ANALYSIS OF EARLY FAILURES AFTER INTRAVESICAL INSTILLATION THERAPY WITH BACILLE CALMETTE-GUERIN FOR CARCINOMA IN-SITU OF THE BLADDER

Objective To analyse the clinical and therapeutic consequences of earl y treatment failure after bacille Calmette-Guerin (BCG) instillation t herapy for carcinoma in situ of the bladder. Patients and methods A to tal of 115 patients with carcinoma in situ (Tis) of the bladder were t reated by intravesical instillation of living BCG vaccine (Immun BCG P asteur F). Twenty five patients had primary Tis and 90 had secondary T is with synchronous or prior superficial papillary tumours. All papill ary tumours were resected before instillation of BCG. All patients com pleted one series of 6 weekly instillations of 120 mg BCG. Results Twe nty-two of 25 patients (88%) with primary Tis responded completely. wi th negative cytology and cystoscopy findings within a median follow-up period of 44 months. Three of the 25 (12%) had cytological evidence o f disease within 9 months of therapy and were considered to be early t reatment failures. One patient had muscle-invasive bladder cancer, one had Tis and invasive cancer of the prostatic urethra, and the last, i n whom a second BCG course also failed, had Tis of both ureters. Seven ty of 90 patients (78%) with secondary Tis had a complete response aft er treatment with BCG, with repeated negative cytology and cystoscopy examinations within a median followup time of 40 months. Twenty of the 90 (22%) with secondary Tis had positive cytology within 9 months aft er BCG therapy and were considered early treatment failures. Five of t hese 20 had a cystectomy, three for persistent Tis of the bladder and two for a solid urothelial carcinoma of the prostate. The remaining 15 early failures received a second course of BCG. Four of these 15 pati ents responded and the remaining 11 failed the second course. The 11 f ailures included two patients with multifocal T1 G3 bladder cancers, f our with invasive bladder cancer, two with solid urothelial carcinomas of the prostatic urethra, and three with Tis of the upper urinary tra ct. Conclusions According to these data, early treatment failure after 6 weekly instillations of 120 mg Immun BCG Pasteur F is an alarming s ignal which requires immediate re-assessment of the patient to exclude a muscle-invasive bladder cancer or an extravesical carcinoma in situ , either in the upper urinary tract or in the prostatic urethra.