Impact of UTUC on Outcomes of Non-Muscle Invasive Bladder Cancer Treated with Intravesical Bacillus Calmette-Guerin

Introduction There is a paucity of information regarding impact of upper tract urothelial carcinoma (UTUC) on the patterns of BCG response in patients with NMIBC treated with BCG. We present the clinicopathological characteristics of patients with a history of NMIBC and UTUC treated with intravesical BCG and evaluate the impact of UTUC on BCG response and progression. Methods An IRB approved review of patients with NMIBC patients treated with at least induction BCG at our institution between 2000 and 2018 was performed. Patients were then stratified by (1) presence of UTUC and (2) time of UTUC onset (prior to NMIBC diagnosis vs synchronous or metachronous disease). Outcomes were calculated from date of index transurethral resection. Results Of 577 patients who received BCG induction for NMIBC, 63 (11%) patients were diagnosed with UTUC. Of these, 36 patients had a history of UTUC prior to NMIBC (median 344 days prior, IQR 211 – 821 days), while 27 developed UTUC after diagnosis of NMIBC (8 synchronous and 19 metachronous, median 350 days after, IQR 25-833 days). There was no difference between the UTUC and no UTUC groups, except that the UTUC group had more multifocal bladder tumors (71% vs 50%, P=0.002) and prostatic urethral involvement (12% vs 5%, P=0.023). The UTUC group had more non-responders to BCG with respect to recurrence (60% vs. 36%, P=0.0002), any stage/grade progression (25% vs 11%, P=0.005), and progression to muscle invasive or metastatic disease (18% vs 8%, P=0.016). There was no significant difference in rates of recurrence or progression based on timing of UTUC with respect to bladder tumor, albeit this analysis is limited by small numbers. Conclusions Presence of UTUC – whether prior to or after diagnosis of bladder cancer - was associated with an almost 2-fold increased recurrence and progression rate following BCG. This should be factored in when counselling patients and designing cohorts for clinical trials.