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Treatment of high-risk, non-muscle-invasive bladder cancer

Nature Clinical Practice Urology volume 3, pages 398–399 (2006)Cite this article

High-risk, non-muscle-invasive bladder cancer is defined as any transitional cell carcinoma (TCC) of the bladder that is high-grade, whether it is primary or recurrent. This high-risk group includes patients with high-grade papillary stage Ta or T1 tumors and any patient with carcinoma in situ (CIS), and makes up 15–44% of patients with non-muscle-invasive cancer in some series.1,2 The probability of progression to muscle-invasive cancer within 5 years of diagnosis is highest for this group of patients, and ranges from 25% to 50%, depending on case mix and treatment; the risk of progression for low-risk and intermediate-risk patients is 5–15%. Progression is invariably associated with a decreased probability of survival. Thus, accurate identification of grade and stage and a carefully thought out and managed treatment plan are paramount to achieving durable disease control and ensuring long-term survival.

Accurate staging, which is imperative for proper treatment planning, is particularly important in patients with a primary stage T1, grade 3 (T1G3) tumor. Consideration should be given to asking a referee pathologist to review the specimen, as there is significant variability in the accuracy of assigning clinical stage and grade. Up to 40% of patients who undergo radical cystectomy are understaged; this would lead to inappropriate therapy if a T2 tumor were misidentified as a T1 tumor. Therefore, re-resection of the bed of a T1G3 tumor within 4–6 weeks of the initial transurethral resection of bladder tumor is essential for accurate staging. Detrusor-muscle tissue should be included in the specimen to ensure accurate stage determination. Muscle bundles in the lamina propria, the muscularis mucosae, can be misinterpreted as muscle invasion. If persistent T1G3 tumor is found, serious consideration should be given to radical cystectomy. The presence of lymphatic or vascular invasion, if confirmed by a referee genitourinary pathologist, should also prompt consideration of radical cystectomy. Other indications for radical cystectomy are micropapillary disease (a particularly aggressive variant of TCC), primary adenocarcinoma, and squamous cell carcinoma—none of which are considered responsive to intravesical therapy.

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  1. Associate Professor and the Beth and Dave Swalm Chair in Urologic Oncology at Baylor College of Medicine, Houston, TX, USA

    Seth P Lerner

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  1. Seth P Lerner
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Correspondence to Seth P Lerner.

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Lerner, S. Treatment of high-risk, non-muscle-invasive bladder cancer. Nat Rev Urol 3, 398–399 (2006). https://doi.org/10.1038/ncpuro0517

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