The long-term outcome in patients with superficial transitional cell carcinoma of the bladder: a single-institutional experience

OBJECTIVE

To determine the natural history of transitional cell carcinoma (TCC) of the bladder, and to identify factors which place patients at lifelong risk of developing progression and dying from bladder carcinoma.

PATIENTS AND METHODS

The long-term outcome was evaluated retrospectively in 231 patients with superficial bladder TCC, assessed for the first time within a 6-year period from 1981 to 1986, with a median follow-up of 108 months. Of 231 patients, 217 (94%) were initially treated by transurethral or segmental resection.

RESULTS

Recurrence developed in 141 of 217 (65%) patients; the duration of the interval free of recurrence was significantly less for patients with initial G3 tumours than that for those with G1 (P<0.01) and for pT1 compared with pTa disease (P<0.01). The disease progressed in 42 of 231 (18%) patients. Differences in the progression-free interval between patients with G1 and G3 tumours, and with pTa and pT1 disease, were statistically significant (P<0. 005 and P<0.001, respectively). In 27 of 231 patients (12%), TCC of the bladder was the cause of death, whilst 118 (51%) died from unrelated causes. There were no deaths among patients with initial pTaG1 tumours, compared with 10 of 26 (38%) deaths in those with pT1G3 disease at presentation.

CONCLUSION

The long-term prognosis is good for patients with pTaG1 tumours, whilst pT1G3 is a potentially aggressive disease. Lifelong endoscopic surveillance is mandatory in patients in whom new tumours are very active, at least in those of younger age. Routine cystoscopy can possibly be discontinued in patients with low-grade, low-stage disease in whom a low liability of recurrence has been shown during follow-up.

MICROPAPILLARY BLADDER CARCINOMA: A CLINICOPATHOLOGICAL STUDY OF 20 CASES

PURPOSE

Micropapillary bladder carcinoma is rare, with only 18 cases reported to date. We report 20 additional cases with long-term followup.

MATERIALS AND METHODS

A total of 680 patients with an initial diagnosis of bladder carcinoma in western Sweden in 1987 and 1989 were prospectively registered. The clinical records of all 816 patients with bladder cancer treated at Sahlgrenska University Hospital with external beam irradiation between 1962 and 1989 were reviewed. The histopathological material was reviewed and immuno-histochemical analyses were performed on 20 cases identified with micropapillary bladder carcinoma.

RESULTS

The incidence of micropapillary bladder carcinoma was 0.7%. Mean patient age at diagnosis was 69 years (range 45 to 82) and the male-to-female ratio was 2.3:1. All but 5 patients had stage T3a disease or higher. There was no difference in stage or prognosis between the 5 prospectively identified patients and those treated with external beam irradiation. Only 2 patients had micropapillary bladder carcinoma as the only pattern, while 1 had 10% and the remainder had 20 to 95% micropapillary bladder carcinoma. Transitional cell carcinoma was noted in 17 patients and 5 had areas of gland forming adenocarcinoma. Carcinoma in situ was noted in 13 patients and 15 had lymphatic invasion. Only 5 patients survived 5 years, 1 of whom died of bladder cancer after 7 years. Radiation and chemotherapy did not seem to be effective.

CONCLUSIONS

The light microscopic appearance, which is strikingly similar to ovarian papillary serous carcinoma, and immunohistochemical staining pattern lend some support to the theory that micropapillary bladder carcinoma is a variant of adenocarcinoma. Since even the focal presence of micropapillary bladder carcinoma is associated with a poor prognosis, recognition of this entity is important. Due to its rarity, the optimal treatment of micropapillary bladder carcinoma needs to be determined in a multicenter study.

[Long-term effects on recurrence and mortality in superficial urothelioma of the bladder treated with endovesical chemotherapy]

BACKGROUND

To evaluate as the natural history of superficial bladder tumors is modified by intravesical chemotherapy and if the behavior of treated tumors allows to forecast subsequent tumoral evolution.

METHODS

125 patients with superficial bladder tumor Ta and T1 were submitted to transurethral resection (TURB) and additional chemotherapy for one year. Mean follow-up was of 92.2 +/- 39.8 months and all patients were observed for four years at least.

RESULTS

Efficacy of treatment was according to the literature: the median of recurrence was estimated about the 10th year (increase of free interval); the percentage of patients free from recurrence after 14 years of follow-up was 35 +/- 19.9, instead that of specific survival was 87.1 +/- 11.8 (inefficacy in a long period); the percentage of tumor related deaths was of 10.4 (inefficacy to avoid the progression). Regarding the risk factors present on the beginning, there was a significance for the T1 that relapsed in the 56.6% versus the 30.9% of the Ta (p = 0.012) and for the multiple tumors that relapsed in the 64.4% versus the 38.7% of the single one (p = 0.009). Also the time and the T category of the first recurrence were interesting factors for the subsequent evolution of disease. In fact, in the 47 patients at beginning T1 that relapsed, there was a 43.4% of tumor related deaths if the recurrence occurred in the first year of follow-up, versus the 12.5% if the recurrence occurred after the first year (p = 0.017). Furthermore the 61.9% of patients "non Ta" (T1 or Tis) to the first recurrence died for tumor but no one if the first recurrence was Ta (p = 0.000).

CONCLUSIONS

Intravesical chemotherapy is still reliable. It is able to increase the free interval of recurrence after TURB. Moreover it can offer a useful criterion to recognize patients with chemoresistant tumors at higher risk of progression.

13-year survival comparison of percutaneous and open nephroureterectomy approaches for management of transitional cell carcinoma of renal collecting system: equivalent outcomes

BACKGROUND AND OBJECTIVE

Transitional cell carcinoma (TCC) of the renal collecting system traditionally has been managed by open nephroureterectomy with en bloc resection of a bladder cuff. However, for a select patient population with a solitary kidney or bilateral disease, the morbidity and mortality associated with chronic renal insufficiency and dialysis is deterring. In these situations, a more conservative approach such as antegrade percutaneous resection should be considered. The long-term disease-free outcome of percutaneous management in comparison with open nephroureterectomy has not been previously reported. We evaluated our experience with two surgical approaches to treat upper tract TCC: percutaneous resection and nephroureterectomy/nephrectomy to assess the clinical efficacy of these surgical modalities.

PATIENTS AND METHODS

We retrospectively identified 162 patients who had clinically localized TCC of the upper urinary tract. Records were reviewed to identify those with 13-year follow-up (N = 110) in respect to tumor grade, stage, disease-free status, length of cancer-specific survival, and overall survival. Statistical analysis of the results of open nephroureterectomy/nephrectomy (N = 60) and percutaneous resection (N = 50) was performed using Kaplan-Meier survival curves and Student's t-test.

RESULTS

All patients had disease in clinical stage Ta through T3. During a mean follow-up of 46.6 (range 6-150) months, grade 1 disease demonstrated little invasive potential. Of the disease-specific deaths, 60% (17/26) were of patients with grade 3 lesions, with a mean cancer survival period of 15.2 months after the initial procedure. Disease-specific survival rates after open and percutaneous approaches for grade 2 disease were 53.8 and 53.3 months, respectively (P > 0.05).

CONCLUSIONS

Tumor grade appeared to be the most important prognostic indicator in patients with renal TCC regardless of the surgical approach. Grade 3 tumors were more aggressive, presenting in an advanced stage with invasion, and recurrences were usually associated with metastasis. In this population, nephroureterectomy is warranted if the patient is a surgical candidate. The percutaneous option for grade 1 or 2 disease may be extended beyond the population with solitary kidneys and a risk of chronic renal failure to be offered to healthy individuals with normal contralateral kidneys who are willing to abide by a strict and lengthy follow-up.

Numerical chromosomal aberrations in muscle invasive squamous cell and transitional cell cancer of the urinary bladder: an alternative to classic prognostic indicators?

OBJECTIVES

To evaluate the prognostic value of chromosomal aberrations in muscle invasive bladder cancer, because they are of diagnostic and prognostic significance in superficial bladder cancer.

METHODS

One hundred ninety patients, who underwent radical cystectomy because of squamous cell carcinoma (SCC) of the urinary bladder in 94 cases and transitional cell carcinoma (TCC) in 96 cases, were studied retrospectively. Numerical aberrations of chromosomes 7, 9, and 17, p53 positivity, histologic stage and grade, histologic tumor type, lymph node status, and the presence of bilharzial eggs were investigated as possible prognostic factors.

RESULTS

Univariate analysis demonstrated the prognostic significance of all parameters analyzed, excluding chromosome 9. Multivariate analysis revealed only T category (P = 0.01095266), lymph node involvement (P = 0.00054877), and p53 positivity (P = 0.0316974) to be independent prognostic factors in muscle invasive SCC and TCC.

CONCLUSIONS

Although chromosomal aberrations are associated with progression-free survival, they are not independent prognostic factors and give the clinician no additional information on patients with muscle invasive bladder cancer.

[Quantification of p53 oncoprotein in bladder carcinoma: 5-year experience]

OBJECTIVE

Mutations in the p53 gene are frequently detected in some types of malignant tumors (bladder, prostate, kidney, lung, breast, colon and rectum). This study analyzed the utility of p53 quantitation in transitional cell carcinoma of the bladder and evaluated the results at 5 years.

METHODS

A prospective clinical cohort study was conducted on 81 patients. The study comprised two groups: nontumoral bladder tissue specimens from 20 patients (group I) and tissue specimens from 61 patients with bladder carcinoma (group II). In both groups the tissue specimens were obtained between November 1992 and November 1993, including the follow-up period until July 1998. p53 expression was determined by a quantitative method based on immunoluminiscence (LIA-MAT p53).

RESULTS

p53 expression was higher in bladder carcinoma than in healthy urothelial tissue; higher values of p53 were found for infiltrating and undifferentiated tumors. The p53 values were higher in patients with tumor recurrence than in those without (NS). The Bonferroni multiple comparisons test showed a higher mortality in patients with p53 > 0.9 than in patients who are alive or have died from other causes (p = 0.000).

CONCLUSION

The results show that p53 LIA-MAT is an independent prognostic factor at a cutoff of 0.9 and permits identification of a subgroup of patients at high risk.

Apoptosis in carcinoma of the bladder: relation with radiation treatment results

PURPOSE

Radiotherapy is widely used in the treatment of bladder cancer. The search for biological parameters that could select patients who will respond to radiation treatment has become essential. The aim of this study is to assess whether the pretreatment apoptotic index is useful in predicting local control and survival in a group of bladder cancer patients treated by radiotherapy.

METHODS AND MATERIALS

Fifty-five patients with invasive bladder carcinoma treated between 1983 and 1996 were included in this study. Radiotherapy was given to a median dose of 66 Gy, mean 63.28 Gy, in 1.8-2 Gy daily fractions. Apoptotic cells were studied in hematoxylin-eosin slides. Clinicopathological tumor characteristics were studied in relation to the apoptotic index, and as prognostic factors for local control and survival in both univariate and multivariate analysis.

RESULTS

Pretreatment apoptotic indexes were related to tumor stage, mitotic index, and Ki67 proliferation index. Five-year actuarial local control for the whole group was 45%. Patients with tumors showing low pretreatment apoptotic indexes had better local control (p < 0.037) and survival (p < 0.01) than highly apoptotic tumors. Tumor stage (T2 vs. T3-4) and the pretreatment apoptotic index were significant predictive factors for local control and survival in multivariate analysis.

CONCLUSIONS

The pretreatment apoptotic index is useful in predicting the clinical outcome of bladder cancer patients treated by radiotherapy. Assessment of biological tumor characteristics could allow the selection of patients for different treatment strategies.

Impact of diagnostic ureteroscopy on long-term survival in patients with upper tract transitional cell carcinoma

PURPOSE

We determine whether diagnostic retrograde ureteroscopy for evaluation of upper tract transitional cell carcinoma adversely affects survival outcomes in terms of urothelial and metastatic tumor recurrence, and tumor-free and overall survival.

MATERIALS AND METHODS

A total of 96 patients underwent total nephroureterectomy or resection of the distal ureter with a bladder cuff for upper tract transitional cell carcinoma. Of the patients 48 (study group) had undergone preoperative diagnostic ureteroscopy while 48 (control group) had not. Grade and stage of disease were compared, and time to recurrence, and disease-free and overall survival were analyzed.

RESULTS

Grade and stage of disease were equivalent in both groups. There were no significant differences in recurrence rates, time to recurrence or mortality between the groups. Metastases developed in 9 patients (18.8%) in the control group and 6 (12.5%) in the study group (p = 0.58), while 5 (10.4%) in each group died of metastases of upper tract carcinoma (p = 1.00). Kaplan-Meier estimates were 0.67 and 0.71 for metastasis-free survival at 5 years (p = 0.25, not significant) and 0.87 and 0.76 for overall 5-year survival (p = 0.75, not significant) for the study and control groups, respectively.

CONCLUSIONS

Diagnostic ureteroscopy has no clinically apparent adverse effect on long-term or disease specific survival of patients with upper tract transitional cell carcinoma who subsequently undergo standard definitive surgical management.

[Means of effective and practical intra-arterial chemotherapy for locally invasive bladder cancer--with special reference to clinical analysis of bladder cancer patients treated by intermittent intra-arterial infusion using an implantable port system]

Fifty-six patients with locally invasive bladder cancer were treated by chemotherapy with intermittent arterial infusion from an implanted reservoir and alteration of intrapelvic blood flow. The tip of an infusion catheter was inserted selectively into an internal iliac artery by an angiographic technique. Superior gluteal artery and the other internal iliac artery were then embolized with steel coils so that the drugs would perfuse throughout the tumor through a single catheter. Treatment consisted of intermittent injection of cisplatin (10 mg/body) and doxorubicin (10 mg/body) or epirubicin (10 mg/body) or pirarubicin (10 mg/body) in a ten-minute period every week (for the first 8 weeks) or every two weeks (after the 8th week). Fifty patients were objectively evaluated and the response rate was 80%. The overall survival rate in 54 patients at 1, 3, 5 and 8 years was 83.7%, 61.2%, 52.6%, and 52.6%. The 1-, 2-, 3-, 5- and 7-year disease free survival rate in evaluable 22 patients who showed a complete response (CR) was 91.8%, 85.2%, 65.6%, 58.3% and 58.3%. No serious side effects, such as severe myelosuppression or renal and/or liver dysfunction, were noted during treatment. These findings suggest that intermittent arterial chemotherapy with an implanted reservoir is clinically useful. This procedure appears safe and is easily performed in the outpatient clinic for the treatment of locally advanced bladder cancer.

Conservative therapy for stage T1b, grade 3 transitional cell carcinoma of the bladder

OBJECTIVES

To retrospectively evaluate the usefulness of transurethral resection of bladder tumor (TURBT) and intravesical instillation for pT1bG3 transitional cell carcinoma of the urinary bladder.

METHODS

Between May 1984 and May 1997, 45 patients with pT1bG3 transitional cell carcinoma of the urinary bladder underwent TURBT and intravesical instillation with bacillus Calmette-Guerin (BCG) or other anticancer agents. Random biopsy was carried out in 37 patients. The recurrence-free survival rate was determined by tumor size, number of tumors, lymphovascular invasion, and drugs used for intravesical instillation. The median follow-up period was 63 months (range 4 to 145) after the initial TURBT.

RESULTS

Of 37 patients who underwent random biopsy, concomitant carcinoma in situ was detected in 18 patients (48.6%). The incidence of concomitant CIS was significantly higher in patients with multiple tumors (P = 0.029). Vesical recurrence was noted in 16 patients (35.6%). The overall 1-, 3-, and 5-year recurrence-free survival rates were 88.5%, 66.7%, and 66.7%, respectively. Progression (muscular invasion) occurred in only 2 patients (4.4%). Total cystectomy was performed in 4 patients, including the 2 patients with progressive disease, and 2 patients with recurrent CIS that resisted BCG therapy. None of the patients died of bladder cancer.

CONCLUSIONS

Our results suggest that aggressive attempts at initial or subsequent TURBT combined with BCG therapy achieved good control of pT1bG3 transitional cell carcinoma of the urinary bladder.

[Comparative study of pure epidermoid carcinoma of the bladder and transitional cell carcinoma with squamous or mixed differentiated foci]

INTRODUCTION

The epidermoid bladder carcinoma is an infrequent tumour in our environment accounting for 5-8% of total vesical tumours, but is not so uncommon to find foci of squamous differentiation within a transitional carcinoma. We conducted a comparative study between these two histologic forms and analyzed the pattern of their clinical behaviour.

MATERIAL AND METHODS

Retrospective study on a total of 32 cases of epidermoid carcinoma diagnosed between 1986-1996 that following histological confirmation were divided into two groups; plain epidermoid carcinoma (PEC), 11 cases; and transitional carcinoma with foci of squamous differentiation (MEC), 19 cases. After further review 2 cases were excluded.

RESULTS

PEC appears in older patients. Both tumoral forms are more frequent in males, the male/female ratio being lower in PEC. Presence of irritative factors is significantly associated to PEC (P < 0.01) and smoking to MEC. Presentation signs are similar in both groups, and haematuria is the most frequent sign. Most usual location in both groups was the trigone, which caused uni/bilateral hydronephrosis in over 50% patients. At the time of diagnosis all PECs were invasive versus only 86% in the MEC group.

TREATMENT

PEC group underwent the following procedures: 4 radical cystectomies, 2 cystectomies plus radiotherapy, 3 palliative TUR and 2 TUR with radiotherapy. In the MEC group there were 3 radical cystectomies, 2 cystectomies plus radiotherapy, 1 cystectomy with previous chemotherapy, 8 palliative TUR, 2 TUR with endovesical chemotherapy, 1 TUR with systemic chemotherapy, 1 TUR with radiotherapy and 1 systemic chemotherapy. Mean survival was 12.5 months (0-43) in PEC and 26.55 (0-96) in MEC. Disease-free time in PEC and MEC was 5 months (0-37) and 10.25 (0-70) respectively. Only one patient achieved 5-year survival.

CONCLUSION

Epidermoid carcinoma both plain and mixed is an aggressive tumour with poor prognosis and short survival. 100% PECs in our series are invasive at diagnosis, and no statistically significant differences were found in survival and disease-free time between both histological variants. Cystectomy remains the choice therapy.

[Intra-arterial chemotherapy for invasive bladder cancer]

The present investigation was conducted to examine the effects of intra-arterial chemotherapy (IAC) for patients with invasive bladder cancer. A total of 37 patients were treated with IAC at Nara Medical University and its affiliated hospitals between January, 1993 and August, 1997. There were 27 patients in the poor risk group. The remaining 10 patients underwent anti-tumor IAC. Thirty of the 37 patients received chemotherapeutic agents via a reservoir, and the remaining 7 patients received a one-shot injection of agents followed by transcatheter arterial embolization (TAE). In the reservoir group, there were 18 patients who received IAC in combination with radiation therapy. As a result, reduction of tumor size was noted in 53%, and the 3-year cause-specific survival rate was 54% in all cases. There was a significant difference in the 3-year survival rate between the radiation-treated group and the group without radiation. The adverse events included anemia, leukopenia, thrombocytopenia and gastrointestinal symptoms, but none of them were severe. The results of the present study indicate that IAC is useful in the treatment of invasive bladder cancer for poor risk patients.

Can p53 help select patients with invasive bladder cancer for bladder preservation?

PURPOSE

We evaluated whether the p53 status of invasive bladder cancer may help to select patients for treatment strategies aimed at bladder preservation.

MATERIALS AND METHODS

A total of 111 patients with muscle invasive (T2 to 3N0M0) transitional cell carcinoma of the bladder received neoadjuvant methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) chemotherapy. Of these patients 60 (54%) had a complete clinical response (TO) to M-VAC. We report the 10-year outcome for these 60 patients, stratified by p53 status (positive versus negative) and stage (T2 versus T3) of the primary bladder neoplasm, and type of surgery (bladder sparing versus cystectomy) after M-VAC.

RESULTS

All 19 patients with T2 (organ confined) p53 negative tumors survived (16 after bladder sparing surgery and 3 after cystectomy) compared with 47% of 19 with T2 p53 positive tumors, 67% of 12 with T3 (extravesical) p53 negative tumors and 60% of 10 with T3 p53 positive tumors.

CONCLUSIONS

Our study suggests that the bladder may be preserved for up to 10 years in patients with tumors confined to the bladder (stage T2) who lack detectable p53 if they respond completely to neoadjuvant chemotherapy. Patients with T3 bladder tumors or T2 p53 positive tumors are best treated currently with cystectomy.

Hydronephrosis as a prognostic indicator in bladder cancer patients

PURPOSE

Pathological stage is the standard measure of prognosis in patients who have undergone radical cystectomy for bladder cancer. Despite the development of new imaging techniques, clinical staging for bladder cancer continues to be inaccurate. We investigated whether the presence of unilateral or bilateral upper tract obstruction could accurately predict advanced cancer stage (extravesical extension, stage greater than p3b or N+).

MATERIALS AND METHODS

A retrospective study of 415 patients diagnosed with transitional cell carcinoma of the bladder who were treated with radical cystectomy between 1983 and 1993 was conducted. All patients were followed for survival. The criteria for analysis included hydronephrosis status (no obstruction, unilateral, bilateral) as well as pathological stage of the tumor.

RESULTS

Of 415 patients 72% presented with no, 22.7% unilateral and 5.3% bilateral obstruction. Our results showed a significant correlation between hydronephrosis and advanced cancer stage (p <0.0001), and decreased patient survival (p <0.0001). More than 90% of patients with bilateral obstruction had disease with extravesical extension. Of the patients with unilateral obstruction a third had disease confined to the bladder with a significant proportion confined to the bladder mucosa.

CONCLUSIONS

The presence of unilateral or bilateral hydronephrosis is a clinical datum that is already available to help accurately stage bladder tumors. The presence of bilateral obstruction is an ominous sign, while a significant proportion of patients presenting with unilateral obstruction have disease confined to the bladder.

[Prognosis in pT3b infiltrating tumors of the bladder treated by adjuvant chemotherapy]

OBJECTIVE

To evaluate the prognosis of stage pT3bM0 invasive urothelial bladder tumours treated by cystectomy alone or combined with adjuvant chemotherapy according to the MVAC protocol (methotrexate, vinblastine, adriamycin and cisplatin).

MATERIAL AND METHODS

From 1987 to 1996, 90 patients with stage pT3M0 urothelial bladder tumours were treated with isolated cystectomy (n = 69) or followed by MVAC chemotherapy (n = 21). Lymph node stage was N0 (n = 55), N+ (n = 29) or Nx (n = 6). Essentially selected because of their good general status, patients treated with chemotherapy had a lymph node stage N0 (n = 7) or N+ (n = 14). Chemotherapy had to be suspended in 2 cases and with a fatal outcome during treatment in 4 cases, due to tumour progression, surgical complication or bone marrow aplasia.

RESULTS

65 deaths have occurred with a follow-up of 2 to 120 months (m = 15), including 2 postoperative deaths, 39 cancer deaths and 14 intercurrent deaths. The 1-year, 2-year and 5-year actuarial survival rates were 70%, 48% and 19% for stage N0 and 54%, 25% and 3% for stage N+, respectively, with corresponding median survivals of 20 and 12 months (p < 0.005). The recurrence rate increased from 40% at stage N0 to 62% at stage N+ (p = 0.05), and the corresponding recurrence-free survivals were 16 months and 7 months (p < 0.02). The median survival without chemotherapy ranged from 11 months at stage N+ to 20 months at stage N0 and, with chemotherapy, from 19 months at stage N+ to 67 months at stage N0. The median recurrence-free survival with and without chemotherapy, was 43 months and 17 months at stage N0 and 12 months and 7 months at stage N+.

CONCLUSION

The prognosis after cystectomy for stage pT3b bladder cancer is severe, especially in the presence of lymph node involvement. Adjuvant chemotherapy according to the MVAC protocol tends to improve survival, especially recurrence-free survival, and appears beneficial at stage N0. However, the value of this adjuvant treatment, which is associated with a high specific morbidity appears to be more relative at stage N+.

[Is neoadjuvant chemotherapy valid in invasive cancer of the bladder?]

The role of neoadjuvant chemotherapy for invasive transitional cell carcinoma (TCC) of the bladder is not determined yet. M-VAC and CMV regimens have a complete response rate of 10-47% with an overall response reaching 80%. In 16.7-35% of all the responders and 42.9-92% of the complete responders a functioning bladder can be preserved. The influence of neoadjuvant chemotherapy on long-term survival is questionable. Nevertheless, the authors conclude that neoadjuvant chemotherapy is feasible in patients with invasive TCC as it improves the results of following surgery and in some cases enables an organ sparing operation.

Altered gamma-catenin expression correlates with poor survival in patients with bladder cancer

PURPOSE

We studied the expression of alpha-, beta-, gamma- catenin and E-cadherin in transitional cell carcinoma (TCC) and normal bladder epithelium and correlated these results with pathological and clinical parameters.

MATERIALS AND METHODS

We used an avidin-biotin immunoperoxidase technique to examine the cellular localization of alpha-catenin, beta-catenin, gamma-catenin and E-cadherin in 68 TCC and 14 normal bladder biopsies.

RESULTS

E-cadherin, alpha-catenin, beta-catenin and gamma-catenin were expressed in a normal membranous pattern in all normal bladder epithelium specimens. Loss of normal surface E-cadherin, alpha-catenin, beta-catenin and gamma-catenin expression was found in 52/68 (76.4%) tumors, 57/68 (83.8%) tumors, 54/68 (79.4%) tumors and 54/68 (79.4%) tumors (p <0.001). There was a significant correlation between the loss of normal membranous expression of catenins and E-cadherin and increased grade (p <0.05). A highly significant correlation was observed between the loss of expression of E-cadherin, alpha-catenin and gamma-catenin, but not beta-catenin, with increased TNM stage (p <0.05). The abnormal expression of gamma-catenin as well as E-cadherin was correlated with poor survival (p <0.05).

CONCLUSIONS

E-cadherin-gamma-catenin complex may be a useful prognostic marker in bladder cancer. Work is in progress to establish whether normal membranous catenin expression can be enhanced by gene transfer or biological therapy to induce a less invasive and metastatic phenotype.

Nm23-H1 protein, DNA-ploidy and S-phase fraction in relation to overall survival and disease free survival in transitional cell carcinoma of the bladder

OBJECTIVES

To explain the overall survival (OS) and disease free survival (DFS) in relation to nm23-H1 protein, DNA-ploidy and S-phase fraction (SPF) in transitional cell carcinoma of the bladder.

PATIENTS AND METHODS

Ninety-four samples were obtained from patients with transitional cell carcinoma of the bladder examined between 1994 and 1996. The patients were underwent cistectomy or surgical biopsy and the material was histologically evaluated according to World Health Organization classification. Nm23-H1 protein expression in immunohistological staining and DNA ploidy, S-phase fraction by flow cytometric were performed.

RESULTS

The correlation between OS and staging, grading, DNA-ploidy and S-phase was significant; whereas the overall survival and nm23-H1 protein, was not significant. The relationship between DFS and stage, DNA-ploidy and S-phase had a significant value. The correlation between DFS and age, sex, grading and nm23-H1 protein was not significant. There was no significant difference in age, sex, stage, grading, DNA-ploidy and SPF distribution between patients with nm23-H1 positive bladder cancer and those with nm23-H1 negative tumours.

CONCLUSION

In our study, multivariate analysis showed that stage, ploidy and SPF were the strongest prognostic factors in predicting disease-free survival and prolonged survival, while nm23-H1 expression was not related to disease progression and/or prolonged survival. This expression, therefore, does not appear to be an independent prognostic factor in bladder cancer, although a still larger number of patients and a longer follow-up period are now needed for a definitive assessment of the prognostic significance of nm23-H1 expression.

The role of Ki67 proliferation assessment in predicting local control in bladder cancer patients treated by radical radiation therapy

PURPOSE

To assess whether tumour proliferation as measured by Ki67 immunostaining has any predictive value for local control in bladder cancer patients treated by radiotherapy.

PATIENTS AND METHODS

Fifty-five patients suffering from infiltrating bladder carcinoma recommended for radical radiotherapy (66 Gy/6-7 weeks) were included in this study. Paraffin-embedded pre-treatment tumour sections were stained with the Ki67 antibody. The percentage of Ki67-positive nuclei was correlated with established prognostic factors, local control and survival.

RESULTS

The Ki67 index was not related to local control in our patients when the median was selected as the cut-off value. Patients with tumours with a very low (<27%) Ki67 index had better local control at 5 years (69%) than patients with tumours with greater (>27%) Ki67 expression indices (31.5%) (P<0.05; log-rank test).

CONCLUSIONS

Ki67 immunostaining was a feasible method to estimate tumour proliferation. Patients with very low proliferating tumours seemed to achieve better local control after fractionated radiotherapy compared to other patients. Further studies are needed with a greater number of patients to accurately define the role of Ki67 expression in predicting tumour repopulation during fractionated radiotherapy.

Expression of CD44 standard and variant-v6 proteins in transitional cell bladder tumours and their relation to prognosis during a long-term follow-up

The expression of the standard CD44 (CD44s) and its v6 isoform (CD44v6) was analysed immunohistochemically in 173 cases of transitional cell bladder cancer. The results of immunohistochemical analyses were related to established prognostic factors and clinical follow-up data. The expression intensity of CD44s in non-basal tumour cells was significantly related to TN classification, S-phase fraction (SPF), mitotic index, grade, density of tumour infiltrating lymphocytes. The expression intensity of CD44v6 in non-basal tumour cells was inversely related to DNA ploidy, SPF, and mitotic index. The expression intensity of CD44v6 in basal tumour cells was also inversely related to T-category, grade, papillary status, DNA ploidy, SPF, and mitotic index. Strong expression of CD44s in non-basal tumour cells was related to unfavourable outcome in univariate analysis (p = 0.008), whereas the strong expression of CD44v6 in both non-basal cells (p = 0.005) and basal cells (p = 0.0008) was related to high survival probability. In multivariate survival analysis, the expression intensity of CD44v6 was independently related to favourable outcome in muscle invasive tumours, while in superficial tumours, CD44s was an independent prognostic factor. The results suggest that the expression of CD44s and CD44v6 is associated with malignant features and prognosis in bladder cancer.

Relationship among cystectomy, microvessel density and prognosis in stage T1 transitional cell carcinoma of the bladder

PURPOSE

The selection of therapy for stage T1 bladder cancer is controversial, and reliable biomarkers that identify patients likely to require cystectomy for local disease control have not been established. We evaluated our experience with T1 bladder cancer to determine whether early cystectomy improves prognosis, and whether microvessel density has prognostic value for T1 lesions and could be used for patient selection.

MATERIALS AND METHODS

We retrospectively reviewed the records of 88 patients with T1 transitional cell carcinoma of the bladder. Patient outcome was correlated with therapeutic intervention. Paraffin embedded tissue from 54 patients was available for factor VIII immunohistochemical staining for microvessel density quantification.

RESULTS

Median followup was 48 months (range 12 to 239). Of the patients 34% had no tumor recurrence. The rates of recurrence only and progression to higher stage disease were 41 and 25%, respectively. The survival of patients in whom disease progressed was diminished (p = 0.0002). Grade did not predict recurrence or progression nor did cystectomy provide a survival advantage. Microvessel density did not correlate with recurrence or progression.

CONCLUSIONS

Patients with T1 bladder cancer have a high risk of recurrence and progression. Tumor progression has a significant negative impact on survival. Neither grade nor early tumor recurrence predicted disease progression. Because early cystectomy did not improve patient outcome, we suggest reserving cystectomy for patients with progression or disease refractory to local therapy. Microvessel density is not a prognostic marker for T1 bladder cancer and has no value in selecting patients with T1 disease for cystectomy.

[Analysis of the prognostic factor in the patients with locally invasive bladder cancer who underwent total cystectomy]

OBJECTIVES

Prognosis and related factors were analysed as for the patients with locally invasive bladder cancer who underwent total cystectomy and pelvic lymph node dissection.

METHODS

Between January 1977 and December 1996, a hundred and one patients with locally invasive bladder cancer underwent total cystectomy and pelvic lymph node dissection at University Hospital. Survival rates of these patients were calculated by Kaplan-Meier method and statistical significances were analysed by univariate and multivariate analyses.

RESULTS

Most significant factor was PS at cystectomy and pN was next. Survival rate of the patients who underwent total cystectomy after 1988 showed significantly better than others. Thirteen patients achieved complete response by preoperative therapy. But, two of them who had positive nodes were died by cancer.

CONCLUSION

Considering from these results, performance status at cystectomy and lymph node metastasis are predictable prognostic factor for locally invasive bladder cancer patients.

Prognostic factors, recurrence, and survival in transitional cell carcinoma of the upper urinary tract: a 30-year experience in 252 patients

OBJECTIVES

To review a large single-center experience of patients treated for upper tract transitional cell carcinoma (TCC) with extended follow-up in order to identify patterns of recurrence, assess patient outcomes, and determine the impact of traditional prognostic factors.

METHODS

We reviewed 252 patients treated surgically for upper tract TCC with a median follow-up of 64 months. Most patients (77%) underwent nephroureterectomy, whereas 17% were treated with a parenchymal sparing approach. Traditional prognostic factors including age, sex, tumor stage, grade, location, and type of surgical treatment were analyzed with respect to disease recurrence and survival.

RESULTS

Disease relapse occurred in 67 patients (27%) at a median time of 12.0 months. Recurrences were local in the retroperitoneum (9%), the bladder (51%), remaining upper tract (18%), or distant in the lung, bone, or liver (22%). The 6 patients with local relapse were among the 73 patients with pT3 or pT4 tumors, and all died of TCC at a median time from diagnosis of 37 months. Significant prognostic factors for recurrence by univariate analysis were tumor grade (P = 0.0014) and stage (P = 0.0001). On multivariate analysis, only tumor stage (P = 0.017) and treatment modality (P = 0.020) were predictors of recurrence. Actuarial 5-year disease-specific survival rates by primary tumor stage were 100% for Ta/cis, 91.7% for T1, 72.6% for T2, and 40.5% for T3. Patients with primary Stage T4 tumors had a median survival of 6 months. Although tumor stage and grade correlated with disease-specific survival on univariate analysis, only patient age (P = 0.042) and stage (P = 0.0001) were significant on multivariate analysis with the type of surgical procedure performed approaching significance (P = 0.0504).

CONCLUSIONS

Primary tumor stage and surgical procedure performed (radical versus parenchymal sparing) are important predictors of disease recurrence. Patient age and tumor stage were the only predictors of disease-specific survival on multivariate analysis with the type of surgical procedure approaching significance. Radical nephroureterectomy achieves excellent local control even in the setting of locally advanced (pT3 or T4) disease. The major clinical feature in this setting is distant failure, and the development of effective systemic therapy is needed to improve the outcome in these patients.

A randomized trial comparing methotrexate and vinblastine (MV) with cisplatin, methotrexate and vinblastine (CMV) in advanced transitional cell carcinoma: results and a report on prognostic factors in a Medical Research Council study. MRC Advanced Bladder Cancer Working Party

Transitional cell carcinomas may arise at any site within the urinary tract and are a source of considerable morbidity and mortality. In particular, patients with metastatic disease have a poor prognosis, with less than 5% alive at 5 years. A multicentre randomized trial comparing methotrexate and vinblastine (MV) with cisplatin, methotrexate and vinblastine (CMV) in advanced or metastatic transitional cell carcinoma was conducted in the UK. From April 1991 to June 1995, 214 patients were entered by 16 centres, 108 randomized to CMV and 106 to MV. A total of 204 patients have died. The hazard ratio (relative risk of dying) was 0.68 (95% CI 0.51-0.90, P-value = 0.0065) in favour of CMV. This translates to an absolute improvement in 1-year survival of 13%, 16% in MV and 29% in CMV. The median survival for CMV and MV was 7 months and 4.5 months respectively. Two hundred and eight patients objectively progressed or died. The hazard ratio was 0.55 (95% CI 0.41-0.73, P-value = 0.0001) in favour of CMV. Two hundred and nine patients symptomatically progressed or died. The hazard ratio was 0.48 (95% CI 0.36-0.64, P-value = 0.0001) in favour of CMV. The most important pretreatment factors influencing overall survival were WHO performance status and extent of disease. These two factors were used to derive a prognostic index which could be used to categorize patients into three prognostic groups. We conclude that the addition of cisplatin to methotrexate and vinblastine should be considered in patients with transitional cell carcinoma, taking into account the increased toxicity.