Risk of subsequent tumour recurrence and stage progression in bacille Calmette-Guérin relapsing non-muscle-invasive bladder cancer

Authors


Eiji Kikuchi, Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. e-mail: eiji-k@kb3.so-net.ne.jp

Abstract

Study Type – Therapy (case series)

Level of Evidence 4

What's known on the subject? and What does the study add?

So far, few previous reports have analysed the risk factors for tumour recurrence and stage progression with a special focus on BCG-relapsing disease, defined as the recurrence after achieving a disease-free status by initial BCG instillations for 6 months. There are no guidelines outlining a specific treatment strategy for BCG-relapsing disease, although many BCG failure cases are attributable to BCG-relapsing disease.

In this study, additional BCG instillation was shown to decrease the subsequent tumour recurrence rate against BCG-relapsing tumours with intermediate pathological risk features; however, a BCG-relapsing tumour with a pathologically high risk was a significant risk factor for both subsequent tumour recurrence and stage progression. This information might identify a therapeutic strategy for BCG-relapsing tumours.

OBJECTIVE

  • • To investigate the risk of subsequent tumour recurrence and stage progression in bacillus Calmette-Guérin (BCG)-relapsing non-muscle-invasive bladder cancer, defined as recurrence after achieving a disease-free status for 6 months.

PATIENTS AND METHODS

  • • A total of 183 patients with BCG-relapsing tumours were treated with conservative therapy between 1985 and 2008 at our three institutions.
  • • We analysed the association between their clinicopathological parameters and subsequent tumour recurrence or stage progression.

RESULTS

  • • Additional induction courses of BCG or anticancer drug (mitomycin C or epirubicin) instillations were performed in 119 patients and 24 patients, respectively. The remaining 40 patients did not undergo any adjuvant therapy.
  • • Multivariate analysis showed that a relapsing tumour with a pathologically high risk (defined as tumours with G3 and/or pT1 and/or concomitant carcinoma in situ) was a significant risk factor for subsequent tumour recurrence (P= 0.002; hazard ratio [HR] 2.15). Additional BCG instillation significantly decreased the subsequent tumour recurrence rate (P < 0.001; HR 0.41).
  • • Multivariate analysis also showed that a relapsing tumour with a pathologically high risk was also significantly associated with stage progression (P < 0.001; HR 8.05).

CONCLUSIONS

  • • An additional course of BCG instillation might be effective in patients with BCG-relapsing tumours with pathologically intermediate risk.
  • • Nevertheless, some patients with high-risk pathological features developed subsequent stage progression. Such patients should be followed up closely and counselled on the need for aggressive therapeutic options, such as radical cystectomy.

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