An updated critical analysis of the treatment strategy for newly diagnosed high-grade T1 (previously T1G3) bladder cancer.
BACKGROUND
High-grade T1 (formerly T1G3) bladder cancer (BCa) has a high propensity to recur and progress. As a result, decisions pertaining to its treatment are difficult. Treatment with bacillus Calmette-Guérin (BCG) risks progression and metastases but may preserve the bladder. Cystectomy may offer the best opportunity for cure but is associated with morbidity and a risk of mortality, and it may constitute potential overtreatment for many cases of T1G3 tumours. For purposes of this review, we continue to refer to high-grade T1 lesions as "T1G3."


OBJECTIVE
To review the current literature on the management of T1G3 BCa and to provide recommendations for its treatment.


METHODS
A National Center for Biotechnology Information (NCBI) PubMed search for relevant articles published between 1996 and 9 January 2009 was performed using the Medical Subject Headings "T1G3" or "T1" and "Bladder cancer." Articles relevant to the treatment of T1G3 BCa were retained.


RESULTS
The diagnosis of T1G3 disease is difficult because pathologic staging is often unreliable and because of the risk of significant understaging at initial transurethral resection (TUR) of bladder tumour. A secondary restaging TUR is recommended for all cases of T1G3. A single dose of immediate post-TUR chemotherapy is recommended. For a bladder-sparing approach, intravesical BCG should be given as induction with maintenance dosing. Immediate or early radical cystectomy (RC) should be offered to all patients with recurrent or multifocal T1G3 disease, those who are at high risk of progression, and those failing BCG treatment.


CONCLUSIONS
Both bladder preservation and RC are appropriate options for T1G3 BCa. Risk stratification of patients based on pathologic features at initial TUR or at recurrence can select those most appropriate for bladder preservation compared to those for whom cystectomy should be strongly considered.
Kulkarni
Girish S
GS
Division of Urology, Department of Surgery, University of Toronto, University Health Network, Toronto, Canada. girish1975@gmail.com
Hakenberg
Oliver W
OW
Gschwend
Juergen E
JE
Thalmann
George
G
Kassouf
Wassim
W
Kamat
Ashish
A
Zlotta
Alexandre
A
D000283:Administration, Intravesical; D000465:Algorithms; D000970:Antineoplastic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D001500:BCG Vaccine / Q000008:administration & dosage* / Q000009:adverse effects; D017024:Chemotherapy, Adjuvant; D015653:Cystectomy / Q000009:adverse effects / Q000379:methods; D018450:Disease Progression; D019317:Evidence-Based Medicine; D006801:Humans; D008207:Lymphatic Metastasis; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D018579:Patient Selection; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000556:secondary / Q000628:therapy*
D000970:Antineoplastic Agents; D001500:BCG Vaccine