UROLOGICAL ONCOLOGY

Factors explaining recurrence in patients undergoing chemoimmunotherapy regimens for frequently recurring superficial bladder carcinoma
Kaasinen E, Rintala E, Hellstrom P, Viitanen J, Juusela H, Rajala P, Korhonen H, Liukkonen T
Hyvinkaa Hospital, Hyvinkaa, Finland
Eur Urol. 2002;42:167-74

• Objectives: To study the factors determining new recurrences in patients with frequently recurring superficial bladder tumors.
• Methods: Of all 205 eligible patients, each received 5 weekly intravesical instillations of mitomycin C (MMC), with the first instillation given perioperatively. This was followed, according to randomization, by BCG instillations alone, or by alternating instillations of interferon-alpha and BCG monthly for up to 1 year. Impact of 12 variables on time to first recurrence, was retrospectively studied with the Cox multiple hazards regression and Kaplan-Meier analysis.
• Results: Type of regimen was the most significant factor determining new recurrences, with preceding recurrence rate being the most important prognostic factor. Timing of the first MMC was the third significant predictor in the main multivariate analysis, with more than a two-fold relative risk for a new recurrence if the first MMC instillation was given later than on day 0.
• Conclusion: Preceding recurrence rate, most accurately reflects, in patients with frequently recurring tumors, the inherent risk for new recurrences. This risk can be considerably reduced by use of an effective chemoimmunotherapy regimen, and in addition, by inclusion of an early perioperative chemotherapy instillation in such a regimen.
  
  
• Editorial Comment
  This study is a follow-up analysis of the trail that was previously published in the Journal of Urology. This late report provides interesting data that supports and emphasizes the previous results. The most important knowledge to gain from this publication is:
  1. Single-shot instillation of cytotoxic drugs after the TUR should be given as early as possible, and not later than day 0, which is the day of TUR (preferably within 6 hours after the operation).
  2. Adjuvant treatment with BCG is superior to alternating BCG and Interferon.
  3. Preceding recurrence rate is the most important prognostic factor for superficial bladder cancer.
  Within the context of further publications on that topic, a possible explanation of point 2 is obviously the number of instillations of BCG given, which was double in the BCG-group as compared to the BCG/Interferon-group, thus making the number of BCG instillations an important therapeutic factor.

Dr. Andreas Böhle
Professor and Deputy Chairman of Urology
Medical University of Luebeck
Luebeck, Germany