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UROSCAN
Year : 2006  |  Volume : 22  |  Issue : 3  |  Page : 286
 

Is intravesical bacillus Calmette-Guerin safe and efficacious in steroid treated and immunocompromized patients


Department of Urology, Christian Medical College, Vellore, Tamilnadu - 632 004, India

Correspondence Address:
Santosh Kumar
Department of Urology, Christian Medical College, Vellore, Tamilnadu - 632 004
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Kumar S, Kekre NS. Is intravesical bacillus Calmette-Guerin safe and efficacious in steroid treated and immunocompromized patients. Indian J Urol 2006;22:286

How to cite this URL:
Kumar S, Kekre NS. Is intravesical bacillus Calmette-Guerin safe and efficacious in steroid treated and immunocompromized patients. Indian J Urol [serial online] 2006 [cited 2019 Jun 26];22:286. Available from: http://www.indianjurol.com/text.asp?2006/22/3/286/27653

Yossepowitch O, Eggener SE, Bochner BH, Donat SM, Herr HW, Dalbagni G. Safety and Efficacy of Intravesical Bacillus Calmette-Guerin Instillations in Steroid Treated and Immunocompromised Patients. J Urol 2006;176:482-5.



   Summary Top


It is generally assumed that intravesical bacillus Calmette-Guerin (BCG) should be avoided in the setting of immunosuppression. This retrospective study[1] from the Memorial Sloan-Kettering Cancer Center was undertaken to assess the safety and efficacy of intravesical BCG instillation in 24 steroid treated and immunocompromised patients between 1991 to 2004. Four patients (17%) had active lymphoma or chronic lymphocytic leukemia during BCG administration and 21 (88%) had a concurrent condition for which oral steroids (11), inhaled steroids (14) or oral and inhaled steroids (4) were administered. All patients received weekly BCG therapy for 6 consecutive weeks. BCG was administered as 81 mg in 50 ml saline retained for 2 hours starting 2 to 3 weeks after the resection. The overall BCG response rate at 6 months was 58%. Ten of the 24 patients had disease recurrence and 3 had disease progression at a median follow-up of 63.5 months. Only one patient treated with oral steroids had adverse effect in the form of self-limited febrile disease and worsening of myalgia 48 hours after his third BCG cycle. They concluded that intravesical BCG is a viable treatment option in this group of patients and that the response rate at 6 months and the side effect profile in these patients were comparable to those patients with no evidence of immunosuppression.


   Comments Top


There are two important issues that come to the mind when intravesical BCG is used in immunocompromised patients. Firstly, whether there is an increased risk of systemic BCG toxicity in this group of patients and secondly if the local inflammatory immune response will be adequate to achieve an optimal antitumor effect. This study provides an affirmative answer to both these questions. Since the number of immunocompromised superficial bladder cancer patients at most institutions will be small, level one evidence (randomized control trials) on the subject is unlikely to be available and we will have to go by such studies. The major limitation of this study is that most patients had minimal immunosupression (inhaled or low dose oral steroids). There is no quantification of the level of immunosuppression. These results should not be the basis for the use of intravesical BCG in severely immunocompromised patients. Further studies are warranted to assess the safety and efficacy of intravesical BCG in critically immunocompromised patients. There is level 1 evidence that intravesical mitomycin C is equally effective as intravesical BCG in high risk superficial bladder cancer[2] except in those patients with Cis and it should be the first intravesical agent in immunocompromised patients.

 
   References Top

1.Yossepowitch O, Eggener SE, Bochner BH, Donat SM, Herr HW, Dalbagni G. Safety and efficacy of intravesical Bacillus Calmette-Guerin instillations in steroid treated and immunocompromized patients. J Urol 2006;176:482-5.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Shelley MD, Wilt TJ, Court J, Coles B, Kynaston H, Mason MD. Intravesical bacillus Calmette-Guerin is superior to mitomycin C in reducing tumor recurrence in high-risk superficial bladder cancer: A meta-analysis of randomized trials. BJU Int 2004;93:485-90.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]




 

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