The indications for radical cystectomy for NMIBC are: no respectability (large tumor in diverticulum), non functioning bladder and high risk bladder cancer (any T1 or high grade, including CIS; progresion rate of 25-50% @ 5 years).
Early cystectomy indications for very High risk:
• T1, HG/G3 associated with concurrentlad bladder CIS
• Multiple and/or large and/or recurrent T1 HG/G3
• T1, HG/G3 with CIS in prostatic urethra
• Micropapillary variant of urotelial carcinoma
One key fact of the conference was that a T1HG tumor is not a superficial cancer (invasive to lamina propia) therefore radical cystectomy can be considered. A T1HG has the same or worse disease specific survival as a prostate cancer cT3b, gleason 5+5, 12/12 positive cores with PSA 75.
There is a common understanding of T1HG disease and the residual disease at the TURB site could be up to 62%, with muscle-invasive (T2) upstaging in up to 10% of the cases. Bladder cancers with lymphovascular invasion have a worse prognosis, a higher risk of metastatic disease and for progression outside the bladder. Initial radical cystectomy should be offered to any patient fit for surgery who has T1HG on repeat TUR or T1HG with CIS, or LVI or variant histology (44% cases of histologic variants are not recognized by community pathologists: lymphoepitelial, plasmocytoid, micropapillary and small cell).
Dr. Kamat expressed that diagnosis of prostatic urethral carcinoma can only be achieved with a TUR biopsy in those patients at risk: CIS, multifocal disease, involvement of trigone or bladder neck, prior intravesical therapy and previous involvement of the prostate.
A radical cystectomy should be considered for a T1HG because this cancer could rapidly progress to a metastatic disease before it reaches other layers of the bladder and lose the opportunity to cure the patient.
Presented by: Dr. Ashish M. Kamat, Professor of Urologic Oncology, MD Anderson Cancer Center, Houston, TX
Written by: Eduardo Gonzalez-Cuenca, MD, medical writer for UroToday.com and Ashish Kamat, MD, Professor of Urology and Director of Urologic Oncology Fellowship at M.D. Anderson Cancer Center, at the Mexican Urologic Oncology Association Meeting - July 26 - 28, 2018