Intravesically administered antisense oligonucleotides targeting heat-shock protein-27 inhibit the growth of non-muscle-invasive bladder cancer

OBJECTIVE

To evaluate the inhibitory effects of a second‐generation antisense oligonucleotide (ASO) targeting the cytoprotective chaperone heat‐shock protein (HSP)‐27 (OGX‐427, OncoGeneX Technologies, Vancouver, Canada) on human bladder cancer growth both in vitro and in vivo as an intravesical agent in an orthotopic murine model.

MATERIALS AND METHODS

Human KU‐7 bladder tumour cells were treated with OGX‐427 or a mismatch (MM) control oligodeoxynucleotide (ODN) in vitro and were assessed for HSP27 expression, proliferation and apoptosis. KU‐7‐luc cells that stably express luciferase were inoculated in female nude mice by intravesical instillation and tumour size was measured using bioluminescence imaging. Mice with established KU‐7‐luc tumours were administered uncomplexed ‘naked’ OGX‐427 or MM ODN as well as controlled‐release microparticulate chitosan/oligonucleotide formulations intravesically. Tumour growth was monitored over time and tumours were analysed after death using immunohistochemistry and Western blotting.

RESULTS

In vitro, OGX‐427 significantly decreased HSP27 protein levels and cellular viability. While naked OGX‐427 showed only a trend in tumour suppression compared with MM ODN, OGX‐427 complexed with chitosan significantly inhibited orthotopic tumour growth. The chitosan preparation induced some haematuria compared to naked ASO, but this formulation had superior tissue uptake of oligonucleotides and suppressed HSP27 tissue levels by 75%.

CONCLUSION

Intravesical OGX‐427 instillation therapy showed promising antitumour activity and minimal toxicity in an orthotopic mouse model of high‐grade bladder cancer. These findings provide pre‐clinical proof‐of‐principle for the use of ASO as intravesical agents for non‐muscle‐invasive bladder cancer, and warrant further evaluation of efficacy and safety in early‐phase clinical trials.     

A comparison of white-light cystoscopy and narrow-band imaging cystoscopy to detect bladder tumour recurrences

OBJECTIVE

To determine whether narrow‐band imaging (NBI) cystoscopy enhances the detection of non‐muscle‐invasive bladder tumours over standard white‐light imaging (WLI) cystoscopy, as surveillance WLI is the standard method used to diagnose patients with recurrent bladder tumours, but they can be missed by WLI cystoscopy, possibly accounting for early recurrences.

PATIENTS AND METHODS

We evaluated 427 patients for recurrent bladder tumours by WLI cystoscopy, followed by NBI cystoscopy as a further procedure, using the same video‐cystoscope. Recurrent tumours visualized by WLI or NBI cystoscopy were mapped, imaged, biopsied and subsequently treated by transurethral resection (TUR) or fulguration. Biopsies or TUR specimens obtained by WLI and NBI were examined separately for presence of tumour.

RESULTS

In all, 103 patients (24%) had tumour recurrences; 90 (87%) were detected by both WLI and NBI and another 13 (100%) only by NBI cystoscopy. NBI detected extra papillary tumours or more extensive carcinoma in situ in 58 (56%) patients found to have recurrences. The mean number of recurrent tumours visualized on WLI cystoscopy was 2.3, vs to 3.4 seen on NBI cystoscopy (P = 0.01).

CONCLUSION

NBI cystoscopy improved the detection of recurrent non‐muscle‐invasive bladder tumours over standard WLI cystoscopy.     

Treatment changes and long‐term recurrence rates after hexaminolevulinate (HAL) fluorescence cystoscopy: does it really make a difference in patients with non‐muscle‐invasive bladder cancer (NMIBC)?

Study Type – Therapy (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? HAL fluorescence cystoscopy is known to improve tumour detection in NMIBC cases and to have a potentially favourable impact concerning the recurrence rates. The present trial assessed the advantages of HAL cystoscopy with regard to postoperative treatment changes and 2 years' recurrence rates, subjects that are poorly evaluated in the literature.

OBJECTIVES

• ? To evaluate in a prospective, randomized study the impact of hexaminolevulinate blue‐light cystoscopy (HAL‐BLC) on the diagnostic accuracy and treatment changes in cases of non‐muscle invasive bladder cancer (NMIBC) compared with standard white‐light cystoscopy (WLC).
• ? To compare the long‐term recurrence rates in the two study arms.

PATIENTS AND METHODS

• ? In all, 362 patients suspected of NMIBC were included in the trial based on positive urinary cytology and/or ultrasonographic suspicion of bladder tumours and underwent transurethral resection of bladder tumours.
• ? A single postoperative mytomicin‐C instillation was performed in all cases, intravesical chemotherapy for intermediate‐risk patients and BCG instillations for high‐risk cases.
• ? The follow‐up protocol consisted of urinary cytology and WLC every 3 months for 2 years.
• ? Only first‐time recurrences after the initial diagnosis were considered.

RESULTS

• ? In the 142 patients with NMIBC in the HAL‐BLC series, tumour detection rates significantly improved for carcinoma in situ, pTa andoverall cases.
• ? In 35.2% of the cases, additional malignant lesions were found by HAL‐BLC and consequently, the recurrence‐ and progression‐risk categories of patients and subsequent treatment improved in 19% of the cases due to fluorescence cystoscopy.
• ? In all, 125 patients in the HAL‐BLC group and 114 of the WLC group completed the follow‐up.
• ? The recurrence rate at 3 months was lower in the HAL‐BLC series (7.2% vs 15.8%) due to fewer ‘other site’ recurrences when compared with the WLC series (0.8% vs 6.1%).
• ? The 1 and 2 years recurrence rates were significantly decreased in the HAL‐BLC group compared with the WLC group (21.6% vs 32.5% and 31.2% vs 45.6%, respectively).

CONCLUSIONS

• ? HAL‐BLC was better than WLC for detecting NMIBC cases and improved tumour detection rates.
• ? HAL‐BLC significantly modified the postoperative treatment of cases.
• ? The 3 months, 1 and 2 years recurrence rates were significantly improved in the HAL‐BLC arm.

     

Narrow‐band imaging cystoscopy to evaluate the response to bacille Calmette‐Guérin therapy: preliminary results

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

OBJECTIVE

To evaluate whether narrow‐band imaging cystoscopy (NBIC) can identify bladder tumour suspected on follow‐up white‐light cystoscopy (WLC) after intravesical bacille Calmette‐Guérin (BCG) therapy, as BCG causes an intense reaction in the bladder, appearing as red lesions on WLC, which might be residual tumour or BCG‐induced inflammation.

PATIENTS AND METHODS

Sixty‐one patients with high‐risk non‐muscle‐invasive bladder tumours were evaluated 3 months after starting induction BCG therapy. All patients had abnormal erythematous lesions on WLC, suspected to be residual carcinoma in situ. After WLC, they were evaluated by NBIC, urine cytology and biopsy, followed by transurethral resection of all visible lesions.

RESULTS

Of the 61 patients, 22 (36%) had residual tumour. NBIC correctly identified tumour in 21 patients, but another 10 had unnecessary biopsy (NBIC positive, negative biopsy). Only one of 30 patients who had negative NBIC findings had tumour. NBIC outperformed urine cytology in detecting residual tumour after BCG therapy.

CONCLUSION

NBIC appears to better identify patients who have suspected residual tumour on follow‐up WLC at 3 months after BCG therapy.     

Long-term outcomes of a randomized controlled trial comparing thermochemotherapy with mitomycin-C alone as adjuvant treatment for non-muscle-invasive bladder cancer (NMIBC)

Study Type – Therapy (RCT) Level of Evidence 1b What’s known on the subject? and What does the study add? Microwave‐induced hyperthermia and mitomycin C is a device‐assisted approach used to treat non‐muscle invasive bladder cancer (NMIBC) either in the adjuvant (prophylactic) set‐up or in an ablative regimen. Until recently, around 20 different studies have been published with data on the short term results of treatment. Previous prospective randomized studies showed the superiority of the chemo‐hyperthermia regimen when compared to intravesical chemotherapy alone in terms of recurrence‐free survival in intermediate and high‐risk NMIBC patients at minimum 24‐month follow‐up. The current study confirmed the result also in long‐term (minimum 10 years) follow‐up. It also represents one of a few to show such extended follow‐up periods for any intravesical therapy for NMIBC.

OBJECTIVE

? To present long‐term efficacy data of intravesical thermochemotherapy vs chemotherapy alone with mitomycin‐C (MMC) randomly administered to patients with non‐muscle‐invasive bladder cancer (NMIBC) as an adjuvant treatment after complete transurethral resection.

PATIENTS AND METHODS

? In all, 83 patients with intermediate‐/high‐risk NMIBC, following complete transurethral resection, were randomly assigned to receive either intravesical thermochemotherapy by means of Synergo® (Medical Enterprises, Amsterdam, The Netherlands) or intravesical chemotherapy alone, for prophylaxis of tumour recurrence. ? Two doses of MMC (20 mg dissolved in 50 mL distilled water administered throughout two consecutive sessions) was used as the chemotherapeutic agent in both arms. ? In all, 75 patients completed the original study (35 of 42 in the treatment arm, 40 of 41 in the control arm), whose results at minimum 2‐year follow‐up have already been published. ? Recently, the files of these patients have been updated for long‐term outcome definition. Data on general health, follow‐up examinations, tumour relapse or progression, and cause of death were collected and analysed.

RESULTS

? Updated complete data collection was available for 65/75 (87%) of the original patients. ? The median follow‐up for tumour‐free patients was 91 months. The 10‐year disease‐free survival rate for thermochemotherapy and chemotherapy alone were 53% and 15%, respectively (P < 0.001). ? An intent‐to‐treat analysis performed to overcome the potential bias introduced by the asymmetrical discontinuation rate still showed a significant advantage of the active treatment over the control treatment. Bladder preservation rates for thermochemotherapy and chemotherapy alone were 86% and 79%, respectively.

CONCLUSION

? This is the first analysis of long‐term follow‐up of patients treated with intravesical thermochemotherapy. The high rate (53%) of patients who were tumour‐free 10 years after treatment completion, as well as the high rate (86%) of bladder preservation, confirms the efficacy of this adjuvant approach for NMIBC at long‐term follow‐up, even in patients with multiple tumours.     

A single‐institution experience with induction and maintenance intravesical docetaxel in the management of non‐muscle‐invasive bladder cancer refractory to bacille Calmette‐Guérin therapy

OBJECTIVE

To analyse the durability of response for patients with non‐muscle‐invasive bladder cancer (NMIBC) refractory to bacille Calmette‐Guérin (BCG) therapy and treated with intravesical docetaxel in a combined induction and maintenance regimen.

PATIENTS AND METHODS

A previous phase I trial showed docetaxel to be safe for intravesical therapy, with no systemic absorption and minimal toxicity after six weekly instillations for patients with BCG‐refractory NMIBC. In that trial, docetaxel gave a 56% complete response (CR) rate at 12 weeks, but the durability was only 22%. Thus a second group of patients was treated with a 6‐week induction and then given monthly maintenance therapy with intravesical docetaxel. Thirteen patients with BCG‐refractory Ta, T1, or Tis transitional cell carcinoma were treated. Induction therapy was administered as six weekly intravesical instillations of 75 mg followed by single‐dose monthly maintenance therapy for nine additional instillations in patients who had a CR. The initial response at 12 weeks from the start of induction therapy was evaluated by cystoscopy with biopsy, and urine cytology. The follow‐up consisted of quarterly cystoscopy with biopsy and cytology, and periodic imaging.

RESULTS

The median follow‐up was 13 months; 10 of 13 patients had a CR after induction, and six have remained disease‐free during the follow‐up. Of those in who the treatment failed, six had transurethral resection of the tumour and one a cystectomy. All 10 initial responders completed at least three instillations of maintenance therapy to date (median nine instillations), of whom six have remained recurrence‐free.

CONCLUSION

Monthly maintenance therapy with intravesical docetaxel appears to extend the durability of response to induction treatment for a selected group of patients with BCG‐refractory NMIBC, and might decrease the overall risk of recurrence in high‐risk NMIBC.     

Prospective trial to identify optimal bladder cancer surveillance protocol: reducing costs while maximizing sensitivity

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? A plethora of urinary markers are available with the purported benefit of identifying bladder tumours that evade detection with cystoscopy alone. Clinicians often infer that this translates into earlier detection of invasive disease and helps control costs. This prospective trial suggests that in experienced hands, cystoscopy alone is the most cost‐effective strategy to detect recurrence of non‐invasive bladder cancer. Using urinary markers in all patients significantly adds to cost and hence must be individualized.

OBJECTIVE

? To assess the cost‐effectiveness of using cytological evaluation, NMP22 BladderChek®, and fluorescence in situ hybridization (FISH) UroVysion® in addition to cystoscopy in patients with a history of bladder cancer undergoing surveillance for recurrence.

PATIENTS AND METHODS

? In all, 200 consecutive patients with a history of bladder cancer not invading the muscle were prospectively enrolled at The University of Texas MD Anderson Cancer Center. ? Five surveillance strategies were compared: (i) cystoscopy alone; (ii) cystoscopy and NMP22; (iii) cystoscopy and FISH; (iv) cystoscopy and cytology; and (v) cystoscopy and positive NMP22 confirmed by positive FISH. ? The cost per cancer detected was calculated. ? For patients with an initial positive test and negative cystoscopy, tumour detected at first follow‐up was assumed to be too small to be visualized at the initial assessment and the biomarker was credited with early detection.

RESULTS

? Cancer was detected in 13 patients at study entry. ? Detection rates for the five surveillance strategies were: (i) 52%, (ii) 56%, (iii) 72%, (iv) 60%, and (v) 56%. ? The costs per tumour detected (at the time of initial marker analysis) were (i) $7692; (ii) $12 000; (iii) $26 462; (iv) $11 846; and (v) $10 292. ? When early detection of biomarkers was factored in, the CPTD became: (i) $7692; (ii) $11 143; (iii) $19 111; (iv) $10 267; and (v) $9557. ? There were 12 new cancers detected at first follow‐up (median time, 4.1 months). None of the tumours detected by biomarkers but not by cystoscopy were invasive.

CONCLUSIONS

? Cystoscopy alone remains the most cost‐effective strategy to detect recurrence of bladder cancer not invading the muscle. ? The addition of urinary markers adds to cost, without improved detection of invasive disease.     

A chemosensitivity test to individualize intravesical treatment for non‐muscle‐invasive bladder cancer

OBJECTIVE

To describe the design of a new chemosensitivity assay based on the expression of genes involved in the resistance to standard intravesical regimens, to allow individualization of therapy for high‐risk non‐muscle‐invasive bladder cancer.

PATIENTS AND METHODS

To date, 35 patients with high‐risk no‐nmuscle‐invasive bladder cancer have been enrolled, all candidates for transurethral resection of the bladder (TURB) followed by intravesical treatment. The intravesical regimen was chosen according to the risk profile of each patient. All patients were evaluated by cystoscopy 3 and 6 months after TURB. According to the molecular characterization of each tumour, our team of molecular oncologists determined for each patient a molecular profile of chemosensitivity to BCG, mitomycin c, anthracyclines and gemcitabine. This profile was then correlated to the response to intravesical therapy 6 months after TURB.

RESULTS

This chemosensitivity test was able to predict response to treatment in 96% of patients. The assay is easy to perform, inexpensive and quick.

CONCLUSION

Our results, although preliminary, are encouraging for the future of an individualized therapeutic approach, with the aim to provide a higher treatment success rate while sparing patients unnecessary toxicity from drugs that are not suited for their tumours.     

Bladder carcinoma among live-donor renal transplant recipients: a single-centre experience and a review of the literature

OBJECTIVES

To present our experience with bladder cancer among a renal transplant population and to review critically the relevant literature.

PATIENTS AND METHODS

In all, 1865 renal graft recipients were followed for a mean (sd ) of 6.5 (5) years. Seven recipients (all men) developed a urothelial bladder tumour. The stage and grade of the tumours were determined. The method of the treatment was selected on the basis of the tumour characteristics and graft function. Patients were regularly followed; the endpoints were cancer‐specific survival, recurrence or metastasis.

RESULTS

All patients presented with gross haematuria. There was non‐muscle‐invasive disease in two patients who were treated by transurethral resection and adjuvant intravesical bacille Calmette‐Guérin immunotherapy. One patient died 24 months later due to complications of end‐stage renal disease. To date the second patient is alive and free of the recurrence. Five recipients with muscle‐invasive disease had a radical cystectomy and orthotopic bladder substitution. The mean (sd ) time to the last follow‐up or death was 14.6 (3.1) months. Three patients died with stable graft function; two from distant metastasis and one from a cerebrovascular stroke. The remaining two patients are still alive, free of disease and with good graft function.

CONCLUSIONS

Urothelial bladder tumours are generally uncommon. The presence of haematuria in renal allograft recipients should be thoroughly investigated. Early diagnosis and prompt treatment are required for managing such tumours, because they are aggressive. Orthotopic bladder substitution is feasible with a good functional outcome for patients in whom cystectomy is indicated.     

Expression of integrin proteins in non‐muscle‐invasive bladder cancer: significance of intravesical recurrence after transurethral resection

Study Type – Aetiology (case control)
Level of Evidence 3b What’s known on the subject? and What does the study add? A number of studies have reported several clinicopathological factors closely associated with intravesical recurrence of non‐muscle invasive bladder cancer (NMIBC). In addition, various types of molecular markers have been shown to be useful for predicting intravesical recurrence of NMIBC following transurethral resection (TUR). Of six subunits of integrin proteins, including α2, α3, α5, α6, β1 and β4, the expression level of the β4 subunit in NMIBC, in addition to pathological T stage and concomitant carcinoma in situ appeared to be independently related to intravesical recurrence. Therefore, consideration of the expression levels of integrins, particularly that of the β4 subunit, in TUR specimens would contribute to further accurate prediction of intravesical recurrence of NMIBC.

OBJECTIVES

• ? To evaluate the expression of integrin proteins, a family of transmembrane heterodimers, in non‐muscle‐invasive bladder cancer (NMIBC).
• ? To assess the significance of these proteins as prognostic indicators in patients undergoing transurethral resection (TUR).

PATIENTS AND METHODS

• ? The present study comprised 161 patients diagnosed as having NMIBC after TUR.
• ? Expression levels of six subunits of integrin proteins, including α2, α3, α5, α6, β1 and β4, were measured in TUR specimens by immunohistochemical staining.

RESULTS

• ? Of the six proteins, expression levels of α2‐, α3‐, α6‐ and β4‐subunits were significantly associated with the incidence of intravesical recurrence. Univariate analysis identified expression levels of α3‐, α6‐ and β4‐subunits as important predictors of intravesical recurrence, while tumour size, pathological T stage and concomitant carcinoma in situ (CIS) were also important.
• ? Multivariate analysis showed that the expression level of the β4 subunit, pathological T stage and concomitant CIS are independently related to intravesical recurrence.
• ? There were significant differences in intravesical recurrence‐free survival for patients who were positive for the three independent risk factors; intravesical recurrence occurred in 10 of 49 (20.4%) patients who were negative for all risk factors, 31 of 68 who were positive for one risk factor (45.6%), and 30 of 44 who were positive for two or three risk factors (68.2%).

CONCLUSIONS

• ? Consideration of the expression levels of integrins, particularly those of the β4 subunit, in TUR specimens, in addition to conventional variables, would contribute to accurate prediction of intravesical recurrence after TUR for NMIBC patients.

     

Reduced bladder tumour recurrence rate associated with narrow‐band imaging surveillance cystoscopy

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Narrow‐band imaging cystoscopy is a new imaging modality developed to enhance conventional standard white‐light cystoscopy to evaluate bladder tumors. The current paper suggests that fulguration of low‐risk papillary bladder tumours using NBI cystoscopy results in fewer subsequent tumour recurrences than fulguration using standard cystoscopy. How, or if, NBI cystoscopy will become integrated into routine management of non‐invasive bladder tumours remains for further study.

OBJECTIVE

To evaluate frequency of recurrences among patients with papillary bladder tumours followed sequentially with conventional white‐light (WLI) cystoscopy and narrow‐band imaging (NBI) cystoscopy.

PATIENTS AND METHODS

A cohort of 126 patients with recurrent low‐grade papillary bladder tumours were followed every 6 months for 3 years by conventional WLI cystoscopy, and then over the next 3 consecutive years by NBI cystoscopy. Recurrent tumours detected were treated by outpatient fulguration or transurethral resection. We compared the tumour recurrence rate during follow‐up with WLI and NBI cystoscopy, using patients as their own controls.

RESULTS

Of the 126 patients, 94% had tumour recurrences during WLI cystoscopy vs 62% during NBI cystoscopy. The mean number of recurrent tumours was 5.2 with WLI cystoscopy vs 2.8 with NBI cystoscopy, and the median recurrence‐free survival time was 13 vs 29 months (P= 0.001).

CONCLUSION

Compared with follow‐up with WLI cystoscopy, NBI cystoscopy was associated with fewer patients having tumour recurrences, fewer numbers of recurrent tumours, and a longer recurrence‐free survival time.     

Paclitaxel incorporated in hydrophobically derivatized hyperbranched polyglycerols for intravesical bladder cancer therapy

OBJECTIVE

To develop paclitaxel incorporated into unimolecular micelles based on hydrophobically derivatized hyperbranched polyglycerols (dHPGs) for use as mucoadhesive intravesical agents against non‐muscle‐invasive bladder cancer.

MATERIALS AND METHODS

Two different types of dHPGs (HPG‐ C10‐polyethylene glycol (PEG) and polyethyleneimine (PEI)‐C18‐HPG) were synthesized and paclitaxel was loaded into these using a solvent evaporation method. After physicochemical characterization of the resulting nanoparticles, four human bladder cancer cell lines were incubated with various concentrations of paclitaxel incorporated in dHPGs and the results were compared with those of paclitaxel formulated in Cremophor‐EL (Taxol®, Bristol‐Myers‐Squibb). In vivo, nude mice with orthotopic KU7‐luc tumours were intravesically instilled with phosphate buffered saline, Taxol, or paclitaxel/HPG‐C10‐PEG.

RESULTS

dHPGs are mucoadhesive nanoparticles with hydrodynamic radii of <10 nm and incorporation of paclitaxel did not affect their size. The release profiles of paclitaxel from dHPGs were characterized by a rapid‐release phase followed by a slower sustained‐release phase. While the PEI‐C18‐HPG formulation released only ≈40% of the initially incorporated paclitaxel, up to 80% was released from HPG‐C10‐PEG. Moreover, only paclitaxel/HPG‐C10‐PEG was stable in acidic urine. In vitro, all paclitaxel formulations potently decreased bladder cancer proliferation although paclitaxel/HPG‐C10‐PEG was slightly less cytotoxic than standard Taxol. By contrast, in vivo, the mucoadhesive HPG‐C10‐PEG formulation of paclitaxel was significantly more effective in reducing orthotopic tumour growth than Taxol and was well tolerated.

CONCLUSION

Intravesical administration of mucoadhesive nanoparticulate formulations of paclitaxel might be a promising approach for instillation therapy of patients with non‐muscle‐invasive bladder cancer.     

Paclitaxel and cisplatin as intravesical agents against non-muscle-invasive bladder cancer

OBJECTIVES

To investigate the effects of cisplatin and paclitaxel against human bladder cancer cells in vitro, and to obtain both pharmacokinetic and pharmacodynamic data after intravesical administration in mice.

MATERIALS AND METHODS

Six bladder cancer cell lines (J82, KU7, RT4, SW780, T24, UMUC3) were treated with various combined doses of both drugs and cell proliferation was evaluated 3 days later. In vivo, solutions of cisplatin and micellar paclitaxel were instilled transurethrally in female mice and pharmacokinetic data were acquired using high‐performance liquid chromatography‐mass spectrometry and atomic absorption methods. To obtain efficacy data, mice with orthotopic KU7‐luc tumours were administered cisplatin and/or micellar paclitaxel intravesically, and the tumour burden quantified using bioluminescence imaging.

RESULTS

In vitro, both cisplatin and paclitaxel potently decreased the proliferation of all cell lines tested, and in combination had an additive but not a synergistic effect. After intravesical instillation, mouse serum concentrations of cisplatin and paclitaxel were in the low microgram/millilitre range and bladder tissue concentrations achieved were 82 and 241 µg/g, respectively. Similar drug levels were reached using combined therapy. In vivo, all chemotherapeutic agents significantly inhibited bladder tumour growth, with the best results for combined therapy and micellar paclitaxel alone. However, there was toxicity in the combined treatment arm.

CONCLUSIONS

Both cisplatin and paclitaxel were absorbed at effective amounts into bladder tissues. As intravesical agents, paclitaxel had slightly stronger anticancer potency than cisplatin. Due to increased adverse events, caution should be exercised when combining both cisplatin and paclitaxel intravesically.     

Immediate radical cystectomy vs conservative management for high grade cT1 bladder cancer: is there a survival difference?

Study Type – Aetiology (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? For patients with high grade (HG) non‐muscle invasive urothelial cell cancer (UCC) of the bladder, transurethral resection of bladder tumor (TURBT) in conjunction with induction and maintenance intravesical therapy is a commonly used treatment modality. Early cystectomy, although offering the best opportunity for cure, would in turn constitute overtreatment in some cases. Conservative management strategies, as opposed to radical surgery, are a viable treatment option within a well selected subset of patients with HG T1 UCC.

OBJECTIVE

• ? To determine whether a survival difference exists between patients with high grade (HG) cT1 urothelial cell carcinoma (UCC) receiving immediate radical cystectomy (IRC) as opposed to those choosing bladder‐sparing therapy.

PATIENTS AND METHODS

• ? Between January 1990 and August 2010, 349 patients were retrospectively identified with a diagnosis of HG cT1 UCC of the bladder. Patients were divided into two groups: those who underwent IRC and those treated with conservative management (CM), consisting of transurethral resection of the bladder tumour (TURBT) and intravesical therapy. IRC was defined as surgery within 90 days of HG cT1 diagnosis with no intervening transurethral resection (TUR) or intravesical therapy (IVT). Trends in patient selection and cancer‐specific survival (CSS) were analyzed over consecutive decades.
• ? The primary outcome was to compare CSS among patients during consecutive decades whereby management paradigms shifted from IRC to CM. The secondary outcome was to examine whether patient selection changed over time for each respective intervention.

RESULTS

• ? One hundred and thirteen patients underwent IRC and 236 had CM. From 1990 to 1999, only 90 patients were diagnosed with HG cT1 disease, and a majority of patients (n= 54) underwent IRC. From 2000 to 2010, only 23% (59/259) of the patients with HG cT1 underwent IRC. Despite 42.3% more patients successfully maintaining their bladder in the long‐term, no difference in 5 year bladder CSS was noted between decades (77% vs 80% consecutively, P= 0.566). A subset analysis of risk factors for bladder cancer progression/recurrence demonstrated more patients with lymphovascular invasion (LVI) on TUR underwent IRC in the current era (13/59 (22.0%) vs 13/200 (6.5%), P < 0.001). These findings remain to be validated in prospective work at other institutions.

CONCLUSION

• ? Conservative management strategies are a viable treatment option within a well selected subset of patients with HG cT1 UCC.

     

A comparison of the performance of microsatellite and methylation urine analysis for predicting the recurrence of urothelial cell carcinoma, and definition of a set of markers by Bayesian network analysis

OBJECTIVE

To compare the potential of two diagnostic methods for detecting recurrence of urothelial cell carcinoma (UCC) of the bladder, by (i) detecting alterations in microsatellite DNA markers and loss of heterozygosity (LOH), and (ii) detecting aberrant gene hypermethylation, as UCC has a high recurrence rate in the urinary tract and the disease can invade muscle if new tumours are overlooked.

PATIENTS AND METHODS

Over 1 year, urine samples were retrieved from 40 patients already diagnosed with bladder UCC (30 pTa, two pTis, eight pT1). Samples were collected 6 months after bladder tumour resection, during the follow‐up schedule. We used samples to analyse nine microsatellite markers and the methylation status of 11 gene promoters. Receiver operating characteristic curves were generated and Bayesian statistics used to create an interaction network between recurrence and the biomarkers.

RESULTS

During the study, 15 of the 40 patients (38%) had a tumour recurrence and 14 were identified by cystoscopy (reference method). Overall, microsatellite markers (area under curve, AUC 0.819, 95% confidence interval, CI, 0.677–0.961) had better performance characteristics than promoter hypermethylation (AUC 0.448, 0.259–0.637) for detecting recurrence. A marker panel of IFNA, MBP, ACTBP2, D9S162 and of RASSF1A, and WIF1 generated a higher diagnostic accuracy of 86% (AUC 0.92, 0.772–0.981).

CONCLUSION

Microsatellite markers have better performance characteristics than promoter hypermethylation for detecting UCC recurrence. These data support the further development of a combination of only six markers from both methods in urinary DNA. Once validated, it could be used routinely during the follow‐up for the early detection and surveillance of UCC from the lower and upper urinary tract.     

Oncological impact of cystoscopic findings in non-muscle-invasive bladder cancer: a meta-analysis

Objective

To assess the association between cystoscopic findings and oncological outcomes in patients with non-muscle-invasive bladder cancer (NMIBC) given that the oncological impact of quantity and quality assessment of tumours with cystoscopy has not been well verified.

Methods

Multiple databases were queried in May 2022 for studies investigating the association of oncological outcomes, such as recurrence-free (RFS), progression-free (PFS), and cancer-specific survival (CSS), with cystoscopic findings, including multiplicity, size, and gross appearance of tumours in patients with NMIBC.

Results

Overall, 73 studies comprising 28 139 patients were eligible for the meta-analysis. Tumour multiplicity was associated with worse RFS (pooled hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.48–1.74) and PFS (pooled HR 1.44, 95% CI 1.18–1.76) in NMIBC patients (including both Ta and T1). Tumour size (≥3 cm) was associated with worse RFS (pooled HR 1.97, 95% CI 1.69–2.30) and PFS (pooled HR 1.81, 95% CI 1.52–2.15) in NMIBC patients. In patients with T1 bladder cancer (BCa), tumour multiplicity and size (≥3 cm) were also associated with worse RFS, PFS and CSS. By contrast, among patients treated with bacillus Calmette-Guérin (BCG), tumour multiplicity was not associated with worse RFS, and tumour size (≥3 cm) was not associated with worse PFS. Sessile tumours were associated with worse RFS (pooled HR 2.14, 95% CI 1.52–3.01) and PFS (pooled HR 2.17, 95% CI 1.42–3.32) compared to pedunculated tumours. Compared to papillary tumours, solid tumours were associated with worse RFS (pooled HR 1.84, 95% CI 1.25–2.72) and PFS (pooled HR 3.06, 95% CI 2.31–4.07) in NMIBC patients, and CSS in T1 BCa patients (pooled HR 2.32, 95% CI 1.63–3.30).

Conclusions

Cystoscopic findings, including tumour multiplicity, size, and gross appearance, strongly predict oncological outcomes in NMIBC patients. Cystoscopic visual features can help in the decision-making process regarding the timeliness and extent of tumour resection as well as future management such as intravesical therapy.     

Successful diagnosis of orthotopic rat superficial bladder tumor model by ultrathin cystoscopy

PURPOSE: In the orthotopic animal bladder tumor model noninvasive evaluation of the tumor establishment and the therapeutic effect has been difficult. To our knowledge we present the first diagnosis of orthotopic rat superficial bladder tumor model by ultrathin cystoscopy. MATERIALS AND METHODS: The established AY-27 rat bladder carcinoma cell line was transplanted orthotopically into 22 female Fischer F344 rats. A cell suspension containing 4 x 10 AY-27 cells was instilled into the bladder, which had been conditioned with mild acid washing. To evaluate tumor growth serial cystoscopy was performed via the urethra with an ultrathin endoscope (diameter 0.75 mm.) 5 to 14 days after tumor cell inoculation. At intervals after cystoscopic tumor detection the rats were sacrificed for autopsy and histological examination. RESULTS: In all 22 rats the orthotopic bladder tumor was established 7 to 10 days after tumor cell implantation and in most it was superficial. Cystoscopy permitted inspection of the urethra and whole bladder surface. We detected all tumors as broad based papillary mass (minimal lesion 1 mm. or less) and inspected its detailed appearance and accurate location. CONCLUSIONS: The orthotopic rat superficial bladder tumor model and the diagnostic procedure by ultrathin cystoscopy would be ideal system for preclinical evaluation of new potential intravesical therapies.     

Use of fluorescein isothiocyanate-human serum albumin for the intravesical photodiagnosis of non-muscle-invasive bladder cancer: an in vitro study using multicellular spheroids composed of normal human urothelial and urothelial cell carcinoma cell lines

OBJECTIVE

• ? To evaluate human serum albumin (HSA), fluorescently labelled with fluorescein isothiocyanate (FITC), as a potential intravesical photodiagnostic method for the early detection of non‐muscle‐invasive bladder cancer.

PATIENTS AND METHODS

• ? By using multicellular spheroids prepared from normal human urothelial (NHU) cells and from different urothelial cell carcinoma (UCC) cell lines (T24, J82), we simulated three‐dimensionally the normal urothelium and non‐muscle‐invasive UCCs present in the bladder of patients.
• ? The distribution of FITC‐HSA in these spheroids was investigated.

RESULTS

• ? Our data showed that fluorescently labelled albumin is quite evenly dispersed throughout the spheroids. However, in the case of the 10 mg/mL incubations, the fluorescence intensity seems to increase slightly towards the spheroid core.
• ? Using 1 mg/mL, the penetration of FITC‐HSA in T24 differed significantly from the penetration in NHU spheroids, but this was not the case for J82 spheroids.
• ? When the concentration of FITC‐HSA was increased 10‐fold, all UCC spheroids exhibited a significantly different accumulation of FITC‐HSA.

CONCLUSIONS

• ? As spheroids represent a suitable in vitro model for predicting the in vivo behaviour of compounds, our data suggest that FITC‐HSA could be used for the early detection of non‐muscle‐invasive bladder cancer.
• ? Human serum albumin conjugates of new or already available intravesical drugs could be generated to create alternative bladder cancer therapies with increased selectivity.

     

Bioluminescence imaging to monitor bladder cancer cell adhesion in vivo: a new approach to optimize a syngeneic, orthotopic, murine bladder cancer model

OBJECTIVE

To improve the orthotopic murine bladder cancer model by using bioluminescent (BL) MB49 tumour cells for noninvasive in vivo monitoring of tumour growth and to examine the efficacy of integrin receptor‐blocking oligopeptides on preventing tumour cell adhesion in this improved bladder cancer model.

MATERIALS AND METHODS

The capacity of oligopeptide combinations to interfere with tumour cell adhesion was assessed in vivo in a syngeneic, orthotopic, murine bladder cancer model. Tumour outgrowth was monitored noninvasively by bioluminescence imaging (BLI) after administration of luciferase‐expressing MB49^LUC bladder cancer cells. The presence of tumour cells was verified histologically and immunohistochemically on paraffin wax‐embedded sections of excised bladders.

RESULTS

Anti‐adhesive oligopeptides effectively inhibited tumour outgrowth. BLI detected tumour cells at an early stage when there were no clinical signs of cancer in any of the mice. The technique has high sensitivity in detecting tumour cell implantation, but is less reliable in assessing tumour volume in advanced‐stage disease due to light attenuation in large tumours.

CONCLUSIONS

Peptides targeting adhesion molecules prevent attachment of bladder cancer cells to the injured bladder wall. BLI is a sensitive method for detecting luminescent bladder cancer cells in an orthotopic mouse model.     

Long-term follow-up of T1 high-grade bladder cancer after intravesical bacille Calmette-Guérin treatment

Study Type – Therapy (cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? High‐grade non muscle invasive bladder cancer is a very aggressive disease, potentially lethal if not managed adequately, because of the ability of these tumours to invade surrounding tissues and become metastatic. Treatment with intravesical BCG has been shown to delay progression to muscle invasive or/and metastatic disease, preserve the bladder, and decrease the risk of death from bladder cancer. However, most studies have analyzed patients with short follow‐up, and long‐term data about the real efficacy of BCG to prevent tumour recurrence, progression and impact mortality are lacking. This study has analyzed a large series of patients with high‐grade non muscle invasive bladder cancer treated with intravesical BCG in two University Institutions (Toronto and Rotterdam), with a central pathology review by a very experienced uro‐pathologist. It provides further insight into the long‐term risks of progression of patients harbouring high‐grade T1 bladder cancer treated with BCG, demonstrating that about 30% of patients are at risk of progression and that late progressions even more than 3 years after the initial resection and BCG treatment are rare but not exceptional.

OBJECTIVE

To report the long‐term results of bacille Calmette‐Guérin (BCG) intravesical therapy in relation to disease progression and recurrence in primary T1 high‐grade (HG) bladder cancer (BC) confirmed by central pathological review.

PATIENTS AND METHODS

In all, 136 patients from two university centres (Rotterdam, n= 49; Toronto, n= 87) were diagnosed with primary T1HG BC. One experienced uro‐pathologist reviewed all slides, ensuring all cases were indeed HG and that muscle was present in all specimens. Patients were treated with BCG induction (six instillations) after transurethral resection (TUR) of the tumour and followed with cystoscopy and urinary cytology. Predictors for recurrence, progression and survival were assessed with multivariable Cox regression models.

RESULTS

Mean (range) follow‐up was 6.5 (0.3–21.6) years. There were no significant differences for recurrence (P= 0.52), progression (P= 0.35) and disease‐specific survival (DSS) (P= 0.69) between the two centres. Among the cohort, 47 patients (35%) recurred and 42 (30.9%) progressed with a median time to progression of 2.1 years; 16 (38%) of these progressions occurred ≥3 years after the initial BCG course; 22 (16%) patients who progressed died from BC. Overall, 96 (71%) patients had no evidence of disease at the last follow‐up. Carcinoma in situ was the only independent predictor for recurrence in multivariate analysis (P= 0.011). No independent predictors were found for progression.

CONCLUSIONS

Conservative treatment with BCG is a valid option in primary T1HG BC. Nevertheless, the aggressive nature of T1HG BC is evident in the fact that 30% progressed, with a high proportion of these progression events occurring ≥3 years after BCG. Caution should be exercised when relying on the long‐term effects of BCG, and close follow‐up of these patients should not be neglected.