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Please be advised that this information was generated on 2021-09-27 and may be subject to change. SUPERFICIAL BLADDER CANCER
PROGNOSIS AND MANAGEMENT
SUPERFICIAL BLADDER CANCER
PROGNOSIS AND MANAGEMENT
een wetenschappelijke proeve op het gebied van de Medische Wetenschappen
Proefschrift
ter verkrijging van de graad van doctor aan de Katholieke Universiteit Nijmegen op gezag van de Rector Magnificus Prof. dr. C. W. P. M. Blom, volgens besluit van het College van Decanen in het openbaar te verdedigen op woensdag 11 december 2002 des morgens om 11.00 uur precies
door
Necmettin Aydin Mungan
geboren op 24 maart 1965 te Ankara Promotor : Prof. dr. F.M.J. Debruyne Co-Promotores : Dr. J.A. Witjes Dr. L.A.L.M. Kiemeney
Manuscriptcommissie : Prof. dr. P. de Mulder Prof. dr. A.L.M. Lagro-Janssen Prof. dr. H. Boonstra
Superficial bladder cancer: prognosis and management
Necmettin Aydin Mungan
ISBN 90-9016303-4
Printed by: ZES Tanitim, Ankara
Cover design: Superficial bladder cancer
Publication of this thesis was sponsored by: Onko&Koçsel Pharmaceuticals and Aventis Pasteur, Schering-Plough and Abbott Laboratories To my wife and kids Science is the truest guide for life, success and everything else in the world.
Mustafa Kemal Ataturk Founder of Republic of Turkey CONTENTS
Chapter Title Page
1 Introduction and outline of the thesis 9
2 Gender differences of (superficial) bladder cancer 21
3 Can sensitivity of voided urinary cytology or bladder 67 wash cytology be improved by the use of different urinary portions?
4 Detection of malignant cells: Can cytology be 79 replaced?
5 Comparison of the diagnostic value of the BTA Stat 101 Test with voided urinary cytology for detection of bladder cancer.
6 The Urinary Bladder Cancer Test: Can it be used as a 113 new urinary tumor marker in the detection of carcinoma in-situ, pTa and pT1 bladder cancer?
7 Bacillus Calmette Guérin in superficial transitional cell 129 carcinoma
8 Management of superficial bladder cancer with 183 intravesical chemotherapy
9 Discussion 211
Summary 237
Samenvatting 243
Acknowledgments 249
Curriculum Vitae 251
CHAPTER 1
Introduction and Outline of the Thesis Introduction and outline of the thesis 10
Introduction and outline of the thesis
CANCER is a very important public health problem. Bladder cancer is one
of the most common malignancies occurring worldwide. For example,
approximately 50,000 new patients are diagnosed with bladder cancer each
year, resulting in about 11,000 deaths annually in the United States (U.S.)
only [1]. In general there is a marked male preponderance of bladder cancer;
not only in transitional cell carcinoma (TCC), but also in squamous cell
carcinomas and adenocarcinomas [2]. Bladder cancer is two to five times
more frequent in males than females, a difference that is not entirely
explained by differences in cigarette smoking or occupational exposure [3].
Ninety-eight percent of all the bladder cancers are epithelial malignancies, with approximately 90% being TCC. TCC is generally divided into
superficial and invasive disease, because the natural history and treatment of the two forms are different. Seventy percent of the TCC are superficial
[carcinoma in-situ (CIS), Ta, T1] at initial presentation [4,5]. CIS comprises
a neoplasm that undermines or replaces the normal urothelium and extends
along the urothelial lining. Stage Ta tumors are lesions confined to the urothelial mucosa that extend papillary fronds surrounding a central
fibrovascular stalk into the lumen of the bladder. Stage T1 tumors are also
papillary lesions that are occasionally more nodular and that penetrate into the lamina propria [6]. Depending on the characteristics of the population
included and the length of the follow-up, 60%-80% of superficial bladder Introduction and outline of the thesis 11
cancers will recur with 2-50% showing stage progression [7]. Multivariate
analyses have indicated that multiplicity, grade, prior recurrences and the
findings at first cystoscopy 3 months after TUR are the most important variables commonly available to the clinician to identify patients at greatest
risk for recurrence. Meanwhile, again grade, tumor size, T category and
prior recurrences are predictive for the risk to develop muscle-invasive
cancer [8]. The early diagnosis of superficial bladder cancer is still a
dilemma. Exophytic tumors are reliably diagnosed but flat TCC, particularly
carcinoma in-situ (CIS), remains an endoscopic problem. Therefore, voided urine cytology and bladder wash cytology are routinely performed to
complement cystoscopy, but its sensitivity is poor, especially in low grade
TCC [9,10]. Recently, tumor markers and computer assisted image analysis
systems have been described for early diagnosis of bladder cancer. A
subject as problematic as early diagnosis is treatment. The standard initial
therapy for superficial bladder cancer is transurethral resection of all visible
tumor, and many patients with high grade or recurrent tumors are
subsequently given adjuvant intravesical immunotherapy or chemotherapy.
There are basically three applications of intravesical therapy: adjuvant,
prophylactic and therapeutic. Adjuvant therapy implies that the agent is used
as a single treatment after apparently complete tumor resection in order to
prevent tumor cell implantation and subsequent recurrence by that
mechanism. Prophylactic use implies the repeated administration of drugs Introduction and outline of the thesis 12
after the apparently complete resection of the tumor in order to prevent de
novo recurrence. Finally, therapeutic use implies repeated drug
administration in order to remove residual un-resected disease, either CIS or
papillary tumor [11]. Because of the heterogeneous nature of superficial bladder cancer and the various therapeutic options available, it is advisable to individualize therapy for patients with superficial bladder cancer.
Incidence and mortality rates of bladder cancer vary with age, race, lifestyle
and gender [12]. However, variations in stage distribution and survival of bladder cancer in both sexes have not been well documented. There are
some suggestions that the prognosis of females with bladder cancer is worse
than that of males [13,14]. Hence, the question was raised whether females
are being diagnosed in more advanced disease stages. The answer to this
question is important as it might lead to significant changes in our
diagnostic approaches in both sexes. In our first study concerning this
subject, the stage distribution in different genders was studied at first
presentation. The results of this study raised a second question; are females being diagnosed with bladder cancer at more advanced stages or is there
even a prognostic difference between genders in case of diagnosis at the
same stage of the disease? Therefore, we have undertaken a second study
based on two large series of U.S. and the Netherlands cancer registries
where the stages have been properly adjusted. In Chapter 2, besides giving
the results of the two studies already mentioned, a review article that Introduction and outline of the thesis 13
summarizes the general properties of the bladder cancer in women is
discussed.
The need for the early diagnosis of the bladder cancer cannot be
overemphasized and the delay in diagnosing the tumor is clearly associated
with poor prognosis. Although cystoscopy and cytology are considered as
the gold standards in this respect, they have a number of important
disadvantages. For example; cystoscopy, even with flexible instruments,
remains invasive and bothersome for the patient. On the other hand, even
though urine cytology has been an integral part of bladder cancer screening
since 1945 [15], it is undeniably inadequate as a gold standard. It is plagued with low sensitivity and remains a subjective diagnostic criterion for the
majority of the lesions. This means that we presently do not have an ideal
diagnostic method for bladder cancer. Given these shortcomings, we will
have either to try to increase the diagnostic value of the existing tests or to
develop new tests to replace them. With regard to the first, we have
concentrated our efforts particularly on urine cytology as one of the most
important diagnostic tests. Cytological interpretation of urine samples can be problematic, as low cellular yields, subtle atypia in low-grade
malignancies, the presence of reactive atypia, degenerative changes, therapeutic alterations, and low inter- and intra-observer reproducibility may
result in low sensitivity in urine cytology [16]. Moreover, negative findings
on cytology do not rule out bladder cancer. A major part of the cytologies Introduction and outline of the thesis 14
are being reported as either acellular or suspicious in terms of bladder tumors. This is because, in the majority of the cases, it is quite difficult to
obtain cells appropriate for a proper cytological evaluation or in sufficient
quantities. This, in turn, constitutes one of the most important causes of low
sensitivity in the cytologies mentioned above. This is the reason why the
present section of the thesis took up this problem, where we carried out
study to obtain better cellular yields of urine for cytology. The ultimate goal
of this investigation was to improve the sensitivity of urine cytology by
using different urinary samples. In Chapter 3, the results of this study are
described. In the second part of our research relating to cytology, on the
other hand, we have concentrated on new tests and methods available to the
urological community. Today, in an attempt to refine the early diagnosis of
bladder cancer, in particular, superficial bladder cancer, and to improve
disease monitoring, research efforts have been focused on developing tests to augment, and perhaps replace, the standard methods such as urine
cytology and cystoscopy. Rapid staining techniques and quantitative
measurement of tumor antigens have been developed in parallel with
attempts towards decreasing the processing time, reducing the cystoscopy
procedure frequency and eliminating cytological errors. Indeed, technological advances have provided significant improvements in
diagnostic skills, but the search still continues for more sensitive and
specific non-invasive bladder tumor markers to replace urine cytology. In Introduction and outline of the thesis 15
order to see the stage that was reached in this process of technological
development, first we reviewed several new techniques and markers that
have been developed for the monitoring and diagnosis of superficial bladder
cancer, and compared them with the results of cytology in Chapter 4. Then, we prospectively assessed the diagnostic value of the Bladder Tumor
Antigen stat test (BTA stat test) and the Urinary Bladder Cancer test (UBC test) in Chapters 5 and 6, respectively. The main objectives of this research was to compare these new techniques with cytology in order to pinpoint their respective advantages and disadvantages, to find out whether they can
replace cytology or be used in combination, and to see whether or not with their use the need for cystoscopy could be reduced.
Mortality rates from bladder cancer in the U.S. fell from 28% to 22% between 1980 and 1999 [23]. The improved survival rate is thought to be
associated with the advent and increased use of intravesical immunotherapy
and intravesical chemotherapy, cisplatinum based systemic chemotherapy
in addition to general advances in diagnosis, surgery and medical
management of malignancies. In this part of the thesis we have concentrated
on intravesical immunotherapy and intravesical chemotherapy that are being
extensively used in the clinic. The best-investigated form of intravesical
immunotherapy for superficial bladder cancer is treatment with bacillus
Calmette-Guérin (BCG) from Mycobacterium bovis. Presently, BCG
immunotherapy is considered as the most effective treatment and Introduction and outline of the thesis 16
prophylaxis for superficial bladder cancer in high-risk patients, but several
aspects of the BCG treatment are still controversial [24,25], such as the
effector mechanism, the optimal dosage, the appropriate strain and the best
clinical schedules. Satisfactory answers to these questions will have to be
found as soon as possible in order to render treatment more effective.
Hence, we particularly focused on these aspects of intravesical BCG in
superficial bladder cancer. Moreover, we aimed to give several informed
guidelines on this treatment modality in this part of thesis.
An antitumor effect may be potentiated when two separately effective
treatment modalities are combined because their mechanisms of action are
different. One of these treatment modalities is intravesical chemo-
immunotherapy for superficial bladder cancer. Hence, we carried out a
study to compare sequential intravesical therapy with mitomycin C and
BCG versus mytomicine C alone in a randomized trial. Our ultimate goal was to achieve a maximum antitumor effect with a minimum of side effects
in this phase III study. In Chapter 7, an overview of the intravesical BCG
immunotherapy and the results of our intravesical chemo-immunotherapy
study are presented.
One other treatment modality of superficial bladder cancer is intravesical
chemotherapy. Intravesical chemotherapy is indicated as a first choice for
low and intermediate risk superficial bladder cancer patients and as an
alternative treatment when BCG is not effective or when the side effects of Introduction and outline of the thesis 17
BCG are intolerable [26]. The use of intravesical chemotherapy for
superficial bladder cancer has become one of the important treatment
modalities. The mechanism of action and the principles of intravesical
chemotherapy are distinctly different from intravesical BCG
immunotherapy. Despite this, as in BCG, the controversy, in this treatment
modality, is still continuing, and the profession is facing many questions where there is no unanimity on the possible answers. Believing that all the
alternative modalities of treatment will have to be considered together for an
effective therapy, in Chapter 8, we have tried to evaluate the real place of
intravesical chemotherapy in the treatment of superficial bladder tumors by
comparatively identifying widely used drugs, the new drugs, additional
measurements, improvements in the efficacy of intravesical therapy and
sequential chemo/immunotherapy.
In Chapter 9, a summary and discussion of the present thesis are presented
in English and in Dutch.
We can summarize the main aims of this thesis as follows:
1. To present new approaches to the diagnosis of bladder cancer by
comparing bladder cancer prognosis in different genders,
2. To help increase the diagnostic value of cytology, as a gold standard,
which in its present form leads to problems in diagnosis due low
sensitivity, Introduction and outline of the thesis 18
3. To assess whether the place of cytology in the diagnostic spectrum has
changed or not and to evaluate the diagnostic capabilities of the two
recently developed urinary tests
4. To define the optimal principles of treatment of superficial bladder
cancer.
References
1. Parkin DM, Pisani P, Ferlay J. Global cancer statistics. CA Cancer J Clin 1999;49:33-64 2. Kantor AF, Hartge P, Hoover RN. Epidemiological characteristics of squamous cell carcinoma and adenocarcinoma of bladder. Cancer Res 1988;48:3853-3857 3. Hartge P, Harvey EB, Marston W. Unexplained excess risk of bladder cancer in men. J Natl Cancer Inst 1990; 82 :1636-1640 4. Younes M, Sussman J, True LD. The usefulness of the level of muscularis mucosae in the staging of invasive transitional cell carcinoma of the urinary bladder. Cancer 1990;66:543-548 5. Hasui Y, Osada Y, Kitada S, Nishi S. Significance of invasion to the muscularis mucosae on the progression of superficial bladder cancer. Urology 1994; 43:782-786 6. Lee R, Droller MJ. The natural history of bladder cancer: implications for therapy. The Urol Clin North Am 2000; 27(1):1-13 7. Fradet Y. Treatment of superficial bladder cancer. Curr Opin Urol 1995;5:267-271 8. Kurth KH, Bouffioux C, Sylvester R, van der Meijden APM, Oosterlinck W, Brausi M and members of the EORTC Genitourinary treatment Group. Treatment of superficial bladder tumors: Achievements and needs. Eur Urol 2000;37 (sppl 3): 1-9 9. Weiner HG, Vooijis GP, van’t Hof-Grootenboer B. Accuracy of urinary cytology in the diagnosis of primary and recurrent bladder cancer. Acta Cytol 1993;37:163-171 Introduction and outline of the thesis 19
10. Raghavan D, Shipley WU, Garnic MB, Russel PJ, Richie JP. Biology and management of bladder cancer. New Engl J Med 1990;322:1129- 1134 11. Sarosdy MF. Principles of intravesical chemotherapy and immunotherapy. Urol Clin North Am 1992;19(3):509-519 12. Hankey BF, Silverman DT, Kaplan R. Urinary bladder cancer SEER cancer statistics review:1973-1990, Miller BA, Reis LAG, Hankey BF eds. NIH pub. No.93.789, Bethesda, MD: National Cancer Institute, 1993;36:1-17 13. Kiemeney LALM, Coebergh JWW, Koper NP, van der Heijden LH, Pauwels RPE, Schapers RFM, Verbeek ALM. Bladder cancer incidence and survival in the southeastern part of Netherlands, 1975 1989. Eur J Cancer 1994;30A(8):1134 14. Fleshner NE, Herr HW, Stewart AK, Murphy GP, Mettlin C, Menck HR. The national cancer database reports on bladder carcinoma. Cancer 1996;78:1505-1513 15. Papanicalaou GN, Marshall VF. Urine sediment smears as a diagnostic procedure in cancers of the urinary tract. Science 1945;101:519-523 16. Ro JY, Staerkel GA, Ayala AG. Cytologic and histological features of superficial bladder cancer. Urol Clin North Am 1992;19 (3):435-453 17. Lee R, Droller MJ. The natural history of bladder cancer. Urol Clin North Am 2000; 27:1-13 18. Burch JD, Rohan TE, Howe GR. Risk of bladder cancer by source and type of tobacco exposure: a case control study. Int J cancer 1989; 44:622-628 19. Ketter B. Protective roles of glutathione and glutathione transferase in mutagenesis and carcinogenesis. Mutat Res 1988;202:343-361 20. Mannervik B, Alin P, Guthenberg C, Jensson H, Tahir MK, Warholm M, Jornvall H. Identification of three classes of cystosolic glutathione transferase common to several mammalian species: correlation between structural data and enzymatic properties. Proc Natl Acad Sci 1985;82:7202-7206 21. Seidegard J, Vorachek WR, Pero RW, Pearson WR. Heredity differences in expression of the human glutathione transferase activation on trans-stilbene oxide due to a gene deletion. Proc Natl Acad Sci 1988;85:7293-7297 22. Bell DA, Thompson CL, Taylor JA. Genetic monitoring of human polymorphic cancer susceptibility genes by polymerase chain reaction: Introduction and outline of the thesis 20
Application to glutathione transferase Mu. Environ Health Perspect 1992;113-117 23. Lamm DL. Preventing progression and improving survival with BCG maintenance. Eur Urol 2000; 37(suppl 1): 9-15 24. Nseyo UO, Lamm DL. Therapy of superficial bladder cancer. Semin Oncol 1996;23:598-604 25. Lamm DL. Long-term results of intravesical therapy for superficial bladder cancer. Urol Clin North Am 1992; 19:573-580 26. Pawinski A, Sylvester R, Kurth KH, Bouffioux C, van der Meijden A, Parmar MKB, Bijnens L, for the members of the European Organization for Research and Treatment of Cancer Group and Genitourinary Tract Cancer Cooperative Group and the Medical Research Council Working Party on Superficial Bladder Cancer: A combined analysis of European Organization for Research and Treatment of Cancer, and the Medical Research Council randomized clinical trials for prophylactic treatment of stage TaT1 bladder cancer. J Urol 1996; 156:1934-1941 CHAPTER 2
Gender differences of (superficial) bladder cancer
Based on:
N.A. Mungan, L.A.L.M. Kiemeney, J.A.A.M. van Dijck, H.G. van der Poel, J.A. Witjes: Gender differences in stage distribution of bladder cancer. Urology 55:368-371, 2000
N.A. Mungan, K.K.H. Aben, M.P. Schoenberg, O. Visser, J.W.W. Coebergh, J.A. Witjes, L.A.L.M. Kiemeney: Gender differences in stage- adjusted bladder cancer survival. Urology 55:876-880, 2000 [CME Article]
H.G. van der Poel, N.A. Mungan, J.A. Witjes: Bladder cancer in women. International Urogynecology Journal 10:207-212, 1999 Gender differences 22
I- GENDER DIFFERENCES IN STAGE DISTRIBUTION OF BLADDER CANCER
Introduction
Bladder cancer is a heterogeneous disease with an unpredictable clinical
course. The heterogeneity makes bladder tumors complex but interesting to
investigate. Although reports about gender differences and stage
distribution of bladder cancer are limited [1-3], a few reports on gender and
survival in patients with bladder cancer are avaliable [4-7]. Although stage
and survival are in some way related, this is not the subject of this study.
We investigated the gender differences in stage distribution of bladder
cancer and upper urinary tract tumors (UUT). The aim of this study was to
compare the stage distribution at the first presentation in male and female
patients with bladder cancer and UUT tumors, using a nation-wide
population-based Cancer Registry in the Netherlands.
Materials and Methods
The Netherlands Cancer Registry is a population-based cancer registry. All bladder malignancies including carcinoma in situ (CIS) and non-invasive bladder cancer, diagnosed from 1989 to 1994 in people living in The
Netherlands were registered nation-wide. The cancer registry collects the
data according to a minimum data set, which includes identification data Gender differences 23
(e.g. name, date of birth, gender, postal code) and tumor data (e.g. topography, morphology, stage, date of incidence). The minimum data set is
based on the item list of the World Health Organization, the International
Agency for Research on Cancer and International Association of Cancer
Registries, which was drawn up to facilitate international exchange of
cancer data. The topography and morphology were coded according to the
International Classification of Diseases for Oncology. Tumors were
classified as transitional cell carcinoma (TCC) (pure or mixed with another
morphology), squamous cell carcinoma, adenocarcinoma and sarcoma.
Recurrences are not registered in the cancer registry if they occur in the
same site as the primary tumor. New primary tumors are only possible if they occur in another site (eg, pyelum after first primary in the bladder) or with another morphology (eg, pure squamous carcinoma after primary
TCC). For the staging of tumors, the TNM classification was used [8]. The
diagnosis of N+ was based on the histological evaluation of resected lymph
nodes during radical cystectomy or computed tomography scans. Because the cancer registry adheres strictly to the TNM classification rules, many tumors are classified as Nx and Mx. Therefore, all Nx and Mx were
considered to be N0 and M0. In cases which no differentiation between T3a
and T3b was given, the tumor was classified as T3. For ureter and pyelum, the same TNM staging was used as for the bladder. All stage percentages
and UUT involvement were calculated in both males and females for all Gender differences 24
types of bladder cancer. The differences in percentages were tested for
statistical significance with the chi-square test; the statistical significance was assumed when the p value was less than 0.05.
Results
The study population consisted of 21,795 patients with bladder cancer who were reported to The Netherlands Cancer Registry between 1989 and 1994.
Of these 21,795 tumors, 20,541 (94.3%) were TCC, of which 16,415 were
in male patients (79.9%) and 4126 were in female patients (20.1%), giving a
male/female ratio of 4:1. The 1254 non-TCC bladder tumors accounted for
5.7% of which 800 were in male patients (63.8%) and 454 in female patients
(36.2%). Male patients had more superficial TCC (pTa, pT1 and CIS) at
first presentation than female patients (71.4% and 62.5% respectively).
Because of the large numbers, this difference is highly significant
(p<0.0001). The largest differences were seen between pT1 and pT4 TCC
(24.9% and 2.8% respectively, for men versus 20.6% and 3.9% respectively,
for women). The stage distribution of these patients is presented in Table I.
In total, 1982 TCC of the UUT were registered, 1328 in men, 654 in
women. Also, superficial TCCs of the UUT (pTa and pT1) were more
frequent in men (48.7% versus 37.3%, p<0.0001, table I). The nonlocalized
bladder tumors were slightly more frequent in women for both N+ (2.2% in
men versus 2.7% in women, p=0.07) and M+ (2.0% in men versus 2.8% Gender differences 25
Table I: Stage distribution of bladder and UUT TCC by gender
BLADDER URETER AND PYELUM STAGEMALEFEMALEMALEFEMALE N%N% N %N% PTa 6540 39.8 1587 38.5 358 27.0 121 18.5 CIS 1100 6.7 253 6.1 58 4.4 28 4.3 pT1 4087 24.9 852 20.6 288 21.7 123 18.8 pT2 1984 12.1 522 12.7 161 2.1 70 10.7 pT3 251 1.5 86 2.1 216 16.3 142 21.7 pT3a 554 3.4 180 4.4 1 0.1 -- pT3b 347 2.1 121 2.9 1 0.1 1 0.2 pT4 455 2.8 159 3.9 31 2.3 27 4.1 N+ 359 2.2 110 2.7 56 4.2 61 9.3 M+ 331 2.0 117 2.8 69 5.2 43 6.6 Unknown 407 2.5 139 3.4 89 6.7 38 5.8 Total 16415 100 4126 100 1328 100 654 100
in women, p=0.001). In patients with UUT tumors, N+ tumors were twice as
frequent in female patients (9.3%) than male patients (4.2%) (p<0.0001). A
small difference in the same direction was also seen in M+ UUT tumors:
5.2% in men and 6.6% in women (p=0.21).
Stage differences were more clear in the other types of bladder cancer
(combined group of squamous cell carcinoma, adenocarcinoma and
sarcoma, n=1254) (Figure I). Gender differences 26
Figure I: stage differences between males and females with non- TCC bladder cancer
18 16 14 ■ 12 1 10 Hmale % - 8 HI female 6 4 2 0 ï1 pTa CIS pT1 pT2 pT3 pT3a pT3b* pT4
Of all tumors 26.4% were superficial in men (3.1% pTa, 7,3% pT1 and
16.3% CIS) compared with 12.1% in women (0.9%, 5.3% and 5.9%
respectively). Except for pT2 tumors (13.9% in male patients versus 13.4%
in female patients), invasive non-TCC tumors were more frequently
diagnosed in female patients: 21.7% pT3 and 11.0% pT4 tumors in women
and 14.5% and 8.4% in men. Although more female patients with N+ tumors were found (7.3% in women versus 5.6% in men), fewer M+ Gender differences 27
patients were seen (5.1% in women versus 6.3% in men).
Discussion
Trends in stage distribution between two sexes have been described using
several statistical methods and different staging systems. The use of
different staging systems makes it difficult to compare various population
groups. Moreover, whether gender differences in bladder cancer exist
remains controversial at the present time because of some contradictory
reports [1-3].
In a retrospective Spanish study on TCC of the bladder between 1975 and
1991, 440 superficial and 117 invasive bladder cancer patients were
included [1]. The relative risk for muscle invasive tumors for men compared with women was 1.05 (95% CI=0.65-1.08). The investigators concluded that
gender differences had no influence on the risk of developing muscle
invasive bladder cancer.
On the other hand, other studies suggest that female patients fare worse.
Kiemeney et al, for example, studied bladder cancer incidence in the
southeastern part of the Netherlands between 1975 and 1989 [2]. On
average, male patients were diagnosed with lower staged disease than
female patients: 28% of male patients with invasive disease had stage III or
IV tumors at diagnosis compared to 43% of female patients.
Fleshner et al presented the National Cancer Data Base Report on bladder Gender differences 28
carcinoma from the United States [3]. A total of 3.700.000 cases were
documented between 1985 and 1993. Cases of unknown stage were
excluded from the study. In this study also, women were slightly more
likely to be diagnosed with advanced stage diseases (stage II, III, and IV) than men (33.1% and 27.7%, respectively). Regardless of the stage at
diagnosis, survival rates for women were not as good as for the men. The
investigators concluded that women tend to fare worse than men, regardless
of stage, and that the reasons for these findings were unclear and deserved
further investigation. However, this worse prognosis in female patients with bladder cancer has not been confirmed by other investigators [4-7]. In these
studies, the survival rates of the men were worse or similar to those of women.
In the present study female patients were found to have a higher percentage
of invasive TCCs of the bladder and UUT at first presentation than male
patients. This outcome was highly statistically significant because of the
large patient numbers. It appears that men with bladder cancer have a 32%
higher chance to be diagnosed with superficial disease than women with bladder cancer (95% CI:22% to 42%). The stage differences for squamous
cell carcinoma, adenocarcinoma and sarcoma of the bladder were even
larger. A statistically significant (p<0.0001) worse stage distribution was
observed in women with these types of bladder cancer.
An explanation for higher stages in female patients with bladder cancer at Gender differences 29
first presentation is difficult. Studies attempting to evaluate the causes for the observed gender differences have not been conclusive. Cultural and
social differences between women and men in some non-western
communities may result in delayed access to care for women. This,
however, cannot be an explanation for The Netherlands, since all people
have equal access to medical care. The initial symptom in more than 80% of
men and more than 70% of women with bladder cancer is painless
macroscopic hematuria [9,10], probably the main reason a patient seeks
medical care. It is possible, however, that there may be some delay in the
diagnosis of bladder cancer in patients with cystitis with or without
hematuria as the presenting symptom [9]. Because cystitis is more common
in women, this might explain a delayed care seeking behavior in women.
Although TCC is 4 times more frequent in men than in women, the sex ratio
in patients with squamous cell carcinomas is significantly lower, and in 10
series of squamous cell carcinoma comprising 915 patients, the sex ratio
was 1.4:1 [11]. It is unclear why squamous cell carcinoma is almost as
common in females as in males, but it may be related to its association with
inflammatory processes. Epidemiological studies have demonstrated an
increased risk of bladder cancer in individuals with chronic urinary tract
infection [11], and urinary tract infection enhances experimental bladder
cancer carcinogenesis [12]. The correlation between chronic inflammation
and squamous cell carcinoma may be an explanation for the differences in Gender differences 30
disease stage distribution between men and women in this particular tumor.
Another hypothesis for gender difference in bladder cancer risk is that men
and women metabolize carcinogens differently [13]. Laboratory studies
suggest that some androgenic hormones stimulate or do not inhibit
oncogenesis in bladder tissue and that estrogenic hormones have the
opposite effect [14]. The oncogenesis in transitional cell tissue of the human bladder is influenced by sex hormones, and hormonal changes related to
pregnancy [13,14]. These observations suggest that bladder cancer risk in
women may be modified by sex hormones, which undergo profound
changes during and after pregnancy. A modulating role in the risk of bladder
cancer associated with exposure to aromatic amines is played by metabolic
polymorphism’s [15]. The observation of gender differences in bladder
cancer, along with possible risk factors, suggests the consideration of
gender-related biological determinants for future investigation.
Female patients had a higher percentage of N+ tumors than did male
patients for all types of bladder cancer and UUT tumors. Another distinct
gender difference in patients with TCC is urethral involvement [16].
Maralani et al., in a small study, showed that tumor was found in the
lymphatic channels and vasculature of periurethral tissue and submucosa of the urethra without mucosal involvement in the most female patients with
TCC [16]. This occurred despite a palpable normal urethra at the time of
cystectomy. They explained this gender difference by the replacement of Gender differences 31
periurethral tissue by the prostate in men. They pointed out that the prostate
capsule and intimate involvement of the prostatic urethra by glandular
prostatic tissue may block the angiolymphatic extension of the tumor that is
seen in women. This may be another explanation of higher stages found in women and the presence of more N+ tumors, although further studies are
necessary to make definite conclusions.
Other factors to explain different risks for bladder cancer or a different stage
distribution remain questionable. Ethnicity, for example, failed to account
for the male/female difference in bladder cancer incidence [17,18]. p53 tumor suppresser gene polymorphism, or pre-existing genotypic differences
in the susceptibility for bladder cancer that results in different bladder
cancer biology in women remains to be confirmed [3,19].
Conclusions
Stage distribution differences were observed between men and women with
bladder cancer and TCC of the UUT in this large series. These differences
were more significantly evident in non-TCC bladder tumors. Despite the
explanations mentioned, bladder cancer still remains a challenge for further
studies. However, female patients should be investigated carefully, and
physicians should be aware of the possibility of higher stages of bladder
cancer in women in whom bladder cancer is diagnosed. Gender differences 32
References
1. Fernandz FA, Escudero GC,Ruiz FM, and et al.: Influencia de la diferencia de sexo en la agresividad biologica del tumor uretelial vesical en su primer diagnostica. Actas Urol Esp, 22 (1):34-36,1998 2. Kiemeney LALM, Coebergh JWW, Koper NP, andet al.: Bladder cancer incidence and survival in the south-eastern part of the Netherlands, 1975-1989. Eur J Cancer, 30A(8):1134-1137, 1994 3. Fleshner NE, Herr HW, Stewart AK, andet al.: The national cancer data base report on bladder carcinoma. Cancer, 78:1505-1513,1996 4. Kiemeney L.ALM, Straatman H, and Witjes JA: Decreasing bladder cancer mortality in the Netherlands. Br J Urol, 78:686-690,1996 5. Koch M, mcPhee MS, Gaedke H, andet al.: Five year follow-up of patients with cancer of the bladder. The Northern Alberta experience. Clin Invest Med, 11(4):253-258, 1988 6. Timberg G, Rahu M, Gornoi K, andet al.: Bladder cancer in Estonia, 1968-1992: incidence, mortality, prevalence and survival. Scand J Urol Nephrol, 31(4):337-342, 1997 7. Berlie J, Janin ML, Hucher M, and et al.: Mortalite par cancer de la vessie en France, de 1952 a 1976. Son evolation crossante et sa repartition geographique particuliere dans sud de la France. Bull Cancer, 66(3):317-326,1979 8. Hermanek P,and Sobin LH: TNM classification of malignant tumors. UICC international Union againist cancer. Forth, fully revised edition, Berlin:Springer-Verlag, 1987 9. Mommsen S, Aagaard J,and Sell A: Presenting symptoms, treatment delay and survival in bladder cancer. Scand J Urol Nephrol, 17:163 167, 1983 10. Kiemeney LALM, Witjes JA, Verbeek ALM,and et al.: The clinical epidemiology of superficial bladder cancer. Br J Cancer, 67:806-912, 1993 11. Johansson SL, and Cohen SM: Epidemiology and aetiology of bladder cancer. Semin Surg Oncol, 13:291-298,1997 12. Lijinsky W, Thomas BJ, and Kovatch RM: Systemic and local carcinogenesis by directly acting N-nitroso compounds given to rats by intravesicular administration. Carcinogenesis, 13:1101-1105,1992 13. Horn EP, Tucker MA, Lambert G, and et al.: A study of gender-based cytochrome p4501A2 variability: a possible mechanism for the male Gender differences 33
excess of bladder cancer. Cancer Epidemil. Biomarkers Prev., 4:529 533,1995 14. Cantor KP, Lynch CF, and Johnson D: Bladder cancer, parity, and age at first birth. Cancer Causes Control, 3:57-62,1992 15. Veneis P, and Pirastu R: Aromatic amines and cancer. Cancer Causes Control, 8:346-355, 1997 16. Maralani S, Wood DP, Grignon D, and et al.: Incidence of urethral involvement in female bladder cancer. Urology, 50(4):537-541, 1997 17. Anton-culver H, Lee-Feldstein A, and Taylor TH: The association of bladder cancer risk with ethnicity, gender, and smoking. Ann Epidemiol, 3(4):429-433, 1993 18. Hartge P, Harvey EB, and Marston W: Unexplained excess risk of bladder cancer in men. J Nat Cancer Inst, 82:1636-40,1990 19. Ersig D, Elmajian D, and Groshen S: Accumulation of nuclear p53 and tumor progression in bladder cancer. N Engl J Med, 331:1259-64, 1994 Gender differences 34
II- GENDER DIFFERENCES IN STAGE-ADJUSTED BLADDER CANCER SURVIVAL
Introduction
Women in the United States and Europe have a considerable longer life
expectancy at birth than men. The same appears to be true after a diagnosis
of cancer. In a study by the EUROCARE Working Group [1], relative
survival was studied among 1,188,469 adult patients derived from
population-based cancer registries in 17 European countries between 1985
and 1989. Overall, a survival advantage appeared to exist for women,
significantly so for cancer of the head and neck, oesophagus, stomach, liver
and pancreas. This led the investigators to suggest that women may be
intrinsically more robust than men in coping with cancer. However, for bladder cancer, only women were found to have a significantly worse
survival rate after adjustment for age and expected mortality: the 5-year
relative survival rate was 60% in females versus 65% in men. The same
finding was reported earlier in large studies from the Netherlands, Italy,
Finland, and the US, [2-5] but not in smaller studies from Canada,
Switzerland, and Estonia [6-8]. It has been suggested that the survival
disadvantage for women with bladder cancer can be explained by a worse
stage distribution at diagnosis [9]. Gender differences 35
Our objective with this study was to evaluate possible gender differences in bladder cancer prognosis after adjustment for disease stage at presentation.
Materials and Methods
Data on survival of patients with bladder cancer diagnosed in the U.S. were
obtained from the public-domain computer package Surveillance,
Epidemiology, and End Results (SEER)* Stat 2.0 (National Cancer
Institute, 1999; see http://www-seer.ims.nci.nih.gov/). This package
contains data on cancer incidence and survival of nine population-based
cancer registries belonging to the SEER program. The SEER Program of the
NCI collects and publishes cancer incidence and survival data from
population-based cancer registries covering approximately 10 percent of the
U.S. population. The selected database was the August 1998 submission with data on 2,325,346 patients diagnosed between 1973 and 1996. For this
study, we selected patients with urinary bladder cancer who were actively
followed, had a tumor with malignant behavior (no pTa or pTis), had no
second primary cancer, and were not registered by death certificate or
autopsy only (n=94,771). Furthermore, patients with an unknown race, age,
or sex were excluded.
Similar data on patients with bladder cancer diagnosed between 1987 and
1994 and registered by two population-based registries in the Netherlands were obtained through the Comprehensive Cancer Centers in the cities of Gender differences 36
Amsterdam and Eindhoven. The Comprehensive Cancer Center in
Amsterdam has registered patients with cancer in the north-western part of the Netherlands since 1987. Information on vital status was available for
patients diagnosed between 1988 and 1994 and living in the metropolitan
area of Amsterdam. The Comprehensive Cancer Center in Eindhoven has
registered patients in the south-eastern part of the Netherlands since 1970.
Vital status information is routinely collected for all of these patients. For this study, data were available for all patients in the catchment area of the
Comprehensive Cancer Center in Eindhoven who were diagnosed between
1987 and 1992. From both centers combined, 1,722 patients with bladder
cancer were available for analyses (pTis and pTa excluded).
In both the U.S. and the Netherlands data bases, no information is provided
on the cause of death. Instead, observed survival can be adjusted for the
expected probability of survival. For the U.S., the expected probability of
survival was generated from age, race, and gender-specific population
statistics from 1970, 1980, and 1990 from the U.S. Bureau of the Census.
These data are also available in the SEER*Stat 2.0 package. In the
Netherlands, expected survival rates were calculated using all-cause age,
gender, and calendar-year specific mortality tables from Statistics
Netherlands. Subsequently, the relative survival was calculated as the ratio between the crude and expected survival [10]. For the Netherlands data,
relative survival rates with standard errors were calculated with a computer Gender differences 37
program from the Finnish Cancer Registry [11]. The analysis of the U.S.
data was performed with the SEER*Stat 2.0 computer package, which uses
the same algorithm from the Finnish Cancer Registry. The survival analyses
on the data from the Netherlands were stratified by disease stage according to the TNM staging system [12] (3 rd revised edition for diagnosis from
1987 to 1988, 4th edition from1989 to1992, and 4th revised edition
from1993 to 1994). The analyses of the SEER data were stratified by
disease stage according to the 4th edition of the American Joint Committee
on Cancer (AJCC) stage grouping [13].
Results
In the U.S. data, 59,625 men and 20,680 women with bladder cancer had
complete information for the calculation of relative survival rates. Men had
a significantly better 5-year relative survival rate than women: 79.5% (95%
CI: 79.0 - 80.0%) and 73.1% (95% CI: 72.2 - 74.0%), respectively. In each
AJCC stage category, the prognosis was found to be better for men than for women (Table I). After stratification by race and calendar period of
diagnosis (data not shown), the differences in relative survival between men
and women remained. A large number of patients with bladder cancer had
an “unknown” (8,496 men and 3,030 women) or “blank” (34,973 men and
12,114 women) disease stage. Again, in these groups’ men, had a 10% and
6% better 5-year relative survival, respectively, compared with women. Gender differences 38
Gender differences were less striking in the Netherlands (Table II). The
overall 5-year relative survival rate of men was found to be 58.3% (95% CI:
54.5 - 62.1%). Survival rate in women was 47.5% (95% CI: 40.8 - 54.2%).
Women seemed to have a similar prognosis as men in disease Stage III and
even a (non-significant) better prognosis in Stage I. In Stages II and IV,
women fared worse than men. Because of the much smaller numbers in
comparison with the U.S. data, the differences in prognosis in the
Netherlands were not statistically significant.
Discussion
Female bladder cancer patients are known to present with somewhat more
advanced disease than male patients [2,5,9]. This difference in stage
distribution has been considered the most important reason for the worse
survival among women with bladder cancer [1,2]. In this study, we found that the relatively poor survival for females remained after stratification by
stage. According to the SEER data, women with bladder cancer appear to
have a 3% (Stage I) to 12% (Stage IV) 5-year survival disadvantage. The
survival difference among patients with Stage I was small. In the
Netherlands, women with Stage I disease even seemed to have a survival
advantage of 5% although the confidence interval of this estimate was wide.
Stage-adjusted gender differences in survival from bladder cancer have been
previously published. In the largest study until now, Fleshner et al. [5] Gender differences 39
reported on The National Cancer Data Base (NCDB), in which data are
combined from more than 2,000 hospital cancer registries across the U.S.
Five-year follow-up information was available for 18,525 males and 6,672
female patients with bladder cancer. Female patients were slightly more
likely to be diagnosed with advanced stage disease (pT2-pT4) than male
patients: 33.1% and 27.7%, respectively. After stratification by stage, women still fared worse than men: the 5-year relative survival rate for men
and women was 94.7 versus. 90.7% for AJCC stage 0, 87.8 versus 84.7%
for Stage I, 68.3 versus 59.3% for Stage II, 48.0 versus 47.7% for Stage III,
and 26.8 versus. 15.4% for Stage IV, respectively. These figures resemble
our findings very closely. However, this is not surprising considering that
both the NCDB and SEER achieve considerable coverage of the U.S. cancer
incidence (approximately 40% and 10%, respectively) and may therefore
even overlap to some extent.
A survival disadvantage for women with bladder cancer was also reported in
a large European study of 17 population-based cancer registries [1].
Unfortunately, that study did not stratify the results by disease stage,
although it was suggested that the longer survival for men with bladder
cancer could be explained by a higher frequency of non-invasive cancer in
men than in women. One of the participating countries to this study
(Finland), however, recently presented stage and gender-specific survival
among patients diagnosed between 1985 and 1994 [4,14]. However, because Gender differences 40
stage was only crudely stratified (localized, regional, or distant metastasis),
residual confounding by stage cannot be ruled out. The 5-year relative
survival rate for men with bladder cancer was calculated to be 72%; the rate
for women was only 63%. After stratification by stage, the difference only
remained among patients with localized disease; the 5-year rate among men
(n=3,423) was 83% versus 76% among women (n=1,015). The estimate for
men and women with regional metastases was 24% (n=71) and 28% (n=22),
respectively, and for men and women with distant metastases it was 9%
(n=337) and 6% (n=157), respectively.
A higher risk of death for women with bladder cancer, after adjustment for
disease stage at presentation, is difficult to explain. Although patient delay
may be the most important factor in explaining the relatively worse disease
stage distribution at presentation among women, it is not likely that patient
delay exists in the diagnosis of disease progression. Gender differences in
genetic or hormonal defence mechanisms against disease progression are
also unlikely considering the apparent survival advantage for women with
other types of cancer. However, anatomic differences exist between men
and women, which may cause differences in the risk of disease progression within each stage category. Men void with a higher intravesical pressure because of the presence of the prostate gland and along urethra. Therefore, a
somewhat thicker detrusor muscle is expected in men. Indeed, in an animal
study, bladders from female rats weighed significantly less than bladders Gender differences 41
from male rats [15]. The thicker detrusor muscle in men may also have an effect on blood perfusion [16], and subsequently on the possibility of metastases. Moreover, anatomic studies in humans showed that at the female bladder neck, the middle circular muscle layer does not appear to be as robust as that of the male, which may have an influence on lymphatic drainage patterns of this portion of the bladder [17]. It has also been suggested that the prostatic capsule and the intimate involvement of the prostatic urethra by glanduler prostatic tissue may block the angiolymphatic extension of a tumor [18].
On the other hand, one may wonder whether gender differences in stage- adjusted survival are artefactual. The relative survival rate is the ratio of the observed (crude) survival to the expected survival. The expected survival rate is calculated using age, gender, race, and calendar-year specific mortality rates for the total population. It is assumed that the presence of cancer is the only factor that distinguishes the cancer patient cohort from the general population, so that the relative survival is assumed to reflect bladder cancer survival adjusted for other mortality. However, in the case of bladder cancer, smoking is an important risk factor. Therefore, bladder cancer patients will consist of a higher proportion of smokers than the general population. Smoking is, however, also related to the risk of dying of causes other than bladder cancer. The expected survival rate for patients with bladder cancer based on the general population will thus be too optimistic. Gender differences 42
Consequently, the relative rates will be lower than they should be [19].
However, because the etiologic fraction of smoking for bladder cancer is
probably higher for men than for women [20], this theoretical bias works in
favor of women when analyzing gender differences in survival. Another
point of concern is the possibility of residual confounding by stage. A lower
level of suspicion for bladder cancer in women in the case of hematuria may
lead to subtle stage differences within each stage category.
Although it is not the focus of this study, there seems to be an enormous
difference between survival from bladder cancer among patients from the
USA and the Netherlands (Table I and Table II). Other European countries
appear to exhibit fairly similar relative survival rates as the Netherlands
[3,4]. Compared with patients in Europe, patients in the U.S. seem to have a
better survival from several cancer sites [3,4,19,21,22]. It is hard to imagine
that these differences are real. In theory, a better relative survival in the U.S.
may be caused by a lower life-expectancy for people living in the U.S., which would lead to a smaller difference between observed survival and
expected survival and, consequently, to a higher relative survival.
Another possibility is that follow-up of vital status among patients with
cancer in the U.S. is not complete. However, life expectancy for U.S. whites
is only 1 year less than that for western Europeans and the NCI reports that
follow-up of the SEER cancer registries is complete in more than 97% [19]. Table I: Relative survival of => pT1 bladder cancer in the U.S. according to stage and gender
Years after diagnosis Stage Gender N 0 1 2 3 4 5 CR 2*se CR 2*se CR 2*se CR 2*se CR 2*se
1 Male 12,418 100% 99.4% 0.4% 99.1% 0.6% 98.3% 0.8% 97.8% 1.0% 96.5% 1.2% Female 3,926 100% 99.0% 0.7% 97.8% 1.0% 96.0% 1.4% 95.2% 1.7% 93.7% 2.1%
2 Males 995 100% 87.9% 2.5% 78.2% 3.4% 73.2% 3.9% 70.9% 4.3% 65.5% 5.0% Female 402 100% 80.5% 4.5% 72.4% 5.5% 66.3% 6.3% 61.9% 6.9% 59.6% 7.6%
3 Males 883 100% 83.9% 3.0% 68.7% 4.0% 61.5% 4.4% 59.1% 4.8% 58.8% 5.3% Female 356 100% 76.5% 4.9% 61.5% 6.0% 54.4% 6.5% 53.4% 6.9% 49.6% 7.5%
4 Males 1,905 100% 56.1% 2.5% 38.4% 2.6% 32.9% 2.6% 29.1% 2.7% 27.1% 2.9% Female 852 100% 40.1% 3.5% 23.6% 3.2% 18.1% 3.1% 16.9% 3.1% 15.2% 3.2%
Total Males 59,625 100% 91.0% 0.3% 86.1% 0.4% 83.3% 0.4% 81.2% 0.5% 79.5% 0.5% Female 20,680 100% 84.7% 0.6% 78.8% 0,7% 76.1% 0.8% 74.3% 0.8% 73.1% 0.9%
Source: SEER*Stat 2.0 (NCI, 1999) CR = relative survival se = standard error Table II: Relative survival of => pT1 bladder cancer in the Netherlands according to stage and gender
Years after diagnosis Stage Gender N 0 1 2 3 4 5 CR 2*se CR 2*se CR 2*se CR 2*se CR 2*se
1 Male 646 100% 96.5% 2.2% 94.6% 3.1% 91.0% 3.9% 87.0% 4.6% 80.8% 5.4% Female 122 100% 95.8% 4.9% 94.0% 6.5% 93.9% 7.6% 90.0% 9.3% 85.7% 11.0%
2 Males 300 100% 76.2% 5.5% 59.5% 6.5% 54.5% 6.9% 51.3% 7.4% 48.7% 7.9% Female 76 100% 76.3% 10.8% 56.3% 12.9% 44.1% 13.5% 42.8% 14.1% 38.5% 14.7%
3 Males 172 100% 66.1% 7.8% 43.8% 8.4% 36.5% 8.6% 34.4% 8.9% 35.6% 9.5% Female 68 100% 51.6% 12.7% 45.4% 13.1% 39.5% 13.6% 36.3% 14.2% 35.0% 14.9%
4 Males 165 100% 42.3% 8.1% 24.4% 7.2% 16.4% 6.5% 11.0% 5.8% 11.7% 6.2% Female 80 100% 28.3% 10.4% 14.1% 8.3% 10.3% 7.4% 9.2% 7.2% 9.6% 7.5%
Total Males 1350 100% 80.1% 2.4% 70.0% 2.9% 65.2% 3.2% 61.5% 3.5% 58.3% 3.8% Female 377 100% 64.9% 5.2% 55.9% 5.7% 51.6% 6.0% 49.6% 6.3% 47.5% 6.7%
Source: Amsterdam Cancer Registry 1988-1994 and Eindhoven Cancer Registry 1987-1992 CR = relative survival se = standard error Gender differences 46
Whatever the reason for these differences, it is unlikely that it has biased the
stage-adjusted gender comparison in our study.
Conclusions
It is unlikely that the worse prognosis for female patients with bladder
cancer can be entirely explained by the more frequent diagnoses of higher
stages at first presentation among women. It is not clear which additional
factor causes a worse prognosis for women.
References
1. Micheli A, Mariotto A, Rossi AG, Gatta G, Muti P and the EUROCARE Working Group. The prognostic role of gender in survival of adult cancer patients. Eur J Cancer 1998; 34(14): 2271-8 2. Kiemeney LALM, Coebergh JWW, Koper NP, van der Heijden LH, Pauwels RPE, Schapers RFM, Verbeek ALM. Bladder cancer incidence and survival in the south-eastern part of the Netherlands, 1975-1989. Eur J Cancer 1994; 30A(8): 1134-7 3. Gatta G, Buiatti E, Conti E, De Lisi V, Falcini F, Federico M, Gafa L, Ponz de Leon M, Vercelli M, Zanetti R. Variations in survival of adult cancer patients in Italy. Tumori 1997; 83(1): 497-504 4. Dickman PW, Hakulinen T, Luostarinen T, Pukkala E, Sankila R, Söderman B, Teppo L. Survival of cancer patients in Finland 1955 1994. Acta Oncologica 1999 (Suppl 12): 1-103 5. Fleshner NE, Herr HW, Stewart AK, Murphy GP, Mettlin C, Menck HR. The National Data Base Report on bladder carcinoma. The American College of Surgeons on Cancer and the American Cancer Society. Cancer 1996; 78: 1505-9 Gender differences 47
6. Koch M, McPhee MS, Gaedke H, Williams Y. Five year follow-up of patients with cancer of the bladder. The Northern Alberta experience. Clin Invest Med 1988; 11(4): 253-8 7. Levi F, Mezzanotte G, Te VC, Vecchia CL. Cancer survival from the incident cases of the registry of Vaud, Switzerland. Tumori 1989; 75: 83-9 8. Timberg G, Rahu M, Gornoi K, Aareleid T, Baburin A. Bladder cancer in Estonia, 1968-1992: incidence, mortality, prevalence and survival. Scand J Urol Nephrol 1997; 31(4): 337-42 9. Mungan NA, Kiemeney LALM, van Dijck JAAM, van der Poel H, Witjes JA. Gender differences in stage distribution of bladder cancer. Urology (in press) 10. Ederer F, Axtell LM, Cutler SJ. The relative survival rate: a statistical methodology. In: NCI Monograph No. 6, pp. 101-121. Bethesda, MD, National Cancer Institute, 1961 11. Hakulinen T, Abeywickrama K. A computer program package for relative survival analysis. Comput Programs Biometrics 1985; 19: 197 207 12. Hermanek P, and Sobin LH (eds) for International Union Against Cancer (UICC). TNM Classification of malignant tumours. 4th ed. Berlin, Sprindger, 1987 13. Beahrs OH, Henson DE, Hutter RVP, Kennedy BJ (Eds) for theAmerican Joint Committee on Cancer.. Manual for staging cancer. 4th edition. Philadelphia: J.B. Lippincott Co., 1992. 14. eppo L, Dickman PW, Hakulinen T, Loustarinen T, Pukkula E, Sankila R, Soderman B. Cancer patient survival. Patterns, comparisons, trends. A population-based cancer registry study in Finland. Acta Oncologica 1999; 38:283-94 15. Longjurst PA, Eika B, Leggett RE. Comparision of the urinary bladder function in 6 and 24 month male and female rats. J urol 148:1615-1620, 1992 16. Pontari MA, Ruggieri MR. Sex differences and role of nitric oxide in blood flow of canine urinary bladder. Am J Physiol 276:R407- R413,1999 17. Brooks JD. Anatomy of the lower urinary tract and male genitelia, in Walsh PC, Retik AB, Stamey TA, et al. (Eds): Campbell’s Urology, 7 th ed. Philadelphia, WB Saunders, 1997, pp 89-91 18. Maralani S, Wood DP, Grignon D, et al. Incidence of urethral involvement in female bladder cancer. Urology 50:537-541,1997 Gender differences 48
19. Ries LAG, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards BK, eds. SEER Cancer Statistics Review, 1973-1996. National Cancer Institute. Bethesda, MD, 1999. 20. Aben KKH, Kiemeney LALM. Epidemiology of bladder cancer. Eur Urol 36/6 (Curric Urol 6:4:1-13) 1999 (in press) 21. Smith JAE, Whatley PM, Redburn CM et al. improving survival of melanoma patients in Europe since 1978, Eur J Cancer 34:2197 2203,1998 22. Gatta G, Lasota MB, Verdecchia A, et al. Survival of European women with gynecological tumors during the period 1978-1989. Eur J Cancer 34:2218-2225,1998 Gender differences 49
III. BLADDER CANCER IN WOMEN
Introduction
The incidence of bladder cancer in women is three to four times lower than
in men. In this paper several differences between male and female bladder
cancer will be highlighted with respect to risk factors, prognosis, and treatment.
Symptoms and Diagnosis
Hematuria is the first symptom in men in 80% of cases. In women, 70% of
patients present with hematuria [1,2]. Often voiding complaints similar to
those found with cystitis occur. Moreover, in women with cystitis-like
symptoms, bladder cancer is more often found (see below). Irritative
symptoms should therefore always be analyzed by urinary sediment and
cytology. When a urinary tract infection is present this should be treated
prior to further evaluation. Urethrocystoscopy should be considered in
women with frequent cystitis or persistant erythrocyturia or leucocyturia
after adequate treatment of cystitis.
Urine cytology showed lower sensitivity for cancer in women than in men.
This may be caused by the frequent presence of other cell types (squamous
cells, leucocytes) in the urine of women [3]. Quantitative cytology may
improve reproducibility of urine cytology [4]. We developed a karyometric
system for bladder wash cytology (Quanticyt) [5] and since 1990 we Gender differences 50
sampled 9172 bladder washings in 3187 patients. Earlier studies showed the use of karyometry using image analysis for grade bladder washing samples based on nuclear DNA content and nuclear shape for the prediction of tumor
[4-7]. Our study population included 2596 men and 591 women (ratio
4.39:1). Based on nuclear DNA content and nuclear shape the samples were
scored as low, intermediate, or high risk for bladder cancer. Interestingly,
high risk samples were found in 19.4% of male and only 10.4% of female
patients (p<0.05). A high risk score is based on the presence of polyploid or
aneuploid cells. Although aneuploidy seemed more frequent in men, when
follow up data were compared, gender was not predictive of either
recurrence or progression [5].
New tests for the detection of malignant cells in urine are the NMP22
(nuclear matrix protein, ELISA test) [6,8] and BARD BTA, STAT (latex
agglutination dipstick), and TRAK tests (ELISA) [7,9,10]. All proved
superior to routine cytology for the detection of low grade papillary lesions.
However, for high-grade lesions, and in particular for carcinoma in situ,
routine cytology shows significantly higher sensitivity [6,7]. Urinary tract
infections resulted in false positive test results, so that in women with
urinary tract infections these tests will be less useful for discrimination
between infection and cancer. No data are currently available suggesting
different sensitivity for the tests between male and female patients. Gender differences 51
The ‘gold standard’ in the diagnosis of bladder cancer is cystoscopy. Both
rigid and flexible cystoscopy can be performed with minimal discomfort, in
particular in the female patient. No currently available test can replace
cystoscopy for the initial diagnosis of bladder cancer.
Incidence
In the Netherlands between 1989 and 1994, 21,795 primary bladder cancers
were diagnosed: 20,541 (94.25%) were transitional cell cancers (TCC), of which 16,415 were in male patients (80%) and 4,126 were in female
patients (20%), a male: female ratio of 4:1. The non-TCC accounted for
5.75% of all tumors: 800 were found in male patients (64%) and 454 in
female patients (36%) (ratio 1.8:1). Similar gender-related incidence figures
for TCC and non-TCC were found in most western countries [11]. In
general the incidence of bladder cancer is two to five times higher in men than in women [12].
Risk factors
Food and Environment: Even when correcting for risk factors such as
cigarette smoking, occupational hazards, and urinary tract infection, the
male and female ratio was estimated to be 2.7 [12]. Several factors are
correlated with the incidence of bladder cancer, such as the consumption of
coffee and alcohol [13]. Interestingly, the odds ratio for coffee drinking was
found to be twice as high for women (5.2) as for men (2.6) [14,15]. As for Gender differences 52
men, a dose-dependent relationship between cigarette smoking and bladder
cancer was found in women [16]. Cultural changes in smoking habits
among women will influence bladder cancer incidence [17,18], as do
environmental factors. In a study on the influence of living environments it was shown that farm residents showed a relative risk of 0.33 compared to the general population [19]. Dry-cleaning workers were found to have an
increased bladder cancer mortality ratio of 2.54 [20]. Overall, the
occupational risk factors for bladder cancer seemed similar for both men
and women [11,12]. It was estimated that cancers attributed to occupational
exposure in the United States are 11% in female compared to 21% in male
patients [21]. The increasing number of working women will be likely to
change this ratio in the future.
Of interest is also the difference between men and women with regard to
second primary tumors. Salminen et al.[22] found an increased risk of lung
(adeno and squamous cell carcinoma) and non-TCC kidney cancers in
10,014 bladder cancer patients in Finland. The incidence ratio for second
primary lung cancer as 1.3 in men and 2.6 in women compared to the
general population. For non-TCC kidney cancer in women this ratio was
3.6. Other studies reported an increased risk of colon carcinoma in patients with bladder cancer compared to the general population or patients suffering
from melanomas [23]. Environmental factors probably play an important
role in this increased cancer risk among bladder cancer patients. Differences Gender differences 53
between men and women do, however, suggest other etiological aspects, that remain to be explored.
Occupational and smoking habits may only partly explain the difference in
incidence of bladder cancer between men and women. Hormonal influence was suggested by some, considering the lower incidence of bladder cancer
in parous compared to nulliparous women [24]. Moreover, mucosal changes
during the menstrual cycle have been reported [25], suggesting an influence
on cell proliferation and differentiation.
Iatrogenic factors: As with men, there are several iatrogenic causes of bladder cancer in women. Special attention should be paid to patients
receiving cyclophosphamide, e.g., for rheumatoid arthritis. Bladder cancer
occurred in 9 out of 119 rheumatoid arthritis patients receiving
cyclophosphamide, whereas none of the control patients not treated with
cyclophosphamide developed cancer [26]. In 3 out of the 9 the bladder
cancer developed more than 14 years after discontinuation of the
medication. Intermittent (self) catheterisation potentiates the carcinogenic
effects of cyclophosphamide [27].
Pelvic radiotherapy also carries a risk for bladder cancer development [28].
Most tumors after radiotherapy are of high grade and often invade through the bladder wall [29]. The interval between irradiation and tumor
presentation was found to be dependent on the dose of radiotherapy: high
doses were correlated with shorter intervals [29]. Intervals ranging from Gender differences 54
16.5 to 30 years were reported. The overall risk of bladder cancer after
radiation for cervical cancer was twofold compared to the general
population [28].
Bladder Cancer and Urinary tract infections: The similarity in symptoms
for bladder cancer and cystitis often delays the correct diagnosis of cancer in women [1,30]. An increased risk for bladder cancer was found in patients
with nephrolithiasis [31,32]. Other studies found an increase of urinary tract
infections in patients with bladder cancer [33,34]. Particularly in
combination with smoking, bladder cancer was 10 times more frequent in
patients with urinary tract infections than the general population [34].
Urinary tract infections seem to be particularly correlated with squamous
cell carcinoma [35].
Death from bladder cancer was found to be 12 times more common in
paraplegic women [33]. Moreover, squamous cell carcinomas were found in the majority of 25-44 year-old paraplegic women with bladder cancer. The
higher frequency of urinary tract infections in these women may partly
account for the increased risk on squamous cell carcinoma [33,35]. Whether
intermittent or continuous catheterization plays a role in this increased risk
remains to be established.
Human papilloma virus infections have been reported to be correlated to
cervical cancers. In bladder cancer different infection rates were found, varying from 3% [36,37] to 33% [38] by either in situ hybridization or Gender differences 55
polymerase chain reaction methods. In the majority of studies HPV subtypes
16 and 18 were found. HPV 16/18 infection was found to be correlated with
more aggressive bladder cancer [38]. Although low infection rates found in
most studies suggested no correlation between HPV infection and bladder
cancer [36,37,39,40], bladder cancer was more frequently found in women
earlier treated for cervical cancer [41,42]. No data are available on HPV
infection in women with both cervical and bladder cancer, the important
role of HPV infections in cervical cancer may play a role in bladder cancer
in these patients as well. Whether factors other then HPV infection such as
smoking are responsible for this relationship remains to be established. As
HPV infection was more frequently found in advanced stage and grade it is
unlikely that the infection plays a role in initial tumor development [37].
Surprisingly, Tenti et al. [38] found higher HPV infection rates in low
grade, papillary lesions. Data on HPV infection and bladder cancer are therefore conflicting. Patient population and detection methods probably a
count partly for the differences between studies. The high incidence of this
infection in the general population, however, warrant further analysis.
Schistosomiasis infections are correlated with bladder cancer. Both transitional cell and squamous cell carcinomas may develop in the bladder
after Schistosomiasis infection [43]. In endemic areas such as Egypt and
eastern-Africa the majority of bladder cancer cases are Schistomiasis
related. N-Nitroso compounds and other carcinogenes secreted in the Gender differences 56
bladder during infection are putatively responsible for tumor development
[44]. In women the infection can extend to the internal genital organs
(Female Genital Schistosomiasis, FGS), most commonly due to
Schistosoma haematobium [45]. Probably as a result of changes in exposure
to infection, the male to female ratio, which was 7.8:1 between 1962 and
1967, changed to 4.9:1 in the period 1987-1992 in Egypt [43].
The higher frequency of urinary tract infections in women may account for
the 1.4:1, male:female ratio of squamous cell carcinoma incidence, as
opposed to the almost 4:1 ratio of urothelial cell carcinoma [46].
Tumor Stage
Recent data from the Netherlands Cancer Registry from 1989 to 1994
showed higher tumor stages at initial diagnosis for both transitional cell
(TCC) and non-transitional cell cancers (non-TCC) of the bladder in women than in men. Male patients had slightly more frequent superficial TCC (pTa,
pT1 and CIS) than females: 71.4% and 62.5% respectively (p<0.0001). In
particular pT4 TCC tumors were more frequent in women (3.9% versus
2.8%). As for TCC, invasive non-TCC was more frequent in female than in
male patients. Except for pT2 tumors, the stage difference was also seen for
invasive non-TCC: 14.5% and 8.4% pT3 and pT4 were found in men, and
21.7% and 11.0% were observed in women, respectively. Other studies
confirmed the worse prognosis of bladder cancer in women: the percentage
of invasive tumors was 27-28% in men and 33-43% in women [47,48]. Gender differences 57
Prognosis
The higher incidence of invasive tumors in women is accompanied by a
shorter 5-year disease specific survival in women (47%) than in men (69%)
[47,49]. The more aggressive behavior of bladder cancer in women also
seems reflected by the fact that the incidence of invasive tumors after an
initial superficial lesion (tumor progression) is higher for women than for
men [50]. No difference in tumor recurrence between men and women was
found for superficial cancer [51].
Superficial explanations for the seemingly more aggressive behavior of bladder cancer in women have been postulated. The more frequent
incidence of urinary tract infections in women may reduce suspicion on bladder cancer in cases of hematuria or voiding problems, resulting in a
delay in detection [1,30].
Cell proliferation is an important aspect of tumor development. The p53
gene product functions as a cell-cycle regulator [52]. Mutations in the p53
gene have been reported to result in uncontrolled cell proliferation.
Mutations result in accumulation of the non-functional gene product.
Immunohistochemical staining studies showed increased recurrence and
progression rates in tumors with increased p53 staining [53]. No difference
in p53 mutations between men and women have been reported, suggesting that differences in progression are not caused by different mutation rates. Gender differences 58
The E6 oncoprotein from the HPV binds p53 resulting in increased protein
degradation. Recently, a polymorphism in exon 4 of the p53 gene was
correlated with an increase in tumorigenesis caused by HPV induced
cervical cancers [54]. In prostate cancer both HPV infection and p53
mutations seem to play a limited role in different phases of tumor
development [55]. Similar findings were reported for bladder cancer: low
grade and low stage lesions were more frequently HPV infected, whereas
p53 mutations were more often found in high-grade lesions [38]. As was
discussed above, however, data between studies vary with respect to the
incidence of HPV infection and tumor stage. Further studies are necessary to elucidate the role of these prognostic parameters in women. The high
incidence of HPV 16 and 18 infections in cervical cancer urge for careful
analysis of HPV in different stages of bladder cancer and the role of p53
mutations and polymorphism.
No data on prognostic markers such DNA ploidy and Ki-67 show gender
differences accounting for the worse prognosis reported in women.
In conclusion, women seem to be diagnosed at a later stage of disease. With
current prognostic markers no explanation can be found for the decreased
survival for women.
Treatm ent
Superficial cancers are managed by transurethral resection. Additional
intravesical instillations with either mitomycin-C and bacillus Calmette Gender differences 59
Guerin (BCG) are optional in multiple, recurrent, or high grade lesions [56].
Although recurrence rate may be reduced by intravesical instillation
therapy, the chance on tumor progression from superficial to invasive cancer
remains unchanged [56]. Overall 50-60% of superficial tumors recur after
initial treatment, and 10-15% progress to invasive disease [2,57].
For invasive tumors radical surgery remains the cornerstone of treatment.
Cystectomy is performed after pelvic lymph node resection; hysterectomy
may be performed simultaneously. In case of an incontinent diversion
(Bricker ileal stoma) or catheterisable pouches (Indiana, Kock etc.),
urethrectomy and resection of the anterior wall of the vagina is commonly
performed.
Orthotopic bladder replacement, initially used mainly in male patients,
proved useful in a selected group of female bladder cancer patients [58,59].
Orthotopic methods use small bowel [60,61] or large bowel/coecum to
construct a pouched connected to the urethra that remains in place and
allows for voiding, in general without the need for self-catheterisation.
Because the urethra is left in place, there is a risk of tumor recurrence.
Urethral recurrence after cystectomy in women with invasive bladder cancer
is seen in 2-13% of cases, particularly where there is bladder neck and trigonal involvement [59,62,63]. Vaginal involvement is found in 3% of
women with invasive bladder cancer [64]. In cases of tumor on the bladder
neck, urethrectomy is advocated [62] and these patients are no candidates Gender differences 60
for orthotopic bladder replacement [64]. With carcinoma in situ the
incidence of urethral localisation was found to be as high as 29%,
suggesting that in these patients urethral recurrence is more likely [65] and urethrectomy should be considered.
Up to 90% daytime continence and spontaneous residual-free micturition is
reported after orthotopic bladder replacement in women [58]. Retention, the
main complication can be avoided by resection of the bladder neck and
proximal urethra [58].
In conclusion, the trend toward orthotopic bladder replacement instead of
continent urinary stomata for the treatment of invasive bladder cancer in
men will also be seen in women.
Conclusions
Bladder cancer in women shows some aspects different from the disease in
men. TCC is 4 times more common in men than in women. In squamous
cell carcinoma the male: female ratio is 1.4:1. Urinary tract infections are
related to bladder cancer in women and urine cytology and cystoscopy
should be performed in case of recurrent infections. The role of HPV
infection is unclear. At initial presentation, invasive tumors are more
common in women than in men. Patients with cervical cancer are at
increased risk of bladder tumors. Orthotopic bladder replacement gives Gender differences 61
good results but should not be performed in patients with tumors located to the bladder neck, considering the increased risk for urethral recurrences.
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Can sensitivity of voided urinary or bladder wash cytology be improved by the use of different urinary portions?
N.A. Mungan, S. Kulacoglu, M. Basar, M. Sahin, J.A. Witjes
Urologia Internationalis 69:209-212, 1999 Sensitivities of different portions of cytology 68
Introduction
Urinary cytology is often a useful adjunct to cystoscopy and biopsies in the
diagnosis of urethelial cancer of the bladder and prostatic urethra. It is more useful, however, in the monitoring of patients with a history of transitional
cell carcinomas (TCCs) [1,2] and if consistently used, it can actually
decrease the frequency with which patients need to be subjected to
cystoscopy [3]. However, in daily practice the value of cytology is not
sufficient to replace cystoscopies. Visual microscopic interpretation of
material has been subject to low inter- and intraobserver reproducibility [4]
and the sensitivities of cytopathological analysis of urine specimens are not
high enough to detect the majority of recurrences, particularly those that are well or moderately differentiated [5]. Low cellular yields, subtle atypia in
low-grade malignancies, the presence of reactive atypia, degenerative
changes, and therapeutic alterations decrease sensitivity of cytology [6]. A
relevant issue, therefore, is whether we can increase the sensitivity of urine
cytology, for example by modification of the sampling technique.
In the present study, we examined the sensitivity of different portions of bladder wash material and voided urine for cytology to detect superficial
TCC of the bladder. Sensitivities of different portions of cytology 69
Materials and methods
Fifty-two patients (44 men and 8 women) were entered prospectively into
this study. Age ranged from 18 to 76 years (mean 59.5 years). The
diagnostic work-up consisted of cystoscopy and a transurethral biopsy,
complete urine and blood tests, intravenous pyelography, transabdominal ultrasonogrphy, chest X-ray and computerize tomography in all.
All had biopsy proven superficial TCC of the bladder (pTa, pT1, pTis).
There were 20 patients (38.5 %) with grade I, 20 patients (38.5 %) with
grade II and 12 patients (23 %) with grade III tumors. The cystoscopies were done by one of two urologists (NAM, MB). Any recent history of
genitourinary trauma, urinary tract infection, intravesical chemo- or
immunotherapy within 3 months were recorded and these patients were not
enrolled into this study.
A voided urine specimen was obtained pre-operatively as a first stream, mid
stream and terminal stream in 48 patients. Then, just before the operation, we rinsed the bladder with 50 ml 0.09% NaCl in 46 patients. The bladder was emptied and the first portion, mid-portion and last portion of this wash
material was used for cytology. All samples were cultured to exclude
infection and dipstick test were used to exclude hematuria.
Of every cytology sample at least two slides were prepared and the samples
were examined twice by a pathologist experienced in cytology. The Sensitivities of different portions of cytology 70
pathologist was blinded towards clinical findings. Cytology samples were
centrifuged and stained with May Grunwald Giemsa and Hematoxylin
Eosin. Cytological diagnoses were subdivided into four groups: (1) no sings
of malignancy (negative), (2) malignant cells present (positive), (3) atypia
suspicious for malignancy (suspicious), (4) no cells were found for cytology
(acellular).
For statistically analysis, binomial distribution was assumed and 95%
confidence intervals (CIs) were calculated. The Mc-Nemar test was used for
comparison of detection rates. Suspicious and cellular results were accepted as a negative result when calculating the sensitivity results. Statistical
significance was assumed when the P value was less then 0.05. The
statistical package for social sciences (SPSS) computer software was used for data documentation and analysis.
Results
The distribution of cytological findings is presented in Table I. The
sensitivities of the first stream, mid stream and terminal stream of VUC were 34.6%, 38.5% and 38.5%, respectively. The sensitivities of the first portion, mid portion and last portion of BWC were 34.6%, 38.5%, 34.6%,
respectively. Comparing the results, there was no statistical significant difference between the sensitivities of the portions of VUC and BWC
(p=0.3). Sensitivities of different portions of cytology 71
Table I. Bladder wash and voided urine cytology with histologic findings (n=52)
Bladder wash cytology Voided urine cytology Histology pI pII pIII sI sII sIII negative 22 18 18 16 16 16 Positive 18 20 18 18 20 20 suspicious 2 4 4 8 6 6 Acellular 4 4 6 6 6 4 not done 6 6 6 4 4 4
key: pI= first portion, pII= mid portion, pIII= last portion sI=first stream, sII=mid-stream, sIII=terminal stream
Correlating the results with grades of the tumor, sensitivity of the first
stream of VUC was 20%, 40% and 50% for grade I, II and III tumors,
respectively. For the mid stream these figures are 25%, 40% and 58.3, and
for the terminal stream of VUC the sensitivities are 25%, 30% and 75%,
respectively. We also investigated these grade sensitivity rates for every
portion of BWC. Sensitivities are 25%, 45% and 33.3% for the first part of
BWC, 25%, 45% and 50% for the mid portion and 25%, 35% and 50% for the last BWC portion for grade I, II and III tumors, respectively. When the
sensitivities correlated to the grade of the tumor were compared, no
significant difference between the portions and grades (p= 0.06) was found. Sensitivities of different portions of cytology 72
Discussion
Urinary cytology has an important role in the diagnosis and follow-up of
patients with bladder cancer. In spite of the introduction of flow cytometry,
most cytopathologist rely on visual cytologic examination of the exfoliated urethelial cells [1]. Exfoliated malignant cells are readily recognized in urinary specimens from patients with bladder carcinoma. These cells have
characteristic nuclear hyperchromasia, an irregular nuclear configuration
and altered chromatin structure [7,8]. These criteria are valuable for
diagnosis of human bladder cancer when the lesions are of high histologic
grade. The criteria are, however, of limited value for the detection of
relatively common, superficial low-grade tumors [9-11].
Exfoliated cells can be obtained by two primary methods, voided urine and bladder-wash material [7,9]. The primary advantage of voided urine is that
it is noninvasive [7,9], but the advantage of bladder irrigation techniques is
more and better preserved cells [12,13]. Indeed, bladder wash material
proved to be superior to voided urine cytology [1,9,14-16]. However,
Badalament et al. concluded that voided urinary cytology continues to be the procedure of choice for detection and monitoring urothelial cancer, because of its proven high specificity, noninvasiveness and wide availability
[13]. In 1981 Murphy et al., reported their experience with cystoscopic urine and bladder washing material. They concluded that although bladder Sensitivities of different portions of cytology 73
washing alone has a greater diagnostic yield than cystoscopic urine,
cystoscopic urine remains a valuable source of diagnostic information [17].
They found that in 20 to 30 percent of the cases, tumor cells were identified
in cystoscopic urine and not in bladder washings. They advised, therefore, that both techniques should be performed. In conclusion; there is still no
agreement which procedure is best, predominantly because of an overall low
sensitivity.
The overall sensitivity of VUC is ranging from 17 to 60%, the specificity is
100% [5,18-20]. The sensitivity of VUC is ranging from 3 to 8% for grade I,
10 to 18% for grade II, 32 to 38% for grade III superficial TCC of the bladder. [18,19]. The sensitivity of VUC was studied extensively by
Sarosdy et al. [18,19]. Sensitivity was determined using frozen voided urine
samples [19] or the unspun urine allocated to cytology testing was processed
as usual with cyto-spin or filtration method in patients undergoing
surveillance cystoscopy for recurrent bladder cancer [18]. In these
prospective and multicenter trails, they found cytology less sensitive than
reported in the literature [5,7,18-20]. They pointed out that these findings
were surprising them and data were reviewed to determine if this low
sensitivity of VUC was caused by some centers only. However, this low
sensitivity was consistent. They found that overall sensitivity was 17-23%,
3-8 % for grade I, 10-18% for grade II and 32-38% for grade III superficial
TCC of the bladder. Our overall and per grade sensitivity results for every Sensitivities of different portions of cytology 74
part of VUC were superior to Sarosdy et al. results. Overall sensitivity
results were between 34.6 and 38.5% for every stream of voided urine in our
study. And, our results also were higher for each grade; 20-25% for grade I,
30-40% for grade II and 50-75% for grade III superficial TCC of the bladder. The explanation could be that we studied a selective group of
patients which all had biopsy proven superficial TCC of the bladder.
Moreover, of every portion of cytology at least two slides were prepared and the samples were examined twice by one pathologist experienced in
cytology in the same center. Another explanation may be differences in
cytological methods and preservation of urine. For example; in this study urine was not frozen, but fresh morning urine was used.
A lot of studies have been done with BWC and the overall sensitive for
detection of tumor by BWC is ranging from 23.0 to 44.8%, the specificity is
92.5% [21-24]. The sensitivity of BWC is ranging from 0 to 28.6% for
grade I, 21.0 to 50% for grade II and 33.0 to 83.3% for grade III superficial
TCC of the bladder [21-24]. D’Hallewin et al. evaluated BWC in 60 patients with superficial bladder cancer at stage Ta and CIS and they reported 32%
overall sensitivity and 0%, 21% and 60% for grade I, II, III, respectively
[24]. Ianari et al. investigated the sensitivity of BWC in 75 patients with a
history of superficial TCC of the bladder undergoing routine follow up
cystoscopy [23]. They found a 23% overall sensitivity for BWC and 0%,
50% and 33% for grade I, II and III, respectively. van der Poel et al. studied Sensitivities of different portions of cytology 75
sensitivity for BWC in 138 patients with superficial TCC of the bladder
[21]. In this study, cells were scored with an automated image analysis
system. An overall sensitivity rate was 44.8% and 28.6%, 29.6% and 83.3%
for grade I, II and III, respectively. In this study, a 34.6 to 38.5% overall
sensitivity and 25%, 35 to 45% and 33 to 50% sensitivity rates for grade I, II
and III were found for BWC, respectively. Another approach of this study is
the investigation of different portions of bladder wash material. Our results
are comparable to the results from the literature with regard to overall
sensitivity of BWC. The influence of the use of different portions of BWC
was expected to be minimal. After installations of saline and rinsing, the whole urinary volume is homogeneous, and the content of different portions
should by the same. The cellular composition of voided urine, on the
otherhand, can have close relation with detrussor activity. Detrussor activity
reaches a maximum at the terminal part of micturation, possibly increasing
the amount of cells in the last portion of micturation. Indeed, we got lowest
acellular rates for the terminal stream of voided urine. In this study, highest
sensitivity rate for grade III tumors was found as expected. Divided VUC
and BWC did not effect detection rates in grade I or II tumors. However,
sensitivity for grade III tumors was highest (75%) in the terminal portion of
voided urine and this was better than the other parts of VUC and BWC. The
other sensitivity rates for grade I and II were comparable for every part of
VUC and BWC. Sensitivities of different portions of cytology 76
Conclusions
Although this study was performed in a selective and small group of
patients, we can conclude that the terminal stream of voided urine may be
more sensitive to detect malignant cells, especially in grade III tumors, than the other parts of VUC and BWC. We believe that further studies are
necessary to evaluate this strategy to improve the sensitivity of VUC.
References
1. Matzkin, H., Moinuddin, S.M., Soloway, M.S.: Value of urine cytology versus bladder washing in bladder cancer. Urology,39(3):201,1992 2. Soloway, M.S.: Initial evaluation and response criteria for patients with superficial bladder cancer, report of a workshop. Br. J. Urol., 66:380,1990 3. Murphy, W.M.: Current status of urinary cytology in the evaluation of bladder neoplasms. Human Pathology, 21(9):886, 1990 4. Sherman, A.B., Koss, L.G., Adams, S.E.: Intraobserver differences in the diagnosis of urethelial cells: comparison with classification by computer. Anal. Quant. Cytol. Histol., 6:112, 1984 5. Badalament, R.A., Hermansen, D.K., Kimmel, M., Gay, H., Her, H.W., Fair, W.: The sensitivity of bladder wash cytometry, bladder wash cytology and voided cytology in detection of bladder carcinoma. Cancer,60:1423, 1987 6. Ro, J.R., Staerkel, G.A., Ayala, A.G.: Cytologic and histologic features of superficial bladder cancer. Urol. Clin. North Am.,19(3):435,1992 7. Murphy, W.M., Soloway, M.S., Jukkola, A.F., Crabtree, W.N., Ford, K.S.: Urinary cytology and bladder cancer: the cellular features of transitional cell neoplasms. Cancer, 53:1555,1984 8. Gammarra, M.C., Zein, T.: Cytologic spectrum of bladder cancer. Urology, 23(suppl):23, 1984 9. Freidell, G.H., Hawkins, I.R., Ahmed, S.W., Schmidt, J.D.: The role of urinary tract cytology in the detection and clinical management of Sensitivities of different portions of cytology 77
bladder cancer; in Bonney, I. and Prout, K. Jr. (eds): Bladder cancer. Baltimore, American Urological Association Monographs, Williams and Wilkins, vol1,pp49-62, 1982 10. Jocham, D., Gottinger, H., Schiedt, E.: Stellenwert der urinzytologie in der urologischen diagnostik:ein 10-jahres-bericht. Urologe [A],21:79,1982 11. Wiener, H.G., Vooijs, G.P., Hof-Grootenboer, B.: Accuracy of the urinary cytology in the diagnosis of primary and recurrent bladder cancer.Acta. Cytologica,37(2):163, 1993 12. Murphy, W.M.: Flow cytometry versus urinary cytology in the evaluation of patients with bladder cancer. J. Urol.,136:815,1986 13. Badalament, R.A., Fair, W.R., Whitmore, W.F., Melamed, M.R.: The relative value of cytometry and cytology in the management of bladder cancer: The Memorial Sloan-Kettering Cancer Center experience. Semin. Urol., 6:22,1988 14. Harris, M.F.: Exfoliate cytology of the urinary bladder irrigation specimen. Acta. Cytol., 15:385,1971 15. Zein, T., Waisman, Z., Englander, L.S., Gammarra, M.C., Lopez, C., Huben, R.P.: Evaluation of bladder washings and urinary cytology in the diagnosis of bladder cancer and its correlation with selected biopsies of the bladder mucosa. J. Urol., 132:670, 1984 16. Aamodt, R.L., Coon, J.S., Deitch, A., deVere-White, R.W., Koss, L.G., Melamed, M.R.: Flow cytometric evaluation of bladder cancer: recommendations of NCI flow cytometry network for bladder cancer. World J. Urol.,10:63,1992 17. Murphy, W.M., Crabtree, W.N., Jukkola, A.F., Soloway, M.S.: The diagnostic value of urine versus bladder washing in the patients with bladder cancer. J. Urol., 126:320, 1981 18. Sarosdy, M.F., de Vere-White, R.W., Soloway, M.S., Scheinfeld, J., Hudson, M.A., Schellhammer, P.F.: Results of multicenter trail using the BTA test to monitor for and diagnose recurrent bladder cancer. J. Urol., 154:379,1995 19. Sarosdy, M.F., Hudson, M.A., Ellis, W.J., Soloway, M.S., de Vere White, R., Scheinfeld, J., Jarowenko, M.V., Schellhammer, P.F., Schervish, E.W., Patel, J.V., Chodak, G.W., Lamm, D.L., Johnson, R.D., Handerson, M., Adams, G., Blumenstein, B. A., Thoelke, K.R., Pfalzgraf, R.D., Murchison, H.A., Brunelle, S.L.: Improved detection of recurrent bladder cancer using the Bart BTA stat test. Urology,50(3):349, 1997 Sensitivities of different portions of cytology 78
20. Cytology and histopathology of bladder cases in prospective longitudinal study. National Bladder Cancer Collaborative Group A. Cancer Res., part 2,37:2911,1977 21. van der Poel, H.G., van Balken, M.R., Schamhart, H.J., Peelen, P., de Reijke, T.H., Debruyne, F.M.J., Schalken, J. A., Witjes, J.A.: Bladder wash cytology, quantitative cytology, and the qualitative BTA test in patients with superficial bladder cancer. Urology, 51(1):44,1998 22. van der Poel, H.G., Witjes, J.A., van Stratum, M.E., Boon, M.E., Debruyne, F.M.J., Schalken, J.A.: Quanticyt: Karyometric analysis of bladder washing for patients with superficial bladder cancer. Urology,48(3):357,1996 23. Ianari, A., Sternberg, N., Rosetti, A., Van Rijn, A., Deidada, A., Giannerelli, D.: Results of Bard BTA test in monitoring patients with a history of transitional cell cancer of the bladder. Urology,49(5):786, 1997 24. D’Hallewin, M.A., Baert, L.: Initial evaluation of the bladder tumor antigen test in superficial bladder cancer. J. Urol.,155:475,1996 CHAPTER 4
Detection of malignant cells, can cytology be replaced?
J.A. Witjes, N.A. Mungan, H.G. van der Poel
European Urology Update Series 7:73-78, 1998 Can cytology be replaced? 80
Introduction
The early diagnosis of bladder cancer is a first step to effective treatment of the disease. Nowadays, cystoscopy is considered the gold standard in
diagnosing tumours in the bladder, although it is invasive and costly.
Cytopathological analysis of urine specimens copes with these
disadvantages. Efforts to replace cystoscopy by examining voided urine for
tumor cells have included cytopathology and flow cytometry but the
sensitivities are not high enough to detect the majority of recurrences,
particularly those that are well or moderately differentiated [1,2]. Hence,
tests are needed for a careful patient fallow up and monitoring of tumor
recurrence and mucosal changes in an early stage. The test should be quick,
have a high sensivity, in particular for high-grade lesions, and also a high
specificity to prevent too many unnecessary cytoscopies. Investigation of a variety of markers to aid in monitoring and diagnosis of bladder carcinoma
is underway. The development of a simple, office-based test to detect urinary shed proteins, such as the bladder tumor antigen test, represents a
significant step in bringing research laboratory efforts into the practical
clinical arena. Can cytology be replaced? 81
BARD-Bladder Tumor Antigen Test
The epithelial layer of the bladder is attached to the called basement
membrane, primarily composed of collagen IV, laminin and proteoglycans
[3]. During the attachment phase the tumor secretes endogenous basement
membrane proteins, which bind to the surface receptors on the basement
membrane. One attached, bladder tumours secrete proteolytic enzymes
(collegenase or laminin) that disrupt the basement membrane into fragments
of its basic compounds [4]. These fragmants are discharged into the bladder
lumen and aggregate into high molecular weight complexes [5]. The Bard
(Bard Diagnostic Sciences, Redmond, Wash) bladder tumor antigen (BTA) test is a latex agglutination test for the qualitative detection of basement
membrane degradation complexes composed of specific polypeptides with
molecular weight ranging from 16-165 kDa in voided urine [6-18]. The
detection of presence of transitional cell carcinoma (TCC) by the BTA test
is a result of basal membrane disruption. This might explain the often
negative test results in carcinoma insitu (CiS), since in CiS basal membrane
disruption is absent. The degree (focal, severe) of basal membrane
interruption and number of tumours per patient associated with basal
membrane interruption may affect the outcome of BTA test considerably
[9]. The BTA test is easy to use and provides rapid results. It requires
minimal technical expertise to perform or interpret [7]. Additionally, the
BTA test results may be available to the urologist before cystoscopy, being Can cytology be replaced? 82
performed upon initial voided urine used for pre-cystoscopy urinalysis. It
can be done within several minutes, rendering it suitable for quick decision
making for the performance of cytoscopy. Cytology, on the other hand, is
relatively expensive and a few days are required for the results [7,8].
The specificity of the BTA test was investigated in healthy individuals and
subjects without genitourinary complaints, and appeared to be 96% [10].
The high specificity has also been found in other large clinical series,
ranging from 82% to 91% [6-8,11]. The specificity of cytology was 100% in these studies [7,11]. However, the sensitivity of BTA test was better than
cytology, mainly because cytology was found much less sensitive than
reported in the literature [7,8,10,11]. Large multicenter series have
confirmed that the sensitivity of the BTA test is higher than that of cytology.
Depending on stage and grade, the sensitivity of the BTA test ranges from
40% to 70% while the sensitivity of cytology is between 17% and 32%
[7,8,10,11]. The reported specificity and sensitivity of both cytology and
BTA test are shown in Table I.
Many of the false-negative BTA test results were in low-grade lesions. It is unlikely that the delay in cystoscopy would affect patients adversely [6,12].
As with cytology, certain conditions may cause false-positive BTA test
results and should be considered limitations to test. Can cytology be replaced? 83
Table I: Comparison of sensitivity and specificity of the Bard BTA tests and cytology
SENSITIVITYSPECIFICITY
BTA test Cytology BTA test Cytology
Ianari et al 54% 23% 91% 100%
Sarosdy et al 40% 17% 96% NI
D’Hallewin et al 65% 32% NINI
Leyh et al 70% 25% 90% 100%
The UK and Erie 58% NI 86% NI Ag Study Group
NI: not indicated
These include prostatic biopsy or resection within 14 days, renal or bladder
calculi, symptomatic sexually transmitted disease and some other
genitourinary cancers, such as penile, ovarian, endometrial or cervical
carcinoma [10,12]. Also previous radiotherapy may give false-positive
results and further studies are needed to determine the sensitivity and
specificity in such patients. Most of the false-positive BTA results can be
explained by the inflammation, since the test is unreliable in the presence of urinary tract infection [6].
The BTA stat is new and simplified test. The BTA stat is technically more
simple to use (one step, no sample preparation) than the BTA test and tests a
different antigen. The BTA test is a four step, latex agglutination assay Can cytology be replaced? 84
performed on buffered urine [10,11]. The BTA stat test is a single-step, 5-
min immunochromatographic assay performed by placing five drops of untreated voided urine into a well on a small disposable test device [13,14].
The BTA stat test is more sensitive than and has equal specificity to the
BTA test. Overall sensitivities for the BTA stat is 66%. The sensitivitiy of
the BTA stat for tumor grades I-III is 39%, 65, and 83%, respectively, versus 43%, 59%, and 70% for BTA test. The sensitivity of the BTA stat test by tumor stage for pTa, pTis, T1 and T2-4 is 45%, 53%, 85% and 75%,
respectively, versus 33%,50%, 64% and 55% for the BTA stat test. In
conclusion, the BTA stat test is not only simpler and faster than the first
generation BTA test, it also more sensitive [14].
The BTA trak test is a quantitative enzyme immunoassay utilising
monoclonal antibodies to bind to bladder tumor antigen in the urine. This test can be performed on fresh or frozen single voided urine samples. Both
sensitivity and specificity of the BTA trak test are better than those of the
BTA test The sensitivity of BTA trak test for tumor grades I, II, and III is
55%, 67%, and 85% respectively. Concentrations of bladder tumor antigen
(U/ml) in urine correlated with tumor grade. The mean concentrations by tumor grades I, II, and III are 210 U/ml, 543 U/ml, and 914 U/ml,
respectively [15].
These results indicate that The BTA stat and trak tests are superior to the
BTA test and possibly will soon replace the BTA test. Can cytology be replaced? 85
Nuclear matrix protein 22 (NMP 22)
Nuclear matrix proteins are part of the internal structural framework of the
nucleus, which may have an important role in DNA replication,
transcription and processing of RNA, and regulation of gene expression
[16,17]. The NMP22 test kit (Matritech, Inc., Newton, Massachusetts)
detects complexed (greater than 1000 kDa) and fragmented (approximately
30 kDa) forms of nuclear mitotic apparatus protein in voided urine [17,18].
The function of nuclear mitotic apparatus protein appears to be a proper
distribution of chromatids to daughter cells [19,20]. This role of the nuclear
mitotic apparatus proteins make it a potential marker for malignant cells in
which abnormal distribution of genetic material is found [17,21]. It has been
shown that intracellular nuclear mitotic apparatus protein concentration is at
least 25-fold greater in bladder cancer cell lines compared to the mean level
in urethelial cells isolated from normal bladders. Similar studies have shown
that intracellular nuclear mitotic apparatus protein concentration is at least
10-fold greater in other cancer tissues and transformed cell lines compared
to normal tissues and normal phenotype cell lines, respectively [17,21,22].
Normal subjects have been shown to have low levels of NMP22 in their
urine, while patients with TCC of the urinary tract have high urinary levels.
In normal healthy volunteers and in subjects with benign conditions median
NMP22 levels are 2.9 and 3.3 U/ml, respectively. In patients with active
TCC the median NMP22 level is 6.04 U/ml, while in those with a history of Can cytology be replaced? 86
TCC but no evidence of disease the median value is 4.11 U/ml. [17]. In
another study the median NMP22 values for urethelial cancer (including bladder cancer, renal pelvic, ureteric and urethral cancer) was 26.5 U/ ml
[23].
Soloway et al. [24] evaluated the use of NMP22 in the detection of occult or
rapidly recurring TCC of the urinary tract following surgical treatment and
showed, the best cut off level for NMP 22 to differentiate recurrence from
non-recurrence to be 10 U/ml. A reference value of 10 U/ml yields a
sensitivity of 70%, specificity 79%, accuracy 76%, positive predictive value
58%, and a negative predictive value 86%. With a reference value of 20
U/ml, the positive predictive value increases to 71%, specificity 91% and
accuracy 80%. Witjes et al. [25] found a sensitivity of 75%, a specificity of
81.6%, a negative predictive value of 91.2%, and a positive predictive value
of 56.3% using 10U/ml cut off level. Stampfer et al. [26] showed that the
overall sensitivity for detection of bladder tumours was 68%, for screening
low-risk tumours 59%, and for screening high-risk and invasive tumours was 80-90%, using cut a off level of 6.4 U/ml. The sensitivity of urinary
NMP22 for urethelial cancer (including bladder cancer, renal pelvic, ureteric
and urethral cancer) was 85.7% which compares favourably with that of voided urine cytology, which was 50% [23].
Higher NMP 22 levels are found in healthy women and blacks [17]. But, there is no difference in urinary NMP22 values between men and women Can cytology be replaced? 87
with TCC [17,18]. Patients receiving intravesical therapy have greater
NMP22 values than those not receiving it [24]. Patients with an ileal
neobladder have very high levels of NMP22. These high levels could be
caused by the higher cellular turn over in ileal tissue compared to normal bladder tissue. This might indicate that the nuclear matrix proteins, used for
NMP22 test are not cancer- or tissue-specific, as already suggested by
earlier laboratory tests [25,27]. It seems probably that in such patients this
test is not useful.
Urinary NMP22 examination is a simple and highly sensitive method for
detecting of bladder carcinoma and has many advantages over conventional
methods such as cystoscopy and voided urine cytology. If NMP22 is <10
U/ml the risk of malignant disease at subsequent cystoscopy is low, and a
planned cystoscopy could be postponed. NMP22 > 20U/ml indicates a high
probability that there will be malignant disease on a subsequent cystoscopic
examination, which may prompt the urologist to intensively follow up the
patient, perhaps not waiting as long to perform cystoscopy, or perhaps
skipping follow-up cystoscopy and performing a procedure that would allow
tissue to be collected for pathological analysis [24,28]. Can cytology be replaced? 88
Quantitative urinary cytology (quanticyt)
The reason why the value of urinary cytology is so low in the detection of
malignant cells is probably due to the fact that visual microscopic
interpretation of material is subject to low inter- and intraobserver
reproducibility [29]. Light microscopic image analysis of cytologic material
allows ploidy analysis as well as objective interpretation of cellular and
nuclear features reflecting malignant deformation. Recently the quanticyt
karyometry system was introduced for the quantitative grading of bladder-
wash cytology [30]. It combines cell nuclear shape and DNA content to
determine potential malignant differentiation. The graphic representation of
several samples makes this method particularly suitable for close monitoring
of changes in the bladder-wash cytology profile of the patients in daily
practise [31]. In fact it objectivetes cytological features already applied by the cytopathologist in reaching the diagnosis. The disadvantages of the technique are that it is more elaborative than routine cytology and that it has
proved to be of value only in bladder-wash material. However, good
reproducibility of objective score enables comparison of subsequent
samples to be made [30,31]. The entire test takes two days including
sample fixation, staining, image processing and analysis.
Bladder-wash material has been proved to be superior to voided urine for
routine cytology as well as for quantitative analysis [32-34]. Flow
cytometric studies showed that ploidy analysis of bladder-wash material is a
sensitive method of tumor detection [33-35], but it does not enable Can cytology be replaced? 89
simultaneous visual interpretation and selection of cells. Moreover, flow
cytometry is not suitable for morphometric analysis. Quantitative light
microscopic techniques can be used for DNA content analysis, as well as for
morphometric analysis [36,37].
The quanticyt score correlates with tumor recurrences and progression in the
patient with superficial bladder cancer [31,37]. Based on nuclear shape and
DNA content, samples can be categorized as low, intermediate and high risk
for the recurrence of a bladder tumor. Overall recurrences rates at 1 year for
quanticyt scores are 5.5% for low-risk samples, 12.55 for intermediate-risk,
and 20.5% for high-risk. Progression rates are 0.5%, 1.3%, and 6.3%,
respectively [37]. In a multivariate analysis, karyometric data provided
significant additional information for the prediction of tumor recurrence and
progression [36,37]. The overall sensitivity for detection of tumor by
bladder-wash cytology is 44.8%; the specificity is 92.5%. Quanticyt’s
overall sensitivity for the detection of tumor is 69%, and the specificity is
85.0 % [38]. The sensitivity for tumor detection is highest for the quanticyt
method as compared to the BTA test and cytology. Detection of low-grade
lesions is low for quanticyt, cytology and also the BTA test. Compared to
cytology the specificity of the quanticyt method is lower (92.5% vs 85%).
This is probably linked to the somewhat higher sensitivity and predictive value of the quanticity score [36,38]. The specificity and sensitivity of both
cytology and quanticity are detailed in Table II. Can cytology be replaced? 90
Table II: The specificity and sensitivity of cytology and quanticyt
CYTOLOGYQUANTICYT
Overall sensitive 44.8% 69.0%
Sensitivity Gr 1 28.6% 57.1%
Sensitivity Gr 2 29.6% 55.6%
Sensitivity Gr 3 83.3% 82.6%
Sensitivity Ta 35.0% 60.0%
Sensitivity T1 85.7% 85.7%
Sensitivity T2 75.0% 100%
Sensitivity T3 66.7% 100%
Specificity 92.5% 85.0%
When the BTA test, bladder-wash cytology, and quantcyt are compared in a
multivariate analysis, the quanticyt shows the best predicton of tumor
recurrence. Furthermore, the quantitative representation of the quanticyt
score may provide a more practical follow-up in daily practise. Multivariate
analysis for the diagnosis of a tumor showed no additional value of a
combination of the different tests [38]. The quanticyt system enables
monitoring of bladder mucosal changes in quantitative and easy-to-read
format. Selecting patients based on risk analysis may reduce the number of
cystoscopies [37]. Can cytology be replaced? 91
Tumor-specific antigens
Using monoclonal antibodies, we can identity tumor-associated antigens
selectively expressed on tumor subtypes with distinct clinical behaviours
[39,40]. Glycoprotein 200 kDa surface antigen 19A211 and the mucinous
antigen M344 are preferentially expressed on papillary superficial tumors
and CIS lesions of the bladder [40,41]. Monoclonal antibodies (mAb)
against both antigens have been developed. MAb 19A211 identifies a series
of cytoplasmic glycoproteins ranging from 90 to 140 kDa present in tumor
cells and, at lower level, in normal urothelial cells, and of a membrane
glycoprotein of 200kDa observed tumor cells only [42,43]. MAb M344
identifies a high molecular weight determinant which is not detected in any
normal tissue [39,41], althought some investigators have shown that tumor-
associated antigens can be found in normal mucosa near superficial and
invasive bladder tumours [44].
M344 is positive in 74.5% of Ta-T1 tumors and 11% of T3-4 tumors.
19A211 is also express preferentially on low-grade superficial bladder
tumors (77% in Ta-T1) and less frequently on deeply infiltrating tumors (10
% in T3-T4) [41,45]. The specificity of these antigens is 83.3% [45]. The
combination of these two antigenic markers in immunocytology and flow
cytometry studies of exfloitedcells has improved the sensitivity of detection
for bladder tumors [40]. When M344 is combined with cytology and DNA Can cytology be replaced? 92
ploidy measurements, the sensitivity for low- grade and high- grade tumors
is 88% and 95%, respectively [46].
Either one or both of these tumor- associated antigens are detected in
approximately 80% of low-grade papillary superficial tumors and CIS of the urinary bladder. The expression of these antigens on a large subset of low-
grade bladder tumors, known to progress in a minority of cases, suggests that phenotypic differences may reflect biological potential. Beyond their
possible significance, antibodies M344 and 19A211 may provide clinically useful probes for the early detection and stratification of bladder tumors
[41,47,48]. These antibodies are currently commercially available as an
immunofluorescent assay (Immunocyt, Diagnocure; Quebec, Canada).
Future developments
Telomerase expression and microsatellite techniques are potentially new
diagnostic tools, though a clinically applicable test is not yet available for
routine use.
Telomerase, the ribonuclear protein that functions to maintain telomeras
length, has been associated with cellular ageing, immortalization, and
cancer. Normal stomatic cells appear to lack telomerase activity and as a
consequence, their chromosomes shorten with each cell division [49]. In
contrast, germ-line cells, immortalized tissue culture cells, and most cancer
cells show Telomerase expression [50,51], enabling them to overcome Can cytology be replaced? 93
apoptosis [52,53]. With only a few exceptions, telomerase has been found in
malignant, but not in benign tissues, and 70-95% of tumors have been found to Telomerase-positive [51,54,55]. Telomerase activity can be detected in a
high percentage of TCC of the bladder using the telomeric repeat
amplification protocol (TRAP) assay, based on the polymerase chain
reaction (PCR) [55,56]. Telomerase activity can be demonstrated in tumor tissue from TCC, exfoliated cells obtained from either spontaneous urine or
lavage fluid. Telomerase activity was demonstrated in 98% of TCC tissue,
and in 89% of exfoliated cells obtained from either spontaneous urine or
lavage fluid [56]. Telomerase activity was identified in voided urine from
100% of patients with grade I, 92% with grade II, and 83% with grade III
lesions [57]. Overall Telomerase expression was found 91% of the tumors
versus 49% for cytology. The difference in detection of grade I and II
lesions is even more striking (95% for telomerase vs 28% for cytology)
[56,57]. The false positive rate of telomerase activity is 24%, and is seen in
patients with benign proliferatif diseases of bladder like interstitial cystitis,
inverted papilloma, and urothelial atypia [54] In conclusion, telomerase is
detectable in nearly all cases of TCC, by means of an objective and non
invasive method. Results are superior to cytology.
Microsatellite techniques have been used as a tool for detection of loss
heterozygosity (LOH) and genomic instability in neoplasia. They are used to
detection TCC by means of testing DNA from urine sediment. LOH was Can cytology be replaced? 94
demonstrated in 95% in urine samples from patients with a pathologically
confirmed bladder tumor. This novel molecular approach may provide a
sensitive assay to detection of bladder cancer [58].
Conclusion
Since urinary cytology has poor sensitivity and specificity for the diagnosis
and prognosis of superficial bladder tumors, other tests are needed. Several urinary tests are currently available or under investigation.
The Bard BTA test, a four-step office based test, has been shown to be
superior to urinary cytology in papillary lesions. CIS, however, is missed
frequently. Moreover, better and simpler BTA tests, BTA stat and BTA trak,
are available, and will probably replace the BTA test in the very near future.
The quantitative urinary NMP22 test is also superior to urinary cytology.
Depending on the cut-off level chosen. It seems feasible to postpone uretroscopy based on NMP22 level below 10 U/ml. Both the BTA and the
NMP22 test have to be interpreted with care in the case of infections, since
in such patients the tests are likely to give false-positive results.
Quantitative bladder-wash cytology is objective and reproducible. Again, this test is superior to urinary cytology, but it is invasive test since a
bladder-wash sample is necessary. An additional advantage of quantitative
urinary cytology is the predictive value with regard to tumor recurrence and
progression. Can cytology be replaced? 95
Tumor specific-antigens have been introduced into daily practice. Their ability to detect low-grade tumors could be of particular help. The promising results of newer techniques, like Telomerase expression and microsatellite techniques, have yet to be confirmed in larger studies.
References 1. Badalament RA, Hermansen DK, Kimmel M, Gay H, Her HW, Fair W. The sensitivity of bladder wash cytometry, bladder wash cytology and voided cytology in detection of bladder carcinoma. Cancer 1987; 60:1423-27 2. Murphy WM. Current status of urinary cytology in the evaluation of bladder neoplasms. Hum Path 1990; 21:886-90 3. Liotta LA. Cancer cell invasion and metastasis. Sci Amer 1992; 266:54-8 4. Alitala K, Keski-Oja J, Vaheri A. Extracelluler matrix proteins characterise human tumor cell lines. Int J Cancer 1981; 27:755-7 5. Margulies IM, Höyhtya M, Evans C, Strocke Ml, Liotta LA, Stetler- Stevenson WG. Urinary type IV colleganese: elevated levels are associated with bladder transitional cell carcinoma. Cancer Epidemiol Biomarkers Prev 1992; 1:467-70 6. The United Kingdom and Erie Bladder Tumor Antigen Study Group. The use of bladder-tumor associated analyse test determine type of cystoscopy in the follow-up of patients with bladder cancer. Br J Urol 1997; 79:362-6 7. Ianari A, Sternberg N, Rosetti A, Van Rijn A, Deidda A, Giannerelli D. Results of Bard BTA test in monitoring patients with a history of transitional cell cancer of the bladder. Urology 1997; 49(5): 786-9 8. D’Hallewin MA, Baert L. Initial evaluation of the bladder tumor antigen test in superficial bladder cancer. J Urol 1996; 155:475-6 9. Schamhart DHJ, de Reijke ThM, van der Poel HG, Witjes JA, de Boer EC, Kurth KH. The bladder tumor antigen (BTA) test its mode of action, sensivity and specificity, compared to cytology of voided urine, in the diagnosis of superficial bladder cancer. Eur Urol (in press) Can cytology be replaced? 96
10. Sarosdy MF, deVere White RW, Soloway MS, Sheinfeld J, Hudson MA, Schellhammer PF. Results of multicenter trail using the BTA test to monitor for and diagnose recurrent bladder cancer. J Urol 1995; 154:379-84 11. Leyh H, Mazeman E, Hall RR, Bennett AH. Results of a European multicenter trail comparing the Bard BTA test to urine cytology in patients suspected of having bladder cancer (abstract 726). J Urol 1996; 155:492A 12. Sarosdy MF. The use of the Bard BTA test in the detection of persistent or recurrent transitional -cell cancer of the bladder. World J Urol 1997; 15(2):103-6 13. Sarosdy MF, Hudson MA, Ellis WJ, Soloway MS, deVere White RW, Sheinfeld J. Detection of recurrent bladder cancer using a new one-step test for bladder tumor antigen. J Urology 1997; 157(4):337-9 14. Sarosdy MF, Hudson MA, Ellis WJ, Soloway MS, deVere White RW, Sheinfeld J. Improved detection of reccurrent bladder cancer using the Bard BTA stat test. Urology 1997; 50(3): 349-53 15. Ishak LM, Enfield DL, Redmond WA, Sarosdy MF, San Antonio, TX; and multicenter group. Detection of recurrent bladder cancer using a new quantitative assay for bladder tumor. J Urol 1997; 157(4) Supp: 1317 A 16. Nakayasu H, Berezney R. Mapping replicational sites in eucaryotic cell nucleus. J Cell Biol 1989; 108:1-12 17. Carpinito GA, Stadler WM, Briggman JV, Chodak GW, Curch PA, Lamm DL. Urinary nuclear matrix protein as a marker for transitional cell carcinoma of the urinary tract. J Urol 1996; 156:1280-5 18. Miyanaga N, Akaza H, Ishikawa S, Ohtani M,Nogichi R, Kawai K. Clinical evaluation of nuclear matrix protein 22(NMP22) in urine as a novel marker for urethelial cancer. Eur Urol 1997; 31(12):163-8 19. Yang CH, Lambie EJ, Snyder M. NuMA : an unusually long coiled-coil related proteins in the mammalian nucleus J Cell Biol 1992; 116:1303 7 20. Compton DA, Cleveland DW. NuMA is required for the proper completion of mitosis. J Cell Biol 1993; 120:947-51 21. Getzenberg RH: the nuclear matrix and regulation of gene expression: tissue specificity. J Cell Biochem 1984; 55:22-31 22. Berezney R,Coffey DS. Nuclear protein matrix : association with newly synthesised DNA. Science 1975; 189:291-3 Can cytology be replaced? 97
23. Akaza H, Miyanaga N, Tsukamoto T, Ishikawa S, Noguchi R, Ohtany M. Evaluation of urinary NMP22 (Nuclear matrix protein) as a diagnostic marker for urothelial cancer-screening for urothelial cancer patients with microscopic hematuria. Jpn J Cancer Chem other 1997; 24(7): 837-42 24. Soloway MS, Briggman JV, Carpentino GA, Chodak GW, Curch PA, Lamm DL. Use of a new tumor marker, urinary NMP22, in the detection of occult or rapidly recurring transitional cell carcinoma of the urinary tract following surgical treatment. J Urol 1996; 156:363-7 25. Witjes JA, van der Poel HG, van Balken MR, Debruyne FMJ, Schalken JA. Urinary NMP22, sediment and karyometry in the diagnosis and follow up of patients with superficial bladder cancer. Eur Urol 1998; 33: 387-91 26. Stampfer DS, Carpinito GA, Rodriquez- Villanueva J, Willsey LW,Dinney CP, Grossman HB. Evaluation of NMP22 in the detection of transitional cell carcinoma. J Urol 1998; 159: 394-8 27. NMP22 principal investigators symposium: trail of NMP22 as an indicator of occult or rapidly recurring transitional cell carcinoma of urinary tract following surgical treatment. Proceedings of meeting, 10 February 1995 28. Shelfo SW, Soloway MS. The role of nuclear matrix protein 22 in the detection of persistent or recurrent transitional cell cancer of the bladder. World J Urol 1997; 15(2):107-11 29. Sherman AB, Koss LG, Adams SE. Intraobserver differences in the diagnosis of urothelial cells: comparison with classification by computer. Anal Quant Cytol Histol 1984; 6:112-8 30. van der Poel HG, van Caubergh RD, Boon ME, Debruyne FMJ, Schalken JA. Karyometry in recurrent superficial transitional cell tumours of the bladder. Urol Res 1992, 20:375-81 31. van der Poel HG, Oosterhof GON, Debruyne FMJ, Schalken JA. Image analysis in superficial transitional cell carcinoma of bladder. Semin Urol 1993; 11:164-70 32. Badalament RA, Gay H, Whitmore WR, Herr HW, Fair WR,Oettgen HK. Monitoring intravesical bacillus Calmette-Guerin treatment of superficial bladder carcinoma by serial flowcytometry. Cancer 1986; 58:2751-60 33. Aamodt RL, Coon JS, Deitch A, deVere-White RW, Koss LGMelamed MR. Flow cytometric evaluation of bladder cancer: recommendations Can cytology be replaced? 98
of NCI flow cytometry network for bladder cancer. World J Urol 1992; 10:63-7 34. Zein T, Waisman Z, Englander LS, Gamarra M, Lopez C, Huben RP. Evaluation of bladder washings and urine cytology for the diagnosis of bladder cancer and its correlation with selected biopsies of the bladder mucosa. J Urol 1984, 132:670-1 35. Murphy WM, Emerson LD, Chandler RW, Moinuddin SM, Soloway MS. Flow cytometry versus urinary cytology in the evaluation of patients with bladder cancer. J Urol 1986; 136:815-9 36. van der Poel HG, Witjes JA, van Stratum ME, Boon ME, Debruyne FMJ, Schalken JA. Quanticyt: Karyometric analysis of bladder washing for patients with superficial bladder cancer. Urology 1996; 48(3):357- 64 37. van der Poel HG, Schaafsma HE, Vooijs GP, Debruyne FMJ, Schalken JA. Quantitative light microscopy in urologic oncology. J Urol 1992; 148:1-13. 38. van der Poel HG, van Balken MR, Schamhart DHJ, Peelen P, de Reijke Th, Debruyne FMJ. Can bladder wash cytology be replaced in patients with bladder cancer: quantitative cytology and the qualitative BARD BTA. Urology 1998; 51: 44-50 39. Chabanas A, Rambeaud JJ, Huo HH, Seigneurin D, Lawrence JJ. Limits of flow -cytometry histogram analysis methods to asses bladder tumour antigen expression. Anal Cell Pathol 1997,: 13(1):39-47 40. Fradet Y, Lafleur L, LaRue H. Strategies of cemoprevention based on antigenic and molecular markers of early premalignant lesions of the bladder. J Cell Biochem Suppl 1992; 161:85-92 41. Cardon-Cardo C, Wartinger DD, Melamed MR, Fair W, Fradet Y. Immunopathologic analysis of human urinary bladder cancer. Characterisation of two new antigens associated with low-grade superficial bladder tumors. Am J Pathol 1992; 140:375-85 42. Bergeron A, LaRue H, Fradet Y. Identification of superficial bladder tumor-associated glycoform of carcinoembryonic antigen by monoclonal antibody 19A211. Cancer Res 1996; 56(4):908-15 43. Bergeron A, LaRue H, Fradet Y. Biochemical analysis of bladder- cancer-associated mucin: structural features and epitope characterisation. Biochem J 1997; 321(Pt3): 889-95 44. Lee E, Schwaibold H, Fradet Y, Huland E, Huland H. Tumor- associated antigens in normal mucosa of patients with superficial transistional cell carcinoma of the bladder. J Urol 1997; 157(3):1070-3 Can cytology be replaced? 99
45. Sagerman PM, Saigo PE, Sheinfeld J, Charitonowicz E, Cordon-Cardo C. Enhanced detection of bladder cancer in urine cytology with Lewis X, M344, and 19A211 antigens. Acta Cytol 1994; 38(4):517-23 46. Bonner RB, Hemstreet GP 3d, Fradet Y, Rao JY, Min KW, Hurst RE. Bladder cancer risk assessment with quantitative fluorescence image analysis of tumor markers in exfoliated cells. Cancer 1993; 72(8):2461-9 47. Fradet Y, La-Rue H, Parent-'Vaugeois C, Bergeron A, Dufour C,Boucher L. Monoclonal antibodies against a tumor-associated sialoglycoprotein of superficial papillary bladder tumors and cervical condylomas. Int J cancer 1990; 46(6):990-7 48. Ravery V, Colombel M, Popov Z, Bastuji S, Paterd JJ, Bellot J.Prognostic value of epidermal growth factor receptor, t138, and T43 expression in bladder cancer. Br J cancer 1995; 71(1):196-200. 49. Meeker AK, Sommerfeld HJ, Coffey DS. Telomerase, a prevalent marker in prostate cancer, is activated in stem cells of rat prostate and seminal vesicles following castration and is repressed following re introduction of testosterone. J Urol 1996; 155 (5):169-353A 50. Kinoshita H, Ogawa O, Oka H, Mishina M, Yoshida O. Telomerase activity in renal cell carcinoma. J Urol 1996; 155(5):189-358A 51. Rohde V, Sattler HP, Forster S, Zwergel T, Wullich B. Association of telomerase activity and DNA aneuploidy in human renal cell carcinoma 1043 A. J Urol 1997; 157(4) Supp:269 52. Muller M, Heicappel R, Steiner U, Krause H, Miller K. Telomerase activity in renal cell carcinoma. 1011A J Urol 1997; 157(4) Supp:258 53. Zhang WW, Kapusta LR, Klotz LH. Telomerase activity in human cancer and various prostatic disorders. 1043A. J Urol 1997; 157(4) Supp:269 54. Lance RS, Wade KA, Blaser J, Thrasher JB. Telomerase activity in solid transitional cell carcinoma (TCC) and bladder washings. 1320A. J Urol 1997; 157(4) Supp:338 55. Kin-ya Y, Kin-ya A, Keiji K, Hiro-omi K, Susumu K. The role of telomerase activity in exfoliated human urothelial cells 47A. J Urol 1997; 157(4) Supp:12 56. Muller M, Heine B, Heicappel R, Stein H, Miller K. Telomerase activity in bladder cancer, bladder washings and in urine. 187A. J Urol 1997; 157(4) Supp:50 Can cytology be replaced? 100
57. Kavaler E, Shu W, Chang Y, Droller MJ, Liu BCS. Detection of human bladder cancer cells in voided urine samples by assaying for the presence of telomerase activity. 1321A. J Urol 1997; 157(4) Supp:338 58. Mao l, Schoenberg MP, Scicchitano M, Erozan YS, Merlo A, Schwab D. Molecular detection of primary bladder cancer by microsatellite analysis. J Urol 1996; 155(5): 1221-616A CHAPTER 5
Comparison of the diagnostic value of the BTA Stat Test with voided urinary cytology for the detection of bladder cancer
N.A. Mungan, A. Atan, U.Y. Tekdogan, Y. Gurbuz, L.A.L.M. Kiemeney, J.A. Witjes
Submitted The BTA stat test 102
Introduction
Superficial bladder cancer (Ta, Tis, T1) has a high tendency to recur after transurethral resection of the tumor (TURT). In our own series the risk of recurrent disease in patients with primary superficial bladder tumors is over 60% in 7 years [1]. In the literature, the recurrence rates after 5, 10 and 15 years are reported to be 65%, 81% and 88% respectively [2]. Cytology suffers from low sensitivity in the presence of low-grade transitional cell carcinoma (TCC). Moreover, the results of urinary cytology vary depending on the training and expertise of the cytopathologist and usually take a few days to process [3]. Its use alone in the follow-up is not recommended [4]. Better noninvasive tests are necessary to diagnose and follow-up patients at risk for bladder cancer in order to avoid frequent cystoscopies. The bladder tumor antigen stat (BTA® stat) test has been recently described to have significant advantages. However, false positive results can be determined in some benign conditions. Therefore, we compared the sensitivity and specificity of voided urine cytology (VUC) and the BTA® stat test for the diagnosis of TCC in our own series to evaluate diagnostic value of this test. The BTA stat test 103
Patients and Methods
In this study, fresh voided urine samples which were obtained from each patient with TCC or benign genitourinary disease (GUD), and healthy volunteers (HV), were used for cytology and the Bard® (Bard Diagnostic Sciences, C.R. Bard, Inc., Redmond, Wash., USA) BTA® stat test. All patients with TCC were investigated by detailed medical history, routine blood and urine analysis, intravenous pyelography, abdominal ultrasonography (USG) and computerized tomography. Each patient with TCC underwent cystoscopy with biopsy or TURT. In case of an invasive tumor radical cystectomy was performed. Patients with TCC plus another benign GUD were excluded from the study. The patients with benign GUD and HV whose samples were used in the specificity study were assumed not to have bladder cancer after careful investigation including abdominal USG, although cystoscopy was not performed. The BTA® stat test was done by placing five drops of fresh voided urine into the sample well of the disposable test device. In the well, the urine mixes with a colloidal gold-conjugated antibody. In the presence of bladder tumor associated antigen, an antigen conjugate complex is formed that creates a visible red line after 5 minutes. Antibodies in the second control window adjacent to the specimen should create another visible red line each time to confirm proper function of the kit. The BTA stat test 104
Urinary specimens were stained according to Papanicolaou staining procedure for cytology. The pathologist performing the cytological examination was blinded for the results of cystoscopy and the BTA® stat test. A smear technique was performed twice for each urine specimen. A positive cytology result was defined if tumor cells were found. Acellular, suspicious or atypical results were considered as negative cytology. Tumors were staged according to the TNM classification of the American Joint Committee on Cancer [5] and graded according to the World Health Organization classification system [6]. Statistical analysis was performed using the statistical package for social sciences (SPSS) computer software. The McNemar test was used to compare the sensitivity and specificity of the BTA® stat test and VUC. Pearson chi-square was used to analyze statistical differences of sensitivity and specificity for tumor grades and stages. A p value <0.05 was considered to be statistically significant.
Results
A total of 117 patients with histologically confirmed TCC were enrolled in this prospective study. Ninety-eight men (83.7%) and 19 women (16.3%) had a mean age of 61,3±9,2 (range 35-80) years. The control group consisted of 94 patients with benign GUD and 21 HV, 84 men (73%) and 31 The BTA stat test 105 women (27%), mean age 41,2±12,8 (range 18-79) years. The patients in the benign GUD group had a cystocele (n=4), urethero-pelvic junction obstruction (n=3), renal cortical cyst (n=1), nephrolithiasis (n=24), benign prostatic hyperplasia (BPH) (n=14), urinary tract infection (UTI) (n=44), 3 follow-up patients with augmentation cystoplasty operation and 1 patient was 18 days after a transvesical prostatectomy. The BTA® stat test was positive in 94 of 117 patients with TCC. VUC was positive in only 33 of these patients. Thirty-six false positive results were found in the control group by the BTA® stat test. All of these had benign GUD: 19 patients with only UTI, 9 BPH patients with UTI, 1 cystocele, 6 nephrolithiasis and 1 patient after transvesical prostatectomy. Antibiotic treatment was given to 21 false positive patients with UTI. Although, the BTA® stat test became negative in these 20 patients after treatment, the test remained as a positive in 1 BPH patient with UTI. In the control group, all VUC samples were reported negative. Only one patient with a T3 grade III TCC was positive by VUC while the BTA® stat test was negative. The overall sensitivity of the BTA® stat test and VUC was 80.3% and 28.2%, respectively. The difference was statistically significant (p<0.005). VUC was more specific than the BTA® stat test; 100% (95%CI=98.2-100%) versus 72.3% (95%CI=63.5-79.6%). The correlation of the BTA® stat test by tumor grade was statistically significant (p<0.005). However, no statistically significant correlation was found between the BTA® stat test The BTA stat test 106 and stage (p>0.05), although detection rates increased by stage. The correlation of VUC by stage and grade was also statistically significant (p<0.05). These results are detailed in Table I.
Table I. Sensitivity of the BTA® stat test and voided urinary cytology by stage and grade Voided Urine Cytology The BTA Stat Test Stage N % 95% CI % 95% CI Ta 33 3 1.7-6.4 52 42.8-61.2 T1 41 10 1.0-19.0 74 64.5-83.5 T2 10 33 24.4-41.6 89 83.3-94.7 T3-4 33 39 30.0-48.0 88 82.0-94.0 Grade 1 44 6 1.8-10.2 52 42.8-61.2 2 53 24 16.2-31.8 88 82.0-94.0 3 20 49 39.8-58.2 93 88.4-97.6 All 117 28.2 20.0-36.4 80.3 72.9-87.7
CI= Confidence Intervals
Discussion
Several attempts have been made to find the ideal tumor marker for the diagnosis and follow up of bladder cancer. The BTA® stat test is one of the promising markers that have been transferred to the clinical arena. The BTA® stat test is an easy, single-step immunochromatographic assay to detect a bladder tumor associated antigen in voided urine with the result being available after 5 minutes. The antigen detected by the BTA® stat test The BTA stat test 107 is a human complement factor-H-related protein (hCFHrp), which is similar in structure and function to human complement factor H (hCFH) [7]. In a cell culture, hCFHrp is produced by several bladder cancer cell lines but not in normal tissue. By interaction with complement factor C3b, hCFH serves to inhibit the formation of a membrane attack complex, thereby preventing cell lysis. Like hCFH, bladder tumor antigens interrupt the complement cascade. In this manner, tumors producing hCFHrp related proteins could be protected from the immune system [8]. The overall sensitivity of the BTA® stat test was reported from 57 to 82.8% [10-15]. Sarosdy et al., investigated the sensitivity of the BTA® stat test and compared this with VUC in patients with recurrent bladder cancer using frozen urine [9]. The BTA® stat test was found to be positive in 147 (67%) of 220 samples. The overall sensitivity of the BTA® stat test and VUC in these patients was 58% and 23%, respectively (p<0.001). Sensitivity of the BTA® stat test was better than VUC for every grade and stage, except for Tis. A slight increase in detection of cancers was seen by combining the BTA® stat test and VUC, but this was not statistically significant. Leyh et al. reported that the overall sensitivity (65%) of the BTA® stat test was considerably higher than cytology (33%) (p<0.001) [10]. Although the BTA® stat test was significantly more sensitive than cytology for grade I and II tumors (p<0.005) and for stage Ta tumors (p<0.001), this was not the case for grade III and Tis, T1-4 tumors. In a multicenter study, the BTA stat The BTA stat test 108 test detected 90.1% of the primary and 73.7% of the recurrent tumors with a 82.8% overall sensitivity [11]. All patients with CIS, high-grade tumors, muscle invasive cancer and tumors larger than 2 cm were diagnosed by the BTA® stat test. Patients under surveillance treated with intravesical BCG, however, had a significant increase in the number of false-positive results. In another study the sensitivity of VUC, BTA® stat, NMP22, fibrin/fibrinogen degradation products, telomerase, chemiluminicent hemoglobin and hemoglobin dipstick were compared to detect bladder cancer in 196 patients [12]. The BTA® stat test had the highest sensitivity of 74%, but was less specific in this study. The overall sensitivity with VUC was only 44%. The urinary telomerase had the highest combination of sensitivity and specificity (70% and 99%, respectively) for TCC detection, but the combination of the BTA® stat test with telomerase revealed a statistically significant improvement (p=0.02). On the other hand, Wiener et al. reported almost equivalent overall sensitivity rates for different urinary diagnostic tests. The overall sensitivity was 48, 57, 58, 59 and 59 % for the NMP22 test, the BTA® stat test, bladder wash cytology, VUC and Quanticyt® [13]. Sensitivity of the cytological evaluation of voided urine and bladder wash material, and Quanticyt® increased as grade and stage increased, in contrast to the NMP22 and BTA® stat test. For grades 1 to 3, sensitivity was 17%, 61% and 90% for urinary cytology, as compared to 48%, 58% and 63% for the BTA® stat test. The BTA stat test 109
In our study, the overall sensitivity of the BTA® stat test was significantly superior to VUC in detecting TCC of the bladder (p<0.005). Both tests performed better with increasing grade, with the BTA® stat test having the higher sensitivity for all grades and stages of TCC compared to VUC. The differences were highest in grade I (6% versus 52%), stage Ta (3% versus 52%) and T1 (10% versus 74%) (p<0.001). The BTA® stat test appears to be especially useful in the detection of low risk tumors. Despite progression and recurrence rates of low and intermediate risk tumors are low, cystoscopy is performed at 3-month intervals for 2 years, 6-month for the next 2 years annually thereafter for the rest of the life in traditional follow- up protocol due to lower sensitivity of VUC to detect these low and intermediate risk tumors. However, many authors have suggested that the first cystoscopic control is one of the most important determinants of risk factor and should not be skipped [14-16]. With the negative first 3-month cystoscopic findings, the BTA® stat test could be helpful to the urologist in order to detect low and intermediate risk tumors owing to its higher sensitivity rates compared to VUC and, unnecessary cystoscopies could be avoided. The BTA® stat test and VUC were not combined to analyze detection rates because there was only one patient with TCC that was not detected by the BTA® stat test while VUC was positive. A potential disadvantage of the BTA® stat test is the specificity. Specificity can be affected in some conditions. The BTA® stat test specificity was 95% The BTA stat test 110 in healthy volunteers and 93% in patients with nongenitourinary disease in a large multicenter study [9]. In this multicenter study, specificity was 88% in patients with BPH and decreased to 50% in patients with stones and 76% in those with inflammatory conditions, such as cystitis, urethritis and prostatisis. Invasive manipulation of the bladder or prostate decreased specificity to 33%. In another study, among 278 cases, 34 (12%) had histologically confirmed bladder cancer. [17]. A specificity of 82.4% and a PPV of 34.9% were found. The specificity and PPV of the BTA® stat test improved (91.5%, 69.7%) with exclusion of 6 clinical categories (infectious or benign inflammatory conditions, urolithiasis, recent history of a foreign body in the urinary tract, bowel segment interposition, another genitourinary cancer or an instrumented urinary sample). Our overall specificity (72.3%) for the BTA® stat test, which was lower than VUC, is comparable with this study. In the patients with exclusion criteria as defined by Sharma et al. [14], the BTA® stat test gave some false (+) results and all HV were negative by the BTA® stat test in our study. In this study, especially UTI and nephrolithiasis cases were considerably affected the specificity of the BTA stat test. hCFH may enter the bladder as a result of different conditions and it can result in a false positive BTA® stat test. Although it is difficult to define exclusion criteria, the urologist should be aware of these conditions causing false positive tests. The BTA stat test 111
Conclusions
The BTA® stat test has significantly higher sensitivity than VUC in the detection of TCC, especially in low-grade tumors. Unfortunately, specificity can be affected by some benign conditions, especially UTI and nephrolithiasis. In the patients with low and intermediate risk tumors, the BTA® stat test may help to reduce the number of cystoscopies during follow up.
References
1. Kiemeney LALM, Witjes JA, Verbeek ALM, Heybroek RP, Debruyne FMJ: The clinical epidemiology of superficial bladder cancer. Brit J Cancer 1993; 67:806-812 2. Lamm DL, Griffith JG: The place of intravesical chemotherapy as defined by results of prospective randomized studies (substances and treatment schemes). Prog Clin Biol Res 1992;378:43-53 3. Ooms ECM, Kurver PHJ, Veldhuizen RW, Alons CL, Boon ME: Morphometric grading of bladder tumors in comparison with histologic grading by pathologists. Hum Path 1983; 144:140-146 4. Giella JG, Ring K, Olsson CA, Karp FS, Benson MC: The predictive value of flow cytometry and urinary cytology in the follow up of patients with transitional cell carcinoma of the bladder. J Urol 1992; 148:293-296 5. American Joint Committee on Cancer. Manual for staging of cancer,3rd edn, Philadelphia: Lippincott, 1988: 194-224 6. Mostofi FK, Sobin LH, Torloni H: Histological typing of urinary bladder tumors. International histological classification of tumors, No.10. Geneva, World Health Organizition,1973: 9-35 The BTA stat test 112
7. Kinders R, Root R, Jones T, Bruce CL, Williams L, Hass GM: Complement factor H-related proteins are expressed in bladder cancers. Cancer Res 1997; 38:29A 8. Kinders R, Jones T, Root R, Murchison H, Bruce CL, Williams L: Human bladder tumor antigen is a member of the RCA (regulators of complement activation) gene family. J Urol 1997; 157 (2):28A110 9. Sarosdy MF, Hudson MA, Ellis WJ, Soloway MS, deVere White R: Improved detection of recurrent bladder cancer using the Bard BTA stat test. Urology 1997; 50(3):349-353 10. Leyh H, Marberger M, Conot P, Sternberg C, Pasadoro V: Comparison of the BTA stat test with voided urine cytology and bladder wash cytology in the diagnosis and monitoring of bladder cancer. Eur Urol, 1999;35:52-56 11. Pode D, Shapiro A, Wald M, Nativ O, Laufer M, Kaver I: Noninvasive detection of bladder cancer with the BTA stat test. J Urol 1999; 161:443-446 12. Ramakumar S, Jalaluddin B, Besse AJ, Roberts SG, Wollan PC, Blute ML: Comparison of screening methods in the detection of bladder cancer. J Urol 1999; 161:388-394 13. Wiener HG, Main CH, Haitel A, Pycha A, Schatzi G, Marberger M: Can urine bound diagnostic tests replace cystoscopy in the management of bladder cancer. J Urol 1998; 159:1876-1880 14. Parmar MKB, Freedman LS, Hargreave TB, Tolley DA: Prognostic factors for recurrence and follow-up policies in treatment of superficial bladder cancer. J Urol 1989;142:284-288 15. Hall RR, Parmar MKB, Richards AB, Smith PH: Proposal for changes in cystoscopic follow-up patients with bladder cancer and adjuvant intravesical chemotherapy. BMJ 1994;308:257-260 16. Öge Ö, Erdem E, Atsü N, Sahin A, Özen H: Proposal for changes in cystoscopic follow-up of patirnts with low grade pTa bladder tumor. Eur Urol 2000;37:271-274 17. Sharma S, Zippe CD, Pandrangi L, Nelson D, Agarwal A: Exclusion criteria enhance the specificity and positive predictive value of NMP22 and BTA stat. J Urol 1999; 162:53-57 CHAPTER 6
The Urinary Bladder Cancer Test: can it be used as a new urinary tumor marker in the detection of carcinoma in-situ, pTa and pT1 bladder cancer?
N.A. Mungan, J.L. Vriesema, C.M. Thomas, L.A.L.M. Kiemeney, J.A. Witjes
Urology 1:56(5): 787-791,2000 The UBC test 114
Introduction.
Researches in cell biology has provided new biological markers of bladder cancer in recent decades. The development of urothelial tumours causes exophytic growth of tumour into the bladder and urethelial cell damage. This can exfoliate lysed and alive malignant cells into bladder and a concomitant discharge of intracellular components into urine. One group of these intracellular components are cytokeratins (CKs). CK fragments are expressed in varying combinations and levels depending on the epithelial type, degree of differentiation, and existence of malignancy [1]. Malignant cells generally retain the intermediate flaments of their progenitor cell type. Moreover, CKs expression is retained throughout almost all stages of epithelial malignancy. For these reasons, CKs have been used to characterize neoplastic cells of epithelial origin [2]. It has also been suggested that CKs may be a specific biomarker for detecting bladder cancer. One such test is the Urinary Bladder Cancer (UBC) test (IDL Biotech, Sollentuna, Sweden), which detects the CK 8/18 pair in urine. However, the biological difference of CK variants between malignant urothelial cells and normal urothelial cells is small. The ability of a test to detect these differences will determine its clinical usefulness. Also, unsolved problems regarding CK testing in bladder cancer, such as the The UBC test 115 stratification of the antigen concentration in relation to the urinary creatinin concentration, still exist. Although other bladder cancer tests and assays have been studied extensively, the experience with the UBC test is limited, since the test is relatively new. It is too early to make conclusions about the value of this marker in patients with bladder cancer. The aim of this study was to evaluate diagnostic performances of the UBC test in the patients in follow- up for superficial bladder cancer.
Material and Methods
Patients: The study population consisted of 101 consecutive patients seen in our outpatient department between October 1998 and March 1999 for follow-up superficial bladder cancer (pTa, pT1 and carcinoma in situ). Voided urinary specimens were collected from all patients, and all patients underwent cystoscopy. Transurethral resection was performed or biopsies were taken in the case of a bladder tumour or suspicion for CIS. Urine sediment and culture were performed for all patients because elevated UBC concentrations may be observed in the case of urinary tract infections (UTI). Patients who had undergone intravesical immunotherapy or chemotherapy less than 1 month before the test were excluded from the study. Tumours were staged and graded according to the TNM classification [3] and World Health Organisation classification [4] systems, respectively. The UBC test 116
Assay: The CK 8/18 fragments were determined in urine by using solid phase double determinant “sandwich” -type immunoenzmmometric assay. Frozen urine specimens were thawed and mixed before testing. Urine specimens, standards, and controls were incubated for 2 hours with monoclonal anti-UBC antibody coated to the wells of microtiter plates simultaneously with a horseradish peroxidase-labelled tracer antibody. During the incubation, both the immobilezed antibody and the horseradish peroxidase-labelled antibody bind to UBC antigen, forming a “sandwich”. The wells were washed and B substrate was added and incubated for 15 minutes. Sulfuric acid was added to stop the reaction. The developed colour is directly proportional to the concentration of CKs. Because the results of assay can be affected by different urinary creatinine level, it is recommended that the UBC concentrations should be corrected by using urinary creatinine concentrations according to the following equation: UBCcorrected (in ^g UBC/mg creatinin)- UBC measured (in ^g /L) / creatinin urinry (in mg/L) X 1000]. Non-corrected UBC antigen concentrations were also evaluated in the present study. Statistical analysis: The diagnostic performance of the uncorrected and corrected UBC test was evaluated in three different ways. First, the median values of the (non-normal) distribution of test results were compared between patients with and without recurrent urothelial cell carcinoma. Possible differences in the distribution between both groups were tested for The UBC test 117 statistical significance using the non-parametric Mann-Whitney test. Second the sensitivity, specificity and positive predictive value (PPV), negative predictive value (NPV) of the uncorrected and corrected UBC test were assessed using a cut-off value 12 pg/L, as advised by IDL Biotech. Also, to summarize the diagnostic value of the test in a single measure, the odds ratio (OR) with corresponding 95% confidence interval (95%CI) was calculated. In a diagnostic setting, this OR reflects the ratio of the likelihood ratio of positive test result (LR+) and the likelihood ratio of negative test result (LR-). If a test does not have any diagnostic value, the OR (LH+/LH-) is close to 1.0. If a test has strong diagnostic value the OR will become extremely high. Third, to avoid an arbitrary value for the test, we reanalysed the data using logistic regression analyses with the cystoscopic (plus histologic) results as a dependent variable and the UBC test as an independent variable. The result from this logistic regression analysis is the OR with 95% CI. However, because in this analysis the UBC test is a continuous variable instead of dichotomy variable, the OR cannot expected to be very high for a test with good diagnostic efficacy. To visualize the diagnostic efficacy of the test in the absence of an arbitrary cut-off value, we also summarized the data using a receiver operating characteristics (ROC) curve. The area under the curve (AUC) was calculated as a single measure for diagnostic efficacy of the continuos test result. If a test does not have any diagnostic value, the The UBC test 118
AUC is close to 0.5. If a test has strong diagnostic value the AUC will be close to 1.0. The Statistical Package for Social Sciences (SPSS), release 9.0, was used for analyses. ROC curves drawn according to Harley and Mc Neil [5].
Results
Eighty-three men and 18 women were enrolled this study. The patients had a mean age of 67.6years (range 40 to 86). In 29 (28.71%) of 101 patients, histologically proven recurrence of transitional cell carcinoma (TCC) was detected: 1 patient had CIS, 26 had stage pTa (19 low grade and 7 high grade), and 2 patients had a high-grade pT1 tumour. Among the patients with tumour, the median non-corrected and corrected UBC value was 3.40 pg/L (range 0 to 54.5) and 2.50 pg/L (range 0 to 39.2), respectively. In patients with without signs of a tumour, the median non-corrected and corrected UBC value was 3.75 pg/L (range 0 to 60) and 3.21 pg/L (range 0 to 45.7), respectively. The non-corrected UBC values were not significantly different between patients with and without a bladder tumour (p=0.75), nor were the corrected values (p=0.77). No differences were found between men and women. The test was not stratified according to stage and/or grade because of the limited number of patients. The sensitivity, specificity, PPV, NPV and OR for the corrected and non corrected test, with and without a specific cut-off level, are listed in Table I. The UBC test 119
The diagnostic value of non-corrected and corrected test without an arbitrary cut-off level is detailed Figures 1 and 2, respectively. Both ROC curves suggest that the UBC test has no diagnostic value in patients who are being followed up for recurrent superficial bladder cancer. The AUC was 0.519 and 0.517, respectively, for the non-corrected and corrected UBC test. The exclusion of patients with a urinary tract infection did not improve the results of test.
R O C C u rve
1 - Specificity
Diagonal segments are produced by ties. Figure 1. ROC curve of the noncorrected UBC test (AUC 0.519; standart error 0.066) The UBC test 120
R O C Curve
1 - Specificity
Diagonal segments are produced by ties. Figure 2. ROC curve of the corrected (for creatinine) UBC test (AUC 0.517; standard error 0.065).
Table I. Sensitivity, specificity, positive and negative predictive values, and odds ratio for the UBC test with confidence interval Non-corrected UBC test Corrected UBC test (Cutoff 12p,g/L) (Cutoff 12p,g/L) Sensitivity (%) 20.7 20.7 Specificity (%) 84.7 79.2 PPP (%) 35.3 28.6 NPV (%) 72.6 71.3 OR 1.44 0.99 95% CI 0.43-3.86 0.34-2.87 OR without cutoff 1.0149 (p=0.46) 1.01 (p=0.65) 95% CI 0.97-1.05 0.97-1.05 UBC=urinary bladder cancer, PPV=positive predictive value, NPV: negative predictive value, OR=odds ratio, CI=confidence interval The UBC test 121
Discussion
CKs are a multigene family of proteins forming water-insoluble intermediate filaments specific for cells of epithelial origin [6]. Twenty different CK has been analysed from different epithelial tissues. They can be further subdivided into type I (CK 9-20) and type II (CK 1-8) [7]. For normal formation of intermediate filaments different types of CKs are necessary (one type I and one type II) and two different CKs form a pair. The smallest CK pair, 8 and 18, is found in large quantities in simple, ductal, and glandular epithelium, pseudostratified epithelium, transitional epithelium and carcinomas arising therefrom [8]. Different CK fragments as a biomarker for bladder carcinoma has been studied in the serum, urine and exfoliated cells. In serum, for example, different tissue polypeptide antigens have been studied. These polypeptide antigens measure CK 8,18 and 19, and they have been used as a serologic markers for the follow-up and diagnosis of bladder cancer [9-12]. The reported results indicated a low sensitivity, particularly in low-grade tumours, and the tests were not considered useful for the early detection of bladder cancer [10-12]. On the other hand, urinary CKs could be useful because of the direct contact of urine with the tumour. For example, because of the overall low sensitivity of serum CYFR 21-1 (CK 19 fragments), this marker was not useful marker for diagnosing TCC [13]. Expression of CK-20 was also found to be a The UBC test 122 potential biomarker for non-invasive detection of bladder carcinoma by assaying uroepithelial cells from the voided urine specimens [14]. Urinary CK fragments can be measured quantitatively by their immunochemical reactivity with the help of both polyvalent and monoclonal antibodies in blocking enzyme-linked immunoabsorbent assay (ELISA) [15]. An example of such a test is the UBC test, which detects the CK 8/18 pair in the urine. Sanchez-Carboya et al. studied the diagnostic performance of the UBC test as a tumour marker for TCC of the bladder [16]. In their first report, the urinary UBC antigen was measured in 5 different groups: 86 patients with active TCC (pTa-pT4, group 1), 76 tumour-free patients in follow-up after resection of TCC (group 2), 25 patients with benign urologic diseases (group 3), 25 patients with other malignant conditions (group 4) and 30 healthy volunteers (group 5). The mean urinary UBC antigen concentration was significantly different between the five groups, except for groups 1 and 4 (p=0.19). For patients, in group 1; no correlation with stage was found (p=0.26), although significant differences were seen between pT1 and pT2 (p=0.001) and between pT2 and pT3 (p<0.0005). No significant difference was evident between grades I and II (p=0.29), but a significant difference between grade II and III (p=0.0006) was found. In their study, the overall sensitivity and specificity for the UBC test was 87% (95% CI 79.2 to 92.7) The UBC test 123 and 86.8% (95% CI 77.1 to 93.5), respectively, with an optimised threshold of 9.74|ig/L. In their second report, group 1 (active TCC) was extended to 111 patients [17]. In that report, the overall sensitivity and specificity was 79.3% and 88.5%, respectively. The sensitivities in group 1 was 78.4%. For pTa tumours, this was 66.7% (16 of 24) and for pT1, 88.7% (47 of 53). The specificity in group 2 was 97.4%. The positive and negative predictive values in group 1 and 2 together was 97.4% and 79.0%, respectively. The false positive rate in group 4 was 44.0%. In this second analysis, no significant correlation was found with regard to tumour stage, grade, size, growth pattern, multifocality, or previous recurrences. Mian et al. compared the UBC test and nuclear matrix protein 22 (NMP22) test using frozen urine for the detection of TCC in 81 patients having symptoms suggestive of TCC and 159 patients under follow-up after transurethral resection [18]. With cutoff levels for bladder cancer of 12 U/ml for NMP22 and 12^g/L for the UBC test, the overall sensitivity in 54 patients with histologically proved TCC was 55.5% and 64.8% for NMP22 and the UBC test, respectively. The sensitivity of UBC test was higher than that of NMP22 for each stage and grade, although not significantly. Thus, low-grade and low-stage tumours especially were better detected with the UBC test. The specificity was 79% for the NMP22 test and 93% for the UBC test. The UBC test 124
In the previous studies, the results of the UBC test were promising. However, we could not confirm these results. In our patient population, the OR was very close to 1.0 and the AUC in the ROC curves was very close to 0.5, suggesting no diagnostic value for the UBC test. With a cutoff value of 9.74^/L, for example, which was the optimal value in the studies of Sanchez-Carboya et al., the sensitivity in our population improved to 38.7%, but the specificity decreased to 60%. Specimen collecting and storage, specimen preparation, and the technical performance of the test were well defined and repeatedly discussed with the manufacturer, so these factors were excluded as possible causes for the discrepancy with previous reports. The most important reason for the discrepancy is probably the different selection criteria for the patients in these studies. Our patient population consisted of patients with superficial bladder cancer in follow-up. The reason we chose to test this population was to evaluate the diagnostic performance of the UBC test in a group of patients in follow-up for recurrence, because we consider this to be the primary indication of a urinary marker such as the UBC test. In the diagnosis of patients with invasive bladder tumours, such as were included in the other two studies urinary marker tests have limited value. Still, Sanchez-Carboya et al. also found a good sensitivity in patients with superficial bladder TCC [17]. Theoretically, antigenic expression may be detected in the urine some time before a recurrent tumour becomes apparent, resulting in a “false-positive” The UBC test 125
UBC test. This would imply a prognostic value for this test, as has been seen with other tests. However, we could not test for a prognostic value, because this marker is not suitable for the detection of recurrent bladder cancer. Sanchez-Carboya et al. also found high UBC concentrations in patients without tumour recurrence during their follow-up [16]. This finding questions any prognostic value of the test, although they suggested that residual tumour or mucosal abnormalities owing to the field detect could cause a CK level below the cutoff level differentiates active tumour from tumour-free disease. Most of our group had low stage and low grade tumours. Although this also could be an explanation for the lack of sensitivity in our study, Mian et al. [18] indicated that, especially in these low-grade and low-stage tumours, the UBC test performs well. Moreover, in the study of Sanchez-Carboya et al., the UBC levels in some cancers other than bladder cancer overlapped with those of the bladder cancer cases, although this overlap remained after exclusion of patients with renal and prostate cancer from the analysis. We did not check our patient population for the other malignancies; however, none of our patients had such a history. Therefore, it is not unlikely that the presence of other malignancies influenced the test result in our patient population. There is also potential overlap between patients with benign conditions and bladder cancer. This has been shown for CYFRA 21-1 [19], particularly in patients with low- The UBC test 126 grade tumours. Since this compromises specificity, it is another undesirable condition for a good tumour marker. In conclusion, from the results of our study, it appears that the UBC test, a new urinary marker, is not useful in the diagnosis of recurrent tumours in the follow-up patients with superficial bladder cancer.
References 1. Feitz WFJ, Debruyne FMJ, Yoonis GP, et al. Intermediate filament proteins as tissue specific markers in normal and malignant urological tissues. J Urol 1986; 136:922-931 2. Osborne M, Weber K. Tumour diagnosis by intermediate filament typing: a novel tool for surgical pathology. Lab Invest 1983; 48:372 394 3. American Joint Committee on Cancer. Manual for staging of cancer,3rd edn, Philadelphia: Lippincott, 1988: 194-224 4. Mostofi FK, Sobin LH, Torloni H. Histological typing of urinary bladder tumors. International histological classification of tumors, No.10. Geneva, World Health Organizition,1973: 9-35 5. Harley JA, McNeil BJ. The meaning and use of the area under receiver operating characteristic curve. Radiology 1982;143:29-36 6. Virtanen I, Miettinen M, Lehto VP, Kariniemi AL, Paasivuo R. Diagnostic application of monoclonal antibodies to intermediate filaments. Ann NY Acad Sci.1985;455:635-647 7. Steinart PM, Steven AC, Roop DR. The molecular biology of intermediate flaments. Cell 1985; 42:411-419 8. Moll R and Schiller DL. The catalogue of human cytokeratins: Patterns of expression in normal epithelia, tumours and cultured cells. Cell 1982; 31:11-24 9. Bennik R, Van Poppel H, Billen J, Decoster M, Baert L, Mortelmans L, Blanckaert N. Serum tissue polypeptide antigen (TPA): monoclonal or polyclonal radio-immunometric assay for the follow-up of bladder cancer. Anticancer Res 1999;19(4A):2609-2613 The UBC test 127
10. Van Poppel H, Billen J, Goethuys H, Elgamal AA, Gerits M, Mortelmans L, Blanckaert N, Beart L. Tissue polypeptide antigen (TPA) as a tumour marker for bladder cancer. Anticancer Res 1996; 16:2205-2208 11. Filella X, Menendez V, Molina R, Alcover J, Carretero P, Ballesta AM. TPA prognostic value in superficial bladder cancer. Anticancer Res 1996;16:2173-2176 12. Stieber P, Schmeller N, Schambeck CH, Hofmann K, Reiter W, Hasholzner U, Fateh-Moghadam. Clinical Relevance of CYFRA 21-1, TPA-IRMA and TPA-LIA-mat in urinary bladder cancer. Anticancer Res 1996;16:3793-3798 13. Pariente JL, Bordenave PM, MJ Latapie, Ducassou D, Guillou ML. Inital evaluation of CYFRA 21-1 diagnostic performances as urinary marker in bladder transitional cell carcinoma. 14. J Urol 1997;158:338-341Klein A, Zemer R, Buchumensky V, Klaper R, Nissenkorn I. Expression of Cytokeratin 20 in urinary cytology of patients with bladder carcinoma. Cancer 1998;82(2):349-354 15. Baker WC, White RD, Rosito PV et al. Quantitative analysis of keratin 18 in the urine of patients with bladder cancer. J Urol 1988; 140:436 439 16. Sanchez-Carboya M, Herrero E, Megais J, Mira A, Espasa A, Chinchilla V, Soria F. Initial evaluation of the diagnostic performance of the new urinary bladder cancer antigen test as a tumour marker for transitional cell carcinoma of the bladder. J Urol 1999; 161:1110-1115 17. Sanchez-Carboya M, Herrero E, Megais J, Mira A, Espasa A, Chinchilla V, Soria F. Initial evaluation of the new urinary bladder cancer rapid test in the detection of transitional cell carcinoma of the bladder. Urology 54:656-661,1999 18. Mian C, Pycha A, Lodde M, Haitel A, Vigl EE, Marberger M. Comparison of the monoclonal UBC-Elisa test and the NMP22 Elisa test for the detection of transitional cell carcinoma of the bladder. J Urol 1999; 19. Pariente JL, Bordenave L, Michel Ph, Latapie MJ, Ducassou D, Guillou M. Initial evaluation of CYFRA 21-1 diagnostic performance as urinary marker in bladder transitional cell carcinoma. J Urol 1997;158:338-341
CHAPTER 7
Bacillus Calmette-Guérin in superficial transitional cell carcinoma
Based on: N.A. Mungan, J.A. Witjes: Bacillus Calmette-Guérin in superficial transitional cell carcinoma British Journal of Urology 82:213-223, 1998 J.A. Witjes, C.T.M. Caris, N.A. Mungan, F.M.J. Debruyne, W.P.J. Witjes: Results of randomized phase III trial of sequential intravesical therapy with mitomycin C and bacillus Calmette-Guérin versus mitomycin C alone in patients with bladder cancer. Journal of Urology 160:1668-1672, 1998 Intravesical BCG 130
I- BACILLUS CALMETTE-GUERIN IN SUPERFICIAL TRANSITIONAL CELL CARCINOMA.
Introduction
The antitumor effect of tuberculosis has been known since 1929, when Pearl reported an autopsy study in which patients with tuberculosis had significantly fewer malignant tumors than a control group [1]. In 1966, Coe and Feldman showed a strong delayed hypersensitivity reaction in the guinea pigs, indicating an immunological response to BCG [2]. In 1976, Morales et al. [3] were the first to use intravesical installations of BCG for superficial bladder cancer. Now, after 22 years, BCG is widely used in the treatment of carcinoma in-situ (CIS) and residual tumor after endoscopic resection (therapeutic use), and after complete endoscopic resection to prevent tumor recurrences and/or progression (prophylactic use) [4].
Effector mechanisms of BCG in cancer Although the clinical use of BCG has gained wide spread acceptance, the mechanism of action has not been completely understood. Studies in animals have suggested that BCG activates the host’s immunologic system and immunocompetence may be necessary for therapeutic effect to be achieved [5,6]. Attachment of BCG to the bladder wall via fibronectin (FN) has been shown to be an important step in initiating its antitumorigenic activity [7].A major 30-32 kDa. protein antigen from Mycobacterium Bovis Intravesical BCG 131
BCG, the so-called antigen 85 complex, is known to bind specifically to the collagen binding region of FN [8]. Antigen 85 is an immunodominant protein complex, associated with protective T cells in tuberculosis and leprosy, and a powerful IL-2 and IFN-y inducer [9]. Hudson et al. found that inhibitors of fibrin clot formation decreased the efficiency of intravesical BCG therapy in patients with superficial bladder cancer. They indicated that the attachment to FN could be decreased by fibrin clot inhibitors. Two possible explanations for these results were proposed. Firstly, fibrin clot inhibitors might have an adverse effect on binding of BCG to FN and thereby inhibit the effect of BCG; second, aspirin-like drugs have anti inflammatory effects [10]. However, in another study these adverse effects of fibrin clot inhibitors could not be confirmed [11]. The mechanism(s) by which BCG mediates the immunological system require lymphokine-activeted killer cells, BCG activated killer cells, T lymphocytes (CD4 helper cells and CD8 suppresser/cytotoxic cells) and monocytes [12,13]. Several immunological effects of BCG have been described: a significant increase in T cell infiltration of the lamina propria has been reported and shown to persist for at least 3 months following treatment [14]. This T cell infiltrate contains immunologically active CD4 and CD8 cells. This effect may result in increased tumor cell-killing activity by cytotoxic T cells and various macrophages [14,15]. Ratliff et al. also showed that both CD4 and CD8 T cells are necessary for the anti-tumor Intravesical BCG 132 effect of BCG [16]. BCG induces the expression of the MHC class II antigen by normal and malignant cells [17]. This antigen interacts with the CD4 T cell and is mandatory for the process of antigen presentation. It has been proposed that, following the induction of the MHC class II antigen, the bladder cancer cells perform an antigen-presenting function and presents the BCG antigen to the CD4 T cells [15,17]. CD4 cells activated in this way produce IL-2, IFN-y and TNF. In a prospective study, the urine of patients receiving BCG therapy for superficial bladder cancer was examined before and after treatment [18]; there was a significant increase in the levels of IL- 1, IL-2 and TNF. These findings suggest that LAK cells may be involved in BCG-mediated antitumor effects. IFN-y appears to have a pivotal role as a powerful immunomodilatory and macrophage-activating cytokine and inhibits the in vitro growth of human bladder cancer cells [19-21]. The role of IFN-y in the overexpression of MHC II molecules on the urethelial cells has been confirmed again by Jackson et al. [22], who showed that the increased expression of these molecules induced by urine after BCG treatment was neutralised by polyclonal antibodies to IFN-y. Moreover several studies suggest that IFN-y is strongly linked to the T-cell mediated response to BCG. In humans, Thanshauser et al. [23] showed that monoclonal antibodies neutralising IFN-y can inhibit the BCG-mediated activation of LAK cells. Intravesical BCG 133
Different parameters of immune response can be monitored during intravesical BCG therapy; when treating superficial bladder cancer with BCG, urethelial cells are exposed to BCG mycobacteria. In vitro, this situation has been shown to up-regulate cytokines synthesis by human bladder tumor cells [24,25]; some of these in vitro observations seem to be analogous to observations in vivo [25-27], supporting the therapy that urethelial cells may contribute to the modulation of BCG induced immunoreaction that is important for antitumor activity [28]. Urinary cytokine induction is an additional aspect of the BCG-induced immunological cascade. IFN-y can only be detected in urine dialysed immediately, TNF-a is unstable at 40 C and 200 C, and IL-1ß and TNF-a determinations are influenced by the presence of cellular material in the urine collection, IL-2 and IL-6 could be the cytokines of choice for routine monitoring during intravesical BCG installations [29,30]
Viability, dose, appropriate strain The efficacy of a BCG vaccine depends on several factors, of which the two most important are the ability of the organisms to multiply in vivo, i.e. viability, which is different in the available strains, and the number of bacilli used in each vial, i.e. the dose. Different strains of BCG and different samples of BCG of the same strain have different numbers of colony forming units (c.f.u.). For example, in the Pasteur BCG strain (Institute Intravesical BCG 134
Armand Frappier, Quebec, Canada) for example the number of c.f.u. varied from 6X106-8 till 1X1012 per ampule. There is a relation between viability and treatment results: patient treated with 6X106-8 per ampule had recurrent tumors in 71%, while patients treated with 3X1011 CFU per ampule showed recurrences in 25% [31]. Storage of BCG at the correct temperature is critical for the survival of mycobacteria. Generous use of lubricants to assist catheterization during intravesical BCG therapy will result in a clinically significant decrease in the number of intravesically instilled viable mycobacteria. Thus, during intravesical immunotherapy with BCG only small amounts of lubricants should be used for urethral catheterization, and use of catheters not requiring lubricants should be considered [32]. The effect of distilled water on exfoliated cells from transitional bladder carcinoma was compared to the effect of BCG dissolved in either saline or distilled water. Distilled water proved to be as effective as BCG in distilled water and much more destructive on cells than BCG in saline within 2 hour [33]. Until now 12 strains of BCG have been used in immunotherapy of superficial bladder cancer Pasteur (Quebec, Canada), Tice (Chicago, USA), Connaught (Toronto, Canada), Pasteur (Paris, France), Glaxo (Greenford, England), Moreu (San Paulo, Brazil), RIVM (Bilthoven, The Netherlands), Tokyo 172 (Tokyo,Japan), Evans (Glaxo, Danish strain), Berna (Italy), Taipei-NIMP (Taiwan, China) and a Russian strain. Studies to compare Intravesical BCG 135 different strains have been done. A prospective randomised multicentre study showed that there is no difference in side effects or efficiency between BCG-TICE and BCG-RIVM [34,35]. Mujkhere et al. studied the Glaxo and Pasteur strain of BCG and also found no difference in efficiency [36]. In another study, Evans BCG and Pasteur BCG were compared to investigate the complete regression of lesions in 97 patients with multiple recurrent Ta, T1 tumors and again no significant statistically difference was found [37]. The culturing methods also differ, resulting in variable ratio of viable organisms on one hand and subcelluler debris and dead bacilli on the other hand. Since we do not know which parts of bacilli are responsible for the immunologic effects, this ratio might also be important, although Hanna demonstrated that BCG components were not effective substitutes for whole viable BCG cells to achieve systemic tumor immunity [38]. In another study, the antitumor effect of intravesical mycobacterium cell wall (MCW) therapy on orthotopic and heterotopic bladder tumors in the mouse was assessed with MRI [39]. Treatment with MCW resulted in significant inhibition of tumor growth compared with untreated animals (p<0.005) although the antitumor effect was less pronounced than that of live BCG. Flow cytometric analysis of bladder washings with phenotype-specific monoclonal antibodies revealed predominantly a CD3 T cell infiltrate in the control and BCG-treated as well as the subset in both the BCG- and MCW- treated animals, and the CD4/CD8 ratio in both of the treated groups Intravesical BCG 136 differed significantly from that of the control untreated groups. Intravesical MCW appears to invoke a similar inflammatory response in the mouse bladder mucosa as the live BCG organism and retains an antitumor action. Zolatta et al. pointed out that the antigen 85 complex secreted in BCG culture filtrate binds specifically to fibronectin and is a powerful T cell stimulus [40]. A major increase in the lymphoproliferative response against purified protein derivative, antigen 85, BCG culture filtrate, whole BCG and pokeweed mitogen was observed in 69.0, 65.5, 79.3, 48.3 and 65.3% of the patients, respectively, analysed after BCG therapy. No correlation could be found between the immunological response against any of the BCG antigens and the clinical evolution of the response. Intravesical BCG installations induce a transient (less than 6 months) peripheral immune activation against several purified BCG antigens and among them the fibronectin binding antigen 85 complex. 2)The number of colony forming units in the preparation of a BCG strain is more important than the dry weight of the preparation. Although the antitumor activity increases with the dose, there seems to be an optimal dose of 5X108-5X109 CFU. A higher dose results in decreasing antitumor activity. Several studies with lower dose BCG therapy have been carried out recently. The results of the first large trail using a low dose regimen (BCG Pasteur, 75 mg) in the prophylaxis of tumor recurrences after transurethral Intravesical BCG 137 resection (TUR) of papillary tumors and in the therapy of CIS were published in 1991 by Pagano et al [41]. Overall, 70 patients were completely treated with a TUR and BCG, 63 were in the control group and 56 in the therapy group (CIS). In the prophylaxis, control and therapy groups, 74, 17, and 57% of patients, respectively, achieved complete responses (CR), all with a mean follow-up of 21 months. Tumor progression subsequently occurred in 4% of patients in prophylaxis group, 17% of the control group (p<0.001) and 12.5% of therapy group. The patients who underwent an additional course, 69% of the prophylaxis group and 50% of the therapy group achieved a CR. They concluded that the 75 mg regimen was as effective as the 150 mg regimen in preventing recurrent superficial transitional cell carcinoma (TCC) of the bladder and in treating CIS. In a subsequent phase III trial, Pagano et al. randomised patients with multiple papillary tumors (Ta-T1 stages) and CIS to receive 75 or 150 mg Pasteur BCG during 6 weeks [42]. The time-to-failure curves showed a disease-free interval significantly higher in the low dose group compared with the standard-dose group. Similar tumor progression rates were reported in both groups (9%). Morales et al reported on small number patients with Tis and T1 plus Tis, and concluded that these tumors can only be treated effectively with a higher dose BCG-Pasteur (120 mg) [43]. Mack and Frick pointed out that the low dose (27 mg) BCG-Connaught Canada regimen was effective in the treatment of high risk superficial TCC of the bladder in a phase II study Intravesical BCG 138
[44]. Complete responses were similar to those achieved with higher doses of BCG. In a study by the CUETO group, 27 mg and 81 mg BCG Connaught were compared in a schedule contemplating 6 weekly installations followed by 6 fortnightly installations. The primary results showed that there is no significance difference in overall reccurence rates (22.3 vs. 19.6 %) and progression (4.7 vs. 2.9 %) between the two groups. Moreover, when making distinction between the different T categories, a trend towards poorer efficacy (although not statistically significant) of the low dose was observed in CIS (replacing rate 11.7 % vs. 31.2 % for low dose), in the overall progression rate (1.5 % in the standard-dose arm vs. 4.3% in the low-dose arm) and in particular in T1 G3 tumor progression rate (4 vs. 18%) [45,46]. In all these dose reduction studies, the toxicity was significantly reduced in the low dose group.
Route of administration There are 5 routes of administration which have been used for BCG in the treatment of superficial bladder cancer: i) Percutaneus administration: Many variables in patient selection and treatment program made it impossible to estimate the value of this route of administration, although antitumor effect was observed [47,48]; ii) Intralesional administration: This has been abolished due to serious hypersensitivity reactions and allergic shock [47,48]; iii) Oral administration: It was studied by Netto and Lemos in 1984. Intravesical BCG 139
They found a complete response of 70% [49]. Others could not confirm these results. Lamm found no measurable antitumor effect of oral BCG in the treatment of superficial tumors comparing oral versus intravesical and percutaneus administration [50]; iv) Intravesical installations plus percutaneus inoculation: With this regime Morales found complete response in 50% of the patients using BCG as a prophylactic therapy, in 58% of the patients with residual disease, and in 77% of the patients with CIS [51]. Other investigators found similar results; v) currently, intravesical administration of BCG alone is accepted in most centres to be the best route of administration, as percutaneous administration does not increase treatment efficacy in three prospective randomised studies [52-54]. The significance of the PPD test is borderline, and should not be used as a prognostic marker in individual patients [55].
Clinical schedules The BCG treatment schedule is initially arbitrary and controversy exists with regard to the optimal treatment protocol. A variety of different BCG treatment regimens have been used that vary in intensity from one weekly instillations for 6 consecutive weeks to 24 weekly installations followed by instillations bimonthly for 3 months and than monthly for 18 months [56,57]. Most urologists use at least an induction course of 6 consecutive weekly BCG instillations, as first proposed by Morales [57]. The efficacy of Intravesical BCG 140 the 6-week course of BCG has been widely reported in the literature. The 6- week course resulted in tumor-free rates of 63 to 100% after one year and 55 to 75% after two years, and in an average time to recurrence of 10 to 22.5 months [58-62]. One course of 6 instillations, however, might not be optimal. When patients fail this course two different schemes can be followed. Brosman advocated maintenance therapy [63]; this regimen consisted of intravesical instillations once weekly for 6 weeks, biweekly for 3 months, and than monthly until recurrence or a maximum of two years. He found better response rates than in a 6 week course. On the other hand Badalament and Hudson found no significant difference in the reduction of recurrent tumors between a 6-week course and maintenance therapy [64,65]. The SWOG compared a 6-week induction course to maintenance therapy consisting of 3 weekly BCG instillations at 3 months, 6 months and every 6 months up to 3 years [66]. They demonstrated a significant superiority of maintenance therapy, not only in patients with rapidly recurring Ta/T1 lesions (p=0.000001) but also in patients with CIS (p=0.04). More importantly, the maintenance therapy has significantly improved the patients’ survival compared to induction only (92 vs. 86% at 4 years, p<0.04). In another study, a 6 and 12-week course with 120 mg Pasteur were compared for the treatment of high-risk superficial bladder cancer [67]. A 70% tumor-free rate and mean interval of 12.9 months to recurrence Intravesical BCG 141 were achieved in the 12 week course compared to 55% and 12.3 months, respectively, in the 6 week course with the 12 week course patients had an overall longer disease-free survival, although not statistically significant. The results showed that the longer BCG course had better overall results. A prospective study by a Chilean group reported the same efficacy of 5 different dose and treatment schedules; 6 weekly instillation with 120 mg BCG, 100 mg weekly during 2 months, 50 mg monthly during 12 months, 20 mg during 12 months, or 1 mg monthly during 12 months [68]. The local and systemic toxicity of the maintenance therapy, however, is more severe and significantly worse than in other protocols [69]. The second possibility for additional treatment is a second 6-week course in patients failing the first course. The response rates could be improved from approximately 60% after one 6 week course to approximately 80% after a second course without the severe toxicity of the maintenance therapy [70,71]. Khana also found that therapy beyond an initial course of 6 weekly instillations increased the percentage of complete responses [72]. He reviewed 13 other studies and found that the greatest improvement in percentage of complete responses occurred with the second course of treatment. Therefore, a second course of BCG seems most useful in patients who have sustained response to the initial treatment. The value of an additional 6-week course in patients who recur after this first course was also demonstrated by Sarosdy and Lamm, who studied the long term results Intravesical BCG 142 of BCG therapy [73]. With retreatment of some of the early failures the initial success rate of 78% was increased to 89%, with a median follow up 5 years, suggesting a durable beneficial response after BCG therapy rather than a simple delay of tumor recurrence. The re-treatment consisted of a second course, followed by maintenance therapy. Coplen et al. reported their long term follow up and concluded that one 6-week course may be ineffective for some patients, and a second 6-week course provided long term tumor free survival for many patients failing the initial course [74]. However, in CIS patients failing both courses a significantly higher risk for muscle invasion was found. This potential danger of repeated BCG courses was also found by Catalona et al., who performed a risk to benefit analysis of repeated courses of intravesical BCG [70]. They found that the risk of developing invasive cancer or metastasis in patients who failed 2 courses of intravesical BCG (respectively 30% and 50%) exceeded the prospects of eradicating the superficial tumor with further BCG treatment. In conclusion, more than 2 courses might be dangerous with regard to disease progression. Some studies have tried to tailor BCG therapy by means of cytokine measurement or p53 determination during therapy.de Reijke et al. showed evidence for a correlation between urinary cytokine induction and clinical response following intravesical BCG therapy for superficial bladder cancer [30]. BCG induced cytokine levels were generally highest after instillation week 5 or 6. During the first 24 hours after BCG instillation the highest Intravesical BCG 143 concentrations were most frequently observed at 4 or 6 hours after instillation. A significant correlation between urinary IL-2 level and tumor recurrence was found (p=0.003) at six months. If the threshold for recurrence was set at 9 or 12 months instead of 6 months the significance of correlation for IL-2 was lost (p=0.090 and p=0.089 respectively). They pointed out that especially, monitoring of IL-2 may potentially be of prognostic value provided that strict precautions regarding urine collection, such as maximal 2-hour sampling and immediate cooling are taken. p53 overexpression is predictive of TCC progression and survival. The detection nuclear p53 over-expression before BCG therapy does not predict response to BCG therapy. Pre-BCG p53 protein overexpression, response to BCG therapy, and pre BCG tumor stage are all independent markers of disease progression. In patients with residual disease after BCG therapy (nonresponders), studies confirmed that posttherapy p53 overexpression was the only independent marker of disease progression [75,76].
Toxicity Side effects after intravesical installations with BCG can be divided in local side effects, allergic reactions and systemic side effects. In a review 1278 patients treated with BCG, cystitis-like complaints were found in over 90% of the patients [77]. These complications increase with the number of installations, but are easily treated with non-steroidal anti-inflammatory Intravesical BCG 144 drugs. Hematuria is seen in 43% of the patients but is seldom severe. Systemic side effects such as fever (28%), malaise (24%), and nausea (8%) generally subside spontaneously. Severe side effects are seen in about 5% of all patients with fever >39.5 C (2.9%), genital infections (1.3%) and hematuria (1.0%) as main problems. However, also serious BCG induced infections were seen such as BCG pneumonia/hepatitis in 0.7% and BCG sepsis in 0.4% [78]. In case of severe irritative bladder symptoms, fever, chills, or malaise, the dose should be lowered to half the initial dose, and patients should be treated with isoniazid 300 mg daily starting on the day before instillation and continue for 3 days or until symptoms resolve [78,79]. In case of severe systemic side effects the treatment with BCG should not be continued, and antituberculosis combination therapy should be given for 3 months (isoniazid 300 mg orally per day, rifampicin 600 mg orally per day, ethambutol 1200 mg orally per day). Prednisolone 40 mg per day can be added to triple tuberculostatics in case of life-threatening BCG reactions [80,81]. In case of acute problems cycloserine (250-500 mg orally twice a day) could be given for the first 3-5 days, because it is effective several days before the classical combination therapy is [81]. Sparks indicated that antituberculous drugs do not seem to interfere with anti-tumor effect of BCG in animal studies [82]. van der Meijden et al. showed that there is a possible inhibition of antitumor efficacy by antibiotics in general, and Intravesical BCG 145 tuberculostatic agents in particular [83]. They reported the sensitivity of different BCG strains for all known antituberculosis drugs. No difference between strains was found, and all were very sensitive to these drugs. In a prospective randomised multicenter study the side effects of intravesical BCG instillations with or without isoniazid were compared in patients with stage pTa and pT1 bladder tumors [84]. Isoniazid was given orally in a dose of 300 mg daily at every instillation in an attempt to decrease the side effects of BCG. No differences in local or systemic adverse reactions after intravesical BCG instillations could be observed between patients treated with or without prophylactic isoniazid therapy. However, analysis of liver function tests after BCG with isoniazid showed slightly more liver toxicity compared to BCG alone. They concluded that prophylactic administration of isoniazid during BCG instillations provides no decrease in any known side effect of BCG. Therefore, the use of prophylactic isoniazid in patients treated with BCG is not recommended. Traumatic catherization seems to play a role in most of the fatal complications. Therefore, it is strongly recommended that if trauma during catheterization occurs, the treatment is postponed for one week [85]. A study to analyse quality of life in patients undergoing BCG therapy showed that in general, the quality of life of these patients is characterised by the disruption of their lifestyle and marked by change in their circumstances [86]. It was pointed out that it is the Intravesical BCG 146 responsibility of the urologist to take the necessary time to educate, comfort and motivate these patients.
Clinical results Three different applications have been described in the treatment of TCC of the bladder with BCG; prophylaxis after a complete TUR, treatment of CIS and treatment of residual tumor. Endoscopic resection remains the first choice therapy for bladder tumors. Approximately 60% of endoscopically resected superficial bladder tumors, however, recur, usually within the first years [69]. In prophylaxis BCG is used to post-pone or prevent recurrences and/or progression. The success rate of BCG treatment is between 58% and 100%, with a minimal follow-up of one year [69,87,88]. BCG is generally accepted as the drug with higher efficacy than chemotherapy when used intravesically for therapy in superficial bladder tumors. For thiotepa and doxorubicin this seems obvious, because all direct comparisons showed an advantage of BCG [89]. Since intravesical chemotherapy, however, has less and less severe side effects, this remains a possible interesting approach. Moreover, direct comparison of BCG and mitomycin C (MMC) did not show a clear advantage of BCG in all studies. Some studies indeed show an advantage of BCG over MMC, while others could not confirm these differences. Intravesical BCG 147
Lundholm et al. studied intravesical therapy with MMC and BCG in 261 high risk patients [90]. Both MMC (40 mg) or BCG Pasteur were given for up to 3 years. After a median follow up of 39 months 49% in the BCG group were free disease, as compared to 34% in the MMC group. In Tis patients this difference was even larger (54% versus 33%). The progression rate (13%) was similar in both groups. Side effects were, as expected, more severe and more frequent in BCG group. In a study of the Finnbladder group BCG also appeared to be superior to MMC [91]. In this randomised prospective multicentric study frequently recurrent Ta-T1 tumors were treated. CR rate, disease free interval and recurrence rate were in favour of BCG. In CIS, however, MMC was more effective (58% CR versus 40% with BCG). Side effects were more severe in the BCG group. A third study indicating superiority of BCG was SWOG study 8795, which was closed early because of a highly significant difference [92]. In all, 469 patients were selected with an increased risk for recurrent disease. BCG Tice or MMC (20 mg) were given 6 times weekly and monthly thereafter for 1 year. In 377 evaluable patients the number of recurrences was significantly better in the BCG group (37/190 versus 61/187, p:0.0052), as was the time to treatment failure (p=0.006). Grade 1 and 2 toxicity was significant higher in the BCG group (74% versus 57%, p<0.001). Grade 3 and 4 toxicity was similar in both treatment arms. Intravesical BCG 148
Other studies, however, failed to confirm a higher efficacy of BCG, for example, in a large German multricentre trail adjuvant MMC or BCG were compared with TUR only [93]. Patients pTa grade 1 were excluded. MMC (20 mg) was given two-weekly for 1 year, and monthly during the second year. BCG (120 mg) was given 6 times weekly and 4 times monthly. At a median follow up of 20 months in 337 evaluable patients the relative risk for recurrences in the BCG group was 0.618 and 0.508 in the MMC group (not statistically significant). The progression rate was estimated at 4.2% per year, and comparable in all three groups. Side effects were common in the BCG group. Witjes et al evaluated 437 patients with primary or recurrent pTa and pT1 bladder tumors, including carcinoma in situ [34]. The number of low risk patients (e.g. primary solitary pTa grade 1) was less than 10%. The median follow up was 36 months. MMC (30 mg) was given 4 times weekly and 5 times monthly, BCG (5X108 CFU Tice BCG or RIVM-BCG) was given 6 times weekly. Again toxicity was significantly more frequent and more severe in the BCG treated patients. Efficacy with regard to recurrence in papillary tumors was the same for MMC and RIVM-BCG (p=0.53), but MMC was more effective than BCG-Tice therapy (p=0.01). There was no significant difference in efficacy when both BCG strains were compared. Results in CIS patients and the progression rate in all patients was similar for the three treatment arms, but numbers are small. In another study the long term follow up of intravesical BCG-RIVM and MMC was Intravesical BCG 149 compared in a randomised prospective trial in 344 patients [35]. This study showed similar efficacy of BCG and MMC. Although MMC seems more effective in the prevention of progression in non CIS patients (5/157 versus 17/147, p=0.006) these numbers are again small. BCG also has been compared with other immunomodulators. Jimenez Cruz et al. enrolled 122 patients with recurrent T1G3 tumors in prospective multicentric trial who were randomised to receive either 150 mg Pasteur BCG or 54 million units a-2a-IFN intravesically [94]. The incidence of recurrences was 39.3% for BCG and 69.3% for IFN with a disease free interval of 19.3 and 15.2 months respectively. The recurrence index was 2.2 for BCG and 5.5 for IFN (p=0.001). In another study the combination of BCG and a-2b-IFN showed that this combination therapy is safe and well tolerated [95]. Early results in a limited patient group showed high response rate. In a randomised comparison of BCG and keyhole-limpet haemocyanin (KLH), tumor recurrence was 41% in KLH treated patients versus 14% in BCG treated patients [96]. CIS, a preinvasive highly aggressive malignancy, is a difficult disease to control. Patients can either have CIS as a primary disease, or have a papillary tumor with concomitant CIS. The efficacy of three chemotherapeutic agents has been defined in clinical trails: Thiotepa has an overall complete response rate of 29%, doxorubicin of 38% and MMC of 48% [97]. With BCG encouraging results have been described with success Intravesical BCG 150 rates between 42% and 83% after minimal follow up of one year. De Jager et al. published long term results in CIS patients from 6 phase II trails [98]. 119 patients were treated with 6 weekly Tice BCG instillations, followed by 12 monthly instillations. In all, 90 (75.6%) patients achieved a CR, including 45 of 63 patients who failed prior intravesical chemotherapy. 45 of the responding patients remained free of disease after a median follow up of>48 months. Cystectomy rate in the non-responders was significantly higher, time to cystectomy significantly shorter. However, there was no difference in survival between BCG responders and non responders. They concluded that Tice BCG is effective for CIS, with or without prior chemotherapy. Harland et al also found “impressive” responses in 53 CIS patients after BCG therapy (53% CR after median follow up of 32 months) [99]. In the group of responders disease progression occurred in 10% of patients, whereas in non responding patients progression was seen in 48%. They also concluded that CIS could be successfully treated with intravesical BCG, but it remains a dangerous disease. Akaza et al. treated 157 patients with papillary bladder tumor and CIS with Tokyo 172 BCG strain, 80 mg weekly for eight times [100]. The efficacy was a CR rate of 84.4% and partial response (PR) of 6.3% for 32 patients with CIS. In another study a total of 115 patients with CIS of the bladder were treated with BCG Pasteur F. 25 patients had primary CIS and 90 had secondary CIS with synchronous or prior superficial papillary tumors [101]. 22 of the 25 patients (88%) with Intravesical BCG 151 primary CIS responded completely, with negative cytology and cystoscopy findings after a median follow up period of 44 months. 3 of the 25 (12%) had cytological evidence of disease within 9 months of therapy and were considered to be early treatment failures. 70 of 90 patients (78%) with secondary CIS had a CR after treatment with BCG, with repeated negative cytology and cystoscopy examinations after a median follow up of 40 months. 20 of the 90 (22%) with secondary CIS had a positive cytology within 9 months after BCG therapy and were considered early treatment failures. 15 of the 20 failures received a second course of BCG. 4 of these patients responded and the remaining 11 also failed the second course. Including two patients with T1G3 bladder cancers, four with invasive bladder cancer, two with solid urothelial carcinomas of the prostatic urethra, and three with Tis of upper urinary tract. According to these data, early treatment failure after 6 weekly instillations is an alarming signal which requires immediate re-assessment of the patient to exclude a muscle invasive bladder cancer or extravesical CIS, either in upper the urinary tract or in the prostatic urethra. The presence of CIS in the prostatic urethra can be managed with endovesical BCG as initial treatment with fairly good success (70-100%) [102-104]. There is no need for TUR, even though a loop biopsy may have to be obtained at the first control examination to make sure there is no stromal invasion [102]. Intravesical BCG 152
BCG also can be used to eliminate residual tumor after an incomplete endoscopic resection or in patients who are unfit for surgery. The number of tumors seems of no consequence as long as they are small and accessible to the action of BCG. Success rates of approximately 60-70% were found [105,106]. Intravesical BCG therapy for the treatment of muscle invasive transitional cell carcinoma of the bladder is ineffective [107]. BCG is not indicated for low and intermediate risk patients, in whom chemotherapy is the first choice because of less frequent and less severe side effects. BCG is also contraindicated in patients with invasive bladder carcinoma =T2, in immunocompromised subjects such as HIV-positive patients, those with congenital immunodeficiency syndromes or patients undergoing immunosuppresive treatment, in patients harbouring other progressive malignancies, leukaemia or Hodgkin’s disease, in patients with active tuberculosis and in pregnant and/or lactating women [108]. Based on several trails reported by the EORTC Genitourinary Group, the following conclusions can be drawn [109]; 1) in patients with a low and intermediate risk for recurrence MMC and BCG are equieffective in preventing recurrence [110,111], whereas in patients with high risk for recurrence (concomitant CIS, T1 lesion, =3 recurrence/year) BCG is superior to either MMC or doxorubicin [92,112]; 2) primary treatment of CIS is best performed with BCG [113]; a maintenance schedule is superior to a single week course [114]; BCG can be successful as second line Intravesical BCG 153 treatment after intravesical chemotherapy has failed to achieve complete tumor response [109].
Summary and conclusions
The mechanisms by which BCG exerts its antitumor activity remain unclear. Attachment of BCG to the bladder via FN has been demonstrated as an important step in initiating its antitumorigenic activity. The mechanism(s) by which BCG operates require LAK cells, BCG activated killer cells, T lymphocytes (CD4 helper cells and CD8 suppresser/cytotoxic cells) and monocytes. The optimal route of administration is the intravesical. The efficacy of a BCG vaccine depends on the viability, dose and strain. Differences in efficacy and side effects have not been shown between different strains. Low-dose regimens give successfully protect from recurrences, with fewer side effects. The initial schedule of BCG is a course of 6 instillations in 6 weeks; when the patients fail this course, two possibilities arise. The first is maintenance therapy; response rates improve but there is more local and systemic toxicity. The second is a further 6-week course, and this seems most useful in those with a sustained response to the initial treatment. The clinical response to BCG therapy can be monitored using cytokine measurement or p53 determination. Toxicity remains a major problem in BCG treatment and triple antituberculosis combination therapy should be given for 3 months in those with severe systemic side effects. The Intravesical BCG 154 use of prophylactic isoniazid is not recommend to decrease side effects. The clinical results of BCG have been good, with success rates of 58-100%, with a minimal follow-up of one year in prophylaxis. BCG seems superior to intravesical therapy, but at the cost of inducing more adverse effects. BCG is not indicated for low- and intermediate-risk patients, in whom chemotherapy is the first choice. BCG can also be used to eliminate tumor after an incomplete TUR, or in patients who are unfit for surgery with a 60 70% success rate. The primary and best treatment for CIS is intravesical BCG; encouraging results have been reported, with success rates of 42- 83% after a minimal follow up of one year. Although currently BCG seems to be the choice for high risk superficial TCC, many questions remain unanswered, especially about the mechanism(s) of action, the optimal dose and clinical schedule.
References
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47. Martinez-Pineiro JA, Muntanola P. Non-specific immunotherapy with BCG vaccine in bladder tumors. A preliminary report. Eur Urol 1977; 3:11-22 48. Martinez-Pineiro JA. BCG vaccine in superficial bladder tumors: eight years later. Eur Urol 1984; 10:93 49. Netto NR jr, Lemos GC. Bacillus Calmette-Guerin immunothrepay of infiltrating bladder cancer. J Urol 1984; 132:675 50. Lamm DL, DeHaven JI, Shriver J, Crispen R, Grau D, Sarosdy MF. A randomised prospective comparison of oral versus intravesical and percutaneus bacillus Calmette-Guerin for superficial cancer. J Urol 1990; 144:65-7 51. Morales A, Nickel JG. Immunotherapy of superficial bladder cancer with BCG. World J Urol 1986; 3:209-14 52. Lamm DL, deHaven JI, Shriver J, Sarosdy MF. Prospective randomised comparison of intravesical with percutaneus bacillus Calmette-Guerin versus intravesical bacillus Calmette-Guerin in superficial bladder cancer. J Urol 1991; 145:738-40 53. Witjes JA, Fransen MPH, van der Meijden, Doesburg WH, Debruyne FMJ. Use of maintenance intravesical bacillus Calmmete-Guerin (BCG), with or without intradermal BCG, in patients with recurrent superficial bladder cancer. Long-term follow-up of a randomised phase 2 study. Urol Int 1993; 51:67-72 54. Luftenegger W, Ackermann DK, Futterlieb A, Kraft R, Minder CE, Nadelhaft P et al. Intravesical versus intravesical plus intradermal bacillus Callmette-Guerin: a prospective randomised study in patients with recurrent superficial bladder tumors.J Urol 1996;155:483-7 55. Torrence RJ, Kavoussi LR, Catalona WJ, Ratliff TL. Prognostic factors in patients treated with intravesical bacillus Calmette-Guerin for superficial bladder cancer. J Urol 1988; 139:941-56-Brosman SA. The use of bacillus Calmette-Guerin in the therapy of the bladder carcinoma in-situ. J Urol 1985; 134:36-42 56. Morales A, Edinger D, Bruce AW. Intracavitery bacillus Calmette- Guerin in the treatment superficial tumors. J Urol 1976; 116:180-3 57. Brosman SA. Bacillus Calmette-Guerin immuno therapy : techniques and results. Urol Clin N Am 1992; 19:557-62 58. Haaf EO, Dresner SM, Ratliff TL, Catalona WJ. Two courses of intravesical Bacillus Calmette-Guerin for transitional cell carcinoma of the bladder. J Urol 1986; 136:820-5 Intravesical BCG 160
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72. Sarosdy MF, Lamm DL. Long term results bacillus Calmette-Guerin therapy for superficial bladder cancer. J Urol 1989; 142:719-22 73. Coplen DE, Marcus MD, Myers JA, Ratliff TL, Catalona WJ. Long term follow up of patients treated with 1 or 2 6-week course of intravesical bacillus Calmette-Guerin : analysis of possible predictors of response of free tumor. J Urol 1990; 144:652-7 74. Caliskan M, Turkeri LN, Mansuroglu B, Toktas G, Aksoy B, Unluer E, et al. Nuclear accumulation of mutant p53 protein: a possible predictor of failure of intravesical therapy in bladder cancer. Br J Urol 1997; 79(3):373-7 75. Lacombe L, Dalbagni G, Zhang ZF, Cordon-Cardo C, Fair WR, Herr HW, et al. Overexpression of p53 protein in a high risk population of patients with superficial bladder cancer before and after bacillus Calmette-Guerin therapy: correlation to clinical out-come. J Clin Oncol 1996; 14(10):2646-52. 76. Lamm DL, Stogdill VD, Stogdill BJ, et al. Complications of bacillus Calmette-Guerin immunotherapy in 1278 patients with bladder cancer. J Urol 1986;135:272-5 77. Lamm DL. Complications of bacillus Calmette-Guerin immunotherapy. Review of 2602 patients and comparison of chemotherapy complications. In: Debruyne FMJ, Deis L, vd Meijden APM (eds): EORTC Genito-Urinary Group Monograph 6:BCG in superficial bladder cancer. New York: Alan R Liss Inc., 1989:335-355 78. vd Meijden APM. Practical approaches to the prevention and treatment of adverse reactions to BCG. Eur Urol 1995; 27 (suppl 1):23-8 79. Lamm DL, vd Meijden APM, Morales A, Brosman SA, Catalona WJ, Herr HW, et al. Incidence and treatment of complications of bacillus Calmette-Guerin intravesical therapy in superficial bladder cancer. J Urol 1992; 147:596-600 80. De Haven JI, Traynellis C, Riggs DR, Ting E, Lamm DL. Antibiotic and steroid therapy of massive systemic bacillus Calmette-Guerin toxicity. J Urol 1992;147:738-42 81. Sparks FC. Hazards and complications BCG immunotherapy. Med Clin N Am 1976; 60:499-506 82. vd Meijden APM, van Klingeren B, Steerenberg PA, De Boer EC, De Jong WH, Debruyne FMJ. The possible influence of antibiotics and tuberculostatics on result of bacillus Calmette-Guerin intravesical therapy for superficial bladder cancer. J Urol 1991; 146:444-6 Intravesical BCG 162
83. Vegt PDJ, vd Meijden APM, Sylvester R, Brausi M, Holth W, de Balincourt C and Members of the EORTC of Cancer Genito-Urinary Group. Does isoniazid reduce side effects of intravesical bacillus Calmette-Guerin therapy in superficial bladder cancer? Interim results of European organisation for research and treatment of cancer protocol 30911. J Urol 1997;157:1246-49 84. Rawls WH, Lamm DL, Lowe BA, Crawford ED, Sarosdy MF, Montie JE, et al. Fatal sepsis following intravesical bacillus Calmette-Guerin administration for bladder cancer. J Urol 1990; 144:1328-30 85. Mack D, Frick J. Quality of life in patients undergoing bacillus Calmette-Guerin therapy for superficial bladder cancer. Br J Urol 1996; 78:369-71 86. Heney N, Ahmed S, Flanagan MJ. Superficial bladder cancer: progression and recurrence. J Urol 1983; 130:1083-6 87. Brosmann SA, Lamm DL, vd Meijden APM. A practical guide to the use of intravesical BCG for management of stage Ta, T1, CIS, transitional cell cancer. In: EORTC Genitourinary Group Monograph 6: BCG in superficial cancer. Debruyne FMJ, vd Meijden APM (eds). New York, Alan R Liss Inc, 1989;311-23 88. Lamm DL. Long term results of intravesical therapy for superficial bladder cancer. Urol Clin North Am 1992;19:573-80 89. Lundholm C, Norlen BJ, Ekman P, Jahnson P, Lagerkvist M, Lindeborg T, et al. A randomised prospective study comparing long term intravesical instillations of mitomycin C and bacillus Calmette- Guerin in patients with superficial bladder carcinoma. J Urol 1996; 156:372-6 90. Rintala E, Jauhiainen K, Alfthan O, Hansson E, Juusela h, Kanerva K, et al. Intravesical chemotherapy (mitomycine C) versus immunotherapy (bacillus Calmette-Guerin) in superficial bladder cancer. Eur Urol 1991;20:19-25 91. Lamm DL, Crawford ED, Blumenstain B, Crissman J, de Vere White R, Wolf M, et al. SWOG 8795: a randomised comparison of bacillus Calmette-Guerin and MMC prophylaxis in stage Ta and T1 transitional cell carcinoma of the bladder. J Urol 1993; 149:282A, abstract 275 92. Krege S, Otto T, Rubben H, Meyer R, Gianni G. Final report on a randomised multricentre trial on adjuvant therapy in superficial bladder cancer. TUR only vs TUR+mitomycin C vs TUR+ bacillus Calmette- Guerin. J Urol 1996; 155:494A, abst. 734 Intravesical BCG 163
93. Jimenez Cruz JF, Vera-Donoso CD, Leiva O, Pamplona m, Rioja LA, Martinez Lasierra M, et al. Intravesical immunoprophylaxis in recurrent bladder cancer (T1): Multicentric trial comparing BCG and alpha Interferon. Urology 1997,in press. 94. Stricker P, Pryor K, Nicholson T, Goldstein D, Golovsky D, Ferguson R, et al. bacillus Calmette-Guerin plus intravesical alpha-2b in patients with superficial bladder cancer. Urology 1996; 48(6):957-62 95. Kalble T, Mohring K, Ikinger U, Reidasch G, Staehler G. Intravesikale Rezidivprophylaxe beim oberflachlichen Harnblasenkarzinom mit BCG und KLH. Ein Prospektive Randomisierte Studie. Urologe [A] 1991;30:118-21 96. Reitsma DJ, Guinan P, Lamm DL. Long term effect of bacillus Calmette-Guerin (BCG) tice strain on flat carcinoma in-situ of the bladder. In: EORTC Genitourinary Group Monograph 6: BCG in superficial cancer. Debruyne FMJ, vd Meijden APM (eds). New York, Alan R Liss Inc., 1989;171-85 97. DeJager R, Guinan P, Lamm DL. Long term complete remission in bladder carcinoma in situ with intravesical Tice bacillus Calmette- Guerin. Overview analysis of six phase II clinical trials. Urology 1991; 38:507-13 98. Harland SJ, Charig CR, Highman W, Parkinson MC, Riddle PR. Outcome in carcinoma in situ of bladder treated with intravesical bacillus Calmette-Guerin. Br J Urol 1992; 70:271-5 99. Akaza H, Hinotsu S, Aso Y, Kakizoe T, Koiso K. Bacillus Calmette- Guerin treatment existing papillary bladder cancer and carcinoma in situ of bladder. Four years results. The Bladder Cancer BCG Study Group. Cancer 1995; 75(2):552-9 100. Merz VW, Marth D, Kraft R, Ackermann DK, Zingg EJ, Studer UE. Analysis of early failures after intravesical instillation therapy with bacillus Calmette-Guerin for carcinoma in situ of the bladder. Br J Urol 1995; 75:180-4 101. Palou J, Xavier B, Laguna P, Montlleo M, Vicente J. In situ transitional cell carcinoma involvement of prostatic urethra: Bacillus Calmette- Guerin therapy without previous transurethral resection of prostate. Urology 1996; 47(4):482-4 102. Schellhammer PF, Ladaga LE, Moritary RP. Intravesical bacillus Calmette-Guerin for treatment of superficial transitional bladder carcinoma of prostatic urethra in association with carcinoma of the bladder. J Urol 1995; 153:53-6 Intravesical BCG 164
103. Bretton PR, Herr HW, Whitmore WF jr, Badalament RA, Kimmel M, Provet J, et al. Intravesical bacillus Calmette-Guerrin therapy for in situ transitional cell carcinoma involving the prostatic urethra. J Urol 1989; 141:853-6 104. Bretton PR, Herr HW, Kimmel M, Whitmore WF jr, Laudone V, Oettgen HF, et al. The response of patients with superficial bladder cancer to a second course of intravesical bacillus Calmette-Guerin. J Urol 1990; 143:710-13 105. Pansadoro V, De Paula F. Intravesical bacillus Calmette-Guerin in the treatment of superficial transitional cell carcinoma of the bladder. J Urol 1987;138:299-301 106. Rosenbaum RS, Park MC, Fleischmann J. Intravesical bacillus Calmette-Guerin therapy for muscle invasive bladder cancer. Urology 1996; 47(2):208-11 107. Pineiro-Martinez J, Pineiro-Martinez L. BCG update: Intravesical therapy. Eur Urol 1997; 31(suppl 1):31-41 108. Kurth KH. Diagnosis and treatment of superficial transitional cell carcinoma of the bladder: facts and perspectives. Eur Urol 1997; 31 (suppl 1):10-9 109. Witjes WPJ, Witjes JA, Oosterhof GON, Debruyne FMJ on behalf of the Dutch south-east Co-operative Urological Group:Update on the Dutch Comparative Trail: Mitomycine versus bacillus Calmette-Guerin RIVM in the treatment of patients with pTa-pT1 papillary carcinoma and carcinoma in-situ of the urinary bladder. Semin Urol Oncol 1996;14(suppl):10-6 110. Vegt PDJ, Witjes JA, Witjes WPJ, Doesburg WH, Debruyne FMJ, vd Meijden APM. A randomised study of intravesical mitomycin C, bacillus Calmette-Guerin TICE and bacillus Calmette-Guerin RIVM treatment in pTa-pT1 papillary carcinoma and carcinoma in-situ of the bladder. J Urol 1995; 153:929-33 111. Lamm DL, Blumenstain BA, Crawford Ed, Montei JE, Scardino P, Grosmann HB,et al. A randomised trail of intravesical doxorubicin and immunotherapy with bacillus Calmette-Guerin for transitional cell carcinoma of the bladder. N Engl J Med 1991; 325:1205-9 112. Kurth KH, Schellhammer PF, Okajima E, Akdas A, Jakse G, Herr HW, et al. Current methods of assessing and treating carcinoma in situ of bladder with or without involvement of the prostatic urethra. Int J Urol 1995; 2(suppl 2):8-22 Intravesical BCG 165
113. Lamm DL, Crawford Ed,Blumenstain BA, Grissman JD, Montei JE, Gottesman J. Maintenance BCG immunotherapy of superficial bladder cancer. A randomised prospective Southwest Oncology Group study. J Urol 1992;147(suppl):274A,242 Intravesical BCG 166
II- RESULTS OF A RANDOMIZED PHASE III TRIAL OF SEQUENTIAL INTRAVESICAL THERAPY WITH MITOMYCIN-C AND BACILLUS CALMETTE-GUERIN VERSUS MITOMYCIN-C ALONE IN PATIENTS WITH SUPERFICIAL BLADDER CANCER.
Introduction
There is a high recurrence rate of superficial transitional cell carcinoma (TCC) of the bladder after transurethral resection (TUR) of the initial tumour. In an attempt to reduce the number of recurrences adjuvant therapy after TUR has become common practice in subgroups of patients at an intermediate or high risk of tumour recurrence. For this purpose, several dosages and schedules of intravesical chemotherapy have been used. There is a clear initial effect on the recurrence rate, but this positive effect seems to disappear after 5 years of follow up [1], although a recent metanalysis indicated that even after a median survival follow up of 7.8 years there was an ongoing reduction in the recurrence rate after intravesical chemotherapy as compared to no additional therapy [2]. Another possibility is the use of intravesical bacillus Calmette-
Guerin (BCG). BCG is considered to be the most effective drug to reduce the number of recurrences, especially if more than one course of 6 instillations or maintenance therapy is used. BCG, however, has more frequent and more severe side effects, often increasing with the number of instillations.
Therefore, BCG is generally reserved for intermediate and high risk patients. Intravesical BCG 167
In an attempt to improve the efficacy of intravesical therapy, recently
intravesical chemotherapy and BCG have been combined [3-6]. These so
called sequential or alternating therapies have several rationales. Since intravesical chemotherapy and BCG have different working mechanisms, there
might be a potentiation of antitumour effect from these two modalities.
Increased efficacy with chemotherapy preceding immunotherapy has been demonstrated in animal experiments in various tumours [7-9]. Secondly,
intravesical chemotherapy causes a chemical cystitis which might have a
positive effect on the adherence of BCG particles to the bladder wall, a necesarry first step in the working mechanism of BCG [10,11]. On the other
hand, however, a combination of a chemotherapeutic drug and BCG might
also enhance the toxicity. Therefore, we studied the incidence and severity of side effects as well as the treatment efficacy of a sequential treatment of
Mitomycin-C (MMC) and BCG as compared to the use of MMC alone in a
multicentre prospective randomized phase III trial with intermediate and high risk superficial bladder cancer patients.
Material and Methods
Patients with histologically proven primary multiple (> 2 tumours) or recurrent
multiple (> 2 tumours) stage pTa or pT1 TCC, patients with solitary or
multiple GIII tumours and patients with primary or concomitant CIS of the
bladder were included in the study. These patients are considered to be at an
intermediate or high risk for recurrence and/or progression. Patients were
ineligible in case of previous radiotherapy and intravesical or systemic Intravesical BCG 168
chemotherapy within 3 months of registration. The presence of a second
primary malignancy or TCC of the upper urinary tract or in the prostatic urethra were also exclusion criteria. In case of TCC of the prostatic urethra
patients were eligible after fractionated TUR of the prostate.
After complete TUR of all visible lesions and random biopsies of normal appearing mucosa, patients were randomized in 1 of the 2 treatment groups. In
group 1, intravesical chemotherapy with MMC (MutamycinR Kyowa, 40 mg
in 50 mL saline) was administered once a week for 4 consecutive weeks, followed by intravesical immunotherapy with BCG-Tice (OncoticeR Organon
Teknika, 5x108 bacilli in 50 mL saline), once a week for 6 weeks. In group 2, 40 mg MMC in 50 mL saline was given once a week during 10 consecutive weeks. Instillations were started between 7 and 15 days after the TUR. After
completion of the instillation therapy, patients were followed every three
months by urine cytology and cystoscopy until recurrence occurred.
Side effects were divided in local, allergic and systemic side effects. Local
toxicity was defined as the occurrence of culture proven bacterial cystitis,
chemical or drug induced cystitis or other local side effects such as
haematuria, prostatitis or epididymitis. In case of bacterial cystitis the patient
was treated with antibiotics and the instillations were postponed until the urine
culture was negative. The severity of side effects was classified in three
categories: requiring no delay of treatment, requiring delay or requiring
cessation of instillation therapy. Side effects were investigated by complaints
registration, physical examination and blood and urine analysis. Intravesical BCG 169
Tumour recurrence had to be proven by biopsy. In case of positive cytology without appearance of a papillary tumour, random biopsies were done, to
diagnose or exclude CIS. In case of a recurrence, the patient went off study
and further therapy was left to the discretion of the individual urologist. After
going off study, patients were followed for survival.
For evaluation of the "test" results the chi-square test was used. For evaluation
of the follow up data the log rank method was used in combination with the
Kaplan Meier representation.
Results
From January 1991 till November 1993 182 patients from 17 centres of the
Dutch South East Cooperative Urological Group entered the study. A total of 90 patients were allocated to group 1 (sequential therapy, MMC plus BCG)
and 92 to group 2 (MMC alone). Toxicity data of all patients are available.
Patients' characteristics and tumour characteristics (Table I and II) are similar in both treatment arms.
For bacterial cystitis, chemical cystitis and other local side effects the
difference between the two groups was not significant. Allergic reactions,
including skin rash, were more frequent in group2 (p=0.08), whereas other
systemic side effects were more frequent in group 1 (p=0.07) (Table III).
There were 29 occurences of other systemic side effects in 16 patients in group
1 compared to 30 occurences in 8 patients in group 2 (Table IV). Intravesical BCG 170
Table I. Tumor characteristics of evaluable patients per treatment group.
Group 1 Group 2 Totals No. Pts 90 92 182 pTa G1 18 13 31 G2 23 16 39 G3 2 7 9 +CIS 3 4 7 pT1 G1 1 3 4 G2 19 28 47 G3 16 16 32 +CIS 8 17 25
primary 62 67 129 recurrent 28 25 53 primary CIS 18 15 33 Total CIS 29 36 65
Table II: Tumor characteristics of evaluable patients with primary tumors per treatment group
Group1 Group 2 Totals No. Pts. 62 67 129 pTa G1 6 6 12 G2 15 13 28 G3 1 3 4 +CIS 3 3 6 pT1 G1 1 1 2 G2 17 26 43 G3 14 11 25 +CIS 7 13 20
Side effects. Local and systemic side effects are shown in Table III. Intravesical BCG 171
Table III: Local and systemic toxicity during instillation period.
Group 1 Group 2 p- value No. pts. 90 92 No. Instillations 860 876
No. pts. 29 38 0.20 without side effects (32%, 95% CI 22-42) (41%, 95% CI 31-51) 23 15 0.13 Bacterial cystitis (26%, 95% CI 17-35) (16%, 95% CI 9-23) 37 29 0.18 Chemical cystitis (41%, 95% CI 31-51) (32%, 95% CI 22-42) Other local side 12 9 0.45 effects (13%, 95% CI 6-20) (10%, 95% CI 4-16) 5 12 0.08 Allergic reactions (6%, 95% CI 1-11) (13%, 95% CI 6-20) Other systemic side 16 8 0.07 effects (18%, 95% CI 11-25) (9%, 95% CI 3-15) CI = 95% confidence interval
Table IV: Other systemic side effects
Group 1 (16 pts.) Group 2 (8pts.) temperature rise >38.5oC 11 Tired 9 general malaise 11 not specified 7 hot flushes 2 back ache 6 headache 2 pain not specified 4 dizziness 1 temperature rise 3 >38.5oC tired 1 fear 1 nausea 1
Total 29 Total 30 Intravesical BCG 172
The severity of side effects is shown in table 5, and is not significantly different for either group (Table V).
Table V: Severity of side effects.
Group 1 Group 2 Bacterial cystitis 23 15 Therapy delay 7 8 Therapy cessation 2 3
Chemical cystitis 37 29 Therapy delay 3 6 Therapy cessation 1 0
Allergic reactions 5 12 Therapy delay 0 1 Therapy cessation 1 5
Systemic side effects 16 8 Therapy delay 2 3 Therapy cessation 1 1
Efficacy. The median follow up is 32 months (range 2 to 65). Recurrences
were seen in 77 of 182 patients (42.3%, 95% confidence interval [CI] 35% to
49%), including 35 (39%, 95%CI 29% to 49%) in group 1 and 42 (46%, 95%
CI 36% to 56%) in group 2 (p=0.36, chi-square test, see figure 1).
At the end of this analysis 39 patients were still at risk for recurrent disease in
group 1 and 43 in group 2. Median time to the first recurrence did not
differ.significantly (43.7 months in group 1, not reached yet in group 2). Intravesical BCG 173
Figure 1. Kaplan Meier curves for recurrent free survival (p=0.53 Log Rank test).
Progression to an invasive TCC of the bladder was seen in 9 patients (4.9%,
95% CI 2% to 8%) of the total group, including 5 in group 1 (6%, 95% CI 1% to 11%) and 4 in group 2 (4%, 95%CI 0% to 8%) (p=0.70, chi-square test). In group1, 21 (23%, 95% CI 14% to 32%) and in group 2, 14 (15%, 95% CI 7% to 22%) patients died (p=0.16, chi-square test). Causes of death in group 1
(n=21) were disease related in 5 (2 malignancies, 3 cause not specified), not disease related in 13 (2 other malignancies, 1 pulmonary, 4 cardiovascular and
6 cause not specified), and cause unknown in 3. Causes of death in group 2 Intravesical BCG 174
(n=14) were disease related in 8 (1 malignancy, 7 cause not specified), not disease related in 5 (cause not specified) and cause inknown in 1.
Discussion
The sequential use of chemotherapy and immunotherapy has some theoretical advantages and disadvantages. The advantages might be the combination of different working mechanisms with possible potentiation of antitumour effect or synergism from two drugs. Increased efficacy with chemotherapy preceding immunotherapy has been demonstrated in various (animal) tumour models [7
9]. In the clinical situation promising effects were achieved in several tumours.
In patients with metastatic renal cell carcinoma treatment with interferon alpha-2a and vinblastine resulted in a objective clinical response in 27.7%, although toxicity was considerable [12]. In patients with advanced cervical cancer interferon-alpha and doxorubicin was shown to have increased efficacy
[13]. A combination of interleukin-2 and dacarbazine in 25 metastatic melanoma patients showed clear activity, but not more than could be expected of interleukin-2 alone [14].
In superficial bladder cancer the intravesical route of administration might have a second advantage. A chemotherapeutic drug causes a chemical cystitis with an increase in the fibronectin (FN) activity [15] which can have a positive effect on the adherence of BCG particles to the bladder wall. Kavoussi et al., for example, found that chemical disruption of the urothelium caused by the Intravesical BCG 175
use of adriamycin prior to BCG, increased the FN mediated BCG attachment to the murine bladder mucosa [16]. It is known that BCG attachment to FN is
an important first step for the development of an immune response and
antitumour activity [10].
A disadvantage could be that intravesical combination of a chemotherapeutic
drug and BCG might also enhance the toxicity, since attempts to improve the
efficacy of intravesical BCG with more courses or maintenance intravesical therapy cause more frequent and more severe side effects. Intravesical BCG in
case of a cystitis is generally not advised, because the likelihood of increased
adverse effects.
In an animal model the combination of intravesical MMC and intravesical
BCG was studied for the immunological effects [17]. Four weekly instillations with MMC were followed by 6 instillations with BCG. Several immunological
parameters (PPD skin reaction, local inflammatory reaction of the bladder wall, BCG granulomas in the iliac lymph nodes, adherence of BCG to the bladder wall) appeared to be similar in the MMC/BCG treated guinea pigs as
compared to those treated with 4 instillations of saline followed by BCG.
These authors concluded that MMC did not potentiate the immune response of
BCG, but that a possible increased antitumour activity was more due to the
separate activity of both drugs.
The clinical experience with sequential intravesical chemo-immunotherapy in
patients with bladder tumours is limited. Intravesical BCG 176
Serretta et al. performed a pilot study on the use of intravesical sequential
combination therapy of epirubicin and interferon alpha-2b in high risk patients
[3]. Four treatment groups were compared. After a mean follow up of 12
months 32 patients (51.6%) showed a recurrence. The recurrence rate was
higher in the low dose groups (NS). No serious side effects were seen. In 12
patients (19.3%) mild to moderate chemical cystitis was seen. This
combination appears to be safe, efficacy cannot be judged.
A combination of intravesical IFN alpha-2b and epirubicin was compared to
IFN alpha-2b monotherapy in 85 patients with superficial bladder cancer [18].
50 MU of IFN was given weekly for 8 weeks, biweekly for 4 months, and
finally monthly for another 4 months. In the combination group 80 mg
epirubicin was given 0, 24 and 48 hours after TUR, whereafter the patients
received the same schedule of IFN. The efficacy of IFN-alpha 2b was
confirmed and the combination with early epirubicin instillations further
reduced the percentage of recurrences and improved the disease free interval.
The Finnbladder group conducted 2 studies comparing MMC alone with an
alternating MMC/BCG schedule in patients with CIS [4] or rapidly recurring
papillary tumours [5]. After TUR (papillary lesions) or biopsy (CIS) 5 MMC
(20-40 mg) instillations were given: the first within 48 hours, followed by 4 weekly instillations. After these 5 instillations 11 monthly and 4 tri-monthly
instillations were given. In group 1 only MMC was given, in group 2 MMC
and BCG (75 mg Pasteur strain) were alternated. In both studies the side Intravesical BCG 177
effects in the MMC/BCG group were similar to those in the MMC group, but side effects of the alternating schedule were fewer compared to BCG monotherapy. In CIS patients the alternating schedule was significantly more effective than MMC alone with regard to the CR rate (74% versus 47% at 24 months, p=0.041), disease free interval (p=0.043) and recurrence rate (0.922 versus 1.834, p=0.013) [4]. Efficacy results in papillary tumours, however, were equal in both arms [5].
A similar approach as in our study was used to study the effect of sequential therapy in patients on a marker lesion [6]. Here 35 patients were treated on a weekly basis with 4 instillations MMC follow by 6 instillations with BCG-
RIVM. In these patients all tumours except one were resected before the instillation therapy was started. Side effects during the treatment period were similar to those reported earlier with MMC and BCG alone. Complete response to therapy, determined 2 weeks after the last instillation, was found in
19 patients (confirmed histologically in 16). Only 1 patient showed progression. It was concluded that the sequential treatment appeared to be safe with regard to toxicity and efficious as an ablative therapy.
Results from this study show that the combination of 4 instillations with MMC and 6 with BCG has comparable toxicity as 10 instillations of MMC alone with regard to bacterial cystitis, chemical cystitis and other local side effects.
Allergic reactions, a well known side effect of MMC [19], were more frequent
(p=0.08) in group 2 than in group 1. Since the number of MMC instillations in Intravesical BCG 178
group 2 was lower (4 versus 10), this seems logical since the skin rash caused by MMC is a type IV hypersensitivity reaction which needs several challenges with MMC to develop. Other systemic side effects, that can be expected with
BCG, were seen more often in group 2 (p=0.07).
We also compared the 6 week BCG instillation period of group 2 with a 6-
week BCG therapy from one of our previous trials [20], in which no
pretreatment was done (Table VI).
Table VI: Side effects during 6 weeks of BCG-Tice with (this study) and without (previous study) MMC pretreatment.
No. Pts (%) Present Study Previous Study 20 Total 90 140 bacterial cystitis 23 (26%) 38 (27%) chemical cystitis 37 (41%) 42 (30%) other local side effects 12 (13%) 23 (16%) allergic reactions 5 (6%) 3 (2%) systemic side effects 16 (18%) 38 (27%)
The number and severity of side effects caused by BCG were not significantly
different, indicating that BCG related toxicity does not seem to increase when
BCG instillations are started directly after a period of intravesical
chemotherapy. With regard to treatment efficacy, the results did not reveal any
differences for the number of recurrences (p=0.36), the time to first recurrence
(p=0.53), progression (p=0.70) or survival (p=0.16). Follow up in the current trial, however, is relatively short. Intravesical BCG 179
Conclusion
The sequential use of intravesical BCG and MMC has no advantage over the use of intravesical MMC alone in intermediate and high risk superficial bladder cancer patients with regard to tumour recurrence and progression.
There was also showed no major differences between the 2 treatment groups in
regard to toxicity, although allergic reactions were more frequent in the MMC treated patients, whereas other systemic side effects were more frequent in the
sequential arm.
References
1. Lamm DL. Long-term results of intravesical therapy for superficial bladder cancer. Urol Clin North Am 19:573-580, 1992. 2. Pawinski A, Sylvester R, Kurth KH, Bouffi oux C, van der Meijden A, Parmar MKB, and Bijnens L. A combined analysis of EORTC and MRC clinical trials for the prophylactic treatment of stage TaT1 bladder cancer. J Urol 156: 1934-41, 1996. 3. Serretta V, Corselli G, Pavone C, Pizzuto Antinoro SA, Pavone Macaluso M. Intravesical sequential combination of epirubicin and interferon alpha- 2b in patients affected by superficial transitional cell carcinoma of the bladder. Results of a pilot study at Palermo University and proposal of basic research. Prog Clin Biol Res 370:185-93, 1991. 4. Rintala E, Jauhiainen K, Rajala P, Ruutu M, Kaasinen E, Alfthan O, Finnbladder Group. Alternating mitomycin C and bacillus Calmette Guerin instillation therapy for carcinoma in situ of the bladder. J Urol 154: 2050-53, 1995. 5. Rintala E, Jauhiainen K, Kaasinen E, Nurmi M, Alfthan O, Finnbladder Group. Alternating mitomycin C and bacillus Calmette Guerin instillation prophylaxis for recurrent papillary (stages Ta to T1) superficial bladder cancer. J Urol 156: 56-60, 1996. Intravesical BCG 180
6. Van der Meijden APM, Hall RR, Macaluso MP, Pawinski A, Sylvester R, Van Glabbeke M. Marker tumor respones to the sequential combination of intravesical therapy with mitomycin-C and BCG-RIVM in multiple superficial bladder tumours. Report from the EORTC-Genitourinary group (EORTC 30897). Eur Urol 29: 199-203, 1996. 7. Scott MT. Analysis of the principles underlying chemo-immunotherapy of mouse tumours I. Treatment with cyclophosphamide followed by Corynebacterium parvum. Cancer Immunol Immunother 6:107-10, 1979. 8. Pang AS, Morales A. Chemoimmunoprophylaxis of an experimental bladder cancer with retinoids and Bacillus Calmette Guerin. J Urol 130: 166-70, 1983. 9. Adolphs HD, Thiele J, Kiel H. Effect of intralesional and systemic BCG application or a combined cyclophosphamide/BCG treatment on experimental bladder cancer. Urol Res 7:71-8, 1979. 10. Ratliff TL. Mechanisms of action of intravesical BCG for bladder cancer. In: EORTC Genito-Urinary Group Monograph 6: BCG in superficial bladder cancer. Debruyne FMJ, Denis L, v.d. Meijden APM (eds.). New York, Alan R. Liss Inc., 107-22, 1989. 11. Hudson MA, Yuan JJ, Catalona WJ, Ratliff TL. Adverse impact of fibrin clot inhibitors on intravesical bacillus Calmette-Guerin therapy for superficial bladder tumors. J Urol 144:1362-4, 1990. 12. Rizzo M, Bartoletti R, Selli C, Sicignano A, Criscuolo D. Interferon alpha-2a and vinblastine in the treatment of metastatic renal carcinoma. Eur Urol 16: 271-7, 1989. 13. Welander CE, Homesley HD, Barrett RJ. Combined interferon alfa and doxorubicin in the treatment of advanced cervical cancer. Am J Onstet Gynaecol 165: 284-90, 1991. 14. Stoter G, Aamdal S, Rodenhuis S, Cleton F, Iacobelli S, Franks CR, Oskam R, Shiloni E. Sequential administration of recombinant human interleukin-2 and dacarbazine in metastatic melanoma. A multicenter phase II study. J Clin Oncol 9: 1687-91, 1991. 15. Mosher DF. Physiology of fibronectin. Ann Rev Med 35:561-75, 1984. 16. Kavoussi LR, Brown EJ, Ritchie JK, Ratliff TL. Fibronectin-mediated Calmette-Guerin Bacillus attachment to murine bladder mucosa. J Clin Invest 85:62-4, 1990. 17. Balemans LT, Vegt PD, Steerenberg PA, de Boer EC, van Swaay A, de Vries RE, van der Meijden AP, den Otter W. Effects of sequential intravesical administration of mitomycin C and bacillus Calmette-Guerin Intravesical BCG 181
on the immune response in the guinea pig bladder. Urol Res 22: 239-45, 1994. 18. Ferrari P, Castagnetti G, Pollastri CA, Ferrari G, Tavoni F, Grassi D. Chemoimmunotherapy for prophylaxis of recurrence in superficial bladder cancer: interferon alpha-2b versus interferon alpha-2b with epirubicin. Anticancer drugs 3 suppl 1: 25-7, 1992. 19. de Groot A, van der Meijden APM, Conemans JMH, Maibach HI. Frequency and nature of cutaneous reactions to intravesical instillation of Mitomycin for superficial bladder cancer. Suppl Urol 40:16-19, 1993. 20. Witjes JA, van der Meijden APM, Witjes WPJ, Doesburg W, Schaafsma HE, Debruyne FMJ. A randomized prospective study comparing intravesical instillations of Mitomycin-C, BCG-Tice, and BCG-RIVM in pTa-pT1 tumors and primary carcinoma in situ of the urinary bladder. Intravesical instillations in superficial bladder cancer. Eur J Cancer 29A: 1672-76, 1993.
CHAPTER 8
Management of superficial bladder cancer with intravesical chemotherapy (Long Version)
J.A. Witjes, N.A. Mungan, F.M.J. Debruyne
Urology 56:19-21, 2000 Intravesical chemotherapy 184
Introduction
Superficial bladder tumours have a high tendency to recur after transurethral resection (TUR). Since superficial bladder cancer is a heterogeneous disease, it may be difficult to predict which patient will develop a recurrence and which one will not. With the help of prognostic factors, such as stage, grade, multifocality, tumour size, previous bladder tumours and positive biopsies, it is possible to identify three groups of patients. A minority of patients has a relatively benign type of superficial transitional cell carcinoma (TCC), with low recurrence rate. These low risk tumours are the primary, small, solitary, well to moderately differentiated pTa tumours. In such a patient adjuvant treatment seems to be unnecessary or one immediate instillation with a chemotherapeutic agent can be given [1,2]. However, recently community practice in the US was studied, and it appeared that the use of BCG for low grade TCC is rather common with significant side effects on a repeated course
[3]. The largest group consists of patients who develop a superficial recurrence, but seldom progression. Adjuvant treatment, such as intravesical chemotherapy, may be given to decrease the recurrence rate, with the hope to prevent or delay tumour progression. A small group of patients, finally, has already a relatively malignant superficial tumour at presentation and will develop invasive cancer despite maximal intravesical treatment (BCG). It is important to select these high-risk patients as early as possible. Intravesical chemotherapy 185
Principles of intravesical prophylaxis and therapy
The mechanism of action for prophylactic intravesical chemotherapy remains
unclear [4]. For example, regular instillations might be practical, but probably
not ideal from a molecular biologic (cell cycle) point of view.
The drug is dissolved in sterile water, that provides better results as a diluent
than saline [5]. The effect of the pH of the solution is not well known.
Theoretically the pH can influence the stability and efficacy of the drug. The
colony forming ability of the cell line, for example, was lowest at a pH of 5.5
for thiotepa and at a pH of 7.0 for ADM and MMC [6]. Cell line sensitivity
under different acidic conditions was specifically studied for MMC [7].
Although these results also indicated a clear relation between acidity and
cytotoxicity of MMC, in this study MMC was most effective under acidic
conditions (pH5.8-6.0). Wientjes and Badalament used known
pharmacokinetic data to develop a computer model to predict the antitumour
effect of MMC [8]. The therapeutic outcome of MMC was influenced by: dose
> residual volume > urine production > dosing volume > urine pH > dwell time. They hypothesized that under optimal conditions the efficacy of MMC
could be improved by 20%, increasing the average recurrence free rate from
56 to 76%.
Although cytotoxicity is proportional to drug concentration and exposure time,
longer instillation time might increase toxicity and it is unpractical [9]. This is
also true for continuous low dose intravesical infusion, which in animal Intravesical chemotherapy 186
experiments was shown to be significantly more effective than intermittent
instillation [10]. An advantage of the intravesical route of administration is that there is no or little systemic uptake of the drug (only in case of a molecular weight of less than 400) and that there is an optimal contact between the tumour or tissue at risk and the drug. Disadvantages are the local side effects
in the bladder because of the high local drug concentration and the need for transurethral manipulation.
In conclusion, although chemotherapeutic drugs have been used
intravesically for decades, pharmacokinetics can probably still be improved.
Thiotepa
Usually 30 to 60 mg is used, although 30 mg in 30 ml seems to be as effective
as 60 mg in 60 ml [11]. The use of 60 mg in 30 ml, however, seems to increase the dose rate to the tumour without increasing systemic toxicity [12]. After 6 weekly instillations generally treatment is continued for 1 year with monthly
instillations.
Although the moleculer weight as low (189), thiotepa induced
myelosuppression is considered to be rare, usually mild and transient [13].
White blood cell count (>4000/mm3) and platelet count (>100,000/mm3)
should be controlled before and during treatment and treatment should be
delayed if necessary. Chemical cystits is another side effect and is seen in
approximately 14% [14]. Intravesical chemotherapy 187
Combining the results of thiotepa as definite therapy from two reviews, the success rate is approximately 38% (109/285) in 10 small series [15,16].
Single adjuvant instillations with thiotepa have been used after a complete
TUR. The Medical Research Councel (MRC) conducted a large randomized trial with 379 eligible patients, comparing immediate thiotepa instillations
(30 mg) versus immediate followed by 4 three-monthly instillations versus controls [17]. They found no advantage in either of the treatment groups
(p=0.4 and p=0.7). These findings were confirmed with long-term follow-up
[18].
When thiotepa as used as adjuvant (non) maintenance therapy after TUR, complete response rates between 35% and 45% [19]. The National Bladder
Cancer Group found success rates of 66% and 54% after 12 and 20 months respectively, versus 40% and 28% for controls [11]. With longer follow up of
48 months, however, only 16 of 45 patients treated with thiotepa remained disease free, compared to 11 of 45 controls [20]. Disease progression was seen in 8 and 5 patients respectively.
Lamm compared the recurrence rate of thiotepa (45%) to the recurrence rate in control groups (62%) in a series of 10 controlled studies with 1009 patients
[21]. Apart from the fact that, these results depended on the follow up period,
5 of the 10 series failed to reach statistical significance, including the three largest series, such as the MRC study, described above. Another large series,
EORTC study (30751), also failed to show a statistical difference in disease Intravesical chemotherapy 188
free interval between thiotepa, controls and the third study arm
epipodophyllotoxin (intravesical VM 26) [22]. However, the recurrence rate of
the treated patients was significantly better than the control group.
Novak et al. treated 409 patients with TUR alone, TUR and thiotepa (6
instillations) or TUR and BCG [23]. Although the recurrence (41.9% versus
56,7%) and progression (16.9% versus 19.8%) rate in the thiotepa group was better than in the TUR group, the difference was not significant.
In two controlled studies thiotepa was compared to ADM. The first used a
schedule of 15 instillations in 1 year with thiotepa, ADM and BCG in 176
patients [14]. After a median follow up of approximately 3 years,
chemotherapy was significantly less effective than BCG, but both
chemotherapeutic drugs were equally effective. The success rates for BCG,
ADM and thiotepa were 86.6%, 56.6% and 64.3% respectively. In the second
study a similar instillation schedule with thiotepa, ADM and cisplatin was used in 184 patients [24]. No significant difference in efficacy between the three groups was found.
In conclusion of thiotepa is better than no additional therapy, although not
always statistically significant. Thiotepa is not used frequently anymore due to
its toxicity and limited efficacy. Intravesical chemotherapy 189
Doxorubicin hydrochloride (Adriamycin, ADM)
The dose of ADM ranges from 30 to 100 mg in several instillation schedules.
ADM has a relatively high molecular weight of 580, thus absorption and
systemic toxicity are extremely rare.
The main side effect of ADM is chemical cystitis in 25-30% of the patients
[25,26]. Rare side effects are allergic reactions (0.3%), gastrointestinal side
effects (1.7%) and fever (0.8%). Most side effects, however, are mild and
disappear after cessation of therapy.
The response rates of ADM used as definite treatment for papillary tumours,
varies between 28 and 56%, with an average of 38% (273/712), depending on
the dose used [16]. For CIS the complete response is only 34% and the median
time to treatment failure is reported as only 5 months [27].
In four large controlled studies where ADM was used as prophylactic, the
percentage of patients with a recurrence in the ADM groups was 38%, versus
56% in the control groups, indicating an advantage for ADM of 18% [21].
However, the three largest series showed no significant advantage for ADM.
For example, in a study in which 268 patients after TUR were randomized for
no further treatment, 12 bi-weekly instillations and 1 year of ADM treatment, there was no significant difference for the recurrence rate, progression and
survival between the three groups [28].
Garnick et al. used an escalating dose schedule, with 60 to 90 mg ADM with
12 instillations and increasing intervals between the treatments [29]. After a Intravesical chemotherapy 190
median follow up of 18 months, 53% of the patients remained free of
recurrence. Flamm compared a course of 6 weekly instillations of 50 mg ADM with maintenance therapy (additional monthly instillations for 2 years) [30].
Both treatment arms were equally effective, indicating that ADM maintenance therapy is of no additional value. In another study the efficacy results of long term ADM treatment (42 instillations of 50 mg in 3 years) were the same as treatment with MMC in different long-term schedules [31].
The Japanese urological cancer research group conducted a series of large
randomized trials on prophylactic intravesical therapy. In the first study only
short-term schedules were used, with two different doses of ADM, MMC and
controls [32]. In all, 575 patients were evaluated. The disease free rates were
significantly better in the 20 mg/40 ml ADM group and in the MMC group
(p<0.05). In a second study, the same drugs and the same dosages were used, but now a 2 year maintenance schedule was used with 18 instillations [32]. In
all, 607 patients were evaluable. In all treatment groups a significant reduction
in recurrence rate was observed (p<0.05). The results of both studies were
comparable, suggesting no advantage of the maintenance therapy. In another
Japanese study, patients receiving long-term (21 instillations in 2 years) therapy were compared to a group receiving 6 instillations with ADM in the 2 weeks prior to TUR [33]. The results in 284 evaluable patients showed no
prophylactic effect of the preoperative instillations as compared to controls. Intravesical chemotherapy 191
Adjuvant instillations were significantly more effective than no treatment
(p<0.01) or pre-TUR treatment (p<0.05).
In conclusion, ADM is a safe drug with almost no systemic side effects. ADM is more effective than no adjuvant treatment, but again these figures often are not significant. ADM maintenance is clearly of no additional value.
Epirubicin (EPI)
The dose of EPI varies from 20 to 80 in several instillation schedules. The antitumour effect of EPI is similar to ADM. Toxicity is mild and not causing discontinuation of therapy. The relative absence of side effects, even when the intravesical instillation is given immediately after the TUR, can be explained by the finding that even under those circumstances the absorption of EPI is very limited due to moleculer weight [34]. Chemical cystitis was reported in
14% patients in a large series by Burk et al [35]. In the EORTC study (30863) with a single instillation of 80 mg of EPI, the frequency of drug induced cystitis was also only 6.8% [2]. In the same study the recurrence rate was significantly less in the EPI group (p<0.0001) as compared to an instillation with sterile water. For patients with solitary pTa grade 1 tumours EPI was of no benefit. The efficacy of one early (<24 hours after TUR) instillation was also studied with 40 mg/40 ml in 119 patients [36]. Again, the yearly recurrence rate was significantly less in the treated group (0.13 versus 0.29) with mild toxicity (13.8% bladder irritation). Intravesical chemotherapy 192
One of the early large randomized clinical trials compared EPI to doxorubicin
[37]. Thirty mg/30 ml of both drugs was used during 1 year (19 instillations) in
114 evaluable Ta/T1 patients. The tumour free rates at 1 and 2 year were
92.8% and 88.6% for EPI, and 86.4% and 81.7% for ADM respectively (not
significant).
Recently an instillation scheme of 6 instillations in 10 days was given with a
new EPI formulation (epirubicin-RTU, 60 mg/30 ml) in 20 patients with
superficial bladder tumours [38]. Of the 18 patients that completed this course
12 complete responders were seen. Side effects were frequent (pollakysuria in
17/20; pain in 17/20; hematuria in 16/20), but all reversible and tolerable.
In another study, 45 patients with primary superficial bladder cancer were treated with EPI 20 mg every second week for 4 months and then once a
month or every 2 weeks for the next 8 months after TUR. The overall
recurrence free rate was 76.1% and 52.3% at 2 and 5 years and these results were better than patients treated with TUR alone [39]. In a randomized UK
study, the difference in response to high and standard doses of intravesical EPI
of a marker tumor was determined [40]. No difference in the marker response
rate was found.
The additional value of EPI (40 mg) maintenance was also studied in 138
patients [41]. Six initial instillations in 4 weeks were followed by 11 additional
monthly instillations in half of the patients. Maintenance therapy did not
improve the efficacy. Intravesical chemotherapy 193
In a conclusion, the efficacy of EPI and results of maintenance therapy with
EPI seems similar to other chemotherapeutic drugs, however, with less drug induced cystitis.
Valrubicin (AD32).
AD32 is a derivative of the anthracycline doxorubicin [42]. In patients with
BCG-refractory CIS or recurrent papillary tumours of the bladder that have failed other intravesical therapies and refuse cystectomy, AD32 has been used.
In a dose ranging trial, 29% complete response during twelve months was reported in patients with CIS [43]. Disease free rates were 32% and 15% respectively, at 6 and 15 months in 170 patients with BCG refractory CIS [44].
As the studies are limited in number, it is not yet possible to make definitive statements about AD32.
Pirarubicin
Another anthracycline under investigation is piraribucin. An initial study comparing 20 mg of ADM, EPI, pirarubicin and a control group, showed no significant difference in efficacy for the three drugs used, although pirarubicin failed to show a significant advantage over the control group [45]. Another study also showed no significant advantage of pirarubicin (20 mg/40 ml) over no treatment [46]. However, the optimal dose and instillation time recently were found to be 30 mg/30 ml during 30 minutes [47]. Intravesical chemotherapy 194
Mitomycin C (MMC)
The dose varies between 20 and 60 mg per instillation. MMC has a molecular weight of 329 and it is hardly absorbed. Myelosuppression is rare (0.7%). For the intravesical route of administration, the most frequent side effects are
chemical cystitis and allergic reactions. The incidence of chemical cystitis
ranges between 6 and 41%, with a mean of 15.8% (97/613) [25]. In case only a
single or 4 three-monthly instillations are used, drug induced cystitis seems
much less frequent [48]. Allergic reactions are mainly skin symptoms, which
are seen up to 9.8% of patients treated with intravesical MMC instillations
[25]. Most skin reactions are due to a delayed type hypersensitivity reaction, usually occurring after the second instillation [49]. Most side effects disappear
after cessation of therapy. Although reports of bladder wall calcifications are
rare in literature [35], we have seen several patients with calcifications at the
site of the TUR after MMC, usually without apparent symptoms.
The overall success rates for MMC in the treatment of papillary lesions is 43%
(270/627) and for CIS 58% (51/88) [50]. With MMC also marker lesions
studies have been done. In an EORTC study (30864), the complete response
rate for the marker lesion after 8 instillations with 80 mg of MMC was 50%
(48/96) [16]. In one patient progression in stage was seen. In a subsequent
EORTC marker lesion study (30897) with sequential MMC and BCG, 4
weekly MMC instillations prior to TUR for low stage, low-grade recurrent
bladder tumours gave a complete response of 69% [51]. Intravesical chemotherapy 195
For prophylactic use, after complete TUR, Lamm reviewed five controlled
trials with 859 patients [21]. The advantage of MMC was 15% (52%
recurrences in the control groups versus 37% in the MMC group). This
advantage of MMC was mainly due to a large MRC series, because in three of the remaining four series the difference was not significant. In this MRC series
patients were randomized after complete TUR between no adjuvant treatment,
one immediate instillation with 40 mg of MMC and one immediate and 4
subsequent three-monthly MMC instillations [48]. With a median follow up of
7 years and 397 evaluable patients 1 and 5 instillations with MMC resulted in
a decreased recurrence rate in all risk categories. Five instillations seemed to
offer a slight advantage to 1 instillation. The effectiviness of a single
immediate MMC instillation in patients with low risk superficial bladder
cancer with short and long term followup was studied by Solsona et al. [52]. In
this prospective controlled trial, 131 patients received no or one immediate
instillation of 30 mg MMC after complete TUR. Recurrences developed
during the first 12 months in 59% of the control group but only 22.2% of the
MMC group (p=0.005). However, at long-term follow-up these differences
were not statistically significant and the recurrence-free interval curves were
parallel. From our first study with 344 eligible patients recently long-term
follow-up (median 7.2 years) was reported [53]. The efficacy with regard to
tumour recurrence was similar for MMC and BCG-RIVM. Progression,
however, was seen more frequently in patients without CIS treated with BCG. Intravesical chemotherapy 196
In the second study, after a median follow up of 5 years, 57% of MMC treated patients remained tumour free [54] Soloway treated 80 patients with persistent superficial bladder cancer [55]. Most tumours were recurrent before MMC was given. His initial response rate at twelve weeks was 37% for pTa, 44% for pT1 and 33% for CIS. Failure at twelve weeks was considered to be an important negative prognostic sign.
The advantage of MMC maintenance therapy is controversial. Some studies showed an advantage of maintenance therapy. Soloway, for example, used a monthly instillation scheme for 1 year and prevented recurrences in most of the patients that had a complete response after the initial course of instillations
[56]. Huland compared 3-year MMC instillation therapy (42 instillations of 20 mg) to no intravesical therapy in a randomized trial after complete TUR [57].
The percentage of recurrences was 10.4% in the MMC group compared to
51% in the control group. A later prospective multicentre trial confirmed these results with the same method of long-term prophylaxis [31]. With a mean follow up of 62.5 months the recurrence rate was higher (20.7%), the overall progression rate 9.3%. However, the majority of these patients were at low risk for recurrence (low grade tumours, low previous recurrence rate). The results of the Japanese group showed no advantage for maintenance MMC therapy over short-term therapy [32]. In another Japanese study, instillations of MMC were combined with ADM [58]. In this study complete responders on an induction course of 5 weekly instillations were randomized between no Intravesical chemotherapy 197
adjuvant therapy and 12 monthly instillations of MMC and ADM. Even in this group of complete responders no beneficial effect of maintenance therapy was seen in patients with papillary tumours. For CIS patients the 2-year recurrence rate after maintenance therapy was significantly better (p<0.05), but the curves suggest that with a longer follow up this difference will disappear.
Two studies compared maintenance MMC with maintenance BCG [59,60]. In one study, the relative risk of recurrence of MMC (0.508) and BCG (0.618) were similar [59]. In a recent study, BCG was superior to MMC for recurrence prophylaxis but no difference was found for progression and survival [60].
In conclusion, although, the frequency of drug-induced cystitis is comparable to other chemotherapeutic drugs and systemic side effects are rare, up to 10% of the patients can experience reversible allergic reactions. The response rates of MMC seem higher than other chemotherapeutic drugs, however again not all studies show a significant advantage of MMC over no additional treatment.
The advantage of MMC maintenance therapy is not clear.
Other intravesical chemotherapeutics
Ethoglucid (epodyl).
The mechanism of action of epodyl is poorly understood. With a molecular weight of 262 it is poorly absorbed and systemic side effects are rare. Drug induced cystitis (13-59%), small capacity bladder and bone marrow Intravesical chemotherapy 198
suppression have been reported [61,62]. The EORTC-GU group found
exactly the same yearly recurrence rate for intravesical ADM and epodyl which was significantly better in the control group (EORTC 30790) [63].
Flamm et al. treated 85 patients with primary tumours with 50 ml 1% epodyl
during 1 year and compared this with intravesical keyhole-limpet hemacyanin
(KLH) immunotherapy (n=76) [62]. After a mean follow-up of 27.5 months
no significant difference in recurrence or progression rate (6.5% KLH versus
9.4% etoglucid) were found. Long-term follow up data were reported after
complete TUR and 12 weekly instillations (n=43) [64]. After the initial 12- week course 72 patients (65%) had a complete response. However, only 33%
remained free of tumour for 5 years.
Cisplatin
Intravesical cisplatin has been used in a randomized EORTC trial (30782), where it was compared with thiotepa and ADM [65]. Final results showed no
significant difference between the three treatment groups with regard to
recurrence and progression. However, in 7 of 68 patients on cisplatin an
anaphylactic reaction occurred, which resulted in closure of this treatment arm
for accrual. Another series reported the use of 50-150 mg intravesical cisplatin
in 24 "high risk" superficial bladder cancer patients [66]. Only 3 patients
(13%) achieved a complete remission and also one patient was reported with Intravesical chemotherapy 199
an acute anaphylaxis. Cisplatin was concluded to be ineffective in this dose
and in these patients.
Additional measurements or to improve the efficacy of intravesical chemotherapy
Several drugs have been combined with intravesical chemotherapy to improve
its efficacy. Efficacy has been found in vitro such as for peroxide, dimethyl
sulfoxide (DMSO), tween 80, 5-Fluorouracil (5-FU) and quinolones, but
clinical data are not yet available.
Intravesical hyperthermia has been used to improve the efficacy of
intravesical MMC. In the patients receiving MMC only pathological complete
response was seen in 5 cases (22%), while complete response was seen in 19
patients (66%) in the MMC/hyperthermia group (p<0.01), indicating that this
combination is safe and effective [67].
Some cells have been shown to display a multi-drug resistance (MDR) to
several natural products and drugs, including chemotherapeutic drugs. One
possibility to overcome MDR is to select drugs that retain their efficacy in
MDR expressing cells. A second possibility is the use of MDR reversers such
as Verapamil, a calcium channel blocker. The mechanism of action remains unclear, but verapamil is not exhibit cytotoxic in itself. In a cell line study,
verapamil increased the cytotoxicity of ADM with a factor 2.5 [68]. This
increased sensitivity for ADM by verapamil was confirmed by others [69]. Intravesical chemotherapy 200
Recently a large randomized controlled trial was published, comparing ADM
and ADM plus verapamil [70]. After a median follow up of 38.5 months the
combined group showed a significantly lower recurrence rate with a similar
incidence of side effects. In conclusion, verapamil has potentially additional value.
Photodynamic therapy (PDT) combines a photosensitizer such as Photofrin
with red laser light to destroy tumour cells [71]. One of the problems with this
form of PDT, however, is cutaneous photosensitivity. Therefore, recently also
the intravesical route of administration has been tested in rats and might be
feasible [72].
Two recent studies addressed the possibility of intravesical electromotive
drug administration (EMDA). Some preliminary results and side effects
were reported by Riedl et al. [73] and Brausi et al. [74].
In conclusion, these methods and drugs are still under investigation to
improve the efficacy of intravesical chemotherapy with promising results.
Further studies are necessary for clinical use.
Sequential chemo/immunotherapy
The sequential use of chemotherapy and immunotherapy has some theoretical
advantages and disadvantages. The advantages might be the combination of
different working mechanisms with possible potentiation of antitumour effect
or synergism from two drugs. In superficial bladder cancer the intravesical Intravesical chemotherapy 201
route of administration might have a second advantage. A chemotherapeutic drug causes a chemical cystitis with an increase in the fibronectin (FN) activity
[75] which can have a positive effect on the adherence of BCG particles to the bladder wall [76]. A disadvantage could be that intravesical combination of a chemotherapeutic drug and BCG might also enhance the toxicity.
The Finnbladder group conducted 2 studies comparing MMC alone with an alternating MMC/BCG schedule in patients with CIS [77] or rapidly recurring papillary tumours [78]. In both studies the side effects in the MMC/BCG group were similar to those in the MMC group, but side effects of the alternating schedule were fewer compared to BCG monotherapy. In CIS patients the alternating schedule was significantly more effective than MMC alone with regard to the CR rate (74% versus 47% at 24 months, p=0.041), disease free interval (p=0.043) and recurrence rate (0.922 versus 1.834, p=0.013) [77]. Efficacy results in papillary tumours, however, were equal in both arms [78].
In an EORTC marker lesion study (30897), 4 instillations of MMC were followed by 6 instillations with BCG-RIVM [79]. The results showed that the sequential treatment was safe with regard to toxicity and efficious as an ablative therapy.
Results from a recent study from our department show that the combination of
4 instillations with MMC and 6 with BCG has comparable toxicity as 10 instillations of MMC alone [80]. Allergic reactions were more frequent in the Intravesical chemotherapy 202
MMC arm. With regard to treatment efficacy, the results did not reveal any
differences for recurrences or progression.
In conclusion, the sequential use of intravesical chemo and immunotherapy
does not seem to increase toxicity, but efficacy also does not seem to be
improved significantly.
Conclusions
Intravesical chemotherapy can be used in the majority of patients with
superficial bladder tumours. One can choose between several
chemotherapeutic drugs and schedules. Drug induced cystitis is seen in 20
30% of patients on intravesical chemotherapy. However, there are differences
in other side effects. There does not seem to be significant difference in
efficacy between these drugs. All are able to improve the recurrence rates with
15 to 20% with a follow up of 5 years. In contrast to another report [81], a
recent EORTC/MRC meta-analyses showed that this reduction in recurrence
rate also remains significant after longer follow up [82]. For all drugs the
advantage of maintenance treatment is doubtful. Intravesical chemotherapy,
however, has no impact on progression and disease specific survival [21,82]. Intravesical chemotherapy 203
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Discussion Discussion 212
Discussion For Chapter 2
In this part of the thesis, we analyzed gender differences in bladder cancer
stage and survival. Women appeared to have a less favorable stage
distribution at first presentation compared with men. The differences were
clearer among patients with non-TCC bladder cancer than among patients with TCC bladder cancer but even in the latter group the gender differences were statistically significant because of the large numbers. It appeared that these differences in stage distribution are responsible for part but not all of the observed gender difference in prognosis. Even after stratification by
stage category, the relative survival of bladder cancer was found to be worse
among women.
Some methodological factors need to be taken into consideration before
adopting the conclusions of these studies. First, comparing gender-specific
stage frequency distributions may be misleading. A higher percentage of
high stage cancers in females may be due to a delayed diagnosis but it may
also be caused by a higher risk of low stage cancers in males which shifts the distribution towards low stage disease in males. For example, if smoking
causes relatively many low-stage cancers, men (who smoke more) will have
a favorable stage distribution. Therefore, it is unknown whether the focus
should lie on etiologic research in low stage and high stage disease, or on
diagnostic delay in women or anatomical gender differences. Discussion 213
Second, the data on survival of patients with bladder cancer were obtained
from large population-based cancer registries. The advantage of using such
population-based cancer registries is the complete coverage of the
population, i.e. a systematic collection of data on all malignant neoplasms
occurring in a geographically defined population. The disadvantage,
however, is that cancer registries strictly adhere to the TNM or AJCC
staging rules. These rules were originally designed for research, not for
everyday practice. In everyday practice, it is common that not all required
diagnostic tests are performed for the formal staging of patients. It may also
be possible that all required diagnostic tests were performed but specific
information is lacking in the medical record. Consequently, when cancer
registrars use the formal staging rules before assigning a specific stage
category to each registered patient, a large number of patients will have an
“unknown” or “blank” disease stage. These patients will be left out of any
stage-stratified analyses. In the analyses of the SEER data, more than two
thirds of all patients appeared to have an unknown disease stage.
Third, because data on bladder cancer specific survival are not available
from population-based cancer registries, we analyzed gender differences in
relative survival. The relative survival represents the percentage of patients
alive after a certain period of follow-up in the hypothetical situation where the cancer in question is the only possible cause of death. It is calculated by
dividing the observed survival in the patient group by the expected survival Discussion 214
based on general population mortality rates. Therefore, the validity of the
relative survival estimate is dependent of the accuracy of the expected
survival and the assumption that non-cancer mortality is independent of
cancer mortality. This latter assumption may not hold. For example,
smoking is one of the most important bladder cancer risk factors. But it is
also closely related to the risk of dying from, e.g., cardiovascular disease
and chronic obstructive pulmonary disease. Consequently, the expected
survival of bladder cancer patients is probably worse than estimated from
population rates resulting in an underestimate of the relative survival. This
phenomenon combined with the possibility that the etiologic fraction of
smoking on the risk of bladder cancer is higher among males than among
females (as is claimed by several epidemiological studies) suggests that the
relative survival is underestimated to a larger extent among males. This
would mean that the favorable prognosis that we found for males may even
be more favorable. On the other hand, the clearest differences in prognosis
were found in the analyses of the SEER data from the US. It was striking to
see, however, that the relative survival rates from the US were much better than those from the Netherlands (and other European countries). Similar
differences can be seen for other tumor sites. The most likely explanation
for this is that the follow-up of cancer patients in the US is incomplete. This
would lead to underestimates of observed survival and consequently to Discussion 215
underestimates of relative survival. It is not clear how all this affects
relatively small differences in gender-specific prognosis.
Fourth, we should be careful in not over interpreting statistical significance.
The findings in our studies were highly statistically significant. However, the data were so abundant that almost any (small) difference would be
statistically significant.
Leads for future research (Chapter 2)
It is important to note that gender differences in bladder cancer stage
distribution and survival are relatively small and that the absolute risk
(incidence) of high stage bladder cancer is still higher among men than
among women. Therefore, future studies on these gender differences will be
more based on scientific curiosity than on anticipated clinical utility.
It is probably not worthwhile to study differences in diagnostic delay between men and women. Such differences may be responsible for
differences in stage distribution but cannot explain stage-adjusted
differences in prognosis.
Apparently, women do not experience a worse prognosis for other tumors.
On the contrary, for many cancer sites the 5-year relative survival rates are better for women than for men [1]. This suggests that it is not likely that
genetic or hormonal factors are responsible for a worse survival of female bladder cancer patients and the study of such factors should therefore not Discussion 216
have priority. However, anatomical differences between men and women
may be important and deserve attention in future research.
The worse prognosis in female patients with bladder cancer may also be
related to a relatively high incidence of squamous cell carcinoma (SCC).
SCC is an aggressive tumor, which is usually invasive and treated by radical
cystectomy. Among women, 30% of all cystectomies were performed for
SCC compared with 6% in men (a ratio of 5:1) [2]. It was not possible to
stratify our data on the prognosis of bladder cancer by morphology.
Possibly, a relatively higher frequency of non-TCC among women may
have caused a worse prognosis. It would be interesting to obtain
morphology specific survival data from the SEER cancer registries.
It is not clear yet why SCC is relatively more common among women. This
may be related to its association with inflammatory processes. Females
more frequently have inflammatory bladder disease compared with males.
Bladder cancer is related to the absorption of carcinogens like nitrosamines
from the urine as a result of increased permeability or damage to the urethelium, which may occur in humans with urinary tract infection.
Furthermore, inflammatory disease affects the Glycosaminoglycan (GAG)
layer and Laminin levels in the bladder. These are bladder barriers for
cancer. The GAG layer and Laminin levels may be compared between men
and women with (different types of) bladder cancer. Discussion 217
Discussion for Chapters 3 - 6
The likelihood that superficial cancer will recur is 50% to 75% in 5 years.
Approximately 15% of all superficial bladder cancers progress to invasive
bladder cancer. Even after a large number of years, recurrences and
progression can occur. This strongly indicates the need for follow-up of
superficial bladder cancer. At present, follow-up of patients with superficial
bladder cancer includes periodic examinations based on cystoscopy and
cytology. Cytology provides a convenient noninvasive means for evaluating
patients with hematuria or irritative symptoms and for screening of high-risk
populations such as persons exposed to known carcinogens, in addition to
bladder tumor follow-up. Its specificity is excellent. Cytology, however, has
certain drawbacks, including its subjectivity, its reliance on the skills of the
pathologist, and its relative insensitivity for low-grade tumors. In addition,
any kind of therapy for bladder cancer (e.g., surgery, radiotherapy, or
intravesical therapy) reduces the accuracy of cytology. Attempts to improve
the sensitivity of cytology have been made by applying new techniques such
as thin membrane filtration, cytocentrifugation, monolayer technology,
fluorescence in-situ hybridization (FISH) combined with flow cytometry or
computerized image analysis techniques (quanticyt). However, these new techniques require a high level of expertise, must be performed in a
specialized laboratory and are not widely available. Furthermore, cell bound
diagnostic tools depend on the quality and quantity of cells in the Discussion 218
specimens. Therefore, several methods have also been used to obtain a high
quality and quantity of cells for cytology such as better storage of urine, bladder wash, and modification of sampling technique. Urine obtained with
catheterization and/or bladder wash provides more and better preserved cells
and less contamination with normal urothelial cells compared with voided urine cytology. However, it requires instrumentation and is an invasive
procedure that may introduce instrumentation artifact. In our study,
described in Chapter 3, which aimed at increasing the amount of cells for
cytology by modification of the sampling technique fractioned voided urinary cytology (VUC) and bladder wash cytology (BWC), did not affect
detection rates especially in grade I and II tumors. This results indicated us that only higher quantity of cells for cytology is not enough to improve
sensitivity of urine cytology without any improvement on identification of
objective diagnostic criteria for malignant cells, particularly in well-
differentiated.
Although urine cytology is not sensitive to detect most low-grade tumors, these tumors are at low risk for disease recurrence or progression. The
sensitivity of cytology is relatively high for CIS and grade III tumors which
are exactly the tumors that should not be missed, although one might argue that detection of new low-grade lesions is of secondary importance for the
early detection of disease progression. Our study offered promising results Discussion 219
in grade III tumors. Therefore, it deserves a place as a basis for further and
larger scale studies.
Chapter 4, in recent years much attention has been directed towards the
possible use of various urinary markers in screening and monitoring because
cytology and cystoscopy have certain drawbacks. Analysis of urinary
specimens for the presence of substances that may reflect the activities of tumor cells in disrupting the basement membrane and extra cellular matrix
in the infiltrating bladder wall, or assessment of these specimens for cells
and cell products are being evaluated for their specific applicability.
However, the past years have showed us that these tests also have their
limitations, besides various advantages.
The BTA stat test is easy to perform in a diagnostic setting. In our study,
Chapter 5, this test presented significantly higher sensitivity than VUC in
detection of TCC, particularly in low grade tumors. However, it can easily
be affected by benign conditions and yield false positive result. Therefore,
we recruited patients with benign urological conditions to determine
possible false-positive results. Unfortunately, the possible confounding
effect of benign urological conditions could not be evaluated completely in
the present study due to the small number of subjects. These conditions
should be evaluated in larger scale studies. On the other hand, if for every
test all kinds of exclusion criteria have to be defined, one could raise
questions about the clinical usefulness of such a test, since “confounding” Discussion 220
benign urological conditions are seen regularly in normal day practice. In the present study, the performance of the urine cytology was low, since we
selected a relatively high number of low-grade tumors in our study group.
However, in these low grade patients the relative influence of confounding
factors on the test result should be highest, giving us the best opportunity to
study the performance of the test in these patients.
In our hands, Chapter 6, the UBC marker appeared not as good as it was
claimed in previous studies. Possible explanations for this are: problems with the technical performance, limited biological differences of antigens between normal and malignant urothelial cells, and different patient
selection. As in previous studies, the technical procedure was performed
according to the manufacturer. Therefore, this factor was excluded as a
possible cause for discrepancy. The cut-off differences between normal and
malignant urothelial CK 8/18 antigens are too small. This could be a reason
for clinical usefulness of this test, but, could not explain differences with
previous studies. The most obvious differences between our study and
others was the “appropriate” patient selection. Only superficial bladder
cancer patients in follow-up were recruited for this study. The reason we
chose this population was to evaluate the diagnostic performance of the
UBC test in a group of patients during follow-up for recurrence, because we
consider this to be the primary indication of a urinary marker such as the
UBC test. The previous studies included invasive bladder cancer patients in Discussion 221
their patient groups as well. Results from studies including invasive TCC
(higher sensitivity) should not be used to predict test performance in
superficial bladder cancer. In our patient population, the diagnostic OR was
very close to 1.0 and the AUC of the ROC curve was very close to 0.5,
suggesting no diagnostic value for the UBC test in this patient population.
Thus, we concluded that the UBC test does not seem to be suitable for use
in superficial bladder cancer patients.
The early detection of (superficial) bladder cancer in patients at risk for
newly diagnosed or recurrent cancers may significantly impact the options
and effectiveness of therapies. This is relevant with sensitivity of diagnostic
test. The sensitivity indicates percentage of patients with disease who have
an abnormal test. The sensitivity is most important because high sensitivity
leads to high negative predictive value (NPV). NPV of one diagnostic test
shows that there is indeed no disease. Specificity is percentage of patients without disease who have normal test. A relatively high false positive rate
(low specificity) is not dramatic because these patients only undergo
cystoscopy. Therefore, high NPV for a diagnostic test for bladder cancer is
one of the most desirable criteria, particularly in follow-up of disease.
However, the major shortcoming of new diagnostic tests is the low NPV. To
date, the Food and Drug Administration (FDA) has approved the
commercial use of new diagnostic tests only as adjuncts to cystoscopy. Discussion 222
The patient’s opinion and preference are also very important parameters in
the evaluation of the diagnostic methods because long-term follow-up is
required. The experience of our department showed that if the sensitivity of
a urinary test is lower than 90%, 89% of patients will prefer flexible video
controlled cystoscopy as the diagnostic method in the follow-up of
superficial bladder cancer instead of a urinary test [3].
In conclusion, several diagnostic tests and methods have been developed in
recent years, but cytology still maintains its important place in the
diagnostic spectrum. While recent reports on the new urinary tumor markers
show markedly improved sensitivity versus urinary cytology particularly in
low-grade tumors, their sensitivity is not yet good enough. Therefore, these
new markers are ancillary techniques. They should be used in a panel with
cytology and cystoscopy. Combining these new markers could optimize their performance, allowing the advantages of one test to correct the
shortcomings of another. The current view is that some of these tests could
influence the frequency of cystoscopic controls, but these tests cannot
completely replace cystoscopy and cytology.
Leads for future research (Chapters 3 - 6)
Overall sensitivity of cytology is poor. Perhaps, the greatest determinant of the quality of cytology is the level of cytopathological expertise. Currently,
modern communication tools are essential in the transfer of educational Discussion 223
information. CD-roms, interactive computers, and mobile interaction are just some examples of modern ways to inform and instruct people. These tools can be used in a direct educational format to improve cytopathological
expertise. Low sensitivity of cytology is also explained by poor criteria for
identifying well-differentiated, low-grade TCC. Further studies should focus
on identifying features to aid in the distinction between normal urothelial
cells and well-differentiated malignant cells by using objective diagnostic
criteria. For example; some useful objective criteria such as cytoplasmic
homogeneity, increased nuclear-to-cytoplasmic ratio and irregular nuclear borders increased the sensitivity to 85% and specificity to 96% when
applied retrospectively. When examined prospectively, the sensitivity
decreased to 33% [4]. Nevertheless, we need better criteria to improve the
diagnostic accuracy of cytology. Furthermore, urine is an inhospitable
medium for desquamated urothelial cells, which leads to difficulties in
assessing cytology specimens. Further studies should focus on obtaining
more and/or better preserved cells by using different methods such as
creating an optimal pH for cells or decreased osmolality of urine. A
phosphate buffer medium with balanced electrolytes may be added to the urine specimen to minimize harmful effects of contents of urine to cells before submitting the specimen to the laboratory.
The application of immunocytochemistry to urine samples using various
monoclonal antibodies against tumor-associated antigens, e.g., Lewis X Discussion 224
antigen, a relative of the ABO blood group antigens, significantly increases
the sensitivity of urine cytology. However, these antigens also suffer from
the common problem of low specificity. Furthermore, spectral imaging of
different cytochemical dyes such as 5-aminolevulinic acid (5-ALA)
fluorescent dye may be used for staining of neoplastic transferred urothelial
cells in urine samples. In vivo application of 5-ALA induces an
accumulation of fluorescent prophyrins in malignant tissues of epithelial
origin. Possible malignant areas reflect fluorescent light. Its combination with certain light sources has shown to improve the diagnostic sensitivity
and specificity of cystoscopy significantly [5]. Nevertheless, it should be
investigated initially whether desquamated cells can take up these
fluorescent dyes.
Another major drawback of cytology is the low cellular yield in voided urinary samples. Cell cultures could be used to cope with this disadvantage.
Currently, cell cultures have been used in various fields of medicine such as
immunology for white blood cells, infectious disease for bacteria and viruses, and oncology for vaccine. However, it has not been tried for
cytology yet. Cell cultures of urine specimens are made by inoculating
appropriate media with a certain amount of urine and activating the cells with external stimuli. The percentage of dead and damaged cells can be
decreased significantly by external proliferative stimuli and an increased
amount of cells can be obtained for cytological investigation of urine within Discussion 225
an acceptable time. An uncontrolled rapid proliferation of neoplastic transformed urothelial cells makes them ideal for cell culture. On the other
hand, cultured cells may show different differentiation stages for
interpretation of urine cytology because large amounts of cells are used.
Moreover, cell proliferation in response to external stimuli is a complex
process. It involves delivery of a signal or set of signals to the cell
membrane, activating intracellular pathways that are not well understood,
like activation and transcription of multiple genes, DNA and protein
synthesis, and finally cell division.
The clinical usefulness of a diagnostic test depends on procedure time,
costs, personnel and material needed in addition to its sensitivity and
specificity. The ideal test besides accurately predicting the presence of
tumor, should also indicate tumor extent and correlate with the severity of
the disease. High sensitivity and specificity are critically important
measures of the test’s utility. However, for a test to be clinically applicable
and useful for routine practice, the test should be reproducible with minimal
intraobserver and interobserver variability. The method of collection should
be simple and practical. The assay should provide a rapid result at
affordable costs, should be simple to run, and, ideally, should be performed
at the point of care. At last, all data regarding new diagnostic tests must be
confirmed by large multicenter studies with an appropriate patient selection,
before clinical practice can be altered. Discussion 226
Discussion and Leads for future research (Chapters 7 and 8)
Because leads for future and discussion of intravesical therapy were closely
related, these were handled together in this part of the thesis. Despite
intensive laboratory research we still have not elucidated the working
mechanism of BCG, Chapter 7. It is known that a complex cascade of
immunological events takes place. It is agreed that the induction course
should exist of 6 instillations. However, long-term results have
demonstrated that the immune protection is not life long and six weekly
instillations is a sub optimal protocol. To evoke the necessary immune
response in the host, repeated instillations are recommended. Lower disease
recurrence rates have been reported after BCG maintenance therapy of up to
3 years. Boosters of BCG were given at 3,6,12,18,24,30 and 36 months [6].
Nevertheless, a maintenance schedule is practically limited by its toxicity.
The majority of patients were not able to complete such intensive protocols.
Several studies suggest that side effects might be less when decreasing the
dose of BCG in patients with an intermediate risk [7,8]. In papillary T1-Ta,
G1-G2 lesions, the dose can be reduced to 25% with the same effectiveness
as the full dose and fewer general side effects. However, in patients with
high-risk superficial bladder cancer, caution should be exercised in selecting
dose. Isoniazid (INH) has also been given prophylactically in an attempt to
reduce side effects, but a reduction of adverse effects was not observed in
clinical studies. EORTC protocol 30911 (phase III study) has shown that Discussion 227
prophylactic INH does not influence the efficacy or toxicity of BCG [9], but
induces some toxicity itself such as temporary liver function disturbances.
We need some objective markers to detect tumor and bladder wall response
after intravesical BCG therapy to prevent unnecessary courses. After binding of BCG to the bladder wall, BCG antigens, likely processed by
monocytes and possibly urothelial (tumor) cells preferentially activate T
helper type 1 (Th1) lymphocytes, which generate a Th1 milieu (such as IL-
2, IL-8, IL-12, interferon-a) at the site of the tumor. Urinary cytokine
production is associated with anti-tumor activity and may be a possible
predictor of the reaction of the bladder wall and subsequent tumor response
during intravesical BCG maintenance therapy. There is a polymorphism in the capacity of each individual to mount an effective Th1 anti-tumor
response following intravesical BCG instillations. Therefore, monitoring the
expression of these cytokines in urine may lead to a more rational basis for the originally arbitrary BCG treatment schedule, designing a more
individualized and possibly more efficacious instillation schedule [10]. At
present, however, a complex and expensive methodology is necessary for
cytokine determinations in urine. This makes the determination of urinary
cytokines not practical for daily clinical use. Development of test reagent
strips and technology will facilitate urinary cytokine determinations
considerably. Some conflicting results are also present in the literature [11] which indicate the necessity of a consensus with regard to sampling (time Discussion 228
and period), pre-analytical workup, assay method and inter-laboratory
standards.
Since BCG probably exerts its anti-tumor activity in superficial bladder
cancer management in part or in total by stimulating the host’s immune
response and by polarizing this response toward a Th1 state, several other biological responses should be evaluated in this field; such as: antibody
response against native heat shock protein (P64) of BCG.
Other immunotherapeutic drugs such as interferons, interleukins and
Keyhole Limpet Hemocyanin (KLH) may have a place in the adjuvant treatment of superficial bladder cancer.
KLH is a non-specific immunomodulator such as interferons and
interleukins. When recognized by macrophages, KLH initiates the
stimulation of a cell-mediated, delayed hypersensitivity reaction and
primary humoral response. KLH also induces secretion of IL-1a in the urine. Despite some promising results were observed in selected patients, the data presented in literature are certainly limited and need to be supported by additional studies.
Intravesical cytokine gene transfer is a novel modality for potential
enhancement of immune response. Vectors bearing the gene to be transferred can be instilled into the bladder transurethrally. Expression of the gene may lead to inhibition of tumor development and growth or to a
novel form of immunotherapy (IL-2 gene transfer) [12]. Discussion 229
Three major parameters are involved in optimal anti-tumor response: the
host, the immunomodulating agent, and the tumor. Despite incomplete understanding of the bladder tumor, immunomodulating agents and host
immune system, the rapid progress in immunology and urology will provide
a framework for more effective and safe interventions. Non-specific and broad stimulation of immunomodulating agents will be replaced by the
highly specific stimulation of immune reactions targeting precisely defined tumor antigens in the near future. Another important issue is the immune
status of the patient. There is increasing evidence that bladder cancer is able to induce an immune-suppression or to counteract the anti-tumor response.
We do not know whether the immune status of the patient, before starting
BCG, is important. This issue deserves further research.
A variety of intravesical chemotherapeutic agents are now available for the treatment of superficial bladder cancer, Chapter 8. The most frequently used chemotherapeutic agents for bladder instillations are mitomycin C,
epirubicin and doxorubicin. No clear evidence suggests that any intravesical
chemotherapeutic drug is superior to the other in terms of tumor recurrence,
progression, and survival. However, the toxicity profile associated with
these agents may make one more appealing than the other. Future studies
should, for example, focus on obtaining higher drug concentrations in the urine and bladder cancer tissue instead of a higher total dose to increase the
efficacy and to decrease the toxicity of intravesical chemotherapy. Discussion 230
Absorption enhancers such as dimethyl sulfoxide (DMSO) may provide
rationale for future clinical trials involving intravesical chemotherapy for
superficial bladder cancers. The concomitant use of DMSO with intravesical
chemotherapeutic agents enhances the absorption of the agent into the entire
bladder wall. In this way, cytotoxicity and antitumor activity could be
enhanced.
Although BCG seems to be the best available prophylactic treatment for
superficial bladder cancer, chemotherapy can provide similar results in
selected patients. The EORTC-GU group designed a randomized
prospective trial comparing intravesical BCG and mytomycin C in
superficial bladder cancer [13]. After a median follow up of 7.2 years, toxicity and efficacy of the two treatment groups was found to be similar. In
terms of progression to invasive disease, mytomycin C was more effective
than BCG in patients without CIS. However, the difference is rather small
(p=0.06). Because one or two BCG courses of 6 weeks were used in this
study, whether maintenance BCG therapy would have made a difference
remains question. Moreover, the patient selection, dose and treatment
schedules were different in this study. Difference of definition of CIS is a
possible bias.
Based on prognostic factors, superficial bladder cancer patients can be
divided into low, intermediate and high-risk groups. One single instillation with epirubicin or mytomycin C is advocated in all low-risk patients. In Discussion 231
intermediate risk-group, efficacy of BCG is similar to intravesical
chemotherapy, but BCG has more severe side effects. It is agreed that BCG
is the state-of-art treatment for high-risk tumors, such as T1GIII and CIS.
Controversy exists whether BCG is able to prevent progression to muscle
invasive disease. It is suggested by some that BCG decreases the chance of
disease progression [14,15]. Others, however, have not been able to confirm
these results [16]. The same question of a decreased chance of disease
progression after intravesical chemotherapy is less controversial. A large
meta-analysis (3,899 patients in 22 randomized prospective controlled
studies) on the long term (5-year) effect of intravesical chemotherapy on
recurrence and progression was performed by Lamm et al. [17].
Maintenance chemotherapy has failed to decrease tumor progression on the
long-term. Among randomized patients progression occurred in 7.5% of
those receiving intravesical chemotherapy and 6.9% of those treated by
surgery alone. The EORTC-GU group has also performed a meta-analysis
on combined data of Ta and T1 bladder cancer that compared transurethral
resection alone or with adjuvant prophylactic intravesical chemotherapy
from four randomized, phase III trials trails carried out by the EORTC-GU
group and two by the Medical Research Council (MRC) studies carried out
in the UK [18]. The results of this meta-analysis suggest that no clear
advantage exists was found with regard to muscle invasive disease
progression, time to appearance of distant metastases or duration of survival Discussion 232
and progression-free survival as well. Adjuvant therapy had only a favorable
impact on the disease-free interval of patients with superficial bladder
cancer. This meta-analysis demonstrated a significant 7% reduction in
tumor recurrence after 5-year follow-up but found no evidence of reduction
in disease progression. Paradoxically, reduction in tumor recurrence does
not necessarily correspond with a reduction in tumor progression, and
freedom from recurrence is not a guarantee against developing muscle
invasive tumours. How can this be explained? A first explanation can be a
statistical one. The incidence of tumor progression is much less than that of
recurrence. Thus, even with effective treatment a very large sample size would be required to demonstrate statistically significant differences.
Patients with a lower risk for recurrence and progression were included in this study. Differences in progression are more difficult to demonstrate in a
low-risk population. Secondly, the most predictive factor for recurrence is
multifocality, whereas high stage, and to a lesser extent, high grade are
correlated with tumor progression. It is likely that recurrence and
progression may be biologically different phenomena. In the third place,
chemotherapy kills cells by direct contact, and cell kill is proportional to the
concentration and duration of exposure to the agent. Tumor cell contact with
intravesical chemotherapy occurs as a result of diffusion down a
concentration gradient. Cells that are most likely to extend into muscle
receive the least effective treatment. In the last place, chemotherapy is Discussion 233
mutagenic, and previous investigations have shown that repeated instillation
of chemotherapy into normal rodent bladders can induce invasive TCC.
These data raise the concern that intravesical chemotherapy might possibly be carcinogenic in humans. Therefore, these treatment options should be
addressed in terms of toxicity, cost effectiviness affectivity and patients’
preferences as well. Future studies are necessary to evaluate preferences of
patients who have experience with intravesical chemo or immune therapy.
Because no single drug available for intravesical chemo and immune therapy is entirely effective in eradicating bladder tumors or in preventing tumor recurrences and progression, a combination of two or more drugs has been investigated. The exact mechanism by which combination therapy
exerts an antitumor effect on bladder cancer, is not known. Combined
chemotherapy and immunotherapy protocols aim to have synergistic
anti tumor effect. Combined protocols of immunomodulating agents for
prophylactic treatment of superficial bladder cancer aim to enhance the cell-
mediated immune function or to induce apoptosis of tumor cells by cytolitic
cytokines. The use of recombinant BCG strains producing immune
enhancing cytokines, such as IL-2 or IL-12, seems to be an exciting future
prospect in immunotherapy for superficial bladder cancer. Although results
are encouraging, combination treatment protocols are scarcely investigated
and the results are not yet conclusive. Therefore, combination modalities of Discussion 234
promising agents should be investigated more intensively to tailor better treatment options for superficial bladder cancer.
References
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bacillus Calmette-Geurin plus isoniazid for intermediate and high risk Ta, T1 papillary carcinoma of the bladder: a European Organization for Research and Treatment of Cancer genito-urinary group randomized phase III trial. J Urol 2001; 166 (2): 476-81 10. Schamhart DHJ, de Boer EC, de Reijke TM, Kurth KH. Urinary cytokines reflecting the immunological response in the urinary bladder to biological response modifiers: their practical use. Eur Urol 2000; 37(suppl 3):16-23 11. Jackson AM, Ivshina AV, Senko O, Kuznetsova A, Sundan A, O’Donnell MA, Clinton S, Alexandroff AB, Selby PJ, James K, Kuznetsov VA.Prognosis of intravesical bacillus Calmette-Guerin therapy for superficial bladder cancer by immunological urinary measurements: Statistically weighted syndromes analysis. J Urol 1998;159:1054-1063 12. Milella M, Jacobelli J, Cavallo F, Guarini A, Velotti F, Frati L, Foa R, Forni G, Santoni A. Interleukin-2 gene transfer into human transitional cell carcinoma of the urinary bladder. Br J Cancer 1999; 79(5-6):770- 779 13. Witjes JA, van der Meijden AP, Sylvester LC, Debruyne FM, van aubel A, Witjes WP. Long-term follow-up of an EORTC randomized prospective trial comparing intravesical bacilli Calmette-Guerin-RIVM and mytomycin C in superficial bladder cancer. EORTC GU Group and Dutch South East Cooperative Urological Group. European Organization for Research and Treatment of Cancer Genito-Urinary Tract Cancer Collaborative Group. Urology 1998; 52(3):403-410 14. Herr HW, Laudone VP, Badalament RA, Oettgen HF, Sogani PC, Freedman BD, Malaned MR, Whitmore WF Jr. Bacille Calmette- Guerin therapy alters the progression of superficial bladder cancer. J Clin Oncol 1988;6:1450-1455 15. Lamm DL. Long term results of intravesical therapy for superficial bladder cancer. Urol Clin North Am 1992;19:573-580 16. Malmstrom PU, Wijkstrom H, Lundholm C, Wesler K, Busch C, Norlen BJ. 5-year follow-up of randomized prospective study comparing mitomycin C and bacillus Calmette-Guerin in patients with superficial bladder carcinoma. J Urol 1999;161:1124-1127 17. Lamm Dl, Riggs DR, Traynelis CL, Nseyo UO. Apparent failure of current intravesical chemotherapy prophylaxis to influence the long term course of superficial transitional cell carcinoma of the bladder. J Urol 1995;153(5):1444-1450 Discussion 236
18. Pawinski A, Sylvester R, Kurth KH, Bouffioux C, van der Meijden A, Parmar MK, Bijnens L. A combined analysis of European Organization for Research and Treatment of Cancer, and Medical Research Council randomized clinical trials for the prophylactic treatment of stage TaT1 bladder cancer. European Organization for Research and Treatment of Genitourinary Tract Cancer Cooperative Group and the Medical Research Council Working Party on Superficial Bladder Cancer. J Urol 1996;156(6):1934-1940 Summary Summary 238
Bladder cancer is an important public health problem, not in the least place because of the high recurrence rate (and hence prevalence) of so called
superficial bladder tumours. Several aspects of these superficial tumors have been studied in this thesis. We studied the impact of gender at first
presentation to get more insight in the consequences of gender on the
prognosis of (superficial) bladder cancer. In an attempt to improve and/or
facilitate the diagnosis of superficial bladder cancer we tried to improve the
performance of urinary cytology and looked at several urinary markers.
Finally, the therapy of superficial bladder cancer is critically discussed.
In Chapter 2, we described stage properties at first presentation and
prognostic discrepancies of (superficial) bladder cancer in men and women.
In our first study, it appears that women with bladder cancer have a higher
chance to be diagnosed at first presentation with invasive disease than men.
It has been suggested that the worse prognosis is caused by a worse stage
distribution at diagnosis among women. The purpose of the second study was to evaluate whether women with bladder cancer have a worse prognosis
even after adjustment for disease stage at first presentation by using U.S and
Dutch cancer registries. In each stage category, female patients had still a
worse prognosis compared to males in both the U.S. and the Dutch
databases after stage adjustment. The higher stages showed a worse 5-year
survival for females compared to males in the same stage, with the largest
difference for pT4 tumors. It is unlikely that the difference can be explained Summary 239
entirely by the more frequent diagnosis of higher stages at first presentation
among women. In the last study, anatomical and other differences between
men and women are discussed which may explain the differences in
prognosis.
In the study presented in Chapter 3, the ultimate goal was to improve the
insufficient sensitivity of urine cytology by using various urinary samples under different pressure profiles of the detrusor activity. For this purpose,
voided urine specimens and bladder wash materials were divided into three
portions as first, mid and last. No statistically significant differences were
found in the sensitivities of voided urine and bladder wash cytology
between either grades or portions in this study. However, malignant cells
and particularly grade III tumors have been detected with highest sensitivity
in the last portion of the voided urine when detrusor activity was maximal.
In Chapter 4, the clinical utility of the BTA test, the BTA stat test, the BTA
track test, NMP22, quanticyt, monoclonal antibodies (surface antigen
19A211 and mucinous antigen M344), telomerase and microsatellite
techniques for the diagnosis and prognosis of superficial bladder cancers
were reviewed. The sensitivities of all these new tests in overall terms and
according to stage and grade were better than those of urine cytology, their
specificities were lower when compared to those of cytology. Although
these new tests have some advantages as compared to cytology, none of these seems to have ideal diagnostic properties. Summary 240
In Chapter 5, we prospectively evaluated and compared the diagnostic
values of the BTA stat test and voided urinary cytology in patients with
histologically confirmed TCC, benign genitourinary disease and healthy volunteers. The BTA stat test was significantly more sensitive than urine
cytology for all grades and stages of the tumor, but was less specific. False
positive results were found in patients with benign genitourinary disease
such as urinary tract infection, BPH, cystocele, nephrolithiasis and previous
prostate operations. Our results suggested that this simple test could
improve the detection of TCC, particularly in low-grade tumors. However,
the urologist should be aware of the fact that this test may be affected by
some benign conditions.
In Chapter 6, the diagnostic value of the UBC test was evaluated in patients
who were under follow-up after transurethral tumor resection for superficial
bladder cancer. There were no significant differences in UBC values (non
corrected and corrected) between patients with or without superficial
bladder cancer. Exclusion of urinary tract infection did not improve the
results. The overall sensitivity, specificity, positive predictive value and
negative predictive value of this new urinary marker were far from
qualifying it as an ideal diagnostic test.
In Chapter 7 and 8, practical guidelines of intravesical BCG and
intravesical chemotherapy in the management of superficial bladder cancer
are presented. Much work has been done to investigate several aspects of Summary 241
the use of intravesical BCG or intravesical chemotherapy in the treatment of
superficial bladder cancer. However, many questions still remain. In the
second part of chapter 7, we presented the results of a randomized phase III
protocol, comparing MMC alone with subsequent administrations of the
MMC and BCG, in patients with moderate and high-risk superficial bladder
cancer. No significant differences were found between the groups in terms
of tumor recurrence, tumor progression, or systemic toxicity.
In conclusion, gender at first presentation appears to have a significant,
although clinically limited, influence on the prognosis of bladder cancer
patients. There is no clear explanation for this finding. Urinary cytology
remains the golden standard in the diagnosis of superficial bladder cancer.
Although urinary cytology is not very sensitive in case of low grade tumors,
it is very specific. Current, commercially available urinary markers seem to
have some additional value over cytology, but cannot replace cytology and
certainly not cystoscopy. Therapy of superficial bladder cancer remains a
choice between intravesical chemotherapy and the more toxic but also more
effective use of BCG.
Samenvatting Samenvatting 244
Blaascarcinoom is een belangrijk probleem voor de volksgezondheid, niet in
de laatste plaats door de hoge recidief frequentie (en dus hoge prevalentie)
van de zogenaamde oppervlakkige tumoren. Verschillende aspecten van
deze oppervlakkige blaastumoren zijn in dit proefschrift bestudeerd. Zo is
gekeken naar de invloed van het geslacht van de patiënt bij primaire
diagnose van (oppervlakkig) blaascarcinoom, om een indruk te krijgen van
de invloed van het geslacht op de prognose. In een poging de diagnose van
het oppervlakkige blaascarcinoom te verbeteren of te vergemakkelijken
hebben we geprobeerd de waarde van urine cytologie te verbeteren, en
hebben we diverse urine makers bestudeerd. Ten slotte is de behandeling
van oppervlakkig blaascarcinoom kritisch bekeken.
In hoofdstuk 2 wordt beschreven dat er verschillen zijn tussen mannen en vrouwen in het stadium van het (oppervlakkige) blaascarcinoom bij primaire
presentatie. De eerste studie laat zien dat vrouwen een hogere kans hebben bij primaire presentatie te worden gediagnosticeerd met een invasieve blaastumor dan mannen. De indruk bestond dat dit kwam door een slechtere
stadium verdeling bij vrouwen vergeleken met mannen. Daarom werd in
een tweede studie gekeken of vrouwen nog steeds een slechtere prognose
hadden indien eerst werd gecorrigeerd voor stadium, door gebruik te maken
van de Amerikaanse en Nederlandse kanker registratie. Ook na correctie bleken vrouwen in elk stadium een slechtere prognose te hebben vergeleken
met mannen, zowel met de Amerikaanse als Nederlandse gegevens. Zo Samenvatting 245
werd een slechtere 5 jaars overleving voor vrouwen gevonden bij hogere
tumor stadia, met een grootste verschil voor pT4 tumoren. Het is
onwaarschijnlijk dat dit verschil alleen kan worden verklaard door
overdiagnostiek van meer invasieve tumoren bij vrouwen. In de laatste
studie, beschreven in dit hoofdstuk, worden meerdere aspecten van blaascarcinoom bij vrouwen besproken. Behalve verschillen in incidentie en
prognose, verschillen blaastumoren bij vrouwen op nog meer punten van blaastumoren bij mannen.
In hoofdstuk 3 wordt een studie beschreven waarbij het uiteindelijke doel was om de (onvoldoende) sensitiviteit van urine cytologie te verbeteren
door verschillende porties urine te verzamelen tijdens verschillende fase van
de mictie en dus verschillende druk profielen van de musculus detrusor.
Porties urine van het begin, midden en eind van de mictie werden vergeleken. Er werd geen significant verschil gevonden voor de sensitiviteit van urine cytologie, noch van blaas spoelings cytologie tussen de
verschillende porties. Wel was de sensitiviteit van cytologie van de laatste
geplast portie urine, wanneer de activiteit van de musculus detrusor
maximaal is, het hoogst.
Hoofdstuk 4 geeft een overzicht van de klinische waarde van verschillende urinetesten. De sensitiviteit van al deze testen is in het algemeen, maar ook voor de diverse stadia en differentiatie graden van tumor, beter dan van
normale urine cytologie. Aan de andere kant is de specificiteit van deze Samenvatting 246
testen lager dan die van urine cytologie. Dus, ondanks het feit dat dergelijke testen enkele praktische voordelen boven urine cytologie hebben, geen van
de huidige testen is ideaal.
In hoofdstuk 5 is de diagnostische waarde van de BTA stat test prospectief vergeleken met die normale urine cytologie bij patiënten met een
histologisch bewezen urotheelcel carcinoom van de blaas, goedaardige
urologische afwijkingen en gezonde vrijwilligers. De BTA stat test was
significant sensitiever voor alle graden en stadia van tumoren, maar minder
specifiek vergeleken met urine cytologie. Fout positieve resultaten werden bij patiënten met infecties, BPH, cystocele, stenen en eerdere prostaat
operaties. Deze studie suggereert dat de simpele BTA stat test de detectie van blaastumoren kan verbeteren, met name in laaggradige tumoren. Aan de
andere kant more de uroloog zich bewust zijn van de invloed van verschillende goedaardige urologische afwijkingen op de uitslag van deze test.
In hoofdstuk 6 wordt de diagnostische waarde van de UBC test beschreven bij patiënten die vervolgd worden na behandeling van een oppervlakkige blaastumor. De UBC test (al dan niet gecorrigeerd), bleek niet te kunnen
discrimineren tussen patiënten met en zonder een recidief van hun
oppervlakkig blaascarcinoom. Uitsluiten van urineweg infecties en corrctie voor geslacht verbeterde de studieresultaten niet. De sensitiviteit, Samenvatting 247
specificiteit en positief voorspellende waarde van deze nieuwe urine test waren verre van ideaal.
Hoofdstukken 7 en 8 geven praktische richtlijnen voor de behandeling van
patiënten met oppervlakkige blaastumoren met intravesicale BCG of
chemotherapie. Ondanks het vele werk in dit gebied blijven vele vragen
onbeantwoord. In het tweede deel van hoofdstuk 7 wordt een
gerandomiseerde fase III studie beschreven, waarin Mitomycine wordt vergeleken met een combinatie van Mitomycine en BCG, bij patiënten met
gemiddeld en hoog risico oppervlakkige blaastumoren. In deze studie werdt
geen significant verschil gevonden tussen beide behandelings armen met betrekking tot tumor recidief, tumor progressie en systemische bijwerkingen.
In conclusie blijkt geslacht een klinisch beperkte maar wel significante
invloed te hebben op de prognose van patiënten met blaascarcinoom, waar vooralsnog geen duidelijke verklaring voor bestaat. De diagnose van het
oppervlakkige blaascarcinoom gebeurt nog steeds met urinecytologie.
Hoewel weinig sensitief voor laaggradige tumoren is het zeer specifiek, en
de huidige commercieel verkrijgbare urinetests lijken in de dagelijkse
praktijk hooguit een aanvulling op urinecytologie, geen vervanging, zeker
niet van een cystoscopie. Therapie van het oppervlakkige blaascarcinoom blijft vooralsnog een keuze tussen intravesicale chemotherapie en het meer toxische maar ook effectievere BCG.
Acknowledgements Acknowledgements 250
It has been a great honor for me to work in the clinic of Prof. Dr. Debruyne. I express my deepest thanks and heart-felt gratitude to Prof. Dr. Debruyne for his immeasurable contributions towards the proper orientation of my academic career and the completion of my doctoral dissertation.
Fred Witjes helped and supported me most with his enormous energy in structuring my dissertation and in going through all of the phases of my Ph.D. work. I extend my infinite thanks to him.
I am also infinitely grateful to Bart Kiemeney for helping me to develop my thesis to its present level. Each piece of the joint work we have done has turned into a valuable learning experience for me thanks to his professional support in scientific subjects.
I offer my deepest thanks to Jean de la Rosette for all invaluable supports.
I would like to extend my thanks also to all of the co-authors for their guidance and stimulating comments. Similar thanks must go to the staff, residents, operation theatre and department nurses for their continuous help and support. I am grateful to all of them.
My wife Görkem was the fortress of support and power that sustained me throughout my PhD process. I feel extremely lucky to have her and I am falling deeper and deeper in love with her everyday.
My parents both helped me learn and appreciate the value of science and scientific research in human life. More importantly, they have selflessly provided me with all that was necessary so that I will become a good human being and a good doctor. I cannot thank them enough for all that they have done.
Finally, I would also like to offer my special thanks to the friendly, hard working and respectful people of Holland who have added a special meaning and a deeper dimension to my scientific work with the friendship. Curriculum Vitae Curriculum Vitae 252
The author was born in Ankara in 1965. He was accepted to the Faculty of Medicine of Ankara University in 1982 and graduated in 1989. He served his obligatory medical service in Altindag Hidirliktepe Health Center between 1989 and 1991. He started his residence training in the Clinic of Urology of Ankara Numune Research and Education Hospital in 1991 and became a specialist in 1995. He performed his military service in the Clinic of Urology of Ankara Mevki Hospital. He worked at the Urology Department of Ankara Numune Education and Research Hospital as a staff member between 1995 and 2000. He became an assistant of professor at the Urology Department of Medical Faculty of Zonguldak Karaelmas University in November, 2000. He was promoted to the associate of professor in April, 2002. He has been working as an associate of professor at the Urology Department of Medical Faculty of Zonguldak Karaelmas University since April, 2002. He comleted European Board of Urology examinations and became a “Fellow of the European Board of Urology” in 2002.
He studied prostate cancer for a short period under the supervision of Professor Scardino in Baylor College, Texas Medical Center, Methodist Hospital, Department of Urology, in the United States of America in 1997. Then he was provided a grant from Nuffic (Nederlandse Organisatie voor Internationale Samenwerking in het Hoger Onderwijs) to research oncology as a fellow under the supervision of Professor F.M.J.Debruyne at the University Hospital of Nijmegen, Department of Urology, in the Netherlands. He has started his Ph.D. research project about superficial bladder cancer in this department in 1997.
He is a member of European Association of Urology, Turkish Association of Urology, Association of Urooncology, Association of Pediatric Urology, Turkish Association of Andrology and International Society of Andrology.
He is married and has two sons.