How to Treat Multifocal Ta High-grade Disease if Bacillus Calmette-Guérin Is Unavailable

Abstract

The patient was a 71-yr-old man with a primary presentation of microhematuria. He was a retired pulmonologist but a current smoker, with a history of 50 pack-years. His cytology was normal, but cystoscopy revealed multiple lesions. At the original hospital, a transurethral resection of the bladder (TURB) without a photodynamic diagnosis (PDD) revealed pTa low-grade tumors; because there were multiple lesions, this was a case of intermediate-risk category.He was given one instillation of mitomycin C (MMC), followed with 6 mo of MMC maintenance. However, this regimen caused urgency, with voiding every 20-30 min, up to Abstract A 71-yr-old man was transferred to our institution with multiple and recurrent high-grade pTa bladder cancer 26 mo after an initial presentation of multiple and large pTa low-grade tumors and concomitant carcinoma in situ, treated with transurethral resection plus 6-mo postoperative mitomycin C. This case discusses several treatment options in the absence of bacillus Calmette-Guérin (BCG). Immediate radical cystectomy is an option with excellent survival, since there is a substantial risk of understaging and disease progression; however, this results in overtreatment in 50% of these patients. Therefore, a conservative approach could be intravesical combination therapy such as gemcitabine/docetaxel or epirubicin/ interferon. In addition, device-assisted intravesical therapy is becoming an option to consider. Finally, patients could be included in trials such as immunotherapy trials. Patient summary: This 71-yr-old patient was diagnosed with recurrent, moderately severe noninvasive bladder tumors, which were removed. The recommended additional therapy, intravesical bacillus Calmette-Guérin (BCG) instillations, was not available. Both the pros and the cons of radical surgery (bladder removal) and a more conservative approach (other intravesical treatments) are discussed.

Bacillus Calmette-Guérin Retains Clinically Relevant Viability for up to 72 Hours After Reconstitution: Potential Implications for Clinical Practice in Times of Shortage

“…shortage of BCG both in the USA and worldwide [2]. Many strategies have been proposed to address BCG shortages, including-based on level 1 evidence [3]-administering one-third of a BCG dose, which in effect means one BCG vial can be split among three patients [4]. This often poses logistical issues as the manufacturer's label empirically recommends administration of BCG within 2 h after reconstitution.…”