title: Characterizing intermediate-risk non-muscle-invasive bladder cancer: Implications for the definition of intermediate risk and treatment strategy.
abstract: Patients with intermediate-risk non-muscle-invasive bladder cancer have traditionally been defined as those not included in the low- or high-risk groups. Therefore, the intermediate-risk group consists of heterogeneous patients.
  
  
  
  We reviewed 326 patients diagnosed with intermediate-risk tumors. We subclassified these patients into 3 groups according to their clinical courses. Group A included patients with initial and multiple low-grade tumors (N = 170). Group B consisted of patients with a low-grade tumor that recurred after a low-risk tumor (N = 97), and Group C consisted of patients with a low-grade tumor that recurred after a high-risk tumor (N = 59).
  
  
  
  The 2-year recurrence-free survival rate was significantly lower in Group C (42%) than in Groups A (69%, P<0.01) and B (70%, P<0.01). Regarding progression-free survival, no significant differences were observed among the groups. In total, 167 patients received adjuvant bacillus Calmette-Guérin (BCG), and 39 received adjuvant chemotherapy instillations. In Groups A and B, there were no significant differences in efficiency against tumor recurrence between BCG and chemotherapy. In Group C, the 5-year recurrence-free survival rate was 65% in patients receiving BCG, which was significantly higher when compared with patients receiving chemotherapy (P = 0.01). Furthermore, Group C included 11 BCG refractory cases, 5 of whom later experienced stage progression during follow-up.
  
  
  
  Our subclassification analysis suggested that intermediate-risk tumors that recurred after a high-risk tumor (Group C) should be treated with adjuvant BCG therapy, owing to the high probability of subsequent recurrence. Furthermore, the definition of intermediate risk may include some BCG refractory cases.
authors.affiliation: Department of Urology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Matsumoto
authors.affiliation: Department of Urology, Keio University School of Medicine, Tokyo, Japan. Electronic address: eiji-k@kb3.so-net.ne.jp.
authors.forename: Eiji
authors.initials: E
authors.lastname: Kikuchi
authors.affiliation: Department of Urology, Tokyo Saiseikai Central Hospital, Tokyo, Japan.
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Yanai
authors.affiliation: Department of Urology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Nozomi
authors.initials: N
authors.lastname: Hayakawa
authors.affiliation: Department of Urology, Tokyo Saiseikai Central Hospital, Tokyo, Japan.
authors.forename: Yujiro
authors.initials: Y
authors.lastname: Ito
authors.affiliation: Department of Urology, Tokyo Saiseikai Central Hospital, Tokyo, Japan.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Maeda
authors.affiliation: Department of Urology, Tokyo Saiseikai Central Hospital, Tokyo, Japan.
authors.forename: Hirohiko
authors.initials: H
authors.lastname: Nagata
authors.affiliation: Department of Urology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Akira
authors.initials: A
authors.lastname: Miyajima
authors.affiliation: Department of Urology, Keio University School of Medicine, Tokyo, Japan.
authors.forename: Mototsugu
authors.initials: M
authors.lastname: Oya
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D001500:BCG Vaccine / Q000627:therapeutic use*; D017024:Chemotherapy, Adjuvant; D018450:Disease Progression; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000188:drug therapy* / Q000601:surgery; D018570:Risk Assessment; D012307:Risk Factors; D001749:Urinary Bladder Neoplasms / Q000145:classification* / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery
chemical_list: D000970:Antineoplastic Agents; D001500:BCG Vaccine
keywords: BCG; Bacillus Calmette-Guérin; Intermediate risk; Non–muscle-invasive bladder cancer