Bacillus Calmette-Guérin instillation treatment for carcinoma in situ of the upper urinary tract

Mitomycin Gel (UGN-101) as a Kidney-sparing Treatment for Upper Tract Urothelial Carcinoma in Patients with Imperative Indications and High-grade Disease

BACKGROUND

Intracavitary UGN-101 is approved for the treatment of low-grade noninvasive upper tract urothelial carcinoma (UTUC). Post-commercialization studies underscore the benefit of UGN-101 administration for patients with imperative indications for whom radical nephroureterectomy (RNU) is not a viable option.

OBJECTIVE

To describe the use, efficacy, and safety of UGN-101 in patients with UTUC with imperative indications for renal preservation, including high-grade disease.

DESIGN, SETTING, AND PARTICIPANTS

Patients receiving UGN-101 with imperative indications were retrospectively analyzed using a multicenter centralized registry from 15 high-volume academic and community centers.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We defined imperative indications as patients with a solitary kidney, the presence of chronic kidney disease (CKD) with a glomerular filtration rate <30 ml/min, bilateral UTUC, and patients unfit for or unwilling to undergo surgical extirpation. Tumor characteristics, disease progression/recurrence, and adverse events were recorded on a per-renal-unit basis.

RESULTS AND LIMITATIONS

UGN-101 was instilled into 52 renal units (38%) in 48 patients for imperative indications, including 29 patients (56%) with a solitary kidney, 11 kidneys (21%) in the setting of bilateral UTUC, six patients (12%) with CKD, and six patients (12%) who were unfit for or unwilling to undergo RNU. Twelve renal units had biopsy-proven high-grade papillary disease. Tumors were completely ablated before induction therapy in 34% of cases, while 66% had tumor present. Following induction therapy, 17 patients (40%) had no evidence of disease (NED) on ureteroscopy, 88% of whom maintained this status at median follow-up of 10.8 mo. In the cohort with high-grade disease, five patients (45%) had NED at initial post-induction primary disease evaluation. Adverse events included pyelonephritis (8%), ureteral stenosis (8%), anemia (6%), and acute renal failure (4%). Limitations include the retrospective study design, the lack of long-term follow up, and patient selection bias.

CONCLUSIONS

Intracavitary therapy with UGN-101 in patients with UTUC and imperative indications shows promise as a kidney-sparing treatment modality. While long-term follow-up is needed, this intracavitary treatment may help in prolonging time to RNU and delaying the morbidity of hemodialysis in this comorbid population.

PATIENT SUMMARY

We reviewed results for patients with cancer in the upper urinary tract and an additional condition that would not allow kidney removal who received treatment with a gel called UGN-101. Our results suggest that UGN-101 shows promise as a kidney-sparing treatment. It may delay the time until kidney removal is needed in these patients and avoid the negative effects associated with dialysis.

The Role of Local Agents for the Treatment of Localized Upper Tract Urothelial Carcinoma: A Review of the Current Evidence

Kidney-sparing surgery (KSS) for upper urinary tract urothelial carcinoma (UTUC) is a promising alternative to radical nephroureterectomy, especially for low-risk cases. However, due to the established risk of ipsilateral UTUC recurrence caused by the implantation of floating neoplastic cells after endoscopic resection, adjuvant endocavitary (endoureteral) instillations have been proposed. Instillation therapy may be also used as primary treatment for UTUC. The two most studied drugs that have been evaluated in both the adjuvant and primary setting of endocavitary instillation are mitomycin C and Bacillus Calmette-Guerin. The current paper provides an overview of the endocavitary treatments for UTUC, focusing on methods of administration, novel formulations, oncologic outcomes (in terms of endocavitary recurrence and progression), as well as on complications. In particular, the role of UGN-101 as a primary chemoablative treatment of primary noninvasive, endoscopically unresectable, low-grade, UTUC has been analysed. The drug achieved a complete response rate of 58% after the induction cycle, with a durable response independently of the maintenance cycle. The cumulative experience on the role of UUT instillation therapy appears encouraging; however, no definitive conclusions can be drawn about its therapeutic benefit. Given the current state of the art, any decision to administer adjuvant endoureteral therapy for UTUC should be carefully weighed against the potential adverse events. Nevertheless, newer investigations that improve visualization during ureteroscopy, genomic characterization, novel drugs and innovative strategies of improved drug delivery are under evaluation. The landscape of KSS for the treatment of the UTUC is evolving and seems promising.

Outcomes of endoscopic management of upper tract urothelial carcinoma

While radical nephroureterectomy (RNU) remains the gold-standard treatment for upper tract urothelial carcinoma (UTUC), a growing volume of literature surrounding endoscopic, organ-sparing procedures has developed over the past few decades. Based on this, endoscopic management of UTUC has gained acceptance as a standard of care approach, particularly among those with low-risk disease or with imperative indications for organ preservation. As a rare disease, however, data is mostly restricted to retrospective single institution series with relatively small numbers. Therefore, comparative outcomes of endoscopic management to RNU remain incompletely defined. Furthermore, the comparative utility of endoscopic approaches (ureteroscopy versus percutaneous resection) and topical therapy following resection lacks prospective analysis. In this article we review the available literature on endoscopic management of UTUC.

Future strategies to enhance kidney preservation in upper urinary tract urothelial carcinoma

Though radical nephroureterectomy remains the gold standard treatment for high grade or invasive disease in upper tract urothelial cancer (UTUC), kidney-sparing surgery has become preferred for low risk disease, in order to minimize morbidity and preserve renal function. Many methods exist for endoscopic management, whether via an antegrade percutaneous or retrograde ureteroscopic approach, including electroresection, laser ablation, and fulguration. There has been an increase in use of adjuvant intracavitary therapy, predominantly using mitomycin and bacillus Calmette-Guerin (BCG), to reduce recurrence after primary endoscopic management for noninvasive tumors, although efficacy remains questionable. Intraluminal BCG has additionally been used for primary treatment of CIS in the upper tract, with around 50% success. Newer investigations include use of narrow band imaging or photodynamic diagnosis with ureteroscopy to improve visualization during diagnosis and treatment. Genomic characterization may improve selection for kidney-sparing surgery as well as identify actionable mutations for systemic therapy. The evolution in adjuvant management has seen strategies to increase the dwell time and the urothelial contact of intraluminal agents. Lastly, chemoablation using a hydrogel for sustained effect of mitomycin is under investigation with promising early results. Continued expansion of the armamentarium available and better identification and characterization of tumors ideal for organ-sparing treatment will further improve kidney preservation in UTUC.

Formidable Scenarios in Urothelial and Variant Cancers of the Urinary Tract

Diagnostic and therapeutic challenges in the field of bladder and upper tract cancers provide opportunities for multidisciplinary care. Urothelial cancers make up the majority of the histologic subtype of bladder and upper tract cancers. Although the existence of variant histology, nonurothelial cancers, and urethral cancers is rare, these cancers pose a challenging clinical dilemma given the lack of well-defined consensus treatment guidelines. This review focuses on key issues of treatment: cisplatin ineligibility with emphasis on the definition, nuances of chemotherapy and frontline immune checkpoint inhibitor therapy, use of radiation in bladder-preservation strategies, upper tract urothelial cancer management, and highlights of urothelial variants and nonurothelial tumors and management.

Therapeutic strategies for upper tract urothelial carcinoma

INTRODUCTION

Many controversies exist regarding the appropriate management of patients with upper tract urothelial carcinoma (UTUC), including staging, surgical management, use of systemic therapy, and prevention of bladder recurrence. Due to the rarity of this condition, high-level evidence is often lacking and in many cases guidelines are extrapolated from existing evidence on urothelial bladder cancer. Areas covered: This review paper summarizes the evidence on proper diagnosis and staging, surgical techniques, prevention of bladder recurrences, the use of local or systemic treatments in both neoadjuvant and adjuvant settings as well as special consideration for hereditary UTUC. Expert commentary: UTUC is a rare malignancy and slow progress is being made in the acquisition of high-quality evidence in this field. Treatments that facilitate preservation of the kidney are being explored such as advanced endoscopic techniques or partial resection of ureteral disease with seemingly acceptable oncological results. Further prospective evidence is needed.

Intracavitary therapies for upper tract urothelial carcinoma

INTRODUCTION

While radical nephroureterectomy remains the gold-standard for upper tract urothelial carcinoma (UTUC), there is a growing push for organ-sparing therapy in low-risk disease. Herein we review the use of intracavitary topical therapy for treatment of UTUC. Areas covered: A PubMed search was performed for studies pertaining to upper tract urothelial carcinoma, with 236 articles reviewed, and distilled for content pertinent to intracavitary therapy for UTUC. Topics discussed include agents used for management of UTUC, most commonly BCG, as well as techniques for administration. Additionally, we review the evidence for curative treatment for Cis versus adjuvant therapy for Ta/T1 disease. Finally, we discuss emerging technologies to improve agent delivery and efficacy in the upper tract. Expert commentary: No significant advances have occurred in topical management of UTUC in the past 2 decades. However, advances in diagnostic techniques such as modern ureteroscopes, and improved diagnostic imaging at the time of ureteroscopy may help improve our patient selection. Additional advances in topical therapy focused on increasing the duration of contact between agent delivered and the upper tract urothelium offer hope that a new leap forward in topical therapy is on the horizon.

Which is best method for instillation of topical therapy to the upper urinary tract? An in vivo porcine study to evaluate three delivery methods

Purpose:

To compare the staining intensity of the upper urinary tract (UUT) urothelium among three UUT delivery methods in an in vivo porcine model.

Materials and methods:

A fluorescent dye solution (indigo carmine) was delivered to the UUT via three different methods: antegrade perfusion, vesico-ureteral reflux via in-dwelling ureteric stent and retrograde perfusion via a 5F open-ended ureteral catheter. Twelve renal units were tested with 4 in each method. After a 2-hour delivery time, the renal-ureter units were harvested en bloc. Time from harvesting to analysis was also standardised to be 2 hours in each arm. Three urothelium samples of the same weight and size were taken from each of the 6 pre-defined points (upper pole, mid pole, lower pole, renal pelvis, mid ureter and distal ureter) and the amount of fluorescence was measured with a spectrometer.

Results:

The mean fluorescence detected at all 6 predefined points of the UUT urothelium was the highest for the retrograde method. This was statistically significant with p-value less than <0.05 at all 6 points.

Conclusions:

Retrograde infusion of UUT by an open ended ureteral catheter resulted in highest mean fluorescence detected at all 6 pre-defined points of the UUT urothelium compared to antegrade infusion and vesico-ureteral reflux via indwelling ureteric stents indicating retrograde method ideal for topical therapy throughout the UUT urothelium. More clinical studies are needed to demonstrate if retrograde method could lead to better clinical outcomes compared to the other two methods.

Biological Behavior and Long-Term Outcomes of Carcinoma In Situ in Upper Urinary Tract Managed by Radical Nephroureterectomy

PURPOSE

In patients with urothelial carcinoma CIS (carcinoma in situ) generally has a poor prognosis. However, to our knowledge the outcomes of pure/primary CIS and the behavior of CIS concomitant with pTa-pT4 upper tract urothelial carcinoma managed by nephroureterectomy have not been previously specified. We explored the biological and prognostic features of concomitant CIS compared with those of pure/primary CIS.

MATERIALS AND METHODS

We queried a multicenter upper tract urothelial carcinoma database. Data from NUOG (Nishinihon Uro-Oncology Group) were analyzed, including patient gender, age, presence of bladder cancer and pT stage. Clinicopathological features were compared between the different subtypes. Cancer specific and overall survival, and the relative excess risk of death were estimated by CIS subtype.

RESULTS

We identified 163 patients with CIS in the upper urinary tract, of whom pure/primary CIS was noted in 24.5%. In the concomitant CIS cohort the pathological diagnosis of the nonCIS region was pTa, pT1, pT2, pT3 and pT4 in 4.9%, 22.8%, 25.2%, 44.7% and 1.6% of patients, respectively. The sensitivity of a selective urine cytology test was higher in the pure/primary CIS group than in the concomitant CIS group (60.0% vs 37.4%). At a median followup of 32 months 10-year estimated mean cancer specific survival was 92.4 months (range 83.7 to 101.0) in the overall CIS cohort. Ten-year estimated mean cancer specific survival in patients with pure/primary CIS was significantly longer than in patients with concomitant carcinoma in situ (111.8 months, range 101.0 to 122.6 vs 85.89, range 75.3 to 96.5, log rank p = 0.007).

CONCLUSIONS

Patients presenting with concomitant CIS have a worse outcome than those who present with pure/primary CIS, suggesting a need to differentiate these 2 entities in the treatment decision process.

Comparison of 3 upper tract anticarcinogenic agent delivery techniques in an ex vivo porcine model

OBJECTIVE

To evaluate the degree of urothelial exposure using 3 upper tract delivery techniques in an ex vivo porcine model, to determine the optimal modality to locally deliver topical anticarcinogenic agents in patients with upper tract urothelial carcinoma.

MATERIALS AND METHODS

An indigo carmine solution was infused into en bloc porcine urinary tracts to test the 3 techniques: antegrade infusion via nephrostomy tube, reflux via indwelling double-pigtail stent, and retrograde administration via a 5F open-ended ureteral catheter. Nine renal units (3 per delivery method) were used. After a 1-hour dwell time, the urinary tracts were bivalved and photographed. Each renal unit was evaluated by 3 blinded reviewers who estimated the total percentage of stained urothelial surface area using a computer-based area approximation system. In addition, as a surrogate for exposure adequacy, a validated equation was used to calculate the staining intensity at 6 predetermined locations in the upper tract, with lower values representing more efficient staining.

RESULTS

Mean percent of surface area stained for the nephrostomy tube, double-pigtail stent, and open-ended ureteral catheter groups was 65.2%, 66.2%, and 83.6%, respectively (P = .002). Mean staining intensities were 40.9, 33.4, and 20.4, respectively (P = .023).

CONCLUSION

Our results suggest that retrograde infusion via open-ended ureteral catheter is the most efficient method of upper tract therapy delivery. Larger studies using in vivo models should be performed to further validate these findings and potentially confirm this method as optimal for delivery of topical anticarcinogenic agents in upper tract urothelial carcinoma.

Outcomes of intrarenal Bacillus Calmette-Guérin/interferon-α2B for biopsy-proven upper-tract carcinoma in situ

BACKGROUND AND PURPOSE

While nephroureterectomy (NU) remains the gold-standard treatment for upper-tract carcinoma in situ (UT-CIS), it may be unnecessarily aggressive in comparison with the treatment of bladder CIS. Upper-tract administration of bacillus Calmette-Guérin (BCG) has shown promise for UT-CIS, but with limited reports and varied results. Furthermore, all previous reports included patients with positive cytology results without biopsy-proven CIS, or combined BCG with other topical therapies that are used for bladder CIS. We report our experience using a novel technique to directly instill BCG with interferon-α2B (BCG/IFN) into the upper-tract in patients with biopsy-proven UT-CIS.

PATIENTS AND METHODS

Patients who received a diagnosis of isolated, biopsy-proven UT-CIS from September 2003 to January 2012 were included. After biopsy, all patients received a 6-week induction course of BCG/IFN, administered via an open-ended ureteral catheter. Initial follow-up was scheduled 1 month after the completion of the intrarenal therapy and consisted of flexible ureteroscopy, selective urinary cytology, retrograde pyelography, and rebiopsy of the upper tract. Complete response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology results, and absence of clinical progression. Absence of visualized lesions with persistently positive cytology results or persistence of lesions after induction was considered no response (NR). New upper-tract lesions after an initial CR were considered recurrences. Patients with a CR were placed on maintenance therapy for 2 years. Surveillance was performed every 3 months with ureteroscopy, selective cytology, and imaging.

RESULTS

Eleven patients (mean age=73 years) were followed for a median of 13.5 months (3.7-103.3 mos). Eight patients had an initial CR, while three initially had NR. Two of the NR patients had negative biopsy results but persistently positive cytology results; both of these patients underwent a second induction course and achieved a CR. The third NR patient had persistence of lesions after induction and was offered a nephroureterctomy. Total kidney preservation rate was 91% (10/11). There were no treatment-related adverse events.

CONCLUSION

This study demonstrates the safety and efficacy of intrarenal BCG/IFN maintenance therapy for patients with UT-CIS. Unlike other mechanisms of delivery, including percutaneous administration or reflux via double pigtail stents, this office-based technique spares the morbidity of a chronically indwelling nephrostomy tube or ureteral stent.

Bacillus Calmette-Guérin for upper tract urothelial cancer: is there a role?

Since the first reported case of using adjuvant topical immunotherapy utilizing bacillus Calmette-Guérin (BCG) was published by Herr and associates, several institutions have utilized numerous agents for topical infusion therapies (BCG, Mitomycin, Epirubicin, Thiotepa or combination therapy of BCG/INF) as adjuncts in the treatment of upper tract papillary transitional cell carcinoma. A comprehensive review of the current data in the treatment of upper tract transitional cell carcinoma (Ta/T1 disease) with adjuvant BCG therapy was completed. Currently, the efficacy of adjuvant BCG therapy was not demonstrated.

Comprehensive management of upper tract urothelial carcinoma

Urothelial carcinoma of the upper urinary tract represents only 5% of all urothelial cancers. The 5-year cancer-specific survival in the United States is roughly 75% with grade and stage being the most powerful predictors of survival. Nephroureterectomy with excision of the ipsilateral ureteral orifice and bladder cuff en bloc remains the gold standard treatment of the upper urinary tract urothelial cancers, while endoscopic and laparoscopic approaches are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. Several controversies remain in their management, including a selection of endoscopic versus laparoscopic approaches, management strategies on the distal ureter, the role of lymphadenectomy, and the value of chemotherapy in upper tract disease. Aims of this paper are to critically review the management of such tumors, including endoscopic management, laparoscopic nephroureterectomy and management of the distal ureter, the role of lymphadenectomy, and the emerging role of chemotherapy in their treatment.

Review of topical treatment of upper tract urothelial carcinoma

A select group of patients with upper tract urothelial carcinoma may be appropriate candidates for minimally invasive management. Organ-preserving endoscopic procedures may be appropriate for patients with an inability to tolerate major surgery, solitary kidney, bilateral disease, poor renal function, small tumor burden, low-grade disease, or carcinoma in situ. We review the published literature on the use of topical treatment for upper tract urothelial carcinoma and provide our approach to treatment in the office setting.

A 20-year experience with percutaneous resection of upper tract transitional carcinoma: is there an oncologic benefit with adjuvant bacillus Calmette Guérin therapy?

OBJECTIVES

To determine whether there is an oncologic benefit of adjuvant bacillus Calmette Guérin (BCG) after resection of upper tract transitional cell carcinoma (UTTCC).

METHODS

A total of 133 renal units (RU) treated by percutaneous resection for UTTCC between 1985 and 2005 were retrospectively analyzed. Forty-four RU were excluded because of carcinoma in situ, high grade/stage, metastatic disease present at initial presentation, and/or the patient could tolerate loss of RU. Eighty-nine RU treated primarily by percutaneous resection were then analyzed. Fifty RU received adjuvant BCG therapy 2 weeks after endoscopic management for a total of 6 courses. Recurrence was defined as a positive biopsy result after the third-look nephroscopy. Progression of disease was assessed at time of recurrence and defined as an increase in grade/stage of disease.

RESULTS

Mean age (+/- SD) of 89 RU was 70.9 +/- 11.1 years. Overall follow-up was 61.1 + 54.8 months. Grade distribution was 56.2% (50 of 89) and 43.8% (39 of 89) for low- and high-grade disease, respectively. There was no statistical difference with regard to tumor grade or stage between treated and nontreated groups (P > .05). Recurrence, time to recurrence, and progression of disease among RU treated with BCG were subselected by grade and compared with the corresponding nontreated group. Statistical significance between any of the treated and nontreated groups was not demonstrated (P > .05).

CONCLUSIONS

Our data demonstrate that there is no overall oncologic benefit in the administration of adjuvant BCG with regard to disease recurrence, interval to recurrence, and progression of disease in the treatment of UTTCC.

Setting a new standard for topical therapy of upper-tract transitional-cell carcinoma: BCG and interferon-alpha2B

BACKGROUND AND PURPOSE

We report our office-based technique and results of BCG and interferon-alpha2B (BCG-IFN) for upper-tract transitional-cell carcinoma (TCC).

TECHNIQUE

Papillary lesions were ablated endoscopically after biopsy. Office flexible cystoscopy was performed, and a 0.038-inch guidewire or Glidewire was advanced into the renal pelvis. A 5F ureteral catheter was placed over the wire, and a free flow of urine was confirmed. Half-strength BCG + 50 million units of IFN was infused under low pressure for 1 hour. The ureteral catheter was removed, and patients were instructed to void 1 hour later.

RESULTS

Between 2000 and 2006, 10 patients with a median age of 72 years were treated with BCG-IFN for upper-tract TCC in 11 renal units. Follow-up ureteroscopy with or without biopsy was performed after a 6-week induction to evaluate response. Complete responders were placed on a maintenance regimen. With a median follow-up of 24 months, 8 patients (80%) demonstrated a complete response (CR) to therapy, and 2 had a partial response (decrease in tumor size, number, or both). Six patients with a CR have continued on maintenance therapy. There were no side effects or complications with the instillation therapy.

CONCLUSION

We describe a safe, minimally invasive, and effective office-based technique for upper-tract BCG-IFN instillation.

Long-term outcome of upper urinary tract carcinoma in situ: Effectiveness of nephroureterectomy versus bacillus Calmette-Guérin therapy

BACKGROUND

We examined the long-term outcome and compared the usefulness of nephroureterectomy with that of bacillus Calmette-Guérin (BCG) therapy for the management of upper urinary tract carcinoma in situ (CIS).

METHODS

We retrospectively reviewed the post-treatment course of 17 patients with CIS of the upper urinary tract who had undergone either a nephroureterectomy (group A, n = 6) or BCG therapy (group B, n = 11) at our institute.

RESULTS

Median follow up was 58.3 months (range 1-120 months). Four of the six patients in group A (67%) had no recurrence and remained cystoscopically, cytologically and radiographically free of disease. The cytology became negative after an 8-week course in nine of the eleven patients in group B (82%; eight of ten units, 77%). Two of the nine patients showed recurrence after BCG therapy. One patient died of respiratory failure caused by a side-effect of BCG, which was interstitial pneumonia. There was no significant difference in either the 5-year recurrence-free survival or the 5-year cancer-specific survival between groups A and B.

CONCLUSIONS

BCG therapy for CIS of the upper urinary tract is as effective as nephroureterectomy in long-term outcome, although it has some dangerous aspects. Further experience with treatment of CIS of the upper urinary tract is required.

Minimally invasive management of upper tract urothelial carcinoma

Recently published studies that evaluated minimally invasive treatments for upper tract urothelial cancer (UTUC) were reviewed, including adjuvant topical therapy. Ureteroscopic management remains the initial diagnostic and possibly therapeutic procedure of choice. Percutaneous management is used to treat bulky tumors or tumors that cannot be accessed ureteroscopically. Low-grade UTUC in appropriately selected patients can be safely and effectively treated endoscopically. High-grade disease tends to fail, regardless of treatment modality, and warrants aggressive therapy. Adjuvant therapy seems to be safe, although its efficacy is debatable. Immunotherapy appears to be most effective in patients with upper tract carcinoma in situ.

Long-term effects of bacille calmette-guérin perfusion therapy for treatment of transitional cell carcinoma in situ of upper urinary tract

OBJECTIVES

To report our experience with bacille Calmette-Guérin (BCG) perfusion therapy for transitional cell carcinoma in situ of the upper urinary tract. BCG perfusion therapy is widely used to treat transitional cell carcinoma in situ of the upper urinary tract. However, it has not yet been established as a standard treatment.

METHODS

Ten patients diagnosed with transitional cell carcinoma in situ of the upper urinary tract were treated with BCG perfusion therapy from January 1990 to May 2002. BCG was instilled weekly for 6 weeks, with a median dose of 65 mg at 1.17 mg/mL (Tokyo 172 strain, dissolved in normal saline).

RESULTS

The mean follow-up period was 50.9 months (range 12 to 134). The initial response to therapy was excellent, and cytology became negative in all patients after one course of BCG perfusion. Five patients developed recurrence after 5, 11, 24, 26, and 45 months, and all died after 46, 12, 41, 134, and 79 months, respectively. The mortality rate was 50% and was 100% in those with recurrence. The mean recurrence-free period was 22.2 months (range 5 to 45). Complications included bladder irritation-related symptoms in all patients, fever greater than 38 degrees C (n = 9), hematuria (n = 2), hydronephrosis (n = 2), and lumbago (n = 1) but all were transient and did not affect long-term prognosis.

CONCLUSIONS

BCG perfusion therapy for carcinoma in situ of the upper urinary tract is safe, and the short-term response is excellent. However, the long-term results were not satisfactory. Therefore, this therapy should be considered experimental, although it may have potential benefits in delaying progression and possibly providing local control for patients in poor condition. Long-term studies are required for additional evaluation of BCG therapy.

Clinical outcome of bacillus Calmette-Guérin perfusion therapy for carcinoma in situ of the upper urinary tract

BACKGROUND

The objective of this study was to evaluate the efficacy of intrarenal bacillus Calmette-Guérin (BCG) instillation for the treatment of carcinoma in situ (CIS) of the upper urinary tract.

METHODS

Sixteen patients who were diagnosed as having CIS of the upper urinary tract were treated with intrarenal BCG instillation. BCG (80 mg) in normal saline was administered once weekly, 6 times in total as one course through a percutaneous nephrostomy tube in 5 patients, and a retrograde ureteric catheterization using a Single-J or Double-J stent in 2 and 9 patients, respectively.

RESULTS

During the median follow-up period of 30 months (range: 9-90 months), no patients died, and 13 patients remained cytologically negative in urine collected from the upper urinary tract after BCG treatment was completed. However, one of these 13 patients had CIS in the bladder and prostatic urethra 34 months after the BCG therapy and had to undergo radical cystectomy. The remaining 3 patients experienced recurrence in the upper urinary tract 4, 8, and 11 months after treatment, despite a favorable response to the initial BCG instillation. Of these 3 patients, one patient received an additional course of BCG therapy, while the remaining 2 underwent nephroureterectomy. Bladder irritability or a fever higher than 38 degrees C was observed in 12 or 9 patients, respectively; however, such side-effects were not clinically significant, and no patient received antitubercular treatment.

CONCLUSION

Intrarenal instillation of BCG appears to be effective and safe for treatment of CIS of the upper urinary tract; however, further experience and longer follow-up studies of this treatment are required.

Long-term experience with bacillus Calmette-Guerin therapy of upper urinary tract transitional cell carcinoma in patients not eligible for surgery

PURPOSE

Carcinoma in situ and urothelial tumors of the upper urinary tract become problematic in cases of bilateral occurrence or solitary kidney. Perfusions with bacillus Calmette-Guerin (BCG) have been reported beneficial, however, only long-term results will determine the validity of this treatment.

MATERIALS AND METHODS

We retrospectively evaluated the results of BCG therapy for upper urinary tract disease in 37 patients. All 37 patients had undergone previous surgical treatment for urothelial cancer, had a positive cytology or biopsy for upper urinary tract cancer and were ineligible for radical nephroureterectomy with a bladder cuff. After placement of a 10Fr nephrostomy tube with the patient under local anesthesia 6 weekly perfusions of BCG were administered after radiological documentation of unhindered flow from the renal pelvis to the bladder or urinary diversion. A total of 25 renal units were treated with curative intent for carcinoma in situ and 16 renal units were treated for Ta or higher urothelial tumors in an adjuvant setting after endoscopic resection.

RESULTS

In 37 patients 41 renal units were treated with BCG perfusions and were followed for a median of 42 months (range 8 to 137). In 1 patient BCG inflammation and in 2 others severe septicemia developed after the first perfusion. There was no tumor seeding along the nephrostomy tract in any patient. BCG perfusion therapy did not alter renal function. Overall median survival was 42 months (range 1 to 137), median recurrence-free survival was 21 months (1 to 137) and progression-free survival was 34 months (1 to 118). Of the 37 patients 14 (38%) died of urothelial cancer, 11 of other causes (29%) and 12 (33%) are alive.

CONCLUSIONS

BCG perfusion therapy of the upper urinary tract for papillary tumors or carcinoma in situ is a valid treatment option with acceptable side effects for patients not amenable to conventional radical surgical therapy. BCG therapy of upper urinary tract urothelial tumors may prevent patients from requiring dialysis and provides cure in those with carcinoma in situ of the upper urinary tract. In this negatively selected patient population BCG buys time for some but does not provide cure except for carcinoma in situ.

Long-term experience with bacillus Calmette-Guerin therapy of upper urinary tract transitional cell carcinoma in patients not eligible for surgery

PURPOSE

Carcinoma in situ and urothelial tumors of the upper urinary tract become problematic in cases of bilateral occurrence or solitary kidney. Perfusions with bacillus Calmette-Guerin (BCG) have been reported beneficial, however, only long-term results will determine the validity of this treatment.

MATERIALS AND METHODS

We retrospectively evaluated the results of BCG therapy for upper urinary tract disease in 37 patients. All 37 patients had undergone previous surgical treatment for urothelial cancer, had a positive cytology or biopsy for upper urinary tract cancer and were ineligible for radical nephroureterectomy with a bladder cuff. After placement of a 10Fr nephrostomy tube with the patient under local anesthesia 6 weekly perfusions of BCG were administered after radiological documentation of unhindered flow from the renal pelvis to the bladder or urinary diversion. A total of 25 renal units were treated with curative intent for carcinoma in situ and 16 renal units were treated for Ta or higher urothelial tumors in an adjuvant setting after endoscopic resection.

RESULTS

In 37 patients 41 renal units were treated with BCG perfusions and were followed for a median of 42 months (range 8 to 137). In 1 patient BCG inflammation and in 2 others severe septicemia developed after the first perfusion. There was no tumor seeding along the nephrostomy tract in any patient. BCG perfusion therapy did not alter renal function. Overall median survival was 42 months (range 1 to 137), median recurrence-free survival was 21 months (1 to 137) and progression-free survival was 34 months (1 to 118). Of the 37 patients 14 (38%) died of urothelial cancer, 11 of other causes (29%) and 12 (33%) are alive.

CONCLUSIONS

BCG perfusion therapy of the upper urinary tract for papillary tumors or carcinoma in situ is a valid treatment option with acceptable side effects for patients not amenable to conventional radical surgical therapy. BCG therapy of upper urinary tract urothelial tumors may prevent patients from requiring dialysis and provides cure in those with carcinoma in situ of the upper urinary tract. In this negatively selected patient population BCG buys time for some but does not provide cure except for carcinoma in situ.

Intravesical instillation of bacille Calmette-Guérin for carcinoma in situ of the urothelium involving the upper urinary tract using vesicoureteral reflux created by a double-pigtail catheter

OBJECTIVES

To evaluate the therapeutic efficacy of bacille Calmette-Guérin (BCG) for carcinoma in situ (CIS) of the urothelium involving the upper urinary tract when the vaccine was administered by way of the bladder using vesicoureteral reflux created by a double-pigtail (DP) catheter.

METHODS

Thirteen upper urinary tracts of 9 patients with cytologically diagnosed CIS, with concomitant bladder CIS in 4, were treated by intravesical BCG instillation. A DP catheter was placed retrogradely, and the appearance of vesicoureteral reflux was confirmed by cystography. BCG (1 to 2 mg/mL) in a volume sufficient to fill the renal caliceal system was administered into the bladder weekly for 6 weeks. The mean follow-up was 36 months (range 8 to 97).

RESULTS

The voided urine cytology turned negative in all 9 patients at a mean of 86 days after the first administration of BCG. The voided urine cytology returned positive afterward in 3 patients, and positive cytology in the upper urinary tract was confirmed in 1 of 13 treated urinary tracts, which were successfully treated by another course of BCG therapy with the DP catheter. Minor adverse effects related to BCG and the DP catheter were seen in 5 patients.

CONCLUSIONS

BCG therapy for the CIS involving the upper urinary tract using a DP catheter might have the potential to be an effective procedure preserving renal units and could be adopted not only as an imperative, but also as an elective, treatment option.

Intrarenal bacillus Calmette-Guérin therapy for carcinoma in situ of the upper urinary tract: long-term follow-up and natural course in cases of failure

OBJECTIVE

To assess the long-term efficacy of intrarenal bacillus Calmette-Guérin (BCG) therapy for the treatment of cytologically diagnosed upper tract carcinoma in situ (CIS) and report the time course in cases of failure.

PATIENTS AND METHODS

Fourteen renal units in 11 patients cytologically diagnosed as having upper urinary tract (UUT) CIS were treated with intrarenal BCG instillation. The BCG solution was administered by retrograde ureteric catheterization weekly for 6 weeks.

RESULTS

Seven units were radiologically and cytologically free of disease at a median follow-up of 60 months. Two units which showed an initial response had recurrence with ipsilateral UUT CIS. The remaining five units did not respond to BCG. Of seven units with an initial negative response or recurrent UUT CIS, nephroureterectomy was undertaken in one because of coincidental renal cell carcinoma. In four of the remaining six units, invasive pelvic tumour developed at a mean follow-up of 20.5 months after the final instillation. Computed tomography showed wall thickening of the renal pelvis in two and mass-forming tumour in the renal parenchyma mimicking renal cell carcinoma in two. In three of these four cases, retrograde pyelography did not show typical findings of renal pelvic tumour, e.g. filling defect, infundibular obstruction or stenosis.

CONCLUSIONS

Intrarenal BCG is effective in the treatment of UUT CIS in a long-term follow-up. In cases with a poor response or ipsilateral recurrence of CIS, there is a high risk of developing invasive tumour. Close follow-up using computed tomography is recommended because of the atypical radiographic findings of such tumours.