Intravesical Therapy and Follow-up of Superficial Transitional Cell Carcinoma of the Bladder

Intravesical therapy is commonly used for the treatment of superficial transitional cell carcinoma (TCC) of the bladder. There are 2 major categories of intravesical therapy; chemotherapy and immunotherapy. The 2 types have different indications and different mechanisms of action. Chemotherapy: there is evidence that intravesical therapy fails to affect disease progression, nevertheless, chemotherapy in the form of thiotepa, mitomycin-C, doxorubicin or epirubicin has been recommended for those patients having low-grade, low-stage tumors (Ta, Grade 1-2) who have multiple tumors at presentation or whose recurrence rate on follow-up is unacceptable. While intravesical chemotherapy reduces the risk of recurrence during the first 3-6 month period after TUR, the difference in recurrence rates becomes less significant with increasing time after resection. Immunotherapy: unlike chemotherapy, intravesical immunotherapy in the form of BCG has been shown to reduce tumor recurrence and prevent progression. Patients who are suitable candidates for intravesical BCG include those with carcinoma in situ (CIS), or with T1 lesions that have been completely or incompletely resected, as well as those patients who have failed intravesical chemotherapy for low-grade, low-stage tumors. BCG must never be given immediately after tumor resection due to the possibility of severe systemic infection. To summarize, the authors practice regarding intravesical therapy for superficial bladder cancer, is the following: 1)for patients at low risk of progression, we initially resect the tumor and do not treat with intravesical therapy; 2)for patients at low risk of progression but with high risk of recurrence, (e.g., those with high grade TCC that are either stage Ta or stage T1), we treat with an immediate single post-TUR dose of thiotepa of 30 mg; 3)for recurrent, low risk tumors, we treat with a course of thiotepa; 4)for patients with a high risk for progression (e.g., those with high grade TCC and stage T1), we administer a 6-week course of BCG; 5)for patients at high risk for progression, where the next tumor recurrence would indicate a cystectomy, we will treat with a 6-week course of BCG followed by maintenance.