(UroToday.com) The 2021 European Association of Urology (EAU) annual meeting had a Controversies in Bladder Cancer 2021: Rapid-fire debates session. The session was introduced by Dr. Ashish Kamat with chairs of the session, Professors Joan Palou and Arnulf Stenzl. There were five rapid-fire debates with case-based discussions, multiple presenters have the opportunity to discuss nuances of common dilemmas facing urologic oncology patients and providers and to use these evidence-based debates to provide clear, rational guidance on the timely management of difficult situations in bladder cancer.
During the first rapid-fire debate, the topic is focused on the management of small local recurrence low-grade bladder tumors with negative cytology. Dr. Morgan Roupret argues for formal TURBT with intravesical chemotherapy while Dr. Wassim Kassouf argues for active surveillance and fulguration. Below I highlight their main points.
Case: The case is a male patient born 1935 (age 81) with multiple medical comorbidities (smoker until age 76, heart attack in 2011, coronary catheterization into 2011, COPD, DM). CCI 9.
- 1/2019 - Underwent TURBT + single instillation MMC for multiple papillary tumors (4 lesions, each 4-10 mm). Pathology: LG Ta urothelial carcinoma
- On 8/2019 cysto: he has a 6 mm papillary lesion on the posterior bladder wall and 5 mm papillary lesion on left bladder wall
Dr. Roupret:
Per Dr. Roupret, his goal is to completely remove all lesions provide a reliable diagnosis based on pathology. Per the guidelines, muscle is not required in the original specimen for LG Ta tumors and re-biopsy is not indicated. So management until this time has been appropriate.
He notes that due to the recurrence this patient meets the criteria for intermediate-risk cancer. For the guidelines, he is eligible for both BCG and chemotherapy as intravesical therapy. The decision for BCG and chemotherapy is dependent on the patient as this represents a broad spectrum of patients. In his practice, he would plan for eight installations of MMC.
Dr. Kamat, one of the chairs, had published a paper that can help guide us in this patient’s case.1 Per that paper, this patient should be continued to be treated as intermediate risk and should get reresection with chemotherapy (adjuvant). If he was younger, Dr. Roupret would have preferred to give him BCG.
Dr. Kassouf:
Dr. Kassouf Notes that 60% of all bladder tumors are LG Ta. These have excellent prognosis with recurrence rates between 30-60%, but very low risk of progression (3% at 10-years) and very low cancer-specific mortality (<1%). These patients, therefore, represent an opportunity for cancer care de-intensification without compromising survival (similar to low-risk PCa and small renal masses).
Prior work by Herr et al.2 noted that in 144 patients with recurrent papillary tumors, cystoscopy correctly staged and graded LG Ta tumors 93% of the time – and with cytology, that increased to 99% of the time. Mariappan et al. provide an update in a prospective double blind study of 248 patients – 88% accuracy if limited to smaller tumors.3 So, Urologists predict low grade tumors accurately.
On the contrary, TURBT is not a benign procedure. Collado et al.4 and Pereira et al.5, those separated by 19 years, both found that the complication rate after TURBT ~5.1%. This included a 3.7% hospital readmission rate and 0.8% mortality.
On the other hand, Office full duration of small superficial tumors with either cautery or laser ablation have been demonstrated to be effective and safe (Donat JUrol 2004,6 Syed J Endourology 20137). The recurrence rate may be high, the progression rates are rare.
Even active surveillance for non-muscle invasive bladder cancer has good data. There is a recent publication by Hurle et al. 8 of 251 patients (>95 had 18+ months follow-up). Treatment free probability at 12 and 36 months what 59% and 40% respectively.
Overall, the advantages of conservative therapy (surveillance and office fulguration) outweigh the morbidity and cost of repeat TURBTs. However, logistically speaking, the office has to be equipped with the right technology. He did comment that ideally the office is also able to give intravesical chemotherapy, but not all offices are equipped. In fact, even his office isn’t equipped to do so.
Presented by:
Marek Babjuk, MD, Ph.D., Professor, Department of Urology, Faculty of Medicine, Hospital Motol, Prague, Czech Republic
Morgan Roupret, MD, PhD, Professor of Urology, Sorbonne Université, Paris (UPMC), ESOU chairman, Paris, France
Wassim Kassouf, MD, CM, FRCSC, is a Professor in the Division of Urology and Vice-Chair of the Department of Surgery at McGill University. Dr. Kassouf’s clinical practice focuses on bladder, prostate, and renal cancer. His clinical and translational research focuses on the biology and therapy of bladder cancer.
Written by: Thenappan (Thenu) Chandrasekar, MD – Urologic Oncologist, Assistant Professor of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, @tchandra_uromd on Twitter during the 2021 European Association of Urology, EAU 2021- Virtual Meeting, July 8-12, 2021.
References:
1. Kamat A., Witjes J.A., Brausi M., et al., Defining and treating the spectrum of intermediate-risk nonmuscle invasive bladder cancer. J Urol. 2014 Aug;192(2):305-15
2. Herr H., Bochner B.,, Dalbagni G,., et al. Impact of the number of lymph nodes retrieved on outcome in patients with muscle invasive bladder cancer. J Urol. 2002 Mar;167(3):1295-8.
3. Mariappan et al. (Urology 2017)
4. Collado A., Chéchile G E., Salvador J. et al. Early complications of endoscopic treatment for superficial bladder tumors. J Urol. 2000 Nov;164(5):1529-32.
5. Pereira JF, Pareek G, Mueller-Leonhard C, et al. The Perioperative Morbidity of Transurethral Resection of Bladder Tumor: Implications for Quality Improvement. Urology. 2019 Mar;125:131-137. doi: 10.1016/j.urology.2018.10.027. Epub 2018 Oct 23. PMID: 30366045.
6. Donat SM, North A, Dalbagni G, et al. Efficacy of office fulguration for recurrent low grade papillary bladder tumors less than 0.5 cm. J Urol. 2004 Feb;171(2 Pt 1):636-9. doi: 10.1097/01.ju.0000103100.22951.5e. PMID: 14713776.
7. Syed HA, Talbot N, Abbas A, et al., Flexible cystoscopy and Holmium:Yttrium aluminum garnet laser ablation for recurrent nonmuscle invasive bladder carcinoma under local anesthesia. J Endourol. 2013 Jul;27(7):886-91. doi: 10.1089/end.2012.0696. Epub 2013 Jun 22. PMID: 23537221.
8. Contieri R, Paciotti M, Lughezzani G, et al., Long-term Follow-up and Factors Associated with Active Surveillance Failure for Patients with Non-muscle-invasive Bladder Cancer: The Bladder Cancer Italian Active Surveillance (BIAS) Experience. Eur Urol Oncol. 2021 May 28:S2588-9311(21)00108-5. doi: 10.1016/j.euo.2021.05.002. Epub ahead of print. PMID: 34059485.