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Management of NMIBC

At diagnosis:

  • Stage the upper tracts also with CT IVP (2 – 5 % risk upper tract cancers)
  • Counsel on smoking cessation

 

Management of low risk disease (solitary LGTa < 3 cm)

  • Resection of initial tumour
  • First cystoscopy at 3 months, then 9 months later, then annually for total of 5 years
  • First cystoscopy at 3 months is important prognostic factor
  • Recurrences are usually low grade and superficial, and office fulguration can be considered
  • Relatively little data on recurrence rates after 5 years – surveillance after 5 years should be considered as ‘shared-decision making’ between patient and clinician
    • Consider ultrasounds as surveillance if patient not willing for cystoscopy
  • AUA suggests no upper tract imaging required as routine for low risk group (upper tract recurrences very rare, and mostly detected symptomatically cf. on imaging)

 

No role for induction intravesical therapy in low risk disease, but consider single post-operative instillation of intravesical chemotherapy within 24 hours of TURBT – destroys circulating tumour cells and remaining tumour cells at base of TURBT

  • ARR 10 – 15 % and relative risk reduction 35 % for recurrence for intravesical gemcitabine.

 

Management of intermediate risk disease (HGTa < 3 cm, early recurrence LGTa within one year, multifocal LGTa or LGTa > 3 cm)

  • Consider cytology with cystoscopies, although risk is primarily of recurrence rather than progression
  • First cystoscopy at 3 months with cytology
  • Then 6 monthly for 2 years with cytology
  • Then annually indefinitely (EAU recommends lifelong follow up)
  • Consider upper tract imaging every 1 – 2 years
  • Consider induction course of intravesical chemotherapy
    • Evidence that all intravesical chemo agents and BCG all reduce risk of recurrence
    • BCG reduces progression also but at a cost of higher toxicity
    • Mitomycin C efficacy suggested to be enhanced by dehydration for 8 hours prior, with complete bladder emptying as well as urinary alkalinisation with sodium bicarb for 3 doses prior
    • Optimal course of induction not known – 6 weeks is often used

 

 

Management of high risk NMIBC (CIS, HGT1, recurrent HGTa, variant histology, LVI, multifocal or > 3 cm HGTa, prostatic urethral involvement)

  • 3 monthly cystoscopy and cytology for first two years
  • 6 monthly cystoscopy and cytology for years 3 – 5
  • Annual cystoscopy and cytology lifelong thereafter
  • Upper tract imaging every 1 – 2 years

 

Patients with CIS should get induction BCG.

  • 30 – 50 % relative risk reduction for recurrence (20 % absolute risk reduction)
  • 20 – 30 % relative risk reduction for progression (5 % absolute risk reduction)
  • May treat residual CIS and papillary tumour not resected
  • Demonstrably better prevention of recurrence cf. intravesical chemo

 

Patients with high grade non muscle invasive disease should have re-resection within 6 weeks.

  • Indications for re-resection
    • HGT1
    • HGTa with no muscle in specimen
    • Incomplete resection
  • For HGTa
    • 50 % residual disease, 15 % upstaged
  • For HGT1
    • 50 % residual or persistent disease, 15 – 30 % upstaged to muscle invasion

If confirmation no muscle invasion, recommendation is induction BCG.

 

Managing carcinoma in situ:

  • CIS diagnosed concurrently with high grade Ta or T1 cancer increases their risk of progression and recurrence
  • CIS should not be considered as able to be cured alone by endoscopic treatment – requires intravesical treatment or cystectomy (if suitable)
  • May have up to 80 – 90 % initial response rate for CIS alone with BCG treatment, with 50 % of patients remaining free of disease at 4 years
  • CIS involving lining of prostatic urethral ducts should be distinguished from tumour directly invading prostatic stroma (T4)
    • CIS of prostatic urethral ducts best treated with TURP followed by induction BCG
  • CIS of the bladder increases risk of UTUC CIS and tumours

 

 

 

Early cystectomy in NMIBCT

Rationale behind early cystectomy for NMIBC:

  • Staging accuracy for T1 disease is low – recall 20 – 30 % of patients may be upstaged at repeat resection, and 27 – 51 % upstaged on cystectomy specimens
  • Some patients with NMIBC progress to MIBC – these patients have poorer prognosis than those with ‘primary’ MIBC
  • Prognosis is good for those with cystectomy prior to muscle invasive diagnosis – 5 year disease free survival well in excess of 80 %

 

Need to balance with complications, morbidity and impact on quality of life from cystectomy.

 

Offer radical cystectomy for:

  • BCG refractory or unresponsive disease
  • Variant histology
  • High volume HGT1 disease which persists on re-resection
  • High volume CIS with HGT1 disease
  • Severely symptomatic bladder
  • Endoscopically unresectable volume of disease
  • High grade disease within diverticulum