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Melgarejo Segura MT, Yáñez Castillo Y, Lozano Lorca M, Morales Martínez A, Arrabal Polo MÁ, Arrabal Martín M. Efficacy of conduction hyperthermia in the treatment of non-muscle invasive bladder cancer: A systematic review. Urol Oncol 2024; 42:251-265. [PMID: 38670818 DOI: 10.1016/j.urolonc.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/01/2024] [Accepted: 03/18/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Intravesical treatment for non-muscle invasive bladder cancer (NMIBC) aims to reduce recurrences and stop progression. Hyperthermia-enhanced chemotherapy with devices like COMBAT BRS, Unithermia, and BR-TRG-I is a promising alternative to conventional Bacillus de Calmette Guerin (BCG) therapy. OBJECTIVE To systematically review the efficacy of hyperthermia generated by conduction devices in the treatment of NMIBC. MATERIAL AND METHODS The review followed the preferred reporting items for systematic reviews and meta-analyses guidelines. A search was performed in the PubMed, Cochrane Library, Scopus, and ClinicalTrials.gov databases. Two reviewers independently assessed the eligibility of candidate studies and abstracted data from studies that met the inclusion criteria. The primary endpoint was assessment of recurrence. Secondary objectives included evaluation of treatment progression and safety. RESULTS Thirty studies meeting inclusion criteria underwent data extraction. In intermediate-risk NMIBC patients, COMBAT versus mitomycin C (MMC) in normothermia revealed no superiority in reducing recurrence or progression. High-risk NMIBC patients using COMBAT achieved similar or superior outcomes to BCG. BR-TRG-I demonstrated superior results over normothermia in intermediate- and high-risk NMIBC patients. Unithermia proved less effective than BCG in high-risk NMIBC. Progression outcomes were promising with COMBAT and BR-TRG-I, but comprehensive analysis was limited due to inconsistent assessment across studies. Adverse events were primarily mild-moderate, with some device-specific differences. CONCLUSIONS Studies on conduction hyperthermia present great variability, which do not allow us to determine the superiority of 1 device over another in terms of recurrence, progression, and/or adverse effects. Further research with consistent administration protocols is crucial for definitive conclusions.
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Affiliation(s)
| | | | - Macarena Lozano Lorca
- Department of Preventive Medicine and Public Health, University of Granada, Melilla, Spain; Institute of Biosanitary Research ibs. Granada, Granada, Spain
| | | | - Miguel Ángel Arrabal Polo
- Department of Urology, University Hospital San Cecilio, Granada, Spain; Institute of Biosanitary Research ibs. Granada, Granada, Spain
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Gontero P, Birtle A, Capoun O, Compérat E, Dominguez-Escrig JL, Liedberg F, Mariappan P, Masson-Lecomte A, Mostafid HA, Pradere B, Rai BP, van Rhijn BWG, Seisen T, Shariat SF, Soria F, Soukup V, Wood R, Xylinas EN. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ)-A Summary of the 2024 Guidelines Update. Eur Urol 2024:S0302-2838(24)02514-4. [PMID: 39155194 DOI: 10.1016/j.eururo.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/29/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND AND OBJECTIVE This publication represents a summary of the updated 2024 European Association of Urology (EAU) guidelines for non-muscle-invasive bladder cancer (NMIBC), TaT1, and carcinoma in situ. The information presented herein is limited to urothelial carcinoma, unless specified otherwise. The aim is to provide practical recommendations on the clinical management of NMIBC with a focus on clinical presentation. METHODS For the 2024 guidelines on NMIBC, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences. KEY FINDINGS AND LIMITATIONS Key recommendations emphasise the importance of thorough diagnosis, treatment, and follow-up for patients with NMIBC. The guidelines stress the importance of defining patients' risk stratification and treating them appropriately. CONCLUSIONS AND CLINICAL IMPLICATIONS This overview of the 2024 EAU guidelines offers valuable insights into risk factors, diagnosis, classification, prognostic factors, treatment, and follow-up of NMIBC. These guidelines are designed for effective integration into clinical practice.
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Affiliation(s)
- Paolo Gontero
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy.
| | - Alison Birtle
- Rosemere Cancer Centre, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Otakar Capoun
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Eva Compérat
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | | | - Fredrik Liedberg
- Institute of Translational Medicine, Lund University, Malmö, Sweden; Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Paramananthan Mariappan
- Edinburgh Bladder Cancer Surgery (EBCS), Western General Hospital, The University of Edinburgh, Edinburgh, UK
| | | | - Hugh A Mostafid
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Benjamin Pradere
- Department of Urology, La Croix Du Sud Hospital, Quint Fonsegrives, France
| | - Bhavan P Rai
- Department of Urology, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Thomas Seisen
- Urology, GRC 5 Predictive Onco-Uro, AP-HP, Pitie-Salpetriere Hospital, Sorbonne University, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Vienna General Hospital, Medical University Vienna, Vienna, Austria
| | - Francesco Soria
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Viktor Soukup
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Robert Wood
- EAU Guidelines Office, Arnhem, The Netherlands
| | - Evanguelos N Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, AP-HP, Université de Paris, Paris, France
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Wong CHM, Ko ICH, Leung DKW, Yuen SKK, Chan SYS, Yee SCH, Chiu PKF, Ng CF, Teoh JYC. Safety and Efficacy of Immediate Hyperthermic Intravesical Chemotherapy Following Transurethral Resection of Bladder Tumour (I-HIVEC). Eur Urol Oncol 2024:S2588-9311(24)00136-6. [PMID: 38806344 DOI: 10.1016/j.euo.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 05/03/2024] [Accepted: 05/16/2024] [Indexed: 05/30/2024]
Abstract
The recurrence rate following endoscopic treatment of non-muscle-invasive bladder cancer (NMIBC) remains high. Standard treatment includes intravesical instillation of chemotoxic agents such as mitomycin C (MMC) to reduce recurrence. It is postulated that upfront administration of hyperthermic intravesical MMC (HIVEC) immediately after transurethral resection of bladder tumour (TURBT) may enhance its efficacy, but evidence from human trials is scant. This pilot study explored the safety of immediate intravesical MMC instillation following TURBT using a conductive HIVEC system (Combat BRS). Patients diagnosed with papillary bladder tumours scheduled for TURBT were recruited. Among 29 patients treated with HIVEC, there was minimal additional postoperative morbidity. The majority (79.3%) were discharged after a hospital stay of 1 d, and no patient required bladder irrigation. There were six grade I-II adverse events (20.7%) and one grade III event (3.4%). No recurrences were observed within 3 mo, and the 12-mo recurrence rate was 4.5%. The study findings demonstrate that immediate HIVEC MMC instillation following TURBT is safe. Further research is needed to assess long-term efficacy in comparison to standard cold MMC. PATIENT SUMMARY: Non-muscle-invasive bladder cancer is treated with tumour removal via a telescope inserted into the bladder through the urethra (called TURBT). We tested the safety of treating the bladder with a warm solution of a chemotherapy drug (mitomycin C) immediately after TURBT, as this may prevent tumour recurrence. The treatment was safe and well tolerated. Further trials are needed with more patients and longer follow-up to confirm the results.
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Affiliation(s)
- Chris Ho-Ming Wong
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Ivan Ching-Ho Ko
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - David Ka-Wai Leung
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Steffi Kar-Kei Yuen
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Samson Yun-Sang Chan
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Samuel Chi-Hang Yee
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Peter Ka-Fung Chiu
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Chi-Fai Ng
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Jeremy Yuen-Chun Teoh
- SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China; Department of Urology, Medical University of Vienna, Vienna, Austria; European Association of Urology Young Academic Urologists Urothelial Cancer Working Group, Arnhem, The Netherlands.
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Pazir Y, Esmeray A, Caglar U, Erbin A, Ozgor F, Sarilar O, Akbulut F. Comparison of hyperthermic intravesical chemotherapy and Bacillus Calmette-Guerin therapy in high-risk non-muscle invasive bladder cancer: a matched-pair analysis. Int Urol Nephrol 2024; 56:957-963. [PMID: 37880493 DOI: 10.1007/s11255-023-03849-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/06/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE To compare adjuvant hyperthermic intravesical chemotherapy (HIVEC) with mitomycin C and standard Bacillus Calmette-Guerin (BCG) therapy in terms of oncological outcomes and adverse events in patients with high-risk non-muscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS The data of patients with high-risk papillary NMIBC treated with adjuvant intravesical BCG instillations or HIVEC in our institution between June 2017 and August 2022 were analyzed retrospectively. Twenty-four patients who received HIVEC were matched 1:1 with patients receiving BCG therapy based on tumor characteristics (tumor stage and grade), age, gender, smoking status, and the number of tumors (single or multiple). HIVEC and standard BCG treatments were compared in terms of recurrence-free survival (RFS), progression-free survival (PFS), and adverse events. RESULTS Forty-eight patients (24 in the BCG group and 24 in the HIVEC group) were included in the study. The median follow-up times of the BCG and HIVEC groups were 32 [interquartile range (IQR): 28.0-47.8] and 28 (IQR: 16.7-41.8) months, respectively (p = 0.11). There was no significant difference between the groups in terms of the 24-month RFS (BCG 83% vs HIVEC 88%, p = 0.64) and the 24-month PFS (BCG 100% vs HIVEC 94%, p = 0.61). Regarding the safety profile, at least one adverse event occurred in 13 (54%) of the patients in the BCG group and 12 (50.0%) of those in the HIVEC group (p = 0.77). CONCLUSION This study demonstrated that HIVEC with mitomycin C has a similar oncological efficacy and safety profile to standard BCG therapy in high-risk NMIBC.
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Affiliation(s)
- Yasar Pazir
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey.
| | - Abdullah Esmeray
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Ufuk Caglar
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Akif Erbin
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Faruk Ozgor
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Omer Sarilar
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Fatih Akbulut
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
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You C, Li Q, Qing L, Li R, Wang Y, Cheng L, Dong Z. Device-assisted intravesical chemotherapy versus bacillus Calmette-Guerin for intermediate or high-risk non-muscle invasive bladder cancer: a systematic reviewer and meta-analysis. Int Urol Nephrol 2024; 56:103-120. [PMID: 37659995 DOI: 10.1007/s11255-023-03765-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 08/19/2023] [Indexed: 09/04/2023]
Abstract
PURPOSE To investigate the effectiveness and safety of device-assisted intravesical chemotherapy compared to Bacillus Calmette-Guerin (BCG) in the treatment of patients with intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC). METHODS In February 2023, a systematic search was conducted on the PubMed, Cochrane, and Embase databases. Following the PRISMA guidelines, a systematic review and meta-analysis of the primary outcomes of interest were performed. The review was prospectively registered on PROSPERO under the registration number CRD42023398559. RESULTS A total of 10 studies involving 1160 patients were included. The results of the meta-analysis showed that compared to BCG, device-assisted chemotherapy had a lower recurrence rate (OR: 0.63, 95% CI: 0.48-0.84, p = 0.001), longer recurrence-free survival (OR: 0.64, 95% CI: 0.47-0.88, p = 0.006), and lower incidence of fever (OR: 0.18, 95% CI: 0.08-0.44, p = 0.0002). However, no significant differences were observed between the two groups in terms of progression, overall survival, progression-free survival, disease-free survival, overall adverse events, serious adverse events, hematuria, allergy, and general discomfort. Subgroup analysis revealed that neither chemohyperthermia (CHT) nor electromotive drug administration (EMDA) showed statistically significant differences in oncological outcomes compared to BCG. Regarding adverse events, both CHT and EMDA groups showed lower rates of fever compared to the BCG group (OR: 0.26, 95% CI: 0.10-0.67, p = 0.005, and OR: 0.14, 95% CI: 0.05-0.37, p < 0.0001, respectively). No significant differences were observed in the remaining adverse events between either the CHT or EMDA group and the BCG group. CONCLUSION Device-assisted intravesical chemotherapy appears to be a safe and viable alternative to BCG for patients with intermediate and high-risk NMIBC, showing comparable oncological outcomes and adverse events.
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Affiliation(s)
- Chengyu You
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Qingchao Li
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Liangliang Qing
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Rongxin Li
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Yanan Wang
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Long Cheng
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China
| | - Zhilong Dong
- Department of Urology, Lanzhou University Second Hospital, Lanzhou, 730000, Gansu, China.
- Institute of Urology, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China.
- Gansu Province Key Laboratory of Urological Diseases, Lanzhou, 730030, Gansu, China.
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Akbulut F, Pazir Y, Esmeray A, Erbin A, Ozgor F, Sarilar O. The efficacy of hyperthermic intravesical chemotherapy in high-risk non-muscle-invasive bladder cancer patients with BCG intolerance. Urologia 2023; 90:631-635. [PMID: 37470319 DOI: 10.1177/03915603231189022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND AND AIM Some patients with high-risk non-muscle-invasive bladder cancer (NMIBC) are unable to receive adequate BCG instillations due to intolerance. In this study we aimed to investigate the efficacy and tolerability of hyperthermic intravesical chemotherapy (HIVEC®) treatment using Mitomycin C (MMC) in BCG-intolerant NMIBC patients. METHODS Retrospectively collected data from a total of 22 high-risk papillary NMIBC patients who received adjuvant HIVEC therapy for BCG intolerance were analyzed. The primary outcomes of the study were recurrence-free survival (RFS), time to recurrence, progression-free survival (PFS), and time to progression following initial TURB. Detection of histologically confirmed urothelial carcinoma during follow-up was considered as recurrence, while detection of muscle-invasive disease was defined as progression. The secondary outcome was adverse events of HIVEC treatment. RESULTS The median follow-up was 32.2 (IQR: 17.8-42.8) months. The RFS and PFS rates were 81.8% and 95.4%, respectively. The mean time to tumor recurrence and progression was 29.2 ± 14.3 and 16.7 months, respectively. Adverse events occurred in 50% of patients, and 95% of adverse events were mild to moderate. CONCLUSION This study demonstrated that adjuvant HIVEC with MMC is an effective and safe alternative bladder sparing treatment in BCG intolerant high risk papillary NMIBC patients.
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Affiliation(s)
- Fatih Akbulut
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Yasar Pazir
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Abdullah Esmeray
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Akif Erbin
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Faruk Ozgor
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Omer Sarilar
- Department of Urology, Haseki Training and Research Hospital, Istanbul, Turkey
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Yim K, Melnick K, Mott SL, Carvalho FLF, Zafar A, Clinton TN, Mossanen M, Steele GS, Hirsch M, Rizzo N, Wu CL, Mouw KW, Wszolek M, Salari K, Feldman A, Kibel AS, O'Donnell MA, Preston MA. Sequential intravesical gemcitabine/docetaxel provides a durable remission in recurrent high-risk NMIBC following BCG therapy. Urol Oncol 2023; 41:458.e1-458.e7. [PMID: 37690933 DOI: 10.1016/j.urolonc.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Bacillus Calmette-Guerin (BCG) is the standard of care for high-risk nonmuscle invasive bladder cancer (NMIBC), but half of patients develop disease recurrence. Intravesical regimens for BCG unresponsive NMIBC are limited. We report the safety, efficacy, and differential response of sequential gemcitabine/docetaxel (gem/doce) depending on BCG failure classification. METHODS Multi-institutional retrospective analysis of patients treated with induction intravesical gem/doce (≥5/6 instillations) for recurrent high-risk NMIBC after BCG therapy from May 2018 to December 2021. Maintenance therapy was provided to those without high-grade (HG) recurrence on surveillance cystoscopy. Kaplan-Meier curves and Cox regression analyses were utilized to assess survival and risk factors for disease recurrence. RESULTS Our cohort included 102 patients with BCG-unresponsive NMIBC. Median age was 72 years and median follow-up was 18 months. Six-, 12-, and 24-month high-grade recurrence-free survival was 78%, 65%, and 49%, respectively. Twenty patients underwent radical cystectomy (median 15.5 months from induction). Six patients progressed to muscle invasive disease. Fifty-seven percent of patients experienced mild/moderate adverse effects (AE), but only 6.9% experienced a delay in treatment schedule. Most common AE were urinary frequency/urgency (41%) and dysuria (21%). Patients with BCG refractory disease were more likely to develop HG recurrence when compared to patients with BCG relapsing disease (HR 2.14; 95% CI 1.02-4.49). CONCLUSIONS In patients with recurrence after BCG therapy, sequential intravesical gem/doce is an effective and well-tolerated alternative to early cystectomy. Patients with BCG relapsing disease are more likely to respond to additional intravesical gem/doce. Further investigation with a prospective trial is imperative.
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Affiliation(s)
- Kendrick Yim
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | - Kevin Melnick
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | - Sarah L Mott
- Department of Urology, University of Iowa, Iowa City, IA
| | | | - Affan Zafar
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | | | | | - Graeme S Steele
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | - Michelle Hirsch
- Department of Pathology, Brigham and Women's Hospital, Boston MA
| | - Natalie Rizzo
- Department of Pathology, Brigham and Women's Hospital, Boston MA
| | - Chin-Lee Wu
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Kent W Mouw
- Department of Radiation Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Matthew Wszolek
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | - Keyan Salari
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | - Adam Feldman
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | - Adam S Kibel
- Division of Urology, Brigham and Women's Hospital, Boston, MA
| | | | - Mark A Preston
- Division of Urology, Brigham and Women's Hospital, Boston, MA.
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Grabe-Heyne K, Henne C, Mariappan P, Geiges G, Pöhlmann J, Pollock RF. Intermediate and high-risk non-muscle-invasive bladder cancer: an overview of epidemiology, burden, and unmet needs. Front Oncol 2023; 13:1170124. [PMID: 37333804 PMCID: PMC10272547 DOI: 10.3389/fonc.2023.1170124] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/19/2023] [Indexed: 06/20/2023] Open
Abstract
Bladder cancer ranks among the most common cancers globally. At diagnosis, 75% of patients have non-muscle-invasive bladder cancer (NMIBC). Patients with low-risk NMIBC have a good prognosis, but recurrence and progression rates remain high in intermediate- and high-risk NMIBC, despite the decades-long availability of effective treatments for NMIBC such as intravesical Bacillus Calmette-Guérin (BCG). The present review provides an overview of NMIBC, including its burden and treatment options, and then reviews aspects that counteract the successful treatment of NMIBC, referred to as unmet treatment needs. The scale and reasons for each unmet need are described based on a comprehensive review of the literature, including insufficient adherence to treatment guidelines by physicians because of insufficient knowledge, training, or access to certain therapy options. Low rates of lifestyle changes and treatment completion by patients, due to BCG shortages or toxicities and adverse events as well as their impact on social activities, represent additional areas of potential improvement. Highly heterogeneous evidence for the effectiveness and safety of some treatments limits the comparability of results across studies. As a result, efforts are underway to standardize treatment schedules for BCG, but intravesical chemotherapy schedules remain unstandardized. In addition, risk-scoring models often perform unsatisfactorily due to significant differences between derivation and real-world cohorts. Reporting in clinical trials suffers from a lack of consistent outcomes reporting in bladder cancer clinical trials, paired with an under-representation of racial and ethnic minorities in many trials.
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Affiliation(s)
| | | | - Paramananthan Mariappan
- Edinburgh Bladder Cancer Surgery (EBCS), Department of Urology, Western General Hospital, Edinburgh, United Kingdom
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Zeng N, Xu MY, Sun JX, Liu CQ, Xu JZ, An Y, Zhong XY, Ma SY, He HD, Xia QD, Wang SG. Hyperthermia intravesical chemotherapy acts as a promising alternative to bacillus Calmette-Guérin instillation in non-muscle-invasive bladder cancer: a network meta-analysis. Front Oncol 2023; 13:1164932. [PMID: 37251942 PMCID: PMC10213538 DOI: 10.3389/fonc.2023.1164932] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction With the shortage of bacillus Calmette-Guérin (BCG) vaccine, it is important to find an alternative to BCG instillation, which is the most commonly used adjuvant treatment for non-muscle-invasive bladder cancer (NMIBC) patients after transurethral resection of bladder tumor treatment (TURBt) to delay tumor recurrence. Hyperthermia intravesical chemotherapy (HIVEC) with mitomycin C (MMC) is a potential treatment choice. We aim to compare HIVEC with BCG instillation for the preventive efficacy of bladder tumor recurrence and progression. Methods A network meta-analysis (NMA) was taken with MMC instillation and TURBt as the attached comparators. Randomized controlled trials (RCTs) with NIMBC patients after TURBt were included. Articles with pure BCG unresponsive patients and combined therapies were excluded. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023390363). Results It was found that HIVEC had a non-significant 22% relative reduction in bladder tumor recurrence compared with BCG instillation [HIVEC vs. BCG: HR 0.78, 95% credible interval (CrI) 0.55-1.08] and a nonsignificant higher risk of bladder tumor progression (BCG vs. HIVEC: HR 0.77, 95% CrI 0.22-3.03). Discussion HIVEC is a potential alternative to BCG, and it is expected to be the standard therapy for NMIBC patients after TURBt during the global shortage of BCG. Systematic Review Registration PROSPERO identifier, CRD42023390363.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Qi-Dong Xia
- *Correspondence: Qi-Dong Xia, ; Shao-Gang Wang,
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Cerrato C, Roupret M, Mir MC. Results from HIVEC-II for Intermediate-risk Non–muscle-invasive Bladder Cancer: Is This a Dead End for Mitomycin C Hyperthermia? Eur Urol 2023; 83:505-507. [PMID: 36967360 DOI: 10.1016/j.eururo.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/06/2023] [Indexed: 04/03/2023]
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Rahnama’i MS, Marand AJB, Janssen D, Mostafaei H, Gatsos S, Hajebrahimi S, Apostolidis A, Taneja R. Botulinum Toxin Therapy for Bladder Pain Syndrome/Interstitial Cystitis. CURRENT BLADDER DYSFUNCTION REPORTS 2023. [DOI: 10.1007/s11884-023-00695-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Abstract
Purpose of Review
Bladder pain syndrome (BPS)/interstitial cystitis (IC) can also be classified as either non-ulcerative or ulcerative, corresponding to the characteristic cystoscopic findings under hydrodistention. Promising therapeutic effects, including decreased bladder pain, have been reported from recent clinical trials using botulinum toxin A (BoNTA) for the treatment of BPS/IC. This review summarizes the current state of the literature on the underlying mechanisms of BoNTA therapy in BPS/IC as well as new forms of its application.
Recent Findings
BoNTA has its effect in the central nervous system in the afferent nerves as well as in the bladder wall. Besides the well-known effects of BoNTA in the nervous system, pain control as well as reduction of urinary urgency in BPS patients could be achieved by mast cell stabilization effecting histamine release as well as modulation of TRPV and PGE2 pathways, among other systems. In addition, new forms of BoNTA administration have focused on intravesical instillation of the drug in order to circumvent bladder wall injections. Hyperthermia, intravesical hydrogel, and lysosomes have been studied as new ways of BoNTA application in BPS/IC patients. From the available studies, bladder instillation of BoNTA in combination with EMDA is the most promising and effective novel approach.
Summary
The most promising novel application methods for BoNTA in patient with BPS/IC are bladder instillations. Future research needs to point out if bladder instillations with BoNTA with some form of bladder absorption enhancement such as hyperthermia or EMDA would be able to replace BoNTA injections in patients with BPS/IC
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Yanagisawa T, Quhal F, Kawada T, Mostafaei H, Motlagh RS, Laukhtina E, Rajwa P, Deimling MV, Bianchi A, Pallauf M, Majdoub M, Pradere B, Moschini M, Karakiewicz PI, Teoh JYC, Miki J, Kimura T, Shariat SF. A Systematic Review and Meta-analysis of Chemoablation for Non–muscle-invasive Bladder Cancer. Eur Urol Focus 2022:S2405-4569(22)00287-5. [DOI: 10.1016/j.euf.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/22/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
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Tan WS, Steinberg G, Witjes JA, Li R, Shariat SF, Roupret M, Babjuk M, Bivalacqua TJ, Psutka SP, Williams SB, Cookson MS, Palou J, Kamat AM. Intermediate-risk Non-muscle-invasive Bladder Cancer: Updated Consensus Definition and Management Recommendations from the International Bladder Cancer Group. Eur Urol Oncol 2022; 5:505-516. [PMID: 35718695 DOI: 10.1016/j.euo.2022.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/22/2022] [Accepted: 05/19/2022] [Indexed: 11/29/2022]
Abstract
CONTEXT Intermediate-risk (IR) non-muscle-invasive bladder cancer (NMIBC) is a heterogeneous disease. OBJECTIVE To update the International Bladder Cancer Group (IBCG) guidance and provide practical recommendations on IR NMIBC management. EVIDENCE ACQUISITION A collaborative review of published randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidance on IR NMIBC published before January 2022 was undertaken using PubMed/Medline. EVIDENCE SYNTHESIS Variation exists between guidelines in defining IR NMIBC. The IBCG recommends defining IR NMIBC as any TaLG tumor that is either recurrent or multifocal or has size ≥3 cm, OR any T1LG tumor. If the 3 tier grading system is used, than any TaG2 tumor would also be considered IR diease regardless of whether new diagnosis or recurrent. Accurate grading and staging of tumor, particularly in ruling out HG/G3 disease and/or carcinoma in situ, are crucial. The IBCG recommends that management of IR NMIBC should be further based on the following risk factors: multifocal tumor (more than one), early recurrence (<1 yr), frequent recurrence (>1/yr), tumor size (≥3 cm), and failure of prior intravesical treatment. Patients with no risk factors are best managed by one dose of postoperative intravesical chemotherapy. Patients with one to two risk factors should be offered additional adjuvant induction intravesical chemotherapy (or bacillus Calmette-Guérin (BCG) if prior chemotherapy has been used). Patients with three or more risk factors should be offered induction plus 1-yr maintenance BCG. Where BCG is not available or recurrent disease following BCG is present, alternative intravesical treatments such as chemotherapy (single agent, combination, or chemohyperthermia) or a clinical trial are recommended. CONCLUSIONS Standardizing the definition of IR NMIBC is critical for appropriate management of patients and for allowing a comparison of outcomes across clinical trials. The IBCG recommends defining IR NMIBC as any TaLG tumor that is either recurrent or multifocal or ≥3 cm, OR any T1LG tumor. If the 3 tier grading system is used, than any TaG2 tumor would also be considered IR disease regardless of whether new diagnosis or recurrent. Adjunctive management should then be based on established risk factors. PATIENT SUMMARY Standardizing the definition of intermediate-risk (IR) non-muscle-invasive bladder cancer (NMIBC), which is a heterogeneous disease, is critical for appropriate management of patients. The International Bladder Cancer Group recommends classification of IR NMIBC tumors and personalized management based on the following risk factors: multifocal tumor (more than one), early recurrence (<1 yr), frequent recurrence (>1/yr), tumor size (≥3 cm), and previous intravesical treatment.
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Affiliation(s)
- Wei Shen Tan
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospitals, London, UK
| | - Gary Steinberg
- Department of Urology, New York University, New York City, NY, USA
| | - J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna, Austria; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Morgan Roupret
- Urology, GRC n°5, Predictive ONCO-URO, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Praha, Czech Republic
| | - Trinity J Bivalacqua
- Department of Urology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Michael S Cookson
- Department of Urology, The University of Oklahoma Health Sciences Center & The Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Juan Palou
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Tan WS, Prendergast A, Ackerman C, Yogeswaran Y, Cresswell J, Mariappan P, Phull J, Hunter-Campbell P, Lazarowicz H, Mishra V, Rane A, Davies M, Warburton H, Cooke P, Mostafid H, Wilby D, Mills R, Issa R, Kelly JD. Adjuvant Intravesical Chemohyperthermia Versus Passive Chemotherapy in Patients with Intermediate-risk Non-muscle-invasive Bladder Cancer (HIVEC-II): A Phase 2, Open-label, Randomised Controlled Trial. Eur Urol 2022; 83:497-504. [PMID: 35999119 DOI: 10.1016/j.eururo.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Adjuvant intravesical chemotherapy following tumour resection is recommended for intermediate-risk non-muscle-invasive bladder cancer (NMIBC). OBJECTIVE To assess the efficacy and safety of adjuvant intravesical chemohyperthermia (CHT) for intermediate-risk NMIBC. DESIGN, SETTING, AND PARTICIPANTS HIVEC-II is an open-label, phase 2 randomised controlled trial of CHT versus chemotherapy alone in patients with intermediate-risk NMIBC recruited at 15 centres between May 2014 and December 2017 (ISRCTN 23639415). Randomisation was stratified by treating hospital. INTERVENTIONS Patients were randomly assigned (1:1) to adjuvant CHT with mitomycin C at 43°C or to room-temperature mitomycin C (control). Both treatment arms received six weekly instillations of 40 mg of mitomycin C lasting for 60 min. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was 24-mo disease-free survival as determined via cystoscopy and urinary cytology. Analysis was by intention to treat. RESULTS A total of 259 patients (131 CHT vs 128 control) were randomised. At 24 mo, 42 patients (32%) in the CHT group and 49 (38%) in the control group had experienced recurrence. Disease-free survival at 24 mo was 61% (95% confidence interval [CI] 51-69%) in the CHT arm and 60% (95% CI 50-68%) in the control arm (hazard ratio [HR] 0.92, 95% CI 0.62-1.37; log-rank p = 0.8). Progression-free survival was higher in the control arm (HR 3.44, 95% CI 1.09-10.82; log-rank p = 0.02) on intention-to-treat analysis but was not significantly higher on per-protocol analysis (HR 2.87, 95% CI 0.83-9.98; log-rank p = 0.06). Overall survival was similar (HR 2.55, 95% CI 0.77-8.40; log-rank p = 0.09). Patients undergoing CHT were less likely to complete their treatment (n =75, 59% vs n = 111, 89%). Adverse events were reported by 164 patients (87 CHT vs 77 control). Major (grade III) adverse events were rare (13 CHT vs 7 control). CONCLUSIONS CHT cannot be recommended over chemotherapy alone for intermediate-risk NMIBC. Adverse events following CHT were of low grade and short-lived, although patients were less likely to complete their treatment. PATIENT SUMMARY The HIVEC-II trial investigated the role of heated chemotherapy instillations in the bladder for treatment of intermediate-risk non-muscle-invasive bladder cancer. We found no cancer control benefit from heated chemotherapy instillations over room-temperature chemotherapy. Adverse events following heated chemotherapy were low grade and short-lived, although these patients were less likely to complete their treatment.
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Affiliation(s)
- Wei Shen Tan
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital, London, UK.
| | - Aaron Prendergast
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Charlotte Ackerman
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Yathushan Yogeswaran
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Joanne Cresswell
- Department of Urology, The James Cook University Hospital, Middlesbrough, UK
| | - Paramananthan Mariappan
- Department of Urology, Edinburgh Bladder Cancer Surgery, Western General Hospital, Edinburgh, UK
| | - Jaspal Phull
- Department of Urology, Royal United Hospital, Bath, UK
| | | | - Henry Lazarowicz
- Department of Urology, The Royal Liverpool University Hospital, Liverpool, UK
| | | | - Abhay Rane
- Department of Urology, East Surry Hospital, Redhill, UK
| | - Melissa Davies
- Department of Urology, Salisbury District Hospital, Salisbury, UK
| | - Hazel Warburton
- Department of Urology, University Hospital of South Manchester, Manchester, UK
| | - Peter Cooke
- Department of Urology, New Cross Hospital, Wolverhampton, UK
| | - Hugh Mostafid
- Department of Urology, The Royal Surrey County Hospital, Guildford, UK
| | - Daniel Wilby
- Department of Urology, Queen Alexandra Hospital, Portsmouth, UK
| | - Robert Mills
- Department of Urology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Rami Issa
- Department of Urology, St George's Hospital, London, UK
| | - John D Kelly
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital, London, UK
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Ward K, Kitchen MO, Mathias SJ, Khanim FL, Bryan RT. Novel intravesical therapeutics in the treatment of non-muscle invasive bladder cancer: Horizon scanning. Front Surg 2022; 9:912438. [PMID: 35959122 PMCID: PMC9360612 DOI: 10.3389/fsurg.2022.912438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/07/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Non-muscle-invasive bladder cancer (NMIBC) is a common and heterogeneous disease; many patients develop recurrent or progress to muscle-invasive disease. Intravesical drug therapy is a pillar in the current management of NMIBC; notwithstanding, Mitomycin C (MMC) and Bacillus Calmette-Guérin (BCG) have numerous limitations including international supply issues, and local and systemic toxicity. Here we review novel intravesical therapeutic options and drug delivery devices with potential for clinical use in the treatment of NMIBC. Methods PubMed, ClinicalTrials.gov and Cochrane Library searches were undertaken. Systematic reviews, meta-analyses, randomised controlled trials, single-arm clinical trials and national/international conference proceedings were included. Results Novel intravesical drugs, including chemotherapeutic agents, immune checkpoint inhibitors, monoclonal antibodies and gene therapies, have demonstrated varying efficacy in the treatment of NMIBC. Current evidence for the majority of treatments is mostly limited to single-arm trials in patients with recurrent NMIBC. Various novel methods of drug delivery have also been investigated, with encouraging preliminary results supporting the intravesical delivery of hyperthermic MMC and MMC hydrogel formulations. Conclusions Novel therapeutic agents and drug delivery systems will be important in the future intravesical management of NMIBC. As our understanding of the molecular diversity of NMIBC develops, molecular subtyping will become fundamental in the personalisation of intravesical treatments. Further randomised studies are urgently required to investigate the efficacy of novel intravesical treatments and novel regimens, in comparison to current standards-of-care, particularly in the context of international BCG shortages.
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Affiliation(s)
- Kelly Ward
- The Bladder Cancer Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Mark O Kitchen
- School of Medicine, Keele University, Stoke-on-Trent, United Kingdom
| | - Suresh-Jay Mathias
- New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - Farhat L Khanim
- The Bladder Cancer Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Richard T Bryan
- The Bladder Cancer Research Centre, University of Birmingham, Birmingham, United Kingdom
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Device-assisted intravesical chemotherapy treatment for nonmuscle invasive bladder cancer: 2022 update. Curr Opin Urol 2022; 32:575-583. [PMID: 35749398 DOI: 10.1097/mou.0000000000001010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To critically analyze the oncological outcomes and safety profile of device-assisted intravesical chemotherapy studies reported in 2021. Studies were considered eligible if they included patients with nonmuscle invasive blood cancer (NMIBC), had a prospective or retrospective design, included at least 10 patients, were published in 2021, and assessed the oncological impact of device-assisted intravesical chemotherapy and/or reported standardized adverse effects (AEs). RECENT FINDINGS Eight new studies reported oncological outcomes after hyperthermic intravesical chemotherapy (HIVEC). In Bacillus Calmette-Guérin (BCG) naive patients, the reported 2-yr. recurrence-free survival (RFS) ranged from 70.7% to 82.4%, with one study reporting 2 yr. progression free survival (PFS) of 92%. In both BCG naive and BCG refractory patients, the reported 1-yr. RFS ranged from 60.5% to 70% and PFS was 94% in one study. For radiofrequency-induced HIVEC, the reported 5-yr. estimates were 38%for RFS and 91.5%for PFS. Regarding AEs, 10.2% of patients had severe AEs. Six studies reported AEs after HIVEC; the majorities were grade 1-2 AEs. SUMMARY Data coming from the studies published in the last years provides support for a consolidating role of device-assisted intravesical chemotherapy as a safe and effective alternative first- or second-line adjuvant treatment of patients with NMIBC.
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Urological Cancer Panorama in the Second Year of the COVID-19 Pandemic. Cancers (Basel) 2022; 14:cancers14030493. [PMID: 35158761 PMCID: PMC8833682 DOI: 10.3390/cancers14030493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 12/04/2022] Open
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