This document provides guidelines for treating non-muscle-invasive bladder cancer. It discusses diagnosing and staging Ta, T1, and Tis tumors using techniques like white-light and blue-light cystoscopy. For cTa low-grade tumors, the guidelines recommend TURBT followed by a single dose of immediate intravesical chemotherapy. For cTa high-grade tumors, options include TURBT followed by observation, mitomycin C, or BCG. For cT1 tumors, the guidelines recommend complete TURBT along with a second TURBT for high-risk cases, followed by adjuvant intravesical therapy.
Opportunities for Immune Therapy and Preventionbkling
Dr. Margaret Gatti-Mays of the National Cancer Institute, a Staff Clinician of Laboratory of Tumor Immunology and Biology and the Co-Director of the Clinical Trial Group, explores the future of immunotherapy in breast cancer treatment.
Opportunities for Immune Therapy and Preventionbkling
Dr. Margaret Gatti-Mays of the National Cancer Institute, a Staff Clinician of Laboratory of Tumor Immunology and Biology and the Co-Director of the Clinical Trial Group, explores the future of immunotherapy in breast cancer treatment.
GB cancer is the 5th most common GIT malignancy(worldwide).200 years later it is still considered to be a highly malignant disease with a poor survival rate
.Here is a brief description regarding
Target audience : Oncology fellows and Oncologists.
Four challenging cases of Bladder cancer and managing decisions including latest management principles are discussed here.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
3. A physical examination usually does not reveal non-
muscle-invasive disease.
Non-muscle-invasive tumors are divided into
noninvasive papillomas or carcinomas (Ta),
tumors invading the lamina propria (T1), and
noninvasive flat carcinoma (Tis), also termed CIS.
These tumors have previously been referred to as
superficial, which is an imprecise term that should be
avoided.
4. In some cases, a papillary or T1 lesion will be
documented as having an associated in situ component
(Tis).
Noninvasive disease may be diagnosed by initial
cystoscopy and cytology.
Once suspected, imaging of upper tract collecting
systems is required.
In addition, a pelvic CT or MRI scan should be
considered before TURBT if sessile or high-grade
disease is suspected.
5. Endoscopic evaluation has traditionally used white-
light cystoscopy (WLC) as part of the diagnosis of non-
muscle-invasive bladder cancer.
More recently blue-light cystoscopy (BLC) has emerged
as an adjunct for diagnosis.
BLC identifies malignant cells through the absorption
of the photosensitizing drug into the urothelial
cytoplasm where it enters the metabolism.
6. In normal cells, the photosensitizer is excreted;
however, enzymatic abnormalities in malignant cells
result in the formation of photoactive porphyrins that
remain in the cell and fluorescence with a red emission
in the presence of blue light.
Earlier studies used the photosensitizer 5-
aminolevulinic acid (5-ALA), although more recently
hexyl-aminolevulinate (HAL) is the only approved
agent.
7. BLC has higher detection rates of non-
muscle-invasive lesions compared to the use
of WLC.
Particularly CIS, which is often missed by
WLC, was detected at a higher rate.
8. Although data show improved detection and
reduced recurrence, this technique does not
prevent progression and there is no
improvement in recurrence-free survival.
Therefore, BLC may have the greatest
advantage in detecting difficult-to-visualize
tumors (eg, CIS tumors) that may be missed
by WLC but has more limited applicability in
disease monitoring.
9. Other impediments to BLC include the need
for appropriate expertise and equipment to
employ this new technology.
The limitations of BLC require judicious
application of this additional diagnostic tool.
10. Standard treatment for Ta, T1, and Tis is
TURBT.
It is used to diagnose, stage, and treat visible
tumors.
TURBT with a bimanual EUA is performed to
resect visible tumor and to sample muscle
within the area of the tumor to assess
whether invasion has occurred.
11. The involvement of the prostatic urethra and ducts in
male patients with Ta, T1, and Tis bladder tumors has
been reported.
The risk is higher in the case of tumors in the bladder
neck.
Therefore, if the lesion is sessile or if Tis or high-grade
disease is suspected, selected mapping biopsies and
transurethral biopsy of prostate must be considered.
12. Clinical investigation of the specimen
obtained by TURBT or biopsies is an
important step in the diagnosis and
subsequent management of bladder
cancer.
A second TURBT is performed when a
high-grade, T1 tumor and possibly a Ta
has been detected at the initial TURBT.
This is especially critical in cases in which
no muscularis propria was included in the
resection.
13. However, depending on the depth of invasion and
grade, intravesical therapy may be recommended
based on the estimated probability of recurrence (i.e.,
new tumor formation within the bladder) and
progression to a more advanced, usually muscle-
invasive stage;
Cystectomy is rarely considered for a Ta, low-grade
lesion.
15. Intravesical therapy is used in two general
settings:
as prophylactic or adjuvant therapy after a
complete endoscopic resection or
rarely, as therapy with the goal of eradicating
residual disease that could not be completely
resected.
16. This distinction is important, because most
published data reflect prophylactic or adjuvant
use with the goal of preventing recurrence or
delaying progression to a higher grade or stage.
In many cases, intravesical therapy may be
overused if given to patients who have a low
probability of recurrence or progression.
17. Bacillus Calmette-Guérin (BCG) has been
shown to be as effective as prophylaxis to
prevent bladder cancer recurrences following
TURBT.
Immediate intravesical chemotherapy prolongs
the recurrence-free interval by 38% and early
recurrences were reduced by 12%
18. Duration of maintenance BCG remains a
question of debate.
Most studies continue BCG maintenance for 3
years.
Duration of 1 year may be suitable for patients at
intermediate risk, but without more data, 3 years
of BCG maintenance remains the
recommendation.
19. Both intravesical gemcitabine and BCG have been used
in patients with non-muscle-invasive bladder cancer as
adjuvant therapies without any significant difference in
quality of life outcome.
More frequent local and systemic side effects with BCG
However, they are mild to moderate and the treatment is
welltolerated in both groups.
21. TURBT is the standard treatment for cTa, low-grade
tumors.
Although a complete TURBT alone can eradicate cTa low-
grade tumors, these tumors have a relatively high risk for
recurrence.
Therefore, after TURBT, the panel recommends
observation and to strongly consider administering a
single dose of immediate intravesicular chemotherapy (not
immunotherapy) within 24 hours of resection.
This therapy decreases the risk of recurrence by 11%
(from 48% down to 37%) following immediate intravesical
therapy in patients having either single or multiple
tumors.Later studies had
22. The immediate intravesical chemotherapy may be
followed by a 6-week induction of intravesical
chemotherapy.
Mitomycin C is the most commonly used agent.
Immunotherapy is not recommended in these patients.
23. The need for adjuvant therapy depends on
the patient prognosis.
If the patient has a low risk for recurrence, a
single immediate intravesical treatment may
be sufficient.
24. Factors to consider include the
Size,
Number,
T category &
grade of the tumor(s), as well as
Concomitant CIS &
Prior recurrence.
25. Meta-analyses have confirmed the efficacy of
adjuvant intravesical chemotherapy in
reducing the risk of recurrence.
Immediate intravesical treatment should be
avoided if TURBT was extensive or if bladder
perforation is suspected.
26. Close follow-up of all patients is needed,
although the risk for progression to a more
advanced stage is low.
As a result, these patients are advised to
undergo a cystoscopy at 3 months initially,
and then at increasing intervals.
28. Tumors staged as cTa, high-grade lesions are
papillary tumors with a relatively high risk for
recurrence and progression towards more
invasiveness.
Restaging TURBT detected residual disease
in 27% of Ta patients when muscle was
present in the original TURBT.
29. In the absence of muscularis propria in the
initial TURBT specimen, 49% of patients with
superficial disease will be understaged
versus 14% if muscle was present.
Repeat resection
is recommended if there is incomplete
resection, or
is strongly considered if there is no muscle in
the specimen.
30. After TURBT, in addition to observation, patients with
Ta, high-grade tumors may be treated with intravesical
BCG or mitomycin C.
BCG after TURBT is superior to TURBT alone, or TURBT
and chemotherapy in preventing recurrences of high-
grade Ta and T1 tumors.
31. The NCCN Bladder Cancer Panel Members
recommend BCG as the preferred option over
mitomycin C for adjuvant treatment of high-
grade lesions.
Observation is also an option.
32. Follow-up is recommended, with a urinary cytology and cystoscopy
at 3 to 6-month intervals for the first 2 years, and at increasing
intervals as appropriate thereafter.
Imaging of the upper tract should be considered every 1 to 2 years
for high-grade tumors.
Urine molecular tests for urothelial tumor markers are now available.
Most of these tests have a better sensitivity for detecting bladder
cancer than urinary cytology, but specificity is lower.
However, it remains unclear whether these tests offer additional
information that is useful for detection and management of non-
muscle-invasive bladder tumors.
Therefore, the panel considers this to be a category 2B
recommendation.
33. NCCN Categories of Evidence and Consensus
Category 1: Based upon high-level evidence, there is
uniform NCCN consensus that the intervention is
appropriate.
Category 2A: Based upon lower-level evidence, there is
uniform NCCN consensus that the intervention is
appropriate.
34. Category 2B: Based upon lower-level evidence, there is
NCCN consensus that the intervention is appropriate.
Category 3: Based upon any level of evidence, there is
major NCCN disagreement that the intervention is
appropriate.
All recommendations are category 2A unless otherwise noted.
36. T1 tumors are those that invade subepithelial
connective tissue (also referred to as lamina propria).
Based on the histologic differentiation, most cT1 lesions
are high grade and considered to be potentially
dangerous with a higher risk for recurrence and
progression.
These tumors may occur as solitary lesions or as
multifocal tumors with or without an associated in situ
component.
37. These tumors are also treated with a complete
endoscopic resection.
In patients with high-risk disease, especially if the
complete resection is uncertain due to
tumor size and location,
lack of muscle in the specimen,
presence of lymphovascular invasion, or
inadequate staging,
repeat TURBT is strongly advised.
38. All patients receive adjuvant intravesical therapy.
Second TURBT within 2 to 6 weeks of the initial TURBT.
The 3-year recurrence-free survival significantly higher
with repeat TURBT versus no repeat TURBT (69% vs.
37%, respectively), especially among patients with
high-grade tumors.
39. Cystectomy in NMIBC??..
Within the category of T1 disease, a particularly high-risk
stratum can be identified:
multifocal lesions,
tumors associated with vascular invasion, or
lesions that recur after BCG treatment.
40. There are data suggesting that early cystectomy may be
preferred if residual disease is found because of the
high risk for progression to a more advanced stage.
Therefore, cystectomy rather than repeat TURBT is
recommended for high-risk tumors.
41. If residual disease is found after a second resection,
immunotherapy with BCG (category 1 recommendation)
or cystectomy is recommended.
If no residual disease is found after the second
resection, intravesical therapy with BCG (preferred;
category 1 recommendation) or mitomycin C (category
2A) is recommended.
42. Observation may be reasonable in very
highly select cases where small-volume
tumors had limited lamina propria invasion
and no CIS.
Follow-up is similar to that for high-grade Ta
disease.
44. Primary Tis (CIS) is a high-grade lesion that
is believed to be a precursor of invasive
bladder cancer.
Standard therapy for this lesion is
resection followed by intravesical therapy
with BCG.
45. This therapy is generally given once a week for 6 weeks,
followed by a rest period of 4 to 6 weeks, with a full re-
evaluation at week 12 (ie, 3 months) after the start of
therapy.
If the patient is unable to tolerate BCG, intravesical
mitomycin C may be administered.
Follow-up is similar to that for cT1 and cTa (high-grade)
tumors.
47. Based on Cystoscopy Results
Patients under observation after initial TURBT, who
show a documented recurrence by positive cystoscopy
results, should undergo another TURBT followed by
adjuvant intravesical therapy based on the stage and
grade of the recurrent lesion, and then followed at 3-
month intervals.
48. Recurrence Following
Intravesical Treatment
Patients with recurrent/persistent tumors
that responded to induction intravesical
therapy, after initial intravesical treatment
and 12-week (3-month) evaluation, can be
given a second induction course of BCG or
mitomycin C induction therapy.
No more than two consecutive induction
courses should be given.
49. If a second course of BCG is given and
residual disease is seen at the second 12-
week (3-month) follow-up, TURBT is
performed.
For patients who have Tis or cTa disease
after TURBT, intravesical therapy with a
different intravesical agent is an alternative
to cystectomy.
50. Valrubicin has been approved for CIS that is
refractory to BCG, although panelists
disagree on its value.
For non-muscle-invasive bladder cancer that
recurred following 2 courses of BCG,
intravesical gemcitabine demonstrated
activity.
The 1-year RFS was 28%
The 2-year RFS was 21%.
51. Intravesical gemcitabine had some activity in the high-
risk group, and may be an option if a candidate is not
eligible for a cystectomy;
however, study results indicate that cystectomy is
preferred when possible.
Similarly, for patients with recurrence of highgrade cT1
disease after TURBT and induction BCG, cystectomy is
the main option.
52. However, non-surgical candidates might
consider concurrent chemoradiation, change
of the intravesical agent, or a clinical trial.
53. For patients showing no residual disease at the follow-
up cystoscopy, whether 1 or 2 courses of induction
therapy were administered, maintenance therapy with
BCG is optional.
This recommendation is based on findings that an
induction course of intravesical therapy followed by a
maintenance regimen produced better outcomes than
intravesical chemotherapy.
54. Mitomycin C is superior to BCG without
maintenance in preventing recurrence, but
inferior to BCG in trials with maintenance.
55. While the optimal maintenance regimen has not been
established, most patients undergo maintenance for 1 to
3 years.
The duration is often limited by toxicity.
No benefit in 3 years of maintenance BCG compared to
1 year for intermediate-risk patients.
56. In high-risk patients, 3-year maintenance BCG reduces
recurrence compared to 1-year maintenance, but did not
impact progression or survival.
Although a few NCCN Member Institutions do not
routinely administer maintenance BCG, panelists agree
that it should be an option.
57. Based on Cytology Results
In patients without a documented recurrence
but with positive cytology and negative
cystoscopy and imaging, TURBT must be
performed with directed or selected mapping
biopsies including transurethral biopsies of
the prostate.
58. In addition, cytology of the upper tract must
be evaluated and ureteroscopy may be
considered for detecting tumors of the upper
tract.
59. If the selected mapping biopsy of the bladder
is positive, then the recommendation is to
administer intravesical BCG treatment
followed by maintenance BCG (preferred) if a
complete response is seen.
60. For tumors that fail BCG or show an incomplete
response, the subsequent management options include
cystectomy, changing the intravesical agent, or
participation in a clinical trial.
Further investigation and validation of results is
warranted for establishing the efficacy of alternative
agents in second-line treatments.
61. If the transurethral biopsies of the bladder and prostate
are negative, then follow-up at 3-month intervals is
recommended and maintenance therapy with BCG is
preferred if prior BCG was given.
If the cytology of the upper tract and uteroscopy is
negative, follow-up at 3-month intervals is
recommended.