Use of Induction and Maintenance Intravesical BCG in a Pediatric Patient with High-grade, Non-muscle Invasive Bladder Cancer
James Rague, MD1; Richard Lee, MD2
1Boston Medical Center, Boston, MA; 2Boston Children's Hospital, Boston, MA
BACKGROUND: Urothelial carcinoma of the bladder is extremely rare in the pediatric population with the majority of cases being solitary, low-grade tumors. Given the rarity of disease, there are currently no guidelines for the management of pediatric bladder malignancies or prior cases in the literature discussing the use of intravesical BCG in instances of high-grade disease. Here we discuss novel use of intravesical BCG in a pediatric patient with evaluation of treatment efficacy and side-effects. METHODS: A single-institution retrospective case report was performed. We evaluated a single female patient, 10 years of age, who was referred to the urology clinic with gross hematuria and found to have high-grade, non-muscle invasive bladder cancer on transurethral resection of bladder tumor. The patient subsequently underwent instillation of induction and maintenance BCG. Patient and disease characteristics, treatment, and adverse effects were reported. The outcome of interest was the role of intravesical BCG in the management of the pediatric patient for reduction of disease recurrence and progression, feasibility of therapy, and therapy associated side effects.
RESULTS: One patient, age 10 years old, was diagnosed with high-grade T1 urothelial carcinoma on transurethral resection of bladder tumor. She underwent induction BCG based on adult protocols. The patient had no disease recurrence after induction course and was therefore continued on maintenance BCG. She has now completed 1.5 years of maintenance therapy without recurrence of disease and with minimal local side effects from therapy.
CONCLUSIONS: Current AUA guidelines in adults recommend induction BCG in newly diagnosed CIS, high-grade T1 or high-risk Ta urothelial carcinoma with the goal of reduction in disease progression and recurrence. Drug manufactory recommendations however state that the safety and efficacy in the pediatric population is unknown. Given similar disease pathophysiology in adult and pediatric patients, it is felt that the beneficial effects of BCG would be equivalent in pediatric patients. Here we demonstrate that intravesical BCG is technically feasible using the same treatment protocol as is used in the adult population with good efficacy and minimal side effects. Given lack of prior reports and a single patient being reviewed, the overall safety and efficacy in all pediatric patients cannot be determined.
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