Resection Of Superficial Bladder Cancer Research Articles

Absorption of Epirubicin Instilled Intravesically Immediately after Transurethral Resection of Superficial Bladder Cancer

As postoperative adjuvant therapy for superficial bladder cancer, intravesical instillation therapy is commonly conducted. In this case, from the view point of prevention of intraoperative dissemination, commencement of instillation therapy at an early postoperative period is preferred. However, increased drug permeability is suspected because of damage to the bladder mucosa during operation. Therefore, this study was conducted to investigate the plasma level of epirubicin (EPI) instilled immediately after transurethral operation. EPI (20 mg/40 ml or 50 mg/100 ml) was instilled immediately after a transurethral operation, and retained in the bladder for 1 h. Blood samples were obtained before instillation, as well as 30, 60, 120 and 240 min after instillation, and EPI levels were assayed. The mean EPI concentrations (ng/ml) among the 20-mg/40 ml group (n = 5) were <2.5 and <2.0 at 30 and 60 min, respectively, after which they were undetectable. The 50-mg/100 ml group (n = 5) recorded 5.0, 4.4 and <3.0 after 30, 60 and 120 min, respectively, and after 240 min it was undetectable. Intravesical instillation of EPI immediately after a transurethral operation causes a small increase in the plasma level and it is thought to cause small systemic side effects.

Clinical assessment of fluorescence cytoscopy during transurethral bladder resection in superficial bladder cancer.

The prognosis of superficial bladder cancer in terms of recurrence and disease progression is related to bladder tumor multiplicity and the presence of concomitant "plane" tumors such as high-grade dysplasia and carcinoma in situ. This study in 33 patients aimed to demonstrate the role of fluorescence cystoscopy in transurethral resection of superficial bladder cancer. The method is based on the detection of protoporphyrin-IX-induced fluorescence in urothelial cancer cells by topical administration of 5-aminolevulinic acid. The sensitivity and the specificity of this procedure on apparently normal mucosa in superficial bladder cancer are estimated to be 82.9% and 81.3%, respectively. Thus, fluorescence cytoscopy is a simple and reliable method for mapping the bladder mucosa, especially in the case of multifocal bladder disease, and it facilitates the screening of occult dysplasia.

Intravesical 4′-epi-doxorubicin(epirubicin) versus bacillus calmette—guérin. A controlled prospective study on the prophylaxis of superficial bladder cancer

The selection of the most appropriate antineoplastic agent and optimal treatment schedule for the prophylaxis of superficial bladder cancer against tumor recurrences is the subject of continual investigations. A controlled prospective trial involving 161 patients evaluated and compared the efficacy of intravesical epirubicin and bacillus Calmette-Guérin (BCG) administration as prophylaxis against recurrences after complete transurethral resection of superficial bladder cancer. The treatment schedule, consisting of one 6- or 8-week course of instillations (50 mg epirubicin or 150 mg BCG per instillation) followed by single maintenance doses to the responders at follow-up examinations, was modified for those of the initial responders who were at high risk for recurrence and who received an additional separate 4-week course of treatment 6 months after the start of therapy. Sixty percent of the patients treated with epirubicin, 68% of the patients treated with BCG, and 41% of the control subjects, who underwent resection only, remained free of recurrences for a mean follow-up of 32.9 months. The only significant difference was found between patients treated with BCG and control subjects, in favor of the former. Conversely, recurrence rate per 100 patient-months and mean interval to recurrence showed both drugs to be superior to resection alone regarding several tumor characteristics. However, a significant benefit in favor of BCG when compared with epirubicin was shown in those patients who had Stage T1 and Grade 3 tumors at presentation. Intravesical epirubicin and BCG were superior to transurethral resection alone in the prophylaxis of superficial bladder cancer, but with respect to superficially invasive and high-grade tumors, BCG demonstrated a remarkable advantage.

Intravesical Bacillus Calmette-Guerin Immunoprophylaxis of Superficial Bladder Cancer: Results of a Controlled Prospective Trial with Modified Treatment Schedule

A controlled prospective trial on 94 patients evaluated the efficacy of intravesical Pasteur strain bacillus Calmette-Guerin (BCG) administration as prophylaxis against tumor recurrences after complete endoscopic resection of superficial bladder cancer. The treatment schedule, consisting of an initial 6-week course of instillations and a single quarterly maintenance dose to the responders, was modified to those of the latter who were at high risk for recurrence and who received an additional separate 4-week course of therapy. The percentage of the patients treated prophylactically with BCG and who remained free of recurrences (68%, mean followup 33.8 months) was significantly higher than that of the controls who underwent transurethral resection only (41%, mean followup 30.2 months). In terms of relative risk of recurrences, recurrence rate per 100 patient-months and disease-free interval, comparisons between the 2 groups of patients revealed a significant benefit for the BCG group overall as for those subjects having stages Ta and Tl tumors, multifocal tumors, a history of disease, and grades 2 and 3 carcinoma. Drug-induced toxicity was acceptable. Our study suggests that our modified treatment protocol is notably safe and effective against recurrent superficial bladder cancer.

Analysis of the immunologic mechanism of intravesical bacillus Calmette-Guerin therapy for superficial bladder tumors: distribution and function of immune cells.

Intravesical bacillus Calmette-Guerin (BCG) administration has been used as an adjuvant therapy after transurethral resection for superficial bladder cancer, but the exact mechanisms of its antitumor activity are not yet known. The aim of this study was to characterize the immunologic aspects of antitumor activity of BCG using an animal model. C3H/He inbred mice and murine bladder tumor cell line, MBT-2 were used. The changes in immune cells such as helper T cells, suppressor T cells, macrophages and natural killer cells in the bladder and spleen were analysed by immunohistochemical method in intravesical BCG instilled in normal bladder, MBT-2 implanted after electrocauterization of the bladder mucosa and MBT-2 implanted and intravesical BCG treated group. The changes in natural killer cell activity of the splenocytes and peritoneal lymphocytes were evaluated using 51chromium release assay at regular time intervals following intraperitoneal BCG instillation. The prophylactic anticancer effect was evaluated by observing the tumor growth in the intravesically BCG treated group after intravesical MBT-2 implantation. In immunohistochemical examination, a remarkable infiltration of macrophage and helper T cell was observed in the lamina propria of the bladder, and the helper and suppressor T cells ratio (Th/Ts ratio) was increased after intravesical BCG therapy. In 51chromium release assay, enhanced natural killer cell activity of the splenocytes and peritoneal lymphocytes was observed after intraperitoneal BCG inoculation. The growth of implanted tumor was suppressed following intravesical instillation of BCG. These results suggest that the antitumor activity of BCG is not related to the simple inflammatory reaction but to the local and systemic immune response in which helper T lymphocytes and mononuclear cells play an important role.

Intravesical BCG administration in the guinea pig

The intravesical administration of bacillus Calmette-Guérin (BCG) is used as an adjuvant therapy after transurethral resection for superficial bladder cancer in man. The aim of this study was to characterize with monoclonal antibodies the cellular infiltrates in the bladder wall occurring after one or two cycles, each comprising six weekly intravesical BCG administrations in guinea pigs. BCG-RIVM and BCG-TICE were instilled once a week in undamaged bladders at weeks 1-6 and 11-16, respectively, and retained in the bladder for 1 h. Autopsy was performed 1 week after the last BCG administration at weeks 7 and 17. By routine histology, a single BCG course induced scattered focal infiltrates consisting of minor to severe accumulations of mononuclear cells. After two cycles of BCG, a much more severe inflammatory reaction sometimes occupying almost the total bladder mucosa was noted. The major component of this inflammation was mononuclear cells, mainly lymphocytes, while typical BCG granulomas were occasionally observed. In general, the epithelial layer of the bladder showed no visible alterations. Immunohistochemical staining showed that the majority of mononuclear cells present in the infiltrate were T-cells. Widely scattered B-cells and macrophages were also present, but were much fewer in number than the T-cells. In general, T-helper/inducer cells were more frequent than T-suppressor/cytotoxic cells. Pseudofollicles, also noted after H&E staining, consisted mainly of B-cells. The second series of BCG administrations produced pseudofollicles in the infiltrates in all animals investigated.(ABSTRACT TRUNCATED AT 250 WORDS)

Stage T1 Bladder Cancer: Grade is the Primary Determinant for Risk of Muscle Invasion

Tumor characteristics believed to predict for deep muscle invasion after transurethral resection of superficial bladder cancer alone were analyzed in 51 patients with stage T1 (stage A) transitional cell carcinoma of the bladder. All patients were treated at Stanford University Medical Center and none had intravesical chemotherapy at any time during the median followup of 78 months. No patient had carcinoma in situ. A total of 14 patients (27%) had deep muscle invasion. None of the patients with grade 1, 5 (22%) with grade 2 and 9 (50%) with grade 3 to 4 tumors had deep muscle invasion. Comparison of the risk of muscle invasion using pathological tumor grade at diagnosis, highest grade at any cystoscopic biopsy before the diagnosis of muscle invasion or highest grade at cystoscopic biopsy immediately antecedent to the cystoscopy at which muscle invasion was diagnosed all showed similar probability of muscle invasion. Mean interval to development of muscle invasion was 6 and 12 months in the grades 2 and 3 to 4 groups, respectively. At 36 months the cumulative probability of invasion-free survival was 62% for grade 2, compared to 50% for grades 3 to 4 cancer patients (p <0.005, Gehan). Univariate regression analysis demonstrated grade to be the only significant factor in predicting for invasive disease (p = 0.005), with tumors in the bladder neck to be of borderline significance (p = 0.159). On multivariate logistic regression analysis, grade remained the single tumor variable predicting for invasive bladder cancer (p = 0.004). These data suggest that of routinely available data at diagnosis and during subsequent followup cystoscopic examinations, tumor grade is the most important biological predictor of progression to muscle invasive cancer.

Neutrophil-Activating Peptide-1/Interleukin-8 Detection in Human Urine during Acute Bladder Inflammation Caused by Transurethral Resection of Superficial Cancer and Bacillus Calmette-Guérin Administration

Neutrophil-activating peptide-1/interleukin-8 (NAP-1/IL-8), secreted by monocytes, macrophages and a number of other cells, acts as a chemoattractant for neutrophil leukocytes and stimulates them to produce a series of responses such as shape change, adherence, exocytosis and respiratory burst, events that are of importance in inflammation. To study the release of NAP-1/IL-8, two human models of inflammation were chosen: transurethral resection of superficial bladder cancer and the subsequent instillation of bacillus Calmette-Guérin (BCG), performed in order to reduce the recurrence rate of papillary bladder tumors. As the secretions of the bladder wall are retained in the urine, patients' urine was collected during 4-hour periods. These urine samples were chromatographed on phosphocellulose. In the elution fractions NAP-1/IL-8 was quantified by a bioassay that measured the elastase release by human neutrophils. The neutrophil-stimulating activity was further purified by reverse phase high performance liquid chromatography. Although no NAP-1/IL-8 activity could be detected in normal individuals, formation of this inflammatory cytokine was observed in patients after transurethral resection and after BCG treatment. The significance and possible use of this secretion are discussed.

Long-Term versus Short-Term Doxorubicin Hydrochloride Instillation after Transurethral Resection of Superficial Bladder Cancer

In a prospective randomized study the influence of short-term instillation therapy versus long-term instillation therapy after transurethral resection of superficial transitional cell bladder cancer on tumor recurrence, tumor progression and patient survival were evaluated. The data of 146 patients of 160 who entered the study were evaluable. After transurethral resection of the initial tumor and random biopsies of the bladder, patients were divided into two groups at random: group 1--doxorubicin weekly for 6 weeks and afterwards no further treatment (short-term regimen) and group 2--doxorubicin weekly for 6 weeks and afterwards monthly instillation for 2 years (long-term regimen). The follow-up was 5 years. Neither frequency of recurrences, nor tumor progression nor survival rate was improved significantly by the long-term instillation regimen.

Intravesical BCG administration in the guinea pig. A histomorphological study.

Intravesical BCG administration is used as an adjuvant therapy after transurethral resection for superficial bladder cancer in man. The mechanisms of its antitumor activity are not known. The aim of this study was to characterize the histomorphological changes in various organs of the guinea pig after intravesical BCG administration. The BCG preparation used was BCG-RIVM, a Dutch BCG preparation. Instillations were performed in previously undamaged bladders weekly for 6 consecutive weeks and lasted 30 min or 1 h. Different doses were used ranging from 10(3) culturable particles (c.p.) to 5 x 10(7) c.p. of BCG. After 6 weeks, the animals were killed and postmortem examination was performed. The bladder wall, retroperitoneal lymph nodes, spleen, liver, lungs and distant lymph nodes were examined histologically. The BCG therapy, with a dose of 10(6) culturable particles and higher, induced an inflammatory reaction consisting of mononuclear infiltrates in the subepithelial tissue of the bladder wall. In approximately 50% of the animals investigated, the infiltrates were accompanied by non-caseating granulomatous lesions indicated by the presence of epithelioid cells. In general, the epithelial layer of the bladder showed no visible alterations. Similarly, a granulomatous inflammatory reaction was observed in the first retroperitoneal (iliac) lymph nodes draining the bladder. Granulomatous lesions were occasionally also present in liver and lung. In three of the 29 animals investigated, lesions were present both in liver and lungs, and in two of these three animals a granulomatous reaction was observed in the spleen and distant lymph nodes indicating a generalized inflammatory response induced by BCG.(ABSTRACT TRUNCATED AT 250 WORDS)

Superficial bladder cancer: the primacy of grade in the development of invasive disease.

Tumor characteristics thought to predict for development of deep muscle invasion after resection of superficial bladder cancer were retrospectively analyzed in 252 patients with transitional cell carcinoma of the bladder at Stanford University Medical Center. Stage 0 patients accounted for 190 of the patient population (75.5%), while stage A and B1 comprised 51 (20%) and 11 (4.5%), respectively. The median follow-up time was 62 months. Forty-three patients subsequently developed deep muscle invasion; these included 24 (12.6%), 14 (27.5%), and 5 (45.5%) of stage 0, A, and B1 patients (P = .002), or 15 (10%), 15 (9%), and 13 (33%) of grade 1, 2, and 3 tumors (P = .001), respectively. When analyzed by univariate logistic regression, grade (P = .0001) and stage (P = .0118) were significant predictors for invasive disease. Site of tumor and number of tumors at presentation were not significant factors for invasion deep into the bladder wall. When multiple logistic regression was performed, only grade remained as a significant tumor variable to predict for invasive disease (P less than .0091). Risk of invasive disease did not appear to increase with increasing number of recurrences, remaining at approximately an 11% invasion rate through 12 recurrences. In this analysis, grade was the most significant tumor variable in superficial bladder cancer predicting for the development of invasive carcinoma. Future clinical trials for definitive or adjuvant therapy of this disease must stratify for this variable.

Use of Mitomycin as Prophylaxis Following Endoscopic Resection of Superficial Bladder Cancer

A prospective controlled study evaluated the influence of long-term mitomycin instillation therapy on tumor recurrence, tumor progression rate, and patient survival after transurethral resection of superficial bladder tumors. In the mitomycin group, 11.1 per cent had recurrent tumors, and among the controls, 54.8 per cent had recurrent tumors during a mean follow-up of thirty-three and one-half and thirty-four and one-half months, respectively. The control group had 8 recurrent tumors of higher stage and 4 of higher grade, whereas all recurrent tumors in the mitomycin group that occurred in the bladder were either the same grade and the same stage (n = 1) or a lower stage and lower grade (n = 6). Side effects were minimal, with 72 per cent of the patients having no side effects. Chemical cystitis was the most common side effect, followed by generalized rash. No general toxic signs such as myelosuppression were seen.