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EAU 2018

EAU 2018: Case-based Debate: How to Treat Multi-focal Ta, HG Disease if BCG is Unavailable?

Copenhagen, Denmark (UroToday.com)  This is one of a series of case-based debates. Each is set up as follows: 2 min case-presentation, 5-min discussant presentation (two sides of the debate, discussion), summary 2 minutes. This was  series arranged by JA Witjes, M. Brausi, and P-U Malmstrom.

Summary | Case Presentation: 71 year old man, 50 pack-year active smoker, pulmonologist. 

Prior to being seen by Dr. Witjes:

  • Feb 2015: multiple LG Ta TCC treated with TURBT/single dose MMC + 6 months MMC
  • Sep 2015: 2 small recurrences, outpatient fulgeration
  • Feb 2016: Multiple pTa HG TCC recurrences treated with TURBT/MMC
  • Nov 2016: Multiple Ta HG TCC treated with TUR alone
At this point he was referred

April 2017 – again with multiple Ta HG TCC. Underwent TURBT.  However, at this time, they had no BCG available. What are the options?


Discussant 1: Dr. Brausi argued in favor of cystectomy in the absence of BCG. 

TaHG TCC key points:

  • Represents only 7% of all NMIBC
  • 40% 1-year recurrence and 5% 1-year progression risk; 17% 5-year progression risk
  • Often understaged! Only a 23% concordance between local and central pathologist
  • Multifocality, size > 3cm are negative predictors
  • About 8% with multiple HG Ta TCC have nodal micrometastases – and node dissection may cure them.
This patient would be considered highest risk as he recurrent HG TCC with CIS!  Disease specific survival with RC in this population is 85-90%. Delaying cystectomy results in reduced CSS. Delayed RC 10-year CSS 51% vs. early RC 78% (Denzinger et al).  However, while RC may be considered overtreatment in up to 50% of patients, it should still be part of the discussion, and likely recommended for this young patient.


Discussant 2: Dr. Malstrom presented bladder sparing options. Some of this was reviewed in a previous section.  First, the progression risk for this patient using the EORTC calculator is small – 5% at 1 year. So, there is time to consider bladder sparing therapies.

1. MMC vs. BCG
- MMC is as effective as BCG in patients without CIS (Malstrom et al JUrol 1999)

2. Epirubicin vs. BCG (EORTC 30911)

- BCG was more effective than epirubicin, but epirubicin still had some efficacy. Progression risk during the trial time was small. 
- Similarly, combining epirubicin with IFN has promising results – not as effective as BCG, but still with approximately 30% 2-year relapse free response. 

3. Gemcitabine

- Shelley BJUI 2012 – systematic review of 6 trials, 704 patients, 3 trials compared to BCG
- Similar efficacy in intermediate risk patients
- Less effective in high risk patients
- Superior in BCG refractory patients
- However, evidence limited due to clinical trial settings

EMDA and chemohypothermia were reviewed briefly. More clinical trial data is required for both.  Therefore, there is time to trial medications without risk of progression.


Presented by: JA Witjes Nijmegen, The Netherlands
Discussants: M. Brausi Modena, Italy and P-U Malmstrom Uppsala, Sweden

Written by: 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