Investig Clin Urol.  2016 Jun;57(Suppl 1):S44-S51. 10.4111/icu.2016.57.S1.S44.

How do we manage high-grade T1 bladder cancer? Conservative or aggressive therapy?

• Yun SJ
• Kim SK
• Kim WJ

• KMID: 2426516
• DOI: http://doi.org/10.4111/icu.2016.57.S1.S44

Abstract

High-grade T1 bladder cancer has a poor prognosis due to a higher incidence of recurrence and progression than other nonmuscle invasive bladder cancer; thus patients with high-grade T1 have to be carefully monitored and managed. If patients are diagnosed with high-grade T1 at initial transurethral resection (TUR), a second TUR is strongly recommended regardless of whether muscle layer is present in the specimen because of the possibility of understating due to incomplete resection. Since high-grade T1 disease shows diverse clinical courses, individual approaches are recommended for treatment. In cases with low risk of progression, cystectomy could represent overtreatment and deteriorate quality of life irreversibly, while, in those with high risk, bacillus Calmette-Guérin (BCG) therapy may worsen survival by delaying definitive therapy. Therefore, a strategy for predicting prognosis based on the risk of progression is needed for managing high-grade T1 disease. Molecular risk classifiers predicting the risk of progression and response to BCG may help identify the optimal management of high-grade T1 disease for each individual.

Keyword

Disease progression; Therapeutics; Urinary bladder neoplasms

MeSH Terms

BCG Vaccine/therapeutic use
Cystectomy/methods
Disease Progression
Humans
Neoplasm Grading
Prognosis
Risk Factors
Urinary Bladder Neoplasms/diagnosis/pathology/*therapy

Figure

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  Fig. 1 T1 disease substaging systems based on depth or width of tumor infiltration. T1a, invasion above muscularis mucosae; T1b, invasion within muscularis mucosae; T1c, invasion below muscularis mucosae; T1m, a single focus of lamina propria invasion ≤0.5 mm; T1e, specimens showing >0.5 mm lamina propria invasion or multiple invasions.

• 

  Fig. 2 Unsupervised hierarchical clustering using 70 patients with T1 who did not experience progression, 10 patients with T1 who experienced progression, and 26 patients with T2 disease (GSE 13507). Interestingly, three of four patients with high-grade T1 who experienced progression were categorized as T2. This means that high-grade T1 gene expression patterns might already have muscle invasive bladder cancer characteristics at initial diagnosis. (A) Heatmap from microarray data. (B) Clustering with clinico-pathological variables. HG, high-grade.

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  Fig. 3 Long-term validation study of the progression-related gene classifier in patients with nonmuscle invasive bladder cancer. Progression-related eight-gene classifier could accurately predict the progression of nonmuscle invasive bladder cancer.

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  Fig. 4 Proposed algorithm for decision-making in high-grade T1 bladder cancer. TUR, transurethral resection; CIS, carcinoma in situ; BCG, bacillus Calmette-Guérin.

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