Role of Neoadjuvant MMC prior to TURBT for Large NMIBC

• 26 Dec 2020 10:02:38 AM
• |Onco Urology

Dear All,

Intravesical Instillation of MMC is advised perioperatively after TURBT as a single dose regime. Recently Marco Racioppi, Luca Gianfrancesco* et al (2019) suggested that adjuvant Intravesical MMC, 3 times a wk for two wks.

https://euoncology.europeanurology.com/article/S2588-9311(18)30151-2/pdf

This resulted in favourable outcomes without need for TURBT and the authors make a plea that this regime could be an alternative for treatment for Low and Intermediate risk groups.  How many of us in India will accept this policy will have to be seen.

But what is more fascinating is the study of M Raber et al (2020 published online Dec 17^th). The endoscopic resection of large and bulky bladder cancers represents a challenge. To reduce the tumour and make it easier to resect, they used neoadjuvant short and intensive intravesical mitomycin (MMC) therapy. After neoadjuvant treatment, all tumours could be resected as the size of tumours reduced considerably (mean size reduced from 5.1 cms to <3 cms). No adverse events were recorded. Hence they opined that Intravesical cytoreductive neoadjuvant MMC as an initial treatment of large NMIBC can be considered safe, effective, and feasible.

The main issue is that this concept has not been validated with larger studies but the concept appears attractive and hopefully will be receiving attention from others in near future.

With warm Regards,

Venu

Comments(2)

• 

  Dr. Roy Chally

  26 Dec 2020 09:54:19 PM

      The paper on adjuvant MMC is for low grade TCC in bladder of less than 1cm. This protocol showed a good number of  tumours disappearing in the short term. The study showed 60%reduction of TURT in a 3yr follow up, compared to the control arm. This study showed a cost reduction. 

     Adverse events with adjuvant MMC, 3 doses in a week for 2 weeks not clear. 
  

      This study does not justify any change in the follow up protocol. This size of tumour could be managed with a cup biopsy and fulguration of base and not TURT. Will this make much of a difference in costs in our country. 

      Patients were enrolled into this protocol without a biopsy. They were assessed to be low grade on morphology. One patient on first follow up had high grade TCC which did not respond with adjuvant MMC. More studies needed to confirm that adjuvant MMC is ineffective in high grade TCC. Fortunately the stage did not change in the case mentioned in the paper. 

      When patients are enrolled into adjuvant MMC based on morphology and not biopsy this is a big risk . 

      

      

       
  

  
  

• 

  Dr. Anil Takvani

  10 Mar 2021 11:45:48 AM

  Concept of neoadjuvent intravesical chemotherapy in large bladder TCC is worth exploring...

  I will try recruit few cases and will provide outcomes...

  Thanks