Contemporary Treatment Contemporary Treatment Guidelines on Bladder CancerGuidelines on Bladder Cancer

Tony Wu.Tony Wu.

Division of UrologyDivision of Urology

Kaohsiung Veterans General HospitalKaohsiung Veterans General Hospital

AUA 2007 guidelinesAUA 2007 guidelines EAU 2008 guidelinesEAU 2008 guidelines NCCN guidelines v.2.2008 NCCN guidelines v.2.2008

Index Patient #1Index Patient #1

Patient presents with an abnormal growth on the urothelium

Standard: biopsy should be obtained Standard:complete eradication of all visible

tumors Standard: periodic surveillance cystoscopy Option: immediate single dose intravesical

chemotherapyAUA

Index Patient #2Index Patient #2

Small volume, low-grade Ta bladder cancer Recommendation: Single dose intravesical

chemotherapy immediately postoperatively Single dose MMC: 17% fewer recurrences Multiple doses:no additional benefit

AUA

Index Patient #3Index Patient #3

Multifocal / large volume, low-grade Ta or

Recurrent low-grade Ta bladder cancer Recommendation: An induction course of

intravesical BCG or MMC BCG:24%, MMC:3% fewer recurrences

Option: Maintenance BCG or MMC BCG:31%, MMC:18% fewer recurrences Affect progression ???

AUA

BCG Maintenance TherapyBCG Maintenance Therapy

SWOG regimensSWOG regimens 6-6-wk induction course of BCGwk induction course of BCG 3-wk maintenance courses at 3, 6, 12, 18, 3-wk maintenance courses at 3, 6, 12, 18,

24, 30, 36 months 24, 30, 36 months

Index Patient #4Index Patient #4

High-grade Ta, T1, and/or CIS Standard: For T1 patients repeat resection

should be performed prior to additional intravesical therapy In the absence of muscularis propria in specimen,

20% to 40% of patients will have either residual tumor and/or unrecognized muscle invasive disease

Recommendation: BCG induction + maintenance

AUA

Index Patient #4Index Patient #4

Option: Cystectomy should be considered for initial therapy in select patients It is not certain whether intravesical therapy alters

risk of progression high cure rate associated with cystectomy large tumor size, high-grade, tumor location in a

site poorly accessible to complete resection, diffuse disease, the presence of carcinoma in situ, infiltration of lymphatic or vascular spaces, and prostatic urethral involvement

AUA

Second TURSecond TUR

Indicated when multiple and/or large tumors are present, or when specimen contained no muscle tissue.

When high-grade, T1 tumor has been detected at the initial TUR.

Second TUR can increase recurrence-free and progression-free survival (level of evidence: 2a).

Most authors recommend resection at 2-6 weeks after the initial TUR.

The procedure should include a resection of the primary tumor site.

EAU

EAU

Risk of recurrence and progression

http://www.eortc.org/tools/bladdercalculator/default.htm

EAU

EAU

NCCN guidelineNCCN guideline

Ta,low-gradeTa,low-grade Observation Observation Single dose chemotheapy within 24 hrsSingle dose chemotheapy within 24 hrs

Ta,high-grade, or T1,low-grade:Ta,high-grade, or T1,low-grade: ObservationObservation BCG instillation BCG instillation

T1, high-grade:T1, high-grade: Re-TUR: positive: BCG or cystectomyRe-TUR: positive: BCG or cystectomy

negative:BCGnegative:BCG CystectomyCystectomy

Index Patient #5Index Patient #5

High-grade Ta, T1, CIS recurred after prior intravesical therapy

Standard: For T1 patients without muscularis propria in specimen, repeat resection should be performed prior to additional intravesical therapy

Recommendation: Cystectomy should be considered as a therapeutic alternative

Option: Further intravesical therapyAUA

Adjuvant ChemotherapyAdjuvant Chemotherapy

Not-resectable TumorNot-resectable Tumor

Metastatic DiseaseMetastatic Disease