Conservative treatment of high grade superficial bladder tumours

To review our previous experience in the treatment of high grade superficial bladder tumour.

Data from 71 consecutive patients (12 women and 59 men) with high grade (G3) superficial (Ta-T1) bladder tumour were considered. After endoscopic treatment 31 patients received intravesical immunotherapy with Bacillus Calmette Guerin (BCG), 14 patients were treated with a combined scheme of intravesical chemotherapy and immunotherapy and respectively 3 patients and one patient with intravesical chemotherapy with mitomycin (MMC) or epirubicin (EPI) alone. A group of 16 patients received no further treatment after TUR and other 6 patients was treated with systemic chemotherapy or radiotherapy. Patients were followed up with urine cytology and cystoscopy every three months, renal sonography every six months and intravenous pyelography every 2 years or in the case of positive cytology associated with negative cystoscopy.

Out of 16 patients treated with TUR alone 11 recurred (69%) BCG was initiated in 31 patients and 12 out of them suffered recurrences (42%), whereas 7 out of 14 patients who had combined epirubicin/BCG therapy developed recurrences (50%). Out of 19 patients who recurred after treatment with BCG alone or combined with epirubicin, five underwent immediate cystectomy and other five delayed cystectomy after a second course of intravesical therapy. In the latter group higher pathological stages were observed. We were not able to identify any factor predictive of recurrence after BCG treatment: sex (M 16/40 vs F 3/5 p = 0.35), stage (Ta 1/6 vs T1 18/39 p = 0.11), associated carcinoma in situ (CIS) (No CIS 1/8 vs CIS 18/37 p = 0.11), multifocal (single 13/31 vs multiple 6/14 p = 1.00), age (66.8 +/- 7.8 vs 62.9 +/- 11.9 years p = 0.19) and number of previous recurrences (0.42 +/- 0.90 vs 1.31 +/- 2.16 p = 0.06). Under chemotherapy (MMC or EPI) all 4 treated patients suffered recurrences (100%). Out of all recurrent patients after conservative treatment of an high grade superficial bladder tumours, seven presented tumours with a low grade histology (downgrading). In all but one of these patients an high grade tumour recurred within 30 months.

The adoption of a correct strategy of intravesical metaphylaxis with BCG allows to spare cistectomy in up to 60% of the patients with high grade superficial bladder carcinoma and the optimisation of treatment protocols will lead to even more effective results. However this tumour still demands the highest level of attention in the follow up and in the case of recurrence primary conservative treatment with BCG should be promptly converted to radical surgical treatment considering that the development of less invasive surgical procedures has reduced the impact on the patient's quality of life