Histological parameters and pitfalls in the interpretation of bladder biopsies in bacillus Calmette-Guerin treatment of superficial bladder cancer.

We report the morphological effects of intravesical bacillus Calmette-Guerin therapy on early post-treatment biopsies of the bladder in 39 patients with superficial transitional cell carcinoma (stage Ta, T1 or Tis) of the bladder. Although submucosal granulomatous inflammation in bladder biopsies of patients receiving intravesical bacillus Calmette-Guerin treatment has been described previously, a complete morphological description of the early effects of bacillus Calmette-Guerin on all bladder layers and the prostatic urethra has not been reported. In the majority of cases the superficial epithelium was eroded and the edematous submucosa contained noncaseating granulomas with a surrounding lymphoplasmocytic and eosinophilic infiltrate. Langhans' giant cells occasionally were found, and acid-fast bacilli were demonstrated only rarely by special stains in the 6-week post-treatment biopsy. In some cases the prostatic urethra and muscle bundles contained noncaseating granulomas. Features distinguishing epithelial atypia resulting from bacillus Calmette-Guerin treatment and superficial cancer include the presence of epithelial maturation, preserved nuclear/cytoplasmic ratio, smooth nuclear contours and lack of nuclear pleomorphism, nucleoli or cytomegaly.

Prognostic value of purified protein derivative skin test and granuloma formation in patients treated with intravesical bacillus Calmette-Guerin.

We evaluated the prognostic value of purified protein derivative skin test reactivity and a granulomatous response in intravesical bacillus Calmette-Guerin therapy. We treated 62 patients with intravesical bacillus Calmette-Guerin once a week for 6 weeks. Purified protein derivative skin tests were performed before and after therapy. Cold cup bladder biopsies were examined in a blind retrospective manner for the presence of granulomas 6 weeks after completion of therapy. A significant correlation between status free of tumor and the presence of either granulomas or positive purified protein derivative skin tests was observed for the total patient population. Of 25 patients whose purified protein derivative test was converted from negative to positive 19 (77 per cent) remained free of tumor, while only 11 of 32 (34 per cent) whose test did not convert to purified protein derivative positive remained free of tumor (p equals 0.0006, chi-square). Similarly, 28 of 37 patients (77 per cent) who had a granulomatous response remained free of tumor, while only 8 of 25 (32 per cent) without a granulomatous response remained free of tumor (p less than 0.003, chi-square). The correlation was similar for each parameter when the total patient population was subdivided into patients treated for carcinoma in situ, residual tumor or prophylaxis. Calculation of predictive values showed that neither purified protein derivative responsiveness, granuloma formation nor a combination of both provided a highly accurate predictive index of therapeutic response in individual patients. False positive or negative rates, ranging from 23 to 24 per cent and 32 to 39 per cent, respectively, were observed. These results suggest that a link between immunological responsiveness and response to therapy exists but that neither the purified protein derivative skin test nor the granulomatous response exhibits sufficient immunological specificity to serve as accurate prognostic indicators in individual patients.

Intravesical bacillus Calmette-Guerin therapy for superficial bladder cancer: effect of bacillus Calmette-Guerin viability on treatment results.

We treated 40 patients with superficial bladder cancer via intravesical bacillus Calmette-Guerin for 1) prophylaxis against tumor recurrence, 2) residual carcinoma or 3) flat carcinoma in situ. A single course of intravesical bacillus Calmette-Guerin therapy was successful in 6 of 11 patients (55 per cent) treated for residual carcinoma and 6 of 12 (50 per cent) treated for carcinoma in situ. Of 17 patients receiving a single course of bacillus Calmette-Guerin for prophylaxis 11 remained free of tumor during short-term followup. A second course of therapy was administered to failures in each treatment category, which resulted in favorable responses in 5 of 6 patients treated for prophylaxis, 2 of 5 treated for residual tumor and 3 of 6 treated for carcinoma in situ. Over-all complete responses were achieved in 16 of 17 patients (94 per cent) treated for prophylaxis, 8 of 11 (73 per cent) for residual carcinoma and 8 of 12 (66 per cent) for carcinoma in situ, with a mean followup from the final treatment of 9.3, 12.3 and 7.9 months, respectively. Favorable results occurred more frequently among patients who exhibited a granulomatous inflammatory response in the bladder and delayed hypersensitivity skin test response to purified protein derivative. Marked variability in viability of bacillus Calmette-Guerin organisms was observed among different lots of bacillus Calmette-Guerin, and a direct relationship was observed between bacillus Calmette-Guerin vaccine viability and therapeutic efficacy. Most patients who failed initial therapy with a low viability lot of bacillus Calmette-Guerin responded favorably to re-treatment with a higher viability lot. The results suggest that the level of viability of each lot of bacillus Calmette-Guerin vaccine should be verified before clinical use.

Heightened interferon-gamma production by mononuclear cells from bladder cancer patients.

Interferon-gamma (IFN-gamma) production by peripheral blood leukocytes from bladder cancer patients was compared with that of patients with prostate cancer and benign prostatic hyperplasia, nontumor-bearing patients with bacterial infections, and normal controls. Leukocyte preparations including mononuclear cells isolated on a Ficoll-Hypaque density gradient (Fraction 2) and glass-nonadherent mononuclear cells (Fraction 3) were stimulated with Protein A from Staphylococcus aureus, and IFN-gamma production was monitored 24 hr later. The class of interferon produced was identified by antibody neutralization experiments which clearly showed S. aureus Protein A-induced interferon to be IFN-gamma. There was significantly heightened IFN-gamma production by Fraction 3 cells from bladder cancer patients and patients with bacterial infections. Heightened IFN-gamma production by bladder cancer patients was not observed in the Fraction 2 cells. No correlation was observed between IFN-gamma production and patients with invasive or noninvasive bladder cancer, but IFN-gamma production was lower in patients having Stage C or D tumors than in those having Stage A or B tumors. These results in conjunction with previous reports demonstrating heightened IFN-gamma production during periods of antigenic stimulation suggest that bladder tumors may induce a cell-mediated immune response in the host as evidenced by the elevation in IFN-gamma production. Moreover, the results suggest that macrophages may be important regulators of IFN-gamma production in bladder cancer patients.

Technical factors affecting the reproducibility of intravesical mouse bladder tumor implantation during therapy with Bacillus Calmette-Guérin.

Four methods of intravesical implantation of the transplantable mouse bladder tumor, MBT-2, and their effects on intravesical therapy with Bacillus Calmette-Guérin (BCG) were compared, and modifications which improved implantation are described. Pretreatment of the bladder with N-methyl-N-nitrosourea (MNU) resulted in tumor implantation in approximately two-thirds of the animals; however, all tumors penetrated the bladder wall. Using the MNU implantation procedure, intravesical BCG therapy was shown to reduce MBT-2 outgrowth by 77%. Tumor cell instillation after electrocautery produced an incidence of tumor implantation similar to that of the MNU procedure. The efficacy of BCG for the electrocautery implantation procedure also was similar to the MNU method. With the electrocautery procedure, the electrode and tumor cells were introduced into the bladder via a catheter prepared from PE 10 polyethylene tubing. The procedure required two catheterizations and produced a 24% incidence of extravesical tumors. Use of a Teflon catheter and a single catheterization for tumor cell instillation resulted in a reproducible method for implanting MBT-2 tumors which were all confined within the bladder. The efficacy of BCG therapy was unchanged from that described for the other implantation techniques.