What is the follow-up for a 60-year-old man diagnosed with a single focus of Carcinoma In Situ (CIS) and treated with six doses of Bacillus Calmette-Guérin (BCG)?

Follow-Up Protocol for a 60-Year-Old Man with CIS Treated with BCG

For a 60-year-old man diagnosed with a single focus of carcinoma in situ (CIS) and treated with six doses of BCG, the recommended follow-up includes cystoscopy and urinary cytology every 3 months for the first 2 years, every 6 months in years 3-4, and then annually thereafter, along with upper tract imaging every 1-2 years.

Initial Follow-Up Evaluation (3 Months Post-BCG)

After completing the 6-week BCG induction course, the first critical evaluation should occur at 12 weeks (3 months) from the start of therapy 1. This evaluation includes:

• Complete cystoscopy
• Urinary cytology
• Directed biopsies of any suspicious areas

Response Assessment

Based on the 3-month evaluation:

1. Complete response: If no residual disease is found:

   • Continue with surveillance protocol
   • Consider maintenance BCG (optional) 1

2. Persistent/recurrent disease: If CIS is still present:

   • A second 6-week course of BCG may be given (no more than 2 consecutive induction courses) 1
   • If disease persists after second BCG course, cystectomy should be strongly considered 1

Ongoing Surveillance Protocol

Years 1-2:

• Cystoscopy and urinary cytology every 3 months 1
• Upper tract imaging (CT urography, IVP, or MRI urogram) at least once within this period 1

Years 3-4:

• Cystoscopy and urinary cytology every 6 months if no recurrences 1
• Upper tract imaging every 1-2 years 1

Year 5 and beyond:

• Annual cystoscopy and urinary cytology 1
• Continued upper tract imaging every 1-2 years 1

Special Considerations

Positive Cytology with Negative Cystoscopy

If follow-up shows positive cytology but negative cystoscopy:

• Perform directed or selected mapping biopsies, including TUR biopsies of the prostate 1
• Evaluate upper tract with cytology and consider ureteroscopy 1
• Urine molecular tests for urothelial tumor markers may be considered (category 2B recommendation) 1

Monitoring for Extravesical Involvement

Particular attention should be paid to:

• Upper urinary tract recurrence (occurs in approximately 11% of patients) 2
• Prostatic urethral involvement (occurs in approximately 5% of patients) 2
• Urethral involvement (particularly concerning as it has high risk for progression) 3

Management of Recurrence

If recurrence is detected during follow-up:

1. Non-invasive recurrence:

   • Repeat TURBT
   • Consider additional intravesical therapy based on the stage/grade of recurrence 1

2. Progression to invasive disease:

   • Radical cystectomy is recommended 1
   • Patients with recurrent superficial tumors before progression to muscle-invasive disease are generally not considered candidates for bladder-sparing approaches 1

Important Caveats

• CIS is a high-grade lesion with significant risk of progression to invasive disease if not properly monitored 1
• The complete response rate to BCG therapy is approximately 68-86.5% 4, 2
• The 5-year progression-free survival rate is approximately 78.5% 2
• The extent of CIS (focal vs. multifocal) is an important prognostic factor for progression 2
• Patients with persistent disease after the first course of BCG have a greater risk of failure (50%) compared to responders (17%) 4

This rigorous follow-up protocol is essential as CIS represents a high-grade lesion with significant risk for progression to invasive bladder cancer if not properly monitored and managed.