title: Antegrade perfusion with bacillus Calmette-Guérin in patients with non-muscle-invasive urothelial carcinoma of the upper urinary tract: who may benefit?
abstract: BACKGROUND
  There is paucity of data on bacillus Calmette-Guérin (BCG) perfusion in patients with non-muscle-invasive urothelial carcinoma (NMIUC) of the upper urinary tract (UUT).
  
  
  OBJECTIVE
  To assess the long-term results of BCG perfusion in patients with UUT NMIUC in terms of efficacy and tolerability.
  
  
  METHODS
  Retrospective analysis of 55 consecutive patients (64 renal units [RUs]) with UUT NMIUC prospectively followed according to a standardised protocol for a median of 42 mo (range: 2-237 mo). Our series includes negatively selected patients, most of whom were not eligible for radical surgery, with additional invasive urothelial carcinoma of the urinary tract in roughly one-third of the cases.
  
  
  METHODS
  Antegrade BCG perfusion of the UUT was performed either with curative intent for carcinoma in situ (Tis; 42 RUs) or with adjuvant intent after ablation of Ta/T1 tumours (22 RUs).
  
  
  METHODS
  Primary outcome measures were recurrence-free, progression-free, and nephroureterectomy-free survival. The secondary outcome measure was treatment tolerability.
  
  
  CONCLUSIONS
  Recurrence occurred in 30 of 64 RUs (47%), 17 of 42 (40%) with Tis and 13 of 22 (59%) with Ta/T1 tumours. Progression occurred in 11 of 64 RUs (17%), 2 of 42 (5%) with Tis and 9 of 22 (41%) with Ta/T1 tumours. Nephroureterectomy was eventually performed in 7 of 64 RUs (11%), 2 of 42 (5%) with Tis and 5 of 22 (23%) with Ta/T1 tumours. Patients treated with curative intent for Tis tended to have better recurrence-free survival (p=0.42) and significantly better progression-free survival (p<0.01) and nephroureterectomy-free survival (p=0.05) compared with those treated with adjuvant intent after ablation of Ta/T1 tumours. Adverse events, mostly minor, occurred in a total of 11 patients (20%), with one case of fatal Escherichia coli septicaemia.
  
  
  CONCLUSIONS
  In our patients with UUT NMIUC, antegrade BCG perfusion resulted in a high kidney-preservation rate. Patients treated with curative intent for Tis apparently benefited in terms of local disease control more than those treated with adjuvant intent after ablation of Ta/T1 tumours. Treatment tolerability was good.
authors.affiliation: Department of Urology, University of Berne, Inselspital, Berne, Switzerland.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Giannarini
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Kessler
authors.forename: Frédéric D
authors.initials: FD
authors.lastname: Birkhäuser
authors.forename: George N
authors.initials: GN
authors.lastname: Thalmann
authors.forename: Urs E
authors.initials: UE
authors.lastname: Studer
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001500:BCG Vaccine / Q000008:administration & dosage* / Q000009:adverse effects; D002277:Carcinoma / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery; D017024:Chemotherapy, Adjuvant; D016009:Chi-Square Distribution; D018572:Disease-Free Survival; D006801:Humans; D053208:Kaplan-Meier Estimate; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D010477:Perfusion; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate; D013557:Switzerland; D013997:Time Factors; D016896:Treatment Outcome; D014571:Urologic Neoplasms / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery; D013520:Urologic Surgical Procedures; D019459:Urothelium / Q000187:drug effects / Q000473:pathology
chemical_list: D000970:Antineoplastic Agents; D001500:BCG Vaccine