Urology>>>>>Bladder Cancer
Question 7#

Intravesical immunotherapy results in a massive local immune response characterised by induced expression of cytokines in the urine and bladder wall and by an influx of granulocytes, mononuclear and dendritic cells. Which of the following statements regarding intravesical BCG immunotherapy is FALSE?

A) The mechanism of action includes direct binding of BCG to fibronectin within the bladder wall, subsequently leading to direct stimulation of cell-based immunologic response and an anti-angiogenic state
B) Overall, response to intravesical immunotherapy may be limited if a patient has an immunosuppressive disease or by advanced age
C) The original regimen described by Morales included an intramuscular dose, which was discontinued after success using a similar intravesical regimen
D) The vaccine is reconstituted with 50 mL of saline and should be administered through a urethral catheter under gravity drainage soon thereafter to avoid aggregation

Correct Answer is C

Comment:

Answer C

BCG is an attenuated mycobacterium developed as a vaccine for tuberculosis that has demonstrated antitumour activity in several different cancers including urothelial cancers. BCG is stored in refrigeration and reconstituted from a lyophilised powder. Connaught, Tice, Armand Frappier, Pasteur, Tokyo and RIVM strains all arise from a common original strain developed at the Pasteur Institute. Treatments are generally begun a minimum of two weeks after tumour resection, allowing time for re-epithelialization, which minimises the potential for intravasation of live bacteria. For the same reason, a urinalysis is usually performed immediately before instillation to further ensure a diminished probability of systemic uptake of BCG. In the event of a traumatic catheterisation, the treatment should be delayed for several days to one week, depending on the extent of injury. After instillation, the patient should try and retain the solution for at least two hours however this is not always possible due to urgency and pain. Fluid, diuretic and caffeine restriction before instillation is essential to limit dilution of the agent with urine and to facilitate retention of the agent for two hours. Patients are instructed to clean their toilet with bleach after voiding and flushing. The original regimen described by Morales included a percutaneous dose, which was discontinued after success using a similar intravesical regimen.