A Risk-Stratified Approach to the Management of High- Grade T1 Bladder Cancer

Miles P. Mannas; Taeweon Lee; Timo K. Nykopp; Jose Batista da Costa; Peter C. Black


Curr Opin Urol. 2018;28(6):563-569. 

In This Article

Abstract and Introduction


Purpose of review: A bladder-preserving approach for high-grade nonmuscle invasive bladder cancer that has invaded the lamina propria (T1HG) may result in increased recurrence, progression, and even death from bladder cancer in some patients. Initial radical cystectomy does have increased cancer-specific survival (CSS), but represents significant overtreatment for many patients. An evidence-based, risk-stratified approach is required to select patients for immediate radical cystectomy in order to improve CSS.

Recent findings: A restaging transurethral resection aids in optimal staging and treatment of T1HG. Intravesical Bacillus Calmette-Guerin induction followed by 3 years of maintenance is the standard adjuvant management. However, when very high-risk (hydronephrosis, abnormal bimanual examination, variant histology, lymphovascular invasion, or residual disease on re-resection, and Bacillus Calmette-Guerin failure or early recurrence) or multiple high-risk factors (concomitant CIS, size >3 cm, multifocality, unfavorable tumor location, extensive lamina propria invasion, and elderly) are present, the risk of progression often outweighs the risk associated with radical cystectomy. In these cases, an immediate radical cystectomy likely provides an improved opportunity for cure compared to a bladder-preserving strategy.

Summary: In order to increase the CSS of patients diagnosed with T1HG bladder cancer, an aggressive approach may benefit those with increased risk of progression.


High-grade urothelial carcinoma of the bladder (UCB) invading into the lamina propria (stage T1) represents a well defined entity that differs from both muscle invasive bladder cancer (MIBC), and noninvasive tumors [Ta and carcinoma in situ (CIS)]. High-grade T1 (T1HG) not only has a high rate of recurrence and progression, but also a non-negligible risk of metastatic dissemination. Representing 10–20% of all new UCB diagnoses, many will recur and approximately 20% will progress to MIBC within 5 years.[1,2] In the subset of patients with T1HG who undergo radical cystectomy, 30–48% show pathologic upstaging and 16–20% have lymph node metastasis. The cancer-specific mortality (CSM) can be as high as 13.3–34%.[1–5]

Although these numbers reflect the high-risk nature of T1HG UCB, a bladder-sparing approach is typically preferred, and only less than 5% of patients undergo immediate radical cystectomy in routine practice.[6] Immediate radical cystectomy implies that the patient proceeds directly to radical cystectomy after the diagnosis of T1HG without any adjuvant intravesical therapy. The merits of immediate radical cystectomy, which include reduced risk of recurrence, progression, and metastasis, must be balanced with the high rate of morbidity (up to 60%) and a 2–9% risk of mortality, even in the best of surgical hands.[7,8] There is no question that radical cystectomy represents overtreatment in many cases. However, with immediate radical cystectomy, the 5-year cancer-specific survival (CSS) is 83–90%, which historically dropped to 52–67% with an initial bladder-sparing approach.[4,9] Current intravesical treatments (IVTs) have likely improved the outcomes of the bladder-sparing approach.[10]

Risk stratification to guide selection of T1HG patients for immediate radical cystectomy versus bladder preservation remains an issue of much debate.[4,6] Clinical risk scoring systems have been developed, but their predictive ability has been poor.[5,11,12] Molecular biomarkers may offer guidance in the future, but none is yet established in clinical practice.[13] Here, we aim to review the clinical and pathologic risk parameters that can be used to optimize the management of patients with TIHG UCB. Recommendations for immediate radical cystectomy must take into account the increased risk of CSM with bladder preservation, while mitigating the probability of overtreatment by taking into account individual risk factors for progression and CSM.