SIU 2017: SIU-ICUD Joint Consultation on Bladder Cancer - Management of NMIBC Urothelial Carcinoma

Lisbon, Portugal (UroToday.com) In this section, Dr. Kassouf reviewed the key recommendations for the management of NMIBC (non-muscle invasive bladder cancer). Many of the recommendations have not changed, but below are highlighted the key points that were addressed today. Some of these overlapped with Dr. Kamat’s presentation, so these are not repeated below.

Staging work-up:

Besides what was previously presented by Dr. Kamat’s, Dr. Kassouf’s group recommend doing an exam under anesthesia (EUA) at the time of initial TURBT (Grade C). 

Prognostic factors for BCa:

Patient-related
  • Age – older age associated with worse disease (LOE 2)
  • Gender – female patients have higher recurrence risk (LOE 3)
  • Race – equivocal, especially regarding patients of African origin
Environmental factors
  • Smoking (LOE 3)
  • Other factors (infection, family history, exposures) – uncertain
Tumor related factors
  • Tumor size > 3cm
  • Multifocality – higher recurrence, ? effect on progression
  • Recurrence (time to recurrence, > 1 recurrence/year)
  • Quality of TUR
Pathology related factors
  • Stage (Grade 2)
  • Grade (Grade 2
  • Concomitant CIS (Grade 3)
  • Prostatic involvement (Grade 3)
  • Lymphovascular involvement (Grade 3)
  • Variant histology (LE 3)
  • T1 substaging
Molecular-related factors
  • Urine markers (previously discussed) – LOE 2 per this group
  • Somatic mutations (LOE 3)
  • Molecular subtyping (LOE 3)
  • Most widely used risk stratification tools: EORTC and CUETO.
  • AUA/SUO lists small volume (<3 cm) HG Ta as intermediate risk. Most others list any HG as high-risk 
  • Most widely used risk stratification tools: EORTC and CUETO. 
          AUA/SUO lists small volume (<3 cm) HG Ta as intermediate risk. Most others list any HG as high-risk 
Management of Positive Cytology and normal WLC

  • R/o extravesical disease (LOE 3, Grade C)
           o   CT Urogram
           o   Random bladder biopsies
           o   Photodynamic evaluation
       
  • If all negative, then bilateral ureteroscopy with biopsy
  • If also negative, then close surveillance
            o   40-75% will find disease on f/u, usually within 1-2 years

Prostatic urethral involvement
  • Routine biopsy on initial evaluation not warranted (LOE 3)
  • TUR loop biopsy is preferable to a cold cup biopsy (LOE 3)
  • HG pTa/T1 or TIS in prostatic urethra
           o   Initial TURP + BCG appears to be safe (LOE 3)
           o   If recurs, radical cystectomy + urethrectomy (LOE 3)

  • TIS in prostatic ducts
            o   Limited data
            o   RC if extensive in ducts (LOE 3)
            o   Alternative it TURP + BCG

  • Prostatic stromal invasion – treat as MIBC

Management of low-risk and intermediate risk NMIBC
No significant change from the 2012 guidelines
Single dose instillation therapy recommended within 6 hours (MMC, epirubicin, pirarubicin) if low-risk

     If intermediate risk, ongoing instillations
     Intermediate risk – risk-adapted approach recommended, based on EORTC risk calculator

In-clinic fulgeration is acceptable for patients with recurrent TaLG with no prior history of high-risk disease of CIS, and negative cytology
New – expectant  management for LG Ta is acceptable (Grade B)
            Urine cytology must be followed and be negative
            A protocol must be established and followed

Management of high-risk NMIBC

  • Repeat TURBT guidelines – similar to what was presented by Dr. Kamat
  • Patients with variant histology, LVI or deeply invasive T1 may not be candidates for bladder sparing therapies and should be considered for early cystectomy (LOE 3, Grade C)
  •  BCG recommendations are unchanged
            o The wording of maintenance (“at least 1 year”) therapy was debated by the group. It was not felt this was strong enough based on the studies that demonstrated benefit with 3 years maintenance. This may be changed prior to publication

  • BCG failure
           o   Relapsing
           o   Refractory: disease progression after one cycle induction or persistent/worsening after two cycles of induction (LOE 3, Grade B)
           o   Unresponsive: BCG refractory and BCG relapsing high risk within 6 months of last BCG exposure
           o   RC is the gold standard for treatment (LOE 3, Grade C)
                - Salvage intavesical therapy only if refuse RC and clinical trials

  • Brief discussion without strong recommendations for alternative therapy (hyperthermia, etc)
           - Grade B recommendations for RF-induced CHT, EMDA-MMC if unfit or unwilling to undergo RC or if BCG not available

Dr. Kassouf covered a lot of ground in this section. Very little was significantly different from the prior edition. Full details to be published in the printed chapter.

Presented by: Wassim Kassouf 

Author: Wassim Kassouf 
Affiliaiton: McGill University, Quebec, Montreal, Canada

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 37th Congress of Société Internationale d’Urologie - October 19-22, 2017- Lisbon, Portugal
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