Clinical Scenario: Low-Grade T1 Tumor

A 72-Year-old woman with a 3 cm low-grade T1 tumor located in the bladder dome and without muscle present in the resected specimen
  • J. Alfred WitjesEmail author
  • Florine W. M. Schlatmann


In this chapter, we present our view on the diagnosis and treatment of a 72-year-old woman with a 3 cm low-grade T1 tumor located in the bladder dome and without muscle present in the resected specimen. Some factors would suggest a good prognosis; some suggest a high risk for recurrence and progression. We discuss age, gender, and tumor size (or, as a possible surrogate, tumor weight) as prognostic factors. Furthermore, variability in grading and staging and the diagnosis of low-grade T1 are addressed. Tumor location as a prognostic factor and the prognostic importance and technical aspects of the tumor resection are discussed. In light of a complete resection, re-resection, random biopsies and the value of fluorescence cystoscopy are reviewed and commented. Finally, we review additional therapies such as intravesical chemotherapy, BCG, and radical surgery in different clinical scenarios.


NMIBC Age Gender Size Location Review pathology Re-TURBT Random biopsies Fluorescence cystoscopy Treatment 



5-Aminolevulinic acid


American Association of Urology


Bacillus Calmette-Guérin


Carcinoma in situ


European Association of Urology


European Organization for Research and Treatment of Cancer


Fluorescence cystoscopy


High grade


Mitomycin C


Non-muscle-invasive bladder cancer


Single postoperative instillation


  1. 1.
    Joudi FN, Smith BJ, O’Donnell MA, Konety BR. The impact of age on the response of patients with superficial bladder cancer to intravesical immunotherapy. J Urol. 2006;175(5):1634–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Herr HW. Age and outcome of superficial bladder cancer treated with bacille CalmetteGuérin therapy. Urology. 2007;70(1):65–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Kohjimoto Y, Iba A, Shintani Y, Inagaki T, Uekado Y, Hara I. Impact of patient age on outcome following bladder-preserving treatment for non-muscle-invasive bladder cancer. World J Urol. 2010;28(4):425–30.PubMedCrossRefGoogle Scholar
  4. 4.
    Shariat SF, Sfakianos JP, Droller MJ, Karakiewicz PI, Meryn S, Bochner BH. The effect of age and gender on bladder cancer: a critical review of the literature. BJU Int. 2009;105(3):300–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Mungan NA, Aben KKH, Schoenberg MP, Visser O, Coebergh JWW, Witjes JA, Kiemeney LALM. Gender differences in stage-adjusted bladder cancer survival. Urology. 2000;55(6):876–80.PubMedCrossRefGoogle Scholar
  6. 6.
    Noon AP, Albertsen PC, Thoams F, Rosario DJ, Catto JWF. Competing mortality in patients diagnosed with bladder cancer: evidence of undertreatment in the elderly and female patients. Br J Cancer. 2013;108(7): 1534–40.PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Sylvester RJ, van der Meijden APM, Oosterlinck W, Witjes JA, Bouffioux C, Denis L, Newling DWW, Kurth KH. Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from 7 EORTC trials. Eur Urol. 2006;49(3):466–77.PubMedCrossRefGoogle Scholar
  8. 8.
    Hall MC, Chang SS, Dalbagni G, Pruthi RS, Seigne JD, Skinner EC, Wolf Jr JS, Schellhammer PF. Guideline for the management of nonmuscle invasive bladder cancer (stages Ta, T1, and Tis): 2007 update. J Urol. 2007;178(6):2314–30.PubMedCrossRefGoogle Scholar
  9. 9.
    Gontero P, Sylvester R, Pisano F, Joniau S, Van der Eeckt K, Serretta V, Larrè S, di Stasi S, Van Rhijn B, Witjes JA, Grotenhuis A, Colombo R, Briganti A, Babjuk M, Soukup V, Malmstrom PU, Irani J, Malats N, Baniel J, Cai T, Cha E, Ardelt P, Varkarakis J, Bartoletti R, Spahn M, Palou J, Dalbagni G, Shariat S, Karnes J. Prognostic factors and risk groups in T1G3 patients initially treated with BCG: results of a multicenter retrospective series. AUA 2013 abstract 1697.Google Scholar
  10. 10.
    Hendricksen K, van der Heijden AG, Cornel EB, Vergunst H, de Reijke TM, van Boven E, Smits GA, Puri R, Gruijs S, Witjes JA. Two-year follow-up of the phase II marker lesion study of intravesical apaziquone for patients with non-muscle invasive bladder cancer. World J Urol. 2009;27(3):337–42.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Kwon DH, Song PH, Kim HT. Multivariate analysis of the prognostic significance of resection weight after transurethral resection of bladder tumor for NMIBC. Korean J Urol. 2012;53(7):457–62.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Witjes JA, Moonen PMJ, van der Heijden AG. Review pathology in superficial bladder cancer trial: the impact of patient risk category. Urology. 2006;67(4):751–5.PubMedCrossRefGoogle Scholar
  13. 13.
    van Rhijn BWG, van Leenders GJLH, Ooms BCM, Kirkels WJ, Zlotta AR, Boevé ER, Jöbsis AC, van der Kwast TH. The pathologist’s mean grade is constant and individualizes the prognostic value of bladder cancer grading. Eur Urol. 2010;57(6):1052–7.PubMedCrossRefGoogle Scholar
  14. 14.
    May M, Brookman-Amissah S, Roigas J, Hartmann A, Störkel S, Kristiansen G, Gilfrich C, Borchardt R, Hoschke B, Kaufmann O, Gunia S. Prognostic accuracy of individual uropathologists in noninvasive urinary bladder carcinoma: a multicentre study comparing the 1973 and 2004 World Health Organisation Classifications. Eur Urol. 2010;57(5):850–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Vukomanovic I, Colovic V, Soldatovic I, Hadzi-Djokic J. Prognostic significance of tumor location in high-grade non-muscle-invasive bladder cancer. Med Oncol. 2012;29(3):1916–20.PubMedCrossRefGoogle Scholar
  16. 16.
    Collado A, Chéchile GE, Salvador J, Vicente J. Early complications of endoscopic treatment for superficial bladder cancer. J Urol. 2000;164(5):1529–32.PubMedCrossRefGoogle Scholar
  17. 17.
    Oelke M, Höfner K, Jonas U, Ubbink D, de la Rosette J, Wijkstra H. Ultrasound measurement of the detrusor wall thickness in healthy adults. Neurourol Urodyn. 2006;25(4):308–17.PubMedCrossRefGoogle Scholar
  18. 18.
    Herkommer K, Hofer C, Gschwend JE, Kron M, Treiber U. Gender and body mass index as risk factors for bladder perforation during primary transurethral resection of bladder tumors. J Urol. 2012;187(5):1566–70.PubMedCrossRefGoogle Scholar
  19. 19.
    Babjuk M, Oosterlinck W, Sylvester R, Kaasinen E, Böhle A, Palou-Redorta J, Rouprêt M. EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder, the 2011 update. Eur Urol. 2011;59(6): 997–1008.PubMedCrossRefGoogle Scholar
  20. 20.
    Witjes JA, Palou J, Soloway M, Lamm D, Kamat AM, Brausi M, Persad R, Buckley R, Colombel M, Böhle A. Current clinical practice gaps in the treatment of intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC) with emphasis on the use of bacillus Calmette-Guérin (BCG): results of an international individual patient data survey (IPDS). BJU Int. Forthcoming 2013.Google Scholar
  21. 21.
    van der Meijden A, Oosterlinck W, Brausi M, Kurth KH, Sylvester R, de Balincourt C. Significance of bladder biopsies in Ta, T1 bladder tumors: a report from the EORTC Genito-Urinary Tract Cancer Cooperative Group EORTC-GU Group Superficial Bladder Committee. Eur Urol. 1999;35(4):267–71.PubMedCrossRefGoogle Scholar
  22. 22.
    Kiemeney LA, Witjes JA, Heijbroek RP, Koper NP, Verbeek AL, Debruyne FM. Should random urothelial biopsies be taken from patients with primary superficial bladder cancer? A decision analysis. Members of the Dutch South-East Co-Operative Urological Group. Br J Urol. 1994;73(2):164–71.PubMedCrossRefGoogle Scholar
  23. 23.
    Burger M, Grossman HB, Droller M, Schmidbauer J, Hermann G, Drăgoescu O, Ray E, Fradet Y, Karl A, Burgués JP, Witjes JA, Stenzl A, Jichlinski P, Jocham D. Photodynamic diagnosis of non-muscle-invasive bladder cancer with hexaminolevulinate cystoscopy: a meta-analysis of detection and recurrence based on raw data. Eur Urol. Forthcoming 2013.Google Scholar
  24. 24.
    Witjes JA, Redorta JP, Jacqmin D, Sofras F, Malmström PU, Riedl C, Jocham D, Conti G, Montorsi F, Arentsen HC, Zaak D, Mostafid AH, Babjuk M. Hexaminolevulinate-guided fluorescence cystoscopy in the diagnosis and follow-up of patients with non-muscle-invasive bladder cancer: review of the evidence and recommendations. Eur Urol. 2010;57(4):607–14.PubMedCrossRefGoogle Scholar
  25. 25.
    Draga RO, Grimbergen MC, Kok ET, Jonges TN, van Swol CF, Bosch JL. Photodynamic diagnosis (5-aminolevulinic acid) of transitional cell carcinoma after bacillus Calmette-Guérin immunotherapy and mitomycin C intravesical therapy. Eur Urol. 2010;57(4):655–60.PubMedCrossRefGoogle Scholar
  26. 26.
    Oddens J, Brausi M, Sylvester R, Bono A, van de Beek C, van Andel G, Gontero P, Hoeltl W, Turkeri L, Marreaud S, Collette S, Oosterlinck W. Final results of an EORTC-GU cancers group randomized study of maintenance bacillus Calmette-Guérin in intermediate- and high-risk Ta, T1 papillary carcinoma of the urinary bladder: one-third dose versus full dose and 1 year versus 3 years of maintenance. Eur Urol. 2013;63(3):462–72.PubMedCrossRefGoogle Scholar
  27. 27.
    Babjuk M, Burger M, Zigeuner R, Shariat S, van Rhijn B, Comperat E, Sylvester R, Kaasinen E, Böhle A, Palou J, Roupret M. Guidelines on Non-muscle-invasive bladder cancer (TaT1 and CIS). EAU Guidelines 2013, presented at the EAU Annual Congress 2013. Arnhem, The Netherlands: European Association of Urology; 2013. Available from
  28. 28.
    van den Bosch S, Witjes JA. Long-term cancer specific survival in patients with high-risk non muscle-invasive bladder cancer and tumour progression: a systematic review. Eur Urol. 2011;60(3):493–500.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of UrologyRadboud University Nijmegen Medical CentreNijmegenThe Netherlands

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