What is the appropriate treatment for a 79-year-old patient with recurrent stage T1a high-grade bladder cancer, who has failed BCG (Bacillus Calmette-Guérin) intravesical therapy and chemo-radiotherapy, and has significant comorbidities including impaired renal function (kidney failure stage 3B), hypertension, diabetes, heart failure with reduced ejection fraction, and an abdominal aneurysm, making radical surgery not a viable option?

Management of BCG-Refractory High-Grade T1a Bladder Cancer in a High-Risk Surgical Patient

For this 79-year-old patient with BCG-refractory high-grade T1a bladder cancer who cannot undergo radical cystectomy due to severe comorbidities (stage 3B CKD, heart failure with EF 30%, abdominal aneurysm), palliative transurethral resection of bladder tumor (TURBT) combined with palliative radiotherapy represents the most appropriate treatment approach to control symptoms and maintain quality of life. 1, 2

Understanding the Clinical Context

This patient has BCG-refractory disease, which is defined as persistent or recurrent high-grade disease despite adequate BCG therapy. 3, 4 The standard recommendation for BCG failure in high-grade T1 disease is radical cystectomy, as this achieves long-term survival rates exceeding 90%. 1, 5 However, this patient's multiple severe comorbidities—particularly the combination of heart failure with severely reduced ejection fraction (30%), stage 3B chronic kidney disease, and abdominal aneurysm—make radical surgery prohibitively high-risk and not a viable option. 1

The patient has also failed chemo-radiotherapy, which further limits treatment options and indicates aggressive disease biology. 1

Primary Treatment Recommendation: Palliative TURBT

Palliative TURBT should be performed as the initial intervention to debulk visible tumor and control local symptoms such as hematuria, dysuria, and urinary obstruction. 1, 6

• This procedure is less invasive than cystectomy and can be performed even in patients with significant comorbidities 1
• TURBT provides immediate symptom relief and reduces tumor burden 1, 6
• The goal is palliative rather than curative, focusing on maintaining quality of life 1

Secondary Treatment: Palliative Radiotherapy

Following TURBT, palliative radiotherapy should be administered to achieve durable local control and symptom management. 1, 2

Radiation Dosing and Technique

• Dose: 20-30 Gy delivered in 5-10 fractions for purely palliative intent, or up to 50 Gy in 25 fractions if the patient can tolerate a more aggressive approach 6, 2
• The higher dose (50 Gy) has demonstrated complete pain resolution and symptom control in patients with recurrent bladder cancer 2
• Radiation should be delivered using 3D-conformal radiation therapy or IMRT techniques 1

Evidence for Palliative Radiotherapy

A case report of an 80-year-old woman with recurrent bladder cancer and intractable pelvic pain demonstrated complete pain resolution with 50 Gy in 25 fractions, allowing significant reduction in opioid requirements and improvement in quality of life. 2 This represents the highest quality evidence for palliative radiotherapy in this specific clinical scenario.

Why Systemic Chemotherapy is NOT Recommended

Systemic chemotherapy should be avoided in this patient due to renal insufficiency and cardiac dysfunction. 1

• Standard cisplatin-based regimens (gemcitabine-cisplatin or MVAC) require adequate renal function and are contraindicated in stage 3B CKD 1
• Carboplatin-based regimens are less effective and still carry significant cardiac and renal toxicity 1
• The patient's heart failure with EF 30% significantly increases the risk of anthracycline cardiotoxicity (if MVAC were considered) 1
• Given prior failure of chemo-radiotherapy, the likelihood of response to systemic chemotherapy is low 1

Alternative Intravesical Salvage Therapy Considerations

Repeat intravesical therapy is generally not recommended after BCG failure in high-grade T1 disease, but could be considered if the patient shows favorable response to TURBT and radiotherapy. 3, 4, 5

• Alternative intravesical agents (valrubicin, gemcitabine, mitomycin, thermochemotherapy) have shown limited efficacy after BCG failure 1, 4, 5
• These options are considered investigational and oncologically inferior to cystectomy 5
• The patient's renal dysfunction may limit tolerance of intravesical chemotherapy 4
• Given the patient has already failed both BCG and chemo-radiotherapy, further intravesical therapy is unlikely to provide meaningful benefit 3, 5

Surveillance Protocol

Close monitoring is essential to detect progression and manage complications. 1

• Cystoscopy and urinary cytology every 3 months for the first 2 years, then every 6 months thereafter 1
• Imaging (CT abdomen/pelvis or MRI) every 3-6 months to assess for progression or metastatic disease 1
• Monitor for upper tract disease with imaging every 6-12 months 1
• If positive cytology occurs without visible bladder disease, perform selective upper tract washings and prostatic urethral biopsy 1

Management of Disease Progression

If invasive recurrence or progression occurs despite palliative treatment: 1

• Additional palliative TURBT can be repeated for symptom control 1
• Additional palliative radiotherapy may be limited if the patient has already received a full course (>65 Gy cumulative dose) 1
• Best supportive care with aggressive symptom management becomes the primary focus 1, 2

Critical Pitfalls to Avoid

• Do not delay palliative intervention while attempting additional intravesical salvage therapies, as high-grade T1 BCG-refractory disease has significant progression risk 3, 5
• Do not attempt cisplatin-based chemotherapy in the setting of stage 3B CKD, as this will cause further renal deterioration and potential dialysis requirement 1
• Do not overlook the abdominal aneurysm when planning any intervention, as BCG therapy has been associated with infectious aneurysms in rare cases 7
• Do not perform aggressive surgical resection given the cardiac risk—even partial cystectomy would carry prohibitive perioperative mortality risk with EF 30% 1

Pain and Symptom Management

Multimodal pain management should be implemented proactively. 2

• Palliative radiotherapy provides excellent pain control and should be the primary pain management strategy 2
• Opioid medications, NSAIDs (if renal function permits), and gabapentin for neuropathic components 6, 2
• Early involvement of palliative care services to optimize quality of life 2

Prognosis Discussion

The patient and family should understand that this is a palliative approach focused on symptom control and quality of life rather than cure. 1, 2 High-grade T1 disease that has failed BCG and chemo-radiotherapy carries a poor prognosis, with high risk of progression to muscle-invasive or metastatic disease. 3, 5 The goal is to maximize remaining quality of life while minimizing treatment-related morbidity. 2