Bacillus Calmette-Guerin Response Research Articles

Abstract B004: Deep learning unveils molecular footprints in histology: predicting molecular subtypes from bladder cancer histology slides

Abstract Introduction: Transurethral resection followed by intravesical bacillus Calmette-Guerin (BCG) is the standard of care for high-risk non-muscle-invasive bladder cancer (HR-NMIBC) patients. However, ≈20% of HR-NMIBC patients progress to muscle-invasive or metastatic disease, which is associated with a high-risk of death. Early identification of patients who are unlikely to benefit from BCG treatment could benefit from an early radical cystectomy or bladder-sparing alternatives. Previously, we showed that molecular subtyping or HR-NMIBC identified BCG response subtypes (BRS 1/2/3). BRS3 tumors were associated with a poor response to BCG and a high-risk of progression. However, molecular subtyping relies on resource-intensive and costly sequencing methods such as next-generation sequencing, and microarray analysis. We employed deep learning (DL) to predict BRS3 vs BRS1/2 molecular subtypes from digitized histology slides. Methods: Haematoxylin and eosin (H&E)-stained slides were digitized, and quality control was performed. The areas where the RNA was extracted were annotated pixel-wise by a trained pathology assistant, using QuPath. Image tiles of 512 × 512 pixels at 10X, 20X, and 40X magnifications were extracted with a 25% overlap. For classification, BRS1 and BRS2 images were grouped, while BRS3 images were categorized separately. After applying Macenko normalization, tiles were split based on individual patients into a 75/25 training/validation ratio via stratified 4-fold cross-validation. Four DL models (DenseNet, Inception, ShuffleNet, ResNet) were trained to classify tiles into BRS3 and BRS1/2, with tile labels based on the patient’s subtype. Patient-level classification was performed using majority voting from tile predictions. Model efficacy was gauged using the area under the ROC curve (AUC). Results: Out of 245 H&E slides, 45 were discarded after quality control. From 200 patients – with a 70:30 distribution between BRS1&2 and BRS3 The DenseNet model at 10x magnification was the best-performing model, achieving the highest AUC compared to all other models and magnifications. On the image tile level, the best DenseNet achieved an average AUC of 0.65 with a standard deviation of 0.03 across the four folds of the validation set. At the patient-level prediction, the best DenseNet reached an average AUC of 0.80 and a standard deviation of 0.05 on the validation set. Conclusion: Our study demonstrates that deep learning classifies BSR3 from BSR1 and 2 subtypes from H&E slides. This method holds potential to identify BRS3 HR-NMIBC patients who may benefit from alternative treatments than BCG. With further refinement, this deep learning strategy can become a key tool in histology, aiding in swift, affordable, and efficient subtype identification. Hence, this method has the potential to bridge the gap between molecular techniques and clinical practice. Future research should prioritize evaluating the model on an external test cohort and consider predicting additional molecular markers to fine-tune prediction outcomes. Citation Format: Farbod Khoraminia, Flouros C de Jong, Farhan Akram, Geert Litjens, Maarten D.J. Jansen, Alberto Nakuama Gonzalez, Danique Lichtenburg, Andrew Stubbs, Nadieh Khalili, Tahlita C.M. Zuiverloon. Deep learning unveils molecular footprints in histology: predicting molecular subtypes from bladder cancer histology slides [abstract]. In: Proceedings of the AACR Special Conference on Bladder Cancer: Transforming the Field; 2024 May 17-20; Charlotte, NC. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(10_Suppl):Abstract nr B004.

An exploratory study investigating the impact of the bladder tumor microbiome on Bacillus Calmette Guerin (BCG) response in non-muscle invasive bladder cancer

PurposeIntravesical Bacillus Calmette-Guerin (BCG) is standard of care for intermediate- and high-risk non-muscle invasive bladder cancer (NMIBC). The effect of the bladder microbiome on response to BCG is unclear. We sought to characterize the microbiome of bladder tumors in BCG-responders and non-responders and identify potential mechanisms that drive treatment response. Materials and methodsPatients with archival pre-treatment biopsy samples (2012-2018) were identified retrospectively. Prospectively, urine and fresh tumor samples were collected from individuals with high-risk NMIBC (2020-2023). BCG response was defined as tumor-free 2 years from induction therapy. Extracted DNA was sequenced for 16S rRNA and shotgun metagenomics. Primary outcomes were species richness (α–diversity) and microbial composition (β-diversity). Paired t-tests were performed for α–diversity (Observed species/Margalef). Statistical analysis for β-diversity (weighted and unweighted UniFrac distances, weighted Bray-Curtis dissimilarity) were conducted through Permanova, with 999 permutations. ResultsMicrobial species richness (P < 0.001) and composition (P = 0.001) differed between BCG responders and non-responders. Lactobacillus spp. were significantly enriched in BCG-responders. Shotgun metagenomics identified possible mechanistic pathways such as assimilatory sulfate reduction. ConclusionA compositional difference exists in the tumor microbiome of BCG responders and non-responders with Lactobacillus having increased abundance in BCG responders.

Biology of BCG response in non-muscle invasive bladder cancer - 2021 IBCN Updates Part III.

Bacillus Calmette-Guerin (BCG) remains the only FDA-approved first-line therapy in patients with high-risk non-muscle invasive bladder cancer. Recurrences, even after adequate BCG therapy, are common and the efficacy of second-line therapies remains modest. Therefore, early identification of patients likely to recur and treatment after recurrence remain critical unmet needs in the clinical care of bladder cancer patients. To address these deficits, a better understanding of the mechanisms of resistance to BCG-therapy is needed. The virtual update of the International Bladder Cancer Network (IBCN) on the biology of response to BCG focused on potential mechanisms and markers of resistance to intravesical BCG therapy. The insights from this meeting will be highlighted and put into context of previously reported mechanisms of resistance to BCG in this review.

Preoperative systemic inflammation response index is an independent prognostic marker for BCG immunotherapy in patients with non-muscle-invasive bladder cancer.

The Systemic Inflammatory Response Index (SIRI) is a novel prognostic biomarker based on peripheral blood counts of neutrophils, monocytes, and lymphocytes. Recent evidence suggests that it is associated with poor prognosis in various cancers. However, the predictive value of the SIRI in non-muscle-invasive bladder cancer (NMIBC) patients treated with intravesical Bacillus Calmette-Guerin (BCG) immunotherapy remains elusive. Therefore, this study aimed to evaluate the potential of SIRI as a prognostic factor in these patients. A total of 540 patients with NMIBC who underwent BCG immunotherapy following transurethral resection of bladder tumor (TURBT) were enrolled in this study. Using receiver operating characteristic (ROC) curves and the Youden index, patients were divided into high and low SIRI groups based on the cutoff values. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of BCG non-response. Thereafter, propensity score matching (PSM) was used to eliminate bias due to confounding factors between the low and high SIRI groups. Finally, the Kaplan-Meier method was used to compare recurrence-free survival (RFS) and progression-free survival (PFS) between the two groups. Multivariable logistic regression analysis revealed that high SIRI (p=0.001), high MLR (p=0.015), and high tumor pathological T stage (p=0.015) were significantly correlated with non-response to BCG therapy. In addition, both RFS and PFS were shorter in the high SIRI group than in the other group before and after PSM (both p < 0.05). Collectively, our results indicate that the combination of tumor pathological T staging and the SIRI can enhance the predictive power of BCG response. Pretreatment peripheral blood SIRI can be employed to predict the response to BCG immunotherapy and the prognosis of NMIBC patients. Taken together, the combination of T stage and SIRI demonstrated robust performance in predicting the response to BCG immunotherapy in NMIBC patients.

Preoperative sarcopenia and systemic immune-inflammation index can predict response to intravesical Bacillus Calmette-Guerin instillation in patients with non-muscle invasive bladder cancer.

BackgroundTo explore the prognostic significance of sarcopenia and systemic immune-inflammation index (SII) for response to intravesical Bacillus Calmette-Guerin (BCG) in patients with intermediate-, and high-risk non-muscle invasive bladder cancer (NMIBC).MethodsWe retrospectively analyzed 183 consecutive patients treated in Qilu hospital of Shandong University for a first diagnosis of intermediate and high risk NMIBC. Using computed tomography scans at the third lumbar vertebra level, we calculated skeletal muscle index (SMI). Sarcopenia was defined as SMI <43 cm2/m2 for males with BMI < 25 kg/m2, <53 cm2/m2 for males with BMI ≥ 25 kg/m2, and <41 cm2/m2 for females. The response to intravesical BCG immunotherapy and relapse-free survival (RFS) were analyzed.ResultsCompared with BCG responders, BCG non-responders were associated with sarcopenia (P < 0.001), carcinoma in situ (P < 0.001), T1 stage (P < 0.001), multiple tumor (P < 0.001), tumor diameter >=3cm (P < 0.001), and have a significant increase of neutrophil-to-lymphocyte ratio (NLR) (P < 0.001), platelet to lymphocyte ratio (PLR) (P = 0.004), SII (P < 0.001). The area under the ROC curve (AUC) of the BMI, NLR, PLR, and SII for response to intravesical BCG immunotherapy were 0.425, 0.693, 0.631, and 0.702 respectively. Logistic regression analysis demonstrated that sarcopenia and SII were predictors of response to intravesical BCG immunotherapy. The Kaplan-Meier survival analysis showed that the RFS of patients with BCG response, lower SII and no sarcopenia was significantly increased compared with that of patients with BCG non-response, higher SII and sarcopenia, respectively. Subgroup analysis demonstrated that the RFS of patients with high SII and sarcopenia was significantly decreased compared with those with low SII and no sarcopenia in Ta stage subgroup, T1 stage subgroup, non-Cis subgroup, multiple tumor subgroup, single tumor subgroup, tumor diameter≥3cm subgroup and tumor diameter<3cm subgroup, respectively (P < 0.05). However, there was no significant difference in RFS for patients in CIS subgroup (P > 0.05). Multivariate Cox analysis shown that sarcopenia (p=0.005) and high SII (p = 0.003) were significantly associated with poor RFS.ConclusionsBoth sarcopenia and high SII are useful predictors of response to intravesical BCG in intermediate- and high-risk NMIBC patients. Patients with intermediate- and high-risk NMIBC that had sarcopenia or high SII at diagnosis were associated with poor RFS, and the combination of sarcopenia and SII may be a better predictor of RFS.

MP59-06 PD-L1 EXPRESSION AND BCG RESPONSE IN NON-MUSCLE INVASIVE BLADDER CANCER

You have accessJournal of UrologyCME1 May 2022MP59-06 PD-L1 EXPRESSION AND BCG RESPONSE IN NON-MUSCLE INVASIVE BLADDER CANCER Solomon Woldu, Thomas Gerald, Vitaly Margulis, Daniel Halstuch, Yaara Ber, Karin Lifshitz, David Margel, Yair Lotan, and Liwei Jia Solomon WolduSolomon Woldu More articles by this author , Thomas GeraldThomas Gerald More articles by this author , Vitaly MargulisVitaly Margulis More articles by this author , Daniel HalstuchDaniel Halstuch More articles by this author , Yaara BerYaara Ber More articles by this author , Karin LifshitzKarin Lifshitz More articles by this author , David MargelDavid Margel More articles by this author , Yair LotanYair Lotan More articles by this author , and Liwei JiaLiwei Jia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002642.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intravesical bacillus Calmette Guerin (BCG) is the standard of care adjuvant therapy for high risk non-muscle invasive bladder cancer (NMIBC), yet many patients experience recurrence or disease progression. The mechanism of BCG is thought to be related to stimulation of immune surveillance. Relatedly, systemic immune checkpoint inhibition is being utilized in advanced bladder cancer and approved for BCG unresponsive NMIBC. We sought to determine the association between PD-L1 expression and BCG treatment. METHODS: We identified 102 BCG-naïve patients with high grade (HG) NMIBC treated with BCG. All patients underwent initial transurethral resection (TUR). Dako 22c3 assay was used to determine PD-L1 expression. Patients were defined as PD-L1 positive if the combined positive score > 0. BCG unresponsiveness was defined by presence of HG disease at 6 months following adequate BCG (one induction and maintenance cycle or two induction cycles) for pT1 or 12 months for CIS or presence of pT1 at 3 months after induction. HG relapse was defined as HG disease after being followed for 6 months after BCG. RESULTS: The median follow-up was 57 months. Median number of BCG maintenance cycles was 1, and 17 (16.7%) patients underwent immediate reinduction BCG. PD-L1 expression was observed in 5.9% of pTa, 30.0% of pT1, and 3.6% of CIS. BCG unresponsiveness and HG relapse were observed in 32 (35.6%) and 29 (34.5%), respectively. On univariate analysis, PD-L1 expression was inversely associated with BCG unresponsiveness (OR=0.11; 95% CI 0.01-0.90) but not HG relapse (OR=0.30; 95% CI 0.06-1.44). The sensitivity, specificity, positive predictive value, and negative predictive value of PD-L1 expression for BCG responsiveness were 22%, 97%, 93%, and 41%, respectively. PD-L1 positive patients had a post-test probability of BCG responsiveness of 93%. On multivariate regression, pT1 (OR = 0.16; 95% CI 0.05-0.60), CIS (OR=0.25; 95% CI 0.07-0.86), and PD-L1 expression (OR=15.63; 95% CI 1.78-142.86) were associated with BCG responsiveness. CONCLUSIONS: PD-L1 expression in HG NMIBC was low, and those with PD-L1 expression at initial TUR were more likely to harbor invasive disease. Patients with PD-L1 expression were more likely to demonstrate BCG responsiveness. These findings suggest a role of PD-L1 in the immune surveillance mechanism of BCG at initial diagnosis and may assist in predicting response to BCG in patients with HG NMIBC. Further investigation is needed to determine if additional immune checkpoint markers have strong correlation with BCG response, particularly among patients without PD-L1 expression. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1003 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Solomon Woldu More articles by this author Thomas Gerald More articles by this author Vitaly Margulis More articles by this author Daniel Halstuch More articles by this author Yaara Ber More articles by this author Karin Lifshitz More articles by this author David Margel More articles by this author Yair Lotan More articles by this author Liwei Jia More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP59-10 EVALUATING EX VIVO INNATE IMMUNE TRAINING AS A PREDICTIVE MEASURE OF RESPONSIVENESS TO BCG IMMUNOTHERAPY IN PATIENTS WITH NON-MUSCLE INVASIVE BLADDER CANCER

You have accessJournal of UrologyCME1 May 2022MP59-10 EVALUATING EX VIVO INNATE IMMUNE TRAINING AS A PREDICTIVE MEASURE OF RESPONSIVENESS TO BCG IMMUNOTHERAPY IN PATIENTS WITH NON-MUSCLE INVASIVE BLADDER CANCER Song Jiang, Gil Redelman-Sidi, Eugene J. Pietzak, Bernard H. Bochner, and Michael Glickman Song JiangSong Jiang More articles by this author , Gil Redelman-SidiGil Redelman-Sidi More articles by this author , Eugene J. PietzakEugene J. Pietzak More articles by this author , Bernard H. BochnerBernard H. Bochner More articles by this author , and Michael GlickmanMichael Glickman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002642.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intravesical instillation of the live attenuated mycobacterium Bacillus Calmette-Guerin (BCG) remains the most effective adjuvant therapy for non-muscle invasive bladder cancer. An increasing body of evidence suggests that the innate immune system has characteristics that involve a heterologous memory of past insults through a process involving epigenetic reprogramming, termed trained immunity. We seek to investigate the potential for innate immune training as a pre-treatment predictor of BCG-response. METHODS: A prospective biospecimen collection was performed on venous blood from non-muscle invasive bladder cancer patients prior to receiving intravesical BCG therapy. To investigate the role of trained immunity in primary monocytes, cells were isolated from peripheral blood mononuclear cells (PBMC) by plate adhesion. In vitro training was performed via stimulation with 10:1 MOI BCG. Cells were then washed in media and allowed to rest 6 days. Subsequently, cells were stimulated with lipopolysaccharide (a TLR4 agonist). Cell free supernatant was measured for TNF-alpha production by enzyme-linked immunosorbent assay. RESULTS: In vitro training of primary monocytes induced an increase in proinflammatory cytokine production upon re-stimulation. This phenotype was dose dependent on stimulation with LPS and confined to the monocyte population. In our in vitro training experiments, there was demonstrable interpatient variability seen pre-BCG exposure in a cohort of NMIBC patients. These results will be correlated with future long term BCG response in this prospective cohort. CONCLUSIONS: We have developed a reliable assay to measure ex vivo innate immune training potential in primary monocytes collected from patient samples. These findings will be correlated with prospective clinical data on BCG responsiveness and recurrence free survival. Such insight will have potential clinical impact on the development of biomarkers and clinical assays that could predict immune responsiveness to BCG a priori, as well as identify possible immunological adjuvants that could enhance the effect of intravesical BCG. Source of Funding: NCI Specialized Programs of Research Excellence (SPORE) in Bladder Cancer P50 CA221745 © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1005 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Song Jiang More articles by this author Gil Redelman-Sidi More articles by this author Eugene J. Pietzak More articles by this author Bernard H. Bochner More articles by this author Michael Glickman More articles by this author Expand All Advertisement PDF DownloadLoading ...

Radiomics of Contrast-Enhanced Computed Tomography: A Potential Biomarker for Pretreatment Prediction of the Response to Bacillus Calmette-Guerin Immunotherapy in Non-Muscle-Invasive Bladder Cancer.

Background: Bacillus Calmette-Guerin (BCG) instillation is recommended postoperatively after transurethral resection of bladder cancer (TURBT) in patients with high-risk non-muscle-invasive bladder cancer (NMIBC). An accurate prediction model for the BCG response can help identify patients with NMIBC who may benefit from alternative therapy. Objective: To investigate the value of computed tomography (CT) radiomics features in predicting the response to BCG instillation among patients with primary high-risk NMIBC. Methods: Patients with pathologically confirmed high-risk NMIBC were retrospectively reviewed. Patients who underwent contrast-enhanced CT examination within one to 2 weeks before TURBT and received ≥5 BCG instillation treatments in two independent hospitals were enrolled. Patients with a routine follow-up of at least 1 year at the outpatient department were included in the final cohort. Radiomics features based on CT images were extracted from the tumor and its periphery in the training cohort, and a radiomics signature was built with recursive feature elimination. Selected features further underwent an unsupervised radiomics analysis using the newly introduced method, non-negative matrix factorization (NMF), to compute factor factorization decompositions of the radiomics matrix. Finally, a robust component, which was most associated with BCG failure in 1 year, was selected. The performance of the selected component was assessed and tested in an external validation cohort. Results: Overall, 128 patients (training cohort, n = 104; external validation cohort, n = 24) were included, including 12 BCG failures in the training cohort and 11 failures in the validation cohort each. NMF revealed five components, of which component 3 was selected for the best discrimination of BCG failure; it had an area under the curve (AUC) of .79, sensitivity of .79, and specificity of .65 in the training set. In the external validation cohort, it achieved an AUC of .68, sensitivity of .73, and specificity of .69. Survival analysis showed that patients with higher component scores had poor recurrence-free survival (RFS) in both cohorts (C-index: training cohort, .69; validation cohort, .68). Conclusion: The study suggested that radiomics components based on NMF might be a potential biomarker to predict BCG response and RFS after BCG treatment in patients with high-risk NMIBC.

PD-L1 expression and BCG response in nonmuscle invasive bladder cancer.

545 Background: Intravesical bacillus Calmette Guerin (BCG) is the standard of care adjuvant therapy for high risk non-muscle invasive bladder cancer (NMIBC), yet many patients experience recurrence or disease progression. The mechanism of action of BCG is believed to be related to stimulation of immune surveillance. Relatedly, systemic immune checkpoint inhibition is currently being utilized in advanced bladder cancer and approved for BCG unresponsive NMIBC. We sought to determine the association between PD-L1 expression and BCG treatment. Methods: We identified 102 BCG-naïve patients with high grade (HG) NMIBC treated with BCG. All patients underwent initial transurethral resection (TUR) for pathologic diagnosis. Dako 22c3 assay was used to determine PD-L1 expression. Patients were defined as PD-L1 positive if the combined positive score (CPS) &gt; 0. BCG unresponsiveness was defined by presence of high grade disease at 6 months following adequate BCG (one induction and maintenance cycle or two induction cycles) for pT1 or 12 months for CIS or presence of pT1 at 3 months following induction. HG relapse was defined as presence of any HG disease after being followed for 6 months after BCG. Results: The median follow-up time was 57 months. Median number of BCG maintenance cycles was 1, and 17 (16.7%) patients underwent immediate reinduction BCG. PD-L1 expression was observed 5.9% of pTa, 30.0% of pT1, and 3.6% of CIS. BCG unresponsiveness and HG relapse were observed in 32 (35.6%) and 29 (34.5%) patients, respectively. On univariate analysis, PD-L1 expression was inversely associated with BCG unresponsiveness (OR = 0.112; 95% CI 0.014-0.898) but not high grade relapse (OR = 0.296; 95% CI 0.061-1.440). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PD-L1 expression for BCG responsiveness were 22%, 97%, 93%, and 41%, respectively. The post-test probability of BCG responsiveness was 93% in patients positive for PD-L1 based on a positive likelihood ratio of 7.33 for PD-L1 expression. On multivariate regression, pT1 (OR = 0.159; 95% CI 0.045-0.600), CIS (OR = 0.247; 95% CI 0.071-0.857), and PD-L1 expression (OR = 15.625; 95% CI 1.779-142.857) were independently associated with BCG responsiveness. Conclusions: PD-L1 expression in HG NMIBC was low, and patients with PD-L1 expression at initial TUR were more likely to harbor invasive disease. Patients showing PD-L1 expression were more likely to demonstrate BCG responsiveness. These findings suggest a role of PD-L1 in the immune surveillance mechanism of BCG at initial pathologic diagnosis and may assist in predicting responses to BCG among patients with HG NMIBC. Further investigation is required to determine if additional immune checkpoint markers have strong correlation with BCG response, particularly among patients without PD-L1 expression.

Defining innate immune training potential as a predictor of Bacillus Calmette-Guérin immunotherapy response in nonmuscle-invasive bladder cancer.

522 Background: Intravesical instillation of the live attenuated mycobacterium Bacillus Calmette-Guerin (BCG) remains the most effective therapy for the treatment of non-muscle invasive bladder cancer. The precise mechanism of BCG is thought to involve phagocytosis, induction of inflammation, activation of the innate immune apparatus, and an effective cell-mediated T cell response. An increasing body of evidence suggests that the innate immune system has characteristics that involve a heterologous memory of past insults through a process thought to involve epigenetic reprogramming, termed trained immunity. We seek to investigate the potential for innate immune training as a predictor of the anti-tumor effects of BCG. Methods: A prospective biospecimen collection was performed on venous blood from non-muscle invasive bladder cancer patients prior to receiving intravesical BCG therapy. To investigate the role of trained immunity in primary monocytes, cells were isolated from peripheral blood mononuclear cells (PBMC) by plate adhesion. 2-5 x 105 cells/well were assayed in 96-well format, cultured in RPMI 1640 supplemented with 10% Fetal Bovine Serum and 2mM L-glutamine and stimulated with 10:1 MOI BCG for 24 hours. Cells were then washed in media and allowed to rest 6 days. Media was changed on day 3 of rest. Subsequently, cells were stimulated with 25 ng/ml lipopolysaccharide (a TLR4 agonist) for 24 hours. Cell free supernatant was measured for TNF-alpha production by enzyme-linked immunosorbent assay. Results: In vitro training of primary monocytes induced an increase in proinflammatory cytokine production upon re-stimulation. This phenotype was dose dependent on stimulation with LPS, however, the relative change between trained and untrained cells was diminished at higher concentrations of agonist. In our in vitro training experiments, there was demonstrable interpatient variability seen pre-BCG exposure in a cohort of NMIBC patients. These results will be correlated with future long term BCG response in this prospective cohort. Conclusions: We present data on a trained innate immune phenotype on primary monocytes collected from patient samples. These data serve as proof of principle for the ability to induce a trained phenotype in vitro. These findings will be correlated with prospective clinical data on BCG responsiveness and recurrence free survival to allow us to garner further insight into the role of trained immunity in BCG immunotherapy. Such insight will have potential clinical impact on the development of biomarkers and clinical assays that could predict immune responsiveness to BCG a priori, as well as identify possible immunological adjuvants that could enhance the effect of intravesical BCG.

BCG efficacy in nonmuscle-invasive bladder cancer after prior radiation treatment for prostate cancer.

482 Background: Prostate radiotherapy is associated with worse oncologic outcomes in patients with bladder cancer. This is thought to be secondary to microvascular damage resulting in propagation of inflammation. There is sparse data on the effect of prior radiotherapy on the efficacy of intravesical Bacillus Calmette-Guerin (BCG) in patients with non-muscle invasive bladder cancer (NMIBC). We sought to evaluate BCG response and outcomes in NMIBC patients who have previously undergone prostate radiotherapy compared to patients with no prior history of pelvic radiotherapy. Methods: This is a retrospective cohort study that includes patients who received intravesical BCG for NMIBC at our institution from 2001 to 2019. Data were collected on patient and pathologic characteristics. Patients were stratified into three cohorts: prior radiotherapy (RT), radical prostatectomy (RP), and no prostate cancer (No PCa). Wilcoxon rank sum test and Chi-squared test were used for comparison between groups. The primary endpoints included recurrence at one-year, progression to MIBC and progression to metastatic disease. Results: In 199 total patients who underwent BCG for NMIBC, 23 had a prior history of radiotherapy treatment for prostate cancer, while 17 underwent prior radical prostatectomy. Overall, 41.2% of patients had recurrence at one year. There was no difference in recurrence at one year between the cohorts: 42.8% No PCa, 29.4% RP and 39.1% RT; p = 0.56. There was also no difference in progression to MIBC (6.9% No PCA, 0% RP, and 8.7% RT) or progression to metastatic disease (6.9% No PCA, 5.9% RP and 4.3% RT) with p = 0.50 and 0.89 respectively. Conclusions: The efficacy of intravesical BCG does not appear to be modified by prior radiation treatment for prostate cancer in patients with NMIBC.[Table: see text]

MP16-06 A NOVEL NOMOGRAM TO PREDICT BCG RESPONSE IN PATIENTS WITH HIGH-GRADE NON-MUSCLE INVASIVE BLADDER CANCER

You have accessJournal of UrologyBladder Cancer: Non-invasive II (MP16)1 Sep 2021MP16-06 A NOVEL NOMOGRAM TO PREDICT BCG RESPONSE IN PATIENTS WITH HIGH-GRADE NON-MUSCLE INVASIVE BLADDER CANCER Kelly Bree, Patrick Hensley, Nathan Brooks, Lianchun Xiao, Yu Shen, Neema Navai, H. Barton Grossman, Colin Dinney, and Ashish Kamat Kelly BreeKelly Bree More articles by this author , Patrick HensleyPatrick Hensley More articles by this author , Nathan BrooksNathan Brooks More articles by this author , Lianchun XiaoLianchun Xiao More articles by this author , Yu ShenYu Shen More articles by this author , Neema NavaiNeema Navai More articles by this author , H. Barton GrossmanH. Barton Grossman More articles by this author , Colin DinneyColin Dinney More articles by this author , and Ashish KamatAshish Kamat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002001.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Current risk tables for outcome prediction in patients with non-muscle invasive bladder cancer (NMIBC) are based upon studies comprised primarily of low-grade tumors. We developed nomograms that predict disease recurrence and progression in patients with high-grade NMIBC using a large institutional dataset. METHODS: The log rank test, univariate and multivariate Cox proportional hazards regression models were used to identify risk factors of histologically confirmed disease recurrence and progression using data on 519 patients treated with adequate induction bacillus Calmette-Guerin (BCG) at our institution from 2000 to 2018. The first set of models predicted bladder cancer recurrence free survival (RFS), and the second set predicted tumor progression (any upstaging) free survival (PFS). RESULTS: At an estimated median follow-up time was 60.4 months (95% CI: 54-66.2), recurrence or death, whichever occurred first was recorded in 248 patients (47.8%) with a median RFS time of 73 months (95% CI, 52.6-91.2). Recurrent tumors (HR 1.78, 95% CI 1.33-2.33, p<0.0001), larger tumor size (HR 1.07, 95% CI 1.00-1.15, p=0.0487), and diabetes mellitus (HR 1.57, 95% CI 1.14-2.15, p=0.0055) were significantly associated with a higher risk of recurrence or death. Conversely, the receipt of maintenance BCG (mBCG) (HR 0.46, 95% CI 0.29-0.73, p=0.0008) and number of doses of mBCG (HR 0.92, 95% CI 0.89-0.94, p<0.0001) were associated with lower risk of events. Progression or death occurred in 128 patients (24.7%) with a median PFS time of 151 months (95% CI, 121.32-NA). Prior BCG (HR 2.19, 95% CI 1.23-3.88, p=0.0075) and older age (HR 1.041, 95% CI 1.02-1.06, p<0.001) were associated with higher risk of progression or death, while BMI≥25 (HR 0.519, 95% CI 0.35-0.78, p=0.0015) and number of doses of mBCG (HR 0.88, 95% CI 0.86-0.91, p<0.0001) were associated with lower risk of progression or death. These prognostic factors were integrated to construct nomograms for prediction of PFS and RFS. CONCLUSIONS: These nomograms provide personalized prediction of recurrence and progression in patients with high-grade NMIBC treated with BCG, and may help identify patients who may benefit most from early radical cystectomy. Source of Funding: This research was supported by the Wayne B. Duddlesten Professorship in Cancer Research, the Raymond and Maria Floyd Bladder Cancer Research Foundation Grant to AMK, and NIH/NCI UTMD Anderson SPORE in Genitourinary Cancer (Bladder) (P50CA091846) to CPND © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e298-e298 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kelly Bree More articles by this author Patrick Hensley More articles by this author Nathan Brooks More articles by this author Lianchun Xiao More articles by this author Yu Shen More articles by this author Neema Navai More articles by this author H. Barton Grossman More articles by this author Colin Dinney More articles by this author Ashish Kamat More articles by this author Expand All Advertisement Loading ...

MP16-12 INTEGRATED GENE EXPRESSION PROFILING AND TARGETED PANEL SEQUENCING TO IMPROVE TREATMENT SELECTION IN NON-MUSCLE INVASIVE BLADDER CANCER

You have accessJournal of UrologyBladder Cancer: Non-invasive II (MP16)1 Sep 2021MP16-12 INTEGRATED GENE EXPRESSION PROFILING AND TARGETED PANEL SEQUENCING TO IMPROVE TREATMENT SELECTION IN NON-MUSCLE INVASIVE BLADDER CANCER Jeffrey Damrauer, Kyle Roell, Markia Smith, Xuezheng Sun, Erin Kirk, Katherine Hoadley, Halei Benefield, Gopa Iyer, David Solit, Matthew Milowsky, William Kim, Matthew Nielsen, Sara Wobker, Guido Dalbagni, Hikmat Al-Ahmadie, Andrew Olshan, Bernard Bochner, Helena Furberg, Melissa Troester, and Eugene Pietzak Jeffrey DamrauerJeffrey Damrauer More articles by this author , Kyle RoellKyle Roell More articles by this author , Markia SmithMarkia Smith More articles by this author , Xuezheng SunXuezheng Sun More articles by this author , Erin KirkErin Kirk More articles by this author , Katherine HoadleyKatherine Hoadley More articles by this author , Halei BenefieldHalei Benefield More articles by this author , Gopa IyerGopa Iyer More articles by this author , David SolitDavid Solit More articles by this author , Matthew MilowskyMatthew Milowsky More articles by this author , William KimWilliam Kim More articles by this author , Matthew NielsenMatthew Nielsen More articles by this author , Sara WobkerSara Wobker More articles by this author , Guido DalbagniGuido Dalbagni More articles by this author , Hikmat Al-AhmadieHikmat Al-Ahmadie More articles by this author , Andrew OlshanAndrew Olshan More articles by this author , Bernard BochnerBernard Bochner More articles by this author , Helena FurbergHelena Furberg More articles by this author , Melissa TroesterMelissa Troester More articles by this author , and Eugene PietzakEugene Pietzak More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002001.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Improved risk stratification and predictive biomarkers of treatment response are needed for non-muscle-invasive bladder cancer (NMIBC). Here we assessed the clinical utility of targeted RNA and DNA molecular profiling in NMIBC. METHODS: Gene expression in NMIBC samples was profiled by NanoString nCounter, a RNA quantification platform, from two independent cohorts (n = 28 & n = 50); targeted panel sequencing was performed in a subgroup (n = 50). Gene signatures were externally validated using a large RNAseq dataset of NMIBC tumors (n = 438). Established molecular subtype classifiers and novel gene expression signatures were assessed for associations with clinicopathologic characteristics, somatic tumor mutations, and treatment outcomes. RESULTS: Molecular subtypes distinguished between low-grade Ta tumors with FGFR3 mutations and overexpression (UROMOL-class 1) and tumors with more aggressive clinicopathologic characteristics (UROMOL-classes 2 and 3), which were significantly enriched with TERT promotor mutations. However, UROMOL subclasses were not associated with recurrence after bacillus Calmette-Guerin (BCG) immunotherapy in two independent cohorts. In contrast, a novel expression signature of an inflamed tumor microenvironment (TME) was associated with improved recurrence-free survival after BCG. Expression of immune checkpoint genes (PD-L1/PD-1/CTLA-4) was associated with an inflamed TME, but not with higher recurrence rates after BCG. FGFR3 mutations and overexpression were both associated with low immune signatures. CONCLUSIONS: Assessment of the immune TME, rather than molecular subtypes, is a promising predictive biomarker of BCG response. Modulating the TME in an immunologically “cold” tumor warrants further investigation. Integrated transcriptomic and exome sequencing should improve treatment selection in NMIBC. Source of Funding: Sidney Kimmel Center for Prostate and Urologic Cancers, Cycle for Survival, Marie-Josée and Henry R. Kravis Center for Molecular Oncology, National Cancer Institute Cancer Center Support Grant P30 CA008748, NCI SPORE in Bladder Cancer P50 CA221745, MSKCC Bladder Cancer SPORE Career Enhancement Award, Bochner-Fleisher Scholars Award, Memorial Sloan Kettering Cancer Center/Weill Medical College of Cornell University Clinical and Translational Science Methodology NIH/NCATS Grant Number UL1-TR002384, NIH/NCI K12 Paul Calabresi Career Development Award for Clinical Oncology (K12 CA184746), Wofchuck Family Young Investigator Award © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e301-e301 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Damrauer More articles by this author Kyle Roell More articles by this author Markia Smith More articles by this author Xuezheng Sun More articles by this author Erin Kirk More articles by this author Katherine Hoadley More articles by this author Halei Benefield More articles by this author Gopa Iyer More articles by this author David Solit More articles by this author Matthew Milowsky More articles by this author William Kim More articles by this author Matthew Nielsen More articles by this author Sara Wobker More articles by this author Guido Dalbagni More articles by this author Hikmat Al-Ahmadie More articles by this author Andrew Olshan More articles by this author Bernard Bochner More articles by this author Helena Furberg More articles by this author Melissa Troester More articles by this author Eugene Pietzak More articles by this author Expand All Advertisement Loading ...

Impact of sex on response to BCG in non-muscle invasive bladder cancer patients: a contemporary review from a tertiary care center.

Female sex has been implicated with higher stage at diagnosis and as a negative prognostic factor amongst patients with non-muscle invasive bladder cancer (NMIBC). Whether this holds true with contemporary management paradigms is unknown. We analyzed a cohort of patients treated with adequate bacillus Calmette-Guerin (BCG) for NMIBC in an effort to identify sex-specific influence on BCG response. An IRB-approved review of patients with NMIBC treated at our institution with at least 'adequate BCG', as defined by the US FDA and EAU, from 2000 to 2018 was performed. Patients were then stratified by sex and response to BCG. Non-parametric tests were used to summarize the data overall and by groups. The Kaplan-Meier product limit method was used to calculate median survival endpoints. Of the 541 patients treated with adequate BCG, 111 (20.5%) were female and 430 (79.5%) were male. Female patients were younger (median 66 vs. 69, p = 0.071), had a lower BMI (median 27.3 vs. 28.8, p = 0.010) and were more likely to have no smoking history (49.5% vs. 27.0%, p < 0.001). Tumor characteristics with respect to stage, size, multifocality, presence of carcinoma in situ, and presence of variant histology were similar between sexes. While rates of recurrence were higher in females than in males this, was not statistically significant (44.1% vs. 34.7%, p = 0.064) and Kaplan-Meier estimates of recurrence-free, progression-free and overall survival demonstrated no significant difference between sexes (p = 0.409, p = 0.253, p = 0.171, respectively). In a contemporary cohort of patients with NMIBC treated with adequate BCG, female sex was not associated with adverse oncologic outcomes.

Frequency of Accelerated Bacillus Calmette-Guerin Response in Bacillus Calmette-Guerin Vaccinated Children

Background: BCG is a vaccine obtained by attenuating Mycobacterium bovis. It is a fairly safe vaccine with no associated complications. Aim: To determine the frequency of accelerated BCG response in BCG vaccinated children. Study design: Descriptive case series. Methodology: A total of 124 already BCG vaccinated patients, having age in the range of 6 months to 10 years of either gender were included in the study. Patients with known case of TB and any other systemic disease were excluded. After this, BCG vaccination was given by the researcher himself who noted the in-duration after 72 hrs of BCG vaccination accelerated response of BCG. Chi square test was applied with P-value &lt;0.05 as significant. Results: Mean age was 6.02±2.22 years. Out of the 124 patients, 63(50.81%) were male and 61(49.19%) were females. Mean duration of previous BCG was 4.75±2.41 years. Frequency of accelerated BCG response in BCG vaccinated children was found in 76(61.29%) patients. Conclusion: This study concluded that the frequency of accelerated BCG response in BCG vaccinated children was 61.29%. So, we suggested that public awareness programs should be arranged to educate people for compulsory BCG vaccination of their children. Keywords: Bacillus Calmette-Guerin (BCG) Vaccine, Accelerated BCG Response and Tuberculosis.

Polymorphism in autophagy gene ATG2B is not associated with bladder cancer recurrence after intravesical Bacillus Calmette-Guerin (BCG) immunotherapy in Asian patients

ObjectivesOptimal patient stratification is critical in the era of personalized medicine. Germline polymorphisms play an important role in the treatment response of various human diseases, including bladder cancer. Intravesical BCG therapy is widely-used for bladder cancer. However, tumor recurrence and progression are very common. Stratification based on germline polymorphisms may contribute to circumvent this clinical challenge. Autophagy pathway plays an important role in the nonspecific protective effects of BCG. Patients that carry C allele of rs3759601 in autophagy gene ATG2B showed increased risk of recurrence and progression in European population. We thus sought to analyze rs3759601 and its relevance in BCG response in Asian NMIBC patients. MethodFunctional impact of rs3759601 ATG2B (p.Gln1383Glu) was analyzed by bioinformatics programs including NCBI Conserved Domain Search, Clustal Omega, Polyphen and SIFT. NMIBC patients who received intravesical BCG at multiple hospitals in Singapore from 1995 to 2016 were included. These patients were genotyped for rs3759601 using high resolution melt analysis. The rs3759601 polymorphism was studied in correlation with the bladder cancer recurrence rate and disease progression rate in our cohort. Statistical analysis was conducted using Kaplan-Meier plots and the Chi-squared analysis. ResultsIn total, 307 individules were included in the study including 161 NMIBC patients and 146 healthy controls, predominately Chinese. The rs3759601 genotype distributions in our NMIBC patients were (GG 72.1%; GC 27.9%; CC 0%), which were distinct from the Dutch report (GG 32.8%; GC 47.4% and CC 19.8%, Buffen K et al, 2014). Consistently, the C allele frequencies of rs3759601 are 0.171 in our controls and 0.177 in East Asians from 1,000 Genome, but 0.406 in Europeans from 1,000 Genome. In silico analysis suggested rs3759601 ATG2B (p.Gln1383Glu) alteration is unlikely to be functionally deleterious. Statistical analysis revealed no significant association between ATG2B rs3759601 C allele and risk of bladder cancer recurrence (P= 0.353, GC vs. GG: hazard ratio [HR]= 1.324), or cancer progression (P= 0.454, GC vs. GG: HR = 0.658). ConclusionIn contrast to European NMIBC patients, ATG2B rs3759601 C allele is much less common in Asians and it not associated with BCG response in Asian NMIBC patients.

The role of neural precursor cell-expressed developmentally down-regulated protein 9 in predicting bacillus Calmette-Guerin response in nonmuscle invasive bladder cancer

ObjectiveTo report the sensitivity and specificity of neural precursor cell-expressed developmentally down-regulated protein 9 (NEDD9) protein high expression in predicting BCG response and its effect on recurrence or progression free survivals. Patients and methodsBetween May 2014 and April 2017, a prospective cohort study was conducted on 105 patients with intermediate or high-risk nonmuscle invasive bladder cancer. Immunohistochemical staining with mouse monoclonal anti-NEDD9 antibody was done. Examination of the slides was done to detect NEDD9 cytoplasmic expression. Intravesical induction bacillus Calmette-Guerin (BCG) instillation therapy was started for all patients 2 to 4 weeks after endoscopy with once weekly instillation for 6 weeks. Intravesical maintenance BCG instillation was then continued every 3 months for at least 1 year. Follow up with cystoscopy every 3 months for 2 years and every 6 months after that. ResultsThe mean age ± SD of the patients was 57 ± 4.5 years. The median follow-up period was 25 (12–36) months. NEDD9 protein was highly expressed in 61 (58.1%) patients, whereas low expression was in 44 (41.9%) patients. Sensitivity and specificity of NEDD9 high expression in predicting recurrence were 83.6% and 64.2%, respectively. Its sensitivity and specificity in predicting progression to muscle invasion or distant metastases were 91.3% and 51.2%, respectively. Its sensitivity and specificity in predicting complete response to BCG therapy were 84.1% and 80.9%. Kaplan-Meier test showed highly significant difference (P<0.0001) in survival without recurrence or progression between patients showing high expression and those showing low expression. ConclusionNEDD9 protein tissue marker could be used as a predictive marker for BCG response in nonmuscle invasive bladder cancer with reasonable sensitivity and specificity.

Prediction of Bacillus Calmette-Guerin Response in Patients with Bladder Cancer after Transurethral Resection of Bladder Tumor by Using Genetic Variation Based on Genomic Studies.

Purpose. We aimed to comprehensively review contemporary literature on genetic and epigenetic biomarkers associated with the prediction of Bacillus Calmette-Guerin (BCG) response after the transurethral resection of a bladder tumor and to discuss the application of these biomarkers in precision cancer care for bladder cancer. Method. We performed a systematic review of published literatures in the databases PubMed and Embase by using the following key words: bladder cancer, BCG, gene, and methylation. Studies associated with cell lines, animal models, and muscle invasive bladder cancer were excluded. Results. The genetic variations associated with BCG response can be classified into three categories: germline variations, somatic variations, and epigenetic alterations. Genes related to BCG response were mainly involved in single-nucleotide polymorphisms, copy number variations, and gene methylations. Conclusions. Although these gene alterations are currently the most promising predictive markers of BCG response, most studies about bladder cancer DNA biomarkers are related to germline variations in candidate genes, and the results are not consistent. Only one study is related to somatic variation, and further evaluation in large-scale validation studies should be conducted to assess the potential clinical application of these findings. In addition, other biomarkers based on different “–omics” technologies should be considered in future studies.

The Efficacy of Intravesical Bacillus Calmette-Guerin in the Treatment of Patients with pT1 Stage Non-muscle-invasive Bladder Cancer

Background: pT1 bladder urothelial carcinomas represent a heterogeneous group of tumors with different biologic behaviors, and identifying the subset of tumors that carries a high risk of disease recurrence and progression is therefore important. Induction and maintenance intravesical Bacillus Calmette-Guerin (BCG) has been proven to reduce tumour recurrence and progression. However, no markers are available to predict BCG response. The aim of this study is to evaluate the prognostic factors of stage in predicting recurrence after intravesical adjuvant BCG immunotherapy in patients with NMIBC.Methods: we retrospectively reviewed the clinical and pathologic data of primary NMIBC from 45 patients who were treated with transurethral resection followed by BCG-immunotherapy. Time follow-up was 30 months. The prognostic significance of clinicopathologics characteristics in determining the risk for recurrence after BCG therapy was studied with both univariate and multivariate methods of analysis.Results: univariate Cox regression analysis of clinicopathologic characteristics revealed that the rate of recurrence was statistically associated with tumor stage. Indeed, a significant concordance was noted between the EORTC s predicted risks and the actuarial recurrence rate of NMIBC at one year. On the other hand, multivariate analysis using Cox regression based on the AIC criteria and biological considerations, selected the score of recurrence as independent predictor of recurrence.Conclusion: The conventional clinicopathological factors used in EORTC model are relevant for the assessment of the outcome of pT1 stage bladder tumors treated by BCG immunotherapy. Management of pT1 bladder cancer patients remains one of the most difficult problems in urologic practice. At this time the decision to preserve the bladder or to perform a cystectomy depends on a number of clinicopathologic parameters, but none are able to sufficiently identify patients for the appropriate therapeutic modality. Additional studies using a more large scale of patients will be required to confirm our findings.

818 HUMAN GENE POLYMORPHISM AND RESPONSE TO BACILLUS CALMETTE-GUERIN IMMUNOTHERAPY FOR SUPERFICIAL BLADDER CANCER

AACR Centennial Conference: Translational Cancer Medicine-- Nov 4-8, 2007; Singapore C61 Objectives: Superficial bladder cancers (SBC) have a 60-70% recurrence rate after transurethral resection, and 10-20% of recurrences progress to invasive cancer. Post-transurethral resection intravesical Bacillus Calmette-Guerin (BCG) instillation has been the ‘gold-standard’ treatment for high risk SBC, for which 20-40% of patients do not respond. There are also frequent, potentially serious side effects to BCG therapy. Although clinical and pathologic variables to predict BCG response and cancer recurrence have been extensively studied, little is known of the role of underlying host genetic susceptibility factors, such as genetic polymorphisms. The NRAMP1 gene has been implicated in susceptibility to tuberculosis and to BCG response in murine models. The Human glutathione peroxidase 1 (hGPX1) is a selenium-dependent enzyme that participates in detoxification of hydrogen peroxide, organic peroxides, and possibly cigarette smoke-derived oxidative radicals. An association between hGPX1 and NRAMP1, and bladder cancer recurrence has been suggested. We aim to determine the predictive value of NRAMP1 and hGPX1 gene polymorphisms in superficial bladder cancer recurrence and response to BCG therapy. Methods: Peripheral blood DNA was prospectively obtained from 99 high risk superficial bladder cancer patients, who underwent post-resection intravesical regimes of BCG (81mg, n=50 or 27mg, n=19) or BCG (27mg) with interferon alpha (IFNa) (n=30), and followed-up for a mean of 4.5 years. The (GT)n and D534N polymorphisms in the NRAMP1 gene, and the Pro198Leu polymorphism in the hGPX1 gene were tested with restriction fragment length polymorphisms and DNA sequencing following PCR amplification. Data was analyzed using Chi-square analysis, multiple logistic regression and Kaplan-Meier curves. Results: The D534N G:A genotype was found to be protective towards cancer recurrence (p=0.016) and cancer-specific death (p=0.036). The presence of allele 3 in the (GT)n gene polymorphism was found to correlate with higher recurrence in BCG treated patients (p=0.003), and had shorter recurrence-free survival (p=0.024) and progression-free survival (p=0.005) in patients treated with a combination of BCG and IFNa. The hGPX1 CC genotype was shown to be protective (p=0.014), while the variant CT genotype (Pro/Leu) was associated with increased bladder cancer recurrence and decreased time to recurrence (p=0.03) after BCG therapy. Conclusion: Our findings suggest that polymorpisms in the NRAMP1 and hGPX1 genes correlate with response to BCG therapy in bladder cancer patients. They may serve as molecular markers to predict BCG failure and cancer recurrence.