E U R O P E A N U R O L O G Y 6 1 ( 2 0 1 2 ) e 1 3

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Letter to the Editor

Re: Sven van den Bosch, J. Alfred Witjes. Long-term

Cancer-specific Survival in Patients with High-risk,

Non–muscle-invasive Bladder Cancer and Tumour

Progression: A Systematic Review. Eur Urol

2011;60:493–500

We commend an excellent piece of work that was done by

van den Bosch and Witjes [1] on a really complex issue of

long-term management of high-risk, non–muscle-invasive

bladder cancer (HRNMIBC; G3pT1 bladder cancer). We

recently undertook a similar retrospective study of

76 patients who were diagnosed with HRNMIBC with at

least a 5-yr follow-up at our institution. Overall survival in

our study group was 47.3%. Survival in patients receiving

radical treatment was better at 66%. Patients receiving

bacillus Calmette-Guerin treatment to start had the survival

rate of 45.9% with or without progression.

Poor survival on progression in this group of patients [2,3],

compared with patients who present with muscle-invasive

disease from the outset, is due possibly to understaging in a

significant proportion of patients. A majority of centres

favour re-resection to improve staging accuracy. However,

re-resection will address only the local understaging

(ie, T category). Nodal and distant metastases are not

assessed at the time of initial diagnosis, hence the majority

of the patients are treated as T1NxMx. None of the major

guidelines, including those of the European Association of

Urology, are clear about the roles of other staging modalities

(eg, radiology in accurate staging of this group of patients).

We believe that a significant proportion of HRNMIBC

patients may be understaged, as they may already have

extravesical disease, despite having pT1 disease in the

bladder. Nodal and extravesical disease would also not be

identified correctly simply by using re-resection as the only

modality of staging. Further T staging may not be accurate

by endoscopic resection alone if the tumour site is relatively

inaccessible (eg, in a diverticulum).

We looked at the role of imaging in this group of patients

[4]. In our study group, 25% (n = 19) of the patients had early

imaging (magnetic resonance imaging) after diagnosis of

G3pT1 disease. Surprisingly, of these, only 36% had normal

imaging and the rest had evidence of lymph node enlarge-

ment (26%), bladder wall invasion (10.5%), ureteric tumour

(10.5%), or distant metastases (17%). The overall 5-yr survival

in patients with normal imaging, abnormal imaging, and no

DOI of original article: 10.1016/j.eururo.2011.05.045

0302-2838/$ – see back matter # 2011 European Association of Urology. Publis

imaging were 11 of 15 (73.3%), 0 of 30 (0%), and 17 of 31

(54.8%), respectively. The relative risk reduction for survival

in patients with normal imaging (who are likely to have

true G3pT1 disease) versus no imaging is 33.7%, with an odds

ratio of 2.2.

We feel that rather than relying on just the re-resection

and endoscopic surveillance, imaging should also be

included to correctly stage this group of patients at the

outset and during follow-up. In this way, patients who have

evidence of extravesical disease, even at presentation,

would be identified and at least some of them would benefit

from early cystectomy and hopefully have better survival.

We fully understand that our study was a retrospective

study and had the limitations of not having a very high

statistical impact. We are in the process of setting up a

randomised prospective study to see if imaging can indeed

play a part in overall management of this complex group of

patients. Until we know the results of a randomised study,

imaging should be considered a part of the staging process

for this group of high-risk patients.

Conflicts of interest: The authors have nothing to disclose.

References

[1] van den Bosch S, Witjes JA. Long-term cancer-specific survival in

patients with high-risk, non–muscle-invasive bladder cancer and

tumour progression: a systematic review. Eur Urol 2011;60:493–500.

[2] Schrier BP, Hollander MP, van Rhijn BWG, Kiemeney LALM,

Witjes JA. Prognosis of muscle-invasive bladder cancer: difference

between primary and progressive tumours and implications for

therapy. Eur Urol 2004;45:292–6.

[3] Raj GV, Herr H, Serio AM, et al. Treatment paradigm shift may

improve survival of patients with high risk superficial bladder

cancer. J Urol 2007;177:1283–6.

[4] Banerjee S, Rafiq M, Vannahme M, Kumar V. Risk stratification in

high risk superficial bladder cancer, does imaging have a role?

Urology 2011;78(Suppl 3A):S203 [abstract].

Srijit Banerjee*

Vivekanandan Kumar

Norfolk and Norwich University Hospital, Urology,

Colney Lane, Norwich, NR4 7UY United Kingdom

*Corresponding author.

E-mail address: dr_srijit@yahoo.co.in (S. Banerjee).

December 14, 2011

Published online on December 22, 2011

hed by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2011.12.025