Papillary Recurrence of Bladder Cancer at First Evaluation after Induction Bacillus Calmette-Guérin Therapy: Implication for Clinical Trial Design

Prognostic Role of Preoperative Neutrophil-To-Lymphocyte Ratio (NLR) and Recurrence at First Evaluation after Bacillus Calmette-Guérin (BCG) Induction in Non-Muscle-Invasive Bladder Cancer

We investigated the prognosis of BCG induction-only treatment and non-complete response (CR) at the first 3-month evaluation and examined factors associated with CR. In total, 209 patients with moderate- and high-risk NMIBC who received BCG induction-only treatment between 2008 and 2020 were retrospectively analyzed. Recurrence-free survival (RFS) and progression-free survival (PFS) were assessed based on the initial NMIBC stage. PFS and associated factors of non-CR compared to CR were also assessed. Initial T1 high-grade (HG) (n = 93) had poorer RFS and PFS after BCG induction-only treatment than Ta low-grade (LG) (p = 0.029, p = 0.002). Non-CR (n = 37) had a different neutrophil-to-lymphocyte ratio (NLR) (2.81 ± 1.02 vs. 1.97 ± 0.92) and T staging from CR (p < 0.001, p = 0.008). T1HG recurrence was associated with a worse PFS compared to non-T1HG (13.7 months vs. 101.7 months, p < 0.001). There was no difference in PFS between T1HG and T1LG. T1 and NLR were predictors of response at 3 months in multivariable analysis (p = 0.004, p = 0.029). NLR was also found to be an associated factor with RFS and PFS of bladder cancer (p < 0.001, p < 0.001). BCG induction-only treatment was effective for high-risk TaLG but not for T1HG. T1HG recurrence at 3 months after BCG induction has a poor prognosis for bladder cancer. Preoperative NLR and T1 were predictors of non-CR, and NLR was also associated with the long-term prognosis of bladder cancer.

Can we offer additional BCG therapy for three-month BCG refractory high grade/T1, Tis bladder cancer patients?

Background

We lack tools to predict treatment and survival outcomes in patients receiving additional BCG therapy as a bladder-preserving therapy in high grade/T1, Tis NMIBC patients who showed persistent/recurrent tumors at three-month follow-up.

Objectives

To assess the predictors of additional BCG response in patients who experienced persistent/recurrent tumors at three-month follow-up after BCG induction.

Patients and methods

We retrospectively analyzed database for NMIBC. Between 2000 and 2019, 231 patients with high-grade T1/Tis NMIBC showed persistent/recurrent tumors at 3-month after BCG-induction, refused or were unfit to radical cystectomy (RC) and were offered additional intravesical BCG as bladder-preserving treatment. Predictors of the outcome after additional BCG were studied using univariate and multivariate logistic regression analysis. Kaplan Meier curve was utilized to estimate the recurrence-free survival (RFS) and progression-free survival (PFS). COX regression analysis was performed to identify independent predictors or RFS and PFS.

Results

During a median (range) of 148 (24-224) months, poor response to additional BCG (tumor recurrence and/or progression) was noted in 112 (48.5%) patients. On multivariate logistic regression analysis, 3-month tumor features (persistent T stage, persistent grade and persistent/new CIS) significantly predicted poor response to additional BCG (OR: 3.4, 95%CI: 1.3-10.8, p = 0.021, OR: 2.1, 95%CI: 1.1-4.1, p = 0.02 and OR: 16.6, 95%CI: 4.5-109, p=<0.001, respectively). The mean RFS was 26 (9-152) months with identified 3-month tumor features (persistent T stage and persistent/new CIS) as independent predictors of RFS (HR = 11.5, 95%CI = 2.7-48.3, p = 0.001 and HR = 2.5, 95%CI = 1.5-4.1, p=<0.001, respectively) on multivariate COX regression analysis. In addition, 3-month tumor features (persistent/new CIS, non-papillary shape and bladder neck involvement) were identified to significantly predict PFS (HR = 6.2, 95%CI = 3.4-11.5, p=<0.001 and HR = 2.3, 95%CI = 1.3-4.3 p = 0.001 and HR = 2.1, 95%CI = 1.2-3.8, p=<0.005, respectively).

Conclusions

Three-month tumor features could be utilized as a tool to predict treatment outcomes and survival benefits when additional intravesical BCG is utilized as a bladder-preserving treatment in patients with recurrent/persistent tumors at three-month follow-up.

French AFU Cancer Committee Guidelines - Update 2022-2024: Non-muscle-invasive bladder cancer (NMIBC)

OBJECTIVE

To update the ccAFU recommendations for the management of bladder tumours that do not infiltrate the bladder muscle (NBMIC).

METHODS

A systematic review (Medline) of the literature from 2020 to 2022 was performed, taking account of the diagnosis, treatment options and surveillance of NMIBC, while evaluating the references with their levels of evidence.

RESULTS

The diagnosis of NMIBC (Ta, T1, CIS) is made after complete full-thickness tumour resection. The use of bladder fluorescence and the indication of a second look (4-6 weeks) help to improve the initial diagnosis. The EORTC score is used to assess the risk of recurrence and/or tumour progression. Through the stratification of patients in low, intermediate and high-risk categories, adjuvant treatment can be proposed: intravesical chemotherapy (immediate postoperative, initiation regimen) or BCG (initiation and maintenance regimen) instillations, or even the indication of cystectomy for BCG-resistant patients.

CONCLUSION

Updating the ccAFU recommendations should contribute to improving patient management, as well as the diagnosis and treatment of NMIBC.

International Bladder Cancer Group Consensus Statement on Clinical Trial Design for Patients with Bacillus Calmette-Guérin-exposed High-risk Non-muscle-invasive Bladder Cancer

CONTEXT

A large proportion of patients with non-muscle-invasive bladder cancer (NMIBC) fall in the gap between bacillus Calmette-Guérin (BCG)-naïve and BCG-unresponsive disease. As multiple therapeutic agents move into this gray area, there is a critical need to define the disease state and establish recommendations for optimal trial design.

OBJECTIVE

To develop a consensus on optimal trial design for patients with BCG-exposed NMIBC, defined as high-grade recurrence after BCG treatment that does not meet the criteria for BCG-unresponsive disease.

EVIDENCE ACQUISITION

We conducted a literature review using the Cochrane Library, Medline, and Embase and a review of clinical trials in ClinicalTrials.gov as a basis to generate consensus recommendations for clinical trial design in BCG-exposed NMIBC.

EVIDENCE SYNTHESIS

BCG-exposed NMIBC encompasses BCG resistance (presence of high-grade Ta or carcinoma in situ [CIS] at 3-mo evaluation after induction BCG) and delayed relapse. Randomized controlled trials are required to compare experimental therapies to a control arm receiving additional BCG, although ongoing BCG shortages may impact our ability to follow an optimal trial design. A placebo should be used in combination with BCG if the treatment arm includes BCG plus a study drug. Trials will either need to separate patients with and without CIS into two cohorts, or stratify by the presence of CIS at the time of randomization. If two cohorts are used, the primary endpoint for CIS patients should be complete response within a predetermined time. The primary endpoint in a cohort with Ta/T1 only, or if a single combined cohort is used, should be the duration of event-free survival. Suggested efficacy thresholds and corresponding sample sizes are provided.

CONCLUSIONS

The International Bladder Cancer Group has developed recommendations regarding definitions, endpoints, and clinical trial design for BCG-exposed NMIBC to encourage uniformity among studies in this disease state.

PATIENT SUMMARY

Our consensus provides a precise definition of the disease state for bladder cancer not invading the bladder muscle and exposed to bacillus Calmette-Guérin (BCG) treatment. Clear guidance for conducting optimal clinical trials in this disease setting was established and we believe that this will promote further progress in this field.

[French ccAFU guidelines - update 2020-2022: bladder cancer]

OBJECTIVE

- To update French guidelines for the management of bladder cancer specifically non-muscle invasive (NMIBC) and muscle-invasive bladder cancers (MIBC).

METHODS

- A Medline search was achieved between 2018 and 2020, notably regarding diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

RESULTS

- Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS <1) and renal function (creatinine clearance >60 mL/min) allow it (only in 50% of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

CONCLUSION

- These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment of patients diagnosed with NMIBC and MIBC.

Emerging treatments for bacillus Calmette-Guérin-unresponsive non-muscle-invasive bladder cancer

Intravesical bacillus Calmette–Guérin (BCG) immunotherapy has been the gold standard adjuvant treatment for intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC) after transurethral resection of bladder tumor (TURBT). BCG immunotherapy prevents disease recurrence and progression to muscle-invasive disease following TURBT. Although most patients initially respond well to intravesical BCG, considerable concern has been raised for patients with BCG failure who are refractory or recur in 6 months after their last BCG, which implies ‘BCG-unresponsiveness’. Based on current clinical guidelines, early radical cystectomy (RC) is recommended to treat BCG-unresponsive NMIBC. However, due to the high risk of morbidity and mortality of RC and patients' desire to preserve their own bladder, there is a critical unmet need for alternative conservative treatments as bladder-sparing strategies in BCG-unresponsive patients. Trials for effective bladder-sparing treatments are ongoing, and several novel agents have been recently tested in the NMIBC setting. The goal of this review is to introduce and summarize recently reported novel and emerging drugs and ongoing clinical trials for BCG-unresponsive NMIBC.

French ccAFU guidelines – Update 2018–2020: Bladder cancer

Objective

To propose updated French guidelines for non-muscle invasive (NMIBC) and muscle-invasive (MIBC) bladder cancers.

Methods

A Medline search was achieved between 2015 and 2018, as regards diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

Results

Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS < 1) and renal function (creatinine clearance > 60 mL/min) allow it (only in 50 % of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

Conclusion

These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment for NMIBC and MIBC.

Salvage therapeutic strategies for bacillus Calmette-Guerin failure

PURPOSE OF REVIEW

To give an overview of current options for conservative treatment of patients failing intravesical bacillus Calmette-Guerin (BCG) and to discuss emerging approaches with potential future clinical applications.

RECENT FINDINGS

Radical cystectomy is the standard-of-care for patients failing BCG therapy. In patients unfit or unwilling to undergo surgery, salvage therapy options could be proposed with the aim to offer local cancer control and prevent progression to muscle-invasive disease. Salvage treatments have been conducted using intravesical chemotherapy regimens, chemoradiation or chemohyperthermia. Intravesical agents such as valrubicin, gemcitabine or docetaxel showed response rates varying between 16 and 40%, whereas combination treatments of gemcitabine with docetaxel or mitomycin reported response rates in up to 50% of all patients with durable responses in about one out of three patients. For chemohyperthermia, 2-year recurrence rates between 41 and 56% have been reported. Ongoing clinical trials are evaluating chemoradiation as well as novel approaches such as systemic immunotherapy, viral gene therapy, targeted therapy or vaccination strategies with promising preliminary outcomes.

SUMMARY

Salvage therapeutic bladder-sparing strategies for BCG failure such as intravesical chemotherapy or chemoradiation should currently only be considered in patients unfit for or refusing surgery. Innovative concepts such as chemohyperthermia, checkpoint inhibitors, targeted therapy or viral gene therapy could lead to major changes in clinical management of BCG failures in the future.

How Should I Manage a Patient with Tumor Recurrence Despite Adequate Bacille Calmette-Guérin?

Intravesical immunotherapy with bacille Calmette-Guérin (BCG) vaccine is the main treatment for non-muscle-invasive bladder cancer (NMIBC), with proven effects on reducing recurrence, progression, and death from NMIBC. However, it is not effective in all patients, and recurrence after adequate BCG therapy can frequently lead to progression to more life-threatening disease. This point-counterpoint review considers how to treat a healthy 60-yr-old patient with T1 high-grade NMIBC fitting the new definition of BCG-unresponsive disease, that is, persistent high-grade disease at 6-12mo, despite an adequate course of induction and maintenance with BCG. PATIENT SUMMARY: When T1 high-grade non-muscle-invasive bladder cancer is persistent or recurs shortly after a full course of bacille Calmette-Guérin (BCG) plus maintenance, further BCG is not likely to work; this meets the new definition of a "BCG unresponsive" disease. For this situation, the safest (curative) option is removal of the bladder. If that is not an accepted alternative, then a clinical trial or combination intravesical chemotherapy or hyperchemotherapy may be another option.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la vessie French ccAFU guidelines — Update 2018—2020: Bladder cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.006. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.006. That newer version of the text should be used when citing the article.

Using Grade of Recurrent Tumor to Guide Further Therapy While on Bacillus Calmette-Guerin: Low-grade Recurrences Are not Benign

BACKGROUND

Tumors that recur after bacillus Calmette-Guerin (BCG) therapy are considered to be of very high risk, and patients are often recommended to undergo radical cystectomy (RC). However, the nuances associated with the grade of tumor recurrence after BCG treatment are not well understood.

OBJECTIVE

To characterize the pattern of bladder cancer progression and cancer-specific survival (CSS) in patients with recurrences dichotomized by low grade (LG) versus high grade (HG) after intravesical BCG treatment, and to assess the safety of continued bladder-sparing therapy in these patients.

DESIGN, SETTING, AND PARTICIPANTS

We performed an Institutional Review Board-approved review of our bladder cancer database. Overall, 146 non-muscle-invasive bladder cancer (NMIBC) patients were found to have NMIBC recurrence while on BCG therapy; this recurrence was LG in 38 and HG in 108. Baseline clinicopathologic characteristics including age, gender, primary tumor grade, stage, size, multiplicity, and concurrent carcinoma in situ were also evaluated. The primary endpoint was progression-free survival (PFS), with progression defined as the development of muscle-invasive bladder cancer (MIBC)/distant metastasis. In addition, recurrence-free survival (RFS), HG RFS, cystectomy-free survival (CFS), and CSS were also compared. Multivariable analysis was performed using the Cox regression model. All tests were two sided, and p<0.05 was considered statistically significant.

INTERVENTION

Further intravesical therapy versus salvage RC.

RESULTS AND LIMITATIONS

Overall, estimated 5-yr PFS was 72.4% (95% confidence interval [CI] 60.4-81.3%). As dichotomized by grade of recurrent tumor, PFS was greater for patients with LG recurrences (85.6%, 95% CI 60.8-95.2%) than for those with HG recurrence (67.9%, 95% CI 54.1-78.4%; p=0.010). Furthermore, patients whose initial recurrence on BCG therapy was LG had improved subsequent RFS (median 62 vs 34mo, p=0.007), HG RFS (median 112 vs 36mo, p<0.001), and CFS (estimated 5-yr CFS 80.8% vs 49.8%, p<0.001) compared with those who had HG initial recurrence. On univariate and multivariate analyses, grade of tumor recurrence after BCG was an independent predictor of time to progression to MIBC/distant metastasis (hazard ratio 3.60, 95% CI 1.18-10.94, p=0.024).

CONCLUSIONS

Grade of tumor recurrence after intravesical BCG is an important predictor of bladder cancer progression to MIBC/metastatic urothelial carcinoma. While, patients with LG recurrences have less than half the progression events compared with those with HG recurrences, their estimated 5-yr progression rate is still 14.4%. Hence all patients should be carefully counseled on bladder-sparing therapy. This also has implications for clinical trial design.

PATIENT SUMMARY

If bladder cancer recurs after bacillus Calmette-Guerin treatment, there are many factors that determine the further clinical outcome. Although low-grade recurrent tumors confer a less aggressive course, disease progression can still occur, and hence continued vigilance is important.

Predicting Response to Intravesical Therapy in Non-muscle-invasive Bladder Cancer

CONTEXT

The ability to predict response to intravesical therapy (IVT) following transurethral resection in non-muscle-invasive bladder cancer holds important prognostic information. However, few predictive tools are available to guide urologists.

OBJECTIVE

We reviewed the most recent studies investigating the predictors of response to IVT.

EVIDENCE ACQUISITION

A literature search was conducted using PubMed database from January 1, 2013 to April 1, 2018 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. For our search strategy, we used the combination of the MeSH terms of "Administration, Intravesical" and "Urinary Bladder Neoplasms" with any of the following words: "Biomarkers," "Predictive Value of Tests," "response," "recurrence," and "progression." We limited our search to the English language.

EVIDENCE SYNTHESIS

Risk stratification models utilizing clinicopathological features are the most cost-effective and widely used tools currently available to predict response to IVT. Additionally, urinary fluorescence in situ hybridization testing and urinary cytokine-based nomograms (Cytokine Panel for Response to Intravesical Therapy) may enhance predictive ability. Protein-based biomarkers have been associated with predicting recurrence. Several gene-based biomarkers quantifying mutations in DNA damage repair genes may have predictive ability. However, genomic data are relatively new and lack validation.

CONCLUSIONS

Clinicopathological criteria remain the most widely utilized tool for predicting IVT response. Further research to validate protein- and genomic-based biomarkers are needed before adoption in clinical practice.

PATIENT SUMMARY

We reviewed contemporary studies that investigated how to predict response to medication instilled in the bladder (intravesical therapy) for bladder cancer. We found that most predictive tools use clinical data, such as tumor stage and grade, to determine the outcome. Newer biological (gene, protein, cytokines) marker tests are being studied. We concluded that the combination of clinical data with levels of certain experimental markers (fluorescence in situ hybridization test or urinary cytokines) may improve predictive ability. Genetic testing methods may also yield additional predictive markers in the future, but this needs more validation.

Indication for early cystectomy in nonmuscle-invasive bladder cancer. Literature review

CONTEXT

High-risk nonmuscle-invasive bladder cancer is a disease that includes a heterogeneous group of patients, for whom close follow-up is recommended due to the risk of progression to a muscle-invasive tumour. The treatment of choice for these tumours is transurethral resection of the bladder tumour followed by a programme of bacillus Calmette-Guerin instillations. There is a subgroup of patients who have a greater risk of progression and who benefit from early radical treatment.

OBJECTIVE

To identify which patient group with nonmuscle-invasive bladder cancer will benefit from early radical treatment.

SEARCHING THE EVIDENCE

We performed a literature review to identify the risk factors for progression for these patients and thereby recommend a treatment that improves their survival rate.

SYNTHESIS OF THE EVIDENCE

We identified the various prognostic factors associated with tumour progression: the persistence of T1 tumour in re-resection of the bladder tumour, the presence of carcinoma in situ, patients refractory to bacillus Calmette-Guerin treatment, patients older than 70 years, tumours larger than 3cm, the substaging of T1 tumours, the presence of lymphovascular invasion and the presence of a tumour in the prostatic urethra. Similarly, we comment on the advantages of radical versus conservative treatment, considering that the performance of an early cystectomy due to a high-risk noninvasive vesical tumour has a better cancer prognosis than those in which the operation is deferred until the progression.

CONCLUSIONS

In this disease, it is important to individualise the patients to provide them personalized treatment. For patients with the previously mentioned characteristics, it is recommended that early cystectomy not be delayed.

High expression of insulin receptor on tumour-associated blood vessels in invasive bladder cancer predicts poor overall and progression-free survival

Bladder cancer is a frequently recurring disease with a very poor prognosis once progressed to invasive stages, and tumour-associated blood vessels play a crucial role in this process. In order to identify novel biomarkers associated with progression, we isolated blood vascular endothelial cells (BECs) from human invasive bladder cancers and matched normal bladder tissue, and found that tumour-associated BECs greatly up-regulated the expression of insulin receptor (INSR). High expression of INSR on BECs of invasive bladder cancers was significantly associated with shorter progression-free and overall survival. Furthermore, increased expression of the INSR ligand IGF-2 in invasive bladder cancers was associated with reduced overall survival. INSR may therefore represent a novel biomarker to predict cancer progression. Mechanistically, we observed pronounced hypoxia in human bladder cancer tissue, and found a positive correlation between the expression of the hypoxia marker gene GLUT1 and vascular INSR expression, indicating that hypoxia drives INSR expression in tumour-associated blood vessels. In line with this, exposure of cultured BECs and human bladder cancer cell lines to hypoxia led to increased expression of INSR and IGF-2, respectively, and IGF-2 increased BEC migration through the activation of INSR in vitro. Taken together, we identified vascular INSR expression as a potential biomarker for progression in bladder cancer. Furthermore, our data suggest that IGF-2/INSR mediated paracrine crosstalk between bladder cancer cells and endothelial cells is functionally involved in tumour angiogenesis and may thus represent a new therapeutic target. Copyright © 2017 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Efficacy of Mycobacterium Phlei Cell Wall-Nucleic Acid Complex (MCNA) in BCG-Unresponsive Patients

Background: We have previously reported the results of a prospective multi-institutional study on the efficacy of MCNA in patients who recurred after intravesical BCG treatment [1]. Since that publication, a new standardized definition for BCG-unresponsiveness has been established [2]. Objective: We re-analyzed the oncologic outcomes following intravesical MCNA in patients classified as BCG-unresponsive according to the new definition. Methods: For this analysis, we focused on the enrolled patients who satisfied the requirements for BCG Unresponsiveness: i.e. adequate BCG treatment (at least 5/6 induction and 2/3 maintenance instillations) and high grade tumor within 6 months of prior BCG. Treatment course included 6 weekly intravesical instillations of 8 mg MCNA followed by 3 weekly instillations at months 3, 6, 12, 18, and 24. Followup assessments included cystoscopy, urine cytology and biopsy. Patients absent of high grade disease confirmed by central review of biopsy were deemed disease-free. Results: Of the 129 patients enrolled, 94 (68 CIS with/without papillary tumors, 26 papillary only tumors) fit the criteria for the new BCG Unresponsive definition. Overall, disease free survival (DFS) for all BCG unresponsive patients was 48.9% (95% CI 38.0-59.0%) at 6 months, 34.8% (95% CI 24.7-45%) at 1 year and 28.3% (15.7-34.3%) at 2 years post induction. In the group with papillary tumors, DFS measured at months 6, 12, and 24 were: 61.2% (38.2-77.8%), 61.2(38.2-77.8%), and 50.1% (27.5-69%). In the CIS-containing group, the corresponding DFS were: 44.8% (32.3-56.4%), 26.5% (16.3-37.9%), and 16.6% (8.6-26.9%), respectively. Conclusions: For patients who are BCG Unresponsive, MCNA has the potential to render 26.5% of patients with CIS and 61.2% of patients with papillary tumors disease-free for at least 1 year with an intact bladder. The higher efficacy noted in the true BCG-unresponsive cohort than was previously reported with all-comers emphasizes the importance of having clearly defined criteria for clinical trials investigating new intravesical therapies after BCG failure.