MANAGEMENT OF STAGE T1 TUMORS OF THE BLADDER: INTERNATIONAL CONSENSUS PANEL ALAN M. NIEDER, MAURIZIO BRAUSI, DONALD LAMM, MICHAEL O’DONNELL, KYOUICHI TOMITA, HENRY WOO, AND MICHAEL A. S. JEWETT ABSTRACT The International Consensus Panel on T1 bladder tumors markers reviewed the subject from a clinical perspective. From diagnosis to treatment decisions, what are the important issues in the management of a new patient? The assessment of prognostic factors for progression requires optimal resection and documentation. The role of immediate adjuvant intravesical chemotherapy after resection remains controversial. How often should the upper tract be assessed for tumor recurrence? The decision on whether to attempt bladder conservation with intravesical therapy or to perform a cystectomy is the most difficult issue in the management of superficial bladder cancer today. Finally, what therapies exist if initial intravesical bacille Calmette-Guérin fails to eradicate the disease or prevent recurrence? The panel thoroughly explored all these subjects and has made recommendations with supporting evidence. UROLOGY 66 (Suppl 6A): 108–125, 2005. © 2005 Elsevier Inc. M ost superficial stage T1 urothelial bladder cancers are high grade and appear to grow rapidly with the potential not only to recur but also to progress to invasion, metastases, and death. In this article, we focus on the elements of treatment success that we define as disease-free survival with a high quality of life, including bladder sparing where possible. Figure 1 is an algorithm for the management of stage T1 urothelial tumors presenting as new or recurrent tumors after previous management of lower-stage tumors. Virtually all T1 urothelial tu- mors are high-grade lesions histologically and present a serious risk of progression in stage by invasion or metastases. Timely and aggressive management of these tumors is essential to mini- mize the risk for the patient. Urologists, in partic- ular, are in a position to make a significant impact on the overall outcome of patients in this category. The following sections describe the sequential steps in the assessment, decision-making, and treatment of patients with T1 tumors. Urologists, pathologists, and radiologists must work together to not only diagnose new or recurrent tumors but also to accurately assess individual risk of progres- sion and to stratify patients for treatment. It is im- portant for the technique of transurethral resection of bladder tumors (TURBT) to be complete and to safely provide sufficient tissue for staging and grad- ing. Random and directed biopsies are frequently indicated. Immediate adjuvant chemotherapy should be used more frequently. In our opinion, repeat TURBT is mandatory if the surgeon cannot guarantee that a complete TURBT has been per- formed or when muscle is not present in the patho- logic specimen. Clinically useful prognostic factors have been defined to stratify patients by risk of progression. Substaging of T1 tumors has been de- scribed but remains controversial. Extravesical tu- mor extension can occur, particularly after bacille Calmette-Guérin (BCG) therapy with an initial complete response; thus screening should be per- formed. The most difficult decision is whether to initiate intravesical therapy or to recommend rad- ical therapy, usually with cystectomy. Initial intra- From the Department of Urology, State University New York at Stony Brook, Stony Brook, New York, USA (AMN); the Depart- ment of Urology, Estense-S. Agostino Hospital, Modena, Italy (MB); the Department of Urology, Bladder Cancer Genitourinary (BCG) Oncology, Phoenix, Arizona, USA (DL); the Department of Urology, University of Iowa, Iowa City, Iowa, USA (MO); the Department of Urology, University of Tokyo, Tokyo, Japan (KT); the Department of Urology, Westmead Hospital, Westmead, New South Wales, Australia (HW); and the Division of Urology, De- partment of Surgical Oncology, University Health Network, Prin- cess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada (MASJ) Reprint requests: Michael A. S. Jewett, MD, Division of Urol- ogy, Department of Surgical Oncology, University of Toronto, 610 University Avenue, 3-124, Toronto, Ontario M5G 2C4, Can- ada. E-mail: m.jewett@utoronto.ca © 2005 ELSEVIER INC. 0090-4295/05/$30.00 108 ALL RIGHTS RESERVED doi:10.1016/j.urology.2005.08.066