Bacillus Calmette-Guérin in Immunosuppressed Patient with High-Grade Nonmuscle Invasive Bladder Carcinoma

Abstract

Due to their immunosuppressed status, solid organ transplant recipients are a special group of patients with an incidence of bladder cancer greater than the rest of the population, especially in the first 6 years after transplantation. Also, treatment with Bacillus Calmette-Guérin, a reference therapy in nonmuscle invasive high-risk bladder cancer, may be less effective in this group of patients and could cause more adverse effects. However, the data published so far and the experience initiated in the Virgen de la Arrixaca Clinical University Hospital do not support these hypotheses.

The safety and efficacy of Bacillus Calmette‐Guerin intravesical therapy in kidney transplant recipients with superficial bladder cancer

“…Kidney transplantation increases the life expectancy of recipients; however, it also increases three‐fold the risk of urothelial cancer 1 . In fact, de novo bladder cancer (BC) can be diagnosed many years after kidney transplantation, with smoking being the most important risk factor 1‐5 . Most BCs in kidney transplant recipients are non‐muscle‐invasive (NMIBC) and are characterized with an aggressive course 1 .…”

“…The main concern with the administration of BCG in kidney transplant recipients remains its safety. Immunosuppression is used to be considered as an absolute contraindication to the use of intravesical BCG, but more recent data suggest that this therapy can be safely used in immunocompromised patients, such as transplant recipients, without any significant increase in side effects 2‐8 . Although some recipients did not receive any antituberculous prophylaxis, 4‐6 others were treated in the peri‐instillation period with isoniazid, rifampicin, 7,8 and ciprofloxacin 2,3 for a short course.…”

“…1 In fact, de novo bladder cancer (BC) can be diagnosed many years after kidney transplantation, with smoking being the most important risk factor. [1][2][3][4][5] Most BCs in kidney transplant recipients are non-muscle-invasive (NMIBC) and are characterized with an aggressive course. 1 Bacillus Calmette-Guerin (BCG) is an attenuated form of Mycobacterium bovis that can be used as adjuvant treatment for high-risk NMIBC.…”

“…6,7 Later on, different BCG regimens were administered to recipients with NMIBC and resulted in favorable oncologic outcomes, 3,5,8 although other recipients needed consolidation BCG therapy and even surgery. 2,4 Table 1 summarizes the most relevant studies that addressed the efficacy of BCG therapy in kidney transplant recipients. These studies consist mainly of case reports…”

“…Immunosuppression is used to be considered as an absolute contraindication to the use of intravesical BCG, but more recent data suggest that this therapy can be safely used in immunocompromised patients, such as transplant recipients, without any significant increase in side effects. [2][3][4][5][6][7][8] Although some recipients did not receive any antituberculous prophylaxis, [4][5][6] others were treated in the peri-instillation period with isoniazid, rifampicin, 7,8 and ciprofloxacin 2,3 for a short course. Despite its reported safety, serious side effects have also been described following the use of BCG therapy in kidney transplant recipients: one patient developed subacute interstitial pneumonitis, 9 and others died from disseminated Mycobacterium bovis infection.…”