Chap93N NMIBC management

  1. Perioperative Intravesical Therapy to Prevent Tumor Implantation?
    • MMC 
    • Epirubicin - used in europe

    A single dose administered within 6 hours lessens recurrence rates, whereas a dose 24 hours later does not.

    BCG can never be safely administered immediately after TUR because the risk of bacterial sepsis and death is high
  2. Successful Perioperative Administration  of Intravesical Chemotherapy?
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  3. MOA of immunotherapy?
    • Induced expression of cytokines in the urine and bladder wall and by an influx of granulocytes, mononuclear, and dendritic cells.
    • The initial step appears to be direct binding to fibronectin within the bladder wall, subsequently leading to direct stimulation of cell-based immunologic response and an antiangiogenic state. 
    • The observed pattern of cytokine induction with preferential upregulation of interferon-γ, IL-2, and IL-12 reflects induction of a T-helper type-1 (Th1) response.
  4. Indication of BCG?
    • In patients with intermediate- and high-risk tumours, intravesical BCG after TURB reduces the risk of tumour recurrence.
    • It is more effective than TURB alone or TURB +intravesical chemotherapy. 
    • Three-year maintenance is more effective than one year to prevent recurrence in patients with high-risk tumours, but not in patients with intermediate-risk tumours.
  5. Method of BCG therapy?
    • Treatments begun 2 to 4 weeks after tumor resection, allowing time for reepithelialization, which minimizes the potential for intravasation of live bacteria. 
    • For the same reason, a urinalysis is usually performed immediately before instillation to further ensure a diminished probability of systemic uptake of BCG.
    • In the event of a traumatic catheterization, the treatment should be delayed for several days to 1 week, depending on the extent of injury.
    • After instillation, the patient should retain the solution for at least 2 hours. Some clinicians have advocated the patient turn from side to side to bathe the entire urothelium, but there is no scientific support for this practice.
    • Fluid, diuretic, and caffeine restriction before instillation is essential to limit dilution of the agent with urine and to facilitate retention of the agent for 2 hours
  6. BCG schedule? *
    Induction phase: weekly for six weeks, followed by check cystoscopy ad cytology. 

    Maintenance phase: on 3,6,12,18,24,30,36 months for 3 weeks on each phase.
  7. Role of Quinolones in BCG therapy?
    Quinolones may affect the viability of BCG and should be avoided if possible during the course of BCG treatments
  8. Contraindications to Bacillus Calmette-Guérin (BCG) Therapy?
    • Absolute Contraindications: 
    • Immunosuppressed and immunocompromised patients
    • Immediately after transurethral resection on the basis of the risk of intravasation and septic death
    • Personal history of BCG sepsis
    • Gross hematuria (intravasation risk)
    • Traumatic catheterization (intravasation risk)
    • Total incontinence (patient will not retain agent)

    • Relative Contraindications
    • Urinary tract infection (intravasation risk)
    • Liver disease (precludes treatment with isoniazid if sepsis occurs)
    • Personal history of tuberculosis (risk theorized but unknown)
    • Poor overall performance status
    • Advanced age
    • No or Insufficient Data on Potential Need for Contraindications
    • Patients with prosthetic materials
    • Ureteral reflux
    • Anti–tumor necrosis factor medications (theoretically predispose to BCG sepsis)
  9. Cleveland Clinic Approach to Management of Bacillus Calmette-Guérin (BCG) Toxicity
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  10. Effect of combination of BCG and interferon?
    Potential superiority of the combination or the possibility of decreasing the dosage of BCG, which may reduce side effects.
  11. Classification of persistent disease after  BCG therapy?
    BCG refractory - nonimproving or worsening disease despite BCG

    BCG resistant - recurrence or persistence of lesser degree, stage, or grade after an initial course, which then resolves with further BCG

    BCG relapsing - recurrence after initial resolution with BCG

    BCG-refractory patients in particular are an especially high-risk group and should be strongly considered for immediate cystectomy if young and in generally good health.

    Declaring failure may take up to 6 months because the response rate for patients with high-grade bladder cancer treated with BCG rose from 57% to 80% between 3 and 6 months after therapy
  12. Treatment of carcinoma in situ?
    • CIS cannot be cured by an endoscopic procedure alone.
    • Compared to intravesical chemotherapy, BCG treatment of CIS increases the complete response rate, the overall percentage of patients who remain disease free, and reduces the risk of tumour progression.
Card Set
Chap93N NMIBC management
Management of NMIBC