Prevention of topic toxicity of BCG with single-dose prulifloxacin. Preliminary results of a randomized pilot study

Introduction

Toxicity is a major problem for patients undergoing intravesical therapy with Bacillus Calmette-Guérin (BCG) for the conservative management of intermediate or high-risk non-muscle invasive bladder cancer (NMI-BC). A prospective pilot trial was designed to evaluate the adoption of a single dose of prulifloxacin to prevent the toxicity of BCG. Treatment tolerability and its possible influence on BCG efficacy have been analyzed.

Materials and Methods

The study was designed to evaluate the action of prulifloxacin in patients with intermediate or high-risk NMI-BC, undergoing 6–week induction cycle of BCG. Main exclusion criteria were previous intravesical therapy, urinary infection and any other factor that could influence tolerability to BCG intravesical immunotherapy. The patients were randomized to receive BCG alone versus BCG plus prulifloxacin. BCG toxicity and local tolerability were evaluated by self-administered EORTC QLQ-BLS24 questionnaire, and BCG adverse events (AEs) were classified according a four-class classification. The toxicity and tolerability evaluations were performed at baseline, one week after every instillation and one week and one month after the last instillation. Cystoscopy and cytology were performed 3–monthly. Recurrence and progression were recorded.

Results

The study included 43 patients receiving 258 instillations of BCG. The patients were randomized to receive BCG alone (Arm A: 132 instillations in 22 patients) versus BCG plus prulifloxacin given as a single oral dose (600 mg) 6 hours after the instillation. An advantage in favor of prulifloxacin prophylaxis emerged, according to EORTC QLQ-BLS24, in overall incidence of nocturnal micturitions (56% vs 28.6%; p=0.001), insomnia (40% vs 14.3%; p=0.002), urgency (70% vs 42.6%; p=0.05), incontinence (44% vs 12.7%; p=0.01) and bothersome events due to intravesical therapy (84% vs 63.5%; p=0.02). Systemic class IIB and III adverse events occurred in only 14.2% and 3.5% of the patients, respectively. No class IV AE was detected. Due to the low incidence no statistically significant difference was evident between the two arms (p=0.6). Three patients of Arm B and 1 patient of Arm A interrupted the treatment, after the 3rd - 4th instillation. Anti-tuberculosis therapy war required for 3 months in only one patient. Three and 2 instillations were postponed for one-(two) week(s) in Arm B and Arm A, respectively. Prulifloxacin, generally well tolerated, was withdrawn in one patient due to skin allergic reaction. Recurrence rate at a mean follow-up of 12 months did not significantly differ between the two arms.

Conclusions

Prulifloxacin decreases the incidence of local symptoms and improves the compliance to BCG intravesical therapy. Due to the low number of events, no evidence emerges in our study about its capability of preventing severe systemic toxicity, although it has proved effective in reducing local symptoms.

Formulation and characterization of EGCG for the treatment of superficial bladder cancer

In the United States, the annual incidence of bladder cancer is approximately 70,000 new cases, with a mortality rate of approximately 15,000/year. The most common subtype (70%) of bladder cancer is superficial, namely hte non-muscle invasive disease form limited to the urothelium. The rate of progression and recurrence is up to 40 and 70%, respectively. Urothelial cell carcinoma of the bladder is typically treated with transurethral resection. The cancerous cells can float onto the adjacent epithelium, increasing the risk of recurrence. The standard of care is to offer adjuvant intravesical agents to reduce the risk of progression and recurrence. Current intravesical treatments are costly and are associated with special biohazard handling protocols. Patients are treated with intravesical therapy with bacillus Calmetter-Guerin (BCG) bacterium, or mitomycin C (MMC) following resection, both of which can cause moderate to severe side-effects which are rarely life-threatening. We previously examined the efficacy of epigallocatechin-3-gallate (EGCG)in comparison with MMC to prevent tumor cell implantation/growth in an animal model of superficial bladder cancer. Experiments revile that EGCG is slightly more effective than MMC at decreasing tumor cell implantation and consequent cancer growth in a bladder. This treatment requires the stringent sterile requirement of EGCG. EGCG can be unstable when sterilized at high temperatures. Thus, we evaluated two low temperature sterilization methods, such as ionizing radiation or the filtration method followed by freeze-drying. Both methods ensure the sterility of the sample; however, infrared and HPLC analysis revealed a slightly better stability of irradiated EGCG over the filtration method. The concentration of stable free radicals following irradiation was low, which are unlikely to exert any damaging effects to EGCG. Therefore, we consider that radiation will be the preferred method of EGCG sterilization, and that this may prove useful for the effective use of EGCG in the treatment of bladder cancer.

Post-intravesical BCG epididymo-orchitis: Case report and a review of the literature

INTRODUCTION

Bladder cancer is a significant epidemiological disease. It is managed by primary resection and on-going surveillance for recurrent disease. Intravesical BCG therapy is used in superficial carcinomas to lower the incidence of recurrence and prolong the time to recurrence. BCG therapy is not without its rare but serious side effects.

PRESENTATION OF CASE

A 75-year-old man presented to the urologist with right testicular pain, after four previous TURBT operations, two courses of intravesical BCG therapy and one STAT dose of intravesical mitomycin. The patient's USS testis showed hypoechoic lesions in the right testis. An orchiectomy was carried out due to the possibility of the USS showing a malignancy. Histology confirmed BCG epididymo-orchitis.

DISCUSSION

This patient presented with testicular pain fifteen months after the cessation of BCG therapy. Clinicians need to be aware of the potentially long dormancy periods for BCG infections, and their complications, as well as the acute infective BCG presentations. The literature is reviewed and shows the wide range of infective BCG presentations from acute disseminated sepsis to insidious focal infections such as parotiditis and discitis.

CONCLUSION

This case report demonstrates that due to the delayed and gradual onset of symptoms, BCG infections are difficult to diagnose. The report and the review remind surgeons to keep BCG infection amongst their differentials when treating patients who present after BCG therapy.

[Adverse events after intravesical therapy: are we always ready to recognize and prevent them?]

Intravesical therapy is widely used in non-muscle-invasive bladder cancer (NMIBC) as adjuvant treatment after transurethral resection of bladder tumor (TURBT). Assuming that adjuvant therapy is necessary for NMIBC in order to reduce recurrence and progression rates, chemotherapy and BCG toxicity become a relevant issue. Both treatments may have local and systemic side effects, which can lead to treatment cessation, resulting in incomplete treatment and poor outcomes. Therefore, urologists, specialist nurses and patients must be aware of the possible adverse events in order to early recognize, prevent and treat them properly. This article summarizes the local and systemic side effects associated with intravesical therapy, presents the recommendations for an effective management of these adverse events based on currently available evidence, and highlights some open questions on these issues.