GuidelinesEAU Guidelines on Non–Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016
Introduction
This overview represents the updated European Association of Urology (EAU) guidelines for Non–muscle-invasive Bladder Cancer (NMIBC): TaT1 and carcinoma in situ (CIS). The information presented is limited to urothelial carcinoma, unless specified otherwise. The aim is to provide practical guidance on the clinical management of NMIBC with a focus on clinical presentation and recommendations.
Clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather they help to focus decisions, also taking personal values and preferences/individual circumstances of patients into account.
Section snippets
Evidence acquisition
A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines was performed. The search was limited to studies representing high levels of evidence (LE) only published in the English language. The search was restricted to articles published during the period from April 1, 2014, to May 31, 2015. Databases covered by the search included Medline, Embase, and the Cochrane Libraries. A total of 1040 unique records were identified, retrieved, and screened for relevance. A
Epidemiology
Bladder cancer (BCa) is the seventh most commonly diagnosed cancer in the male population worldwide. It drops to 11th when both genders are considered [1]. The worldwide age-standardised incidence rate (per 100 000 person-years) is 9.0 for men and 2.2 for women [1]. In the European Union, the age-standardised incidence rate is 19.1 for men and 4.0 for women [1]. In Europe, the highest age-standardised incidence rate was reported in Belgium (31 in men and 6.2 in women) and the lowest in Finland
Risk factors
Tobacco smoking is the most important risk factor for BCa, accounting for approximately 50% of cases [2], [4] (LE: 3). Occupational exposure to aromatic amines, polycyclic aromatic hydrocarbons, and chlorinated hydrocarbons accounts for about 10% of cases. This type of exposure occurs mainly in industrial plants processing paint, dye, metal, and petroleum products [2], [5]. Genetic predisposition has an influence on susceptibility to other risk factors [2], [6].
The chlorination of drinking
Definition of non–muscle-invasive bladder cancer
Papillary tumours confined to the mucosa or invading the lamina propria are classified as stage Ta or T1, respectively, according to the TNM classification system. Flat high-grade (HG) tumours confined to the mucosa are classified as CIS (Tis). These tumours are grouped under the heading of NMIBC for therapeutic purposes. However, molecular biology techniques and clinical experience have demonstrated the highly malignant potential of CIS and T1 lesions. Consequently, the terms NMIBC and
Patient history, signs, and symptoms
A comprehensive patient history is mandatory. Haematuria is the most common finding in NMIBC. CIS might be suspected in patients with storage lower urinary tract symptoms.
Physical examination
Physical examination does not reveal NMIBC.
Imaging
Computed tomography (CT) urography is used to detect papillary tumours in the urinary tract that can be seen as filling defects or indicated by hydronephrosis. Intravenous urography (IVU) can be an alternative if CT is not available [19] (LE: 3), but particularly in muscle-invasive
Prognosis of TaT1 tumours
To predict separately the short- and long-term risks of disease recurrence and progression in individual patients, the European Organisation for the Research and Treatment of Cancer-Genito-Urinary Cancer Group (EORTC-GUCG) developed a scoring system and risk tables [56]. These tables are based on individual patient data from 2596 patients with TaT1 tumours who were randomised into seven EORTC trials and did not undergo a second TURB or receive maintenance BCG.
The scoring system is based on the
Counselling of smoking cessation
It has been confirmed that smoking increases the risk of tumour recurrence and progression [66], [67] (LE: 3).
Intravesical chemotherapy
Although TURB by itself can eradicate a TaT1 tumour completely, these tumours commonly recur and can progress to muscle-invasive BCa. It is therefore necessary to consider adjuvant therapy in all patients.
Follow-up of patients with non–muscle-invasive bladder cancer
As a result of the risk of recurrence and progression, patients with NMIBC need to be followed up. However, the frequency and duration of cystoscopy and imaging should reflect the individual patient's degree of risk. When planning the follow-up schedule and methods, the following aspects should be considered:
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The prompt detection of muscle-invasive and HG/G3 NMIBC recurrence is crucial because a delay in diagnosis and therapy can be life threatening.
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Tumour recurrence in the low-risk group is
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Guidelines associate.