A Second Look at the pT1 G3 Bladder Tumour

Bladder-Preserving Trimodality Treatment for High-Grade T1 Bladder Cancer: Results From Phase II Protocol NRG Oncology/RTOG 0926

PURPOSE

To investigate the use of radiation with radiosensitizing chemotherapy following repeated transurethral resection (trimodality therapy) as an alternative to radical cystectomy in T1 bladder cancer which has failed Bacillus Calmette-Guerin (BCG).

PATIENTS AND METHODS

Patients with recurrent T1 bladders who had failed BCG and were recommended to undergo cystectomy were treated with trimodality therapy. The primary end point was 3-year freedom from cystectomy. Secondary end points were distant metastasis at 3 and 5 years, local recurrence, disease-specific and overall survival (OS), and safety.

RESULTS

This single-arm phase II study enrolled 37 patients. Efficacy and safety were evaluated in 34 patients after three exclusions. The median follow-up was 5.1 years. The 3-year freedom from cystectomy rate was 88% (lower one-sided 97.5% confidence limit [CI], 72%), meeting the primary study goal. OS at 3 and 5 years was 69% (95% CI, 54 to 85) and 56% (95% CI, 39 to 74), respectively. The distant metastasis rates at 3 and 5 years were 12% (95% CI, 4 to 26) and 19% (95% CI, 7 to 34), respectively. Eight patients died due to urothelial cancer, 12 exhibited local recurrence at 3 years (cumulative incidence: 32%; 95% CI, 17 to 48), 18 experienced grade 3 adverse events, mostly hematological, and one developed grade 4 neutropenia.

CONCLUSION

Trimodality therapy is an effective potential alternative to radical cystectomy for recurrent high-grade T1 urothelial cancer of the bladder. At 3 years, 88% of the patients remained free of cystectomy.

Radiotherapy for High-grade T1 Bladder Cancer

Radiotherapy is rarely used for T1 bladder cancer. We discuss the potential reasons for this, the current evidence, and make suggestions for future research. PATIENT SUMMARY: Despite its success in muscle-invasive disease, radiotherapy is rarely used for non-muscle-invasive bladder cancer. We discuss the current evidence and suggest that, with further research, radiotherapy holds much promise as a bladder-preserving strategy.

A Randomized Trial of Radical Radiotherapy for the Management of pT1G3 NXM0 Transitional Cell Carcinoma of the Bladder

PURPOSE

We conducted a multicenter randomized trial in the United Kingdom to determine the efficacy of radical radiotherapy in reducing the incidence of progression of pT1G3 transitional cell carcinoma of the bladder to muscle invasive disease and subsequent disease fatality.

MATERIALS AND METHODS

Patients with a new diagnosis of pT1G3 NXM0 transitional cell carcinoma with unifocal disease and no carcinoma in situ (group 1), or with multifocal disease and/or carcinoma in situ (group 2) were eligible for the trial. Patients in group 1 were randomized between observation and radiotherapy to the bladder, and in group 2 between intravesical therapy and radiotherapy.

RESULTS

From September 1991 to February 2003 a total of 210 patients from 37 centers in the United Kingdom were entered into the study. There were 77 patients in group 1 and 133 patients in group 2, and 6 patients were excluded from analysis because they were found to have pT2 disease by the reference pathologist. No evidence of an advantage with radiotherapy was found in terms of progression-free interval (hazard ratio 1.07; 95% CI 0.65, 1.74; p = 0.785), progression-free survival (hazard ratio 1.35; 95% CI 0.92, 1.98; p = 0.133) or overall survival (hazard ratio 1.32; 95% CI 0.86, 2.04; p = 0.193).

CONCLUSIONS

To our knowledge this is the largest randomized trial performed in patients with pT1G3 disease for which 210 patients were recruited during 11 years. There is no evidence that radiotherapy is better than more conservative treatment. The prognosis of this group of patients appears to be poor irrespective of treatment and new treatment strategies need to be investigated.

Case report: differential diagnosis of isolated iliac lymphadenopathy following Bacillus Calmette-Guérin treatment for high-risk superficial bladder cancer

We report the unusual case of a patient with G3 pT1 transitional cell carcinoma (TCC) of the bladder, which was treated with repeated transurethral resection and maintenance intravesical Bacillus Calmette-Guérin (BCG) therapy. At 30 months follow-up, a symptomatic, solitary iliac lymph node mass was identified and biopsied. Histology demonstrated granulomatous tissue only, in the absence of any intravesical bladder tumour recurrence. Following 6 months of anti-tuberculous medication, the mass had progressed, and repeat biopsy revealed undifferentiated carcinoma (of a bladder primary). This is a rare case of metastatic superficial bladder cancer progression without local recurrence after BCG therapy. As such, it can be viewed as a diagnostic challenge.

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.