Bacillus Calmette-Guerin-refractory superficial bladder cancers: focus on pretreatment episodes

Reasons for development of bacillus Calmette-Guerin(BCG)-refractory superficial bladder cancers are unknown. In the present study, a series of cases was therefore analyzed, focusing on the influence of treatment before BCG application.

A total of 96 patients with superficial bladder cancers received six weekly intravesical instillations of BCG followed in some cases by a further six applications at monthly intervals. If tumors recurred, a further course of treatment in association with surgery or some other therapy was chosen, depending on the patient and the tumor condition.

Thirty-three cases (34.4%) demonstrated tumor recurrence within 24 to 146 months, including 9 with progression. Pretreatments had been performed in 19 of these cases (57.6%) whereas they had been conducted for only 10 (15.9%) of the BCG-effective cases. Of the total 96 patients, 29 received pretreatment with open surgery, systemic chemotherapy, intravesical instillation or oral administration of anticancer drugs, or immunotherapy. Sixty-six percent of these proved BCG refractory, in contrast to only 20.9% in the no-pretreatment group. Furthermore, 7 of the 9 patients demonstrating progression had undergone pretreatment.

The data suggest that intravesical instillation of BCG is more effective when no prior treatment has been attempted, and that best results may be achieved if BCG is chosen as the initial therapy for superficial bladder cancer. When pretreatment has been performed and pT1 lesions recur, however, immediate total cystectomy should be advised.