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Intravesical bacillus Calmette-Guérin instillation therapy for non-muscle-invasive bladder cancer following solid organ transplantation

Die intravesikale Instillationstherapie mit Bacillus Calmette-Guérin bei organtransplantierten Patienten mit oberflächlichem Blasenkarzinom

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Summary

Background

Solid organ recipients have a substantial risk of developing bladder cancer, with high-risk non-muscle-invasive bladder cancer (NMIBC) being the most frequent diagnosis. Theoretically, adjuvant bacillus Calmette–Guérin (BCG) therapy is contraindicated, but limited data indicate its feasibility. The objective of this study was to evaluate the safety and efficacy of BCG following solid organ transplantation.

Materials and methods

We reviewed the data of four solid organ recipients who received adjuvant BCG for high-risk NMIBC at our institution. Additionally, individual data of 12 patients were extracted from case series and case reports, which were identified through a systematic review of the literature. A meta-analysis was performed.

Results

Fourteen patients (88 %) had received a kidney, one a heart, and one a liver transplant. The median time from transplantation to bladder cancer was 60.5 months. The regimen of immunosuppression was not modified in 12 patients (75 %). Forty-two percent of patients did not receive prophylactic antibiotics, and 70 % had no side effects. Ten patients (63 %) experienced recurrence after a median of 14 months. Progression to muscle-invasive or metastatic disease was observed in two patients (13 %). Four patients (25 %) underwent radical cystectomy, and two patients died of the disease.

Conclusions

BCG therapy is a safe option for patients with high-risk NMIBC following solid organ transplantation. However, there is a substantial risk of recurrence and progression. Urologists and patients considering BCG therapy should be aware of this and may consider early cystectomy. There is no evidence to support the need for prophylactic antibiotics.

Zusammenfassung

Hintergrund

Organtransplantierte Patienten haben ein signifikantes Risiko, ein Urothelkarzinom der Harnblase (HCA) zu entwickeln. Dabei sind oberflächliche HCA mit hohem Rezidiv- und Progressionsrisiko der häufigste Befund. Die adjuvante Instillationstherapie mit Bacillus Calmette-Guérin (BCG) ist kontraindiziert, obwohl einige Autoren diese Therapie beschrieben haben. Ziel dieser Arbeit ist die Evaluation der Sicherheit und Effektivität von BCG bei organtransplantierten Patienten.

Material und Methoden

Es wurden die unizentrischen Daten von vier transplantierten Patienten erhoben, welche sich aufgrund eines HCA einer adjuvanten BCG-Instillationstherapie unterzogen. Eine systematische Literaturrecherche mit Meta-Analyse von insgesamt 16 Patienten wurde durchgeführt.

Ergebnisse

Bei 14 Patienten (88 %) bestand ein Zustand nach Nierentransplantation und bei jeweils einem nach Herz- bzw. Lebertransplantation. Das mediane Intervall vom Zeitpunkt der Transplantation bis zum HCA betrug 60,5 Monate. Die Immunsuppression wurde bei 12/16 Patienten (75 %) nicht modifiziert. Insgesamt erhielten 42 % keine begleitende Antibiotikatherapie und 70 % hatten keine therapie-assoziierten Nebenwirkungen. Zehn Patienten (63 %) entwickelten ein Tumorrezidiv nach einem medianen Zeitraum von 14 Monaten. Eine HCA-Progression in ein muskelinvasives oder metastasiertes Stadium wurde bei zwei Patienten (13 %) beobachtet. Vier Patienten (25 %) unterzogen sich letztlich einer radikalen Zystektomie und zwei Patienten verstarben am HCA.

Schlussfolgerungen

BCG-Instillationen sind eine sichere Therapieoption bei organtransplantierten Patienten mit HCA, wobei ein signifikantes Risiko für Tumorrezidiv und Progress vorliegt. Eine frühe Zystektomie sollte daher in Erwägung gezogen werden. Für eine begleitende Antibiotikatherapie gibt es keine Evidenz.

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Abbreviations

BCG:

Bacillus Calmette–Guérin

NMIBC:

Non-muscle-invasive bladder cancer

UBC:

Urothelial bladder cancer

TURBT:

Transurethral resection of bladder tumor

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Conflict of interest

The authors declare that there are no actual or potential conflicts of interest in relation to this article.

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Authors and Affiliations

  1. Department of Urology, Medical University of Vienna, Währinger Gürtel 18–20, 1090, Vienna, Austria

    Natalia Swietek, Matthias Waldert, Georg Schatzl &  Tobias Klatte

  2. Department of Clinical Pathology, Medical University of Vienna, Vienna, Austria

    Martin Susani

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  1. Natalia Swietek
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  2. Matthias Waldert
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Correspondence to Tobias Klatte.

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Swietek, N., Waldert, M., Susani, M. et al. Intravesical bacillus Calmette-Guérin instillation therapy for non-muscle-invasive bladder cancer following solid organ transplantation. Wien Klin Wochenschr 125, 189–195 (2013). https://doi.org/10.1007/s00508-013-0343-1

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