Page 5 - Management of non-muscle invasive bladder cancer

Kassouf et al.

follow-up in 124 patients, Grimm and colleagues found that recurrence, and potentially delays tumour progression (Level
63% of those who underwent a repeat TURBT had tumour- of Evidence 2). 74
free bladders compared with 40% of those who did not. 74
A more recent study from Memorial Sloan-Kettering Cancer Follow-up
Center confirmed the need for restaging TURBT, especially
in high-risk NMIBC. In a retrospective analysis of 1021 • Cystoscopy at 3 months following TURBT is recom-
patients with high-risk NMIBC, Sfakianos and colleagues mended for all patients (Grade A recommendation).
found that viable tumour was found in 55% of patients with • Generally, cystoscopy with urine cytology (or other
high-grade NMIBC when undergoing a restaging TURBT. A urine marker) is recommended every 3 to 4 months for
follow-up of these patients by TUR at 3 months showed that 2 years, then every 6 months for years 3 and 4, then
patients who had a restaging TURBT had significantly fewer yearly thereafter (Grade B recommendation). Patients
recurrences compared with those with a single resection with low-risk Ta tumours may undergo cystoscopy at
(9.6% vs. 44.3%). Restaging TUR was associated with less 3 and 12 months, then annually (Level of Evidence 3).
recurrence (62% vs. 77%) and prolonged progression-free • Upper tract imaging every 1 to 2 years is recommended
survival (82% vs. 67%, p < 0.001) at 5-year follow-up. 75 for patients with high-risk NMIBC (Grade C recom-
Divrik and colleagues prospectively evaluated 142 mendation).
patients who were randomized into 2 groups. The first
group received MMC after a restaging TURBT and the sec- All patients are recommended to undergo a cystoscopy
ond group had MMC directly after an initial TURBT. All at 3 months following TURBT, as cystoscopic findings at
patients received 8 weekly MMC instillations. Patients with 3 months have been shown to be a prognostic factor of
incomplete resection, CIS or muscle-invasive disease were recurrence and progression of disease (Grade A recom -
excluded from study. The mean follow-up was 31.5 months. mendation). 24,78-82 Prospective studies to better refine the
Restaging TUR significantly decreased recurrences regard- surveillance schedule are sorely needed. Although there is
less of tumour grade. The study also showed that intravesical no consensus for surveillance strategies, our general recom-
chemotherapy does not compensate for inadequate resec- mendation is to perform a follow-up cystoscopy with urine
tion. Restaging TUR was not associated with lower pro - cytology (or other urine marker) every 3 to 4 months for 2
gression, although there was a trend favouring the repeat years, then every 6 months for years 3 and 4, then yearly
76
TURBT group (4% vs. 11.8%, p = 0.097). The major flaw thereafter (Grade B recommendation).
of this study, however, was due to a lack of intention-to- Patients with a primary, solitary, low-grade Ta tumour
treat analysis. may have less frequent cystoscopic examination (3 and 12
Herr and colleagues demonstrated that a restaging TUR months, then annually thereafter) (Level of Evidence 3).
improved initial response to intravesical immunotherapy. 42 Mariappan and colleagues followed 115 low-risk patients
The results were also corroborated by another study by over 20 years, and showed that the recurrence rate of low-
Guevara and colleagues that showed that patients who risk NMIBC dropped significantly after 5 years of follow-up.
were tumour-free at repeat TUR have a better response to In patients who did not recur after 5 years, 98.3% remained
maintenance BCG in terms of tumour recurrence compared tumour-free after 20 years. This study had many patients
83
to patients with residual disease on repeat TUR (11.4% vs. that were excluded from long-term follow-up and the data
27.7%). During follow-up, tumour-free patients on repeat are contrary to other retrospective data suggesting that
TUR were more likely to recur with low-grade lesions long-term follow-up is necessary in patients with low-grade
compared to patients who had residual disease on repeat NMIBC. For patients with low-grade disease and no recur-
84
TUR. 77 rence for 10 years, discontinuation of routine cystoscopic
We recommend that a second TUR always be performed surveillance or replacement with urinary markers and/or
2 to 6 weeks after the initial resection when the initial TUR is ultrasonography may be considered (Level of Evidence 3).
incomplete or a T1 tumour is detected in the absence of mus- However, patients with high-risk NMIBC require lifelong
cularis propria in the specimen (Grade A recommendation). cystoscopic surveillance. Any recurrence resets the clock
A second TUR is also recommended for any high-grade or in the follow-up schedule.
T1 tumours with benign muscularis propria in the specimen
(Grade C recommendation). Larger studies evaluating the Upper tract surveillance
role of re-TUR stratified by the extent of invasion of the initial
tumour (T1a, T1b, T1c) are needed. Collectively, removing Although the sensitivity and specificity of computed tomogra-
all residual tumours in a second therapeutic TURBT allows phy (CT) urography is high for detecting upper tract tumours,
for more accurate staging, improves patient selection (and the probability of discovering a new upper tract lesion is low
thus response) to BCG therapy, reduces the frequency of on routine imaging. In a retrospective study of 935 patients

E694 CUAJ • September-October 2015 • Volume 9, Issues 9-10