Treatment of Multifocal, Non-invasive High-Grade Papillary Urothelial Carcinoma

Primary Treatment Options

The National Comprehensive Cancer Network recommends intravesical BCG therapy as the first-line treatment option for patients with multifocal, non-invasive high-grade papillary urothelial carcinoma, involving the right ureter and bladder, who have had unsuccessful surgical resection attempts 1, 2
BCG is the preferred intravesical agent for high-grade, non-invasive urothelial carcinoma and should be administered as a 6-week induction course followed by maintenance therapy, as recommended by the National Comprehensive Cancer Network 1, 2
BCG has demonstrated superior efficacy compared to chemotherapy in preventing recurrences of high-grade Ta tumors, as confirmed by multiple meta-analyses, with a high strength of evidence 2, 3

The National Comprehensive Cancer Network defines BCG-refractory as persistent high-grade disease at 6 months despite adequate BCG treatment, and BCG-relapsing as recurrence of high-grade disease after achieving disease-free state at 6 months, with a moderate strength of evidence 4, 7
Radical cystectomy remains the standard recommendation for BCG-unresponsive disease due to high risk of progression, as recommended by the European Association of Urology, with a high strength of evidence 4, 7
Thermochemotherapy has shown 2-year disease-free survival in 47% of patients with BCG-unresponsive disease, with a low strength of evidence 4, 7

The National Comprehensive Cancer Network recommends urinary cytology and cystoscopy every 3 months for the first 1-2 years, with a moderate strength of evidence 2, 3
Gradually increasing intervals for follow-up examinations after the initial 2 years if no recurrence, as recommended by the National Comprehensive Cancer Network, with a moderate strength of evidence 2, 8
Imaging of the upper urinary tract every 1-2 years for high-grade tumors, with a moderate strength of evidence 2, 3

The European Association of Urology recommends considering more aggressive follow-up schedule for patients with involvement of both bladder and upper tract due to higher risk of recurrence, with a moderate strength of evidence 4
Failure to adequately treat both the bladder and upper tract components can lead to recurrence, with a high strength of evidence 4
Delayed recognition of progression to muscle-invasive disease can worsen prognosis, as recommended by the National Comprehensive Cancer Network, with a high strength of evidence 2, 4