Scripta Scientifica Medico, vol. 27 (1990), pp. 86-93 Copyright © Medicina i Fizkultura, Sofia

BLADDER CANCER IMMUNOTHERAPY

A. Hinev*, D. Gochev*, A. Engibarov**, V. Ajladunov*, L Ralichkova*. K. Kisyova***, M. Chuchkova**

•Department of Surgery, Clinic of Urology, Higher Institute of Medicine, Varna; **Research Institute for Infectious and Parasitic Diseases, Sofia; * "Clinic of Allergology and Immunology, Higher Institute of Medicine, Varna

Key-words: Bladder cancer - immunotherapy - BCG CALGEVAX - prophylaxis - side effects

Bladder tumours represent between 3 and 5 per cent of all neoplasms and between 35 and 50 per cent of all oncourological diseases [2]. Relapses occur in 75 per cent of the cases and approximately one third of the recurrent tumours are of an advanced stage and higher grade [8].

In order to decrease the great number of relapses, intravesical chemotherapy has been widely used nowadays. Thiotepa, Mitomycin С and Farmorubicin are considered to be some of the most effective local chemotherapeutics.

Non-specific immunotherapy introduced in 1976 by Morales et al. [9] is a principally new approach in the treatment and prophylaxis of superficial bladder cancer.

The well-expressed antigenicity of the BCG vaccine proved many times experimentally and clinically, the great cellular surface associated with the small size of superficial bladder tumours, the possibility of close contact between BCG and the tumour and prolonged (2 h) action on

Table 1 BCG strains used in intravesical therapy. Weight and strength

Strain Weight / ampule Colony-forming units (CFU)

Tice (Organon) Pasteur F (Paris) Connaught Armand Frappier Glaxo (=Evans) Moreau RIVM

50 mg 75 mg 40 mg 120 mg 75 mg 100 mg ?

2 - 6 x 1 0 ? C F U 6 x 1 0 8 C F U 8 - 3 2 x 1 0 8 C F U 10XFU 8 - 2 6 x 1 0 6 C F U 2 x 109 viable bacilli 109 viable bacilli

bladder mucosa - all these factors demonstrate some unexpected possibilities for immunotherapy of superficial bladder cancer and make it most favourable for such treatment than any other human tumours.

A great experience with BCG immunotherapy was accomplished in the recent 10-15 years. Summarized data show that this therapy was successful in about 60-90 per cent of the cases [7].

Bladder cancer immunotherapy 87

There are several types of BCG vaccine prepared from different BCG strains and it is not clear yet whether all these strains are equally effective [5] (table 1).

BCG GALGEVAX, a product of the Research Institute for Infectious and Parasitic Diseases, Sofia, was used first in 1983. It has been applied to more than 200 bladder tumour patients till now [1]. In June, 1987, the vaccine was used for the first time in the Clinic of Urology, Department of Surgery, Higher Institute of Medicine, Varna.

This paper presents the early results of the non-specific immunotherapy and immunoprophylaxis with BCG CALGEVAX. It is an attempt to study the side-effects and the complications of BCG CALGEVAX due to its intravesical way of administration, to compare its efficacy to that of some local chemotherapeutics (Mitomycin С and Thiotepa) and to TUR alone, and, finally, to define its role and place in the complex treatment of bladder tumours.

MATERIAL AND METHODS

A total of 21 patients with histologically proved superficial bladder cancer (of stages pTjs, pTa

and pTi) were covered in the present study. Two of them had persistent recurrent superficial bladder tumours. BCG CALGEVAX was used as a non-specific immunotherapy in this group. The rest 19 patients had no visible tumour, negative cytology and biopsy specimens at the initial examination. BCG CALGEVAX was applied as a prophylaxis against relapses in these cases.

Tab le 2

Patients' characteristics

Parameter BCG CALGEVAX prophylaxis treatment

MMC TT TUR alone

n

Sex male

female

Age range median

Follow-up (in months)

range mean

19 2

17 1 2 1

46-77 63-76 60 70

16-24 18-20 19 19

10

8 2

37-68 58

16-29 24

8

4 4

55-73 65

16-36 25

20

16 4

47-72 61

16-36 24

Patients' characteristics is presented on table 2. Tumour categories (stage and grade) are summarized on table 3. .

All patients were treated by BCG CALGEVAX, CALGEVAX is produced by a special technology on the basis of BCG-I - Moscow strain which is very closely related to the original Calmette-Guerin's strain (BCG-Paris). One mg of BCG CALGEVAX contains 2,67 - 8,0 x 106 viable bacilli [4|.

88 A. Hinev, D. Gochev, A. Engibarov, V. Ajladunov, L. Ralichkova, K. Kisyova, M. Chuchkova i

Т а Ы е З V

Tumour categories 1 urn • •

Parameter BCG CALGEVAX prophylaxis treatment

MMC TT TUR alone

Tumour stage pTis pTa

PTi

Tumourt grade

III r d

1 3

15 2

8 7 2 4

10

4 4 2

1 7

4 3 1

2 18

11 6 3

Table4

Therapeutic schedules

Medicament Schedule

BCG CALGEVAX prophylaxis (n = 1<£)

treatment (0-2)

Mitomycin С (MMC) (n = 10)

Thiotepa (TT) (n = 8)

TUR alone (n = 20)

6 ml (120 mg) fluid or 5 ampules dry, [375 mg) suspended in 50 ml saline \ x week / 6 weeks 1 x month / 1 year

5 ampules (375 mg) dry 1 x week / till response 1 x month / 1 year

30 mg 1 week / 8 weeks 1 month /1 year 1 week / 4 weeks

1 month /1 year 60 mg

Bladder cancer immunotherapy

The initial course includes 6 weekly instillations of 6 ml fluid (120 mg) or 5 ampules dry (375 mg) of BCG CALGEVAX, both suspensed in 50 ml saline. It was followed by monthly instillations of the same doses for 1 year.

Patients were asked to retain the vaccine for 2 hours. Control studies were done on admission to the protocol, after the initial course and every 3

months thereafter. They included: cystoscopy (with or without) cold-cup biopsy; cytology; roll blood and urine analysis; routine microbiological, echographic, X-ray and radiological examinations; immune status, including* leukocyte count, proteinogram, percentage of T a and 1\ cells and i.d. test for immune deficiency, using standard antigens (tuberculin, candidin, tetanic anatoxin and trichophytin).

The follow-up period was between 16 and 24 months. The first BCG instillation was usually done 1 month after the operation after the first control

cystoscopy. Three other patients' groups (given Mitomycin C, Thiotepa and TUR alone) were used as

controls in order to compare vaccine efficacy. Patients' age, tumour stage and grade, number of previous relapses, etc., were similar to these of the former BCG group (table 2 and 3). Treatment schedules used in these groups are presented on table 4.

Statistical analysis was earned out by using of Student-Fisher's test.

RESULTS AND DISCUSSION

Patients from control groups were either without any complaints during treatment, or the latter were insignificant and self-limited: bladder irritability in a few cases and just one incident of haematuria in a Mitomycin С-treated patient (table 5).

However, complaints of BCG-treated patients were much more expressed. All of them had dysuria which was quite severe in 3 (143 per cent) of the cases. One of these three patients had to be hospitalized and treated with tuberculostatics. In most cases dysuria was mild and transitory - lasting not longer than 2-3 days. Other side-effects, such as haematuria, fever, etc., were also noted (table 5).

T a b l e 5

Side-effects and complications

Side-effects Mitomycin С n = 10

Thioteoa BCG CALGEVAX n = 21

Bladder irritability Haematuria Fever Weakness and malaise Nausea Skin reaction

2(20%) 1 (10 %)

1 (12,5%) 21 (100%) 9(42,9% 8(38,1% 8 38.1% 1 !4l%) 2(9,5%

90 A. Hinev, D. Gochev, A. Engibarov, V. Ajladunov, L. Ralichkova, K. Kisyova, M. Chuchkova

Т а Ы е б

Prophylactic results Parameter BCG CALGEVAX

n=19 MMC n=10

TT n=8

TUR alone n=20

Patients with relapse (rV%)

F 1 low-up (in months)

range mean

4/21,05%

16-24

19

5/50%

16-29

24

3/37,5%

16-36

25

11/55%

16 -36

24

Note: BCG versus TUR alone, p < 0,05 BCG versus MMC, p >0,05 BCG versus TT, p > 0,05.

Fig. L Staining with hemataxylin-eosin. Magn. x 100

Bladder cancer immunotherapy 91

Fig. 2 Staining with hemataxylin-eosin. Magi, x 200

We did not establish any dangerous complications of BCG therapy described in the literature, such as TBC dissemination, granulomatous hepatitis, microcystis, etc. [12].

In spite of these considerable side-effects and possible complications of the intracavitary BCG application, yet, the recurrence rate in this group was the lowest one - 4 relapses only (21,05 per cent) (table 6). There was a significant difference (p,05) when it was compared with tie group of TUR alone (55 per cent of recurrences). However, this difference was not significant when the rest two groups were concerned (BCG versus Thiotepa and BCG versus Mitomycin C) (p0,05). A total of 78,3 per cent of all relapses in these groups have appeared in the first 12 months after TUR administration.

BCG CALGEVAX proved to be efficient as therapeutic agent, too. One patient with two recurrent bladder tumours (of 3-5 mm in size) was free of them after 7 consecutive weekly instillations of BCG CALGEVAX, i.e. there was a complete curative effect. The cold-cup biopsies taken from the same place showed just non-specific inflammatory alterations without any signs of anaplasia.

The second female patient had multiple recurrent tumours (T1G2). There was just a partial effect after 6 weekly instillations: some of the smaller tumours disappeared while the bigger ones lost their papillas and got a fibrous coating. We applied TUR of these tumours not waiting for a complete healing effect mainly because this patient had no immune deficiency and previously applied non-specific immunotherapy with Levamisol had not given the expected result. The histological examination of the resected tumours was very demonstrative. There were obvious degenerative changes and tumour mass reduction.

The examination of patients' immune status revealed a manifested immune deficiency prior to BCG immunotherapy in approximately 90 per cent of our cases. Cellular immunity was favourably influenced after vaccine application in 55 per cent of the cases. This fact suggests that BCG CALGEVAX possesses a systemic effect when applied locally which makes its simultaneous percutaneous administration useless, indeed. Therefore, we accepted Morales' modified schedule who does not use i.d. BCG applications as well [10].

BCG CALGEVAX induces an intensive inflammatory response which involves the superficial

92 A. Hinev, D. Gochev, A. Engibarov, V. Ajladunov, L. Ralichkova, K. Kisyova, M. Chuchkova

mucosa and submucosa (Fig. 1). We fail to establish any specific morphological changes - giant cells, microorganisms, etc. Lymphocytes and plasrnocytes represent the prevailing cellular type (Fig. 2). We relate their local accumulation to the good therapeutic results. However, we could not prove their exact role in the intimate mechanisms of the immune response.

The most important issue concerning BCG immunotherapy consists in the unclarified mechanisms of BCG antitumour activity. BCG may in dependence on the dose, manner of application and its timing, exert a stimulating or suppressive effect. It has the potential to act as a non-specific immunomodulator by various ways involving different cells of the immune system.

Recently, in addition to these systemic effects, a great attention is paid to the local antitumour effect of the vaccine.

Boehle et al. [3] report a considerable local Т-cell proliferation as a response to the BCG-induced inflammation. The absolute number of mononuclear cells increases significantly after BCG therapy. Besides the ratio of local T-helper/T-suppressor cells is inverse showing a value of 2:1. An intensive cytokine (IL-1,11^2, TNF) production is also established. The detection of B-cells which are absent in the normal bladder in the early period after BCG instillation indicates the involvement of the humoral component of the immune response, too. The activation of peripheral macrophages after intravesical BCG is previously described 111]. The massive local infiltration with macrophages emphasizes their role as effector cells in the focal immune response.

All these data demonstrate a complex local immune response to the BCG - induced inflammation involving the cellular and humoral components of the immune system.

R E F E R E N C E S

1. Дамянов, X., А. Енгибаров, Т. Патрашков, Т. Тончев, М. Чуйкова Хирургия, 1988, № 2, 23-28.- 2. Куманов, С. Тачев.- В: Тумори на урогениталната система у мъжа. София, ЦНИМЗ, 1984, 39-48.- 3. Boehle, A, et al.- In: Immunotherapy of Urogenital Tumours. Edinburgh, etc., Churchill-Livingstone, 1990, 83-106.- 4. Engibarov, A,, M . Chouchkova, R. Ikonopisov. Develop. Biol. Standard, 58,1986,365-369.- 5. DeBruyne, F. A. Van der Meijden, A. Geboers. Urology (Suppl.), 31,1988, p. 20.- 6. DeKernion, J . , et al. J. Urol., 133,1985,598-601.- 7. Kelley, D., et аl. J. Urol., 134, 1985, 48-53.- 8. Lamm, D., et al. J. Urol., 128, 1982, 931-935.- 9. Morales, A., D. Eidinger, A Bruce.J. Urol., 116,1976,180-183.-10. Morales, A.J. Urol., 132,1984, 457-459.-11. Nissenkorn, I . , et al.Europ. Urol., 13,1987,246.-12. Robinson, M., et al.- In: Bladder Tumours and Other Topics in Urological Oncology. New York, Plenum Press, 1980, p. 171.

ИММУНОТЕРАПИЯ РАКА МОЧЕВОГО ПУЗЫРЯ

А. ХинеВ, Д. Гочев, А. ЭнгибароВ, В. АйладыноВ, Л. РаличкоВа, К. КисеВа, М. ЧучкоВа

Р Е З Ю М Е

21 пациенту со злокачественной опухолью мочевого пузыря интракавитарно была введена бацилла Кальмета-Гсрсна (БЦЖ) в качестве нсспецифичной иммунотерапии и иммунопрофилактики. !>ЦЖ КАЛЬГЕВАКС (6 мл жидкой /120 мг/ или 5 ампул сухой /375 мг/ вакцины, растворенной в 50 мл физиологической сыворотки), вводилась в мочевой пузырь один раз н неделю в течение 6 недель как начальный курс лечения, вслед за которым делались месячные инстиляции до одною юла. Непосредственно перед лечением, после окончания начального курса и через каждые три месяца после нею проводились контрольные исследования: иммунный статус, цистоскопия с

Bladder cancer immunotherapy биопсией при помощи щипц, цитологическое исследование мочи, рутинные лабораторные,эхо графские, рентгенологические и радиологические исследования. Период наблюдения был между 16 и 24 месяцами, в среднем - в течение 19 месяцев.

Были отмечены наиболее частые побочные эффекты: раздражение мочевого пузыря (100 %), гематурия (42,9 %), повышенная температура (38,1 %) и другие. Большинство из них однако являлись легкими и длились не более двух-трех дней.

Эффективность м « ч и н » была сопоставлена с эффективностью некоторых локальных химиотерапевтических средств (Митомицина С и Тиотепа), как и с самой ТУР. В качестве иммунопрофилактического средства БЦЖ КАЛЬГЕВАКС показала наиболее ниский процент рецидивов - 4 (21,05 %) , по сравнению с самой ТУР - 11 (55 %) (р<0,05); с Митомицином С - 5 (50 %) и с Тиотепом - 3 (37,5 %). В качестве иммунотерапевтического средства БЦЖ КАЛЬГЕВАКС достигла полного ответа у одного пациента и частичного ответа у другого.

Эти хорошие терапевтические результаты очевидно связаны с индуцированным вакциной БЦЖ локальным иммунным ответом, проявлением которого является накопление лимфоцитов и плазмоцитов в мукозном и субмукозном слоях мочевого пузыря.