CHOICE OF ADJUVANT INTRAVESICAL THERAPY IN RECURRING INTERMEDIATE-RISK NMI-BC

Objective: The therapeutic strategy for patients affected by intermediate risk non-muscle invasive bladder cancer (NMIBC) recurring after intravesical therapy is not definitively established. Only few studies have been published on secondline intravesical therapy. BCG is advocated when intravesical chemotherapy fails and is often repeated. On the other hand, some patients that suffer recurrence repeat intravesical chemotherapy. A retrospective analysis of 179 intermediaterisk patients submitted to second-line intravesical therapy is reported. Patients and Methods: The clinical files of patients affected by intermediate risk NMI-BC and submitted to second-line adjuvant intravesical therapy were reviewed. Patients not receiving at least six instillations of BCG or intravesical chemotherapy after the first diagnosis and again after the transurethral resection (TUR) of the first recurrence were excluded. Only mitomycin c and epirubicin were accepted as chemotherapy. Only patients with intermediaterisk tumors with a recurrence-risk score between 5 and 9 according to the EORTC risk tables and in absence of Tis were selected. A multivariate analysis was performed for recurrence-free survival (RFS) and progression, considering first line intravesical therapy (BCG versus ICH), previous recurrence-free interval, tumor T category, G grade, multiplicity, second-line intravesical therapy (BCG versus ICH) and maintenance regimen. Results: The study included 179 patients. Chemotherapy was administered as first-line therapy in 131 (73.2%) and BCG in 48 (26.8%) patients. Second-line therapy was represented by BCG in 83 (46.4%) and chemotherapy in 96 (53.6%) patients, with maintenance of at least 12 months in 31% and 38% of patients, respectively. Of the 48 patients previously treated by BCG, 40 (83.3%) received BCG again, while of the 131 previously treated by chemotherapy, 88 (67.2%) repeated it and 43 (32.8%) received BCG. At a median follow-up of 29 months after the second TUR, 65 (36.3%) patients experienced recurrence, 25 (30.1%) and 40 (41.7%) after BCG and chemotherapy, respectively. Thirteen patients showed progression at a median interval of 19 months. At multivariate analysis, no statistically significant correlation was detected. Surprisingly, no statistical difference emerged in terms of recurrence-free interval between first- and second-line therapy and between BCG and chemotherapy as second-line therapy at recurrence after chemotherapy (p=0.28) Conclusion: Almost 65% of patients experiencing recurrence after intravesical chemotherapy received intravesical therapy again. No difference in efficacy was detected between firstand second-line therapies or between BCG and chemotherapy given at recurrence after chemotherapy.