Renal Tuberculosis Following Intravesical Bacillus Calmette–Guérin (BCG) Immunotherapy for the Treatment of Bladder Cancer

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Abstract

Introduction:

Non-muscle-invasive bladder cancer (NMIBC) is usually effectively treated with transurethral resection (TUR), most often followed by intravesical instillation of bacillus Calmette-Guérin (BCG) or intravesical chemotherapy. Although the precise mechanism of BCG immunotherapy is still unclear, a local immune response is presumed. However, a number of severe side effects and complications are related to intravesical immunotherapy.

AIM:

Aim of this report is to present rare case of the renal granulomatous disease in a patient previously treated with intravesical instillation of BCG immunotherapy, following TURBT. In addition, we performed review of previously reported cases of renal granulomas following intravesical BCG immunotherapy.

Case report:

A 79-year-old man was presented to Urology Clinic due to clinically verified tumor of the urinary bladder. After transurethral resection of bladder tumor, histopathological analysis revealed the diagnosis of papillary urothelial high-grade pT1 carcinoma. Intravesical BCG immunotherapy was initiated, according to protocol currently used in our institution. Upon completion of therapy with BCG, we re-examined the patient and, using ultrasound, found a change in the right kidney, resembling moth bites not seen on CT scan before TURBT. Additionally, CT-guided core-needle biopsy of the affected kidney was performed, and the specimen was sent for histopathological analysis, which revealed chronic necrotizing granulomatous inflammation. Antituberculotic therapy was initiated for 6 months. Upon completion of antituberculotic therapy, control CT-scan was performed at follow-up, indicating regression of changes on the right kidney.

Conclusion:

This case report emphasizes the importance of consistent implementation of follow-up protocol and the identification of lesions during the asymptomatic period and enables the proper treatment of the disease. To reduce the incidence of adverse effects of BCG treatment for bladder tumors, an individualized approach is needed.

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Most cited references 30

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The mechanism of action of BCG therapy for bladder cancer--a current perspective.

Gil Redelman-Sidi, Michael S Glickman, Bernard Bochner (2014)

Bacillus Calmette-Guérin (BCG) has been used to treat non-muscle-invasive bladder cancer for more than 30 years. It is one of the most successful biotherapies for cancer in use. Despite long clinical experience with BCG, the mechanism of its therapeutic effect is still under investigation. Available evidence suggests that urothelial cells (including bladder cancer cells themselves) and cells of the immune system both have crucial roles in the therapeutic antitumour effect of BCG. The possible involvement of bladder cancer cells includes attachment and internalization of BCG, secretion of cytokines and chemokines, and presentation of BCG and/or cancer cell antigens to cells of the immune system. Immune system cell subsets that have potential roles in BCG therapy include CD4(+) and CD8(+) lymphocytes, natural killer cells, granulocytes, macrophages, and dendritic cells. Bladder cancer cells are killed through direct cytotoxicity by these cells, by secretion of soluble factors such as TRAIL (tumour necrosis factor-related apoptosis-inducing ligand), and, to some degree, by the direct action of BCG. Several gaps still exist in our knowledge that should be addressed in future efforts to understand this biotherapy of cancer.

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Guideline of guidelines: non-muscle-invasive bladder cancer

Yair Lotan, Aditya Bagrodia, Solomon L Woldu (2017)

Non-muscle invasive bladder cancer (NMIBC) represents the vast majority of bladder cancer diagnoses, however this definition represents a spectrum of disease with a variable clinical course notable for significant risk of recurrence and potential for progression. Management involves risk-adapted strategies of cystoscopic surveillance and intravesical therapy with a goal of bladder preservation when safe to do so. Multiple organizational guidelines exist to help practitioners manage this complicated disease process, however adherence to management principles amongt practicing urologists is reportedly low. We review four major organizational guidelines on NMIBC: American Urological Association (AUA)/Society of Urologic Oncology (SUO), European Association of Urology (EAU), National Comprehensive Cancer Network (NCCN), and National Institute for Health and Care Excellence (NICE).

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Bacillus Calmette-Guérin (BCG) Infection Following Intravesical BCG Administration as Adjunctive Therapy For Bladder Cancer

María Asunción Pérez-Jacoiste Asín, Mario Fernández-Ruiz, Francisco López-Medrano … (2014)

Abstract Bacillus Calmette-Guérin (BCG) is the most effective intravesical immunotherapy for superficial bladder cancer. Although generally well tolerated, BCG-related infectious complications may occur following instillation. Much of the current knowledge about this complication comes from single case reports, with heterogeneous diagnostic and therapeutic approaches and no investigation on risk factors for its occurrence. We retrospectively analyzed 256 patients treated with intravesical BCG in our institution during a 6-year period, with a minimum follow-up of 6 months after the last instillation. We also conducted a comprehensive review and pooled analysis of additional cases reported in the literature since 1975. Eleven patients (4.3%) developed systemic BCG infection in our institution, with miliary tuberculosis as the most common form (6 cases). A 3-drug antituberculosis regimen was initiated in all but 1 patient, with a favorable outcome in 9/10 cases. There were no significant differences in the mean number of transurethral resections prior to the first instillation, the time interval between both procedures, the overall mean number of instillations, or the presence of underlying immunosuppression between patients with or without BCG infection. We included 282 patients in the pooled analysis (271 from the literature and 11 from our institution). Disseminated (34.4%), genitourinary (23.4%), and osteomuscular (19.9%) infections were the most common presentations of disease. Specimens for microbiologic diagnosis were obtained in 87.2% of cases, and the diagnostic performances for acid-fast staining, conventional culture, and polymerase chain reaction (PCR)-based assays were 25.3%, 40.9%, and 41.8%, respectively. Most patients (82.5%) received antituberculosis therapy for a median of 6.0 (interquartile range: 4.0–9.0) months. Patients with disseminated infection more commonly received antituberculosis therapy and adjuvant corticosteroids, whereas those with reactive arthritis were frequently treated only with nonsteroidal antiinflammatory drugs (p < 0.001 for all comparisons). Attributable mortality was higher for patients aged ≥65 years (7.4% vs 2.1%; p = 0.091) and those with disseminated infection (9.9% vs 3.0%; p = 0.040) and vascular involvement (16.7% vs 4.6%; p = 0.064). The scheduled BCG regimen was resumed in only 2 of 36 patients with available data (5.6%), with an uneventful outcome. In the absence of an apparent predictor of the development of disseminated BCG infection after intravesical therapy, and considering the protean variety of clinical manifestations, it is essential to keep a high index of suspicion to initiate adequate therapy promptly and to evaluate carefully the risk-benefit balance of resuming intravesical BCG immunotherapy.

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Author and article information

Journal

Journal ID (nlm-ta): Med Arch

Journal ID (iso-abbrev): Med Arch

Journal ID (publisher-id): Medical Archives

Title: Medical Archives

Publisher: Academy of Medical Sciences of Bosnia and Herzegovina

ISSN (Print): 0350-199X

ISSN (Electronic): 1986-5961

Publication date (Print): April 2020

Volume: 74

Issue: 2

Pages: 146-150

Affiliations

[1 ]Urology Clinic, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina

[2 ]Medical Faculty, University Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina

[3 ]Institute of Pathology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina

[4 ]Insitute of Radiology, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina

[5 ]Oncology Clinic, University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina

Author notes

Corresponding author:Senad Bajramovic, MD, PhD. Urology Clinic, University Clinical Center of Sarajevo, Bolnicka 25, SarajevoBosnia and Herzegovina senad.bajramovic@ 123456ssst.edu.ba ORCID ID: http//www.orcid.org/0000-0001-9387-5081

Article

DOI: 10.5455/medarh.2020.74.146-150

PMC ID: 7296402

PubMed ID: 32577059

SO-VID: f59ff34b-191f-455c-b433-207c86894f0f

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Renal Tuberculosis Following Intravesical Bacillus Calmette–Guérin (BCG) Immunotherapy for the Treatment of Bladder Cancer

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Abstract

Introduction:

AIM:

Case report:

Conclusion:

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Cancer Immunotherapy

Most cited references 30

The mechanism of action of BCG therapy for bladder cancer--a current perspective.

Guideline of guidelines: non-muscle-invasive bladder cancer

Bacillus Calmette-Guérin (BCG) Infection Following Intravesical BCG Administration as Adjunctive Therapy For Bladder Cancer

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