Invasive Carcinoma Of Urinary Bladder Research Articles

Outcome of radical cystectomy in remote area of Pakistan: Recep Tayyip Erdogan Hospital, Muzaffargarh (IHHN)

Background: Radical cystectomy with bilateral pelvic lymphadenectomy is the standard treatment for high grade/ muscle invasive urinary bladder tumor. Continent or incontinent urinary diversion is the part of this major operation. High volume centers perform routinely but low volume centers do less frequent. It might be because of availability of equipment and trained surgeon in remote area of Pakistan. Objectives: to assess the results of radical cystectomy at a low-volume center for high-grade muscle-invasive bladder tumours. For patients aged 50 to 75, this involves evaluating surgical complications, overall survival, and the absence of tumour recurrence throughout a one-year follow-up period. Study design: A Retrospective StudyDuration and place of study: Recep Tayyip Erdogan hospital, Muzaffargarh from October 2018 to August 2022 Methods: total Cases from both genders and 50 to 75 years old with High grade/ Muscle invasive urinary bladder carcinoma, incomplete resection during TURBT due to high volume of mass (irresistible) included. Performa designed for collection of information. All the patients underwent same procedure by same urologist. Patients were followed for one year after surgery. Results: All participants were followed for one year. 33.3% patients had paralytic ileus (CDC I), 13.3% had wound infection (CDC I) and 6.7% had urinary leakage (CDC IIIb). There was 86.6% overall survival rate. 6.7% lost to follow up. Mean operative time was 308 ±95 minutes. There was no recurrence noted throughout the study period. Conclusion: Good operative results can also achieve at low volume centers. High level of surveillance and expertise help to achieve better outcomes in remote. Keywords: cystectomy, radical cystectomy, bladder tumor, ileal conduit

A PROSPECTIVE COMPARATIVE STUDY ON MUSCLE INVASIVE BLADDER CANCER TREATED WITH BLADDER PRESERVATION APPROACH USING NEOADVJUVANT CHEMOTHERAPY FOLLOWED BY RADIOTHERAPY VERSUS CONCURRENT CHEMORADIATION

BACKGROUND-There are two established Bladder preservation approach in the treatment of muscle invasive carcinoma of urinary bladder - concurrent chemoradiotherapy and neo-adjuvant chemotherapy followed by radiotherapy. Our study was aimed at comparing these two bladder preservation approaches in terms of therapeutic response and acute toxicity prole. MATERIALS AND METHODS- Patients with non-metastatic muscle invasive primary urothelial carcinoma of urinary bladder staged II-IVA 2 (T2-T4, N0, M0) were randomised in two arms. Study arm received four weekly induction chemotherapy with Gemcitabine (1000 mg/m IV on 2 D1,8, 15) and Cisplatin (70 mg/m IV on D 1) for 3cycles. Patients who achieved response to therapy (partial response/complete response) received 3D-conformal radiotherapy (50 Gy /25#s/5weeks) to the whole bladder and pelvic nodes and then up to 64Gy to the residual disease or to the gross disease bearing area. Control arm received radiotherapy (3DCRT) at a dose of 64 Gy / 32 fractions over 6.5 weeks with concurrent weekly 2 Injection cisplatin (40mg/m ). During treatment patients were weekly monitored for assessment of acute toxicity. After completion of treatment, response assessment was done and patients were followed up monthly for rst three months and then 3 monthly for at least 6 months. RESULTS- Overall response (CR+PR) was seen in 85.18% of study arm compared to 72% of control arm. Although statistically not signicant, 29.6% of patients showed CR in Neo-adjuvant chemotherapy containing arm than 12% of CTRT only arm (0.386). Bowel toxicity of Grade 2 (18.5% vs 36%) and Grade 3(4% vs 0%) was signicantly less in NACTcontaining arm patients (p value 0.044). Higher grade of rectal toxicity was also signicantly less (36% vs 7%) in study arm (p-value 0.011). CONCLUSION- In terms of acute toxicity prole, neo-adjuvant chemotherapy followed by radiotherapy is better than concurrent chemoradiotherapy alone and though statistically insignicant, the neo-adjuvant chemotherapy-based approach had better therapeutic response than CTRT.

Mitotic activity index and CD25+ lymphocytes predict risk of stage progression in non-muscle invasive bladder cancer.

In urothelial cell type non-muscle invasive urinary bladder carcinoma, TNM stage and WHO grade are widely used to classify patients into low and high‑risk groups for prognostic and therapeutic decision-making. However, stage and grade reproducibility and prediction accuracy are wanting. This may lead to suboptimal treatment. We evaluated whether proliferation features, nuclear area of the epithelial cancer cells and the composition of stromal and tumor infiltrating lymphocytes have independent prognostic value. In 183 primary non-muscle invasive bladder cancer patients with long follow-up (median for stage progression cohort: 119 months, range 5-173; median for tumor recurrence cohort: 82, range 3-165) proliferation features Ki67, PPH3 and Mitotic Activity Index (MAI), Mean Nuclear Area (MNA), lymphocyte subsets (CD8+, CD4+, CD25+) and plasma cells (CD138+) were assessed on consecutive sections. Post-resection instillation treatments (none, mitomycin, BCG) were strictly standardized during the intake period. Risk of recurrence was associated with expression of Ki67 (≤ 39 vs. > 39) and Multifocality (p = 0.01). Patients with low Ki67 had a higher recurrence rate than those with high Ki67. Lymphocyte composition did not predict recurrence. Stage progression was strongly associated with high values for MAI (>15) and CD25+ (>0.2%). In a multivariate analysis the combination of MAI and CD25+ was the single most prognostic feature (p<0.001). Validation of these results in additional, independent studies is warranted.

Prospective evaluation of definitive chemoradiotherapy with volumetric modulated arc therapy in patients with muscle invasive carcinoma of urinary bladder.

IntroductionConcurrent chemoradiotherapy (CTRT) remains one of the treatment options in patients with muscle invasive bladder cancer (MIBC) unwilling/unsuitable for radical surgery. We evaluated the role of volumetric modulated arc therapy (VMAT) in MIBC patients treated with definitive CTRT.Material and methods25 patients of histologically proven transitional cell MIBC (T2–T4a, N0, M0) unwilling/unsuitable for radical surgery (after maximal transurethral resection of bladder tumour) were recruited in this prospective study. Primary clinical target volume (CTV) consisted of the gross tumour and whole bladder. Primary planning target volume (PTV) and nodal PTV were prescribed 60 Gy and 54 Gy (both in 30 fractions). Concurrent chemotherapy was cisplatin (40 mg/m2) weekly. Acute toxicities were assessed as per Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Survival estimates were done from the date of registration using the Kaplan-Meier method.ResultsMedian age was 70 years (37–80 years). Median overall treatment time was 45 days (44–51). Median number of chemotherapy cycles was 5 (range 3–6). 5 (20%) and 4 (16%) patients respectively suffered from acute grade ≥ 2 gastrointestinal and grade ≥ 2 genitourinary toxicities during treatment. One patient each had grade 3 anaemia and neutropenia. At a median follow-up of 34 months (10–45 months), 3-year progression-free survival and overall survival were 65.6% and 81.2% respectively. 3-year distant metastasis-free survival was 90.5%. Bladder preservation rate at 3 years was 68%.ConclusionsDefinitive CTRT with VMAT is well tolerated in patients with MIBC unsuitable for surgery and yields decent survival and bladder preservation outcome.

Preliminary experience on subcutaneous venous access device (chemoport) in a teaching hospital in Kathmandu

Background: Modern subcutaneous venous access device or chemo port nowadays is a vital device used in case of chronic diseases. It is now an established device for administration of medication and blood withdrawal without difficulty and negating repeated skin punctures for those patients who need repeated and long term intravenous medication. But, these devices are not without complications.Objective: To assess preliminary technical success and complication rates of the ultrasound and fluoroscopy guided placement of subcutaneous venous access device.Methods: Between November 2012 to May 2015, 10 port catheter components were implanted. All components were inserted under image guidance. Ultrasound guided puncture of right internal jugular vein was preferred and position of tip of catheter was confirmed by fluoroscopy. Early and late complications were evaluated. The overall cost of the chemo port was also taken into consideration.Results: The implantation was inserted in ten cases. Four patients had ovarian carcinoma, three patients metastatic colonic carcinoma, one had testicular cancer with meditational mass, one patient had metastatic invasive urinary bladder carcinoma and another one had porphyries whose peripheral venous access were all thromboses due to repeated puncture. Peri-procedural early complications like blockage, thrombosis, leak were not observed, however one patient had catheter related fever. Late complications like blockage, port, fractures, dislodgement, venous thrombosis were also not found but One patient had port pocket infection. The cost of the port device in all cases was about 50,000 Nepalese rupees.Conclusion: Larger number of case is required for better statistical evaluation. The main reason for the refusal of subcutaneous venous access device insertion by the patients was the high cost of the device. Cather-related morbidity was in acceptable range so chemo port insertion is feasible in Nepal. Major life threatening complication was not observed.Journal of Kathmandu Medical College, Vol. 4, No. 2, Issue 12, Apr.-Jun., 2015

Radiation therapy outcomes in muscle invasive urinary bladder cancer: A single institution experience.

To audit the survival outcomes and loco-regional control in muscle invasive urinary bladder cancer patients treated with external beam radiation therapy (RT). From November 2008 through December 2011, 50 consecutively diagnosed muscle invasive urinary bladder carcinoma (T2-4a N0-2, M0) patients were included in this retrospective study. All these patients received external beam RT to a median dose of 60 Gy (range 30-66 Gy), and were not suitable for radical surgery due to patients' preference or medical comorbidities. A stepwise procedure using proportional hazard regression was used to identify prognostic factors with respect to survival. Completion trans-urethral resection of bladder tumor was done in 38 (76%) patients of the cohort and 47 (94%) had transitional cell carcinoma on histopathology. Clinical stage T2 was diagnosed in 40 (80%) patients. The median follow-up for the entire cohort was 14 ± 8.9 months (range 1-36 months). In conclusion, 24 patients (48%) were free of disease, 5 patients (10%) had residual disease, and 13 patients (26%) had died of disease. Two-year and 3 year overall survival of intact bladder for the entire cohort was 58% and 43.6%, respectively. Cox regression modeling strongly suggested clinical stage (P = 0.01) and RT dose (P = 0.001) as being predictors for overall survival. RT shows reliable outcomes and excellent compliance in this advanced disease. Prescribing a higher RT dose could potentially correlate to better intact bladder control rates while maintaining good quality of life in selected patients.

Invasive carcinoma of urinary bladder in a patient with a spinal cord injury with non-functioning Brindley sacral anterior root stimulator: a case report

BackgroundAnterior sacral root stimulation combined with sacral posterior rhizotomy restores bladder function in spinal cord-injured patients suffering from hyperactive bladder. After successful implantation of bladder stimulator, urinary infection rate decreases, and patients are able to get rid of indwelling urinary catheters, which in turn reduce the risks for vesical malignancy. We present a spinal cord injury patient with non-functioning Brindley sacral anterior root stimulator, who developed carcinoma of urinary bladder.Case presentationA Caucasian male, who was born in 1943, sustained paraplegia at T-4 (ASIA-B) in 1981. This patient underwent implantation of sacral anterior root stimulator in September 1985. The bladder stimulator started giving trouble since 1996 and the patient went back to using indwelling urethral catheter. In August 2006, this patient passed blood in urine after a routine change of indwelling catheter. Cystoscopy showed unhealthy bladder mucosa. Bladder biopsy revealed carcinoma, which was infiltrating bundles of muscularis propria. Many of the nests showed evidence of squamous differentiation, while others could be transitional or squamous. This patient underwent cystectomy with lymphadenectomy in March 2007 in a hospital nearer his home. Histology showed three nodes involved. This patient has been doing well since the operation.ConclusionOccurrence of vesical malignancy in this patient with non-functioning bladder stimulator is a timely reminder to all health professionals, and health care managers that concerted efforts should be made to rectify a non-functioning sacral anterior root stimulator as soon as possible. Otherwise, facilities should be made available in the community for the spinal cord injury patient to use intermittent catheterisation and thereby, avoid permanent indwelling catheter, vesical calculi and urine infections, which are risk factors for bladder cancer.

Outcome following radical cystectomy and bladder-preservation therapy in patients with invasive carcinoma of urinary bladder

Background:Invasive bladder cancer is a lethal disease with a 50% cancer-related mortality even in the best healthcare systems. Optimum combination of surgery, external beam radiotherapy and platinum-based chemotherapy has yet to be determined.Purpose:To audit the outcome of multi-modality treatment and compare this with the existing literature in order to set future priorities and re-audit in patients with invasive carcinoma of urinary bladder.Materials and Methods:Between January 2001 and December 2004, 97 patients with invasive carcinoma of urinary bladder were analyzed. Radical surgery was done in 18(18%) patients and adjuvant radiation was given to 20(21%) patients. Radical radiation alone, (≥50 Gy) was given to 26(27%) and chemoradiation to 33(34%) patients respectively. Patients in the chemoradiation arm were given the same dose of radiation with weekly concomitant cisplatin at 40 mg/ m2 one hour before radiation during the first phase only. At a median follow-up of 32 months the outcome studied included locoregional failure, distant failure, disease-free survival (DFS) and overall survival (OS) using univariate and multivariate analyses. The OS and DFS were calculated according to Kaplan-Meier. Log rank test was used for statistical significance.Results:Median age of the patients was 58 years. Males comprised 93% of the total patients. Most (93%) of the patients had transitional cell histology. In patients treated with radiation alone overall response rate was 60%, with a complete response (CR) rate of 42%. The CR in patients treated with chemoradiation was 51%. Bladder was preserved in 61% of patients who received chemoradiation as compared to 42% in patients treated with radical radiation. With radical radiation local recurrence rate was 19% as compared to 22% with surgery and 6% with chemoradiation, respectively. Local recurrence rate was only 5% in patients treated with adjuvant radiation. Distant metastasis rate was least with chemoradiation (9%) as compared to 11.5% in radical radiation: curable dose of radiation and 33% with surgery alone, respectively. Patients with adjuvant radiation had a distant metastases rate of 15%. Median OS was 36 months. Factors affecting OS were histology (P = 0.023) and nodal involvement (P = 0.034). Median DFS was 26 months. Significant factors affecting DFS on univariate analysis were histology (P = 0.046) and nodal involvement (P = 0.004). On multivariate analysis the only factor affecting DFS and OS was nodal involvement (P = 0.01; Hazard Ratio, 0.085-0.719).Conclusion:In patients with invasive bladder cancer, combined modality in the form of radical cystectomy followed by radiation give best local control. Radiation alone is not effective to control muscle-invasive local disease; however, Chemoradiation is an effective alternative to radical cystectomy to preserve bladder function.

Diffusion-Weighted MR Imaging in Diagnosis of Superficial and Invasive Urinary Bladder Carcinoma: A Preliminary Prospective Study

We conducted a prospective study to demonstrate the feasibility of using diffusionweighted (DW) magnetic resonance imaging (MRI) for the detection of urinary bladder carcinomas. Between January to June 2007, 43 patients with single bladder tumor were included in our study. Before taking a biopsy, DW MRI was obtained in the axial plane under free breathing scanning with a multisection, spin-echo type, single-shot echo planar sequence with a body coil. Moreover, the apparent diffusion coefficient (ADC) value was measured in a circular region of interest within the carcinoma, urine, normal bladder wall, prostate, and seminal vesicle. All carcinomas in the 43 patients were clearly shown as high signal intensity relative to the surrounding structure. The sensitivity and positive predictive values of DW MRI were 100% in terms of correctly detecting the carcinomas. The ADC value in the carcinoma (1.40 ± 0.51) was significantly lower compared with that of urine (3.50 ± 0.43) (p < 0.001), normal bladder wall (2.29 ± 0.78) (p < 0.001), peripheral zone of prostate (1.77 ± 0.44) (p < 0.05), transition zone of prostate (1.88 ± 0.54) (p < 0.05), and the seminal vesicle (2.12 ± 0.43) (p < 0.001). There was no statistical difference in ADC values between different histological subtypes. There was no overlap between the ADC values of the tumors and the urine, but there was no clear cutoff between the tumor and bladder wall, prostate, or seminal vesicles. Bladder carcinomas have significantly lower ADC when compared to surroundings. Clinical experience with this method is still preliminary and further studies are required.

POS-02.11: Prognostic significance of Her2/neu overexpression in patients of muscle invasive urinary bladder carcinoma treated with radical cystectomy

The aim of the present study was to evaluate the status of HER2 protein expression in patients with muscle-invasive urothelial carcinomas of bladder treated with radical cystectomy and correlate it with clinical outcome.

A prospective study evaluating surgery and chemo radiation in muscle invasive bladder cancer

The aim of our study was to compare the two standard treatment approaches in muscle invasive carcinoma of urinary bladder--radical cystectomy and chemo radiation. Transitional cell carcinoma (TCC) of bladder of stages, T2 to T4, N0/N1/N2 and M0 were included in the study. Patients were allotted to two arms of the study. Arm A consisted of radical cystectomy. Adjuvant CMV chemotherapy was given for T3/T4 or Node positive disease only. Arm B received 2 cycles of neoadjuvant CMV chemo therapy followed by concurrent chemo radiation. Forty-four patients were recruited into the study. Thirty patients in the surgical arm and 13 patients in the chemo radiation arm. The actuarial two-year survival rate in surgical arm is 56% while in chemo radiation arm it is 54%. There was no statistically significant difference in disease-free survival also between the two groups. Chemo radiation yielded equivalent survival results with radical cystectomy. So it is worth giving preference to chemo radiation that will give a better quality of life for the patient.

Small volume versus standard volume radiotherapy in invasive carcinoma of urinary bladder

4590 Background: Reducing the volume of irradiation may minimize the incidence of acute and late radiation effects on normal tissue and subsequently improve the quality of life. In this trial we evaluated the impact of reducing the irradiated volume on disease free survival (DFS), overall survival (OS) and quality of life (QOL) in patients with bladder cancer. Methods: This trial included 61 consecutive patients with invasive bladder cancer (T2-T4a). All patients received 3 cycles neo-adjuvant chemotherapy (Gemcitabine 1250 mg/m2 D1 + D8 and cisplatin 70 mg/m2 D1), then patients were randomized into two arms: arm I: 30 patients received standard volume radiotherapy (45 Gy to the whole pelvis + 20 Gy boost to the bladder to a total dose of 65 Gy), arm II: 31 patients received small volume radiotherapy by conformal technique (65 Gy to the tumor plus 2 cm around). Both arms received cisplatin 20 mg/m2 hours before each radiation fraction on days 1–5 and 29–33. QOL was assessed in all patients included using QOL questionnaire. Results: The CR rate to neoadjuvant chemotherapy was 32.8% in the whole group of patients (33.3% in arm I and 32.3% in arm II) and the PR rate was 29.5% (23.3% in arm I and 35.5% in arm II) p=0.56. The CR rate after concurrent chemo-radiotherapy was 62.3% in the whole group of patients (60% in arm I and 64.5% in arm II) and the PR rate was 18% (13.3% in arm I and 22.6% in arm II) p=0.52. Acute toxicities that occurred with concurrent chemo-radiotherapy mainly affected the bladder and GIT. Acute diarrhea was higher in arm I (G1 33.3%, G2 20%, and G3 10%) than in arm II (G1 19.4%, G2 3.2%, and G3 0%) p=0.006. Also acute proctitis was higher in arm I (G1 36.7%, and G2 13.3%) than in arm II (G1 19.4 and G2 0%) p=0.019. There was no significant difference in OS and DFS between the two treatment arms. The mean OS in arm 1 was 20.38 months and in arm II it was 22.19 P=0.88. The mean DFS in arm 1 was 19.96 months and in arm II it was 22.93 P=0.73. There was a statistically significant difference in the rectal and physical subscales of the quality of life questionnaire P=0.004 and 0.037 respectively. Conclusions: Reduction of the treatment volume resulted in decrease in the rate of acute GIT toxicities but did not have negative impact on tumor control or survival. No significant financial relationships to disclose.

Aberrations of the Chk2 tumour suppressor in advanced urinary bladder cancer.

Checkpoint kinase 2 (Chk2) is a tumour suppressor and signal transducer in genome integrity checkpoints that coordinate cell-cycle progression with DNA repair or cell death in response to DNA damage. Defects of Chk2 occur in subsets of diverse sporadic malignancies and predispose to several types of hereditary carcinomas. However, the status of Chk2 in tumours of the urinary bladder remains unknown. Here, we report that among 58 advanced (grade T2-T4) human bladder carcinomas, immunohistochemical analysis revealed tumour-specific reduction or lack of Chk2 protein in 6 (10.3%) cases. Genetic analysis of the latter subset showed that a Chk2-negative carcinoma #668 harboured a truncating mutation 1100delC, in one Chk2 allele and loss of the corresponding second allele. The 1100delC mutation was also found in the germ line of this patient. Sequencing of TP53 in tumour #668 identified two missense mutations. Furthermore, the vast majority of the tumours showed 'unscheduled' activatory phosphorylation on Thr68 of Chk2 in the absence of any DNA-damaging treatment. Our results indicate that the otherwise dormant DNA damage signal transducer Chk2 is aberrantly and constitutively activated in invasive urinary bladder carcinomas, and that such likely proapoptotic checkpoint signalling can be disabled by inactivation of Chk2 and/or p53 tumour suppressors in subsets of these tumours.

A Systematic Overview of Radiation Therapy Effects in Urinary Bladder Cancer

A systematic review of radiation therapy trials in several tumour types was performed by The Swedish Council of Technology Assessment in Health Care (SBU). The procedures for evaluation of the scientific literature are described separately (Acta Oncol 2003; 42: 357-365). This synthesis of the literature on radiation therapy for urinary bladder cancer is based on data from 3 meta-analyses and 33 randomized trials. The studies include 4 333 patients. The results were compared with those of a similar overview from 1996 including 15 042 patients. The conclusions reached can be summarized as these points: <list id="l1" type="5"> <item>There is moderate evidence for an overall survival benefit with preoperative radiotherapy followed by cystectomy compared to curative radiotherapy based on early studies (1964-1986). Since that time surgical as well as radiation techniques have developed considerably. Therefore, the conclusion may not be relevant to modern treatment of invasive urinary bladder carcinoma.</item><item>There is only one small study reporting on curative radiotherapy where increased dose per fraction is compared with conventionally fractionated radiotherapy to the same total dose. Thus, no conclusions can be drawn concerning optimal fraction dose.</item><item>A meta-analysis based on two studies on hyperfractionated radiotherapy gives moderate evidence of a survival benefit at 5 and 10 years and an increased local control rate compared with conventional fractionation.</item><item>The documentation of local control and overall survival rate after split-course radiation treatment compared to continuous therapy is conflicting. No firm conclusions can be drawn.</item><item>Four small and early studies have compared radiation treatment using neutrons with photon treatment. The reports favour therapy with photons with respect to overall treatment results. There is moderate evidence for this conclusion.</item><item>There is fairly strong evidence in early studies that radiation treatment in combination with hyperbaric oxygen does not confer a treatment benefit compared to radiation in normal atmosphere.</item><item>There is no indication of a treatment benefit with the addition of either hyperthermia or misonidazole.</item><item>A large number of phase II studies, suggesting an increased possibility for bladder preservation with concomitant chemoradiotherapy compared to radiotherapy alone, have been reviewed in a previous SBU report on chemotherapy. Only one small randomized study has been reported where concomitant chemoradiotherapy with cisplatin is compared to radiation alone. No conclusion on the therapeutic benefit of combined treatment can be drawn. Large randomized studies are needed.</item><item>There is some evidence that preoperative radiotherapy followed by cystectomy does not confer any significant survival benefit compared to cystectomy alone.</item><item>There is moderate evidence that palliative radiotherapy of invasive bladder carcinoma can rapidly induce tumour-related symptom relief.</item><item>There is moderate evidence that palliative hypofractionated radiotherapy, 3 fractions during one week, gives the same relief of symptoms as 10 fractions during 2 weeks.</item></list>

Prognostic Significance of p53 Nuclear Overexpression in Patients of Muscle Invasive Urinary Bladder Carcinoma Treated with Cystectomy

Introduction: The objective of the study was to determine the pattern of p53 expression in patients with muscle invasive bladder cancer treated with cystectomy and to assess the prognostic value of p53 expression in this group of patients. Materials and Methods: We retrospectively analyzed data of 100 patients who underwent cystectomy for invasive transitional cell carcinoma of the urinary bladder. These patients were seen at 3-monthly intervals during the first 2 years, 6-monthly in the third year, and yearly thereafter. Immunohistochemical analysis for p53 was done on paraffin-fixed tissues with DO-7 antibodies. The tumours with >30% cells staining for p53 proteins were considered p53 positive. Results: There were 95 males and 5 females with a mean age of 54 years. Two patients died in the perioperative period and were excluded from analysis. Over a median follow-up period of 2 years (range 3 months to 10 years) 62 patients are alive without disease while 36 had relapse and of these, 31 have died. The p53 expression was significantly related to stage and grade of the tumour. p53-negative tumours were more likely to be organ confined and of lower grade as compared to p53-positive tumours. The stage of tumour was significantly related to outcome but grade and p53 immunohistochemistry did not provide any prognostic information. Conclusions: p53 immunostaining was positive in 57% of muscle invasive urinary bladder tumours. The p53 positivity correlated well with the stage and grade of the disease, whereas it has no additional prognostic value.

Molecular cytogenetic alterations associated with rapid tumor cell proliferation in advanced urinary bladder cancer.

Invasive urinary bladder carcinomas are characterized by a high number of cytogenetic alterations which are thought to pinpoint the location of critical genes, some of which may be involved in cell cycle control. To identify genomic alterations that may affect such genes the proliferative activity (Ki67 labeling index) was assessed in 93 invasively growing bladder carcinomas analyzed by comparative genomic hybridization. Only a few changes were significantly associated with rapid tumor cell proliferation, including 3p+ (p=0.0357), 6p+ (p=0.003), 8q+ (p=0.0273), and 11q- (p=0.0329). Among these alterations 6p+ is of particular interest because high level 6p22 amplifications occur frequently in bladder cancer. The particular strong association between 6p+ and a high tumor cell proliferation being independent of grade and stage suggests that a putative oncogene on 6p22 involved in cell cycle regulation.

LOH and mutational analysis of p53 alleles in mouse urinary bladder carcinomas induced by N-butyl-N-(4-hydroxybutyl) nitrosamine.

In human urinary bladder carcinogenesis, alterations in the p53 tumor suppressor gene are common events. We have previously reported that they are also frequent in invasive urinary bladder carcinomas induced by N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN) in NON/Shi mice. To further investigate the significance of the p53 gene status for mouse urinary bladder carcinogenesis, we examined both allele loss and mutational alterations in urinary bladder cancers of (NON/Shi x C3H/He/Shi) F1 hybrid mice exposed to the carcinogen for 12 weeks and then maintained for a further 9 weeks without treatment. An intragenic silent polymorphism within exon 7 of the p53 gene between NON/Shi and C3H/He/Shi mice allows assessment of allele loss of the p53 gene and determination of the parental origin of mutated and/or lost alleles. A tissue microdissection method was employed to obtain carcinoma samples without excessive contamination with normal tissue. Allele losses were detected in one of 14 tumors (7.1%) and nine mutations in eight of 14 (57%) tumors were found in exons 5-8 by polymerase chain reaction-single strand conformation polymorphism followed by DNA direct sequencing analysis. All mutations involved one base substitution with an amino acid change, although the types of base substitution were random. In conclusion, the high incidence of p53 alterations suggests a significant role in the genesis of invasive urinary bladder tumors in BBN-treated mice.

Enhancement of urinary bladder carcinogenesis in nullizygous p53-deficient mice by N-butyl- N-(4-hydroxybutyl)nitrosamine

We recently reported p53 mutations to be frequent in mouse invasive urinary bladder carcinomas, with and without metastasis. However, the role of p53 dysfunctions during carcinogenesis remains unclear. In the present study, heterozygous and nullizygous p53-deficient mice and their littermates were treated with the urinary bladder carcinogen, N-butyl- N-(4-hydroxybutyl)-nitrosamine (BBN), at a concentration of 0.01% in the drinking water throughout the experiment. This markedly accelerated urinary bladder carcinogenesis but not development of other tumors in the nullizygous p53-deficient mice. Thus the appearance of neoplastic urothelial lesions in nullizygotes (at day 60 of the experiment) was earlier than in wild-type mice and heterozygotes (at day 125). Moreover, malignant vascular tumors (hemangiosarcomas (HS)) were found in all four nullizygotes killed later than day 108. Mutational inactivation of the wild-type allele was not apparent in either the single transitional cell carcinoma observed in a wild-type mouse and a hemangiosarcoma in a heterozygote. Overall, it can be concluded that the number of normal p53 alleles is a significant determining factor in the susceptibility of urothelial cells to carcinogens. The role of the p53 defect in mouse urinary bladder carcinogenesis may thus be to diminish the threshold for occurrence of additional genetic alterations.

Infrequent involvement of microsatellite instability in urinary bladder carcinomas of the NON/Shi mouse treated with N-butyl- N-(4-hydroxybutyl)nitrosamine

Variation in the frequency of microsatellite instability (MSI) has been reported in different kinds of human malignant tumors, with less than one-third of invasive urinary bladder carcinoma cases estimated to be affected. Here we investigated the MSI for 27 microsatellite sequences in invasive urinary bladder carcinomas of the NON/Shi mouse induced by N-butyl- N-(4-hydroxybutyl)nitrosamine. A total of 28 urinary bladder carcinomas of both transitional cell and squamous cell types were studied. All were invasive (greater than pT3) and high-grade and 10 of them had metastasis. Only two (11%) of 18 primary bladder carcinomas without metastasis foci showed alterations in one or two loci. None of 10 pairs of urinary bladder carcinomas and metastasis foci demonstrated any alterations. In conclusion, MSI which represents a defect in the DNA mismatch repair system is infrequent and therefore unlikely to be a critical step in genesis of invasive mouse urinary bladder carcinomas.

Phase II study of a new combined primary chemotherapy regimen, intravenous methotrexate and vincristine and intraarterial Adriamycin and cisplatin, for locally advanced urinary bladder cancer: preliminary results

A phase II study of a new combination therapy was performed using intraarterial (i.a.) cisplatin and Adriamycin in combination with i.v. methotrexate and vincristine for 27 patients with invasive urinary bladder carcinoma of stages T2-3NOMO, and the therapeutic effects were assessed. Methotrexate (20 mg/m2) was given i.v. on days 1,15, and 22, and vincristine (0.7 mg/m2) was injected i.v. on day 2 before i.a. infusion therapy and on days 15 and 22. The i.a. chemotherapy was performed after both superior gluteal arteries had been embolized using 3- or 5-mm stainless-steel coils. A mixture of cisplatin (50-70 mg/m2) and Adriamycin (20 mg/m2) was infused i.a. via both internal iliac arteries over a period of 20-30 min. Angiotensin II (mean dose, 21 micrograms) was simultaneously infused i.a. in 15 of 27 patients. In 24 of the 27 patients, at least 2 cycles of full-dose chemotherapy were completed. The dose was decreased in the remaining 3 patients because of their poor health status and advanced age. Among the 27 patients, 9 and 14 had complete (CR) and partial responses (PR), respectively; 3 manifested no change (NC), and 1 had progressive disease (PD). The objective response rate (CR+PR) was 85.2%. Among the 27 patients staged T2-3 NOMO, 6 (CR, 1; PR, 5) underwent total cystectomies and 18 (CR, 8; PR, 8; NC, 2) had transurethral resection of a bladder tumor (TUR-Bt) or partial resections following chemotherapy. The remaining 3 diminished-dose patients had no surgery. Of the 27 patients, 22 were alive after a median follow-up period of 21+ (range, 7-48+) months. No significant side effect was observed except for lower extremity paresthesias in 5 patients (18.5%). These results point to the effectiveness of this therapy and to the possibility of urinary bladder preservation in patients with invasive, advanced urinary bladder cancers.