Research Article
Single Ablative Intravesical Electromotive Mitomycin C Administration for Small Non-Muscle-Invasive Bladder Cancer: A Prospective Study
Karel Decaestecker, Nicolaas Lumen, Christel Van Camp and Willem Oosterlinck*
Department of Urology, Ghent University Hospital, Ghent, Belgium
*Corresponding author: Willem Oosterlinck, Department of Urology, Ghent University Hospital, Ghent, Belgium
Published: 31 Mar, 2017
Cite this article as: Decaestecker K, Lumen N, Van Camp
C, Oosterlinck W. Single Ablative
Intravesical Electromotive Mitomycin C
Administration for Small Non-Muscle-
Invasive Bladder Cancer: A Prospective
Study. Clin Oncol. 2017; 2: 1253.
Abstract
Aim: To explore the effect of Electromotive Drug Administration Of Mitomycin C (EMDA-MMC) using a single dose of intravesical mitomycin C (MMC) to avoid transurethral resection (TURBT)
for small non-muscle-invasive bladder cancer.
Material and Methods: All patients presenting small papillary bladder tumors were proposed to
undergo a single EMDA-MMC session with 60mg MMC before planning TURBT. The end point is
complete disappearance of all papillary tumors at 2 to 4 weeks after EMDA-MMC.
Results: Thirty-six sessions were given to 32 patients. In general the treatment was well supported,
except for two patients who had severe bladder spasms, resulting in early evacuation of the MMC.
Complete response occurred in 28% (10/36 sessions). In 4 sessions with multiple tumors some
tumors disappeared while others remained. In 61% (22/36) the tumors remained unchanged.
Conclusion: A single EMDA-MMC in small papillary bladder tumors gives insufficient ablative
effect.
Keywords: Electromotive drug administration; Mitomycin; Intravesical chemotherapy; Urothelial bladder cancer; Chemoresection; Superficialbladder tumors; Non-muscle-invasivebladder cancer
Introduction
The ablative effect of repeated intravesical chemotherapy on small papillary non-muscle-invasive bladder tumors has been used to avoid transurethral resection of bladder tumors (TURBT) in about half of the cases [1-3]. In 1999, Masters et al. [4] obtained similar results even with a single instillation of epirubicin. This amazing experience was never repeated or at least not published by others. The excellent results obtained in the prevention of recurrences with the use of electromotive drug administration (EMDA) [5-10] let us expect an even better response than with a chemotherapeutic drug alone. It was our intention to repeat the experience of Masters et al. [4] with the use of a single electromotive drug administration of mitomycin C (EMDA-MMC). We hypothesize to avoid TURBT and to postpone recurrence in the responders in at least half of the patients.
Methods
Between May 2012 and September 2015 all patients in the department of urology presenting
with, primary or recurrent, small (≤2cm) papillary bladder tumors were proposed to undergo
an EMDA-MMC session before planning TURBT. Tumor size was estimated on cystoscopy and
ultrasound. Recurrent patients treated with intravesical MMC within the last year or patients
with a history of Tis of the bladder were excluded. On the basis of earlier ablative studies with
mitomycin [1-4], the patients were given a 50% probability to avoid anesthesia and TURBT. A
control cystoscopy was performed 2 to 4 weeks after EMDA-MMC and TURBT scheduled only
when the tumors were persistent. The primary end point of this study is complete response, defined
as complete disappearance of all papillary tumors at cystoscopy at 2-4 weeks after the treatment,
in order to avoid TURBT. The secondary end point is toxicity. To identify potential predictors for
complete response, tumor characteristics (primary versus recurrent, previous instillations, number
and size of tumors and positive versus negative urinary cytology) were assessed with chi-square
statistics. Written informed consent was obtained from all patients and the study was approved by
local ethics committee (UZG 2012/459).
Technique of EMDA-MMC
The technique as described in the review publication of Kalsi
et al. [10]. Using intravesical EMDA, drug delivery through the
bladder mucosa is accelerated by the application of an electric field
across the bladder wall, which stimulates directional ionic and solute
movement. A low electric current, controllable between 0-30mA
and 0 to 55V, is passed between 2 electrodes connected with the
battery powered generator Physionizer 30 manufactured by Physion®
(Mirandola, Italy). The dispersive ground electrodes are placed on
a cleaned and unblemished skin of the lower abdominal wall with a
wide area of contact. The active intravesical electrode is incorporated
in a specifically designed single use, 18 Fr urethral Foley catheter,
with a 3 ml balloon. The urethral catheter is inserted using the
standard sterile technique and intraurethral local anesthetic lubricant
gel. The bladder is carefully drained and washed with distillated water
to clear all solutes which can alter the electromotive activity. MMC
60mg dissolved in 100ml bi-distillated water is injected in the bladder
through the catheter. The catheter electrode and the abdominal
electrodes are then connected to the generator and a 25mA current
is applied during 25 min. At completion the generator switches off
automatically.
Results
Thirty-six EMDA-MMC sessions were given to 32 patients, including 4 patients who received a second session at a new recurrence. Patient and tumor characteristics are given in Table 1. Complete responseoccurred in 25% (8/32) of the patients, in 28% (10/36) of all EMDA-MMC sessions, and in 50% (2/4) of the repeated sessions. In cases with multiple tumors (n=16), some tumorsdisappeared in 4 of them, while others remained unchanged (partial response). In 61% (22/36), the tumors remained unchanged. The results according to tumor characteristics are summarized in Table 1. None of the tumor characteristics could predict for complete response. In general the treatment was well supported. However, two patients suffered severe bladder spasms when the EMDA current was applicated. One urinated immediately upon and one 9 minutes after the start of EMDA-MMC. Both patients were failures. One patient refused TURBT and disappeared for further follow-up. In 2 others, the TURBT was not performed because of serious undercurrent disease that made this patients unfit for surgery. The pathology of the resected tumors (Table 2) was TaG1 in 10, papillary urothelial neoplasia of low malignant potential (PUNLMP) in 2,Ta G2 in 3, Ta G3 in 3 and adenocarcinoma of the bladder in 1 patient. In 4 the delivered specimen was insufficient for an adequate pathology report.
Discussion
It has been well established that 4 intravesical instillations of
MMC are able to completely destroy small papillary tumors and
consequently have the possibility to avoid TURBT in about half of the
patients [1-3]. Only one publication reports on the efficacy of a single
chemotherapeutic intravesical instillation, comparing epirubicin
50mg and 100mg, before TURBT [4] in patients with small papillary
lesions. In the 50mg epirubicin group, 24 out of 52 patients became
tumor free and TURB could be avoided; in the 100mg dose group, 21
out of 50 patients responded. The authors concluded that doubling
the concentration of the drug did not improve the efficacy. An overall
"chemoresection" of 45 out of 102 patients with a single intravesical
instillation is an amazing result. Repeating this experience with
EMDA, which was considered as very promising by several authors
[9,10], lets us expect that probably half of the patients can be spared a TURBT. Our previous experience showed that recurrent patients,
previously treated with TURBT and intravesical instillations, largely
prefer instillations over TURBT if they are given this opportunity [3].
The results of the present study are disappointing: only 10 complete
responses in 36 sessions (28%). Therefore, we do not advocate the
technique of a single EMDA-MMC session to avoid TURBT. In
11% (4/36) with multiple tumors, some tumors disappeared while
others remained unchanged. One can call this a partial response, but
of course the goal of the study, to avoid TURB, was not obtained.
This 11% compares with the 13% partial response that we have seen
in our previous study [3] with 4 MMC instillations. This supports
the heterogeneous nature of TCC even within the same patient and
therefore sensitivity to chemoresection may differ among tumors
in the same patient. As we have also previously noted [3], bladder
tumors can become resistant to intravesical chemotherapy over time,
as we noticed that patients who completely respond to a first session,
do only respond in half of the cases to a repeated session given for
a recurrence. Previously MMC treated, larger tumors, multiple,
primary or recurrent tumors, all had some CR. The best results were
obtained in patients with small tumors (<5mm) and those with
negative cytology however without reaching statistical significance. A
study with a larger group of patients is needed whether this favorable
trend could be confirmed.
We cannot explain the differences between our results and those
obtained with a single instillation of epirubicin in the study of Masters
[4]. Although the drug was different in both studies, major differences
between the outcomes of MMC and epirubicin have not been reported in the large number of publications on the intravesical use of
both drugs in bladder tumors. On the contrary, given the theoretical
advantages of EMDA in penetration of an intravesical delivered drug
into the bladder wall, one would rather expect better results. It were
the successful results of previous clinical investigations with 4 MMC
instillations before TURBT [1-3], which incited us to the explore
the effect of one single instillation, possibly improved by EMDA. It
is possible that 2 or more instillation are more successful but this
considerably diminishes cost effectiveness, exposes some patients to
ineffective treatment and delays correct pathology with some weeks.
Therefore we have not the intention to perform such studies.
The present study does not contradict the results obtained with
EMDA-MMC in the prevention of recurrence and progression of
bladder tumors the ablative effect of visible tumors is clearly different
from the preventive setting.
Our study has some limitations. Our patient cohort is small and
heterogeneous regarding primary or recurrent patients. However,
all studies reporting on chemoresection have only between 25-102
patients and consistently report a 50% chance of complete remission,
mainly in the recurrent setting [1-4]. As the number of complete
remissions is low, only 10, it is impossible to find a relationship
between response and urinary cytology, multifocality, primary or
recurrent tumor, previous MMC use, volume of the tumors or final
pathology of the resected tumors. We can only state that all types of
tumors responded to a certain degree. The EMDA-MMC treatment
also was started on the visual judgment of the tumor and it is nearly
certain that some of the “tumors” were not urothelial neoplasms.
When they disappear after intravesical chemotherapy it is most
likely true, but when pathology in the non-responders could not
demonstrate with certainty a tumor, as was the case in 7 treatments,
the diagnosis remains uncertain. Excluding those 7 cases and the 2
cases which did not receive the full treatment because of intolerance
to intravesical MMC, the CR would become 37% (10/27 EMDAMMC
sessions). But even such result remains below our expectations
and in real life one would continue to propose EMDA-MMC after
visual judgment of the tumor at diagnostic cystoscopy, including a
few papillary formations which are not urothelial neoplasms.
Table 1
Table 2
Conclusion
A single EMDA-MMC in small papillary bladder tumors gives insufficient ablative effect to be advocated to avoid TURB. The best response occurred in single, small, recurrent papillary tumors with negative cytology but statistical significance was not reached. It was noticed that in the same patient some tumors disappeared by intravesical chemotherapy while others were resistant to the treatment. It was also observed that resistance to MMC developed over time.
References
- Maffezzini M, Simonato A, Zanon M, Raber M, Carmignani G. Up-front intravesical chemotherapy for low stage, low grade recurrent bladder cancer. J Urol. 1996;155(1):91-3.
- Colombo R, Rocchini L, Suardi N, Benigni F, Colciago G, Bettiga A, et al. Neoadjuvant short-term intensive intravesical mitomycin C regimen compared with weekly schedule for low-grade recurrent non-muscle-invasive bladder cancer: preliminary results of a randomised phase 2 study. Eur Urol. 2012;62:797-802.
- Decaestecker K, Lumen N, Ringoir A, Oosterlinck W. Ablative Intravesical Chemotherapy for Small Recurrent Non-Muscle-Invasive Bladder Cancer: A Prospective Study. Urologia Internationalis. 2016;96:14-9.
- Masters JR, Popert RJ, Thompson PM, Gibson D, Coptcoat MJ, Parmar MK. Intravesical chemotherapy with epirubicin: a dose response study. J Urol. 1999;161(5):1490-3.
- Di Stasi SM, Vespasiani G, Giannantoni A, Massoud R, Dolci S, Micali F. Electromotive delivery of mitomycin C into human bladder wall. Cancer Res. 1997;57(5):875-80.
- Di Stasi SM, Giannantoni A, Stephen RL, Capelli G, Navarra P, Massoud R, et al. Intravesical electromotive mitomycin C versus passive transport mitomycin C for high risk superficial bladder cancer: a prospective randomized study. J Urol. 2003;170:777-82.
- Di Stasi SM, Giannantoni A, Giurioli A, Valenti M, Zampa G, Storti L, et al. Sequential BCG and electromotive mitomycin versus BCG alone for high-risk superficial bladder cancer: a randomised controlled trial. Lancet Oncol. 2006;7:43-51.
- Di Stasi SM, Riedl C. Updates in intravesical electromotive drug administration of mitomycin-C for non-muscle invasive bladder cancer. World J Urol. 2009;27:325-30.
- Di Stasi SM, Valenti M, Verri C, Liberati E, Giurioli A, Leprini G, et al. Electromotive instillation of mitomycin immediately before transurethral resection for patients with primary urothelial non-muscle invasive bladder cancer: a randomised controlled trial. Lancet Oncol. 2011;12:871-9.
- Kalsi J, Harland SJ, Feneley MR. Electromotive drug administration with mitomycin C for intravesical treatment of non-muscle invasive transitional cell carcinoma. Expert Opin Drug Deliv. 2008;5(1):137-45.