Upper tract transitional cell carcinoma following treatment of superficial bladder cancer with BCG

Eighty-two consecutive patients treated with intravesical bacillus Calmette-Guerin (BCG) for recurrent superficial bladder tumors were evaluated for development of metachronous upper tract tumors (UTT). All patients had normal upper tract studies within three months of starting BCG treatment. With a median follow-up of sixty-two months (range 25 to 124), 11 patients (13.4%) were found to have UTT. The median interval between initiation of BCG therapy and diagnosis of the UTT occurrence was thirty-eight months (range 7 to 110). All patients were asymptomatic when the UTT was diagnosed. An abnormal surveillance intravenous or retrograde pyelogram was the method of diagnosis in 8 patients. Positive cytology alone directed diagnoses in 2 patients, and 1 patient was diagnosed in the workup of hematuria. Overall upper tract cytology was positive in 7 of 11 patients. Nephroureterectomy was performed in 9 patients and 2 had ureteroscopic biopsy and fulguration. Median follow-up after treatment of UTT was thirty-two months (range 3 to 80). UTT pathologic stage was Pa in 2 patients, P 1 in 1 patient, and P2 or higher in 8 patients. Distant metastasis developed in 7 patients, 2 patients have recurrent superficial bladder tumors, and 2 patients are free of disease. The reported incidence in the literature for UTT tumors in patients with previous superficial or muscle invasive tumors ranges from 1.6 percent to 8.5 percent. The 13.4 percent incidence of UTT in the present study demonstrates the increased risk for patients in this series who were selected for BCG therapy. These risk factors include high tumor grade, associated carcinoma in situ (CIS), multiple tumors, T1 tumors, and failure of prior intravesical therapy. The fact that all patients were asymptomatic at the time of diagnosis of UTT emphasizes the importance of long-term periodic surveillance with radiographic and cytologic studies of the upper tracts for patients with similar risk factors.