Biyabani, S R

Burney, I A

Noor, M A

Talatia, J

English

eCommons@AKU

eCommons@AKUSection of Urology Department of SurgeryDecember 2002Symptomatic granulomatous prostatitis followingbacillus Calmette-Guerin immunotherapy forbladder cancerM A. NoorS R. BiyabaniAga Khan University, raziuddin.biyabani@aku.eduI A. BurneyAga Khan UniversityJ TalatiaAga Khan University, jamsheer.talati@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_urolPart of the Urology CommonsRecommended CitationNoor, M. A., Biyabani, S. R., Burney, I. A., Talatia, J. (2002). Symptomatic granulomatous prostatitis following bacillus Calmette-Guerin immunotherapy for bladder cancer. Journal of Pakistan Medical Association, 52(12), 578-580.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_urol/134Symptomatic Granulomatous Prostatitis following BacillusCalmette-Guerin Immunotherapy for Bladder CancerM. A.Noor,S. R. Biyabani,J. Talatia  ( Departments of Surgery (Section of Urology), The Aga Khan University Hospital,Karachi. ) I. A. Burney  ( Departments of Medicine (Section of Oncology), The Aga Khan University Hospital, Karachi. ) Introduction Intravesical instillation of Bacillus Calmette -Guerin (BCG) is widely used as immunotherapy for thetreatment of non-muscle invasive transitional cell carcinoma (TCC) of the urinary bladder. One of thecomplications of this therapy, is granulomatous prostatitis (Gran P). This is usually asymptomatic. Wedescribe a patient treated with intravesical BCG who developed symptomatic Gran P.Case Report A 51-year-old male, a known hypertensive and smoker, presented with a history of microscopichematuria for 3 years. At the age of 8, he had undergone a repair of perforation of the urinary bladdersecondary to a road traffic accident. Digital rectal examination (DRE) revealed a moderately enlargedsoft prostate overlying mucosa was mobile, the central sulcus was not obliterated and there was nonodularity. Investigations revealed a prostate specific antigen (PSA) of 0.39 ngfml , and a serumcreatinine of 1.2 mgfdl. A trans-rectal ultmsound (TRUS) showed the volume of prostate to be 24 gmswith no hypoechoeic areas. An intravenous urography was suggestive of a filling defect in the urinarybladder. A cystoscopic examination revealed a 2.5cm cauliflower like broad-based growth at roof of thebladder, around 3-4 cm from bladder neck. The patient underwent transurethral resection of bladdertumor (TUR-BT). The histopathology showed poorly differentiated TCC of the urinary bladder with noevidence of muscle invasion (pTl G3 ). A CT-scan showed anterior vesical wall thickening but nolocoregional or distant metastases.In view of the poorly differentiated nature of the resected lesion, the patient received six doses ofintravesical BCG immuno-therapy. One mg of Oncotice strain of BCG was administered and retainedin the bladder for 2 hours. One week following the sixth instillation, the patient presented with painfulhematuria, suprapubic tenderness and severe dysuria. A DRE showed an enlarged , tender, nodular leftlobe of the prostate. The patient was afebrile. Investigations revealed a total leucocyte count (TLC) of9,200/ui , ESR 55 mm, serum creatinine 1.6 mg/dl, and urinalysis revealed> 20 RBCs/HPF and 5WBCs/HPF.A TRUS was performed which showed multiple areas of calcification and a peripheral hypoechoeicnodule in the left lobe of the prostate (Figure 1).The patient was catheterized and started on intravenous antibiotics and anticholinergic medication. ATRUS- guided biopsy and aspiration showed eosinophiis and histiocytes along with a collection ofmultinucleated giant cells forming langerhan’s type mixed cells, suggestive of necrotizinggranulomatous Prostatitis (Figure 2).Patient was started on Jsoniazid 300mg/day and Rifampicin 600mg/day.The supra-pubic tenderness and severe urethral pain continued despite the antituberculous therapy for 6weeks. A repeat cystoscopy showed bladder erythema with normal bladder capacity . A bladder biopsyshowed fibrosis and smooth muscle tissue with mild non-specific inflammation.Isoniazid was stopped after 6 weeks because of altered vision and numbness in the fingers. Thesymptoms improved following commencement of Gabapentine,Tryptanol and Diclofenac. Thesymptoms of prostatitis also disappeared after 3 months of treatment with Rifampicin. A checkcystoscopy three months later did not show any erythema or evidence of prostatitis. The patientremains symptom free six months after completion of treatment.Discussion Treatment options for poorly differentiated non-invasive TCC bladder are a matter of ongoing trials.TURBT alone is considered to be inadequate as the recurrence rate is reported to be between 70% and80% and the progression rate ranging from 29% to 50%1. Given the 40% reduction in tumor recurrencerates with the use of BCG in the well-to-moderately differentiated pTl tumors, it’s role in pTIG3 tumoris widely advocated and practiced2. Adverse effects following intravesical BCG therapy are related tostrain virulence, allergic reactions, or to nosocomial urinary tract infections. The effects may be BCG-specific or nonspecific in origin3. Most common side effects are self-limiting local reactions of urinaryfrequency, hematuria and bladder irritation reflecting topical immune stimulation. In addition Gran P,fever and cystitis have been reported to be some of the most frequent side effect of intravesical BCGtherapy4-6. Mukamel et al6 highlighted the difficulty in differentiating Gran P from Carcinoma of theprostate (Ca P) on digital rectal examination or even on TRUS. PSA leves is also not useful indiagnosis. Ca P PSA may be elevated after intravesical instillation of BCG and normal in patients withCa p7.When BCG is administered intra-dermally for prophylaxis of T.B., disseminated granulomatous lesionsoccur in less than I per million individuals8 The frequency of Gran P in men treated with intravesicalBCG varies from 1.3% to 41%5 and has been reported to be as high as 75%9, In one study reviewing32 patients the mean time between therapy and diagnosis of Gran P was 11.5 months5A tentative diagnosis of Gran P is usually entertained on the basis of symptomatology, physicalfindings and TRUS. However, it requires histopathology for confirmation10. The symptoms are thoseof nonspecific prostatitis, few develop a palpable lesion in the prostate on DRE. Imaging findings arenon-specific. TRUS is the most frequently used imaging modality and the predominant finding is ahypoechoic peripheral nodule, Some patients may have focal asymmetric flow to the lesion on colordoppler ultrasound9,11, On MRI, the lesion appears as a focal low intensity signal12.Conclusion The frequency of Gran P after intravesical BCG is very variable, It can become severely symptomaticand cause distressing symptoms. Antituberculous therapy is required in symptomatic patients.References 1.Pham HT, Sdoway MS High risk superficial bladder cancer: intravesical therapy for TI 03 transitionalcell Carcinoma of the urinary Wadder. Scmin. Urol. Oncol., 1997; 15:147-53.2.Ockrim JL , Abel PD. Treatment options in superficial (pTa/pTl/CIS) Bladder Cancer. In TreatmentOptions in Urological Cancer, ln:Waxman J. (ed). Oxford: Blackwell ,2002, pp. 118-36.3.Rischmann P, Desgranddchamp B, Malavaund B. BCG intravesical instillation: recommendations forside-effects management, Eur. Urol., 2000; 37:33-36.4.Lamm DL.,Stogdill VD, Stogdill BJ, et al. Complications of bacillus Calmette-Guerinimmunotherapy in 1,278 patients with bladder cancer. J. Urol., 1986; 135 : 272-74.5.Oates RD. Stilmant MM, Freedlund MC. et al. Granulomatous prostatitis following bacilluscalamette guerin immunotherapy of bladder cancer. 3. Urol,, 1988; 140: 75 1-54.6.Mukamel E, Konichezky M, Engelstein D, et al. Clinical and pathological findings in prostatesfollowing intravesical Bacillus Calamette-Guerin instillations. 3, Urol., 1990; 144: 1399-400.7.Bahnson RR. Elevation of prostate specific antigen from bacillus calametteguerin-inducedgranulomatous prostatitis. J. Urol., 1991; 146:1368-69.8.Lotte A, Wasz-Hockert 0, Poisson N, et al. BCG complications. Estimates of the risks amongvaccinated subjects and statistical analysis of their main characteristics. Adv. Tubercle. Res., 1984 ; 21:107.9.Rificin MD, Franklin N,Tessler FN, et al. US case of the day. GP resulting from BCG therapyRadiographics, 1998; 18 :1605-7.10.LaFontaine PD. Middleman BR, Graham SD Jr. et al, Incidence of granulomatous prostatitis andacid-fast bacilli after intravesical BCG therapy. Urology, 1997; 49:363-66.11.Clemcnts R, Thomas KG, Griffiths GJ. et al. Transrectal ultrasound appearences of’ granulomatousprostatitis. Clin. Radiol., 1993; 47 :174-76.12.Szolar DH, Ranner G, Preidler KW, et al. Non-granulomatous prostatitis: MRI image withendorectal surface coil (Endo-MRI). Aktuelle, Radiol., 1995; 5: 67-69.

Symptomatic granulomatous prostatitis following bacillus Calmette-Guerin immunotherapy for bladder cancer

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Symptomatic granulomatous prostatitis following bacillus Calmette-Guerin immunotherapy for bladder cancer

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