Assessing treatment response after intravesical bacillus Calmette–Guerin induction cycle: are routine bladder biopsies necessary?

Abstract

Purpose To determine the need for routine bladder biopsies (BBs) in assessing response to the induction cycle of intravesical bacillus Calmette–Guérin (BCG) for high-risk non-muscle-invasive bladder cancer (NMIBC). Methods Our prospectively maintained NMIBC database was queried to identify patients with high-risk disease (carcinoma in situ, high-grade Ta/T1) who underwent BBs after BCG induction cycle. Urine cytology, cystoscopy, and BBs findings were evaluated. Results A total of 219 patients met the inclusion criteria. Urine cytology was positive in 20 patients and negative in 199; cystoscopy was positive in 35 patients, suspicious in 32 and normal in 152 patients. BBs yielded bladder cancer (BCa) in 43 (19.6%) patients, with a BCa rate of 9.3% in patients with negative cytology and cystoscopy as opposed to 38.0% in patients whereby one or both exams were suspicious/positive. The diagnostic accuracy of urine cytology, cystoscopy, and combined tests was 0.56, 0.70, and 0.71, respectively. The negative predictive value of combined tests was 90.7%. Performing BBs only in patients with positive cytology and/or positive/suspicious cystoscopy would have spared 140 (64%) patients to undergo this procedure while missing BCa in 13 (9.3%) of them, representing 30% of all BCa cases. Conclusion Performing BBs only in patients with positive cytology and suspicious/positive cystoscopy would spare 64% of un-necessary BBs but miss a non-negligible number of BCas. While no data are available regarding the potential consequences of missing such BCas, such information should be taken into account in patient’s counselling.

Conservative treatment for high-risk NMIBC failing BCG treatment: who benefits from adding electromotive drug administration (EMDA) of mitomycin C (MMC) to a second BCG induction cycle?

“…According to our policy, all patients having completed the first BCG induction cycle underwent bladder biopsies [ 11 ] to assess treatment efficacy. In the absence of recurrent HG disease or CIS, patients were scheduled for BCG maintenance with a monthly BCG instillation for at least 1 year.…”

Are We Ready to Implement Molecular Subtyping of Bladder Cancer in Clinical Practice? Part 1: General Issues and Marker Expression

“…This is a heterogeneous group of tumors, including both low- and high-grade non-invasive BCs, along with superficially invasive (stage pT1) tumors, with variable rates of recurrence and progression to higher-stage disease, the latter occurring in 31–78% of all NMIBC patients [ 10 , 11 ]. The main treatment options for NMIBCs include transurethral resection, intravesical instillations, and/or patients’ follow-up with cytology and repeated cystoscopies [ 10 , 12 ]. Intravesical administration of bacillus Calmette–Guérin (BCG) is the mainstay of treatment in high-grade NMIBC, though treatment failure occurs in a substantial number of cases [ 13 ], due to the development of resistance over time, or to toxicity [ 14 , 15 ], thus warranting a more aggressive treatment with RC [ 10 ].…”

Latest Developments and Current Problems in Bladder Cancer

“…Four articles, in this issue, focus on the important topic of NMIBC, including Bacille Calmette-Guerin (BCG) treatment and the role of biomarkers such as PD-L1 in this setting. Disease progression during or recurrence following BCG treatment is a common and extremely challenging event [10,11]. Lebacle et al summarize the current and upcoming treatment options, involving device-assisted therapy and chemotherapy, such as immune checkpoint inhibitors (ICI), novel intravesical and systemic agents, and sequential combinations of these newer modalities with conventional therapy.…”