Effectiveness of transurethral resection under the control of photodynamic diagnosis and intravesical instillation of bacillus Calmette–Guérin in case of poorly differentiated non-muscle-invasive bladder cancer

Abstract

Background. High-grade non-muscle-invasive bladder cancer (NMIBC) is characterized by a high rate of recurrence, progression, and mortality associated with this disease. Organ-preserving treatment by transurethral resection and immunotherapy with bacillus Calmette-Guerin (BCG) is an initial approach to therapy in these patients. However, the efficacy of such therapy is limited. This justifies the use of other methods of treatment, such as TUR under the control of photodynamic diagnosis (PDD). Aim of this study was to evaluate the effectiveness of therapeutic interventions in patients with high-grade NMIBC. Materials and methods. We have retrospectively analyzed results of follow-up of patients with primary or recurrent high-grade transitional cell NMIBC, treatment by TUR in conjunction with BCG or without it N.N. Alexandrov National Cancer Centre in the period from 2004 to 2013. In total, the study included 113 patients (27 women and 86 men), in the median age of 72 years. We have evaluated 5-year recurrence- and progression-free survival, analyzed an influence of prognostic factors and methods of treatment on the risk of recurrence and progression with Cox model and Kaplan–Meier method. Results. With a median of follow up of 59 (12–116) months the rates of 5-year recurrence- and progression-free survival were respectively 42.5 and 71.6 %. Statistically significant association with the risk of recurrence was observed in multivariate Cox regression analysis for recurrent tumors (hazard ratio (HR) 2.73; 95 % confidence interval (CI) 1.61–4.62) and immunotherapy with BCG (HR 0.56; 95 % CI 0.31–0.99). BCG significantly increased recurrence-free survival in patients with both primary tumors, and with recurrent ones. Significant factors in the multivariate analysis with regard to the risk of progression were suspicion for muscle-invasive tumors according to the cystoscopic picture (HR 3.36; 95 % CI 1.09–10.4), abnormal tumor-free bladder mucosa, suspicious for carcinoma in situ (HR 7.23; 95 % CI 2.64–19.8), localization of tumor in the bladder neck, orifice zone, prostatic urethra (HR 2.91; 95 % CI 1.17–7.25) and PDD-assisted TUR (HR 0.10; 95 % CI 0.01–0.78). TUR under the control of photodynamic diagnosis significantly increased the survival to progression, regardless of the risk of progression, while BCG did not significantly affect the progression-free survival. Conclusions. 6-week course of BCG therapy in patients with high-grade NMIBC significantly reduces the risk of recurrence and has no effect on the risk of tumor progression. PDD-assisted TUR provides a significant reduction in the risk of progression, but not recurrence. The findings justify the inclusion of both modalities in the treatment of high-grade NMIBC.