Treatment of High-Risk Non-Muscle-Invasive Bladder Cancer (T1 HG/G3 or CIS)
This first-line protocol applies to patients with non-muscle-invasive bladder cancer (NMIBC) classified in the high-risk group — a distinct subpopulation defined by tumour grade, depth of invasion, presence of carcinoma in situ, and specific additional clinical risk factors.
Clinical Scenario — Who Qualifies
Patients fall into this high-risk group under any of the following staging and risk-factor combinations:
- T1 high-grade / G3 tumour without carcinoma in situ (CIS)
- Carcinoma in situ (CIS) — any presentation
- Ta LG/G2 or T1 G1 without CIS, with all three additional risk factors (age >70, multiple tumours, tumour diameter >3 cm)
- Ta HG/G3 or T1 LG without CIS, with at least two of the three additional risk factors
- T1 G2 without CIS, with at least one additional risk factor
Excluded from this group: CIS involving the prostatic urethra, lymphovascular invasion, and aggressive urothelial carcinoma subtypes — these place the patient in a higher-risk category.
Treatment Approach (Partial Overview)
Management begins with endoscopic resection of the bladder tumour; in certain circumstances a second resection is performed within the following weeks. This is followed by a structured course of intravesical immunotherapy, with the treatment duration tailored to the patient's risk profile. Immediate radical surgery is also a consideration that should be discussed with the patient. The complete treatment algorithm — including the approach in BCG-naive patients and when additional systemic agents may apply — is available in the full protocol.
Treatment Goals
- No high-grade bladder tumour on cystoscopy at 3 months
- No carcinoma in situ on bladder biopsy at 6 months
- Negative urine cytology for high-grade urothelial carcinoma
References
- All T1 HG/G3 without CIS, EXCEPT those included in the very high-risk group.
- All CIS patients, EXCEPT those included in the very high-risk group.
- Ta LG/G2 or T1 G1, no CIS with all three risk factors.
- Ta HG/G3 or T1 LG, no CIS with at least two risk factors.
- T1 G2 no CIS with at least one risk factor.
- Perform a second TURBT in the following situations: after incomplete initial TURBT, or in case of doubt about completeness of a TURBT; if there is no detrusor muscle in the specimen after initial resection, with the exception of Ta LG/G1 tumours and primary CIS; in T1 tumours.
- If indicated, perform a second TURBT within two to six weeks after the initial resection.
- Offer intravesical full-dose BCG instillations for one to three years but discuss immediate radical cystectomy (RC).
- Immediate radical cystectomy (RC) should also be discussed with the patient.
- The first cystoscopy after TURBT at three months is an important prognostic indicator for recurrence and progression.
- If CIS (without concomitant papillary tumour) is present at three months and persists at six months after either re-induction or first course of maintenance.
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