EAU 2018: How Should I Treat a Patient with Initial T1HG Disease and No Tumour on Re-TUR?
Summary | Case Presentation: 64 year old man with first time gross hematuria. 1 pack/day smoker x 30 years. Ultrasound – single bladder mass. Urine cytology positive. Cystoscopy – 3 cm papillary lesion on left side, solitary.
TURBT – 3 cm pT1 HG TCC (no variant). +CIS. Muscle in specimen (not involved). No LVI. Re-TURBT – pT0.
What is next?
Intravesical BCG +/- maintenance
Early radical cystectomy
Discussant 1: J.W.F. Catto Sheffield, UK
Unfortunately, Dr. Catto’s slides were not uploaded. He verbally highlighted his main points. He would recommend early cystectomy if the patient is a good surgical candidate (which he is) – BCG only if the patient wants bladder preservation. The CIS is worrisome and a negative predictor, favoring early cystectomy. Other than that, he would also recommend smoking cessation.
Discussant 2: P. Gontero Turin, Italy
Dr. Gontero was on the other side of the debate and argued for BCG. First and foremost, he agreed that this was a discussion with the patient – and the decision for treatment should be patient driven. However, he felt that BCG was not an unreasonable option. Gontero et al 2015 – Over a 20-year follow-up period, patients treated with BCG had a 20% progression rate. 79% of 2530 patients with T1 high-grade disease did not progress at 10 years; 77% kept their bladder. In contrast, even in patients who undergo cystectomy, there is a proportion of patients who progress – hence, RC cannot be considered a guaranteed cure! 10 year RFS/PFS following RC was 78% for pN0 patients. So, up to 20% aren’t cured by RC alone.
Additionally, in this patient, he was pT0 at re-resection. This clearly has implications, as pT0 patients have a much lower risk of recurrence/progression – Harry Herr (MSKCC, NYC) data would suggest 9% risk of progression for pT0. Dr. Gontero’s own data is approximately 14% (median follow-up 5 years). In these patients, cancer-specific death was low at 6%. Therefore, all things being equal between RC and BCG, the bladder-sparing BCG option is probably better for this patient. However, he does note that the CIS would make this patient slightly less favorable towards BCG and lean slightly towards RC. Ultimately, it is a balancing act between these two options and they must be discussed honestly with the patient.
Presented by: S. Shariat Vienna, Austria
Discussants: J.W.F. Catto Sheffield, UK and P. Gontero Turin, Italy
Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark