Clinical presentation of bacille Calmette-Guérin (BCG) infections after BCG instillation therapy

OBJECTIVES

To investigate the timing of the clinical presentation of various types of bacille Calmette-Guérin (BCG) infections in a Finnish population of patients with bladder cancer treated with BCG instillation therapy.

PATIENTS AND METHODS

We identified patients with a history of post-instillation BCG infection from 1996 to 2016 using the Finnish Cancer Registry and the Finnish National Infectious Diseases Registry. We categorised infections as systemic if the infection was found in the non-urogenital system and genitourinary (GU) if the infection affected the urogenital tract. We calculated the time interval between the last BCG instillation and the presentation of the infection. The infection was considered late if the time interval was ≥1 year.

RESULTS

A total of 100 patients with BCG infection were identified during the study period. In all, 39 (39%) infections presented as systemic and 61 (61%) were in the GU tract. The majority of the systemic infections presented rapidly after the last instillation, while five (13%) presented after a latency of ≥1 year. The presentation of GU infections was more heterogeneous, with 12 (20%) presenting as late infections.

CONCLUSION

This study confirms the concept of early and late infection types, especially among systemic infections. However, late infections appeared to be rarer than previously described. Urologists should be aware of the possibility of late BCG infection if patients develop symptoms even several years after the BCG regimen.

The Impact of SARS-CoV-2 Pandemic on Time to Primary, Secondary Resection and Adjuvant Intravesical Therapy in Patients with High-Risk Non-Muscle Invasive Bladder Cancer: A Retrospective Multi-Institutional Cohort Analysis

Simple Summary

The worldwide COVID-19 emergency has had an important impact on healthcare systems with the need to assist infected patients and also treat non-deferrable oncological conditions. In urology, the main concern has been for patients with bladder cancer, the tenth most common malignancy, where the quality and the alacrity of treatment has a clear well-demonstrated impact on the survivor. The aim of our Italian multi-institutional retrospective study was to assess the impact of the COVID-19 outbreak on diagnosis and treatment of non-muscle invasive bladder cancer. We observed a significant delay between diagnosis and surgical treatment, with a lower adherence to the standard therapeutic scheme such as BCG intravesical instillation and urological guidelines. We also recorded a different attitude in treatment depending on the patients’ location in Italy. Further investigation could show the impact of the pandemic on the survival of these patients.

Abstract

Background: To investigate the impact of COVID-19 outbreak on the diagnosis and treatment of non-muscle invasive bladder cancer (NMIBC). Methods: A retrospective analysis was performed using an Italian multi-institutional database of TURBT patients with high-risk urothelial NMIBC between January 2019 and February 2021, followed by Re-TURBT and/or adjuvant intravesical BCG. Results: A total of 2591 patients from 27 institutions with primary TURBT were included. Of these, 1534 (59.2%) and 1056 (40.8%) underwent TURBT before and during the COVID-19 outbreak, respectively. Time between diagnosis and TURBT was significantly longer during the COVID-19 period (65 vs. 52 days, p = 0.002). One thousand and sixty-six patients (41.1%) received Re-TURBT, 604 (56.7%) during the pre-COVID-19. The median time to secondary resection was significantly longer during the COVID-19 period (55 vs. 48 days, p < 0.0001). A total of 977 patients underwent adjuvant intravesical therapy after primary or secondary resection, with a similar distribution across the two groups (n = 453, 86% vs. n = 388, 86.2%). However, the proportion of the patients who underwent maintenance significantly differed (79.5% vs. 60.4%, p < 0.0001). Conclusions: The COVID-19 pandemic represented an unprecedented challenge to our health system. Our study did not show significant differences in TURBT quality. However, a delay in treatment schedule and disease management was observed. Investigation of the oncological impacts of those differences should be advocated.

Incidence of and mortality from Bacille Calmette-Guérin (BCG) infections after BCG instillation therapy

OBJECTIVES

To investigate the incidence of and mortality associated with Bacille Calmette-Guérin (BCG) infections in a Finnish population of patients with bladder cancer treated with BCG instillations.

MATERIALS AND METHODS

We conducted a nationwide register study and identified patients with BCG infections in Finland during 1996 to 2016 using the Finnish Cancer Registry and the Finnish National Infectious Diseases Register. We estimated the number of patients treated with BCG instillations based on data on national consumed BCG doses used to treat patients with bladder cancer, and calculated the annual incidence proportion of BCG infections. We further performed a detailed medical chart review to describe the clinical features and outcomes of the treated BCG infections.

RESULTS

In total, 87 patients with BCG infection after BCG treatment of bladder cancer were identified. The incidence proportion increased gradually, yielding a cumulative incidence proportion of 2.5% during the latter half of the study period. BCG infections led to significant mortality, with 10% overall mortality and 17.5% mortality from systemic infections, which is notably higher than previously reported.

CONCLUSION

The incidence proportion of BCG infections among bladder cancer patients treated with BCG has increased in Finland up to 2.5% at a nationwide level, with a notably higher mortality rate than previously reported.

The Evaluation of Cases with Ocular Complications due to Bacillus Calmette-Guerin (BCG) Treatment using the Pool Analysis Method

OBJECTIVE

The aim of this study was to investigate cases with ocular complications associated with intravesical BCG therapy in terms of clinical features, demographic features and type of ocular involvement.

METHODS

PubMed database was scanned for relevant publications using the keywords. Thirty-seven publications and 147 reported cases were identified related to the development of ocular complications due to intravesical BCG treatment.

RESULTS

As a result of the analysis performed according to eye involvement, there were 17 cases of conjunctivitis, 7 uveitis, and 5 endophthalmitis. Only 27 (18.3%) cases were of primary ocular involvement and Reiter's syndrome was present in 120 (81.6%) of all cases.

CONCLUSIONS

Most of the side-effects of BCG therapy are minor and of short duration. Although rare, it has been reported that potentially serious ocular complications can develop after treatment. Physicians must keep these facts in mind and be alert to the development of ocular symptoms following BCG therapy.

Novel and emerging approaches in the management of non-muscle invasive urothelial carcinoma

Non-muscle invasive bladder cancer (NMIBC) has traditionally been managed with transurethral resection followed by intravesical chemotherapy and/or bacillus Calmette-Guerin (BCG) in a risk-adapted manner. These tumors commonly recur and can progress potentially to lethal muscle invasive disease. A major unmet need in the field of NMIBC is bladder preserving therapy for recurrent high-grade NMIBC after adequate intravesical BCG therapy. The current gold standard treatment for these BCG-unresponsive patients is radical cystectomy, which is associated with considerable morbidity and mortality, particularly in older and frailer patients. It is therefore critical to provide alternative treatment options with acceptable oncological outcomes. In this review we explore novel bladder-sparing treatment options including combination intravesical therapy, enhanced instillation methods, immunotherapy, gene therapy, targeted therapy, photodynamic therapy and BCG variants across the spectrum of NMIBC disease states, ranging from low grade BCG-naïve patients through to high-grade BCG-unresponsive NMIBC.

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.

The epidemiology of bacille Calmette-Guérin infections after bladder instillation from 2002 through 2017: a nationwide retrospective cohort study

OBJECTIVE

To describe incidence and clinical characteristics of bacille Calmette-Guérin (BCG) infections after BCG bladder instillation amongst patients with non-muscle-invasive bladder cancer in Denmark.

PATIENTS AND METHODS

We conducted a nationwide register-based cohort study in Denmark between 2002 through 2017. Patients with BCG infection were identified by cross-linking data from the Danish National Hospital Registry on patients treated with BCG instillations and patients diagnosed with tuberculosis according to the International Classification of Diseases 10, and data obtained from International Reference Laboratory of Mycobacteriology. Hospital records were reviewed for clinical information.

RESULTS

During the study period, 6753 patients (5281 men; mean [SD] age 71.1 (0.1) years) received BCG instillations, of which 66 patients (1%) developed BCG infections. There were no differences in age or Charlson Comorbidity Index between the patients in the study population stratified by BCG infection. The median (interquartile range) time from first BCG instillation until symptoms of BCG infection was 169.5 (38-585) days. Extrapulmonary localisation of BCG infections (37 patients, 56.1%) was significantly more frequent than pulmonary BCG infections (20 patients, 30.3%; P < 0.001). The most common extrapulmonary localisation was the genitourinary tract (29 patients, 78.4%).

CONCLUSION

BCG infections after bladder instillation are rare, mainly affect male patients, and are most frequently extrapulmonary. BCG infections should be suspected despite a long time span between occurrence of symptoms and prior bladder instillation.

A retrospective analysis of patients treated with intravesical BCG for high-risk nonmuscle invasive bladder cancer

Background

Adjuvant intravesical immunotherapy with Bacillus Calmette-Guerin (BCG) is considered as the first-line agent in patients with high-risk nonmuscle invasive bladder cancer (NMIBC) after surgery. There are no data in India where there is a high prevalence of tubercle bacillus and inherent immunity against Bacillus sp. The present study aims to evaluate the outcomes of intravesical BCG in the Indian population.

Methods

A retrospective study of 101 patients who underwent intravesical BCG for high-risk NMIBC between January 2006 and December 2015 was carried out in a single centre. We compared the recurrence-free rate and progression rate of patients who received induction alone and induction with maintenance BCG therapy. The safety profile of intravesical BCG therapy was also assessed in the study.

Results

After a median follow up of 2 years, the disease-free survival (DFS) rates of the induction group and maintenance group were 82% and 88% respectively (p = 0.233). There was no difference in progression-free survival (PFS) rates at 2 years in those who receive maintenance BCG (95%) and those with induction BCG (94.7%; p = 0.721). A total of 69.36% of our patients had local adverse events.

Conclusion

Our results suggest that maintenance therapy does not enhance the therapeutic effects of BCG in patients who respond favourably to 6 weeks of induction. Additional prospective studies are warranted in those countries where tuberculosis exposure is prevalent.

Disseminated Mycobacterium bovis infection post-kidney transplant following remote intravesical BCG therapy for bladder cancer

Intravesical Bacillus Camlette-Guérin (BCG) is the treatment of choice for non-muscle invasive bladder cancer, and has been used successfully for over 40 years. A rare and potentially fatal complication of intravesical BCG therapy is BCG-induced sepsis. We report a rare case in which a patient with end-stage renal disease secondary to chronic granulomatous interstitial nephritis underwent remote, pre-transplant intravesical BCG treatment for high-grade non-invasive papillary bladder carcinoma. The patient subsequently received a deceased donor kidney transplant 5 years after BCG therapy, with thymoglobulin induction therapy and standard triple maintenance immunosuppression. Two years post-transplant, he developed BCG-induced sepsis confirmed by cultures from urine, blood, and left native kidney biopsy. He died from disseminated BCG-induced sepsis and failure of his renal allograft. This case highlights the potential adverse reactions associated with intravesical BCG therapy that may occur years after bladder cancer therapy is completed, and should heighten physician awareness for BCG-related infections during pre-transplant assessment and post-transplant care of solid organ transplants recipients.

Systemic BCG-osis following intravesical BCG instillation for bladder carcinoma

Intravesical instillation of Bacillus Calmette-Guérin (BCG) has been shown to be an effective form of immunotherapy for bladder cancer. This case report describes a patient who develops systemic BCG-osis following intravesical BCG instillation and demonstrates the importance of being aware of more severe complications associated with BCG immunotherapy.

Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Instillation for the Treatment of Superficial Transitional Cell Carcinoma of the Bladder

BACKGROUND

Intravesical instillation of Bacillus Calmette–Guérin (BCG) remains a first-line treatment for superficial transitional cell carcinoma of the bladder. Although its use is relatively safe, severe complications such as granulomatous hepatitis, osteomyelitis, pneumonitis, and sepsis occur in few patients. Complications of intravesical instillation of BCG can be local or systemic, with early or late presentation.

CASE PRESENTATION

Here, we report an 88-year-old man who developed fever, rigors, and episodes of syncope following fourth intravesical BCG instillation for the treatment of superficial transitional cell carcinoma of the bladder. Pancytopenia, disseminated intravascular coagulation, ground glass appearance on computerized tomography of the chest scan in addition to multiple bone marrow granulomas, suggested the diagnosis of disseminated BCG infection. All these features recovered on antituberculosis treatment.

CONCLUSION

Our case study highlights the importance of early recognition and prompt treatment of patients with disseminated BCG infection following intravesical instillation. Although isolation of mycobacterium is desirable to make the diagnosis, it is not unusual to have negative smears and cultures and this should not be used to dismiss the possibility of BCG infection.

Peritoneal tuberculosis presenting as recurrent peritonitis secondary to treatment with intravesical Bacillus Calmette-Guérin in a patient receiving peritoneal dialysis

Intravesical Bacillus Calmette-Guérin (BCG) is an established treatment for high-risk superficial bladder cancer [Morales A, Eidinger D, Bruce AW. Intracavitary Bacillus Calmette-Guérin in the treatment of superficial bladder tumors.1976. J Urol 2002; 167: 891-893, Lamm DL, van der Meijden APM, Morales A et al. Incidence and treatment of complications of Bacillus Calmette-Guérin intravesical therapy in superficial bladder cancer. J Urol 1992; 147: 596-600]. We describe a patient receiving peritoneal dialysis (PD), who developed peritoneal tuberculosis following treatment of bladder cancer with intravesical BCG instillations. To the best of our knowledge, this is the first case of peritoneal tuberculosis following intravesical BCG treatment in which the mycobacterium has been typed and confirmed as a BCG strain with genetic analysis.

Use of bacillus Calmette-Guérin in stage T1 bladder cancer: Long-term observation of a population-based cohort

OBJECTIVE

The aim of this study was to analyse the rate of use of bacillus Calmette-Guérin (BCG) at a population-based level, and the overall mortality and bladder cancer mortality due to stage T1 bladder cancer in a national, population-based register.

MATERIALS AND METHODS

In total, 3758 patients with primary stage T1 bladder cancer, registered in the Swedish Bladder Cancer Register between 1997 and 2006, were included. Age, gender, tumour grade and primary treatment in the first 3-6 months were registered. High-volume hospitals registered 10 or more T1 tumours per year. Date and cause of death were obtained from the National Board of Health and Welfare Cause of Death Register.

RESULTS

BCG was given to 896 patients (24%). The use of BCG increased from 18% between 1997 and 2000, to 24% between 2001 and 2003, and to 31% between 2004 and 2006. BCG was given more often to patients with G3 tumours, patients younger than 75 years and patients attending high-volume hospitals. BCG treatment, grade 2 tumours and patient age younger than 75 years were associated with lower mortality due to bladder cancer. Hospital volume, gender and year of diagnosis were not related to bladder cancer mortality. However, selection factors might have affected the results since comorbidity, number of tumours and tumour size were unknown.

CONCLUSIONS

Intravesical BCG is underused at a population-based level in stage T1 bladder cancer in Sweden, particularly in patients 75 years or older, and in those treated at low-volume hospitals. BCG should be offered more frequently to patients with stage T1 bladder cancer in Sweden.