Adjuvant therapy in different risk-groups of patients with superficial bladder cancer

We assessed and compared the outcomes of two different courses of adjuvant therapy to patients with superficial bladder TCC.

The study included 142 patients (28 women and 114 men with a median age of 58.5 years) with newly diagnosed bladder transitional cell carcinoma (TCC), who underwent transurethral resection of bladder tumor (TURBT) between October 2002 and October 2003. Before surgery patients underwent routine examination, including measurement of tPSA level and transrectal ultrasound sonography (TRUS). In 26 (18.3%) patients with considerably enlarged prostate and LUTS we simultaneously performed TURBT and transurethral resection of the prostate (TURP). Pathological findings showed pTa stage in 20 (14.1%), pT1G1-2 in 99 (69.7%), pT1G3 in 15 (10.6%) and pTis in 3 (2.1%) cases; we additionally examined prostate specimens after TURP. The main criteria for adjuvant treatment were: grade, number and location of the tumor in the bladder The group of patients (group A) with G3 and multicentric lesions, localized at the lower third of the bladder, underwent BCG-therapy according the conventional schedule (60 patients, 42.3%). In group B (82 patients, 57.7%) patients underwent local chemotherapy (Thiotepa 80 mg p/week or Doxorubicin 50 mg p/week), started within 24 hours after operation. A second-look TURBT was performed within 6 weeks of treatment course in both groups. The morphological records of surgery were reviewed, compared with the initial findings and analysed statistically.

Recurrence rate in groups A and B was 18.3% (11 patients) and 25.6% (21 patients), respectively (with common level 22.5%) (p=0.04). Three (5.0%) patients of group A and five (6.1%) of group B withdrew consent. We observed recurrent low-grade pTa tumours in 4 patients (36.4%) and 8 patients (38.1%) respectively in group A and B (p<0.03) and pT1 G1-2 tumours in 5 patients (45.5%) and 8 patients (38.1%) respectively in group A and B (p<0.005). We observed pT1G3 in two (18.2%) cases of group A, and in two (9.5%) cases of group B. In addition, two (9.5%) patients of B group had T2G2 lesions. Adjuvant therapy was continued in all patients, except four patients with G3 and two patients with T2 stage who underwent more aggressive treatment (4 cystectomies and 2 external beam radiotherapy). We switched 16 patients in group B with recurrent cancer to BCG treatment. Nobody of TURP-operated patients had recurrence in the distal part of urethra, and toxicity level of TURP-operated patients was not worse than in the whole patients cohort (not more than grade II).

BCG adjuvant therapy demonstrated good results in the treatment of the recurrence of superficial TCC. However, in patients with low recurrence risk we used chemotherapy successfully. A second-look TURBT within 6 weeks after the initial surgery provided important prognostic information. Patients with T1G3 tumors, being at high risk of residual, or even invasive, cancer, could be offered definitive therapy within a 1-year period. Patients who underwent simultaneous TURP for relief of LUTS did not show cancer recurrences in the operated area or an higher toxicity of adjuvant treatment.