Treatment efficacy and tolerability of intravesical bacillus Calmette-Guerin (BCG)-RIVM strain: induction and maintenance protocol in high grade and recurrent low grade non-muscle invasive bladder cancer (NMIBC)

Background

BCG-RIVM strain was used in many treatment protocols for non-muscle invasive bladder cancer only as induction courses. Cho et al. (Anticancer Res 2012) compared BCG-RIVM induction and 'standard' maintenance (Lamm et al., J Urol. 2000) to mitomycin C. They found no statistically significant differences regarding disease recurrence and progression. The purpose of our study was to determine the efficacy & tolerability of this specific BCG RIVM strain, using six-weekly, induction course and single monthly instillations as maintenance for one year, in high risk recurrent, multifocal low grade and multifocal high grade pTa/pT1, CIS transitional cell carcinoma of bladder.

Methods

From 2003 - 2012, BCG-naive patients treated with intravesical BCG-RIVM for high-risk multifocal NMIBC were identified. Transurethral resection of bladder tumor (TURBT) and re-staging TURBT within six weeks, was done for accurate staging and complete elimination of disease. A six-weekly induction course, started 2-3 weeks after the last TURBT, followed by monthly maintenance protocol for one year. Recurrence, progression, cystectomy free survivals, cancer specific and over-all survival were determined.

Results

Sixty evaluable patients - median age 63, median follow-up 3.98 years. Forty-two patients (70%) completed BCG-RIVM treatment as planned. BCG termination was necessary in 18 patients (30%). Recurrence occurred in 16 patients (26.7%) at a median follow-up of 24.2 months while progression occurred in five patients (8.3%) at a median follow-up of 33 months. Recurrence-free survival and progression-free survival rates were 73% and 92% respectively. Cystectomy was performed in seven patients (12%) with a cystectomy-free survival of 88%. There were no cancer specific deaths. Two patients died of other causes (3.3%). The overall survival rate was 97%.

Conclusions

Our study is the first to show the clinical efficacy and tolerability of BCG-RIVM strain in the management of high risk NMIBC when given in a schedule of six-weekly induction with monthly maintenance for one year. Our maintenance protocol, achieved equivalent recurrence-free, progression-free, disease specific survival and overall survival to the reported literature and the more intense three-years South West Oncology Group (SWOG) protocol.

Urinary tract infections in adult and adolescent males of a developing community: pattern, bacteriology and genito-urinary predisposing factors

OBJECTIVES

Analysis of 95 consecutive adult and adolescent males with urinary tract infections to determine the pattern, bacteriology and the predisposing causes.

METHODS

The period was 12 months, and the number of patients was 95 consecutive cases. They were adult and adolescent males with urinary tract infection. Their age ranged from 13-100 years, (median 55, mean 53.3 years).

RESULTS

Hospital and community acquired urinary tract infections occurred in 40% and 60% of patients respectively. E. coli was isolated from 66.7% of community acquired infections, which was well below the reported literature of 80-90%.

CONCLUSIONS

Enterococci and Enterobacter spp. Appear to be emerging as important hospital and community acquired urinary tract pathogens in males. Bladder outflow obstruction accounted for over 50% of all genito urinary causes of urinary tract infections, while genitourinary malignancy occurred in nearly 20% of patients. The implications of these findings are discussed.

Urinary tract infections in adult and adolescent females of a developing community: pattern, bacteriology and genitourinary predisposing factors

One hundred and twenty-seven consecutive adult and adolescent female patients with culture-proven urinary tract infections were analyzed to determine the pattern, bacteriology and the predisposing causes. Age ranged from 13 to 70 years (median 32, mean 35.7 years). Community acquired urinary tract infections occurred in 85%, while hospital acquired infections in 15% of cases. Urinary tract stones were the most frequently identified genitourinary predisposing causes, which occurred in 16 patients (15%). However, 52.3% of all patients had no identifiable predisposing cause. E. coli, the most frequently isolated organisms from patients with community acquired urinary tract infections, occurred in only 55.6%, while gram-positive cocci isolated from 28 patients (22%) are emerging as important hospital and community acquired urinary tract pathogens. The implications of these findings and a comparison with the reported literature are discussed.

Ureteric obstruction in renal transplants: the role of percutaneous balloon dilatation

With widespread use of balloon dilatation catheters outside the vascular system, percutaneous balloon dilatation has become an accepted alternative to surgery. Seventeen patients who developed ureteric stenosis following renal transplantation underwent 21 transrenal angioplastic balloon dilatations. Fifteen patients had lower ureteric strictures (2-22 mm long), and two had multiple strictures. The time interval between transplantation and obstruction ranged from 11 to 1370 days (median 71, mean 228.9 days). Nine patients were treated successfully (53%) with no stricture recurrence during the follow-up period, which ranged from 3 to 44 months (median 16, mean 17.8 months). In eight of nine patients in this group, the stricture impression on the inflation balloon was eliminated, and this appears to correlate best with a successful outcome. The eight patients who failed balloon dilatation and restenosed, did so within 7-42 days in seven patients; one patient had late stricturing at 238 days. Serious complications occurred in only one patient, who developed an A-V fistula not amenable to correction and necessitating transplant nephrectomy.

Measurement of the plasma clearance of urographic contrast media for the determination of glomerular filtration rate

Further experience with a new method to determine glomerular filtration rate is presented. The method depends on measurement by an x-ray fluorescence technique of the plasma disappearance of the injected iodine in standard nonionic radiographic contrast media used during excretory urography. The results of comparison of contrast clearance with 99m technetium-diethylenetriaminepentaacetic acid clearance in 33 cases showed excellent agreement with a correlation coefficient of 0.95. Reproducibility of the contrast clearance method was confirmed by repeated examination of 10 plasma samples at weekly intervals for 6 weeks, the results of which showed no significant differences. The contrast clearance technique for the measurement of glomerular filtration rate during excretory urography is simple, quick and accurate, and merits further development.

High pressure chronic retention. Incidence, aetiology and sinister implications

A prospective analysis of 36 consecutive cases of high pressure chronic retention presenting over a 3-year period is described. Thirty-nine per cent of patients had malignant prostates and 14% had bladder tumours (overall malignancy rate 53%). The dangers of mismanagement of high pressure chronic retention include uraemic death and hypovolaemic circulatory collapse from neglected post-obstructive diuresis. The clinician should be prepared to find a high incidence of urological malignant disease in patients presenting with this syndrome.

Accuracy and reproducibility of a new contrast clearance method for the determination of glomerular filtration rate

A new method for determining the glomerular filtration rate was analysed prospectively. The method uses an x ray fluorescence technique to measure disappearance from the plasma of injected non-ionic iodinated contrast media. Eighty seven patients were studied. Fifty four had an intravenous dose of 100 ml iohexol (Omnipaque) and 33 had 50 ml iohexol. Clearances of chromium-51 labelled edetic acid (51Cr-EDTA) were measured simultaneously. In the patients given 100 ml iohexol there was excellent correlation with 51Cr-EDTA clearance (r = 0.90). The correlation using 50 ml iohexol was also good (r = 0.85). Correlation between creatinine clearance and clearance of 51Cr-EDTA in 33 patients was less satisfactory (r = 0.69). There were no adverse reactions to the contrast media. The equipment used for measuring contrast clearance was robust and simple to operate. Freezing plasma samples in 10 studies and re-examining them weekly for six weeks showed no significant variation in results; hence reproducibility was good. This new and accurate method for determining the glomerular filtration rate merits further study and might find a useful place in routine clinical practice.

The choroid--an unusual site for metastasis in patients with adenocarcinoma of the rectum--a case report

Metastatic carcinoma is the commonest malignant tumour of the eye and usually presents with a disturbance of vision. A rare case of choroidal metastasis secondary to adenocarcinoma of the rectum is reported to emphasize the need to investigate visual symptoms in patients with known or suspected malignant disease.