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Holmberg L, Skogmar S, Garmo H, Hagberg O, Häggström C, Gårdmark T, Ströck V, Aljabery F, Jahnson S, Hosseini A, Jerlström T, Sherif A, Söderkvist K, Ullén A, Malmström PU, Liedberg F. Cumulative incidence of and risk factors for BCG infection after adjuvant BCG instillations. BJU Int 2024; 134:229-238. [PMID: 38403809 DOI: 10.1111/bju.16303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
OBJECTIVES To investigate the cumulative incidence proportion of disseminated or local Bacillus Calmette-Guérin (BCG) infections after adjuvant BCG instillations in patients with non-muscle-invasive bladder cancer (NMIBC). PATIENTS AND METHODS We analysed the timing and occurrence of BCG infections and absolute and relative risk in relation to patient characteristics available in the Swedish nationwide database 'BladderBaSe 2.0'. The cumulative incidence proportion of a BCG infection was indicated by a reported diagnosis of tuberculosis (TB) in the patient registry or filing a prescription for tuberculostatic drugs. RESULTS The cumulative incidence proportion was 1.1% at the 5-year follow-up in 5033 patients exposed to adjuvant BCG instillations. The incidence rate was highest during the first 2 years after start of BCG instillations. Women had a lower risk than men (hazard ratio 0.23, 95% confidence interval 0.07-0.74). Age and calendar time at diagnosis, comorbidity, tumour risk group, previous medication with corticosteroids, immunosuppressive drugs, or time between transurethral resection of the bladder tumour and commencing the adjuvant BCG instillation were not associated with risk. CONCLUSIONS These data further supports that the overall risk of a BCG infection after BCG-instillation treatment for NMIBC is low. The great majority of infections occur in the first 2 years, calling for an awareness of the diverse symptoms of BCG infection during this period. We provide evidence for male sex as a risk factor; however, the statistical precision is low and with a risk of selection bias, making it difficult to rule out the other suggested risk factors without further studies with different approaches.
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Affiliation(s)
- Lars Holmberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Sten Skogmar
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Hans Garmo
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Oskar Hagberg
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Christel Häggström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Northern Register Centre, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Truls Gårdmark
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Viveka Ströck
- Department of Urology, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Firas Aljabery
- Division of Urology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Staffan Jahnson
- Division of Urology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Abolfazl Hosseini
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Urology, Danderyd Hospital, Stockholm, Sweden
| | - Tomas Jerlström
- Department of Urology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Amir Sherif
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | | | - Anders Ullén
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Per-Uno Malmström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Fredrik Liedberg
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology, Skåne University Hospital, Malmö, Sweden
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Aubert C, Culty T, Zidane M, Bigot P, Lebdai S. Antibiotic therapy impact on intravesical BCG therapy efficacy for high-risk localized bladder cancer treatment. Front Oncol 2024; 13:1240378. [PMID: 38525411 PMCID: PMC10957779 DOI: 10.3389/fonc.2023.1240378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/29/2023] [Indexed: 03/26/2024] Open
Abstract
Intravesical Bacillus Calmettes-Guerin (BCG) instillations is the gold standard adjuvant treatment for high and very high-risk non-muscle-invasive bladder cancer (NMIBC). Antibiotics may be required to treat asymptomatic bacteriuria before instillations or to prevent side effects. By modifying the bladder microbiota and through its bactericidal action, it could modify the efficacy of BCG. This study evaluates the impact of antibiotics received during BCG-induction treatment on the oncological outcomes for high and very high risk NMIBC. We retrospectively included all patients who received a full induction regimen of BCG therapy between January 2017 and June 2022. Clinical and tumor characteristics as well as tolerability were collected. Recurrence-free survival (RFS) and progression-free survival (PFS) were compared according to the prescription of antibiotics, its type and duration. A total of 126 patients were included, 86.5% of the tumors were high risk and 13.5% very high risk. The median follow-up was 31 months (7-60). 36% of the patients received antibiotics during BCG-induction treatment (among which 44% received fluoroquinolones). 21.4% of patients had tumor recurrence. There was no difference in RFS (p=0.902) or PFS (p=0.88) according to the duration or the type of antibiotics received. The use of a prolonged antibiotic treatment (> 7 days) significantly increased the duration of the BCG-induction treatment from 35 to 41,5 days (p=0,049) and the median number of delayed treatments by 1,5 [0-4]. Neither the use of antibiotics nor their duration modified the risk of recurrence or the intensity of side effects in multivariate analysis. Antibiotics received during BCG-induction immunotherapy did not influence oncological short-term outcomes or intensity of side effects.
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Affiliation(s)
- Cécile Aubert
- Urology Department, University Hospital of Angers, Angers, France
| | - Thibaut Culty
- Urology Department, University Hospital of Angers, Angers, France
| | - Merzouka Zidane
- Pathology Department, University Hospital of Angers, Angers, France
| | - Pierre Bigot
- Urology Department, University Hospital of Angers, Angers, France
| | - Souhil Lebdai
- Urology Department, University Hospital of Angers, Angers, France
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Liedberg F, Xylinas E, Gontero P. Quinolone Prophylaxis in Conjunction with Bacillus Calmette-Guérin Instillations for Bladder Cancer: Time To Reconsider the Evidence and Open the Quinolone Box? Eur Urol Focus 2023:S2405-4569(23)00249-3. [PMID: 37993346 DOI: 10.1016/j.euf.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 11/24/2023]
Abstract
Adjuvant bacillus Calmette-Guérin (BCG) instillations represent a cornerstone in the treatment of non-muscle-invasive bladder cancer. Instillation schedule and dose modifications have been evaluated in efforts to reduce the incidence of adverse events (AEs), but none so far has the same treatment efficacy as the full-dose recommended schedule. It has been shown that prophylactic quinolone use in conjunction with BCG instillations reduces AE incidence and improves timely completion of instillation regimens and patient survival. However, the European Medicines Agency imposed restrictions on the use of quinolones in 2019 because of side effects. Nevertheless, rational use of quinolone prophylaxis could be considered for selected individuals treated with BCG without risk factors for quinolone-associated side effects in conjunction with patient information about side-effect symptoms. PATIENT SUMMARY: Bladder instillations of BCG (bacillus Calmette-Guérin) are used in the treatment of non-muscle-invasive bladder cancer. Antibiotics from the quinolone class can reduce the adverse effects of BCG and help patients in completing the treatment course; however, these antibiotics have their own side effects. Our mini review suggests that the antibiotics could be used in selective cases if patients are given adequate information on these side effects and their symptoms.
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Affiliation(s)
- Fredrik Liedberg
- Department of Urology, Skåne University Hospital, Malmö, Sweden; Institute of Translational Medicine, Lund University, Malmö, Sweden.
| | - Evanguelos Xylinas
- Department of Urology, Bichat-Claude Bernard Hospital, AP-HP, Université de Paris Cité, Paris, France
| | - Paolo Gontero
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
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Li Z, Qi N, Gao Z, Ding L, Zhu J, Guo Q, Wang J, Wen R, Li H. How to Perform Intravesical Chemotherapy after Second TURBT for Non-Muscle-Invasive Bladder Cancer: A Single-Center Experience. J Clin Med 2022; 12:jcm12010169. [PMID: 36614970 PMCID: PMC9820835 DOI: 10.3390/jcm12010169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/05/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
PURPOSE The objective of this study aimed to explore whether the original IVC regimen should be continued after the second TURBT or whether the IVC induction phase should be restarted from the beginning. METHODS A retrospective analysis was performed on 137 patients who underwent a second TURBT at the Affiliated Hospital of Xuzhou Medical University between April 2014 and June 2022. Based on the pathological findings, patients were divided into two groups: group A patients, who did not have a residual tumor on pathological examination after the second TURBT; and group B patients, who had residual tumor. Recurrence was determined using cystoscopy and imaging every three months. The endpoint was recurrence-free survival. RESULT In the entire cohort, there was a statistically significant difference in the RFS between patients in the two IVC regimens (p = 0.029). The RFS of patients in group B1 was significantly lower than that of patients in group B2 (p = 0.009). There was no significant difference in RFS between the subgroups A1 and A2 (p = 0.560). Multivariate Cox regression analysis confirmed that the IVC regimen after a second TURBT (p = 0.012) and T stage after a second TURBT (p = 0.005) were both independent predictors for patient RFS. CONCLUSION If the pathological findings of the second TURBT specimen is benign, patients can continue their previous treatment regimen without restarting an IVC induction phase. Unnecessary IVC can be avoided in these patients. In contrast, for patients with residual tumors in the second TURBT specimen, the need to restart the IVC induction phase should be emphasized to improve patient prognosis.
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Affiliation(s)
- Zhen Li
- Department of Urology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
- Graduate School, Xuzhou Medical University, Xuzhou 221000, China
| | - Nienie Qi
- Department of Urology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
| | - Zhimin Gao
- Department of Urology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
- Graduate School, Xuzhou Medical University, Xuzhou 221000, China
| | - Li Ding
- Department of Urology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
- Graduate School, Xuzhou Medical University, Xuzhou 221000, China
| | - Jiawei Zhu
- Department of Urology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
- Graduate School, Xuzhou Medical University, Xuzhou 221000, China
| | - Qingxiang Guo
- Department of Urology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
- Graduate School, Xuzhou Medical University, Xuzhou 221000, China
| | - Junqi Wang
- Department of Urology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
| | - Rumin Wen
- Department of Urology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
- Correspondence: (R.W.); (H.L.)
| | - Hailong Li
- Department of Urology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou 221000, China
- Correspondence: (R.W.); (H.L.)
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5
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Numakura K, Kobayashi M, Ishida T, Okane K, Suzuki K, Shimoda N, Suzuki T, Kumazawa T, Sasaki R, Fukuda H, Kashima S, Yamamoto R, Koizumi A, Nara T, Kanda S, Huang M, Saito M, Narita S, Inoue T, Tsuchiya N, Habuchi T. Effect of Levofloxacin on the Efficacy and Adverse Events in Intravesical Bacillus Calmette-Guerin Treatment for Bladder Cancer: Results of a Randomized, Prospective, Multicenter Study. Eur Urol Focus 2022; 8:1666-1672. [PMID: 35717522 DOI: 10.1016/j.euf.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 05/14/2022] [Accepted: 06/04/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Although bacillus Calmette-Guerin (BCG) is a standard treatment for high-risk non-muscle-invasive bladder cancer (NMIBC), a high rate of adverse events with a variety of grades remains a difficulty. OBJECTIVE In this randomized, prospective, multicenter study, we examined whether levofloxacin, given after each intravesical instillation of BCG, could improve its tolerance in patients with intermediate- to high-risk urothelial carcinoma of the bladder without compromising its efficacy. DESIGN, SETTING, AND PARTICIPANTS Overall, 106 Japanese patients (85 men and 21 women; age: median, 69.5 yr) with primary or recurrent NMIBC were randomized after transurethral resection to induce treatment with intravesical BCG plus levofloxacin (group 1) or BCG alone (group 2). INTERVENTION Patients who underwent intravesical instillation of BCG were randomized with or without levofloxacin administration. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Adverse events were assessed using the National Cancer Institute-Common Toxicity Criteria version 3.0. Cumulative incidence functions and Kaplan-Meier methods were applied to estimate survival outcomes. RESULTS AND LIMITATIONS There was no significant difference in baseline characteristics between the groups. The completion rate of group 1 (85.5%) was not significantly lower than that of group 2 (76.5%; p = 0.321). There was no significant difference in the completion rate of patients with pollakisuria, painful micturition, gross hematuria, fever elevation, and others between the groups. The incidence of adverse events in patients with high-grade pollakisuria (7.3% vs 25.4%, p = 0.041) and fever (0% vs 9.1%, p = 0.034) was significantly lower in group 1. The 5-yr progression-free and cancer-specific survival rates were significantly better in group 1. CONCLUSIONS Prophylactic levofloxacin administration may reduce the severity of adverse events and contribute to better outcomes from BCG intravesical therapy in patients with NMIBC. PATIENT SUMMARY Levofloxacin administration seems to be a safe and effective therapy for non-muscle-invasive bladder cancer patients treated with bacillus Calmette-Guerin intravesical therapy.
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Affiliation(s)
- Kazuyuki Numakura
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan.
| | - Mizuki Kobayashi
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Toshiya Ishida
- Department of Urology, Akita City Hospital, Akita, Japan
| | - Katsumi Okane
- Department of Urology, Akita Kousei Medical Center, Akita, Japan
| | - Kazumasa Suzuki
- Department of Urology, Kakunodate General Hospital, Senboku, Japan
| | - Naotake Shimoda
- Department of Urology, Japanese Red Cross Akita Hospital, Akita, Japan
| | - Takehiro Suzuki
- Department of Urology, Hiraka General Hospital, Yokote, Japan
| | - Teruaki Kumazawa
- Department of Urology, Omagari Kousei Medical Center, Daisen, Japan
| | - Ryusei Sasaki
- Department of Urology, Kitaakita Municipal Hospital, Kitaakita, Japan
| | - Hisami Fukuda
- Department of Urology, Fujiwara Memorial Hospital, Katagami, Japan
| | - Soki Kashima
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Ryohei Yamamoto
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Atsushi Koizumi
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Taketoshi Nara
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Sohei Kanda
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Mingguo Huang
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Mitsuru Saito
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Shintaro Narita
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Takamitsu Inoue
- Department of Renal and Urological Surgery, International University of Health and Welfare, Narita, Japan
| | - Norihiko Tsuchiya
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Tomonori Habuchi
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
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6
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Leon P, Saint F, Audenet F, Roumiguié M, Allory Y, Loriot Y, Masson-Lecomte A, Pradère B, Seisen T, Traxer O, Xylinas E, Roupret M, Neuzillet Y. Recommandations du Comité de cancérologie de l’Association Française d’Urologie (CC-AFU) pour la bonne pratique des instillations intravésicales de mitomycine C, d’épirubicine et de BCG pour le traitement des tumeurs de la vessie n’infiltrant pas le muscle (TVNIM). Prog Urol 2022; 32:299-311. [DOI: 10.1016/j.purol.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/02/2022] [Accepted: 01/10/2022] [Indexed: 12/01/2022]
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7
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Audenet F, Sotto A, Roumiguié M, Allory Y, Andrejak C, Leon P, Loriot Y, Masson-Lecomte A, Pradère B, Seisen T, Traxer O, Xylinas E, Bruyère F, Roupret M, Saint F, Neuzillet Y. Recommandations des Comités de cancérologie (CC-AFU) et d’infectiologie (CI-AFU) de l’Association française d’urologie pour la prise en charge effets indésirables et complications du BCG. Prog Urol 2022; 32:165-176. [DOI: 10.1016/j.purol.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/02/2022] [Accepted: 01/10/2022] [Indexed: 12/01/2022]
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Galsky MD, Balar AV, Black PC, Campbell MT, Dykstra GS, Grivas P, Gupta S, Hoimes CJ, Lopez LP, Meeks JJ, Plimack ER, Rosenberg JE, Shore N, Steinberg GD, Kamat AM. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of urothelial cancer. J Immunother Cancer 2021; 9:e002552. [PMID: 34266883 PMCID: PMC8286774 DOI: 10.1136/jitc-2021-002552] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 12/12/2022] Open
Abstract
A number of immunotherapies have been developed and adopted for the treatment of urothelial cancer (encompassing cancers arising from the bladder, urethra, or renal pelvis). For these immunotherapies to positively impact patient outcomes, optimal selection of agents and treatment scheduling, especially in conjunction with existing treatment paradigms, is paramount. Immunotherapies also warrant specific and unique considerations regarding patient management, emphasizing both the prompt identification and treatment of potential toxicities. In order to address these issues, the Society for Immunotherapy of Cancer (SITC) convened a panel of experts in the field of immunotherapy for urothelial cancer. The expert panel developed this clinical practice guideline (CPG) to inform healthcare professionals on important aspects of immunotherapeutic treatment for urothelial cancer, including diagnostic testing, treatment planning, immune-related adverse events (irAEs), and patient quality of life (QOL) considerations. The evidence- and consensus-based recommendations in this CPG are intended to give guidance to cancer care providers treating patients with urothelial cancer.
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Affiliation(s)
- Matthew D Galsky
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Arjun V Balar
- Perlmutter Cancer Center, New York University Langone Medical Center, New York, New York, USA
| | - Peter C Black
- Department of Urologic Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew T Campbell
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gail S Dykstra
- Bladder Cancer Advocacy Network (BCAN), Bethesda, Maryland, USA
- Dykstra Research, Seattle, Washington, USA
| | - Petros Grivas
- Department of Medicine, Division of Oncology, University of Washington, Seattle, Washington, USA
- Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Shilpa Gupta
- Department of Hematology and Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Christoper J Hoimes
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Lidia P Lopez
- Division of Hematology-Oncology, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Joshua J Meeks
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- The Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Elizabeth R Plimack
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Jonathan E Rosenberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Deparment of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Neal Shore
- Carolina Urologic Research Center, Myrtle Beach, South Carolina, USA
| | - Gary D Steinberg
- Department of Urology and Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York, USA
| | - Ashish M Kamat
- Department of Urology under Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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9
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Pak S, Kim SY, Kim SH, Joung JY, Park WS, Chung J, Lee KH, Seo HK. Association Between Antibiotic Treatment and the Efficacy of Intravesical BCG Therapy in Patients With High-Risk Non-Muscle Invasive Bladder Cancer. Front Oncol 2021; 11:570077. [PMID: 33868985 PMCID: PMC8051584 DOI: 10.3389/fonc.2021.570077] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 03/15/2021] [Indexed: 12/22/2022] Open
Abstract
Objective To investigate the association between antibiotic therapy and the efficacy of intravesical BCG therapy in patients with high-risk non-muscle invasive bladder cancer (NMIBC). Methods This study involved the retrospective review of medical records of patients who underwent transurethral resection of bladder tumors for high-risk NMIBC followed by intravesical BCG therapy between 2008 and 2017. Patients were categorized as none, short- (2-6 days), and long-course use (≥7 days) based on the duration of antibiotic treatment concurrent with or initiated ≤30 days before BCG therapy. Oncologic outcomes, including recurrence-free survival and progression-free survival, were analyzed. Results Of the 276 patients enrolled in the study, 162 (58.7%) had pathologic T1 disease and 206 (80.2%) had high-grade disease. Concurrently with or prior to BCG therapy, 114 patients had (41.3%) received short-course antibiotic therapy, and 96 (34.8%) patients had received long-course antibiotics. The 5-year recurrence-free survival (62.2% vs 26.9%; log rank, p <0.001) and progression-free survival (79.6% vs. 53.3%; log rank, p=0.001) rates were significantly higher in patients who did not receive antibiotic therapy than in those treated with long-course antibiotics. Multivariable analysis revealed that antibiotic treatment for more than 7 days was independently associated with increased risks of recurrence (hazard ratio [HR], 2.45; 95% confidence interval [CI], 1.49-4.05; p < 0.001) and progression (HR, 3.68; 95% CI, 1.65-8.22 p = 0.001). Conclusion Long-course antibiotic treatment concurrently with or prior to intravesical BCG adversely influenced disease recurrence and progression outcomes in patients with high-risk NMIBC. Careful use of antibiotics may be required to enhance the efficacy of intravesical BCG therapy. Further mechanistic and prospective studies are warranted.
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Affiliation(s)
- Sahyun Pak
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, South Korea.,Department of Urology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Sun-Young Kim
- Biometrics Research Branch, Research Institute, National Cancer Center, Goyang, South Korea
| | - Sung Han Kim
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, South Korea.,Division of Tumor Immunology, Research Institute, National Cancer Center, Goyang, South Korea
| | - Jae Young Joung
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, South Korea
| | - Weon Seo Park
- Department of Pathology, National Cancer Center, Goyang, South Korea
| | - Jinsoo Chung
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, South Korea
| | - Kang Hyun Lee
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, South Korea
| | - Ho Kyung Seo
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, South Korea.,Division of Tumor Immunology, Research Institute, National Cancer Center, Goyang, South Korea
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10
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Lee LJ, Kwon CS, Forsythe A, Mamolo CM, Masters ET, Jacobs IA. Humanistic and Economic Burden of Non-Muscle Invasive Bladder Cancer: Results of Two Systematic Literature Reviews. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:693-709. [PMID: 33262624 PMCID: PMC7695604 DOI: 10.2147/ceor.s274951] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/29/2020] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Non-muscle invasive bladder cancer (NMIBC) is a malignancy restricted to the inner lining of the bladder. Intravesical Bacillus Calmette-Guerin (BCG) following transurethral resection of the bladder tumor is the mainstay first-line treatment for high-risk NMIBC patients. Two systematic literature reviews (SLRs) were conducted to further assess the current evidence on BCG use in NMIBC and the humanistic and economic burden of disease. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, Embase® and MEDLINE® were searched using the Ovid platform to identify interventional or real-world evidence studies on the health-related quality of life (HRQoL) and economic burden in NMIBC. Limited evidence was found from initial economic SLR searches in NMIBC, so additional targeted searches for bladder cancer were conducted to expand findings. RESULTS Fifty-nine publications were included in the HRQoL SLR, of which 23 reported HRQoL and symptoms in NMIBC. At diagnosis, HRQoL was comparable with population norms but worsened considerably 2 years following diagnosis. Maintenance therapy with intravesical BCG was associated with reduced HRQoL, and treatment-related adverse events (AEs) resembled typical NMIBC symptoms. Twenty-two studies reported decreasing BCG compliance over time. Common AEs with BCG were frequent urination, lower urinary tract symptoms, pain, and hematuria. Forty-two publications were included in the economic SLR, of which nine assessed healthcare costs and resource use in NMIBC or bladder cancer. High-risk disease and high-intensity treatment were associated with increased healthcare costs. CONCLUSION NMIBC has a considerable symptomatic, HRQoL, and economic burden. Symptoms persisted and HRQoL worsened despite intravesical BCG treatment. NMIBC is a costly disease, with higher healthcare costs associated with increased risk of disease progression and recurrence. There is a high unmet need for safe and effective treatments that reduce the risk of disease progression and recurrence, provide symptomatic relief, and improve HRQoL for patients.
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Affiliation(s)
- Lauren J Lee
- Patient Health and Impact, Pfizer Inc, New York, NY, USA
| | - Christina S Kwon
- Evidence Generation, Purple Squirrel Economics, New York, NY, USA
| | - Anna Forsythe
- Evidence Generation, Purple Squirrel Economics, New York, NY, USA
| | | | | | - Ira A Jacobs
- Worldwide Research and Development, Pfizer Inc, New York, NY, USA
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11
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Waked R, Choucair J, Chehata N, Haddad E, Saliba G. Intravesical Bacillus Calmette-Guérin (BCG) treatment's severe complications: A single institution review of incidence, presentation and treatment outcome. J Clin Tuberc Other Mycobact Dis 2020; 19:100149. [PMID: 32099909 PMCID: PMC7016447 DOI: 10.1016/j.jctube.2020.100149] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES Intravesical Bacillus Calmette-Guérin (BCG) treatment for superficial bladder cancer is interrupted in approximatively 8% of cases as a result of complications. The objective is to report the severe related complications of Bacillus Calmette-Guérin (BCG) following an intravesical instillation for bladder tumor encountered at our institution for the past 5 years. METHODS Medical records of a tertiary teaching hospital, located in Beirut, Lebanon, were retrospectively analyzed from June 2014 to June 2019 searching for severe related complications of BCG. A comprehensive review of articles on this subject was conducted. RESULTS The incidence of severe systemic adverse events related to BCG instillation was 1.5% (5 out of 332 patients). A total of five patients were found to have a severe BCG related complication, with fever, chills, and irritative urinary signs being the most frequent symptoms. All patients received antituberculosis therapy (Isoniazid, Rifampin and Ethambutol). Two were put on add-on corticosteroids. Three patients had a computed tomography scan image in favor of an infection. Two patients had a favorable outcome, three patients died. CONCLUSION BCG severe adverse events were mostly seen in patients with a traumatic instillation. Treatment used at our institution was similar to most cases reported in the literature. A standardized diagnostic and treatment approach should be implemented to help physicians tackle these life-threatening complications.
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Affiliation(s)
- R. Waked
- Department of Infectious Diseases, Faculty of Medicine, Saint Joseph University, Damascus street, PO BOX 11-5076, Riad El Solh, Beirut 1107 2180, Lebanon
| | - J. Choucair
- Coordinator of the Infectious Diseases department, Saint Joseph University, Beirut, Lebanon
| | - N. Chehata
- Department of Infectious Diseases, Faculty of Medicine, Saint Joseph University, Damascus street, PO BOX 11-5076, Riad El Solh, Beirut 1107 2180, Lebanon
| | - E. Haddad
- Department of Infectious Diseases, Faculty of Medicine, Saint Joseph University, Damascus street, PO BOX 11-5076, Riad El Solh, Beirut 1107 2180, Lebanon
| | - G. Saliba
- Department of Infectious Diseases, Faculty of Medicine, Saint Joseph University, Damascus street, PO BOX 11-5076, Riad El Solh, Beirut 1107 2180, Lebanon
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12
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A systematic review of preventive and therapeutic options for symptoms of cystitis in patients with bladder cancer receiving intravesical bacillus Calmette–Guérin immunotherapy. Anticancer Drugs 2019; 30:517-522. [DOI: 10.1097/cad.0000000000000775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Clinical Spectrum of Complications Induced by Intravesical Immunotherapy of Bacillus Calmette-Guérin for Bladder Cancer. JOURNAL OF ONCOLOGY 2019; 2019:6230409. [PMID: 30984262 PMCID: PMC6431507 DOI: 10.1155/2019/6230409] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/24/2019] [Accepted: 02/12/2019] [Indexed: 12/13/2022]
Abstract
Because of its proven efficacy, intravesical Bacillus Calmette-Guérin (BCG) immunotherapy is an important treatment for nonmuscle invasive bladder cancer at high risk of recurrence or progression. However, approximately 8% of patients have to stop BCG instillation as a result of its complications. Complications induced by BCG therapy can have a variety of clinical manifestations. These adverse reactions may occur in conjunction with BCG instillation or may not develop until months or years after BCG cessation. An essential step in the management complications arising from BCG is early establishment of diagnosis, particularly for distant, disseminated, and obscure infections. Therefore we reviewed the literature on the potential complications after intravesical BCG immunotherapy for bladder cancer and provide an overview on the incidence, diagnosis, and treatment modality of genitourinary and systemic BCG-induced complications.
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Serretta V, Ruggirello A, Giaimo R, Sommatino F, Bilione V, Allegro R, Melloni D. Prevention of topic toxicity of BCG with single-dose prulifloxacin. Preliminary results of a randomized pilot study. Urologia 2018. [DOI: 10.1177/039156031007700403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Toxicity is a major problem for patients undergoing intravesical therapy with Bacillus Calmette-Guérin (BCG) for the conservative management of intermediate or high-risk non-muscle invasive bladder cancer (NMI-BC). A prospective pilot trial was designed to evaluate the adoption of a single dose of prulifloxacin to prevent the toxicity of BCG. Treatment tolerability and its possible influence on BCG efficacy have been analyzed. Materials and Methods The study was designed to evaluate the action of prulifloxacin in patients with intermediate or high-risk NMI-BC, undergoing 6–week induction cycle of BCG. Main exclusion criteria were previous intravesical therapy, urinary infection and any other factor that could influence tolerability to BCG intravesical immunotherapy. The patients were randomized to receive BCG alone versus BCG plus prulifloxacin. BCG toxicity and local tolerability were evaluated by self-administered EORTC QLQ-BLS24 questionnaire, and BCG adverse events (AEs) were classified according a four-class classification. The toxicity and tolerability evaluations were performed at baseline, one week after every instillation and one week and one month after the last instillation. Cystoscopy and cytology were performed 3–monthly. Recurrence and progression were recorded. Results The study included 43 patients receiving 258 instillations of BCG. The patients were randomized to receive BCG alone (Arm A: 132 instillations in 22 patients) versus BCG plus prulifloxacin given as a single oral dose (600 mg) 6 hours after the instillation. An advantage in favor of prulifloxacin prophylaxis emerged, according to EORTC QLQ-BLS24, in overall incidence of nocturnal micturitions (56% vs 28.6%; p=0.001), insomnia (40% vs 14.3%; p=0.002), urgency (70% vs 42.6%; p=0.05), incontinence (44% vs 12.7%; p=0.01) and bothersome events due to intravesical therapy (84% vs 63.5%; p=0.02). Systemic class IIB and III adverse events occurred in only 14.2% and 3.5% of the patients, respectively. No class IV AE was detected. Due to the low incidence no statistically significant difference was evident between the two arms (p=0.6). Three patients of Arm B and 1 patient of Arm A interrupted the treatment, after the 3rd - 4th instillation. Anti-tuberculosis therapy war required for 3 months in only one patient. Three and 2 instillations were postponed for one-(two) week(s) in Arm B and Arm A, respectively. Prulifloxacin, generally well tolerated, was withdrawn in one patient due to skin allergic reaction. Recurrence rate at a mean follow-up of 12 months did not significantly differ between the two arms. Conclusions Prulifloxacin decreases the incidence of local symptoms and improves the compliance to BCG intravesical therapy. Due to the low number of events, no evidence emerges in our study about its capability of preventing severe systemic toxicity, although it has proved effective in reducing local symptoms.
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Affiliation(s)
- Vincenzo Serretta
- Sezione di Urologia, Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefro-Urologiche Università degli Studi di Palermo - Italy
| | - Antonina Ruggirello
- Sezione di Urologia, Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefro-Urologiche Università degli Studi di Palermo - Italy
| | - Rosellina Giaimo
- Sezione di Urologia, Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefro-Urologiche Università degli Studi di Palermo - Italy
| | - Francesco Sommatino
- Sezione di Urologia, Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefro-Urologiche Università degli Studi di Palermo - Italy
| | - Valentina Bilione
- Sezione di Urologia, Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefro-Urologiche Università degli Studi di Palermo - Italy
| | - Rosalinda Allegro
- Sezione di Urologia, Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefro-Urologiche Università degli Studi di Palermo - Italy
| | - Darvinio Melloni
- Sezione di Urologia, Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefro-Urologiche Università degli Studi di Palermo - Italy
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15
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Clark PE, Spiess PE, Agarwal N, Bangs R, Boorjian SA, Buyyounouski MK, Efstathiou JA, Flaig TW, Friedlander T, Greenberg RE, Guru KA, Hahn N, Herr HW, Hoimes C, Inman BA, Kader AK, Kibel AS, Kuzel TM, Lele SM, Meeks JJ, Michalski J, Montgomery JS, Pagliaro LC, Pal SK, Patterson A, Petrylak D, Plimack ER, Pohar KS, Porter MP, Sexton WJ, Siefker-Radtke AO, Sonpavde G, Tward J, Wile G, Dwyer MA, Smith C. NCCN Guidelines Insights: Bladder Cancer, Version 2.2016. J Natl Compr Canc Netw 2017; 14:1213-1224. [PMID: 27697976 DOI: 10.6004/jnccn.2016.0131] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
These NCCN Guidelines Insights discuss the major recent updates to the NCCN Guidelines for Bladder Cancer based on the review of the evidence in conjunction with the expert opinion of the panel. Recent updates include (1) refining the recommendation of intravesical bacillus Calmette-Guérin, (2) strengthening the recommendations for perioperative systemic chemotherapy, and (3) incorporating immunotherapy into second-line therapy for locally advanced or metastatic disease. These NCCN Guidelines Insights further discuss factors that affect integration of these recommendations into clinical practice.
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16
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Kamat AM, Bellmunt J, Galsky MD, Konety BR, Lamm DL, Langham D, Lee CT, Milowsky MI, O'Donnell MA, O'Donnell PH, Petrylak DP, Sharma P, Skinner EC, Sonpavde G, Taylor JA, Abraham P, Rosenberg JE. Society for Immunotherapy of Cancer consensus statement on immunotherapy for the treatment of bladder carcinoma. J Immunother Cancer 2017; 5:68. [PMID: 28807024 PMCID: PMC5557323 DOI: 10.1186/s40425-017-0271-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/25/2017] [Indexed: 12/21/2022] Open
Abstract
The standard of care for most patients with non-muscle-invasive bladder cancer (NMIBC) is immunotherapy with intravesical Bacillus Calmette-Guérin (BCG), which activates the immune system to recognize and destroy malignant cells and has demonstrated durable clinical benefit. Urologic best-practice guidelines and consensus reports have been developed and strengthened based on data on the timing, dose, and duration of therapy from randomized clinical trials, as well as by critical evaluation of criteria for progression. However, these reports have not penetrated the community, and many patients do not receive appropriate therapy. Additionally, several immune checkpoint inhibitors have recently been approved for treatment of metastatic disease. The approval of immune checkpoint blockade for patients with platinum-resistant or -ineligible metastatic bladder cancer has led to considerations of expanded use for both advanced and, potentially, localized disease. To address these issues and others surrounding the appropriate use of immunotherapy for the treatment of bladder cancer, the Society for Immunotherapy of Cancer (SITC) convened a Task Force of experts, including physicians, patient advocates, and nurses, to address issues related to patient selection, toxicity management, clinical endpoints, as well as the combination and sequencing of therapies. Following the standard approach established by the Society for other cancers, a systematic literature review and analysis of data, combined with consensus voting was used to generate guidelines. Here, we provide a consensus statement for the use of immunotherapy in patients with bladder cancer, with plans to update these recommendations as the field progresses.
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Affiliation(s)
- Ashish M Kamat
- University of Texas MD Anderson Cancer Center, 1515 Pressler Unit 1373, Houston, TX, 77030, USA.
| | | | - Matthew D Galsky
- Tisch Cancer Institute at Mount Sinai Medical Center, New York, NY, 10029, USA
| | | | | | - David Langham
- Bladder Cancer Advocacy Network, North Carolina Triangle Chapter, Chapel Hill, NC, 27517, USA
| | - Cheryl T Lee
- The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | | | | | | | | | - Padmanee Sharma
- University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | | | - John A Taylor
- University of Kansas Cancer Center, Kansas City, KS, 66160, USA
| | - Prasanth Abraham
- University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
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17
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Kassouf W, Traboulsi SL, Kulkarni GS, Breau RH, Zlotta A, Fairey A, So A, Lacombe L, Rendon R, Aprikian AG, Siemens DR, Izawa JI, Black P. CUA guidelines on the management of non-muscle invasive bladder cancer. Can Urol Assoc J 2015; 9:E690-704. [PMID: 26664503 PMCID: PMC4662433 DOI: 10.5489/cuaj.3320] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | | | | | | | | | - Andrew Fairey
- Division of Urology, University of Alberta, Edmonton, AB
| | - Alan So
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC
| | | | | | | | | | | | - Peter Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC
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18
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Consensus statement on best practice management regarding the use of intravesical immunotherapy with BCG for bladder cancer. Nat Rev Urol 2015; 12:225-35. [DOI: 10.1038/nrurol.2015.58] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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19
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Marquez-Batalla S, Fraile-Villarejo E, Belhassen-García M, Gutierrez-Zubiaurre N, Cordero-Sánchez M. Disseminated infection due to Mycobacterium bovis after intravesical BCG instillation. World J Clin Cases 2014; 2:301-303. [PMID: 25032208 PMCID: PMC4097160 DOI: 10.12998/wjcc.v2.i7.301] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 03/24/2014] [Accepted: 04/29/2014] [Indexed: 02/05/2023] Open
Abstract
Intravesical bacillus Calmette-Guerin (BCG) instillation has been adopted for the treatment of patients with superficial bladder cancer. Severe adverse events due to local instillation of BCG are uncommon, with an overall rate of serious complications of less than 5%. We report the case of an immunocompetent adult patient with multi-system effects, namely pneumonitis, granulomatous hepatitis and meningitis, who responded well to standard treatment for Mycobacterium bovis. This case highlights the importance of a thorough assessment of this type of patient.
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21
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Prulifloxacin: a review focusing on its use beyond respiratory and urinary tract infections. Int J Antimicrob Agents 2011; 37:283-90. [DOI: 10.1016/j.ijantimicag.2010.11.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 11/19/2010] [Indexed: 11/22/2022]
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