Monitoring
Non-Muscle Invasive Bladder Cancer
After TURBT, the first cystoscopy should be done after 3 months because
it is an important prognostic indicator for recurrence and progression in
patients with Ta, T1 tumors, and CIS. For low-risk patients, cystoscopy should
be done at the third month post-treatment. If negative, subsequent cystoscopy
is suggested 12 months later, then annually thereafter up to the fifth-year
post-treatment. Baseline imaging is suggested during the first year and
follow-up imaging studies may be obtained as clinically indicated.
Intermediate-risk patients with Ta tumors should have an in-between follow-up
scheme using cystoscopy and cytology according to personal and subjective
factors. Cystoscopy and urinary cytology at 3, 6, and 12 months in the first
year, every 6 months in the second year, then once
a year thereafter up to the fifth year is suggested. Baseline imaging is
suggested during the first year, then may obtain follow-up imaging studies as
clinically indicated.
Patients with high-risk tumors should undergo cystoscopy and urinary
cytology at 3-month intervals for the first 2 years, at 6-month intervals from
the third to fifth year, then annually thereafter. Baseline imaging of the
upper tract should be obtained during the first follow-up and after 12 months,
then every 1 to 2 years until 10 years post-treatment, and as clinically
indicated thereafter. Urine cytology is recommended every 3 months in the first
2 years, then at 6-month intervals for the next 3 years, and annually
thereafter. Baseline imaging of the abdomen/pelvis should be obtained during the
first follow-up then as clinically indicated thereafter.
For post-cystectomy patients, CT or MRI urography at 3 and 12 months is
recommended, then annually until 5 years post-cystectomy, and annual renal
ultrasound afterwards. Hematologic tests for creatinine and electrolytes and
liver function tests (LFTs) every 3–6 months are recommended in the first year
of follow-up, then annually. Annual B12 levels should be obtained every year
after the first year post-cystectomy. If chemotherapy was given, CBC and
comprehensive metabolic panel every 3–6 months for the first year of follow-up
should be considered. Urine cytology at 6- to 12-month intervals during the
first year is recommended. Urethral wash cytology
should be considered every 6 to 12 months, particularly in patients with
high-risk disease (eg positive urethral margin, multifocal CIS or prostatic
urethral invasion).
During follow-up in patients with positive
cytology and no visible tumor in the bladder, selective mapping or random
biopsies, or biopsies with photodynamic diagnosis and investigation of
extravesical locations including CT urography and prostatic urethra biopsy are
recommended.
Bladder Cancer_Follow-UpMuscle Invasive Bladder Cancer
After radical cystectomy, follow-up should include imaging of the chest, upper tracts, abdomen, and pelvis every 3–6 months for 2 years based on the risk of recurrence, and then as clinically indicated. CT or MRI urography and chest radiography or CT scan every 3–6 months are recommended for the first 2 years and annually thereafter. Annual renal ultrasound is recommended after 5 years of follow-up. FDG-PET/CT may be performed to confirm the presence of metastatic disease. The recommended schedule for creatinine and electrolytes, liver function tests (LFTs), B12 levels, CBC, comprehensive metabolic panel, and urine cytology is the same as with patients treated for non-muscle invasive bladder cancer. After a partial cystectomy or chemoradiation, follow-up is similar to that for a radical cystectomy, with the addition of monitoring for relapse in the bladder by serial cystoscopies at 3-month intervals for the first 2 years, at 6-month intervals during years 3 and 4, annually until 10 years post-cystectomy, and then according to clinical discretion. Most Asian centers have a check using cystoscopy at 3 months after adjuvant intravesical treatment, then at increasing intervals as appropriate. Urinary urothelial markers (eg nuclear matrix protein 22 and bladder tumor antigen) can be used in Asian countries.
BCG-unresponsive Tumor
BCG-unresponsive tumor include patients with BCG-refractory tumors as defined as follows:
- If a T1 high-grade/G3 tumor is present at 3 months or
- If a Ta high-grade/G3 tumor is present after 3 months and/or at 6 months following either re-induction or the first course of maintenance or
- If CIS without concurrent papillary tumor is present at 3 months and persists at 6 months after either re-induction or the first course of maintenance or
- If a high-grade tumor develops during BCG maintenance therapy
It also includes if there is recurrence of
T1 or Ta high-grade tumors within 6 months after completing adequate BCG
therapy, or CIS develops within 12 months after completion of adequate BCG
therapy, defined as completion of at least 5 or 6 doses of an initial induction
course plus at least 2 out of 6 dosses of second induction course of 2 out of 3
doses of maintenance therapy.
Metastatic Disease
For patients with metastatic disease, serial cystoscopy should be done
every 3–6 months as clinically indicated. Urine cytology should be done during
cystoscopy if the bladder is in situ. CT or MRI urography and CT scan of
the chest, abdomen, and pelvis should be done every 3–6 months if clinically
indicated, or if there are new symptoms or a clinical change. Hematologic
studies such as CBC and comprehensive metabolic panel every 1–3 months are
recommended. Annual B12 levels should be requested for post-cystectomy
patients.