European Urology 46 (2004)

European Urology European Urology 46 (2004) 339 343 Phase II Study to Investigate the Ablative Efficacy of Intravesical Administration of Gemcitabine in Intermediate-Risk Superficial Bladder Cancer (SBC) Paolo Gontero a,*, Giovanni Casetta b, Gloria Maso a, Filippo Sogni a, Giuliano Pretti a, Andrea Zitella b, Bruno Frea a, Alessandro Tizzani b a Department of Medical Sciences, Urology Clinic, University of Piemonte Orientale, Via Solaroli, 17, 28100 Novara, Italy b Urology Clinic I, University of Studies of Torino, Torino, Italy Accepted 7 May 2004 Available online 2 June 2004 Abstract Objective: Phase I studies have so far demonstrated that intravesical Gemcitabine up to a 40 mg/ml concentration is well tolerated and has a substantial ablative activity on high-risk BCG refractory SBC. New treatment options are needed for intermediate-risk SBC recurring after conventional intravesical treatments. The purpose of the present study was to investigate the ablative efficacy of intravesical Gemcitabine on intermediate-risk SBC. Methods: The study was designed as a two-stage phase II trial, with a sample size of 39 patients. The efficacy of intravesical Gemcitabine at a concentration of 40 mg/ml (2000 mg in 50 ml saline solution) administered weekly for 6 weeks was assessed on a single marker tumour left in the bladder after a complete TUR of all other lesions. Patients underwent TUR or biopsy at the site of the marker lesion 2 weeks after completion of the treatment. Results: Complete response was observed in 22 out of 39 patients (56%). No progression was observed among the 17 non-responders. Neither systemic nor local side effects generally exceeded grade I toxicity. Conclusion: The ablative effect of Gemcitabine produced a higher number of responses than the minimum required by the protocol to indicate a significant probability of drug efficacy. It is worth testing the drug in phase III trials to assess for durability of response. # 2004 Elsevier B.V. All rights reserved. Keywords: Gemcitabine; Intravesical; Marker lesion; Superficial bladder cancer 1. Introduction Nearly 40% of all superficial transitional cell carcinomas (TCCs) of the bladder are classified as intermediate risk for recurrence and progression. This category comprises multiple and recurrent Ta, T1 and G1, G2 papillary lesions for which adjuvant intravesical agents are strongly recommended following TUR [1]. While the overall progression rate for these tumours is low, the long-term risk of recurrence remains high despite extensive administration of * Corresponding author. Tel. þ39-03478600447; Fax: þ39-03213733763. E-mail address: paolo.gontero@med.unipmn.it (P. Gontero). prophylactic chemoterapeutic agents [2,3]. Maintenance BCG immunotherapy is currently considered the most effective regimen in decreasing subsequent recurrences but this can lead to some increase in side effects [4,5]. New treatment options for recurrent superficial TCCs refractory to both intravesical immunotherapy and chemotherapy are needed and should ideally combine proven efficacy with good tolerability. The pyrimidine antimetabolite Gemcitabine is an active and well tolerated systemic chemotherapeutic agent used in the treatment of metastatic bladder cancer [6]. Several characteristics make it a promising candidate for intravesical therapy for superficial TCCs. High drug concentrations in the bladder have not resulted in drug-induced cystitis in preclinical studies in dogs [7]. 0302-2838/$ see front matter # 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2004.05.001

340 P. Gontero et al. / European Urology 46 (2004) 339 343 This observation has been supported by the finding in an in vitro model of a selective cytotoxicity for Gemcitabine to human and rodent TCC cell lines with relative sparing of fibroblast [8]. Its molecular weight as low as 299 is crucial for bladder mucosa penetration, making the intravesical treatment of early invasive disease possible [7]. At the same time its high total body clearance as a result of rapid transformation into an inactive metabolite may prevent significant systemic toxicity [9]. Human phase I studies have confirmed these premises. Intravesical Gemcitabine exposure for 1 or 2 hours at doses of up to 2000 mg produced immeasurably low plasma levels [10] and no active drug was detected in patient plasma more than 60 minutes after instillation [11]. Neither systemic nor urinary toxicities exceeded grade 1 in the majority of patients exposed [10,11]. Substantial activity of intravesical Gemcitabine has been reported in 18 high-risk BCG refractory superficial TCCs with the finding of a complete response in 7 patients [12]. To assess the efficacy of new agents in intermediaterisk superficial bladder cancer an indicator lesion of some sort is necessary and this can be achieved by a marker tumour study [13,14]. The EORTC GU Group and the MRC have conducted trials using marker tumours which provided evidence that this methodology is safe, logical and ethically acceptable [15,16]. This type of study allows researchers to test the ablative activity of the investigational drug on a single papillary marker lesion and to assess the incidence and severity of early side effects, in relatively few patients and in a relatively short period of treatment. Several marker lesion studies have evaluated the ablative activity of different drugs alone or in combination (mitomycin C, epirubicin, BCG) with a complete response of 50 60% [17 19]. The primary purpose of the present study was to evaluate the ablative activity of Gemcitabine when administered intravesically in patients with a residual marker lesion in superficial bladder cancer. Assessments of local and systemic toxic effects of therapy constituted secondary end-points. 2. Patients and methods 2.1. Inclusion and exclusion criteria Superficial bladder cancer patients selected for the study had to be at intermediate risk of recurrence and progression according to the EORTC GU Group recommendations on marker lesion studies [14]. Specifically, a history of histologically proven recurrent multiple (but no more than 7) Ta, T1 and G1, G2 bladder TCC with a normal upper urinary tract on a recent intravenous urogram and no histologically proven CIS or severe dysplasia on a pre-study urine cytology were required. Other pre-treatment assessments included a full medical history and examination, plain chest X- ray, urine culture, full blood count, and liver and kidney function. Informed consent, a WHO performance status of 0 2, no clinical evidence of other malignancies except for healed basal cell carcinoma, WBC > 3000, PLT > 100.000, Hb 10 g/dl, renal and hepatic function values not exceeding 2 times the upper normal value were also required for study entry. Concomitant or recurrent urinary tract infections or the presence of significant urological disease interfering with intravesical therapy constituted exclusion criteria. Previous intravesical immunotherapy or chemotherapy more than 3 months before the start of the study was allowed. All visible lesions and suspicious areas seen at baseline video cystoscopy had to be completely resected except for a solitary marker lesion, approximately 0.5 1 cm in diameter. In the case of a single papillary recurrent lesion not exceeding 1 cm and judged by the investigator not to be muscle invasive, the patient was eligible and the lesion was left untouched as the marker tumour. The approximate tumour size was estimated by comparison with the 0.8 cm loop of the resectoscope and the location of the marker tumour was drawn on a bladder diagram. Where possible a photograph of the lesion was taken and filed in the patient notes. It should not have been possible to feel a mass during the bimanual physical examination performed immediately after the resection. 2.2. Drug schedule and toxicity monitoring Intravesical Gemcitabine was administered at the maximum dose found to be safe in previous phase I studies [12,20]. Two thousand mg of Gemcitabine (Gemzar, Eli Lilly) were diluted in 50 ml of normal saline (0.9%) with a final concentration of 40 mg/ ml and instilled in the bladder. The ph of the reconstituted solution varied between 2 and 3 and no buffering was adopted. The patients were asked to avoid urinating for 1 hour after the instillation. Protocol therapy consisted of 6 weekly instillations to be started within 15 days of the cystoscopy or TUR. Urine cytology, urine culture, full blood count, and liver and renal function were assessed before each instillation. Patients were asked to record the occurrence of any systemic and urinary side effects on a leaflet before each treatment administration. When side effects were reported, the following measures were adopted according to the Common Terminology Criteria for Adverse Events [21]. Treatment was delayed by 1 week if toxicity reached grade 2 for WBC, PTL, dysuria, cystitis, or systemic allergy or grade 3 for dermatitis or gastrointestinal symptoms. At any occurrence of grade 3 toxicity for WBC, PTL, dysuria, cystitis, or systemic allergy or grade 4 toxicities for dermatitis or gastrointestinal symptoms, instillations were stopped and the patient underwent immediate TUR. If high-grade atypical transitional cells were found on urine cytology at any time, the patient was withdrawn from the study and underwent immediate cystoscopy. Patients completing the treatment underwent a deep resection of the residual lesion, if present, or a cold biopsy of the bladder at the site of the previous tumour two weeks after the last instillation (at week 10 from the baseline TUR). 2.3. Definition of response A complete response (CR) was defined as the complete disappearance of the marker lesion without the appearance of any new lesions at cystoscopy. This had to be confirmed by a negative histological examination of a biopsy of the site previously occupied by the marker lesion and negative urine cytology (grade 1 to 3). Anything other than CR was considered as no response (NR). A positive histology for Ta, T1 and G1, G2 at the site of the marker

P. Gontero et al. / European Urology 46 (2004) 339 343 341 lesion or elsewhere in the bladder was defined as NR without disease progression. A positive histology for muscle invasive TCC (T2 or greater) or any G3 lesion or a positive urine cytology for high-grade atypical transitional cells was defined as NR with disease progression. Patients withdrawn from the study before finishing the course of instillations with a positive histology or cytology were considered as NR. If a complete response was achieved, patients were followed up with a urine cytology and cystoscopy every 3 months for the first 3 years and every 6 months thereafter. No further treatment was given until recurrence. Non-responders were withdrawn from the study. 2.4. Trial design and statistical considerations The primary endpoint of the study was the overall objective complete pathological response rate. The study was designed as a two-stage phase II trial with the possibility of stopping the trial early if there was evidence that the drug had insufficient activity in order to minimize the number of patients who might be exposed to a potentially inactive drug. The sample size was calculated using Simon s Minimax method [22]. Based on previous marker lesion series assessing other intravesical agents [17 19], it was determined that the treatment tested in this study would deserve further attention if it was able to produce responses in at least 60% of the patients (p1 ¼ 0.60). The treatment activity would be considered too low if 40% or fewer of the patients achieved a response (p0 ¼ 0.40). With a type I error probability of 5% (a ¼ 0.05) and a type II error probability of 20% (b ¼ 0.20), at the end of the first stage of accrual the drug therapy would have been declared of no further interest and the study stopped if the number of responders was 17 or fewer in 34 patients. If 18 or more responders were observed, the study would have continued and at the final second step the drug would have been declared to have a significant activity if the number of responders was 21 or more out of a total of 39 entered patients. The study protocol and the informed consent form were approved by the Regional Ethical Committee of Piedmont and by the Hospital Ethical Committee of the two participating centres. 3. Results During the first phase of the study from June 2002 to March 2003, thirty five patients were recruited. One patient was considered ineligible because of severe intractable urge incontinence and did not receive treatment. Because the number of CR (19 out of 34 patients) reached the minimum level of efficacy required by the protocol, the study proceeded to the second phase until completion of the enrolment in September 2003. Baseline characteristics for the final 39 eligible patients are reported in Table 1. ECOG performance status was 0 1 in 35 patients and 2 in 4 patients. At study entry 2 patients had multiple primary papillary lesions, 35 had multiple recurrent tumours and 2 had a solitary papillary recurrent lesion from a previous Ta, T1, G1, G2 TCC. Thirty patients (80%) had been previously treated with at least one type of intravesical chemotherapy or immunotherapy. Nearly half of those cases had received BCG. Table 1 Patient characteristics (N ¼ 39) Median age (range) 69 (47 80) Males 31 (79%) Females 8 (21%) Previous treatment BCG only 11 (28%) MMC only 8 (21%) Epirubicin only 3 (8%) BCG þ MMC 3 (8%) BCG þ Epirubicin 1 (2%) BCG þ Epirubicin þ MMC 1 (2%) Epirubicin þ MMC 3 (8%) No treatment 9 (23%) Histology at study entry Ta 36 (92%) T1 3 (8%) G1 19 (48.7%) G2 20 (51.3%) Table 2 reports on treatment efficacy. Overall a complete response was achieved in 22 out of 39 cases (56%). There was no disease progression either to muscle invasion or to CIS. Among the 17 non-responders, the persistence of the marker lesion was confirmed by histology in 12 cases. In one case the lesion was macroscopically unchanged and the patient was judged as a non-responder despite negative histology. In the other 4 patients, CR at the site of the marker tumour was associated with the appearance of a new lesion. All patients completed the scheduled treatment. Six out of 39 patients usually had to empty their bladder Table 2 Treatment response Response N (%) CR 22 (56.4) NR 17 (43.6) Type of no response NR without progression 17 (100) NR with progression NR with patients withdrawal Site of no response Marker lesion only 11 (65) Marker lesion þ new lesion 2 (12) New lesion only 4 (23) Histology Ta 15 T1 1 G1 12 G2 4 Normal bladder mucosa a 1 a One case with macroscopic evidence of persistent marker lesion and negative TUR biopsy was considered as NR.

342 P. Gontero et al. / European Urology 46 (2004) 339 343 Table 3 Patients toxicity classification and grading according to the Common Toxicity Criteria (CTC) scale (version 2.0) Toxicity Grade I Grade II N (%) N (%) Hematological WBC 2 (5) PTL 4 (10) Hb 6 (15) Liver SGPT 1 (2.5) Genitourinary Hematuria 6 (15) Dysuria a 13 (33) 2 (5) Frequency 3 (8) Urgency 3 (8) Incontinence 1 (2.5) Gastrointestinal Nausea 5 (13) Others Fatigue 1 (1) a In two patients a positive urine culture for E. Faecalis was demonstrated on one occasion and successfully treated with a specific antibiotic course. after 50 minutes whereas the remaining could easily retain the drug for 1 hour at all times. Side effects and their severity according to the Common Toxicity Criteria classification are listed in Table 3. Hematological toxicity was rare and did not go beyond grade 1. Other systemic side effects included mild and transient nausea in 5 patients and fatigue in 1. Dysuria was the most frequent local side effect, described by 38% of patients. It was generally mild, self resolving in a few hours and not exceeding grade 1 level. Two cases were considered grade 2 because antibiotic treatment was required for a positive urine culture. Treatment postponement was not necessary in any case. 4. Discussion Intravesical chemotherapy in intermediate risk bladder TCCs is currently administered with the prophylactic intent of reducing the tumour recurrence rate. The risk of progression for this tumour category is generally low and it is not taken as a primary treatment endpoint. The ability of a new chemotherapeutic agent to prevent superficial TCC tumour formation relies on its cytotoxic efficacy on bladder cancer cells. In this perspective a marker tumour study represents an excellent in vivo model to test the cytoreductive ability of a given treatment and is recommended before embarking on any phase III study [14]. Ethical concerns have been recently raised about the risk of incurring tumour progression by deliberately leaving an unresected bladder tumour [23]. This risk has been found to be as low as 0.9% during the 10-week duration of a marker lesion study [14,15]. Patients enrolled in our protocol underwent weekly urine cytology testing during the treatment phase with a view to early withdrawal in case of severe dysplasia. We believe the risk of progression was even more negligible with this precaution. In a phase I dose escalation study employing intravesical Gemcitabine, Dalbagni [12] enrolled 18 patients with high-risk BCG refractory superficial bladder cancer who refused cystectomy and reported complete responses in 7 cases. We obtained 22 (56%) complete responses in 39 eligible patients with intermediate-risk superficial TCC. The ablative effect of Gemcitabine produced a higher number of responses than the minimum required by the protocol to indicate a significant probability of drug efficacy. 80% of our cases were recurrences after previous intravesical treatment and half of them had received BCG which is currently gauged as the most effective intravesical agent. While these figures may reflect a higher compliance to a marker lesion study by patients for whom previous intravesical agents had failed, the efficacy of the drug is reinforced by the recent observation that recurrences after prior intravesical therapy appear less responsive to subsequent treatment [24]. Dosage and schedule selection for our study were based on initial pharmacokinetics and phase I studies on dogs and humans [7,20]. The safety and tolerability of a 40 mg/ml drug concentration administered weekly for 6 weeks has been confirmed by recent reports [10,11]. In our study, hematological tests carried out before each treatment administration did not show changes beyond a grade 1 toxicity level. Laufer [11] evaluated plasmatic drug concentrations and bone marrow function at different time intervals during intravesical Gemcitabine exposure with the finding of undetectable active drug after 60 minutes and no significant hematological changes. Gemcitabine produced remarkably low and rapidly self resolving genito-urinary side effects in the present series. Conversely grade 3 or severe urinary symptoms have been described in 10 to 20% of patients in marker lesion series employing BCG and in up to 10% using standard intravesical chemotherapeutic agents [17 19]. Based on both the toxicity and the efficacy profile, we confirm that 2000 mg in 50 ml (40 mg/ml) should be the dose of choice employed in future investigations. In conclusion, intravesical Gemcitabine, administered as in the current study, showed an ablative activity on marker lesion tumours comparable if not better than that reported in previous similar studies on BCG and

P. Gontero et al. / European Urology 46 (2004) 339 343 343 chemotherapeutic agents. The tolerability profile was excellent. Phase III studies should be undertaken to demonstrate if this chemoablative efficacy will also translate into a durable recurrence-free survival. Acknowledgements A draft of the protocol was developed during the EORTC Workshop held in Flims in June 2002. References [1] Oosterlinck W, Lobel B, Jakse G, Malmstrom PU, Stockle M, Sternberg C. Guidelines on bladder cancer. European Association of Urology (EAU) Working Group on Oncological Urology. Eur Urol 2002;41(2):105 12. [2] Huland H, Otto U, Droese M, Kloppel G. Long-term mitomycin C instillation after transurethral resection of superficial bladder carcinoma: influence on recurrence, progression and survival. J Urol 1994;132:27 9. [3] Koga H, Kuroiwa K, Yamaguchi A, Osada Y, Tsuneyoshi M, Naito S. 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