Displayed in above Chart after Second TURBT - T1 displays heterogeneous Entities.

heterogeneous mixture consists of visibly different substances or phases. The three phases or states of matter are gas, liquid, and solid.

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Course of Action

Course of Action : Alternative Intravescial BCG

Course of Action : Standard (Recommended) Radical Cystectomy.

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Treatment and Management of High-Grade T1 Bladder Cancer: what should we do after second TURBT?

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Most T1 Bladder Cancers are High Grade and have the potential to progress to Muscle Invasion and Extravesical Dissemination.

 

Many studies reported that ∼50% of patients displayed Residual Tumors when a Second Transurethral Resection was performed 2–6 weeks after the Initial Resection for patients who were diagnosed with T1 Bladder Cancer.

 

Furthermore, Muscle-Invasive Disease was detected by the Second Transurethral Resection in 10–25% of those patients. Therefore, a second transurethral resection is strongly recommended for patients newly diagnosed with high-Grade T1 Bladder Cancer in various guidelines. T1 Bladder Cancers are Heterogeneous in terms of progression and prognosis after the Second Transurethral Resection. 

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Optimal management and treatment should be considered for patients with T1 Bladder Cancer based on the Pathological findings for the Second Transurethral Resection Specimen.

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If the Second Transurethral Resection reveals Residual Tumors, aggressive treatments based on the pathological findings should be performed. Conversely, over-treatment with respect to the tumor status should be avoided.

 

Since the evidence of Pathological Diagnosis at the Second Transurethral Resection is insufficient and many retrospective studies were carried out before the Second Transurethral Resection era, Prospective Randomised studies should be conducted.

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Introduction

Bladder Cancer is the seventh most common cancer in men and the 17th most common in women worldwide. Approximately 75% of patients with Bladder Cancer present with Non-Muscle-Invasive Disease confined to the Mucosa [Ta or Carcinoma in situ (CIS)] or lamina propria (T1).

 

In Non-Muscle-Invasive Bladder Cancer (NMIBC), ∼70% of the patients present with Ta, 20% with T1 and 10% with CIS lesions. Most T1 tumors are high grade (HG) and have the potential to progress to Muscle Invasion and Extravesical Dissemination.

 

A long-term study of High-Risk NMIBC including T1 tumors showed progression and Cancer Death Rates as high as 53 and 34%, respectively. Thus T1 Bladder Cancers are associated with a significant risk of metastasis and death.

 

The International Bladder Cancer Group defines progression of NMIBC as an increase in the

T stage not only as development of T2 or greater, but also as an increase in the T stage from CIS or Ta to T1.

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Transurethral resection of bladder tumor (TURBT) is aimed at staging Ta, T1 or CIS and removing all Endoscopically Visible Lesions. However, many studies have reported that ∼50% of patients display residual tumors when a second TURBT is performed 2–6 weeks after the Initial Resection for patients who were diagnosed with T1 Bladder Cancer.

 

Furthermore, muscle-invasive bladder cancer (MIBC) is detected by the second TURBT in 10–25% of those patients. According to a meta-analysis, residual and up-staging rates at the second TURBT were 47 and 24%, respectively. Therefore, a second TURBT within 6 weeks after the Primary TURBT is strongly recommended for patients newly diagnosed HG T1 Bladder Cancer in various guidelines.

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In any case, T1 bladder cancers are Heterogeneous with respect to progression and prognosis after a second TURBT. Some tumors have the potential to progress to Muscle-Invasive or Metastatic Disease, which should be considered when deciding whether to perform aggressive treatment, e.g. Radical Cystectomy.

 

On the other hand, some Tumors can be completely resected by the Initial TURBT, meaning that aggressive Post-TURBT Treatment may be excessive. Although the current standard treatment for patients with HG T1 bladder cancer who have pT0 histology at the second TURBT is Intravesical Bacillus Calmette-Guérin (BCG) therapy, there is no evidence concerning whether Intravesical additional therapy is necessary for those patients.

 

Thus, Optimal Management and treatment should be considered for patients with T1 bladder cancer based on the pathological findings for the Second TURBT Specimen.

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Conclusions

T1 Bladder Cancers are considered to be Invasive with the potential to progress to Muscle-Invasive or Metastatic Disease. Second TURBT is mandatory in all patients who are diagnosed with T1 Bladder Cancer at the Initial TURBT.

 

If the second TURBT reveals Residual Tumours, aggressive treatments should be performed based on the Pathological findings. High-Quality TURBT (for both the Initial TURBT and Second TURBT) is required, which may influence the Oncological outcome thereafter.

 

Since the evidence for each situation of Pathological Diagnosis at the Second TURBT is insufficient and many retrospective studies were carried out before the Second TURBT era, prospective randomised studies should be conducted to establish the standard treatment strategies for HG T1 Bladder Cancers that are Heterogeneous Clinical Entities.

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Most Tumours are Understaged at Initial TURBT.

There is no doubt about the need to perform Radical Cystectomy for patients with Muscle-Invasive Disease at the Second TURBT. Most of these Tumours are understaged at the Initial TURBT due to Technical Problems.

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