Should all patients with non-muscle-invasive bladder cancer receive early intravesical chemotherapy after transurethral resection? The results of a prospective randomised multicentre study

Abstract

Urological Survey downstaged to lower than T1G3. Within a median follow-up of 48 mo, 35.5% of patients died of metastatic UCB.Conclusions: Approximately half of the patients treated with RC without neoadjuvant chemotherapy for clinical T1G3 UCB are upstaged to muscle-invasive UCB. These rates support the inadequacy of clinical decision making based on current treatment paradigms and staging tools. Therefore, identification of patients with clinical T1G3 disease at high risk of disease progression is of the utmost importance, as these patients are likely to benefit from early RC. Editorial CommentThe optimal primary treatment of stage and grade T1G3 bladder cancer, radical or conservative, is a matter of debate since years. Here, 12 international centers with a large experience in radical cystectomies present their data on this aggressive "borderline" tumor. They found a high rate of nearly 50% of tumor upstaging to muscle invasive disease.Alas, this study suffers from several drawbacks. No indication on previous intravesical therapy, or on the time between first diagnosis of bladder cancer and cystectomy are given. These data would have made it much easier to judge on the delay as reason for the high rate of upstaging and to get information on the proportion of "true aggressive" T1G3 tumors which would indeed need immediate cystectomy without an initial trial of TUR, re-TUR and BCG.All in all, these data reflect the aggressive nature of T1G3 bladder cancer and the need for stringent management, be it conservative or radical. Dr. Andreas Bohle Professor of Urology HELIOS Agnes Karll HospitalBad Schwartau, Germany E-mail: boehle@urologie-bad-schwartau.de Background: To decrease recurrences in non-muscle-invasive bladder cancer (NMIBC), the European Association of Urology (EAU) guidelines recommend immediate, intravesical chemotherapy after transurethral resection (TUR) for all patients with Ta/T1 tumours. Objective: To study the benefits of a single, early, intravesical instillation of epirubicin after TUR in patients with low-to intermediate-risk NMIBC. Design, Setting, and Participants: In this prospective randomised multicentre trial, 305 patients with primary as well as recurrent low-to intermediate-risk (Ta/T1, G1/G2) tumours were enrolled between 1997 and 2004. Patients were randomly allocated to receive 80 mg of epirubicin in 50 ml of saline intravesically within 24 h of TUR or no further treatment after TUR. Measurements: The primary end point was time to first recurrence.