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Organ-Preserving Approach in Bladder Cancer: Assessment of the Current Situation

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Organ-Preserving Approach in Bladder Cancer: Assessment of the Current Situation Review DO I: 10.4274/uob.967 Bulletin of Urooncology 2018;17:63-67 Organ-Preserving Approach in Bladder Cancer: Assessment of the Current Situation Reha Girgin MD, N. Aydın Mungan MD Bülent Ecevit University Faculty of Medicine, Department of Urology, Zonguldak, Turkey Abstract Intravesical bacillus Calmette-Guerin (BCG) therapy is the gold standard treatment option in high-risk non-invasive bladder cancer. However, BCG is a very toxic agent. A significant proportion of patients have BCG intolerance after beginning intravesical treatment. Radical cystectomy is the recommended approach for patients with either BCG failure or BCG intolerance. Alternative intravesical salvage treatments are needed for patients who cannot tolerate radical cystectomy due to comorbidities or who refuse surgery. In this review, current intravesical treatment alternatives to radical cystectomy in intravesical BCG failure are discussed with oncologic outcomes. Keywords: Bladder cancer, bacillus Calmette-Guérin failure, intravesical salvage therapy Introduction Although NMIBC patients can be successfully treated with intravesical BCG, they exhibit relapse and progression rates of Bladder cancer is the seventh most common type of cancer 80% and 40% respectively at 5-year follow-up. As described in a among males and eleventh among both genders combined (1). 2000 study by the Southwestern Oncological Group (SWOG), the In 2016 alone, 76,960 new cases were diagnosed and 16,390 intravesical BCG regimen is administered as a 6-week induction cancer-related deaths were reported in the United States of course followed by 3 years of maintenance therapy if there are America (2). Cancer staging and treatment planning can be no signs of tumor in follow-up endoscopic examinations (6). achieved with a successful endoscopic resection and when However, in the presence of persistent or recurrent NMIBC, a necessary, metastatic evaluation. Although 70% of cases are substantial proportion of patients may benefit from an additional non-muscle invasive superficial cancers (NMIBC) at the time 6-week induction course with or without interferon (IFN) alpha of diagnosis, about 20% of these are grade Ta and T1 tumors (3). Findings indicating BCG resistance during therapy include including carcinoma in situ (CIS), which form a special group high-grade NMIBC in the first cystoscopic examination, CIS in associated with high risk of cancer progression and relapse the first or second cystoscopic examination, and high-grade (3). Intravesical bacillus Calmette-Guérin (BCG) therapy is cancer in follow-up cystoscopic examinations during or after the primary treatment method for these high-risk NMIBCs completing the intravesical BCG protocol (7). The occurrence of (4). For non-metastatic muscle-invasive bladder cancer, radical adverse effects that prevent continuation of treatment is referred cystectomy is considered the gold standard treatment option to as BCG intolerance (7,8). NMIBC patients exhibiting BCG that provides the longest survival. With a goal of complete tumor resistance or intolerance are candidates for radical cystectomy elimination, grade 3-4 complication rate of 13% and mortality (9). However, the various comorbidities in elderly patients and rate of 2.5-5.2% are considered acceptable (5). the reluctance of younger patients to risk undergoing such a Ad dress for Cor res pon den ce: Reha Girgin MD, Bülent Ecevit University Faculty of Medicine, Department of Urology, Zonguldak, Turkey E-mail: [email protected] ORCID-ID: orcid.org/0000-0003-1132-8629 Re cei ved: 04.01.2018 Ac cep ted: 29.01.2018 ©Copyright 2018 by Urooncology Association Bulletin of Urooncology / Published by Galenos Yayınevi 63 Girgin and Mungan Bladder Preservation Approach in Bacillus Calmette-Guérin Resistance procedure have led to a search for local therapeutic alternatives rate of 21% and disease-free rate of 8% at the end of 18 to radical cystectomy (5). months follow-up in 90 patients with BCG-refractory CIS. As a result of this study, intravesical valrubicin therapy is the Mitomycin C only chemotherapeutic agent approved by the FDA for BCG- refractory CIS (20). Thiotepa, adriamycin, and mitomycin C (MMC) were initially the preferred first-line agents for patients who were sensitive Taxanes (Docetaxel and Paclitaxel) to BCG but could not undergo BCG therapy (9). Today, only MMC still holds this position (10). MMC has an important place Agents in the taxane group act by disrupting microtubule among chemotherapeutic agents. It is an alkylating agent that function and halting cell division at M-phase (21). Preclinical disrupts DNA synthesis (4). It is used perioperatively in NMIBC studies have shown that taxane chemotherapeutics are highly treatment due to its ability to block tumor seeding in particular effective on bladder cancer cells (22). Laudano et al. (22) (4). However, maintenance therapy does not yield satisfactory conducted a phase 1 trial in which intravesical docetaxel outcomes when BCG fails (10). To that end, it seems that (DTX) was administered to 18 patients who did not respond advances in intravesical drug administration techniques are to intravesical BCG, and reported a complete response rate of starting to provide favorable outcomes. Chemohyperthermia 22%, partial response rate of 17%, and non-response rate of (CHT) and electromotive drug administration (EMDA) are two 61% during a mean follow-up of 48 months (22). In another methods developed to achieve this aim. In CHT, a specialized study by Barlow et al. (23) 54 non-responders to BCG where urethral catheter is used to deliver radiofrequency waves inside administered intravesical DTX, and recurrence-free rates at 1 the bladder, thus raising the temperature. This increases cell and 3 years were 40% and 25%, respectively. permeability to MMC and promotes apoptosis by inducing Intravesical agents must remain in the bladder for 2 hours stress in tumor cells (11). After using this technique in 111 to achieve maximum efficacy (24). However, due to reasons patients with failed BCG, Nativ et al. (12) reported recurrence- such as bladder irritability or low bladder capacity, this waiting free rates of 85% at 1 year and 56% at 2 years. In another period is often unachievable (24). Since paclitaxel (PTX) study including 51 patients with failed BCG from 15 centers was first introduced in 1967, many carrier agents have been in Europe, Witjes et al. (13) reported complete response investigated to increase the efficacy of taxanes due to their rates of 92% initially and 50% after 2 years. Although CHT is lipophilic properties and low cell penetration (4). In the phase 1 recognized by many authorities, it is still in the Food and Drug study by McKiernan et al. (25) using PTX bound to intravesical Administration (FDA) review process. EMDA aims to create an nanoparticle albumin (NPA), the complete response rate at 6 electromagnetic field to increase bladder surface epithelial cell weeks was 28% and only grade 1 toxicity occurred in 10 of permeability to MMC (14). Like CHT, EMDA was designed to the 18 patients. In a subsequent phase 2 study, the complete increase the efficacy of MMC in moderate and high-risk NMIBC, response rate was 35.7% and toxicity rate was 32.1% at 1 year but was unable to provide satisfactory results when applied after (26). Robins et al. (27) recently reported a disease-free rate of resistance to BCG. Sockett et al. (15) reported 31% relapse at 15 18% and a cancer-specific survival rate of 9% at the end of 41 months in 13 patients with failed BCG who were given MMC months follow-up in patients treated with NPA-bound PTX after by EMDA. BCG failure. Gemcitabine Interferon Gemcitabine (GC) is a nucleotide antimetabolite that disrupts IFN is a cytokine with immunomodulatory, antiproliferative, and DNA synthesis in tumor cells by inhibiting ribonucleotide antiviral properties (28). Earlier research established that IFN reductase and cystine diaminase (4). In a randomized controlled monotherapy had no utility in the treatment of NMIBC (28). study, Addeo et al. (16) determined that GC was more effective The first of these studies was a 1990 prospective randomized and less toxic than MMC. In their phase 2 trial, Skinner et study by Glashan (29) including 87 patients who were treated al. (17) reported a recurrence-free rate of 28% after 1 year with either low-dose (10 million U) or high-dose (100 million of treatment with intravesical GC. Prasanna et al. (18) also U) intravesical IFN monotherapy and followed for 12 months. reported in their study that intravesical GC provided a similar After 1 year, complete response rate was 43% in the high-dose disease-free survival to intravesical BCG and caused less toxicity. arm and 5% in the low-dose arm (29). The most common Although intravesical BCG is currently the gold standard side effects were influenza-like symptoms, which occurred in treatment for high-risk NMIBC, GC may be recommended as 17% of patients in the high-dose arm and 8% of those in the an alternative first-line intravesical therapy for BCG-resistant low-dose arm (29). However, in 1995, Hudson and Ratliff (30) patients not suitable for cystectomy and patients who cannot conducted a prospective study with 12 patients who were tolerate the toxicity of BCG (18). treated with intravesical IFN (100 million U) after non-response Valrubicin to previous BCG treatment, and they reported a complete response rate of 8% at the end of 24 months. In a multi-center Valrubicin is a synthetic anthracycline analogue that exerts randomized phase 2 trial of intravesical BCG and IFN combined a toxic effect by penetrating nucleic acid sequences and therapy conducted by Joudi et al. (31) a cancer-free survival arresting the cell cycle (19). Steinberg et al. (19), who comprise rate of 13% was reported at the end of 24 months follow-up. the valrubicin study group, reported a complete response In another prospective study including 50 patients treated 64 Girgin and Mungan Bladder Preservation Approach in Bacillus Calmette-Guérin Resistance with a combination of BCG and IFN, Bazarbashi et al.
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