Urologic Oncology: Seminars and Original Investigations. A Twenty-Fifth Anniversary History

This narrative reviews the history of Urologic Oncology: Seminars and Original Investigations from its inception and founding through its development to reach its current status. It describes the difficulties it experienced during its initial years when it almost folded, its resuscitation when it was designated as the "official journal" of the Society of Urologic Oncology, its merger with Seminars in Urologic Oncology to strengthen the content of both journals in a new format, its acceptance for indexation by the National Library of Medicine, its progress to monthly publication in addressing the needs of both authors and readership, and its current status as a leading multidisciplinary journal in urologic oncology. As a founding editor and managing editor for the first 5 years and then as editor-in-chief for the next 20 years, the author has been integrally involved in each step of the Journal's development and maturation. The Journal has been referred to as "the journal that almost never was" as it now has reached its 25th year of publication. This article commemorates the Journal's 25th Anniversary and gratefully acknowledges all of those investigators, authors, reviewers, editors, publishers and the readership who have contributed to the Journal's ongoing success.

An up-to-date catalog of available urinary biomarkers for the surveillance of non-muscle invasive bladder cancer

OBJECTIVES

With the advent of novel genomic and transcriptomic technologies, new urinary biomarkers have been identified and tested for bladder cancer (BCa) surveillance. To summarize the current status of urinary biomarkers for the detection of recurrence and/or progression in the follow-up of non-muscle invasive BCa patients, and to assess the value of urinary biomarkers in predicting response to intravesical Bacillus Calmette-Guerin (BCG) therapy.

METHODS AND MATERIALS

A medline/pubmed© literature search was performed. The performance of commercially available and investigational biomarkers has been reviewed. End points were cancer detection (recurrence), cancer progression, and response to BCG therapy.

RESULTS

The performance requirements for biomarkers are variable according to the clinical scenario. The clinical role of urinary biomarkers in the follow-up of non-muscle invasive BCa patients remains undefined. The FDA-approved tests provide unsatisfactory sensitivity and specificity levels and their use is limited. Fluorescence in situ hybridization (FISH) has been shown to be useful in specific scenarios, mostly as a reflex test and in the setting of equivocal urinary cytology. FISH and immunocytology could conceivably be used to assess BCG response. Recently developed biomarkers have shown promising results; upcoming large trials will test their utility in specific clinical scenarios in a manner similar to a phased drug development strategy.

CONCLUSIONS

Current commercially available urinary biomarker-based tests are not sufficiently validated to be widely used in clinical practice. Several novel biomarkers are currently under investigation. Prospective multicenter analyses will be needed to establish their clinical relevance and value.

Micropapillary bladder cancer: current treatment patterns and review of the literature

OBJECTIVES

No guidelines exist for the management of micropapillary bladder cancer (MPBC) and most reports of this variant of urothelial carcinoma are case series comprising small numbers of patients. We sought to determine current practice patterns for MPBC using a survey sent to the Society of Urologic Oncology (SUO) and to present those results in the setting of a comprehensive review of the existing literature.

MATERIALS AND METHODS

A survey developed by the Translational Science Working Group of the Bladder Cancer Advocacy Network-sponsored Think Tank meeting was distributed to members of the SUO. The results from 118 respondents were analyzed and presented with a literature review.

RESULTS

Most survey respondents were urologists, with 80% considering bladder cancer their primary area of interest. Although 78% of the respondents reported a dedicated genitourinary pathologist at their institution, there were discrepant opinions on how a pathologic diagnosis of MPBC is determined as well as variability on the proportion of MPBC that is clinically significant. Among them, 78% treat MPBC differently than conventional urothelial carcinoma, with 81% reporting that they would treat cT1 MPBC with upfront radical cystectomy. However, the respondents had split opinions regarding the sensitivity of MPBC to cisplatin-based chemotherapy, which affected utilization of neoadjuvant chemotherapy in muscle-invasive disease.

CONCLUSIONS

The management of MPBC is diverse among members of the SUO. Although most favors early cystectomy for cT1 MPBC, there is no consensus on the use of neoadjuvant chemotherapy for muscle-invasive MPBC.

Do Gleason patterns 3 and 4 prostate cancer represent separate disease states?

PURPOSE

The Gleason scoring system has been the traditional basis for studies on the assessment and treatment of prostate cancer. Recent reports of long-term prostate cancer outcomes stratified by Gleason score based on the 2005 ISUP (International Society of Urological Pathology) update suggest that important aspects of the biology of prostate cancer correlate with commonly available histopathological information. In this review we present a conceptual framework for the possible existence of distinct but interrelated developmental pathways in the context of the Gleason score in considering various biological and clinical aspects of prostate cancer. This may be useful in characterizing prostate cancer as an indolent condition in some and an aggressive disease in others, in decision making for treatment, and in the interpretation of the biological course and treatment outcomes.

MATERIALS AND METHODS

A comprehensive review of clinical, pathological and investigational biological literature on this topic was conducted. In addition, the biological behavior of prostate cancer as interpreted from this survey was compared to that of other solid neoplasms in developing a schema for characterizing the pathogenesis of various forms of the disease.

RESULTS

The Gleason scoring system has been found to have fundamental value in predicting the behavior of prostate cancer and assessing outcomes of its treatment. Increasingly, the proportion of Gleason pattern 4 in a prostatectomy specimen is being recognized as a critical factor in predicting the rates of biochemical recurrence and prostate cancer specific mortality. Under the current Gleason classification, a Gleason 3 + 3 = 6 cancer carries a minimal long-term risk of progression or mortality. Risk of biochemical recurrence and prostate cancer specific mortality increases with increasing proportions of the Gleason 4 component in the prostatectomy specimen, from 3 + 3 = 6 with tertiary 4 (ie less than 5% of a 4 component) to 3 + 4 = 7, 4 + 3 = 7 and 4 + 4 = 8. Assuming that the Gleason 4 component increases in volume more rapidly with time than well differentiated components, it can be inferred that a smaller proportion of Gleason 4 could mean that the cancer has been identified at an earlier phase in the natural history of the disease. This could explain the improved prognosis on the basis of length and lead time biases, and conceivably on the basis of a decreased likelihood of cancer cells having metastasized. Correspondingly, increasing amounts of Gleason 4 cancer in a prostate specimen might be explained in 2 ways, as the preferential growth of a single clone of Gleason 4 cells, possibly with intraprostatic spread, or the evolution of Gleason 3 cancer cells to become Gleason 4. These hypotheses have been examined by genetic analysis of metastatic deposits and by comparisons of multiple foci of cancer within individual prostates. The clinical significance of these concepts in regard to disease status at diagnosis, treatment selection, outcomes of treatment, and implications for future research on the basis of clinical and molecular observations are the basis of the developmental schemata we propose.

CONCLUSIONS

Given the relatively benign nature of homogeneous, low volume Gleason 3 tumors, and the progressive risk of biochemical recurrence and prostate cancer specific mortality with increasing quantities of Gleason 4 components, we propose that Gleason 4 (and 5) cancers constitute cancer diatheses distinct from that of Gleason 3 cancer. This distinction may contribute to the understanding of the prognosis intrinsic to these biological behavioral patterns, and help guide the translation of findings at molecular and histological levels to a more precise selection of treatments.

New optical imaging technologies for bladder cancer: considerations and perspectives

PURPOSE

Bladder cancer presents as a spectrum of different diatheses. Accurate assessment for individualized treatment depends on initial diagnostic accuracy. Detection relies on white light cystoscopy accuracy and comprehensiveness. Aside from invasiveness and potential risks, white light cystoscopy shortcomings include difficult flat lesion detection, precise tumor delineation to enable complete resection, inflammation and malignancy differentiation, and grade and stage determination. Each shortcoming depends on surgeon ability and experience with the technology available for visualization and resection. Fluorescence cystoscopy/photodynamic diagnosis, narrow band imaging, confocal laser endomicroscopy and optical coherence tomography address the limitations and have in vivo feasibility. They detect suspicious lesions (photodynamic diagnosis and narrow band imaging) and further characterize lesions (optical coherence tomography and confocal laser endomicroscopy). We analyzed the added value of each technology beyond white light cystoscopy and evaluated their maturity to alter the cancer course.

MATERIALS AND METHODS

Detailed PubMed® searches were done using the terms "fluorescence cystoscopy," "photodynamic diagnosis," "narrow band imaging," "optical coherence tomography" and "confocal laser endomicroscopy" with "optical imaging," "bladder cancer" and "urothelial carcinoma." Diagnostic accuracy reports and all prospective studies were selected for analysis. We explored technological principles, preclinical and clinical evidence supporting nonmuscle invasive bladder cancer detection and characterization, and whether improved sensitivity vs specificity translates into improved correlation of diagnostic accuracy with recurrence and progression. Emerging preclinical technologies with potential application were reviewed.

RESULTS

Photodynamic diagnosis and narrow band imaging improve nonmuscle invasive bladder cancer detection, including carcinoma in situ. Photodynamic diagnosis identifies more papillary lesions than white light cystoscopy, enabling more complete resection and fewer residual tumors. Despite improved treatment current data on photodynamic diagnosis do not support improved high risk diathetic detection and characterization or correlation with disease progression. Prospective recurrence data are lacking on narrow band imaging. Confocal laser endomicroscopy and optical coherence tomography potentially grade and stage lesions but data are lacking on diagnostic accuracy. Several emerging preclinical technologies may enhance the diagnostic capability of endoscopic imaging.

CONCLUSIONS

New optical imaging technologies may improve bladder cancer detection and characterization, and transurethral resection quality. While data on photodynamic diagnosis are strongest, the clinical effectiveness of these technologies is not proven. Prospective studies are needed, particularly of narrow band imaging, confocal laser endomicroscopy and optical coherence tomography. As each technology matures and new ones emerge, cost-effectiveness analysis must be addressed in the context of the various bladder cancer types.

The effect of age and gender on bladder cancer: a critical review of the literature

While patient age and gender are important factors in the clinical decision-making for treating urothelial carcinoma of the bladder (UCB), there are no evidence-based recommendations to guide healthcare professionals. We review previous reports on the influence of age and gender on the incidence, biology, mortality and treatment of UCB. Using MEDLINE, we searched for previous reports published between January 1966 and July 2009. While men are three to four times more likely to develop UCB than women, women present with more advanced disease and have worse survival rates. The disparity among genders is proposed to be the result of a differential exposure to carcinogens (i.e. tobacco and chemicals) as well as reflecting genetic, anatomical, hormonal, societal and environmental factors. Inpatient length of stay, referral patterns for haematuria and surgical outcomes suggest that inferior quality of care for women might be an additional cause of gender inequalities. Age is the greatest single risk factor for developing UCB and dying from it once diagnosed. Elderly patients face both clinical and institutional barriers to appropriate treatment; they receive less aggressive treatment and sub-therapeutic dosing. Much evidence suggests that chronological age alone is an inadequate indicator in determining the clinical and behavioural response of older patients to UCB and its treatment. Epidemiological and mechanistic molecular studies should be encouraged to design, analyse and report gender- and age-specific associations. Improved bladder cancer awareness in the lay and medical communities, careful patient selection, treatment tailored to the needs and the physiological and physical reserve of the individual patient, and proactive postoperative care are particularly important. We must strive to develop transdisciplinary collaborative efforts to provide tailored gender- and age-specific care for patients with UCB.

Bladder cancer in the elderly

INTRODUCTION

Age is now widely accepted as the greatest single risk factor for developing bladder cancer, and bladder cancer is considered as primarily a disease of the elderly. Because of the close link between age and incidence of bladder cancer, it can be expected that this disease will become an enormous challenge with the growth of an aging population in the years ahead.

METHODS

Using MEDLINE, a search of the literature between January 1966 and July 2007 was performed to describe normative physiologic changes associated with aging, elucidate genetic and epigenetic alterations that associate aging with bladder cancer and its phenotypes; and to characterize how aging influences efficacies, risks, side effects, and potential complications of the treatments needed for the various stages of bladder cancer.

RESULTS

We discuss influence of aging on host physiology, genetic and epigenetic changes, environmental influences, and host factors in the development and treatment of bladder cancer. Treatments with intravesical bacille Calmette Guerin, radical cystectomy, and perioperative chemotherapy are less well tolerated and have poorer response in elderly patients compared with their younger counterparts. Elderly patients face both clinical and broader institutional barriers to appropriate treatment and may receive less aggressive treatment and sub-therapeutic dosing. However, when appropriately selected, elderly patients tolerate and respond well to cancer treatments.

CONCLUSIONS

The decision to undergo treatment for cancer is a tradeoff between loss of function and/or independence and extension of life, which is complicated by a host of concomitant issues such as comorbid medical conditions, functional declines and "frailty", family dynamics, and social and psychologic issues. Chronological age should not preclude definitive surgical therapy. It is imperative that healthcare practitioners and researchers from disparate disciplines collectively focus efforts towards gaining a better understanding of what the consequences of bladder cancer and its treatments are for older adults and how to appropriately meet the multifaceted medical and psychosocial needs of this growing population.