Conservative Management and Survival of Patients Affected by T1G3 Bladder Tumours. When Shall we Indicate it and When the Cystectomy?

Abstract

Introduction Conservative management is not applicable to all T1G3 tumors. The appropriate treatment should minimize mortality while assuring reduced morbidity and good quality of life. Several attempts have been done to identify categories of T1G3 patients at higher risk. The role of biologic markers is unclear and the prognostic risk factors are mainly clinical. The proper time to abandon the conservative approach in favor of cystectomy is still object of debate. Objectives The aim of the present study is to assess the clinical tumor features showing a detrimental effect on survival, identify the clinical risk factors impacting survival in patients undergoing conservative management of T1G3 bladder tumor, and to analyze the prognostic role of recurrence. Methods The present analysis is extended to 236 patients with T1G3 bladder tumors treated by TUR plus intravesical therapy between 1976 and 2005. Patients with previous T1G3, Tis, more than 3 tumors or greater than 3cm were excluded. Urinary cytology was obtained within 30 days after TUR. Since 2000 re-TUR has been performed. A sequential combination of mitomycin-C (30mg/30ml) and epirubicin (50mg/50ml) was adopted in 106 patients (44.9%). BCG or other agents were given intravesically in 85 (36.0%) and 38 (16.1%) patients, respectively. Seven (3%) patients refused intravescical therapy. In the case of Ta-T1 recurrence, TUR and one year of adjuvant intravesical therapy were repeated. Patients went off study if Tis, T1G3 or T-category tumor over T1 were detected. Age, previous history, number of tumors, re-TUR, adjuvant therapy, recurrence and progression were considered for survival analysis. Results Tumors were primary in 177 (75.3%) and single in 144 (61.5%) cases. At a mean follow-up of 52 months (range: 3–246 months), 116 patients (49.2%) relapsed. The recurring tumor was T1 in 47 (40.5%) cases and T1G3 in 33 (28.4%). In 11 additional patients (9.5%) a Tis was detected. Twenty-five patients (10.6%) progressed and 15 patients (6.4%) underwent cystectomy. Median overall survival was 167 months. The 5-year progression-free survival rate was 87.8%. Thirty-two patients (13.6%) died, 22 (9.3%) for bladder cancer. A higher mortality was detected in recurrent (p= 0.002) and multiple (p=0.009) tumors undergoing conservative management. Survival was decreased by NMI recurrence (p<0.0001) and by progression (p=0.009). No statistical significant difference in survival was evident in relation to the grade and stage of the recurrent tumor. Conclusions Previous positive history and multiplicity are relevant risk factors for survival in patients affected by T1G3 NMI TCCB conservatively treated. Survival is decreased if conservative management is not given up at the time of NMI recurrence, independently from its grade and stage.