Treatment of Large Non-Muscle-Invasive Bladder Cancer: The Potential Role of Neoadjuvant Intravesical Chemotherapy - Beyond the Abstract

Most transitional cell carcinoma (TCC) of the bladder is non-invasive at diagnosis. However, while maintaining its non-invasive features, the tumor may grow unnoticed and without symptoms until it reaches a large size. These large intraluminal masses upon first presentation raise some diagnostic and therapeutic challenges. They may not have any invasive features on imaging, and histopathology is often inconclusive. Immediate radical cystectomy might not be possible. On the other hand, a bladder sparing strategy (possible staged resection, instillations) might delay necessary radical treatment.

In our experience in our admittedly small series of patients, we observed that invasive features are possible in those large bladder TCC, but not as widely encountered as perhaps expected. This means that immediate radical cystectomy might be an overtreatment in many of these tumors. On the other hand, these large bladder masses are hardly resectable transurethrally.

Therefore, similarly to other tumors, we considered applying neoadjuvant chemo-resection to reduce the tumor size before surgical treatment.

Our intention was to use the cytoreductive effect of mitomycin to resect all those bulky tumors completely in a single session. The short intensive schedule of intravesical instillations of mitomycin significantly reduced the tumor size before endoscopic resection. It allowed us to stage accurately and to spare most of the bladders, without delaying a possible radical cystectomy significantly where needed.

Even if radical cystectomy is a suitable and oncologically safe treatment for high-risk non-muscle-invasive bladder cancer, in high-risk patients with significant co-morbidities, and those refusing cystectomy, one can consider this bladder sparing strategy.

Written by: Marco Raber, MD1,2 Noor Buchholz, MD1,3

  1. U-merge (Urology in Emerging Countries), London, United Kingdom
  2. Mediclinic Middle East, Dubai, United Arab Emirates
  3. Department of Urology and Men’s Health, Al Garhoud Private Hospital, Dubai, United Arab Emirates
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