What are the next steps for a patient with a completely resected 2cm high-grade T1 (Tumor, stage 1) bladder tumor?

Management of a Completely Resected 2cm High-Grade T1 Bladder Tumor

For a completely resected 2cm high-grade T1 bladder tumor, a repeat TURBT within 2-6 weeks followed by intravesical BCG immunotherapy is strongly recommended as the next step in management. 1

Initial Management

Repeat TURBT

• A repeat transurethral resection of bladder tumor (TURBT) should be performed within 2-6 weeks of the initial resection for all high-grade T1 tumors, even if the initial resection appeared complete 1
• This recommendation is supported by evidence showing that repeat TURBT significantly improves 3-year recurrence-free survival (69% vs 37%) compared to no repeat TURBT 1
• Repeat TURBT is particularly important for high-risk features such as:
  • High-grade T1 tumors (as in this case)
  • Cases where complete resection is uncertain
  • When no muscle is present in the specimen
  • When lymphovascular invasion is present 1

Adjuvant Therapy After Repeat TURBT

• If no residual disease is found on repeat TURBT:

  • Intravesical BCG immunotherapy is the preferred treatment (category 1 recommendation) 1
  • BCG should be administered once weekly for 6 weeks, followed by a rest period of 4-6 weeks, with evaluation at 12 weeks after starting therapy 1, 2
  • Maintenance BCG therapy should follow the induction course to further reduce recurrence risk 1, 3

• If residual disease is found on repeat TURBT:

  • Intravesical BCG immunotherapy (category 1 recommendation) or consideration of cystectomy 1
  • For particularly high-risk T1 tumors (multifocal, with CIS, lymphovascular invasion, or variant histology), early cystectomy may be preferred due to high risk of progression 1

Evidence Supporting BCG Over Other Options

• BCG is FDA-approved for prophylaxis of primary or recurrent stage Ta and/or T1 papillary tumors following transurethral resection 2
• Multiple meta-analyses confirm that BCG after TURBT is superior to TURBT alone or TURBT with chemotherapy in preventing recurrences of high-grade Ta and T1 tumors 1
• Studies show that BCG therapy can reduce mortality by 23% in eligible patients 1
• Long-term studies demonstrate excellent outcomes with BCG for high-grade T1 tumors, with 70% of patients alive with intact bladder at median follow-up of 71 months 4

Follow-up Protocol

• Urinary cytology and cystoscopy every 3 months for the first 2 years 1, 5
• Increasing intervals for follow-up after the first 2 years if no recurrence 1
• Imaging of the upper tract should be considered every 1-2 years for high-grade tumors 1
• Urine molecular tests for urothelial tumor markers may be considered during surveillance (category 2B recommendation) 1

Potential Complications and Management

• BCG can cause local irritative symptoms (dysuria in up to 60% of patients) and flu-like symptoms lasting 48-72 hours 1
• Management of side effects with single-dose, short-term quinolones and/or anticholinergics can reduce adverse events 1
• If BCG is not tolerated, intravesical mitomycin C may be considered as an alternative, though it is less effective 1
• No more than 2 consecutive induction courses of BCG should be given if recurrence occurs 1

Special Considerations

• For patients with particularly high-risk T1 disease (multifocal lesions, vascular invasion, or recurrence after BCG), early cystectomy should be considered due to high risk of progression 1
• The 3-year recurrence-free survival rate with repeat TURBT followed by BCG is significantly higher than with a single TURBT (69% vs 37%) 1
• Maintenance BCG therapy doubles the median recurrence-free survival time compared to induction therapy alone 3