BCG for Bladder carcinoma

1. BCG for superficial TCC
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,
Chennai. 2

3. Natural history of superficial
TCC after TURBT alone
• Risk of recurrence –70%
• Risk of progression – Ta G1 5%
• T1G3 40%
• T1G3 + CIS 50%
3
Dept of Urology, GRH and KMC,
Chennai.

4. Progression Risk
• Ta - 11% lifelong risk of dying from TCC
• T1 - 30% lifelong risk of dying from TCC
• CIS - up to 50% risk of progression to invasive
disease in untreated cases within 2 years
4
Dept of Urology, GRH and KMC,
Chennai.

5. Studies for adjuvant therapy
• BCG decreases recurrence from 70 – 30%
• SWOG – BCG Vs Doxo
• Progression 15% Vs 37%
• Pagano et al – dec progression from 17-
4%
• Various studies confirm superiority of BCG
5
Dept of Urology, GRH and KMC,
Chennai.

6. BCG
• It is an attenuated live mycobacterium
• Used as a vaccine for tuberculosis
• Anti tumor activity against several different
cancers.
6
Dept of Urology, GRH and KMC,
Chennai.

7. Role of BCG
• Effective form of intravesical therapy for
prophylaxis & treatment of superficial
bladder cancer.
• Also effective against treating CIS,
residual papillary disease
• Prophylaxis against recurrent superficial
disease.
7
Dept of Urology, GRH and KMC,
Chennai.

8. Mechanism of action
• BCG contacts tumor cells principally
through a novel fibronectin attachment
protein that is required to initiate any
interaction.
• Expression of IL-2 , IFN –GAMMA as well
as T cell populations noted at the site of
BCG inflammation
8
Dept of Urology, GRH and KMC,
Chennai.

9. • IL-12 ,a strong polarizer of the T- HELPER
CELL (Th1 ) response and inducer of
interferon detected after BCG ,in urine
• Th1 response probably mediates the
therapeutic effect of BCG
9
Dept of Urology, GRH and KMC,
Chennai.

10. Anti tumour effect is associated with
delayed hypersensitivity reaction
• Anti tumor effect also due to induction of
NITRIC ACID SYNTHETASE by BCG
•
• HIGH nitric acid concentration inhibits
bladder tumour growth.
10
Dept of Urology, GRH and KMC,
Chennai.

11. INDICATIONS
• Multiple tumors
• Large tumors
• High grade tumors
• CIS / Concomitant CIS
• Prostatic urethral involvement
• Positive urine cytology
11
Dept of Urology, GRH and KMC,
Chennai.

12. CONTRAINDICATIONS
• Gross haematuria
• Active bacterial infection
• Immune suppressed & Immuno-
compromised patients.
• Poor overall performance status &
advanced age ,
• prior history of TB- relative
contraindications.
12
Dept of Urology, GRH and KMC,
Chennai.

13. Schedule
• Morales – 6 weekly administration
• Studies – better response with
maintenance for 1 yr
• Ideal regimen ???
• SWOG regimen
13
Dept of Urology, GRH and KMC,
Chennai.

14. • Effective treatment for low volume G3 and CIS
• Initial course weekly for 6 weeks. Rescope after
4 to 6 weeks
– Complete response - put on maintenance treatment
– Partial response - repeat 6 week course and rescope
– Progression – change to MMC or early cystectomy
14
Dept of Urology, GRH and KMC,
Chennai.

15. PREPARATION &
ADMINISTRATION
• Lyophilized powder
• Stored in 4 degrees C until instillation
• TICE, CONNAUGHT, PASTEUR,
TOKYO,RIVM, DANISH 1331
• Therapeutic efficacy associated with the
ability to deliver approx 10 MILLION
organisms per instillation
15
Dept of Urology, GRH and KMC,
Chennai.

16. • Reconstituted with 50 ml of saline,
administer immediately
• Treatment - min 2-4 weeks after TUR
16
Dept of Urology, GRH and KMC,
Chennai.

17. - Traumatic catheterization;- treatment
should be delayed for several days.
Gravity method of administration
Dwell / Contact time- 1-2 hours
• Change in position ??
17
Dept of Urology, GRH and KMC,
Chennai.

18. CIS
• Initial tumour free response- 76%
• BCG replaced cystectomy in initial form of
therapy.
• In CIS - failure to respond to 6 week
course, early recurrence of high-risk
disease requires more aggressive therapy
18
Dept of Urology, GRH and KMC,
Chennai.

19. RESIDUAL TUMOUR
• Effectively treat residual papillary disease
• Response rate around 60%
19
Dept of Urology, GRH and KMC,
Chennai.

20. TUMOUR PROPHYLAXIS
• T1 & HIGH GRADE Ta treated
prophylactically after TUR
• DECREASED TUMOUR RECURRENCE
OF AROUND 40%
• DOSE - 6 WEEK induction course is
insufficient
20
Dept of Urology, GRH and KMC,
Chennai.

21. SWOG- 6+3 REGIMEN
• 6 WEEK INDUCTION COURSE followed by 3
weekly instillations at 3 & 6 monthes,then every
6 monthes for 3 years.
• 5 year survival of non maintainance group is
78%, maintainance group is 83%
• 16% only tolerated full dose regimen
• Post therapy p53 over expression is an
independent marker of disease progression.
21
Dept of Urology, GRH and KMC,
Chennai.

22. SIDE EFFECTS OF BCG
THERAPY
• Fever 3%
• Haematuria 1%
• Granulomatous Prostatitis 1%
• Pneumonitis / Hepatitis <1%
• Epididymitis
• Sepsis
• Rash
• Ureteral Obstruction
• Contracted bladder
22
Dept of Urology, GRH and KMC,
Chennai.

23. • Low grade fever or slight malaise;- fever
>38.5’c >24 hours not resolve with
antipyretic ,,fever >39.5’c ;- treated with
INH 300 mg for 3 months
• Systemic BCGosis ;- treatment INH –RIFX
6 MONTHS
• BCG SEPSIS;- 0-4% ;- TREAT;- LIFE
SUPPORT , TRIPLE DRUG THERAPY
23
Dept of Urology, GRH and KMC,
Chennai.

24. • Carcinoma of mucosa & superficial ducts
of prostate can be treated with BCG.
• TUMOUR free rate around 50% is
ATTAINED.
24
Dept of Urology, GRH and KMC,
Chennai.

25. • Response rates to treatment up to 70%
disease free at 36 months
– 40 % response to first course
– 30% more respond to a second course
– Problems relate to patients managing to
remain on maintenance therapy
25
Dept of Urology, GRH and KMC,
Chennai.

26. Advantages
• Persistent activity
• Deeper activity
• Panurothelial effect
26
Dept of Urology, GRH and KMC,
Chennai.

27. Combination therapy
• High dose Vit A,B6,E & Zn
• IFN Alpha
• Increased panurothelial effect and
decreased dose
27
Dept of Urology, GRH and KMC,
Chennai.

28. Treatment for BCG Failures
• 6
 Repeat BCG treatment
 20 - 40% CR
 Toxicity BCG- systemic mycobacterial
infection
• (1% disseminated M bovis, 6% anti-TB
meds),
28
Dept of Urology, GRH and KMC,
Chennai.

29. • cystitis, hematuria, fever, dysuria and
frequency,
• malaise, and nausea
 Interferon + BCG
 50% CR in patients failing BCG
induction
 Only Phase 2 data available
 No significant long term data reported
29
Dept of Urology, GRH and KMC,
Chennai.

30. Treatment for BCG Failures
 Valrubicin
 21% CR in patients who have failed at
• least one previous treatment with BCG
 Only FDA approved treatment for BCG
• failures
 GM-CSF
 CR observed in 6/11
patients following
• intravesical treatment
 Single study only
30
Dept of Urology, GRH and KMC,
Chennai.

31. Treatment for BCG Failures
 Cystectomy
 2 - 4% treatment-related mortality
 10 - 30% post-operative complication
rate
 infection, lymphedema (ADD)
 Neobladder or urostomy- life-long
• consequence
 Negative impact on QOL
31
Dept of Urology, GRH and KMC,
Chennai.

32. CONCLUSIONS
• BCG is effective in decreasing the
recurrence and progression of sup TCC
• Toxicity is a important criteria
• Ineffective in muscle invasive disease
• Atleast 1 yr maintanence is reqd.
• Ideal regimen still found wanting
32
Dept of Urology, GRH and KMC,
Chennai.