How to Treat Multifocal Ta High-grade Disease if Bacillus Calmette-Guérin Is Unavailable

A 71-yr-old man was transferred to our institution with multiple and recurrent high-grade pTa bladder cancer 26mo after an initial presentation of multiple and large pTa low-grade tumors and concomitant carcinoma in situ, treated with transurethral resection plus 6-mo postoperative mitomycin C. This case discusses several treatment options in the absence of bacillus Calmette-Guérin (BCG). Immediate radical cystectomy is an option with excellent survival, since there is a substantial risk of understaging and disease progression; however, this results in overtreatment in ∼50% of these patients. Therefore, a conservative approach could be intravesical combination therapy such as gemcitabine/docetaxel or epirubicin/interferon. In addition, device-assisted intravesical therapy is becoming an option to consider. Finally, patients could be included in trials such as immunotherapy trials. PATIENT SUMMARY: This 71-yr-old patient was diagnosed with recurrent, moderately severe noninvasive bladder tumors, which were removed. The recommended additional therapy, intravesical bacillus Calmette-Guérin (BCG) instillations, was not available. Both the pros and the cons of radical surgery (bladder removal) and a more conservative approach (other intravesical treatments) are discussed.