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
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