Re-treatment by intravesical therapy in recurring patients affected by intermediate risk non-muscle invasive bladder cancer (NMIBC)

Introduction & Objectives: Up to 70% of patients affected by intermediate risk NMI-BC recur after intravesical therapy (IT). The majority of them will be retreated by IT. The therapeutic strategy for these patients is not well defined. BCG is advocated when intravesical chemotherapy (ICH) fails. However, some patients are retreated by ICH and some others repeat BCG adopted as the first treatment. Not many studies have been published on second line IT. A retrospective analysis on 179 intermediate-risk patients undergoing re-treatment by IT is presented. Materials & Methods: The clinical files of patients affected by NMI-BC recurring after TUR and IT and retreated by IT were reviewed. The patients not receiving at least 6 instillations of BCG or ICH after the first diagnosis and again after the TUR of the first recurrence were excluded. Only mitomycin c and epirubicin were accepted as chemotherapy. Only intermediate-risk tumours with a recurrencerisk 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 interval (RFI) and progression considering, first line IT (BCG versus ICH), previous recurrence free interval, tumour’s T-category, G-grade, multiplicity, second line IT (BCG versus ICH) and maintenance regimen. Results: The study included 179 patients. The first line IT was ICH in 131 (73.2%) and BCG in 48 (26.8%) patients. The median RFI was 16 months. At recurrence, BCG in 83 (46.4%) and ICH in 96 (53.6%) patients were administered, 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 ICH, 88 (67.2%) received ICH again and 43 (32.8%) BCG. Thus, only 8 patients received ICH at recurrence after BCG. At a median follow-up of 29 months, 65 (36.3%) patients recurred with a median RFI of 15 months, 25 (30.1%) and 40 (41.7%) after BCG and ICH respectively. Thirteen patients showed progression at a median interval of 19 months. At multivariate analysis no statistically significant correlation was detected among the considered parameters. Surprisingly, no statistical difference emerged in terms of RFI between first and second line IT (16 versus 15 months), and between patients receiving BCG or ICH as second line therapy at recurrence after ICH (=0.28). Conclusions: No reduction in RFI emerged in patients with intermediate-risk NMIBC recurring after a first cycle of intravesical therapy and retreated by intravesical chemotherapy or BCG. In patients recurring after intravesical chemotherapy, intravesical chemotherapy and BCG, as a second line therapy, resulted equally effective in preventing recurrence.