M.L. is a very healthy 60 year old woman who presented with an episode of gross hematuria in November 2018. A CT scan indicated a bladder tumor on the left wall. The upper urinary tract was normal. Her past medical history was entirely negative. An outpatient flexible cystoscopy identified a papillary exophytic solitary tumor on the left lateral wall of the bladder. The remainder of the bladder was normal.
She underwent a transurethral resection of the tumor (Figs. 1, 2). The pathology revealed a high grade urothelial carcinoma, which had minimal invasion into the lamina propria. Muscularis propria was present and uninvolved by the tumor. The stage was thus pT1a.
Papillary tumor left wall of the bladder.
Appearance of the bladder after the resection.
I considered a repeat TUR BT but after reviewing the histology with the urologic pathologist I was convinced that there was only microinvasion and a repeat resection would almost certainly find no cancer. A post TUR urine for cytology and bladder wash was negative for high grade cancer.
She received 6 weeks of BCG. This was well tolerated. A flexible cystoscopy in 1/19 identified a small cluster of abnormal urothelium in the area of the prior resection site, i.e. the left wall (Figs. 3, 4). A formal TUR of these areas was then performed (Figs. 5, 6). Most of the small “tumors” were removed with a cold cup forceps to avoid cautery artifact. The base was resected with the loop electrode. The pathology report was a nested variant of urothelial cancer with microinvasion into the lamina propria.
Small tumor left wall seen on post BCG cystoscopy.
Narrow band imaging of same area showing small tumors. They are not papillary and very small.
Small tumors at time of resection.
Post TUR tumor bed.
This presented a difficult decision. Is the presence of a new T1 tumor despite a 6 week course of BCG sufficient to warrant a cystectomy? Is a course of intravesical chemotherapy reasonable? These were clearly very small new tumors and not a recurrence of the initial tumor. Does the variant histology, i.e. nested, dictate a different approach?
After a thorough discussion with the patient who is reluctant to proceed with removal of her bladder she has been given gemcitabine weekly for 6 weeks.