bcg theraphy in urology . . . . ... . . . .

1. BCG theraphy
Dr. VINAYAK, UROLOGY RESIDENT , G.M.K.M.C.H SALEM

2. Introduction
● Albert Calmette, a bacteriologist, and Camille Guerin, a veterinarian, were working
together at the Pasteur Institute in Lille (France) and discovered Bacillus Calmette-
Guerin (BCG) in 1908. (Virulent strain of Mycobacterium Bovis from the udder of an
infected cow )
● In 1950s Lloyd Old demonstrated BCG as a cancer therapy.
● In 1976 that Alvaro Morales, an urologist in Canada, was the first to test topical
BCG in the bladder: the first use of intravesical BCG against Nonmuscle-invasive
bladder cancer (NMIBC) .

3. Mechanism of action
- Numerous cytokines involved in the initiation or maintenance of inflammatory
processes including TNF-α, GM-CSF, IFN-γ, & IL-1, IL-2, IL-5, IL-6, IL-8, IL-10, IL-
12, and IL-18 have been detected in the urine.
- The preferential upregulation of IFN-γ, IL-2, and IL-12 reflects induction of a T-
helper type-1 (Th1) response which activates cell-mediated cytotoxic mechanisms
which prevents tumor implantation
- Urinary cytokine levels peak at 3rd week after an induction course.

5. Risk of progression in
• Low risk group - 0 - 4 percent
• Intermediate risk group - 10 -15 percent and
• High risk group – 30 - 40 percent

6. Indications
• Low risk - no role of BCG ( TURBT+ Mitomycin single dose)
• Intermediate risk - induction + maintenance for 1 year
• High risk - induction + maintenance for 3 years
• Intravesical BCG reduces recurrence from 40% to 15% and progression by 40 to
4.4%
• Initial tumor-free response rate is as high as 84%

7. Contraindications
Absolute contraindications of BCG intravesical instillation are:
- During the first two weeks after TURBT;
- Gross hematuria;
- Traumatic catheterization (Delay for a week)
- Symptomatic urinary tract infection
- Immunocompromised Status
- H/o BCG sepsis

8. RELATIVE CONTRAINDICATIONS
● Liver disease
● UTI
● History of tuberculosis, H/O Drug Reactions
● Poor overall performance status

9. BCG Treatment Schedule- SWOG Regimen
- Two to four weeks after TURBT
- Induction dose: One dose weekly for 6 weeks
- Maintenance dose: 3 weekly (1 dose per week for 3 weeks) BCG @ 3, 6, 12, 18,
24, 30, 36m from the initiation of induction therapy ( but not from the date of Turbt)
Total 27 doses

11. - 1 to 2 weeks before each BCG cycle, call the pt for cystoscopy & urine cytology
- This 1 to 2 weeks gap between cystoscopy & BCG is must to prevent systemic
complications of BCG

12. In Intermediate risk
- Induction + maintenance @ 3,6,12 months
- Cystoscopy & cytology @ 3months interval in 1st year then @ 6 months interval till
5years and then yearly
In HIGH risk
- Induction + maintenance @ 3,6,12,18,24,30,36 months
- Cystoscopy & cytology @ 3months interval in first two years & then @ 6 months
interval till 5years and then yearly

13. Procedure
- Patient is advised to restrict fluid intake 4 hours before and 2 hours after
instillation.
- Avoid diuretic, caffeine in the morning of procedure, empty bladder before
instillation, and also counsel regarding post instillation mild irritable symptoms
- Patient is advised not to void for 2 hours post installation

14. - Low dose-80mg (120mg causes more ADR but same benefit) onco BCG is mixed in
50 of normal saline (sterile water will kill live bacteria by osmotic swelling)
- Administered into the bladder using an IFT under gravity. IFT removed, and
disposed separately in bleaching solution
- Change positions every 15 minutes & after 2 hour increase fluid intake and void
regularly in sitting position
- Reconstructed BCG should be used with 2 hrs

15. Bcg toxicity
- Bacillus Calmette-Guérin intravesical treatment is associated with more side effects
compared to intravesical chemotherapy
- Serious side effects are encountered in < 5% of patients
- The incidence of BCG infections after BCG instillations was 1%
- Side effects requiring treatment stoppage were seen more often in the first year of
therapy

17. No role of pyrazinamide in BCG sepsis

18. Management of Bacille Calmette-Guérin
(BCG) Toxicity

22. Efficacy
Recurrence rate
- Five meta-analyses have confirmed that BCG after TURB is superior to TURB alone
or TURB + chemotherapy for preventing the recurrence of NMIBC
- Decreased tumor recurrence of approximately 30% when a 6-week course of BCG
was administered after recovery from TURBT
- Addition of maintenance phase further improves recurrence free survival ( 35.7
months v/s 76.8 months )
- In the trials with BCG maintenance, there was a 32% reduction in the risk of
recurrence for BCG compared to MMC

23. Progression
- At a 10-year follow-up, the progression-free rate was longer for patients who had
received BCG (62 versus 37 percent without BCG)♧
- A reduction of 27% in the odds of progression with BCG maintenance treatment is
observed
- The size of the reduction was similar in patients with TaT1 papillary tumours and in
those with CIS

24. Management of recurrent or persistent non-
muscle invasive bladder cancer

25. RISK OF RECURRENCE
1. EORTC scoring system and risk tables (European Org For Research &
Treatment Of Cancer)
1. Club Urológico Español de Tratamiento Oncológico (CUETO) model- spanish
urology group

26. EORTC scoring system
- Basis for these tables are individual patient data from 2,596 patients diagnosed with
TaT1 tumours.Patients with CIS alone were not included.
- They were randomised into seven EORTC trials.
- Seventy-eight percent of patients received intravesical treatment, mostly
chemotherapy.
- However, they did not undergo a second TURB or receive maintenance BCG.

27. EORTC scoring system

29. CUETO model
- Based on analysis of 1,062 patients from four CUETO trials who received 12 doses
of intravesical BCG over a 5 to 6 month period following TURB
- The scoring system is based on the evaluation of seven prognostic factors:
1. Age
2. Prior recurrence status
3. Number of tumours
4. Sex
5. Tumour grade
6. Associated CIS
7. T category

31. - Using CUETO model, the calculated risk of recurrence & progression are lower than
that obtained by the EORTC tables
- The lower risks in the CUETO tables may be attributed to the use of BCG in this
sample.
( Remember intra vesical BCG decreases the risk of recurrence and progression
more than the chemotherapy)

32. EORTC found that the
- prior disease-recurrence rate and number of tumours were the most important
prognostic factors for disease recurrence,
- stage and grade for disease progression and disease-specific survival
- Age and grade were the most important prognostic factors for OS

33. DEFINITION OF RECURRENCE STATES

34. Recurrence without prior adjuvant intravesical therapy
- This group usually includes recurrence in pts with low-grade papillary NMIBC
because intermediate & high risk pts receive BCG therapy
- Recurrent low-grade non-muscle invasive bladder cancer constitutes intermediate-
risk disease in most cases; however, it can constitute high-risk disease if the
recurrence is both large (>3 cm) and multifocal.
- Whether the patient previously received a single perioperative dose of intravesical
chemotherapy is not usually considered important in defining this disease state

35. Recurrence after prior adjuvant intravesical therapy
- In this situation, it is critical to distinguish intermediate- from high-risk, and prior
intravesical chemotherapy from intravesical BCG in choosing the next line of
therapy.
- BCG failure refers to patients with either intermediate- or high-risk non-muscle
invasive bladder cancer who received a single round of induction BCG without
maintenance therapy

36. Classification of BCG failure
● If a pt develops MIBC during the course of BCG or during followup
● Adequate BCG
Completion of at least 5 of 6 doses of an initial induction course plus at least 2
out of 6 doses of a second induction course or 2 out of 3 doses of maintenance
therapy.

37. • BCG-refractory tumour
- If T1G3/HG tumour is present at 3 months
- If TaG3/HG tumour is present after 3 months and/or at 6 months, after either re-induction or
first course of maintenance I.e., if pt has Ta/HG @ 3 months give second reinduction or 1st
course of maintenance and do cystoscopy @6 months,only when Ta/HG is seen@ 6mon you
can label it as BCG refractory
- If CIS (without concomitant papillary tumour) is present at 3 months and persists at 6 months
after either re-induction or first course of maintenance. If patients with CIS present at 3
months, an additional BCG course cause complete response in > 50% cases
- If HG tumour appears during BCG maintenance therapy*.

38. ● BCG-relapsing tumour( despite initial response )
a) Early relapse(<12 months)
T1Ta/HG recurrence within 6 months of completion of adequate BCG exposure or
development of CIS within 12 months of completion of adequate BCG exposure
a) Late relapse ( >12 months)
T1Ta/HG recurrence > 6 months or CIS > 12 months of last BCG exposure
● BCG intolerance
- Severe side effects that prevent further BCG instillation before completing
treatment

39. - A low-grade papillary (Ta) recurrence does not qualify as BCG unresponsive and is
generally not considered an indication to discontinue BCG therapy in a patient being
treated for high-risk disease
- There is no standardization of disease states following intravesical chemotherapy
since BCG is considered the more effective therapy

40. Treatment

41. Guidelines for the treatment of BCG failure

42. T1 high grade disease
- In recurrent high-grade T1 disease after intravesical
therapy patients should undergo radical cystectomy.
- If the patient refuses cystectomy or is unfit for more
aggressive surgery and does not undergo
radiotherapy, then re-TURBT should be considered
to stage the patient optimally, minimize the residual
disease, and potentially optimize subsequent
courses of intravesical therapy.

43. Recurrent intermediate-risk category
- Intermediate-risk non-muscle invasive bladder cancer represents a spectrum of
disease, and it should not be automatic that all patients with recurrent low-grade
disease need intravesical therapy.
- A balance must be struck between the risk of progression, on the one hand, and the
risk of toxicity from treatment on the other hand.
- The International Bladder Cancer Group developed a consensus statement that
offers a risk-adapted treatment algorithm for different patient subsets within the
context of intermediate-risk non-muscle invasive bladder cancer

44. Sub classification of recurrent intermediate-risk group
- Based on the number of risk factors that a patient with intermediate-risk disease
has, they are treated as low risk (0 risk factors), intermediate-risk (1 to 2 risk
factors), or high risk (3 to 4)

45. - Those treated as low risk do not require anything beyond TURBT and optional
single perioperative dose of chemotherapy, even though they are classified as
having intermediate-risk disease. These include the infrequently recurring, solitary,
small Ta lesions.
- Those treated as intermediate-risk should receive adjuvant intravesical
chemotherapy or BCG including one year maintenance therapy, and those treated
as high risk should receive intravesical BCG with three years of maintenance
therapy.

46. Salvage treatment strategies for recurrent NMIBC
- include both intravesical therapy and radical cystectomy
- it is important not to discontinue first-line therapy too soon and label a patient as a
treatment failure.
- This is particularly true for patients with CIS, who can have a delayed response
after induction BCG and should not be deemed treatment failures until after
completion of the first round of maintenance BCG.

47. - If a patient has BCG-unresponsive, high-risk non-muscle invasive bladder cancer,
outcomes after intravesical chemotherapy with a variety of agents in the second-line
setting have been uniformly poor, with two-year recurrence-free survival (RFS) rates
typically below 20 percent
- Radical cystectomy is considered the standard-of-care for these patients.
- Salvage therapeutic strategies for BCG failures unfit or unwilling to undergo surgery
comprise intravesical chemotherapy, chemoradiation or chemohyperthermia

48. BCG + INF alpha

49. - Interferon α has anti-angiogenic and pro-apoptotic properties, and induces dendritic
cell maturation promoting tumor cell recognition by T cells and NK cells
- But how it helps prevent bladder tumor recurrence is not precisely known.
- Because interferon α induces programmed death ligand 1 (PD-L1) expression, it is
possible that its combination with a systemic PD-L1 inhibitor would have additive or
even synergistic efficacy.

51. Thank you