Zlotta Alexandre R, Fleshner Neil E, Jewett Michael A
Department of Surgery, Division of Urology, University of Toronto;
Can Urol Assoc J. 2009 Dec;3(6 Suppl 4):S199-205. doi: 10.5489/cuaj.1196.
Up to 40% of patients with non-muscle-invasive bladder cancer (NMIBC) will fail intravesical bacillus Calmette-Guérin (BCG) therapy. There is unfortunately no current gold standard for salvage intravesical therapy after appropriate BCG treatment. Indeed, outcomes are at best suboptimal. The vast majority of low-grade NMIBC are prone to recur but very rarely progress. Failure after intravesical BCG in these patients is usually superficial and low-grade. At the other end of the spectrum, failure to respond to BCG in high-risk T1 bladder cancer and/or carcinoma in situ (CIS or TIS) is more problematic, since those tumours often have the potential to progress to muscle invasion. In these cases, radical cystectomy remains the mainstay after BCG failure. With appropriate selection, certain patients who "fail" BCG (but with favourable risk factors) can be managed with intravesical regimens, including repeated BCG, BCG plus cytokines, intravesical chemotherapy, thermochemotherapy or new immunotherapeutic modalities. In this review, reasons explaining BCG failure, how to define BCG failure, optimal risk stratification and prediction of response and management of BCG failures are discussed.
高达40%的非肌层浸润性膀胱癌（NMIBC）患者膀胱内卡介苗（BCG）治疗会失败。遗憾的是，目前对于适当BCG治疗后挽救性膀胱内治疗尚无金标准。事实上，治疗效果至多只能说是次优的。绝大多数低级别NMIBC易于复发，但很少进展。这些患者膀胱内BCG治疗失败通常是表浅且低级别病变。另一方面，高危T1期膀胱癌和/或原位癌（CIS或Tis）对BCG无反应则更成问题，因为这些肿瘤往往有可能进展为肌层浸润。在这些情况下，根治性膀胱切除术仍是BCG治疗失败后的主要治疗方法。经过适当筛选，某些“BCG治疗失败”（但具有有利风险因素）的患者可采用膀胱内治疗方案，包括重复BCG治疗、BCG加细胞因子、膀胱内化疗、热化疗或新的免疫治疗方法。在本综述中，将讨论解释BCG治疗失败的原因、如何定义BCG治疗失败、最佳风险分层以及BCG治疗失败的反应预测和管理。
