Survival risk factors in T1G3 non-muscle-invasive (NMI) bladder cancer consevatively treated. Long term results.

Introduction: The most relevant risk factor in T1G3 NMI transitional cell carcinoma of the bladder (TCCB) is the presence of Tis. The long term results of conservative management still are a matter of controversy. The role of BCG in preventing progression and death in this category of NMI TCCB is not definitely proved. The published experiences of conservative treatment of high risk TCCB often include unselected patients, small numbers and short follow-up. Immediate radical cystectomy is advocated by many urologists. Objectives: The aim of the study is to identify the survival risk factors in 236 selected patients conservatively treated. Methods: Between January 1976 and December 2005, 236 patients with T1G3 bladder tumors were treated by TUR plus adjuvant intravesical therapy. Patients with previuos T1G3, Tis, more than 3 tumors or greater than 3 cm were excluded. Tumors were primary in 177 (75.3%) and single in 144 (61.5%) cases. Urinary cytology was obtained within 30 days after TUR, the last 51 (21.6%) patients, since 2000, were submitted to re-TUR. A sequential combination of mitomycin C (30mg/30ml) and epirubicin (50mg/50ml) was adopted in 106 patients (44.9%). BCG or other agents were given intravesically in 85 (36.0%) and 38 (16.1%) patients respectively for 12 months. Seven (3%) patients refused intravescical therapy. In the case of Ta-T1 recurrence. TUR and one year of adjuvant intravesical therapy were repeated. Patients went off study if Tis, T1G3 or T-category tumor over T1 were detected. Age, previuos history, number of tumors, time to recurrence, re-TUR, adjuvant therapy, and response to treatment were considered for survival in multivariate analysis. Results: At a mean follow-up period of 52 months (range: 3-246 months), 116 patients (49.2%) recurred. The recurring tumor was T1 in 47 (40.5%) cases and T1G3 in 33 cases (28.4%). In 11 additional patients (9.5%) a Tis was detected. Twenty-five patients (10.6%) progressed and 15 patients (6.4%) underwent cystectomy. Median overall survival was 167 months. Median survival in 195 patients (82.6%) preserving their bladder was 119 months. The 5-year progression-free survival rate was 87.8%. Thirty-two patients (13.6%) died, 22 (9.3%) for bladder cancer.. Recurrence was found significantly lower in single tumors (p=0.012) and in BCG-treated patients (<0.0001). Primary (p= 0.002) and single (p=0.009) tumors, BCG therapy, the absence of recurrence (p<0.0001) and/or progression (p=0.009) during conservative management were characterized by a longer survival. Conclusions: Previous positive history and multiplicity are relevant risk factors for survival in patients affected by T1G3 NMI TCCB conservatively treated. Conservative management can not be applied to all T1G3 bladder tumors since recurrence and progression are related to a higher mortality.