male patients undergoing BCG treatment for non-muscle invasive bladder cancer were enrolled in the study. Their mean age was 60.4 years. None of the patients had risk factors for erectile dysfunction (ED). All subjects underwent a BCG standard schedule therapy (once weekly instillation for 6 weeks). International Index of Erectile Function (IIEF-5) and International Prostate Symptom score (I-PSS) were addressed to the patients during the treatment schedule (at fourth or fifth instillation) and 1 month after the last instillation. The mean IIEF-5 score was 17.6 +/- 6.7 during therapy and 21.7 +/- 2.92 a month after the last instillation (P=0.008). Baseline ED and the association with lower urinary tract symptoms are variables significantly connected with post-treatment results (P=0.016 and 0.00 respectively) whereas the age seems not to be related to ED (P=0.256). No major side effects were recorded. It is concluded that BCG treatment is effective for prophylaxis of non-muscle invasive bladder cancer; however, it may induce a high incidence of ED. Although this effect is transient and reversible, erectile failure is another source of psychological distress that adversely affects the quality of life of men undergoing BCG treatment.

Treatment paradigm shift may improve survival of patients with high risk superficial bladder cancer

PURPOSE

Historically patients with recurrent T1 bladder tumors after bacillus Calmette-Guerin have been treated with bladder sparing approaches. Recently a paradigm shift has occurred since patients are increasingly offered radical cystectomy before disease progression to muscle invasion. In this study we explored the effect of this paradigm shift on progression rates and disease specific survival.

MATERIALS AND METHODS

The historical cohort consisted of 307 patients from 3 prospective intravesical bacillus Calmette-Guerin protocols from 1980 to 1989. An institutional review board approved review identified 589 patients treated with bacillus Calmette-Guerin in a contemporary cohort from 1992 to 2004.

RESULTS

In the historical cohort the 85 patients with documented T1 recurrence were initially treated with repeat transurethral resection and intravesical bacillus Calmette-Guerin. Of these 85 patients 60 had progression to muscle invasive disease. At 5 years after T1 recurrence, the cumulative incidence of progression to T2 disease was 71% (95% CI 61%, 81%) and the cumulative incidence of death from disease was 48% (95% CI 39%, 60%). In the contemporary cohort 129 patients had documented T1 recurrence. In this cohort 65 of the 129 patients with recurrent T1 underwent immediate radical cystectomy. At 5 years after T1 recurrence, the cumulative incidence of progression to muscle invasive disease was 28% (95% CI 20%, 38%) and the cumulative incidence of death from disease was 31% (95% CI 22%, 42%).

CONCLUSIONS

Preemptive radical cystectomy performed for recurrent T1 disease following intravesical bacillus Calmette-Guerin therapy may be associated with better disease specific survival.

Mathematical Model of BCG Immunotherapy in Superficial Bladder Cancer

Immunotherapy with Bacillus Calmette-Guérin (BCG)-an attenuated strain of Mycobacterium bovis (M. bovis) used for anti tuberculosis immunization-is a clinically established procedure for the treatment of superficial bladder cancer. However, the mode of action has not yet been fully elucidated, despite much extensive biological experience. The purpose of this paper is to develop a first mathematical model that describes tumor-immune interactions in the bladder as a result of BCG therapy. A mathematical analysis of the ODE model identifies multiple equilibrium points, their stability properties, and bifurcation points. Intriguing regimes of bistability are identified in which treatment has potential to result in a tumor-free equilibrium or a full-blown tumor depending only on initial conditions. Attention is given to estimating parameters and validating the model using published data taken from in vitro, mouse and human studies. The model makes clear that intensity of immunotherapy must be kept in limited bounds. While small treatment levels may fail to clear the tumor, a treatment that is too large can lead to an over-stimulated immune system having dangerous side effects for the patient.

[Pronostic factors on recurrence and progression of superficial bladder cancer. Risk groups (part II)]

INTRODUCTION

We try to establish risk groups combining the characteristics of each bladder tumour, for a better monitoring of these patients.

MATERIAL AND METHODS

Once known the variables implied in recurrence and progression we analyze the data to establish the extreme groups, so, the one with the worse and the one with the better prognostic, remaining a residual group that would correspond of the tumours of intermediate prognostic.

RESULTS

From the results obtained, we can establish three risk groups: Bad prognostic group (high risk) : High grade tumours (G3), isolated or associated Tis and multiple or recurrent grade 2 tumours that were recurred in less than 6 months; Intermediate prognostic group: multiple TaG1 tumours, as well as not multiple Ta-1G2 and T1GI (less than 3 tumours) and Group of low risk: Single TaG1 tumours.

DISCUSSION

According to these results the group of badly risk, involves a high risk of recurrence and progression. The most effective treatment was the BCG (bacillus Calmette-Guerin) with maintenance, requiring a long-term control, more intense in the 2 first years after the RTU. In the group of intermediate risk, the rates of long-term superficial recurrence were as high as those of the high risk group, being needed a long-term control, in this group was effective the treatment with chemotherapy or BCG being preferably the maintenance. Finally in the group of good risk we don't objectify progressions being the time to the recurrence the longest one, with stabilization of the rate of recurrences after one year.

Can Restaging Transurethral Resection of T1 Bladder Cancer Select Patients for Immediate Cystectomy?

PURPOSE

We determined whether pathological findings on restaging transurethral resection predict early stage progression of T1 bladder cancer.

MATERIALS AND METHODS

A cohort of 352 patients presenting with T1 bladder cancer on initial transurethral resection was evaluated by second or restaging transurethral resection. All patients received bacillus Calmette-Guerin therapy and 88% were followed for 5 years. Pathological findings on restaging transurethral resection were correlated with tumor features, stage progression frequency and progression-free survival.

RESULTS

Of the 352 patients with T1 tumors 203 (58%) had residual tumor on restaging transurethral resection, including 92 (26%) with residual nonmuscle invasive (T1) cancer. During 5 years 66% of cases recurred and 35% progressed in stage. Of the 92 patients with residual T1 cancer 75 (82%) progressed to muscle invasion within 5 years compared to 49 of 260 (19%) who had no or nonT1 tumor detected on restaging transurethral resection.

CONCLUSIONS

Restaging transurethral resection identifies patients with T1 bladder cancer who are at high risk for early tumor progression, justifying immediate cystectomy.

Superficial and Muscle-Invasive Bladder Cancer: Principles of Management for Outcomes Assessments

Bladder cancer is a heterogeneous disease. Non–muscle-invasive bladder cancer embraces a spectrum of tumors with varying degrees of clinical behavior. Transurethral resection remains the surgical mainstay for the treatment of non–muscle-invasive bladder cancer. In an attempt to decrease the recurrence or progression rate, intravesical chemotherapy or immunotherapy is also used. Radical cystectomy with bilateral pelvic lymph node dissection remains the gold standard for treating muscle-invasive bladder cancer. Over the last decade, the orthotopic neobladder has gained widespread popularity as the preferred mode of urinary diversion in both males and females with similar oncologic and functional outcomes. Well-designed trials with effective chemotherapy have shown a beneficial role for neoadjuvant chemotherapy.

A re-staging transurethral resection predicts early progression of superficial bladder cancer

OBJECTIVE

To determine whether pathology on a re-staging transurethral resection (TUR) predicts the early progression of superficial bladder cancer.

PATIENTS AND METHODS

In all, 710 patients presenting with multiple superficial bladder cancers were evaluated by re-staging TUR and followed for 5 years. Tumours were classified by stage as confined to mucosa (Ta) or invading submucosa (T1), and by grade (low- or high-grade). Pathology on re-staging TUR was correlated with the endpoints of tumour recurrence and stage progression.

RESULTS

Of the 710 patients, 490 (69%) had a recurrence and 149 (21%) progressed over 5 years. Eighty patients had high-grade invasive (T1G3) cancer on re-staging TUR and 61 (76%) progressed to muscle invasion (median time to progression 15 months), compared with 88 of 630 (14%) who had no evidence of tumour (T0) or other than T1 tumours detected on re-staging TUR.

CONCLUSION

A re-staging TUR identifies patients with superficial bladder cancer who are at high risk of early tumour progression.

Antisense oligodeoxynucleotide therapy for bladder cancer: recent advances and future prospects

Despite remarkable progress in therapeutic options for the management of bladder cancer, it remains a challenge for urologists to achieve successful outcomes in the treatment of both superficial and invasive bladder cancers. In this review, recent advances in the field of antisense oligodeoxynucleotide therapy targeting several genes playing functionally important roles in the progression and recurrence of bladder cancer are summarized. Data showing the synergistic antitumor activities of antisense oligodeoxynucleotide therapy, combined with several treatments, including cytotoxic chemotherapy, radiation and other molecular targeting therapies, are also presented. Finally, the future direction of antisense oligodeoxynucleotide therapy in the therapeutic strategy of bladder cancer is discussed. These findings may help clarify the significance of antisense oligodeoxynucleotide therapy as an attractive alternative to conventional strategies.

Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials

OBJECTIVES

To provide tables that allow urologists to easily calculate a superficial bladder cancer patient's short- and long-term risks of recurrence and progression after transurethral resection.

METHODS

A combined analysis was carried out of individual patient data from 2596 superficial bladder cancer patients included in seven European Organization for Research and Treatment of Cancer trials.

RESULTS

A simple scoring system was derived based on six clinical and pathological factors: number of tumors, tumor size, prior recurrence rate, T category, carcinoma in situ, and grade. The probabilities of recurrence and progression at one year ranged from 15% to 61% and from less than 1% to 17%, respectively. At five years, the probabilities of recurrence and progression ranged from 31% to 78% and from less than 1% to 45%.

CONCLUSIONS

With these probabilities, the urologist can discuss the different options with the patient to determine the most appropriate treatment and frequency of follow-up.

Factores pronósticos en la recidiva y progresión del cáncer superficial vesical. Grupos de riesgo (Parte I)

INTRODUCTION

We have carried out a retrospective study on a series of superficial bladder tumours, analyzing the clinical-pathological factors that can determine the subsequent evolution of the tumour as for recurrence and progression.

MATERIAL AND METHODS

They were revised on the whole 473, of which finally 419 superficial bladder tumours were useful for the study (223 primary tumours and 196 recurrent). Studies are carried out univariate and multivariate on 24 variables of each tumour referred to the characteristics and to the evolution of the tumour.

RESULTS

We find significant differences in the free time to recurrence, diminishing it in the tumours that recurred in less than 12 months, in multiple tumours (3 or more tumours) and in bladder dome tumours. Also statistically significant differences existed when were studied two homogeneous groups of surgeons, while the treatment with bladder instillations increased it. The time to progression, diminishes in: Tumours that had recurred prematurely (in 6 months), tumours over 3 cm, high grade tumours and when two groups of surgeons were studied, we also find that the maintenance therapy with BCG (bacillus Calmette-Guerin) showed a greater time to progression versus induction therapy.

DISCUSSION

The independent factors to explain smaller free time till superficial recurrence were: recurrence in the 1 degree year, multiplicity, surgical technique, not employment of bladder washes, treatment with low dose of BCG and use of intravesical therapy with induction therapy versus maintenance. About the progression, we objectify that the factors with greater influence in the progression were, recurrence in the first 6 months, grade (grade 2 and grade 3 + Tis) and treatment with maintenance therapy versus induction.

RESTAGING TRANSURETHRAL RESECTION OF HIGH RISK SUPERFICIAL BLADDER CANCER IMPROVES THE INITIAL RESPONSE TO BACILLUS CALMETTE-GUERIN THERAPY

PURPOSE

This study was an evaluation of whether restaging transurethral resection (TUR) of superficial bladder cancer improves the early response to bacillus Calmette-Guerin (BCG) therapy.

MATERIALS AND METHODS

A total of 347 patients with high risk superficial bladder cancer (high grade Ta and T1 tumors associated with carcinoma in situ) underwent a single transurethral resection (TUR, 132 patients) or restaging TUR (215 patients) before receiving 6 weekly intravesical BCG treatments. The patients were evaluated for response (presence or absence of tumor) at first followup cystoscopy, at 6 and 12 months after treatment, and evaluated for disease stage progression within 3 years of followup.

RESULTS

Of the 132 patients who underwent a single TUR before BCG therapy, 75 (57%) had residual or recurrent tumor at the first cystoscopy and 45 (34%) later had progression, compared with 62 of 215 patients (29%) who had residual or recurrent tumors and 16 (7%) who had progression after undergoing restaging TUR (p = 0.001).

CONCLUSIONS

Restaging TUR of high risk superficial bladder cancer improves the initial response rate to BCG therapy, reduces the frequency of subsequent tumor recurrence and appears to delay early tumor progression.

Immunostimulatory CpG oligonucleotides reduce tumor burden after intravesical administration in an orthotopic murine bladder cancer model

Bacillus Calmette-Guérin is established in the prophylaxis of recurrent intermediate and high-risk superficial bladder cancer and induces an unspecific, Th1-biased local immune response. Small CpG oligonucleotides (CpG ODN) containing a central unmethylated CpG motif are able to mimic the immunostimulatory activity of bacterial DNA. The purpose of the present study was to evaluate the antineoplastic properties of intravesically administered CpG ODN in an orthotopic murine bladder cancer model. MB49 tumor cell suspension was instilled transurethrally in female C57/BL6 mice on day 0. Mice were divided in three groups of 12 animals. Four mice in each group received either stimulative CpG ODN, non-stimulative GpC ODN or PBS intravesically: group I on day 3, group II on day 5, group III on day 7. After sacrifice 7 days after treatment, bladders were removed and histological examinations were performed. Single instillation of CpG ODN revealed antineoplastic effects in every group demonstrated by significantly lower bladder weight compared with non-stimulative GpC ODN- and PBS-treated mice. Histological examination showed extensive infiltration of macrophages and lymphocytes in CpG ODN-treated mice, whereas PBS- and GpC ODN-treated mice showed solid tumor growth with only few leucocytes. Intravesically applied immunostimulative DNA demonstrated antitumoral activity in an orthotopic murine bladder cancer model. A single instillation seems to be sufficient to reduce tumor load.

Surgical factors in the treatment of superficial and invasive bladder cancer

Tumor stage, grade, and variations in biologic behavior are primary features that largely determine bladder cancer outcomes. Quality of surgery used to assess and treat bladder tumors is critical to a successful outcome. Diagnosis, prognosis, local tumor control, and survival are highly dependent on surgical factors associated with the quality of surgical methods. In cases of superficial bladder tumors, this involves an aggressive TUR of all visible and suspected tumors, including a second resection in most cases. For invasive bladder cancers, radical cystectomy and a complete PLND are required. Both procedures require a high level of skill to achieve a successful outcome. Urologists have no control over the extent of disease or tumor biology, but can control how they evaluate and treat patients. The challenge is how to get better at maximizing surgical efforts. The who and how of surgery in bladder cancer does indeed matter.