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Intravesical BCG Versus Radical Cystectomy for High-Risk NMIBC with Histologic Variants - Expert Commentary

The optimal management of non-muscle invasive bladder cancer (NMIBC), some histologic variants, including squamous and glandular, is challenging. A recent article published by Suh et al. in Scientific Reports compared Bacillus Calmette-Guérin (BCG) instillation to radical cystectomy in high-risk NMIBC patients with squamous/glandular variants. In this retrospective study, the authors identified 1263 high-risk NMIBC patients from January 2000 to December 2017. 62 out of 1263 (4.9%) had squamous or glandular histologic variants. Of these 30 patients who received BCG, 15 patients underwent radical cystectomy and 17 patients were observed.

The authors noted differences in the baseline clinical characteristics in different groups. Of note, the patients selected for observation included those with a large proportion of low T stage (Ta, 35.3%) rather than BCG instillation (13.3%) and radical cystectomy (0.0%) groups. The investigators found no statistically significant difference in the 5-year overall survival and cancer-specific survival between the BCG group and the radical cystectomy group. BCG instillation was associated with better overall survival (p = 0.019) and cancer-specific survival (p = 0.038) compared to the observation group.

Determining the optimal management strategy for NMIBC patients with histologic variants is an important need. Standardizing pathological definitions and prospectively testing different management strategies including BCG and early cystectomy will improve the quality of evidence to guide clinical management. 

Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine, New York City, New York

Reference: 

1. Suh, Jungyo, Kyung Chul Moon, Jae Hyun Jung, Junghoon Lee, Won Hoon Song, Yu Jin Kang, Chang Wook Jeong, Cheol Kwak, Hyeon Hoe Kim, and Ja Hyeon Ku. "BCG instillation versus radical cystectomy for high-risk NMIBC with squamous/glandular histologic variants." Scientific Reports 9, no. 1 (2019): 1-6.

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