[2] Neoadjuvant intravesical chemotherapy to treat extended large non-muscle-invasive bladder cancer

Objective

To report our experience with the use of neoadjuvant intravesical chemotherapy in the treatment of large exophytic bladder tumours. About 75% of bladder cancers are superficial at diagnosis. Sometimes, symptoms are mild or absent, and the tumour can grow unnoticed into a large intra-luminal, bulky mass.

Methods

At transurethral resection of bladder tumour (TURBT), the aim was to perform a complete resection as far as possible, or at least a reliable tumour biopsy, and to resect to the tumour base to exclude deeply invasive disease. At 15 days postoperatively, patients were started on a short and intensive schedule of intravesical bladder chemotherapy with six doses of 40 mg mitomycin (MMC). This was followed by a second TURBT with deep bladder wall biopsies to complete resection and staging.

Results

In all reported cases, an initial complete resection was not possible. In seven cases (47%) T staging was inconclusive (Tx), with six of the seven cases having high-grade tumours and one a low-grade tumour. In the remaining eight of 15 cases, six (40%) were of a Ta-low grade, and two (13%) were of a T1-high grade. The two patients with a Ta-low grade tumour refused the option of immediate radical cystectomy (RC) and preferred a bladder-sparing treatment option. After neoadjuvant intravesical chemotherapy, complete resection was then feasible in all patients. One patient (7%) was consequently diagnosed with a T2 tumour and underwent RC. Two patients (13%) had no muscle cells in their histology and thus remained unstaged.

Conclusion

A neoadjuvant MMC schedule after initial incomplete resection of large non-muscle-invasive bladder tumours and before a second complete resection appears to be a viable and safe alternative. If done carefully and expediently, it does not delay a potentially curative early RC.