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Hugh Mostafid Consultant Urologist North Hampshire Hospital Basingstoke Latest Developments in Intravesical Therapy
Intravesical therapy in 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Intravesical therapy in 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Treatment based on risk groups ,[object Object],[object Object],[object Object],[object Object],[object Object],EORTC risk tables Sylvester 2006 1-17 <1-5 46-62 24-38 35 Intermediate Risk Progression Recurrence  % of total 6-45 1-17 46-78 24-61 15 High Risk 1-6 <1 31-46 15-24 50 Low Risk 5yr 1yr 5 yr 1 yr
Intravesical therapy in 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Intermediate risk group Ta-T1,G1-2 Multifocal >3cm diameter ,[object Object],[object Object],1-17 <1-5 46-62 24-38 35 Intermediate Risk Progression Recurrence  % of total 6-45 1-17 46-78 24-61 15 High Risk 1-6 <1 31-46 15-24 50 Low Risk 5yr 1yr 5 yr 1 yr
Intermediate risk group ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Intravesical therapy in 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Long term maintenance chemotherapy in Intermediate risk group ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Intravesical therapy in 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
BCG maintenance ,[object Object],[object Object],[object Object],[object Object],[object Object]
BCG Toxicity Spanish CUETO group 53 61 69 Median followup 430 155 500 N 1/3 and 1/6 dose have same toxicity 1/3 dose toxicity lower 1/3 dose toxicity lower Toxicity 1/3 dose is minimum effective dose for int risk 27mg vs. 13.5.mg vs. 30 mg MMC intermediate risk 95.011 2007 1/3 dose as effective as full dose for high risk disease 81mg vs. 27mg in high risk tumours 95.012 2005 No diff in rec. or prog except for multifocal tumours.  Trend towards lower RR with full dose in high risk tumours 81mg vs. 27mg BCG Connaught 90.008 2002 Oncological outcome Groups
Low Dose BCG vs. MMC ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
BCG Toxicity ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
EORTC ,[object Object],[object Object],[object Object]
Reducing BCG side-effects ,[object Object],[object Object]
Intravesical therapy in 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
High Risk group G3T1 Multifocal >3 recurrences in 24 months CIS  progression  side-effects acceptable 1-17 <1-5 46-62 24-38 35 Intermediate Risk Progression Recurrence  % of total 6-45 1-17 46-78 24-61 15 High Risk 1-6 <1 31-46 15-24 50 Low Risk 5yr 1yr 5 yr 1 yr
Device assisted therapy ,[object Object],BCG once a week for 6 weeks (n=105) BCG infused once a week for 2 weeks, followed by 40 mg EMDA MMC for three weeks (n=107) 212 Stage pT1 patients BCG once a month for 10 months 40 mg EMDA MMC once a month for 2 months followed by BCG once a month as 1 cycle, for 3 cycles DiStasi 2006
EMDA MMC/BCG vs BCG ,[object Object],[object Object],10.6  p=0.01 10.9  p=0.045 12.6  p=0.004 16  p=0.0012 48  p=0.0012 Difference 16.2 32.4 21.9 57.9 21 BCG 5.6 21.5 9.3 41.9 69 EMDA MMC + BCG Disease-specific mortality % Overall mortality % Progression % Recurrence % Disease free interval (months)
Intravesical therapy in 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Thermochemotherapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Gofrit 2004 Van der Heijden 2004 Witjes EAU 2007
TCT vs EMDA vs MMC vs BCG ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Di Stasi 2003
Intravesical therapy in 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
BCG failures   ,[object Object],[object Object],[object Object],[object Object],[object Object]
Intravesical therapy in 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
New Agents - Phase I studies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
New Agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
New Agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Van der Heijden 2006
New Agents ,[object Object],[object Object],[object Object],[object Object],[object Object]
New Agents ,[object Object],[object Object],[object Object],[object Object],[object Object]
New concepts ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Low Risk group Single TaG1, <3cm  Recurrence rate    Side effects not justified 1-17 <1-5 46-62 24-38 35 Intermediate Risk Progression Recurrence  % of total 6-45 1-17 46-78 24-61 15 High Risk 1-6 <1 31-46 15-24 50 Low Risk 5yr 1yr 5 yr 1 yr
New concepts: Low risk group ,[object Object],[object Object],[object Object],[object Object],[object Object]
Conclusions ,[object Object],[object Object],[object Object],[object Object],[object Object]

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Latest Developments in Intravesical Therapy

  • 1. Hugh Mostafid Consultant Urologist North Hampshire Hospital Basingstoke Latest Developments in Intravesical Therapy
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  • 12. BCG Toxicity Spanish CUETO group 53 61 69 Median followup 430 155 500 N 1/3 and 1/6 dose have same toxicity 1/3 dose toxicity lower 1/3 dose toxicity lower Toxicity 1/3 dose is minimum effective dose for int risk 27mg vs. 13.5.mg vs. 30 mg MMC intermediate risk 95.011 2007 1/3 dose as effective as full dose for high risk disease 81mg vs. 27mg in high risk tumours 95.012 2005 No diff in rec. or prog except for multifocal tumours. Trend towards lower RR with full dose in high risk tumours 81mg vs. 27mg BCG Connaught 90.008 2002 Oncological outcome Groups
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  • 17.
  • 18. High Risk group G3T1 Multifocal >3 recurrences in 24 months CIS  progression  side-effects acceptable 1-17 <1-5 46-62 24-38 35 Intermediate Risk Progression Recurrence % of total 6-45 1-17 46-78 24-61 15 High Risk 1-6 <1 31-46 15-24 50 Low Risk 5yr 1yr 5 yr 1 yr
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  • 29.
  • 30.
  • 31.
  • 32.
  • 33. Low Risk group Single TaG1, <3cm  Recurrence rate  Side effects not justified 1-17 <1-5 46-62 24-38 35 Intermediate Risk Progression Recurrence % of total 6-45 1-17 46-78 24-61 15 High Risk 1-6 <1 31-46 15-24 50 Low Risk 5yr 1yr 5 yr 1 yr
  • 34.
  • 35.