title: [Superficial bladder neoplasia unresponsive to endocavitary treatment: when should the treatment approach be changed?].
abstract: OBJECTIVE
  The appropriate treatment of superficial bladder neoplasm is still debated. The urologist must weigh the risk of tumor recurrence and progression against the possible side effects of conservative treatment (transurethral resection, intravesical therapy). Furthermore it is difficult to decide exactly when to abandon the conservative therapy and proceed with radical cystectomy and urinary diversion in order to prevent the potentially lethal sequelae of invasive bladder cancer. There are no certain scientific data on the appropriate therapeutic approach of recurrences of superficial bladder cancer after intravesical therapy and often the urologist takes a decision based on his personal experience ("art rather than science"). Based on these considerations, our aim was to evaluate applicable criteria to predict the risks of tumor recurrence and progression and so decide the best treatment for each patient.
  
  
  METHODS
  148 patients with multifocal, multirecurrent or persistent superficial bladder cancer (stage Ta-T1-Tis, G1-3) were treated with transurethral resection and/or two or more administration of intravesical chemo- (Mitomycin C, Doxorubicin, Epirubicin, Mitoxantron) or immuno-therapy (BCG) using common treatment schedule. Our first end point was the disease-free survival (DFS) evaluated by three different criteria: 1) "dynamic" stage (stage T1 diagnosed at the beginning, or during the follow-up or never); 2) "dynamic" grade (G3 tumor diagnosed at the beginning or during the follow-up or never); 3) "number of positive cystoscopies at the 3-year follow-up". Data were evaluated by a univariate statistical analysis (log-rank test) and a multivariate ones (MPLR stepwise procedure and L-ratio Cox's test).
  
  
  RESULTS
  "Dynamic" stage: patients who never developed a T1 stage tumor have a better DFS than patients who developed a T1 stage tumor and even more than patients in which T1 was diagnosed from the beginning (p < 0.0001). "Dynamic" grade: patients who never developed a G3 tumor have a better DFS than patients who developed a G3 tumor and patients in which G3 tumor was diagnosed from the beginning (p < 0.0017). "Number of positive cystoscopies at the 3-year follow-up": patients with less than 3 positive cystoscopies have a better prognosis than patients with 3 or more positive cystoscopies at the three-year follow-up (p < 0.0380).
  
  
  CONCLUSIONS
  We have found three independent predictive prognostic factors: "dynamic" stage, "dynamic" grade and number of positive cystoscopies at the 3-year follow-up. The statistical univariate and multivariate analyses allow us to define three risk categories for tumor progression (> or = T2): low, moderate, high.
authors.affiliation: Istituto di Urologia, Università di Padova, Italia. bassipf@uxl.unipd.it
authors.forename: P
authors.initials: P
authors.lastname: Bassi
authors.forename: M
authors.initials: M
authors.lastname: Iafrate
authors.forename: R
authors.initials: R
authors.lastname: Spinadin
authors.forename: R
authors.initials: R
authors.lastname: Carando
authors.forename: R
authors.initials: R
authors.lastname: Iannello
authors.forename: M
authors.initials: M
authors.lastname: Repele
authors.forename: G
authors.initials: G
authors.lastname: Mostaccio
authors.forename: A
authors.initials: A
authors.lastname: Ingrassia
authors.forename: G
authors.initials: G
authors.lastname: Pappagallo
mesh_terms: D000283:Administration, Intravesical; D000970:Antineoplastic Agents / Q000009:adverse effects*; D002295:Carcinoma, Transitional Cell / Q000188:drug therapy* / Q000473:pathology; D006801:Humans; D017211:Treatment Failure; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy* / Q000473:pathology
chemical_list: D000970:Antineoplastic Agents