Reexamining treatment of high-grade T1 bladder cancer according to depth of lamina propria invasion: a prospective trial of 200 patients

Abstract

Background:Management of high-grade T1 (HGT1) bladder cancer represents a major challenge. We studied a treatment strategy according to substaging by depth of lamina propria invasion.Methods:In this prospective observational cohort study, patients received initial transurethral resection (TUR), mitomycin-C, and BCG. Subjects with shallower lamina propria invasion (HGT1a) were followed without further surgery, whereas subjects with HGT1b received a second TUR. Association of clinical and histological features with outcomes (primary: progression; secondary: recurrence and cancer-specific survival) was assessed using Cox regression.Results:Median age was 71 years; 89.5% were males, with 89 (44.5%) cases T1a and 111 (55.5%) T1b. At median follow-up of 71 months, disease progression was observed in 31 (15.5%) and in univariate analysis, substaging, carcinoma in situ, tumour size, and tumour pattern predicted progression. On multivariate analysis only substaging, associated carcinoma in situ, and tumour size remained significant for progression.Conclusions:In HGT1 bladder cancer, the strategy of performing a second TUR only in T1b cases results in a global low progression rate of 15.5%. Tumours deeply invading the lamina propria (HGT1b) showed a three-fold increase in risk of progression. Substaging should be routinely evaluated, with HGT1b cases being thoroughly evaluated for cystectomy. Inclusion in the TNM system should also be carefully considered.

Easily Available Blood Test Neutrophil-To-Lymphocyte Ratio Predicts Progression in High-Risk Non-Muscle Invasive Bladder Cancer

“…Recently, a prospective study assessed the importance of second TURB in T1b patients because there is a tree times higher risk of progression (17). This is why all our patients underwent routinely re-TURB, but even in this case, there is a high risk of progression in this sub-group of patients.…”

Is restaging transurethral resection necessary in patients with non-muscle invasive bladder cancer and limited lamina propria invasion?

“…The meta-analysis performed by Martin-Doyle et al based on 1,431 patients identified depth of invasion into lamina propria (T1b/c) as the risk factor with the highest impact: they found a progression hazard ratio [HR] = 3.34 (p < 0.001) and a cancer-specific survival HR = 2.02 (p < 0.001) [6]. In a prospective study, pT1 substaging was used to determine the indication of re-TUR after BCG [26] and in multivariate analysis, substaging, CIS and tumor size were significant predictors of progression. Recent evidence suggests that histopathologic classification into T1a and T1b can be translated into a molecular signature, reflecting progressive dysregulation and resulting in more invasive stages [27].…”

Staging of bladder cancer

“…69 Nonetheless, beginning in 1990 with Younes et al, 62 many studies have investigated pT1 substaging relative to the muscularis mucosae and/or vascular plexus with mixed, but generally positive, results. 26,[45][46][47][48][49]54,[58][59][60][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85][86] Some of these studies substaged pT1 into three categories (i.e. above, into or below the muscularis mucosae/vascular plexus), while others utilised only two substages (i.e.…”