1. Contemporary Treatment Guidelines on Bladder Cancer
Tony Wu.
Division of Urology
Kaohsiung Veterans General Hospital

2. AUA 2007 guidelines
EAU 2008 guidelines
NCCN guidelines v

5. Index Patient #1
Patient presents with an abnormal growth on the urothelium
Standard: biopsy should be obtained
Standard:complete eradication of all visible tumors
Standard: periodic surveillance cystoscopy
Option: immediate single dose intravesical chemotherapy
AUA

7. Index Patient #2 Small volume, low-grade Ta bladder cancer
Recommendation: Single dose intravesical chemotherapy immediately postoperatively
Single dose MMC: 17% fewer recurrences
Multiple doses:no additional benefit
AUA

8. Index Patient #3 Multifocal / large volume, low-grade Ta or
Recurrent low-grade Ta bladder cancer
Recommendation: An induction course of intravesical BCG or MMC
BCG:24%, MMC:3% fewer recurrences
Option: Maintenance BCG or MMC
BCG:31%, MMC:18% fewer recurrences
Affect progression ???
AUA

9. BCG Maintenance Therapy
SWOG regimens
6-wk induction course of BCG
3-wk maintenance courses at 3, 6, 12, 18, 24, 30, 36 months

10. Index Patient #4 High-grade Ta, T1, and/or CIS
Standard: For T1 patients repeat resection should be performed prior to additional intravesical therapy
In the absence of muscularis propria in specimen, 20% to 40% of patients will have either residual tumor and/or unrecognized muscle invasive disease
Recommendation: BCG induction + maintenance
AUA

11. Index Patient #4
Option: Cystectomy should be considered for initial therapy in select patients
It is not certain whether intravesical therapy alters risk of progression
high cure rate associated with cystectomy
large tumor size, high-grade, tumor location in a site poorly accessible to complete resection, diffuse disease, the presence of carcinoma in situ, infiltration of lymphatic or vascular spaces, and prostatic urethral involvement
AUA

12. Second TUR
Indicated when multiple and/or large tumors are present, or when specimen contained no muscle tissue.
When high-grade, T1 tumor has been detected at the initial TUR.
Second TUR can increase recurrence-free and progression-free survival (level of evidence: 2a).
Most authors recommend resection at 2-6 weeks after the initial TUR.
The procedure should include a resection of the primary tumor site.
EAU

13. EAU

14. Risk of recurrence and progression
EAU

15. EAU

17. NCCN guideline Ta,low-grade Ta,high-grade, or T1,low-grade:
Observation
Single dose chemotheapy within 24 hrs
Ta,high-grade, or T1,low-grade:
BCG instillation
T1, high-grade:
Re-TUR: positive: BCG or cystectomy
negative:BCG
Cystectomy

18. Index Patient #5
High-grade Ta, T1, CIS recurred after prior intravesical therapy
Standard: For T1 patients without muscularis propria in specimen, repeat resection should be performed prior to additional intravesical therapy
Recommendation: Cystectomy should be considered as a therapeutic alternative
Option: Further intravesical therapy
AUA

22. Adjuvant Chemotherapy

23. Not-resectable Tumor

24. Metastatic Disease