Watchful waiting versus intravesical BCG therapy for high-grade pT1 bladder cancer with pT0 histology after second transurethral resection: Japan Clinical Oncology Group Study JCOG1019

Photodynamic diagnosis-assisted transurethral resection of bladder tumor for high-risk non-muscle invasive bladder cancer improves intravesical recurrence-free survival (BRIGHT study)

OBJECTIVES

In a primary analysis of data from the BRIGHT study (UMIN000035712), photodynamic diagnosis-assisted transurethral resection of bladder tumor (PDD-TURBT) using oral 5-aminolevulinic acid hydrochloride reduced residual tumors in high-risk non-muscle invasive bladder cancer (NMIBC). We aimed to evaluate the effectiveness of PDD-TURBT for intravesical recurrence after a second transurethral resection for high-risk NMIBC.

METHODS

High-risk NMIBC patients initially treated with PDD-TURBT (PDD group) were prospectively registered between 2018 and 2020. High-risk patients with NMIBC who were initially treated with white-light TURBT (WL group) were retrospectively registered. Intravesical recurrence-free survival after the second transurethral resection was compared between the PDD and WL groups using propensity score matching analysis.

RESULTS

In total, 177 patients were enrolled in the PDD group, and 306 patients were registered in the WL group. After propensity score matching (146 cases in each group), intravesical recurrence within 1 year was significantly less frequent in the PDD group than in the WL group (p = 0.004; hazard ratio [HR] 0.44, 95% confidence interval [CI]: 0.25-0.77). In subgroup analysis, PDD-TURBT showed a particularly high efficacy in reducing intravesical recurrence within 1 year, especially in cases of tumors measuring less than 3 cm (p = 0.003; HR 0.31, 95% CI: 0.14-0.67), absence of residual tumor at second transurethral resection (p = 0.020; HR 0.37, 95% CI: 0.16-0.86), and no postoperative intravesical Bacillus Calmette-Guérin therapy (p < 0.001; HR 0.27, 95% CI: 0.13-0.58).

CONCLUSIONS

PDD-TURBT may reduce short-term intravesical recurrence in patients with high-risk NMIBC.

Bladder cancer prospective cohort study on high-risk non-muscle invasive bladder cancer after photodynamic diagnosis-assisted transurethral resection of the bladder tumor (BRIGHT study)

Objectives

Transurethral resection of bladder tumor with photodynamic diagnosis has been reported to result in lower residual tumor and intravesical recurrence rates in non‐muscle invasive bladder cancer. We aimed to evaluate the usefulness of photodynamic diagnosis‐transurethral resection of bladder tumor combined with oral 5‐aminolevulinic acid hydrochloride for high‐risk non‐muscle invasive bladder cancer.

Methods

High‐risk non‐muscle invasive bladder cancer patients with an initial photodynamic diagnosis‐transurethral resection of bladder tumor (photodynamic diagnosis group) were prospectively registered between 2018 to 2020. High‐risk non‐muscle invasive bladder cancer cases with a history of initial white‐light transurethral resection of bladder tumor (white‐light group) were retrospectively registered. Propensity score‐matching analysis was used to compare residual tumor rates, and factors that could predict residual tumors at the first transurethral resection of bladder tumor were evaluated.

Results

Analyses were conducted with 177 and 306 cases in the photodynamic diagnosis and white‐light groups, respectively. The residual tumor rates in the photodynamic diagnosis and white‐light groups were 25.7% and 47.3%, respectively. Factor analysis for predicting residual tumors in the photodynamic diagnosis group showed that the residual tumor rate was significantly higher in cases with a current/past smoking history, multiple tumors, and pT1/pTis. When each factor was set as a risk level of 1, cases with a total risk score ≤1 showed a significantly lower residual tumor rate than cases with a total risk score ≥2 (8.3% vs 33.3%, odds ratio 5.46 [1.81–22.28]).

Conclusions

In high‐risk non‐muscle invasive bladder cancer cases, the odds of a residual tumor after initial photodynamic diagnosis‐transurethral resection of bladder tumor were 0.39‐fold that of the odds of those after initial white‐light transurethral resection of bladder tumor. A risk stratification model could be used to omit the second transurethral resection of bladder tumor in 27% of the cases.

Practice pattern of non-muscle invasive bladder cancer in Japan, Korea and Taiwan: A Web-based survey

OBJECTIVES

To investigate the treatment pattern of non-muscle invasive bladder cancer patients among urologists in Japan, Korea and Taiwan, with emphasis on compliance with important treatment guidelines.

METHODS

A Web-based questionnaire survey was conceived by representative members of each country's urological oncology society and was open from June 2016 to February 2017 to each society's members. Descriptive statistics and multinomial logistic regression analysis were used.

RESULTS

A total of 2334 urologists were invited and 701 responded to the survey with a response rate of 30.0%. Instruments used during transurethral resection of bladder cancer varied significantly between countries and depended on their availability. The re-transurethral resection rate for pT1 or high-grade disease >50% of the time was significantly higher in Japan than in the other two countries, but the collective rate was just 49%. The frequency of intravesical therapy in intermediate- to high-risk disease was generally consistent across countries. However, the choice of agent between chemotherapy and bacillus Calmette-Guérin was significantly different between countries. Maintenance bacillus Calmette-Guérin was used <10% of the time by 45% of respondents, the most important reasons being fear of side-effects, followed by a lack of efficacy and shortage of drug supply.

CONCLUSIONS

There are significant differences between Japan, Korea and Taiwan in the management of intermediate- to high-risk non-muscle invasive bladder cancer. The results of this survey can serve as the basis for joint efforts to develop common clinical guidelines.

Intravesical bacillus Calmette-Guerin therapy after second transurethral resection for primary T1 bladder cancer

BACKGROUND

To evaluate the effect of intravesical bacillus Calmette-Guerin (BCG) instillation therapy after second transurethral resection (TUR) on primary T1 bladder cancer.

METHODS

The subjects were 180 patients diagnosed with T1 bladder cancer at our university and at affiliated hospitals between January 1990 and December 2015. Tumor residual rate, intravesical recurrence rate, and risk factors for intravesical recurrence were investigated.

RESULTS

The median follow-up period was 26 (1-175) months. Of the 180 patients, 78 (43%) underwent a second TUR. Residual tumors were detected in 42 patients (53.8%), and no up-staging cases were observed. Within the whole group, 42 patients were treated with intravesical BCG therapy following a second TUR (group 1), 36 were treated with second TUR alone (group 2), 28 were treated with intravesical BCG therapy alone (group 3), and 74 were treated without second TUR or intravesical BCG therapy (group 4). The 1- and 5-year recurrence-free survival rates of the four groups were 80.7 and 59.7% (group 1), 69.0 and 26.3% (group 2), 76.3 and 56.6% (group 3), 64.6 and 48.6% (group 4), respectively. There was no significant difference between group 1 and group 3 (p = 0.401). Intravesical BCG therapy was the only factor preventing intravesical recurrence (p = 0.013).

CONCLUSIONS

Intravesical BCG therapy alone showed a significant preventive effect with regard to intravesical recurrence. In our cohort, however, second TUR did not improve recurrence-free survival in those individuals who underwent BCG instillation.

How do we manage high-grade T1 bladder cancer? Conservative or aggressive therapy?

High-grade T1 bladder cancer has a poor prognosis due to a higher incidence of recurrence and progression than other nonmuscle invasive bladder cancer; thus patients with high-grade T1 have to be carefully monitored and managed. If patients are diagnosed with high-grade T1 at initial transurethral resection (TUR), a second TUR is strongly recommended regardless of whether muscle layer is present in the specimen because of the possibility of understating due to incomplete resection. Since high-grade T1 disease shows diverse clinical courses, individual approaches are recommended for treatment. In cases with low risk of progression, cystectomy could represent overtreatment and deteriorate quality of life irreversibly, while, in those with high risk, bacillus Calmette-Guérin (BCG) therapy may worsen survival by delaying definitive therapy. Therefore, a strategy for predicting prognosis based on the risk of progression is needed for managing high-grade T1 disease. Molecular risk classifiers predicting the risk of progression and response to BCG may help identify the optimal management of high-grade T1 disease for each individual.

Results of second transurethral resection for high-grade T1 bladder cancer

Background:

The aim of this study was to examine the histological outcome and potential therapeutic benefit of second transurethral resection (TUR) for high-grade T1 bladder cancer.

Patients and Methods:

The subjects were 171 patients who underwent initial TUR between January 1993 and December 2013, and were diagnosed with high-grade T1 bladder cancer. Second TUR was performed within 4–6 weeks after the initial resection. Intravesical recurrence, invasive intravesical recurrence, and disease-free, progression-free, and overall survival were examined between second TUR group and no second TUR group.

Results:

Of the 171 patients, 79 (46.2%) underwent second TUR. Histological findings from second TUR were no cancer in 33 (41.8%), carcinoma in situ in 18 (22.9%), Ta in 15 (19.0%), T1 in 12 (15.2%), and muscle invasive bladder cancer (T2) in 1 case (1.3%). The 5- and 10-year intravesical recurrence-free survival rates were 72.0% and 57.4%, respectively, and the disease-free survival rates at these times were 69.7% and 49.6%, respectively. Second TUR had no influence on intravesical recurrence, regardless of the use of Bacillus Calmette–Guerin (BCG) therapy. No BCG therapy and recurrent cancer were significantly associated with intravesical recurrence in multivariate analysis. Recurrent cancer was also a significant risk factor for invasive intravesical recurrence. BCG therapy significantly improved disease-free survival. Second TUR was a significant factor in overall survival. In the histological results for second TUR, no cancer and Tis cases had reduced intravesical recurrence compared to Ta and T1 cases.

Conclusion:

Second TUR allows more accurate staging and pT0 cases in second TUR have a better outcome, indicating a possible therapeutic benefit of the procedure.

Treatment and management of high-grade T1 bladder cancer: what should we do after second TUR?

Most T1 bladder cancers are high grade and have the potential to progress to muscle invasion and extravesical dissemination. Many studies reported that ∼50% of patients displayed residual tumors when a second transurethral resection was performed 2-6 weeks after the initial resection for patients who were diagnosed with T1 bladder cancer. Furthermore, muscle-invasive disease was detected by the second transurethral resection in 10-25% of those patients. Therefore, a second transurethral resection is strongly recommended for patients newly diagnosed with high-grade T1 bladder cancer in various guidelines. T1 bladder cancers are heterogeneous in terms of progression and prognosis after the second transurethral resection. Optimal management and treatment should be considered for patients with T1 bladder cancer based on the pathological findings for the second transurethral resection specimen. If the second transurethral resection reveals residual tumors, aggressive treatments based on the pathological findings should be performed. Conversely, overtreatment with respect to the tumor status should be avoided. Since the evidence of pathological diagnosis at the second transurethral resection is insufficient and many retrospective studies were carried out before the second transurethral resection era, prospective randomized studies should be conducted.

Can intravesical bacillus Calmette-Guérin reduce recurrence in patients with non-muscle invasive bladder cancer? An update and cumulative meta-analysis

Approximately 70% of newly diagnosed bladder tumors are non-muscle invasive bladder cancer (NMIBC). NMIBC accounts for approximately 80% of total bladder cancer cases. Bacillus Calmette-Guérin (BCG) instillation and maintenance is considered as the standard adjuvant treatment for superficial bladder cancer. A number of randomized studies have focused on the benefit of maintenance therapy following initial BCG induction. To provide further insights into the effect of intravesical instillation on recurrence in patients with NMIBC, we analyzed this relationship by conducting an updated detailed meta-analysis. Evidence suggested that adjuvant intravesical BCG with maintenance treatment is significantly effective for the prophylaxis of tumor recurrence in patients with NMIBC.