What is the treatment for a 78-year-old patient with high-grade non-muscle invasive urothelial carcinoma (NMIBC) of the urinary bladder, with carcinoma invading the lamina propria and muscularis propria present but not involved?

Treatment of High-Grade Non-Muscle Invasive Bladder Cancer in a 78-Year-Old Patient

Intravesical BCG therapy is the recommended first-line treatment for this 78-year-old patient with high-grade non-muscle invasive bladder cancer (NMIBC) invading the lamina propria (T1). 1

Disease Classification and Risk Assessment

This patient has:

• High-grade urothelial carcinoma
• Invasion into lamina propria (T1)
• Muscularis propria present but not involved
• Age: 78 years

This classifies the patient as having high-risk non-muscle invasive bladder cancer according to NCCN guidelines 1.

Treatment Algorithm

Step 1: Ensure Complete Initial Resection

• Verify that the initial TURBT (Transurethral Resection of Bladder Tumor) was complete
• A second/repeat TURBT is strongly recommended within 2-6 weeks of the initial resection 1
  • This is critical as residual disease is found in up to 27% of patients with T1 tumors even when muscle was present in the original specimen 1

Step 2: Intravesical Therapy

• Primary treatment: Intravesical BCG immunotherapy 1
  • Full-dose BCG induction (once weekly for 6 weeks)
  • Followed by maintenance therapy (minimum 1 year, preferably 3 years) 1
  • BCG is superior to chemotherapy in preventing recurrences of high-grade T1 tumors 1

Step 3: Follow-up and Surveillance

• Cystoscopy and urinary cytology every 3 months for the first 2 years 1
• If no recurrence, increase intervals in subsequent years
• Upper tract imaging every 1-2 years 1

Alternative Options for BCG Failure or Intolerance

If the patient fails BCG therapy or cannot tolerate it:

1. Radical cystectomy - Should be strongly considered, especially for high-grade T1 disease 1, 2
2. Alternative intravesical agents - Mitomycin C, gemcitabine, or device-assisted chemotherapy 2

Important Considerations

• Age factor: At 78 years, the patient's comorbidities and functional status should be evaluated when considering the intensity of maintenance therapy, but age alone should not preclude BCG treatment 3

• BCG efficacy: Meta-analyses demonstrate that BCG after TURBT is superior to TURBT alone or TURBT with chemotherapy in preventing recurrences of high-grade T1 tumors 1

• Progression risk: Without appropriate treatment, high-grade T1 tumors have a significant risk (10-15%) of progression to muscle-invasive disease 2

Common Pitfalls to Avoid

1. Skipping repeat TURBT: Failure to perform a second TURBT can lead to understaging and inadequate treatment 1

2. Inadequate BCG course: Using reduced doses or shortened maintenance schedules results in suboptimal outcomes for high-risk patients 2

3. Delaying definitive treatment: Postponing radical cystectomy until progression to muscle-invasive disease may negatively impact survival in BCG-refractory cases 2

4. Insufficient follow-up: High-grade T1 tumors require rigorous surveillance due to their high recurrence and progression potential 1

By following this treatment algorithm, the patient has the best chance of avoiding disease recurrence and progression while maintaining quality of life and bladder function.