Adjustments in the Use of Intravesical Instillations of Bacillus Calmette-Guérin for High-risk Non-muscle-invasive Bladder Cancer During the COVID-19 Pandemic

Intravesical BCG in bladder cancer induces innate immune responses against SARS-CoV-2

BCG is the most efficient adjuvant therapy for high-risk, non-muscle-invasive bladder cancer (NMIBC). Both innate and adaptive immune responses have been implicated in BCG-mediated effects. BCG vaccination can boost innate immune responses via trained immunity (TI), resulting in an increased resistance to respiratory viral infections. Here we evaluated for the first time whether intravesical application of BCG triggers increased immunity against SARS-CoV-2 in patients with high-risk NMIBC. Serum and peripheral blood mononuclear cells (PBMCs) from heparinized whole blood samples of 11 unvaccinated SARS-CoV-2-naïve high-risk NMIBC patients were collected at baseline and during BCG treatment in a pre-COVID-19 era. To examine B-cell or T cell-dependent adaptive immunity against SARS-CoV-2, sera were tested for the presence of SARS-CoV-2 neutralizing antibodies. Using a SARS-CoV-2 peptide pool, virus-specific T cells were quantified via IFNγ ELISpot assays. To analyze innate immune responses, mRNA and protein expression levels of pro- and anti-inflammatory cytokines were measured after a 24-hour stimulation of PBMCs with either BCG or SARS-CoV-2 wildtype. ATAC- sequencing was performed to identify a potential epigenetic reprogramming in immune cells. We neither identified SARS-CoV-2 neutralizing antibodies nor SARS-CoV-2- reactive T cells, indicating that intravesical BCG did not induce adaptive immunity against SARS-CoV-2. However, a significant increase in mRNA as well as protein expression of IL-1β, IL-6 and TNFα, which are key cytokines of trained immunity, could be observed after at least four intravesical BCG instillations. Genomic regions in the proximity of TI genes (TLR2, IGF1R, AKT1, MTOR, MAPK14, HSP90AA1) were more accessible during BCG compared to baseline. Although intravesical BCG did not induce adaptive immune responses, repetitive intravesical instillations of BCG induced circulating innate immune cells that produce TI cytokines also in response to SARS-CoV-2.

Interruption of BCG Therapy for NMIBC During COVID-19 Crisis, Dilemma in Its Continuation: a Review of Available Evidence and Suggested Management Strategies

The COVID-19 disease, caused by SARS-CoV-2 virus, has been one of the worst pandemics ever to hit the human mankind. Undoubtedly the start of the second wave of COVID-19 has literally ripped apart the hearts of millions of people. Cancer patients have been left of the beaten track to their fate, with no access to treatments. Intravesical BCG instillation is the standard of care for patients with non-muscle invasive bladder cancer (NMIBC). Several patients were in the middle of their treatment regimen when this pandemic struck. As slowly the word is recuperating from concussion effect of this pandemic and routine health services are being restored, uro-oncologist will face a unique scenario with respect to intravesical BCG therapy i.e., whether to restart the course of BCG therapy or to continue course from where it was interrupted. There are no studies in literature to directly answer this peculiar question and to resolve this dilemma. So, we in this review article propose to explore the literature for the most appropriate therapeutic regimen for these patients with interruption of intravesical BCG therapy. We plan to divide the patients with interruption to BCG therapy into the following three groups:Group 1: Patients who had interruption during the induction period.Group 2: Patients who completed the induction course but maintenance course could not be started.Group 3: Patients who had interruption during maintenance phase of BCG therapy. We will compile the recent recommendations by NCCN, AUA, and EAU for the administration of intravesical BCG in non-muscle invasive bladder cancer. We herein want to review the literature to propose the most appropriate strategy, its safety profile for these subsets of patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-023-01742-8.

The role of gut microbiome in immune modulation in metastatic renal cell carcinoma

Treatment of metastatic renal cell carcinomas (mRCC) has drastically improved since the advent of immunotherapy with immune checkpoint inhibitors (ICIs), with a significant proportion of patients achieving durable responses. While this has revolutionized treatment and improved outcomes for mRCC patients, a large subset of patients still does not respond to treatment with ICIs. Moreover, ICIs can induce various immune-related adverse events, limiting their use in many patients. Therefore, there is a need to identify the predictive biomarkers of both efficacy and toxicity associated with ICIs, which would allow for a more personalized approach and help with clinical decision-making. This review aims to explore the role of the gut microbiome in RCC to overcome primary resistance and predict response to treatment with ICIs. First, current therapeutic strategies and mechanisms of action of ICI therapies for RCC treatment will be reviewed. With the technological development of shotgun whole-genome sequencing, the gut microbiome has emerged as an exciting field of research within oncology. Thus, the role of the microbiome and its bidirectional interaction with ICIs and other drugs will be explored, with a particular focus on the microbiome profile in RCC. Lastly, the rationale for future clinical interventions to overcome resistance to ICIs using fecal microbiota transplantation in patients with RCC will be presented.

Effects of intravesical BCG maintenance therapy duration on recurrence rate in high-risk non-muscle invasive bladder cancer (NMIBC): Systematic review and network meta-analysis according to EAU COVID-19 recommendations

Purpose

During the coronavirus disease 2019 (COVID-19) pandemic, the European Association of Urology (EAU) recommended that courses of intravesical bacillus Calmette-Guérin (BCG) therapy lasting more than 1 year could be safely terminated for patients with high-risk non-muscle-invasive bladder cancer (NMIBC). Thus, we conducted a systematic review and network meta-analysis according to EAU’s COVID-19 recommendations.

Materials and methods

A systematic review was performed following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. We conducted a network meta-analysis of recurrence rate in patients with NMIBC receiving induction therapy (M0) and those receiving maintenance therapy lasting 1 year (M1) and more than 1 year (M2).

Results

Nineteen studies of 3,957 patients were included for the network meta-analysis. In a node-split forest plot using Bayesian Markov Chain Monte Carlo (MCMC) modeling, there were no differences between the M1 and M2 groups in recurrence rate [odds ratio (OR) 0.95 (0.73–1.2)]. However, recurrence rate in the M0 group was higher than that in the M1 [OR 1.9 (1.5–2.5)] and M2 [OR 2.0 (1.7–2.4)] groups. P-score tests using frequentist inference to rank the treatments in the network demonstrated that the therapy used in the M2 group (P-score 0.8701) was superior to that used in the M1 (P-score 0.6299) and M0 groups (P-score 0). In rank-probability tests using MCMC modeling, the M2 group showed the highest rank, followed by the M1 and M0 groups.

Conclusion

In the network meta-analysis, there were no differences between those receiving BCG maintenance therapies in terms of recurrence rate. In the rank tests, therapy lasting more than 1-year appears to be most effective. During the COVID-19 pandemic, 1-year maintenance therapy can be used, but after the COVID-19 pandemic, therapy lasting more than 1-year could be beneficial.

100 years of Bacillus Calmette-Guérin immunotherapy: from cattle to COVID-19

Bacillus Calmette-Guérin (BCG) is the most widely used vaccine worldwide and has been used to prevent tuberculosis for a century. BCG also stimulates an anti-tumour immune response, which urologists have harnessed for the treatment of non-muscle-invasive bladder cancer. A growing body of evidence indicates that BCG offers protection against various non-mycobacterial and viral infections. The non-specific effects of BCG occur via the induction of trained immunity and form the basis for the hypothesis that BCG vaccination could be used to protect against the severity of coronavirus disease 2019 (COVID-19). This Perspective article highlights key milestones in the 100-year history of BCG and projects its potential role in the COVID-19 pandemic.

Impact of SARS-CoV-2 Pandemic on Kidney Cancer Management

BACKGROUND: The SARS-CoV-2 pandemic still has a huge impact on the management of many chronic diseases such as cancer. Few data are presently available reagarding how the management of renal cell carcinoma (RCC) has changed due to this unprecedented situation. OBJECTIVE: To discuss the challenges and issues of the diagnosis and treatment of RCC in the COVID-19 era, and to provide recommendations based on the collected literature and our personal experience. METHODS: Systematic review of the available Literature regarding the management of RCC during the SARS-CoV-2 pandemic. RESULTS: Our review showed a prevalence of narrative publications, raising the issue of the real relevance of the evidence retrieved. Indeed, the only original data about RCC and COVID-19 found were a small retrospective case series and two surveys, providing either patients’ or physicians’ viewpoints. CONCLUSIONS: The expected delayed diagnosis of RCC could lead to an increase of advanced/metastatic cases; thus, proper therapeutic choices for patients with small renal masses should be carefully evaluated case by case, in order to avoid negative effects on long-term survival rates. The controversial interaction between immune checkpoint blockade and COVID-19 pathogenesis is more hypothetical than evidence-based, and thus immunotherapy should not be denied, whenever appropriate. To avoid treatments which won’t have an impact on patients’ survival, a honest and accurate evaluation of the cost/benefit ratio of each treatment option should be always performed. Finally, SARS-CoV-2 swab positivity should not prevent the continuation of ongoing active treatments in asymptomatic cases, or or after symptoms’ resolution.

The Impact of COVID-19 Disease on Urology Practice

The diagnosis and timely treatment of cancer patients should not be compromised during an infectious disease pandemic. The pandemic of coronavirus disease 2019 (COVID-19) has serious implications on urology practice and raises particular questions for urologists about the management of different conditions. It was recommended to cancel most of the elective urological surgeries. Urological cancers surgeries that should be prioritized are radical cystectomy for selective tumors, orchiectomy for suspected testicular tumors, nephrectomy for c T3 + , nephroureterectomy for high-grade disease, and radical adrenalectomy for tumors >6 cm or adrenal carcinoma. Most prostatectomies can be delayed without compromising the survival rate of patients. Urological emergencies should be treated adequately even during this pandemic. There is a potential risk of coronavirus diffusion during minimally invasive procedures performed. It is crucial to use specific precautions when urologists performed those type of surgeries. It was also recommended to suspend the kidney transplantation program during the COVID-19 pandemic except for specific cases. In this review, we discussed the triage of urological surgeries, the risk of minimally invasive urological procedure, the kidney transplantation challenges, the systemic therapies, intravesical instillation of Bacillus Calmette-Guérin (BCG), endourology, teleconferencing, and telemedicine application in urology during the COVID-19 pandemic.

Protective role of intravesical BCG in COVID-19 severity

OBJECTIVES

To establish the role of BCG instillations in the incidence and mortality of COVID-19.

PATIENTS AND METHODS

NMIBC patients in instillations with BCG (induction or maintenance) during 2019/2020 were included, establishing a COVID-19 group (with a diagnosis according to the national registry) and a control group (NO-COVID). The cumulative incidence (cases/total patients) and the case fatality rate (deaths/cases) were established, and compared with the national statistics for the same age group. T-test was used for continuous variables and Fisher's exact test for categorical variables.

RESULTS

175 patients were included. Eleven patients presented CIS (11/175, 6.3%), 84/175 (48.0%) Ta and 68/175 (38.9%) T1. Average number of instillations = 13.25 ± 7.4. One hundred sixty-seven patients (95.4%) had complete induction. Forty-three patients (cumulative incidence 24.6%) were diagnosed with COVID-19. There is no difference between COVID-19 and NO-COVID group in age, gender or proportion of maintenance completed. COVID-19 group fatality rate = 1/43 (2.3%). Accumulated Chilean incidence 70-79 years = 6.3%. Chilean fatality rate 70-79 years = 14%.

CONCLUSIONS

According to our results, patients with NMIBC submitted to instillations with BCG have a lower case-fatality rate than the national registry of patients between 70 and 79 years (2.3% vs. 14%, respectively). Intravesical BCG could decrease the mortality due to COVID-19, so instillation schemes should not be suspended in a pandemic.

Disease management in a patient diagnosed with COVID-19 disease during induction intravesical BCG therapy: A case report and review of the literature

OBJECTIVE

To discuss the patient diagnosed with COVID-19 disease while receiving intravesical induction bacillus Calmette-Guérin (BCG) treatment for non-muscle-invasive bladder cancer, its management in the light of the literature.

PATIENT AND METHODS

A 52-year-old male patient, who received intravesical BCG treatment for high-grade pT1 papillary urothelial carcinoma, presented 12 h after taking the fourth dose of induction therapy 38.2° fever and chills. The patient's reverse transcriptase-polymerase chain reaction test was positive, and Thorax CT imaging showed a few ground-glass pneumonic infiltrations in bilateral lung bases consistent with COVID-19 disease.

RESULTS

Although international urology associations have current recommendations regarding the pandemic process, only one study has made specific recommendations regarding the patient group diagnosed with COVID-19 while receiving intravesical BCG treatment. According to this recommendation, we interrupted our patient's BCG treatment for 3 weeks and then completed the treatment for 6 weeks. A maintenance treatment not exceeding 1 year was planned.

CONCLUSION

This group of patients' recommendation is to delay BCG therapy for at least 3 weeks after initial symptoms to allow for complete recovery. Although the administration schedule varies, maintenance therapy is recommended for no more than 1 year.

Effect of COVID-19 Pandemic on Diagnosis and Treatment Delays in Urological Disease: Single-Institution Experience

Purpose

In the background of the global pandemic, we aim to investigate the effect of COVID-19 on diagnosis and treatment delay in urology patients.

Patients and Methods

A total of 4919 inpatients were identified from the urological department in our institution, including 2947 and 1972 patients within 9 months before and after the outbreak (group A and group B). The baseline characteristics and residential population of different types of diseases were compared in the two groups. Patients who underwent delay of diagnosis or treatment with poor outcomes were described.

Results

Our result revealed a 33.1% decrease of total resident population as well as a 44.8% decline in bed utilization rate after the outbreak. Significant differences were found between group A and group B in gender (P=0.024) and patients living alone or not (P=0.026). The hospitalization rate of patients with malignancy increased significantly while that of benign patients decreased during the epidemic (P<0.001). Besides, we identified 5 cases with bladder cancer and 3 cases with prostate cancer that underwent delay of diagnosis or treatment with unfavorable consequences.

Conclusion

With the impact of COVID-19, delay in diagnosis or treatment of non-COVID-19 diseases is inevitable whether the medical resources allocation is effective or not. Psychological status of patients might be the major cause of postponing diagnosis or treatment. For urological patients with locally advanced tumor or rapid progression, who need long-term postoperative intervention, the delay of regular treatment could lead to inevitable progression or recurrence.

Overview of the italian experience in surgical management of bladder cancer during first month of COVID-19 pandemic

OBJECTIVE

Overview of bladder cancer (BC) management in Italy during the first month of the COVID-19 pandemic (March 2020) with head to head comparison of the data from March 2019, considered "usual activity" period. The aim is to analyze performance of different Italian Centers in North, Center and South, with a special eye for Lombardy (the Italian epicenter).

PATIENTS AND METHODS

During April 2020, a survey containing 14 multiple-choice questions focused on general staffing and surgical activity related to BC during the months of March 2019 and March 2020 was sent to 32 Italian Centers. Statistical analysis was performed using IBM SPSS Statistics (v26) software. A Medline search was performed, in order to attempt a comparative analysis with published papers.

RESULTS

28 Centers answered, for a response rate of 87.5%. Most of the urology staff in the Lombardy region were employed in COVID wards (p = 0.003), with a statistically significant reduction in the number of radical cystectomies (RC) performed during that time (p = 0.036). The total amount of RC across Italy remained the same between 2019 and 2020, however there was an increase in the number of surgeries performed in the Southern region. This was most likely due to travel restrictions limiting travel the North. The number of Trans-Urethral Resection of Bladder Tumors (TURBT) (p = 0.046) was higher in Academic Centers (AC) in 2020 (p = 0.037).

CONCLUSIONS

The data of our survey, although limited, represents a snap shot of the management of BC during the first month of the COVD-19 pandemic, which posed a major challenge for cancer centers seeking to provide care during an extremely dynamic clinical and political situation which requires maximum flexibility to be appropriately managed.

Challenges in Urology during the COVID-19 Pandemic

The COVID-19 pandemic has caused a global health threat. This disease has brought about huge changes in the priorities of medical and surgical procedures. This short review article summarizes several test methods for COVID-19 that are currently being used or under development. This paper also introduces the corresponding changes in the diagnosis and treatment of urological diseases during the COVID-19 pandemic. We further discuss the potential impacts of the pandemic on urology, including the outpatient setting, clinical work, teaching, and research.

The Impact of the COVID-19 Pandemic on Genitourinary Cancer Care: Re-envisioning the Future

CONTEXT

The coronavirus disease 2019 (COVID-19) pandemic necessitated rapid changes in medical practice. Many of these changes may add value to care, creating opportunities going forward.

OBJECTIVE

To provide an evidence-informed, expert-derived review of genitourinary cancer care moving forward following the initial COVID-19 pandemic.

EVIDENCE ACQUISITION

A collaborative narrative review was conducted using literature published through May 2020 (PubMed), which comprised three main topics: reduced in-person interactions arguing for increasing virtual and image-based care, optimisation of the delivery of care, and the effect of COVID-19 in health care facilities on decision-making by patients and their families.

EVIDENCE SYNTHESIS

Patterns of care will evolve following the COVID-19 pandemic. Telemedicine, virtual care, and telemonitoring will increase and could offer broader access to multidisciplinary expertise without increasing costs. Comprehensive and integrative telehealth solutions will be necessary, and should consider patients' mental health and access differences due to socioeconomic status. Investigations and treatments will need to maximise efficiency and minimise health care interactions. Solutions such as one stop clinics, day case surgery, hypofractionated radiotherapy, and oral or less frequent drug dosing will be preferred. The pandemic necessitated a triage of those patients whose treatment should be expedited, delayed, or avoided, and may persist with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in circulation. Patients whose demographic characteristics are at the highest risk of complications from COVID-19 may re-evaluate the benefit of intervention for less aggressive cancers. Clinical research will need to accommodate virtual care and trial participation. Research dissemination and medical education will increasingly utilise virtual platforms, limiting in-person professional engagement; ensure data dissemination; and aim to enhance patient engagement.

CONCLUSIONS

The COVID-19 pandemic will have lasting effects on the delivery of health care. These changes offer opportunities to improve access, delivery, and the value of care for patients with genitourinary cancers but raise concerns that physicians and health administrators must consider in order to ensure equitable access to care.

PATIENT SUMMARY

The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the care provided to many patients with genitourinary cancers. This has necessitated a transition to telemedicine, changes in threshold or delays in many treatments, and an opportunity to reimagine patient care to maintain safety and improve value moving forward.

Intravescical instillation of Calmette-Guérin bacillus and COVID-19 risk

It has been theorized that Calmette-Guérin bacillus may prevent or reduce the severity of COVID-19 through a nonspecific stimulation of the immune system. A preliminary assessment of SARS-CoV-2 infection rates and outcomes among 2803 individuals affected with high risk non-muscle-invasive bladder cancer and treated with intra-bladder instillation of BCG, showed no evidence of a protective effect. However, the interpretation of these data need some caution, due to the low prevalence of infection (<1%) observed within this population, along with the fact that intra-bladder administration cannot mirror the usual intradermal administration of BCG, in particular in patients partially immunocompromised. Confirmation by larger prospective studies is required.

Intravesical BCG amid COVID-19: To give or not to give?

During the coronavirus disease 2019 pandemic, there has been a reduction in the provision of all elective services. This poses enormous pressure on urologists as regards to patients with bladder cancer who need intravesical Bacille Calmette Guerin (BCG) treatment. The evolving situation of the pandemic mandates a pragmatic approach in clinical decisions; to date, there are no uniform consensus guidelines about how to manage these patients and the factors affecting our decision for service provision. These concerns need to be addressed not only for the current crisis but also for the upcoming next phase of the pandemic.