Intravesical bacille Calmette-Guérin in Stage T1 grade 3 bladder cancer therapy: a 7-year follow-up

Significance of inflammatory pseudotumors in patients with a history of bladder cancer

OBJECTIVE

To study the significance of inflammatory pseudotumor (IPT) in patients with a history of bladder cancer.

METHODS

We surveyed our hospital database for patients who developed IPT during follow-up of bladder cancer. The original histologic blocks were reviewed and immunostained for vimentin, anaplastic large cell lymphoma (ALK), and pancytokeratin.

RESULTS

Between the years 1988 and 2005, a total of 809 patients were registered in the database, and 16 patients (2%) developed IPT during follow-up. All patients had initial high-grade tumor. Immunostaining for vimentin was positive in all patients, ALK was negative in all patients, and pancytokeratin positive in only 2 patients. During follow-up, 12 patients (75%) developed tumor recurrence, 9 patients (56%) tumor progression, and 6 patients (37.5%) died of bladder cancer. Median period from the finding of IPT to tumor recurrence was 16 months, to progression 7 months, and to mortality 26 months.

CONCLUSIONS

The finding of IPT in a patient with a history of bladder cancer is associated with a high risk of tumor recurrence, progression, and cancer-related mortality. Second- and possibly third-look bladder biopsies should be considered. The unique characteristics of IPT in patients with a history of bladder cancer suggest that this is a separate disease entity.

Long-Term Follow-up of Patients with Stage T1 High-Grade Transitional Cell Carcinoma Managed by Bacille Calmette-Guérin Immunotherapy

OBJECTIVES

To report the long-term outcome of patients with Stage T1 high-grade transitional cell carcinoma of the bladder treated initially by transurethral resection and adjuvant intravesical bacille Calmette-Guérin.

METHODS

From June 1984 to November 1995, 78 consecutive patients with Stage T1 high-grade bladder cancer underwent transurethral resection and adjuvant intravesical bacille Calmette-Guérin therapy. The results at the interim follow-up (median 56 months) were reported in 1998. The median duration of follow-up for the present study was 107 months (range 16 to 238). The endpoints were tumor recurrence (Stage Ta, T1, or Tis), tumor progression (to T2 or greater), and disease-specific survival.

RESULTS

Of the 78 patients, 34 (44%) were alive for the present analysis and 44 (56%) had died, 12 (16%) of transitional cell carcinoma and 32 (72%) of other causes. Recurrence was documented in 27 patients (35%) at a median of 8.5 months (range 5 to 129) after treatment, and progression in 14 patients (18%) at a median of 31.4 months (range 5 to 88) after treatment. The 2, 5, and 10-year recurrence-free survival and progression-free survival rates were 76%, 72%, and 62% and 92%, 82%, and 80%, respectively. The corresponding disease-free survival rates were 99%, 90%, and 85%. Disease progression occurred in 10 (37%) of 27 patients with recurrence, of whom 9 died. Of the 14 patients with disease progression, 12 died of their disease.

CONCLUSIONS

Bacille Calmette-Guérin is an effective conservative treatment for patients with Stage T1 high-grade bladder cancer. More than one half the recurrences appeared within the first year, but a small risk remains throughout the patient's life. Progression during follow-up appears to carry a high risk of cancer-specific death.

Management of stage T1 tumors of the bladder: International Consensus Panel

The International Consensus Panel on T1 bladder tumors markers reviewed the subject from a clinical perspective. From diagnosis to treatment decisions, what are the important issues in the management of a new patient? The assessment of prognostic factors for progression requires optimal resection and documentation. The role of immediate adjuvant intravesical chemotherapy after resection remains controversial. How often should the upper tract be assessed for tumor recurrence? The decision on whether to attempt bladder conservation with intravesical therapy or to perform a cystectomy is the most difficult issue in the management of superficial bladder cancer today. Finally, what therapies exist if initial intravesical bacille Calmette-Guérin fails to eradicate the disease or prevent recurrence? The panel thoroughly explored all these subjects and has made recommendations with supporting evidence.

Reactive arthritis following BCG immunotherapy for urinary bladder carcinoma: a systematic review

Intravesical instillation of Bacillus Calmette-Guerin (BCG) is used with efficacy and safety in the treatment of patients with intermediate and high-risk superficial bladder carcinoma. Arthralgia and/or arthritis is one of the rare severe complications following intravesical BCG immunotherapy. We searched MEDLINE in order to analyze the frequency of this clinical complication, its pathogenesis and outcome. The electronic search was conducted using the following key words: "BCG immunotherapy" and "Arthritis, arthralgias and BCG immunotherapy". At the end of a process of abstract analysis, 48 papers were included in the systematic review. All the selected papers, except one that was a clinical review, described at least one case of arthritis after BCG therapy. The BCG immunotherapy resulted to be safe and efficacious in the treatment of bladder cancer; the development of reactive arthritis is rare and can evolve in a chronic process. The review of the literature highlighted that reactive arthritis following BCG intravesical instillation is a complication usually well controlled with the discontinuation of the immunotherapy and nonsteroidal anti-inflammatory drugs (NSAIDs) treatment. Only a small portion of patients with a particular genetic background will develop a chronic process.

A Second Look at the pT1 G3 Bladder Tumour

People with pT1 G3 bladder cancer are at high risk of tumour progression and death. Induction and maintenance intravesical Bacillus Calmette-Guerin (BCG) has been proven to reduce tumour progression in superficial bladder cancer at moderate risk of progression. By extrapolation, this treatment is often now given for pT1 G3 bladder cancer. Phase II studies published over the past 10 years on the use of adjuvant intravesical BCG following transurethral resection (TUR) of the tumour(s) suggest an important effect on the number of patients progressing. The data are mixed, however. A randomised study of the use of adjuvant radiotherapy in pT1 G3 bladder cancer has shown that it is not of benefit and that, overall, the progression rate remains high. Early cystectomy for high-risk cases is not commonly used, and its results are often disappointing, presumably a consequence of negative selection. Identification of patients at extra high risk of progression is desirable. Tumour size, the co-existence of carcinoma in situ and early tumour recurrence may be prognostic indicators, but the data are at present insufficient.

HAS A 3-FOLD DECREASED DOSE OF BACILLUS CALMETTE-GUERIN THE SAME EFFICACY AGAINST RECURRENCES AND PROGRESSION OF T1G3 AND TIS BLADDER TUMORS THAN THE STANDARD DOSE? RESULTS OF A PROSPECTIVE RANDOMIZED TRIAL

PURPOSE

We determined if a third of the dose of intravesical bacillus Calmette-Guerin (BCG) has the same efficacy than a standard dose for decreasing the risk of recurrence and progression after transurethral resection in patients with superficial high risk (stages T1G3 and carcinoma in situ) bladder cancer. Also, we evaluated toxic side effects.

MATERIAL AND METHODS

A total of 155 patients with a mean age +/- SD of 67 +/- 10.1 years with superficial bladder cancer, including stages T1G3 in 90, a Tis primary tumor in 23 and associated Tis disease in 42, were enrolled and randomly assigned to be treated after transurethral resection of all visible lesions with intravesical BCG, Connaught strain (weekly x 6 and fortnightly x 6 thereafter) with the standard dose of 81 mg or with the decreased dose of 27 mg.

RESULTS

Median followup was 61 months (range 3 to 102). Disease recurred in 32 patients (39%) treated with the standard dose and in 33 (45%) treated with the decreased dose. Median time to recurrence was not attained in the standard dose arm and it was 63 months in the decreased dose arm. Kaplan-Meier estimates for time to recurrence did not reveal differences between the 2 doses (p = 0.405). Tumor progressed in 20 patients (24.7%) with the standard dose and in 19 (26%) with the decreased dose. Four patients (6.1%) with Tis had local extension into the prostatic urethra and ducts, including 3 (8.3%) treated with the standard dose and 1 (3.4%) treated with the decreased dose. Median time to progression was not attained in either arm. Kaplan-Meier estimates for time to progression did not differ significantly (p = 0.7997). Deferred cystectomy for progression was performed in 7 patients (8.4%) treated with the standard dose and in 7 (9.5%) of those treated with the decreased dose. Subgroup analysis by patient age, tumor status, number, size and T stage (T1G3 vs Tis) did not differ significantly. The groups did not differ in disease specific mortality, which was 12.2% in the standard dose arm and 16.4% in the decreased dose arm. Mean disease specific survival +/- SE was 86.96 +/- 4.14 and 83.73 +/- 4.73 months, respectively.

CONCLUSIONS

Our results suggest that a 3-fold decreased dose of intravesical BCG is as effective as the standard dose against progression in patients with high risk stages T1G3 and Tis superficial bladder carcinoma but with significantly less toxicity.

Optimal Management of the T1G3 Bladder Cancer

TIG3 transitional cell carcinoma of the bladder represents a highly malignant tumor with a variable and unpredictable biologic potential. The most critical aspect of management requires a detailed discussion with the patient regarding the treatment options. Both the physician and the patient should be willing to reconsider the treatment options as the disease continues to evolve. In most cases initial management involves complete resection of the tumor, accurate staging of the disease, and intravesical immunotherapy or chemotherapy. Rigorous surveillance with long-term follow-up is crucial for managing these cases. In selected cases with adverse prognostic factors immediate cystectomy should be considered. The choice and timing of the decision to abandon bladder preservation and proceed with cystectomy should be continuously reconsidered on an individual patient basis, in concordance with the evolution of the disease (Fig. 1). The goal is to spare the bladder when possible but not at the risk of death from metastatic disease. Radical cystectomy in high-grade stage T1 transitional cell carcinoma offers excellent results in regard to the prevention of recurrence and progression and survival. Improvements in urinary diversion and nerve-sparing techniques have decreased the magnitude of social implications related to cystectomy in most patients regardless of gender. The discovery of reliable markers may contribute to better selection of patients for bladder sparing. Until then, the optimal treatment for the T1G3 tumor remains controversial.

Reactive arthritis following BCG immunotherapy for bladder carcinoma

Intravesical instillation of bacillus Calmette-Guérin (BCG) is used in the treatment of patients with intermediate and high-risk superficial bladder carcinoma with efficacy and safety. The vast majority of patients do not present any side effects and only 5% of patients have mild and short-lived clinical manifestations such as malaise, low-grade fever, cystitis, and hematuria. Arthralgia and/or arthritis is one of the rare severe complications following intravesical BCG immunotherapy. We report here the case of a patient with reactive arthritis successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs) after the discontinuation of BCG immunotherapy.

TUR and Adjuvant Intravesical Chemotherapy in T1G3 Bladder Tumors: Recurrence, Progression and Survival in 137 Selected Patients Followed Up to 20 Years

OBJECTIVES

To evaluate a highly selected population of patients affected by T1G3 bladder transitional cell carcinoma (TCCB) treated by transurethral resection (TUR) and adjuvant intravesical chemotherapy.

MATERIALS AND METHODS

Between January 1976 and April 1999, 137 patients with T1G3 TCCB were treated by TUR plus intravesical chemotherapy. Particularly, a sequential combination of mitomycin C (MMC) and epirubicin (EPI) was adopted in 91 patients (66.4%). The main exclusion criteria were concomitant or previous Tis, previous T1G3 TCCB, tumor size greater than 3 centimeters and number of tumors more than 3. TUR was repeated if a superficial tumor recurred. Patients went off study if Tis, recurrent T1G3 or invasive tumor were detected during treatment or thereafter. Adjuvant therapy, recurrence and progression were considered in multivariate analysis regarding recurrence, progression and survival respectively.

RESULTS

Observation period was up to 240 months with a minimum of 2 years in 112 patients (82%). Seventy patients (51%) recurred. The recurring tumor was again a T1G3 in 22 (16%) patients. Thirteen patients (9.5%) progressed. The 5-year progression-free survival rate was 90%. Median progression-free survival was 149 months. Twenty-two patients (16%) died, 9 (6.6%) of whom due to bladder cancer. Median overall survival was 155 months. The 3- and 5-year disease-free overall survival rates were 89% and 80% respectively. Ten cystectomies (7.3%) were performed. In conclusion, 123 patients (90%) maintained their intact bladder with a mean disease-free overall survival of 104 months. The sequential combination of MMC and EPI adjuvant therapy resulted more effective to be than single drug chemotherapy on recurrence rate (p=0.0021) but had no impact upon progression (p=0.127) and specific survival (p=0.163). Progression (p<0.001) after conservative treatment was the main prognostic factor for survival.

CONCLUSION

A conservative approach is an appropriate therapeutic option for the initial management of selected T1G3 bladder tumors.

T1G3 transitional cell carcinoma of the bladder: recurrence, progression and survival

OBJECTIVES

To report our experience with T1G3 bladder tumours over the last 10 years.

PATIENTS AND METHODS

We analysed the outcome of 74 consecutive patients treated for a T1G3 bladder cancer between 1991 and 2001. Fifty-seven patients (77%) were treated with transurethral resection (TUR) plus six weekly instillations of bacillus Calmette-Guérin (BCG) therapy. Ten patients (13.5%) with contraindications to BCG or with a small T1a tumour were treated with TUR plus mitomycin-C, and seven (9.5%) were treated with TUR alone because of their age. Patients treated with BCG had systematic biopsies taken at the end of the first course. Patients with residual tumour received a second course of six weekly instillations. Patients with negative biopsies received maintenance BCG therapy consisting of intravesical instillations each week for 3 weeks given 3, 6, 12, 18, 24, 30 and 36 months after the first course.

RESULTS

The median follow-up was 53 months. The overall recurrence rate was 46% and the overall progression rate 19%. The rate of delayed cystectomy was 8% and that of disease-specific survival 91%. In patients who received BCG therapy, the recurrence and progression rates were 42% and 23%, respectively. In this group the rate of disease-specific survival was 88%.

CONCLUSION

This study confirms that maintenance BCG therapy is an effective treatment for T1G3 bladder tumours, with an acceptable rate of bladder preservation.

Initial Tumor Stage and Grade as a Predictive Factor for Recurrence in Patients With Stage T1 Grade 3 Bladder Cancer

PURPOSE

We evaluated whether the risk of progression and the recurrence rate were different in patients with primary and nonprimary stage T1 grade 3 transitional cell carcinoma of the bladder.

MATERIALS AND METHODS

Between 1983 and 1997, 75 patients were treated for stage T1 grade 3 transitional cell carcinoma of the bladder. Of these patients 68 (primary and nonprimary tumor in 58 and 14, respectively) without carcinoma in situ who had not undergone complete cystectomy immediately after diagnosis were included in the study. No maintenance regimen was used. Median followup was 100 months (range 9 to 217).

RESULTS

The incidence of multiple tumors in patients with nonprimary tumors was significantly higher than in patients with primary disease (p = 0.035). However, the recurrence-free survival rate in patients with primary T1 GIII bladder tumor was significantly lower than that of patients with nonprimary T1 GIII bladder tumor (p = 0.0016). Multivariate analysis using Cox's proportional hazard regression model revealed that only initial tumor status had statistically significant effects on tumor recurrence (p = 0.007) and no other factors had a significant influence on recurrence-free survival. Progression-free and cancer specific survival rates were also significantly different between the 2 groups (p = 0.036 and 0.0307, respectively).

CONCLUSIONS

Our study indicates that patients with primary stage T1 grade 3 bladder cancers have higher recurrence and progression potential than those with nonprimary disease despite the higher incidence of multiple tumors in patients with nonprimary tumors.

Intravesical bacillus Calmette-Guerin therapy for stage T1 grade 3 transitional cell carcinoma of the bladder: recurrence, progression and survival in a study of 57 patients

PURPOSE

Stage T1 grade 3 transitional cell carcinoma of the bladder is associated with a high risk of tumor recurrence and progression. We report our experience with stage T1 grade 3 bladder tumors treated with bacillus Calmette-Guerin (BCG) therapy in the last 10 years.

MATERIALS AND METHODS

We analyzed the outcome in 57 consecutive patients treated with intravesical BCG for stage T1 grade 3 bladder cancer between 1991 and 2001. After initial transurethral resection all patients received a 6-week course of BCG therapy consisting of 1 instillation weekly. All patients underwent systematic biopsies at the end of the first BCG course. Patients with negative biopsies received maintenance BCG therapy, consisting of intravesical instillations each week for 3 weeks given 3, 6, 12, 18, 24, 30 and 36 months after the first course. Patients with residual tumor received a second course of 6 weekly instillations. Time to tumor recurrence and progression, and the rate of patient survival were retrospectively analyzed.

RESULTS

Median followup was 53 months (range 9 to 110). Minimum followup was 2 years in 36 cases (63.2%) and 5 years in 28 (49.1%). After the first BCG course 50 patients (87.7%) had no residual disease, while 7 (12.3%) had residual tumor. The recurrence and progression rates were 42.1% and 22.8%, respectively. The rate of delayed cystectomy was 14%. The rate of disease specific survival was 87.7%.

CONCLUSIONS

Our study confirms that BCG therapy is effective conservative treatment for patients with stage T1 grade 3 bladder tumors.

Lymphocytic infiltration of bladder after local cellular immunotherapy

BACKGROUND

This is a case report of a patient who received cellular immunotherapy, in the form of local injections of autologous stimulated lymphocytes (ASL) into individual tumors in the urinary bladder. A major consideration in cellular immunotherapy being the ability of immune cells to reach all target areas, we hypothesized that direct delivery of effector cells into individual bladder tumors might assure such access.

METHODS

ASL were generated by exposing the patient's PBL to phytohemagglutinin and culturing them in the presence of IL-2 to expand the population. ASL were injected into the base of individual bladder tumors three times at intervals of 3 weeks.

RESULTS

The patient died of a myocardial infarct, unrelated to cell therapy, 20 days after the third injection. An autopsy was performed. Histological sections of the bladder showed extensive lymphocytic infiltration of virtually the entire organ.

DISCUSSION

No conclusions about the therapeutic efficacy of local immunotherapy using ASL are possible. Nevertheless, the observations reported, taken together with reports of therapeutic efficacy of other immunotherapy regimens in the management of bladder cancer, suggest that ready access of stimulated lymphocytes to all regions of the organ may account, in part, for the relatively high rate of therapeutic success reported for various immunotherapy regimens for this malignancy.

Clinical outcome of conservative therapy for stage T1, grade 3 transitional cell carcinoma of the bladder

BACKGROUND

The objective of this study was to retrospectively investigate the effectiveness of transurethral resection of bladder tumor (TURBT) and intravesical instillation therapy for stage T1, grade 3 (T1G3) transitional cell carcinoma (TCC) of the urinary bladder.

METHODS

Between January 1995 and December 1997, 97 patients with T1G3 TCC of the urinary bladder were treated by TURBT and adjuvant intravesical instillation with bacillus Calmette-Guérin (BCG) or other anticancer agents. The recurrence-free survival rates were evaluated according to several clinicopathological factors. The cases that progressed to muscle invasive disease were also analysed.

RESULTS

In this series, the median follow-up period was 25 months (range, 5- 41) after the initial TURBT. Intravesical recurrence was noted in 44 patients (45%), and the 1, 2, and 3 year recurrence-free survival rates were 72%, 58%, and 42%, respectively. Multivariate analyses revealed that the risk of intravesical recurrence was significantly higher for patients who did not receive BCG therapy, irrespective of age, gender, tumor size, multiplicity, pathological stage, concomitant carcinoma in situ, and lymphovascular involvement. Moreover, after a median of 10 months, disease progression occurred in seven patients (7%), of which only one patient was treated by BCG therapy after initial TURBT.

CONCLUSION

These findings suggest that intravesical instillation with BCG combined with TURBT is an effective conservative treatment for T1G3 TCC of the bladder. Patients with negative prognostic factors should be treated by BCG rather than other anticancer agents after TURBT.

A retrospective analysis of 153 patients treated with or without intravesical bacillus Calmette-Guerin for primary stage T1 grade 3 bladder cancer: recurrence, progression and survival

PURPOSE

We retrospectively evaluated the long-term outcome in patients with newly diagnosed stage T1 grade 3 bladder cancer treated with transurethral resection with or without intravesical bacillus Calmette-Guerin (BCG).

MATERIALS AND METHODS

Of 153 patients with a median age of 67 years (range 36 to 88) and a male-to-female ratio of 4:1 we treated 92 with transurethral bladder resection and additional BCG, and 61 with transurethral bladder resection alone. BCG was administered intravesically as 120 mg. BCG Pasteur F dissolved in 50 ml. saline, retained for up to 2 hours weekly for 6 weeks and repeated as necessary.

RESULTS

Median followup was 5.3 years (range 0.4 to 18.2). Disease recurred in 70% of the patients treated with BCG and in 75% treated with transurethral resection alone. Median time to recurrence was 38 and 22 months for BCG and resection alone (p = 0.19). Tumor progressed in 33% of patients with BCG and in 36% with resection alone. Deferred cystectomy was performed in 29% of the patients with BCG and in 31% with resection alone. Overall and disease specific survival did not differ significantly.

CONCLUSIONS

Our results suggest that intravesical BCG therapy after transurethral bladder resection for stage T1 grade 3 bladder cancer may delay the time to recurrence and cystectomy but it does not substantially alter the final outcome. Our findings reflect the rule of 30% for stage T1 grade 3 cancer, namely approximately 30% of patients never have recurrence, 30% ultimately die of metastatic disease and 30% require deferred cystectomy.

Prognostic value of cystocopically pseudotumoral lesions (inflammation/granuloma) in primary stage T1 grade 3 bladder tumors treated with BCG

OBJECTIVE

The aim of this study is to find out whether the pseudotumoral lesions (inflammation/granuloma) seen at the follow-up cystoscopy performed three to six months after transurethral resection of primary stage T1 grade 3 bladder tumor and instillations of BCG therapy might have some prognostic value as far as recurrence and/or long term progression are concerned.

MATERIAL AND METHODS

From the first group of one hundred and thirteen patients with primary stage of T1 grade 3 bladder tumor treated with 81 mg of BCG Connaught (weekly/during six weeks), those with recurrent tumor at the 3rd and 6th month were excluded, so we evaluated 99 patients. We identified 13 patients with cystoscopically pseudotumoral lesions.

RESULTS

of the 13 cystoscopically pseudotumoral lesions, we observed recurrence in two cases (15%), while among the rest of the 86 patients, we observed 22 recurrences (26%) (p = 0.9; not significant). Concerning progression, eight cases were reported out of 86 patients (9%) within the cistocopically normal group. No cases of progression were reported among the 13 patients with cystoscopically pseudotumoral lesions. This difference was not statistically significant (p = 0.5).

CONCLUSIONS

The patients with cystoscopically pseudotumoral lesions (inflammation/granuloma) are a reduced group (13%) with less tendency to recurrence and without progression, even though this relationship is not significant.

Intravesical Bacillus Calmette-Guerin treatment improves patient survival in T1G3 bladder tumours

OBJECTIVE

To study the clinical and pathological factors that affect recurrence, progression and survival in pT1G3 bladder tumours treated conservatively.

MATERIAL AND METHODS

From January 1979 to December 1996, 80 patients were conservatively treated for pT1G3 bladder tumours. All patients were studied for potential prognostic factors such as: age, sex, previous tumour recurrence, tumour size, multiple tumours, carcinoma in situ, and intravesical instillations. A longitudinal, retrospective, observational and analytical study was conducted to evaluate four different types of events: recurrence, progression, overall survival, and disease-specific survival. The chi(2) (Fischer exact test) and student t tests were used to assess the prognostic value of the qualitative and quantitative variables. Estimations of the survival distributions were calculated according to the Kaplan-Meier method and compared with the Log rank test. Multivariate analysis of the data was performed with Cox proportional hazard models.

RESULTS

Among the 80 patients, 67 (84%) were men and 13 (16%) were women, with median age of 65.5 years. The median tumour size was 20 mm, most had single tumour (58.8%) and carcinoma in situ was found in six patients (7.5%). Thirty patients were treated with transurethral resection (TUR) of the bladder tumour and 50 patients were treated with TUR followed by BCG. The two groups of patients were comparable and followed up during a median time of 61 and 65 months, respectively (p=0.454). Kaplan-Meier estimators and Log rank tests demonstrated that patients with TUR alone recurred (p<0.0001), progressed (p<0.040) and died (overall survival: p<0.009; disease-specific p<0.040) earlier than patients who received intravesical instillations of BCG. The results were confirmed with Cox models and odds-ratios are presented.

CONCLUSION

In this study, BCG adjuvant immunotherapy was the only factor affecting recurrence, progression and survival. Conservative treatment using TUR followed by BCG may improve disease-specific survival.

Long-term follow-up of G3T1 transitional cell carcinoma of the bladder treated with intravesical bacille Calmette-Guérin: 18-year experience

OBJECTIVES

Immunotherapy with bacille Calmette-Guérin (BCG) has been proposed in the past decade as first-line treatment for high-grade superficial bladder cancer (G3T1). We report our 18-year experience in the treatment of patients with G3T1 bladder cancer.

METHODS

From January 1989 to July 1997, 670 patients underwent transurethral resection for superficial bladder cancer. Eighty-one patients (12%) had G3T1 tumors. All of these patients were treated with an innovative schedule of Pasteur strain BCG followed by maintenance BCG therapy. Treatment consisted of four cycles of 6 instillations per cycle of BCG. The first cycle was administered weekly x 6, the second was given every 2 weeks x 6, the third cycle was given monthly x 6, and the fourth was given every 3 months x 6 instillations.

RESULTS

Sixty-nine patients (84%) completed at least the first two cycles. At a median follow-up of 76 months (range 30 to 197), the overall recurrence rate was 33% (27 of 81). The median time to recurrence was 20 months (range 5 to 128). Of these patients, 12 (15%) had progression at a median follow-up of 16 months (range 8 to 58). Cystectomy was required in 7 patients (8%). Death from disease occurred in 5 (6%) of 81 patients. One patient died of adenocarcinoma at the ureterosigmoidostomy site. Sixty patients (74%) were alive at a median follow-up of 79+ months (range 15 to 182). Of these, 56 (69%) were alive with a functioning bladder.

CONCLUSIONS

Conservative treatment with BCG is a reasonable approach for patients with primary G3T1 transitional cell carcinoma of the bladder. The long-term results of BCG therapy are good. Cystectomy may not be justified as the therapy of choice in first-line treatment of high-grade superficial carcinoma of the bladder.

Tumor progression and survival in patients with T1G3 bladder tumors: multicentric retrospective study comparing 94 patients treated during 17 years

OBJECTIVES

To compare tumor recurrence, progression, and patient survival in T1G3 bladder tumors treated with transurethral resection (TUR) alone, early cystectomy, or TUR with an adjuvant 6-week course of bacille Calmette-Guérin (BCG) and followed up for a minimum of 5 years.

METHODS

Between 1979 and 1996, 94 patients with T1G3 bladder tumors (lamina propria invasion) were treated at nine different centers. The time to tumor recurrence, tumor stage and grade progression, number of delayed cystectomies, and patient survival were analyzed retrospectively in relation to the initial treatment.

RESULTS

The mean follow-up was 62 months. Thirty patients were treated by TUR alone (32%), 50 patients by TUR plus BCG (53%), and 14 patients by primary cystectomy (15%). The recurrence, progression, and cystectomy rates were significantly different between patients treated by TUR alone and TUR plus BCG (Fisher's exact test, P = 0.0005, P = 0.02, and P = 0.005, respectively). The disease-free survival was also significantly different when comparing TUR plus BCG with TUR alone or primary cystectomy (Kaplan-Meier analysis, log-rank test, P = 0.02).

CONCLUSIONS

Endoscopic resection plus BCG treatment of pT1G3 tumors allows an 80% rate of disease-free 5-year survival with bladder preservation. This conservative option has been widely accepted as first-line treatment, offering good cancer control with excellent quality of life. Very accurate surgical and pathologic evaluations before treatment and lifelong follow-up are obviously required.

[Preliminary results of the treatment of high grade (T1G3) superficial tumors of the bladder with transurethral resection]

OBJECTIVE

To examine the results of monotherapy with TUR in the treatment of primary T1G3 transitional cell carcinoma (TCC).

METHODOLOGY

Thirty-two patients with primary TCC of the bladder were allocated into a surveillance program. Risk factors for progression to muscle-invasive disease were determined. Immediately, projections of disease-free and progression-free survival were calculated.

RESULTS

Five patients (15.6%) were lost in follow-up. Twenty-three (85%) had superficial recurrences. Four patients (14.8%) progressed to muscle-invasive or metastatic disease. No independent risk-factors for progression were disclosed. Median disease-free survival was 8 months. Projection of the risk of recurrence at 79 months was 84.9%. Median time to progression has not been reached yet. Projection of progression at 79 months was 46.3%.

CONCLUSIONS

The above mentioned treatment schedule is associated with very high recurrence rates. In addition, recurrences are very frequent. Nevertheless, in the medium run, projections of progression suggest that surveillance can be an alternative to other treatments in the management of T1G3 TCC of the bladder.