再発例に対するSecond course BCG膀胱内注入療法の功罪

Abstract

BCG膀胱内注入療法後のハイリスク表在性膀胱癌(pT1または上皮内癌)再発例に対する膀胱温存療法として, second course BCG膀胱内注入療法を試みてきたので, その治療成績を後方視的に検討した.初回療法でNCであった15例中9例と, CR後再発した49例中22例にsecond course BCG膀胱内注入療法を施行した結果, 初回でNC例は8例がCRとなったが, うち2例は8.5 ヵ月後, 12.9ヵ月後に再発した.萎縮膀胱を1例に認め, 13ヵ月後に膀胱全摘除術が施行された.再発例中では17例に再々発を認め, うち7例は浸潤癌で, 最終的には10例に膀胱全摘出術が施行された.上部尿路再発を9例, 前立腺浸潤3例に認め, 2例が癌死した.BCG抵抗性膀胱癌に対するsecond course BCG膀胱内注入療法は, 初回NC例に対する追加療法としては有効であるが, いったんCRとなった後に再発を来した症例に対しての効果は限界があり, 根治療法を必要とする可能性が高いことを認識すべきである

We evaluated the usefulness of second course intravesical bacillus Calmette-Guerin (BCG) therapy for carcinoma in situ (CIS) of the bladder that failed to respond to the initial BCG therapy. Between January 1995 and December 2000, 185 patients with CIS of the bladder underwent an initial 6- or 8-week course of intravesical BCG instillation with an average follow-up period of 40.9 months (range: 3.8 to 94.8 months). Of the 185 patients, 160 (86.5%) completely responded to an initial course of BCG therapy. During follow up, 49 (30.6%) of the complete responders had recurrent transitional cell carcinoma. Overall, 9 (36.0%) of the 25 patients who did not respond completely to the initial 6- or 8-week course of BCG therapy and 22 (44.9%) of the 49 who had recurrent tumor after initial complete response, a total of 31 patients received the second course intravesical BCG therapy. Of the 9 incomplete responders, 8 (88.9%) achieved a complete response after the second course BCG therapy. With an average follow-up period of 39.6 months (range: 2.8 to 62.2 months), 2 (22.2%) of the 8 had recurrence. On the other hand, 17 (77.3%) of the 22 with recurrent tumor after the initial complete response developed recurrence with an average follow-up period of 14.1 months (range: 2.8 to 55.2 months). Seven (31.8%) of the 17 patients had disease progression to muscle invasion. Subsequently, cystectomy was done in 10 (58.8%) and radiation in 1 (5.9%). Our results suggest that a selected group of incomplete responders with initial BCG therapy may benefit from continued second course BCG. However, in patients who had recurrence after initial BCG success, the benefits of second course BCG therapy are limited. Careful surveillance and aggressive therapy on optimal timing are mandatory.