Editing Non-Muscle Invasive Bladder Cancer (section)

== Prognosis ==

=== Recurrence ===
* '''<span style="color:#ff0000">Recurrence rate: ≈60-70%</span>'''
** '''Primary theories for recurrent tumor formation (2):'''
**# '''Genetic field defect exists with multiple new tumors spontaneously arising within the bladder'''
**# '''Local reimplantation of tumor cells after tumor resection'''
**#* '''Tumor cell implantation immediately after resection may be responsible for many early recurrences, and this has been used to explain the observation that initial tumors are most commonly found on the floor and lower sidewalls of the bladder, whereas recurrences are often located near the dome as a result of “flotation”'''
* <span style="color:#ff0000">'''Risk factors (3):[https://pubmed.ncbi.nlm.nih.gov/33938798/ $$]'''</span>
*# <span style="color:#ff0000">'''Prior recurrence rate'''</span> (<1 year)
*# <span style="color:#ff0000">'''Number of tumours'''</span>
*# <span style="color:#ff0000">'''Tumour size'''</span> (>3 cm)

=== Progression ===
* '''<span style="color:#ff0000">Progression rates (defined by higher grade or stage): ≈20-30%</span>'''
* '''<span style="color:#ff0000">Risk factors (3):[https://pubmed.ncbi.nlm.nih.gov/33938798/ $$]</span>'''
*# '''<span style="color:#ff0000">Grade (most important)</span>'''
*#* '''<span style="color:#ff0000">Grade more important than stage (unlike other cancers where stage is more important)</span>'''
*#** '''<span style="color:#ff0000">High-grade tumors progress with similar frequency regardless of whether they are invasive (T1) or non-invasive (Ta)</span>'''
*#** '''<span style="color:#ff0000">Stage Ta are usually LG; however, ≈7% of Ta disease is HG</span>'''
*# '''<span style="color:#ff0000">Stage (second most important)</span>'''
*#* '''<span style="color:#ff0000">TaLG: high recurrence rate (≈55%), but much lower stage progression rate ≈6%</span>'''
*#* '''<span style="color:#ff0000">T1HG: high recurrence rate (≈45%) and high progression rate ≈17% [different numbers than Chapter 93]</span>'''
*# '''<span style="color:#ff0000">CIS</span>'''
*#* If CIS is treated only with TURBT,
*#** High risk of recurrence (as high as 90%)
*#** High risk (> 50%) for progressing to muscle-invasive disease.
*#* Even patients with a complete response to intravesical BCG will experience progression in 30% to 40% of cases on longitudinal follow-up
*#* Concomitant CIS is associated with significantly increased risk of disease progression and disease-specific mortality
'''<span style="color:#ff0000">Other risk factors</span>'''
* '''Mentioned in [https://pubmed.ncbi.nlm.nih.gov/33938798/ 2021 CUA NMIBC Guidelines] (5):'''
*# '''<span style="color:#ff0000">Age > 70 yr</span>'''
*# '''<span style="color:#ff0000">Extensive invasion of the lamina propria</span>'''
*#* Extent of invasion of T1 tumours has been evaluated using two different criteria:
*## Micrometric: evaluates the millimetric extent of invasion into the lamina propria
*## Microanatomic: evaluates the level of invasion in relation to the muscularis mucosa (T1a – no muscularis mucosa invasion, T1b – invasion at the level of the muscularis mucosa and T1c – invasion beyond the muscularis mucosa)
*#*No single approach has been universally adopted
*# '''<span style="color:#ff0000">Lymphovascular invasion (LVI)</span>'''
*#* '''Retrospective studies demonstrate that the presence of LVI is an independent factor for progression in patients with high-risk NMIBC'''.
*#** '''Use of LVI as a prognostic variable on transurethral resection (TUR) specimen requires prospective validation'''
*#* In NIMBC, LVI is associated with increased risk of recurrence and progression in BCG-treated patients with T1 NMIBC[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4719750/ §]
*# '''<span style="color:#ff0000">Aggressive histological variants such as (3): micropapillary, plasmacytoid, and sarcomatoid</span>'''
*#* See Bladder Cancer: Pathology & TNM Staging
*#* '''<span style="color:#ff0000">Associated with under-staging and early progression to muscle invasive disease</span>'''
*# '''<span style="color:#ff0000">First assessment after TURBT</span>'''
*#* Persistent disease at the first surveillance cystoscopy after induction intravesical treatment has been shown to be a risk factor associated with progression
* '''Mentioned in Campbell’s'''
** '''Tumour architecture: papillary vs. sessile'''
** '''Status of the remaining urothelium'''

=== Cancer-specific Survival ===

* 70-85% in high-grade NMIBC[https://pubmed.ncbi.nlm.nih.gov/38265030/], higher in low-grade disease

=== Estimating Prognosis ===
*[http://www.eortc.be/tools/bladdercalculator/ European Organization for Research and Treatment of Cancer (EORTC) Risk Tables]
**Provides individualized probability of recurrence and progression of NMIBC 
**Developed from individual patient data from 2596 patients diagnosed with Ta/T1 tumours who were randomized in 7 EORTC trials.
**Estimates based on can be calculated based on (6):
**# Number of tumors
**# Tumor size
**# Prior recurrence rate
**# T category
**# Concomitant carcinoma in situ
**# Grade
** Note that the EORTC risk calculator likely overestimates the risk of recurrence and progression, as very few of the patients in these prospective trials received intravesical BCG