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T1G3 Transitional Cell Carcinoma of the Bladder: Recurrence, Progression and Survival
2088
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
This is the first report of long-term results following whole-bladder PDT using diffusion medium for isotropic light distribution. More than half of the patients with TCC refractory to traditional intravesical therapy received benefit from a single PDT session. Patients with extensive flat papillary lesions do not appear to respond well. Patients who achieve a CR have less likelihood of and longer time interval before needing cystectomy for progressive disease than NR patients. Our PDT protocol is associated with minimal morbidity in these high-risk patients. Editorial Comment: Refractory high grade “superficial” urothelial cancer, particularly diffuse carcinoma in situ, creates a major therapeutic problem—it is a diathesis that is curable by cystectomy but patients are often reluctant to accept removal of the bladder. As a consequence, the aggressive potential of this diathesis often creates a scenario in which the disease may have progressed to muscle invasion (or even metastasized) when patients are finally ready to accept this treatment. A treatment approach in which a photodynamic agent is taken up by cancer cells and then activated by a specific wavelength of light, killing the cancer cells, offers a potentially powerful tool to eradicate cancers even if they are not endoscopically visible. This study demonstrates some of the problems that still affect this approach. First is the question as to whether all of the cancer cells actually take up the sensitizing agent. There is also the issue of long-term response. In addition, there is the potential side effect of bladder contracture developing even if treatment efficacy against a cancer is achieved. The most suitable role for this approach is in patients with diffuse carcinoma in situ. However, this group of patients is probably the most difficult to treat successfully, since the risk of progression is real if there is not a prompt and definitively complete response. Clearly, further study of this approach is important, since intravesical bacillus Calmette-Guerin, which has come to be the standard of treatment for this diathesis, is ultimately likely to fail, with failure often taking the form of rapidly aggressive invasive and possibly metastatic disease. Michael J. Droller, M.D.
T1G3 Transitional Cell Carcinoma of the Bladder: Recurrence, Progression and Survival M. PEYROMAURE
AND
M. ZERBIB, Department of Urology, Cochin Hospital, Paris, France
BJU Int, 93: 60 – 63, 2004 OBJECTIVES: To report our experience with T1G3 bladder tumours over the last 10 years. PATIENTS AND METHODS: We analysed the outcome of 74 consecutive patients treated for a T1G3 bladder cancer between 1991 and 2001. Fifty-seven patients (77%) were treated with transurethral resection (TUR) plus six weekly instillations of bacillus Calmette-Guerin (BCG) therapy. Ten patients (13.5%) with contraindications to BCG or with a small T1a tumour were treated with TUR plus mitomycin-C, and seven (9.5%) were treated with TUR alone because of their age. Patients treated with BCG had systematic biopsies taken at the end of the first course. Patients with residual tumour received a second course of six weekly instillations. Patients with negative biopsies received maintenance BCG therapy consisting of intravesical instillations each week for 3 weeks given 3, 6, 12, 18, 24, 30 and 36 months after the first course. RESULTS: The median follow-up was 53 months. The overall recurrence rate was 46% and the overall progression rate 19%. The rate of delayed cystectomy was 8% and that of disease-specific survival 91%. In patients who received BCG therapy, the recurrence and progression rates were 42% and 23%, respectively. In this group the rate of disease-specific survival was 88%. CONCLUSION: This study confirms that maintenance BCG therapy is an effective treatment for T1G3 bladder tumours, with an acceptable rate of bladder preservation. Editorial Comment: This report on 74 consecutive patients with T1 grade 3 urothelial cancer, a majority of whom were treated with intravesical BCG following transurethral resection, demonstrates the high risk of disease recurrence and progression manifested by this particular tumor diathesis. The recurrence rate ranged from approximately 40% to 50%, with a progression rate of 20% to 25%. The use of booster treatments, consisting of 3 weekly instillations at 6-month intervals (following an initial 3-month treatment), seemed to preserve the treatment response. However, toxicities occurred in one-third of these patients. More than 40% of the patients in this study had multifocal disease and were “difficult” to treat. The need for documentation of a prompt and complete response to these treatments is critical for success in dealing with these types of neoplastic diatheses. Otherwise, patients may be at risk for rapid progression to an incurable situation. Michael J. Droller, M.D.
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
This is the first report of long-term results following whole-bladder PDT using diffusion medium for isotropic light distribution. More than half of the patients with TCC refractory to traditional intravesical therapy received benefit from a single PDT session. Patients with extensive flat papillary lesions do not appear to respond well. Patients who achieve a CR have less likelihood of and longer time interval before needing cystectomy for progressive disease than NR patients. Our PDT protocol is associated with minimal morbidity in these high-risk patients. Editorial Comment: Refractory high grade “superficial” urothelial cancer, particularly diffuse carcinoma in situ, creates a major therapeutic problem—it is a diathesis that is curable by cystectomy but patients are often reluctant to accept removal of the bladder. As a consequence, the aggressive potential of this diathesis often creates a scenario in which the disease may have progressed to muscle invasion (or even metastasized) when patients are finally ready to accept this treatment. A treatment approach in which a photodynamic agent is taken up by cancer cells and then activated by a specific wavelength of light, killing the cancer cells, offers a potentially powerful tool to eradicate cancers even if they are not endoscopically visible. This study demonstrates some of the problems that still affect this approach. First is the question as to whether all of the cancer cells actually take up the sensitizing agent. There is also the issue of long-term response. In addition, there is the potential side effect of bladder contracture developing even if treatment efficacy against a cancer is achieved. The most suitable role for this approach is in patients with diffuse carcinoma in situ. However, this group of patients is probably the most difficult to treat successfully, since the risk of progression is real if there is not a prompt and definitively complete response. Clearly, further study of this approach is important, since intravesical bacillus Calmette-Guerin, which has come to be the standard of treatment for this diathesis, is ultimately likely to fail, with failure often taking the form of rapidly aggressive invasive and possibly metastatic disease. Michael J. Droller, M.D.
T1G3 Transitional Cell Carcinoma of the Bladder: Recurrence, Progression and Survival M. PEYROMAURE
AND
M. ZERBIB, Department of Urology, Cochin Hospital, Paris, France
BJU Int, 93: 60 – 63, 2004 OBJECTIVES: To report our experience with T1G3 bladder tumours over the last 10 years. PATIENTS AND METHODS: We analysed the outcome of 74 consecutive patients treated for a T1G3 bladder cancer between 1991 and 2001. Fifty-seven patients (77%) were treated with transurethral resection (TUR) plus six weekly instillations of bacillus Calmette-Guerin (BCG) therapy. Ten patients (13.5%) with contraindications to BCG or with a small T1a tumour were treated with TUR plus mitomycin-C, and seven (9.5%) were treated with TUR alone because of their age. Patients treated with BCG had systematic biopsies taken at the end of the first course. Patients with residual tumour received a second course of six weekly instillations. Patients with negative biopsies received maintenance BCG therapy consisting of intravesical instillations each week for 3 weeks given 3, 6, 12, 18, 24, 30 and 36 months after the first course. RESULTS: The median follow-up was 53 months. The overall recurrence rate was 46% and the overall progression rate 19%. The rate of delayed cystectomy was 8% and that of disease-specific survival 91%. In patients who received BCG therapy, the recurrence and progression rates were 42% and 23%, respectively. In this group the rate of disease-specific survival was 88%. CONCLUSION: This study confirms that maintenance BCG therapy is an effective treatment for T1G3 bladder tumours, with an acceptable rate of bladder preservation. Editorial Comment: This report on 74 consecutive patients with T1 grade 3 urothelial cancer, a majority of whom were treated with intravesical BCG following transurethral resection, demonstrates the high risk of disease recurrence and progression manifested by this particular tumor diathesis. The recurrence rate ranged from approximately 40% to 50%, with a progression rate of 20% to 25%. The use of booster treatments, consisting of 3 weekly instillations at 6-month intervals (following an initial 3-month treatment), seemed to preserve the treatment response. However, toxicities occurred in one-third of these patients. More than 40% of the patients in this study had multifocal disease and were “difficult” to treat. The need for documentation of a prompt and complete response to these treatments is critical for success in dealing with these types of neoplastic diatheses. Otherwise, patients may be at risk for rapid progression to an incurable situation. Michael J. Droller, M.D.