Expression of urokinase-type plasminogen activator system in non-metastatic prostate cancer

PURPOSE

To investigate the prognostic role of expression of urokinase-type plasminogen activator system members, such as urokinase-type activator (uPA), uPA-receptor (uPAR), and plasminogen activator inhibitor-1 (PAI-1), in patients treated with radical prostatectomy (RP) for prostate cancer (PCa).

METHODS

Immunohistochemical staining for uPA system was performed on a tissue microarray of specimens from 3121 patients who underwent RP. Cox regression analyses were performed to investigate the association of overexpression of these markers alone or in combination with biochemical recurrence (BCR). Decision curve analysis was used to assess the clinical impact of these markers.

RESULTS

uPA, uPAR, and PAI-1 were overexpressed in 1012 (32.4%), 1271 (40.7%), and 1311 (42%) patients, respectively. uPA overexpression was associated with all clinicopathologic characteristics of biologically aggressive PCa. On multivariable analysis, uPA, uPAR, and PAI-1 overexpression were all three associated with BCR (HR: 1.75, p < 0.01, HR: 1.22, p = 0.01 and HR: 1.20, p = 0.03, respectively). Moreover, the probability of BCR increased incrementally with increasing cumulative number of overexpressed markers. Decision curve analysis showed that addition of uPA, uPAR, and PAI-1 resulted in a net benefit compared to a base model comparing standard clinicopathologic features across the entire threshold probability range. In subgroup analyses, overexpression of all three markers remained associated with BCR in patients with favorable pathologic characteristics.

CONCLUSION

Overexpression of uPA, uPAR, and PAI-1 in PCa tissue were each associated with worse BCR. Additionally, overexpression of all three markers is informative even in patients with favorable pathologic characteristics potentially helping clinical decision-making regarding adjuvant therapy and/or intensified follow-up.

Overactive bladder symptoms in patients undergoing rigid and flexible cystoscopy

PURPOSE

To evaluate overactive bladder (OAB) symptoms in patients undergoing diagnostic cystoscopy. Overall changes in the entire study population were assessed, as well as broken down by various subgroups.

METHODS

A prospective multi-center study among consecutive 450 adults undergoing diagnostic cystoscopy was conducted. OAB-symptoms were evaluated with the validated eight-item OAB Screening Awareness Tool (OAB-V8) immediately before and on days 1, 4, and 7 after cystoscopy. Patients were distinguished between being OAB-negative and OAB-positive (< 8 and ≥ 8 sum-score, respectively). Average sum-scores and subdomains were evaluated.

RESULTS

Before cystoscopy, 44.7% of patients were screened OAB-positive and 55.3% OAB-negative. Out of those being screened negative, development of de-novo OAB was noticed in 16.8%, declining to 8.1% on day 7 (p < 0.001). In patients being OAB-positive before cystoscopy, a decline of OAB-positivity was noted during follow-up (p < 0.001). No statistically significant differences were noted when broken down by gender (p = 0.92), age (p = 0.82) and type cystoscope (rigid vs. flexible, p = 0.38). Average sum-scores declined from 8.68 before cystoscopy to 6.9 during follow-up. Flexible cystoscopy was superior over rigid in four subdomains: uncomfortable urge to urinate (p = 0.04), sudden urge to urinate with little or no warning (p = 0.02), uncontrollable urge to urinate (p = 0.03), and urine loss associated with a strong desire to void (p = 0.009).

CONCLUSION

OAB-symptoms are common in patients undergoing cystoscopy. Cystoscopy itself can cause de-novo OAB-symptoms. Controversially, a decline of OAB-symptoms was noted after cystoscopy when patients were screened OAB-positive before cystoscopy. Flexible scopes were superior in some subdomains.

Differences in trends in the use of robot-assisted and open radical cystectomy and changes over time in peri-operative outcomes among selected centres in North America and Europe: an international multicentre collaboration

OBJECTIVES

To compare trends in the use of robot-assisted radical cystectomy (RARC) and changes over time in peri-operative outcomes in selected North American and European centres.

MATERIALS AND METHODS

We conducted a retrospective evaluation of 2401 patients treated with open radical cystectomy (ORC) or RARC for bladder cancer at 12 centres in North America and Europe between 2006 and 2018. We used the Kruskal-Wallis and chi-squared test to evaluate differences between continuous and categorical variables.

RESULTS

Overall, 49.5% of patients underwent RARC and 51.5% ORC. RARC became the most commonly performed procedure in contemporary patients, with an increase from 29% in 2006-2008 to 54% in 2015-2018 (P < 0.001). In the North American centres the use of RARC was higher than that of ORC from 2006, and remained stable over time, whereas in the European centres its use increased exponentially from 2% to 50%. In both groups patients who underwent RARC had less advanced T stages (P < 0.001), lower American Society of Anesthesiologists scores (P < 0.05), lower blood loss (P = 0.001) and shorter length of hospital stay (P < 0.05). No differences were found in early complications. Early readmission and re-operation rates were worse for patients treated with RARC in the European centres; however, when contemporary patients only were considered, the statistical significance was lost.

CONCLUSION

The present study shows that the use of RARC has constantly increased since its introduction, overtaking ORC in the most contemporary series. While RARC was more frequently performed than ORC since its introduction in the North American centres and its use remained substantially stable over time, its use increased exponentially in the European centres. The different trends in use of RARC/ORC and changes over time in peri-operative outcomes between the North American and European centres can be attributed to the earlier introduction and spread of RARC in the former compared with the latter.

Association of Smoking Status With Recurrence, Metastasis, and Mortality Among Patients With Localized Prostate Cancer Undergoing Prostatectomy or Radiotherapy: A Systematic Review and Meta-analysis

Importance

Studies investigating the association of cigarette smoking with prostate cancer incidence and outcomes have revealed controversial results.

Objective

To systematically review and analyze the association of smoking status with biochemical recurrence, metastasis, and cancer-specific mortality among patients with localized prostate cancer undergoing primary radical prostatectomy or radiotherapy.

Data Sources

A systematic search of original articles published between January 2000 and March 2017 was performed using PubMed, MEDLINE, Embase, and Cochrane Library databases in March 2017.

Study Selection

Observational studies reporting Cox proportional hazards regression or logistic regression analyses were independently screened.

Data Extraction and Synthesis

This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions. Available multivariable hazard ratios (HRs) and corresponding 95% CIs were included in quantitative analysis. A risk-of-bias assessment was completed for nonrandomized studies.

Main Outcomes and Measures

Prespecified outcomes of interest were biochemical recurrence, metastasis, and cancer-specific mortality.

Results

A total of 5157 reports were identified, of which 16 articles were selected for qualitative analysis and 11 articles were selected for quantitative analysis. All included studies were observational and nonrandomized and comprised a total of 22 549 patients. Overall, 4202 patients (18.6%) were current smokers. The overall median follow-up was 72 months. Current smokers had a statistically significantly higher risk of biochemical recurrence (HR, 1.40; 95% CI, 1.18-1.66; P < .001 [10 studies]), as did former smokers (HR, 1.19; 95% CI, 1.09-1.30; P < .001 [7 studies]). Current smokers were also at a higher risk of metastasis (HR, 2.51; 95% CI, 1.80-3.51; P < .001 [3 studies]) and cancer-specific mortality (HR, 1.89; 95% CI, 1.37-2.60; P < .001 [5 studies]), whereas former smokers were not (metastasis: HR, 1.61; 95% CI, 0.65-3.97; P = .31 [2 studies]; cancer-specific mortality: HR, 1.05; 95% CI, 0.81-1.37; P = .70 [4 studies]).

Conclusions and Relevance

Current smokers at the time of primary curative treatment for localized prostate cancer are at higher risk of experiencing biochemical recurrence, metastasis, and cancer-specific mortality.

Impact of Patients' Gender on Efficacy of Immunotherapy in Patients With Metastatic Kidney Cancer: A Systematic Review and Meta-analysis

Recent meta-analyses on checkpoint inhibitors in cancer report conflicting data regarding the association of patient gender with inhibitor efficacy. In advanced kidney cancer, checkpoint inhibitors have shown improved outcomes in first- and second-line settings compared with standard of care, but the role of patient gender on treatment outcome is unclear. We aimed to assess the efficacy of immunotherapy according to patient gender in advanced kidney cancer. We performed a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search was performed using PubMed, Scopus, Web of Science, and The Cochrane Library to identify eligible studies published through February 16, 2019. Studies were included if they reported on the differential outcomes of male and female patients with metastatic kidney cancer receiving immunotherapy. Our outcomes of interest were overall survival (OS) or progression-free survival (PFS). Four randomized controlled trials comprising a total of 3664 patients (2715 males and 949 females) met our inclusion criteria. Both men and women with metastatic kidney cancer had an OS and PFS advantage with immunotherapy compared with standard-of-care, but no statistically significant difference between the genders was observed (OS hazard ratio [HR] for men, 0.69; 95% confidence interval [CI], 0.59-0.8; P = .40; HR for women, 0.62; 95% CI, 0.48-0.81; P = .13; PFS HR for men, 0.7; 95% CI, 0.59-0.82; P = .24; HR for women, 0.68; 95% CI, 0.52-0.90; P = .105). In patients with advanced kidney cancer receiving checkpoint inhibitors, there seems to be no association of patient gender with treatment outcome.

Development and external validation of a pathological nodal staging score for patients with clear cell renal cell carcinoma

OBJECTIVES

To develop and externally validate a model that quantifies the likelihood that a pathologically node-negative patient with clear cell renal cell carcinoma (cRCC) has, indeed, no lymph node metastasis (LNM).

PATIENTS AND METHODS

Data from 1389 patients treated with radical nephrectomy (RN) and lymph node dissection (LND) were analyzed. For external validation, we used data from 2270 patients in the Surveillance, Epidemiology and End Results (SEER) database. We estimated the sensitivity of pathologic nodal staging using a beta-binomial model and developed a pathological nodal staging score (pNSS), which represents the probability that a patient is correctly staged as node negative as a function of the number of examined lymph nodes (LNs).

RESULTS

The mean and median number of LNs removed were 7.0 and 5.0 (standard deviation, SD 6.6; interquartile range, IQR 7.0) in the development cohort and 5.6 and 2.0 (SD 8.6, IQR 5.0) in the validation cohort, respectively. The probability of missing a positive LN decreased with increasing number of LNs examined. In both the validation and the development cohort, the number of LNs needed for correctly staging a patient as node negative increased with higher pathological tumor stage and Fuhrman grade.

CONCLUSIONS

The number of examined LNs needed for adequate nodal staging in cRCC depends on pathological tumor stage and Fuhrman grade. We developed here and then externally validated a pNSS, which could help to refine patient counseling, decision-making regarding risk-stratified surveillance regimens and inclusion criteria for clinical trials of adjuvant therapy.

Prognostic role of the urokinase plasminogen activator (uPA) system in patients with nonmuscle invasive bladder cancer

OBJECTIVES

To assess the role of the urokinase plasminogen activator (uPA) system as a prognostic biomarker in patients with nonmuscle invasive bladder cancer (NMIBC) treated with transurethral resection of the bladder (TURB) with or without adjuvant intravesical therapy.

MATERIAL AND METHODS

We stained TURB tissue from 827 NMIBC patients with uPA, its receptor (uPAR) and its inhibitor (PAI-1). The status of these markers was categorized as normal vs. overexpressed using the cutoffs of 30% for uPA, 50% for uPAR, and 30% for PAI-1. Multivariable Cox regression analyses were performed to evaluate the prognostic value of these markers.

RESULTS

uPA was overexpressed in 37.7% of patients, uPAR in 44.7% and PAI-1 in 44.6%. Overexpression of these markers was associated with high tumor grade. Within a median follow-up was 60 months (interquartile range: 22-109), uPA (hazard ratio [HR]: 1.40; P = 0.006), uPAR (HR: 1.70; P < 0.001), PAI-1 (HR: 1.35; P = 0.014), and the combination of all 3 markers (HR: 3.38; P < 0.001) were associated with recurrence-free survival (RFS); uPA (HR: 1.68; P = 0.035) and the combination of all 3 markers (HR: 8.79; P = 0.005) were associated with progression-free survival (PFS). The addition of the uPA system to a base model improved the discrimination by 1.3% for RFS and 2.1% for PFS. In subgroup analyses, uPA (HR: 2.19; P = 0.018) was associated with PFS in T1G3 patients and its addition to a base model improved the discrimination by 2.5%. uPA (HR: 1.44; P = 0.019), uPAR (HR: 1.54; P = 0.006), PAI-1 (HR: 1.46; P = 0.013) and the combination of all 3 markers (HR: 3.48; P < 0.001) were associated with RFS in TaG1-2 patients and their addition to a base model improved the discrimination by 2.1%.

CONCLUSION

uPA, uPAR, and PAI-1 are overexpressed in one-third to half of patients with NMIBC. Their overexpression is an independent prognosticator of RFS and PFS which improved the predictive accuracy of current clinicopathological characteristics. Biomarkers that capture the biological and clinical behavior of individual tumors may help personalize clinical decision-making in patients with NMIBC.

Prevalence and Prognostic Value of the Polymorphic Variant 1245A>C of HSD3B1 in Castration-resistant Prostate Cancer

INTRODUCTION

The purpose of this study was to investigate the prevalence and prognostic value of the polymorphic variant (1245A>C), a single nucleotide polymorphism (SNP) of the HSD3B1 gene, in the tumors of patients with castration-resistant prostate cancer (CRPC).

MATERIALS AND METHODS

We retrospectively evaluated 44 patients with CRPC who underwent palliative transurethral resection of the prostate. Genomic DNA was extracted from formalin-fixed and paraffin-embedded material, and 1245A>C SNP of the HSD3B1 gene was analyzed via Sanger sequencing. Cox regression analysis was used to assess the prognostic value of the respective SNP with time to progression as well as cancer-specific and overall survival in the subgroup of patients receiving second systemic treatment.

RESULTS

The SNP was present in 20 patients (51.2%) who received second line systemic treatment additionally to androgen deprivation, of which 16 (80%) patients were heterozygous and 4 (20%) were homozygous. Correlation analysis revealed no association of the SNP with any clinical characteristics at initiation of second-line systemic treatment. Moreover, the presence of the variant (1245A>C) of HSD3B1 was not associated with any survival endpoint.

CONCLUSIONS

The variant allele 1245C of the HSD3B1 gene is present in approximately one-half of patients with CRPC; however, it is not associated with oncologic outcomes. These findings, however, need to be interpreted with caution as the sample size is small. Further research on biomarkers is needed to help tailor clinical decision making in prostate cancer, especially in the increasingly complex therapeutic landscape of CRPC.

Comparison of perioperative complications and health-related quality of life between robot-assisted and open radical cystectomy: A systematic review and meta-analysis

To compare postoperative complications and health‐related quality of life of patients undergoing robot‐assisted radical cystectomy with those of patients undergoing open radical cystectomy. A systematic search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement. A pooled meta‐analysis was carried out to assess the differences between robot‐assisted radical cystectomy and open radical cystectomy according to randomized and non‐randomized comparative studies, respectively. We identified six randomized comparative studies and 31 non‐randomized comparative studies. Most robot‐assisted radical cystectomy patients were treated with extracorporeal urinary diversion. Robot‐assisted radical cystectomy was associated with longer operative times, and lower blood loss and transfusion rates compared with open radical cystectomy in both randomized comparative studies and non‐randomized comparative studies. There was no significant difference between robot‐assisted radical cystectomy and open radical cystectomy in the rate of patients with any or major complications within 90 days both in randomized comparative studies and non‐randomized comparative studies. Non‐randomized comparative studies reported a lower rate of complications at 30 days, mortality at 90 days and length of stay for patients treated with robot‐assisted radical cystectomy, which were not confirmed in randomized comparative studies. Additionally, there were no differences in postoperative quality of life score assessment at 3 and 6 months between robot‐assisted radical cystectomy and open radical cystectomy. Robot‐assisted radical cystectomy is associated with less blood loss and lower transfusion rates. There is no difference in complications, length of stay, mortality, and quality of life between robot‐assisted radical cystectomy and open radical cystectomy. Data from non‐randomized comparative studies favor perioperative outcomes in robot‐assisted radical cystectomy patients, the failure to confirm in randomized comparative studies, likely due to bias in study design and reporting. Further randomized comparative studies comparing postoperative complications and quality of life between robot‐assisted radical cystectomy with intracorporeal urinary diversion and open radical cystectomy are required to assess potential differences between these two surgical approaches.

Focal Neuroendocrine Differentiation of Conventional Prostate Adenocarcinoma as a Prognostic Factor after Radical Prostatectomy: A Systematic Review and Meta-Analysis

The biologic and prognostic value of focal neuroendocrine differentiation (NED) in conventional prostate adenocarcinoma (PC) patients who undergo radical prostatectomy (RP) remains controversial. In this systematic review and meta-analysis, we assessed the association of focal NED in conventional PC with oncological outcomes after RP. A literature search using PubMed, Scopus, Web of Science, and Cochrane Library was conducted on December 2018 to find relevant studies according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We used a fixed-effect model to analyze the impact of focal NED in RP specimen on progression-free survival defined by biochemical recurrence (BCR). A total of 16 studies with the outcomes of disease progression and survival were eligible. No patient in these studies received androgen deprivation therapy prior to RP. Eleven studies found no significant correlation between focal NED and outcomes of interest, while five studies reported a significant association of focal NED assessed by immunohistochemical chromogranin A or serotonin staining with BCR or survival. Focal NED was associated with higher BCR rates after RP with a pooled HR of 1.39 (95% CI 1.07‒1.81) in five studies. No heterogeneity was reported in this analysis (I² = 21.7%, p = 0.276). In conclusion, focal NED in conventional PC is associated with worse prognosis after RP. Its presence should be reported in pathologic reports and its true clinical impact should be assessed in well-designed prospective controlled studies.

Prognostic Value of Concomitant Carcinoma In Situ in the Radical Cystectomy Specimen: A Systematic Review and Meta-Analysis

PURPOSE

We investigated the prognostic impact of concomitant carcinoma in situ in radical cystectomy specimens.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis using MEDLINE®, Scopus®, Web of Science™ and The Cochrane Library to identify eligible studies published until October 2017. Studies were eligible for analysis if they compared patients with concomitant carcinoma in situ in radical cystectomy specimens for bladder cancer to patients without concomitant carcinoma in situ to determine its value to prognosticate overall mortality, recurrence-free survival, cancer specific mortality and ureteral involvement using multivariable analysis. The protocol for this systematic review was registered in PROSPERO (Prospective Register of Systematic Reviews, CRD42018086539) and is available in full on the University of York website.

RESULTS

Overall 23 studies published between 2006 and 2017 including a total of 20,647 patients were selected for the systematic review and meta-analysis. Concomitant carcinoma in situ was reported in 39.4% of radical cystectomy specimens. In studies analyzing all patients the presence of concomitant carcinoma in situ was not associated with overall mortality (pooled HR 0.92, 0.77-1.10), recurrence-free survival (pooled HR 1.06, 0.99-1.13) or cancer specific mortality (pooled HR 1.00, 0.93-1.07). It was associated with ureteral involvement (pooled OR 4.51, 2.59-7.84). On subanalysis of studies restricted to patients with organ confined bladder cancer at radical cystectomy concomitant carcinoma in situ was associated with worse recurrence-free survival (pooled HR 1.57, 1.12-2.21) and cancer specific mortality (pooled HR 1.51, 1.001-2.280).

CONCLUSIONS

Concomitant carcinoma in situ is significantly associated with ureteral involvement in patients treated with radical cystectomy. In patients with organ confined disease concomitant carcinoma in situ in the radical cystectomy specimen is a prognosticator of recurrence-free survival and cancer specific mortality.

Prognostic value of nutritional indices and body composition parameters including sarcopenia in patients treated with radiotherapy for urothelial carcinoma of the bladder

PURPOSE

To assess the prognostic importance of sarcopenia in survival in patients with high-risk urothelial carcinoma of the bladder (UCB) who were unfit for radical cystectomy or systemic chemotherapy and were, therefore, treated with radiotherapy only.

METHODS

We evaluated 94 patients treated with transurethral resection of the bladder and radiotherapy for UCB. Sarcopenia, identified from pretreatment computed tomography scans, was defined as a skeletal muscle index of <39 cm²/m² for women and <55 cm²/m² for men. Body mass index -adjusted definition of sarcopenia was used to evaluate for sarcopenic obesity. Univariate models were used to assess the association between body composition and nutritional parameters with survival outcomes.

RESULTS

Overall, 68 patients were eligible for the final analysis, and 49 (72%) patients were sarcopenic. After body mass index adjustment of the definition of sarcopenia, its prevalence changed to 53.8% in women and 52.7% in men. Median age was 82 (interquartile range [IQR] 75-86) years, with a median, age-adjusted comorbidity index of 7.5 (IQR 6-10). The median time of follow-up was 12.5 (IQR 5.1-23.5) months. There were 42 (61.7%) patients who died of any cause and 19 (45.2%) who died because of UCB during the study period. Of all the body composition and nutritional parameters investigated, sarcopenic obesity was associated with cancer-specific survival (hazard ratio 5.0, 95% confidence interval 1.4-16.7, P = 0.01) and a low prognostic nutritional index was associated with overall survival (hazard ratio 0.46, 95% confidence interval 0.2-0.9, P = 0.02).

CONCLUSION

In patients who are too high risk for the standard treatment of UCB, sarcopenia is highly prevalent, but not prognostic of survival. Nevertheless, sarcopenic obesity and the prognostic nutritional index might act as prognostic markers for patients with UCB undergoing radiotherapy.

Comparative Effectiveness in Perioperative Outcomes of Robotic versus Open Radical Cystectomy: Results from a Multicenter Contemporary Retrospective Cohort Study

BACKGROUND

The comparative effectiveness of robotic-assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) in terms of perioperative outcomes is still a matter of debate affecting payors, physicians, and patients.

OBJECTIVE

To evaluate comparative perioperative and longer-term morbidity of RARC versus ORC in a multicenter contemporary retrospective cohort of patients.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective multicenter study included patients with bladder cancer treated with radical cystectomy at 10 academic centers between 2000 and 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Intraoperative outcomes including blood loss and operative time as well as postoperative outcomes including time to discharge, complication, readmission, reoperation, and mortality rates at 30 and 90 d were assessed. Multiple imputation and inverse probability of treatment weighting (IPTW) were used. IPTW-multivariable-adjusted regression and logistic analyses were performed to evaluate the associations of RARC versus ORC with perioperative outcomes at 30 and 90 d.

RESULTS AND LIMITATIONS

Overall, 1887 patients (1197 RARC and 690 ORC) were included in the study. After IPTW-adjusted analysis, no differences between the groups in terms of preoperative characteristics were observed. RARC was associated with lower blood loss (p<0.001), shorter length of stay (p<0.001), and longer operative time (p=0.007). On IPTW-adjusted multivariable logistic regression analyses, no differences in terms of 30- and 90-d complications, reoperation, and mortality rates were observed. RARC was independently associated with a higher readmission rate at both 30 and 90 d. Limitations are mainly related to the retrospective nature of the study.

CONCLUSIONS

While RARC was associated with less blood loss and shorter hospital stay, it also led to longer operation times and more readmissions. There were no differences in 30- and 90-d complications. Because there are no apparent differences in safety between ORC and RARC in expert centers, differences in oncologic and cost-effectiveness outcomes are likely to drive decision making regarding RARC utilization.

PATIENT SUMMARY

In this study we investigated the differences between RARC and ORC in terms of perioperative outcomes. We found no difference in early and late complications. We concluded that, to date, differences in oncologic and cost-effectiveness outcomes should drive decision making regarding RARC utilization.

Surgical checklist impact on recurrence-free survival of patients with non-muscle-invasive bladder cancer undergoing transurethral resection of bladder tumour

OBJECTIVES

To evaluate the impact of an eight-item surgical checklist (SC) on the recurrence-free survival (RFS) of patients with non-muscle-invasive bladder cancer (NMIBC) undergoing transurethral resection of bladder tumour (TURBT).

PATIENTS AND METHODS

A group of urologists at two tertiary referral centres, with expertise in bladder cancer, identified eight critical items that should be performed in every high-quality TURBT. An eight-item SC was prospectively implemented into clinical practice and the operative reports of TURBTs performed before and after implementation were reviewed. Results from both institutions were combined to estimate the impact of introducing the SC on oncological outcomes. Multivariable logistic and Cox hazards regression analyses were performed to evaluate the impact of the SC on the presence of detrusor muscle in the TURBT specimen and on RFS, respectively.

RESULTS

The operative reports of 266 TURBTs performed after the SC implementation were reviewed and compared to those of 281 TURBTs performed prior to the SC introduction. The SC was independently associated with a significant improvement in RFS (P = 0.02). However, the introduction of the SC was not significantly associated with the presence of detrusor muscle in the surgical specimen (P = 0.4).

CONCLUSION

The use of an eight-item SC during TURBT in clinical practice increases the quality of operative reports thereby potentially improving individualised risk-stratification and care resulting in lower disease recurrence rates. Therefore, the introduction of a SC can be recommended to enhance oncological outcomes by improving surgical standardisation and operative reporting.

A systematic review and meta-analysis of the impact of lymphovascular invasion in bladder cancer transurethral resection specimens

The aim of the present review was to assess the prognostic impact of lymphovascular invasion (LVI) in transurethral resection (TUR) of bladder cancer (BCa) specimens on clinical outcomes. A systematic review and meta-analysis of the available literature from the past 10 years was performed using MEDLINE, EMBASE and Cochrane library in August 2017. The protocol for this systematic review was registered on PROSPERO (Central Registration Depository: CRD42018084876) and is available in full on the University of York website. Overall, 33 studies (including 6194 patients) evaluating the presence of LVI at TUR were retrieved. LVI was detected in 17.3% of TUR specimens. In 19 studies, including 2941 patients with ≤cT1 stage only, LVI was detected in 15% of specimens. In patients with ≤cT1 stage, LVI at TUR of the bladder tumour (TURBT) was a significant prognostic factor for disease recurrence (pooled hazard ratio [HR] 1.97, 95% CI: 1.47-2.62) and progression (pooled HR 2.95, 95% CI: 2.11-4.13), without heterogeneity (I² = 0.0%, P = 0.84 and I² = 0.0%, P = 0.93, respectively). For patients with cT1-2 disease, LVI was significantly associated with upstaging at time of radical cystectomy (pooled odds ratio 2.39, 95% CI: 1.45-3.96), with heterogeneity among studies (I² = 53.6%, P = 0.044). LVI at TURBT is a robust prognostic factor of disease recurrence and progression in non-muscle invasive BCa. Furthermore, LVI has a strong impact on upstaging in patients with organ-confined disease. The assessment of LVI should be standardized, reported, and considered for inclusion in the TNM classification system, helping clinicians in decision-making and patient counselling.

Progressive tissue biomarker profiling in non-muscle-invasive bladder cancer

INTRODUCTION

The recurrence rate of non-muscle-invasive bladder cancer (NMIBC) is up to 60% within the first year of therapy. Accurate risk stratification is necessary for patient counselling, follow-up scheduling and individualized therapeutic decision making. Current prognostic models rely on clinicopathologic features, but their discrimination remains limited when in external cohorts. Despite intense efforts regarding the value of biomarkers in prognosticating outcomes in NMIBC, clinical utility remains suboptimal. It is clear that a single biomarker is not enough for the prediction of disease recurrence. Therefore, panels of non-redundant biomarkers have been created and integrated in clinical prognostic model further research relying on high throughput technologies is required. Areas covered: We performed a systematic research of the English-language literature on tissue biomarkers for prediction of NMIBC outcomes up to December 2017. Expert commentary: Despite the essential milestones achieved in our knowledge and understanding of the molecular biology underlying NMIBC, no biomarker has been implemented together with clinical feature in clinical practice. Integration of such biomarkers into predictive and prognostic model could, however, improve our accuracy, thereby paving the way for personalized medicine in the management of NMIBC.

A systematic review and meta-analysis of lymphovascular invasion in patients treated with radical cystectomy for bladder cancer

PURPOSE

Lymphovascular invasion (LVI) is an important step in bladder cancer cell dissemination. We aimed to perform a systematic review and meta-analysis of the literature to assess the prognostic value of LVI in radical cystectomy (RC) specimens.

PATIENTS AND METHODS

A systematic review and meta-analysis of the last 10 years was performed using the MEDLINE, EMBASE, and the Cochrane libraries in July 2017. The analyses were performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.

RESULTS

We retrieved 65 studies (including 78,107 patients) evaluating the effect of LVI on oncologic outcomes in patients treated with RC. LVI was reported in 35.4% of patients. LVI was associated with disease recurrence (pooled hazard ratio [HR] = 1.57; 95% CI: 1.45-1.70) and cancer-specific mortality (CSM) (pooled HR = 1.59; 95% CI: 1.48-1.73) in all studies regardless of tumor stage and node status (pT1-4 pN0-2). LVI was associated with recurrence and CSM in patients with node-negative bladder cancer (BC). In patients with node-negative BC, LVI rate increased and was associated with worse oncologic outcome. LVI had a lower but still significant association with disease recurrence and CSM in node-positive BC.

CONCLUSIONS

LVI is a strong prognostic factor of worse prognosis in patients treated with RC for bladder cancer. This association is strongest in node-negative BC, but it is also in node-positive BC. LVI should be part of all pathological reporting and could provide additional information for treatment-decision making regarding adjuvant therapy after RC.

The impact of moderate wine consumption on the risk of developing prostate cancer

Objective

To investigate the impact of moderate wine consumption on the risk of prostate cancer (PCa). We focused on the differential effect of moderate consumption of red versus white wine.

Design

This study was a meta-analysis that includes data from case–control and cohort studies.

Materials and methods

A systematic search of Web of Science, Medline/PubMed, and Cochrane library was performed on December 1, 2017. Studies were deemed eligible if they assessed the risk of PCa due to red, white, or any wine using multivariable logistic regression analysis. We performed a formal meta-analysis for the risk of PCa according to moderate wine and wine type consumption (white or red). Heterogeneity between studies was assessed using Cochrane’s Q test and I² statistics. Publication bias was assessed using Egger’s regression test.

Results

A total of 930 abstracts and titles were initially identified. After removal of duplicates, reviews, and conference abstracts, 83 full-text original articles were screened. Seventeen studies (611,169 subjects) were included for final evaluation and fulfilled the inclusion criteria. In the case of moderate wine consumption: the pooled risk ratio (RR) for the risk of PCa was 0.98 (95% CI 0.92–1.05, p=0.57) in the multivariable analysis. Moderate white wine consumption increased the risk of PCa with a pooled RR of 1.26 (95% CI 1.10–1.43, p=0.001) in the multi-variable analysis. Meanwhile, moderate red wine consumption had a protective role reducing the risk by 12% (RR 0.88, 95% CI 0.78–0.999, p=0.047) in the multivariable analysis that comprised 222,447 subjects.

Conclusions

In this meta-analysis, moderate wine consumption did not impact the risk of PCa. Interestingly, regarding the type of wine, moderate consumption of white wine increased the risk of PCa, whereas moderate consumption of red wine had a protective effect. Further analyses are needed to assess the differential molecular effect of white and red wine conferring their impact on PCa risk.

Waiting in the wings: the emerging role of molecular biomarkers in bladder cancer

INTRODUCTION

Bladder cancer (BCa) is the fifth most frequently diagnosed cancer worldwide and is, in fact, the most expensive cancer on a per-patient to treat basis. There is a critical need to implement new tests into clinical practice to improve the quality of clinical care, decrease unnecessary invasive therapies and ultimately save costs. Currently, no molecular or genetic biomarker has been widely integrated into daily clinical practice. However, major milestones have been achieved in our understanding of the molecular alterations in BCa that will provide the basis for integrating molecular and genetic biomarkers into clinical decision making to guide management. Clinical implementation of such novel molecular and genetic concepts is the cornerstone in an effort to usher the age of precision medicine into patient care. Areas covered: In this review, the authors discuss the emerging role of molecular biomarkers in patients receiving BCG immunotherapy as well as neoadjuvant and adjuvant chemotherapy in BCa. Expert commentary: Molecular predictive and prognostic biomarkers in BCa are promising diagnostic options that will pave the way for molecular-based personalized medicine.

Accurate prediction of progression to muscle-invasive disease in patients with pT1G3 bladder cancer: A clinical decision-making tool

PURPOSE

To improve current prognostic models for the selection of patients with T1G3 urothelial bladder cancer who are more likely to fail intravesical therapy and progress to muscle-invasive bladder cancer (MIBC).

MATERIALS AND METHODS

We performed a retrospective analysis of 1,289 patients with pT1G3 urothelial bladder cancer who were treated with transurethral resection of the bladder (TURB) and adjuvant intravesical bacillus-Calmette-Guérin (BCG). Random-split sample data and competing-risk regression were used to identify the independent impact of lymphovascular invasion (LVI) and variant histology (VH) on progression to MIBC. We developed a nomogram for predicting patient-specific probability of disease progression at 2 and 5 years after TURB. Decision curve analysis (DCA) was performed to evaluate the clinical benefit associated with the use of our nomogram.

RESULTS

In the development cohort, within a median follow-up of 51.6 months (IQR: 19.3-92.5), disease progression occurred in 89 patients (13.8%). A total of 84 (13%) patients were found to have VH and 57 (8.8%) with LVI at TURB. Both factors were independently associated with disease progression on multivariable competing-risk analysis (HR: 4.4; 95% CI: 2.8-6.9; P<0.001 and HR: 3.5; 95% CI: 2.1-5.8; P<0.001, respectively). DCA showed superior net benefits for the nomogram within a threshold probability of progression between 5% and 55%. Limitations are inherent to the retrospective design.

CONCLUSIONS

We demonstrated the clinical value of the integration of LVI and VH in a prognostic model for the prediction of MIBC. Indeed, our tool provides superior individualized risk estimation of progression facilitating decision-making regarding early RC.

Genetic determinants for chemo- and radiotherapy resistance in bladder cancer

Bladder cancer (BCa) is burdened by high rates of chemo- and radio-resistance. We reviewed and summarized the current evidence regarding the genetic determinants of resistance in patients treated with chemotherapy and/or radiotherapy (RT) for BCa. Genetic heterogeneity may preexist to treatment arising with tumorigenesis or increasing progressively during the treatment. Several biological pathways seem to be involved in the cellular response to treatment. These pathways comprehend mechanisms leading to modify the intracellular concentration of the drug, mechanisms leading to increase the repair of DNA damage caused by the treatment, mechanisms leading to increase cell survival, despite DNA damage, acting on the signaling pathways affecting apoptosis, mechanisms promoting autophagy. In the present review, we focused on the genetic determinants of resistance affecting the aforementioned mechanisms.

Patterns and predictors of recurrence after open radical cystectomy for bladder cancer: a comprehensive review of the literature

Purpose

To review the currently available literature reporting the patterns of recurrence and their predictive factors after open radical cystectomy (RC) for bladder cancer.

Methods

A review of the literature was performed using the MEDLINE, Scopus and Web of Sciences databases from January 1997 to May 2017. The PRISMA guidelines were followed for the conduct of the study.

Results

Local recurrence rate ranges between 30 and 54%. Distant recurrence is not often standardized and is reported in up to 50% of cases. The overall 5-year recurrence-free survival rates from 58 to 81%. The mean follow-up of studies included in the analysis ranged from 18 to 350 months. Details on the most important demographic and epidemiological, clinical, histologic and pathologic predictors of recurrence after radical cystectomy are provided through an evidence-based approach. The impact of the extension of lymph node dissection on recurrence after RC is investigated.

Conclusions

A correct prognostic assessment is essential for patients undergoing radical cystectomy for bladder cancer, thereby potentially improving their oncologic outcomes.

Electronic supplementary material

The online version of this article (10.1007/s00345-017-2115-4) contains supplementary material, which is available to authorized users.

Oncologic Effect of Cumulative Smoking Exposure in Patients Treated With Salvage Radical Prostatectomy for Radiation-recurrent Prostate Cancer

INTRODUCTION

The purpose of the present study was to investigate the association of smoking with biochemical recurrence (BCR) and metastasis in radiation-recurrent prostate cancer (PCa) patients undergoing salvage radical prostatectomy (SRP).

PATIENTS AND METHODS

A total of 214 patients treated with SRP for radiation-recurrent PCa in 5 tertiary referral centers were included from January 2007 to December 2015. Kaplan-Meier analyses were used to assess the time to BCR and metastasis. Pre- and postoperative multivariable Cox proportional hazard regression models were fitted.

RESULTS

Overall, 120 (56.1%), 49 (22.9%), and 45 (21%) patients were never, former, and current smokers, respectively. Low-, medium-, and high-cumulative smoking exposure was registered in 59.8%, 16.4%, and 23.8% of cases, respectively. Patients with high cumulative smoking exposure had a significantly greater rate of a pathologic Gleason score of ≥ 8 (P = .01) and extracapsular extension (P = .004). Smoking status, cumulative smoking exposure, intensity, and duration were significantly associated with BCR-free survival (P < .001 for all). Smoking status, cumulative smoking exposure, and smoking intensity were significantly associated with metastasis-free survival (P = .03 for all). High cumulative smoking exposure was independently associated with BCR in both pre- (hazard ratio, 2.23; P = .001) and postoperative (hazard ratio, 1.64; P = .04) multivariable models adjusted for the effects of established clinicopathologic features. Smoking cessation did not affect either BCR- or metastasis-free survival (P = .56 and P = .40, respectively).

CONCLUSION

High cumulative smoking exposure was associated with the biologic and clinical aggressiveness of PCa in patients treated with SRP for radiation-recurrent disease. Smoking is a modifiable risk factor that detrimentally affected the outcomes, even in patients with advanced PCa.

The Role of Surgery in Metastatic Bladder Cancer: A Systematic Review

CONTEXT

The role of surgery in metastatic bladder cancer (BCa) is unclear.

OBJECTIVE

In this collaborative review article, we reviewed the contemporary literature on the surgical management of metastatic BCa and factors associated with outcomes to support the development of clinical guidelines as well as informed clinical decision-making.

EVIDENCE ACQUISITION

A systematic search of English language literature using PubMed-Medline and Scopus from 1999 to 2016 was performed.

EVIDENCE SYNTHESIS

The beneficial role of consolidation surgery in metastatic BCa is still unproven. In patients with clinically evident lymph node metastasis, data suggest a survival advantage for patients undergoing postchemotherapy radical cystectomy with lymphadenectomy, especially in those with measurable response to chemotherapy (CHT). Intraoperatively identified enlarged pelvic lymph nodes should be removed. Anecdotal reports of resection of pulmonary metastasis as part of multimodal approach suggest possible improved survival in well-selected patients. Cytoreductive radical cystectomy as local treatment has also been explored in patients with metastatic disease, although its benefits remain to be assessed.

CONCLUSIONS

Consolidative extirpative surgery may be considered in patients with clinically evident pelvic or retroperitoneal lymph nodal metastases but only if they have had a response to CHT. Surgery for limited pulmonary metastases may also be considered in very selected cases. Best candidates are those with resectable disease who demonstrate measurable response to CHT with good performance status. In the absence of data from prospective randomized studies, each patient should be evaluated on an individual basis and decisions made together with the patient and multidisciplinary teams.

PATIENT SUMMARY

Surgical resection of metastases is technically feasible and can be safely performed. It may help improve cancer control and eventually survival in very selected patients with limited metastatic burden. In a patient who is motivated to receive chemotherapy and to undergo extirpative surgical intervention, surgery should be discussed with the patient among other consolidation therapies in the setting of multidisciplinary teams.

Comparison of the EORTC tables and the EAU categories for risk stratification of patients with nonmuscle-invasive bladder cancer

PURPOSE

To characterize outcomes of patients with TaT1 urothelial carcinoma of the bladder stratified by the European Association of Urology (EAU) categories and to compare them with European Organization for Research and Treatment of Cancer (EORTC) risk groups to assess the rate and effect of reclassification.

PATIENTS AND METHODS

A multi-institutional database of 5,122 patients with TaT1 urothelial carcinoma of the bladder who underwent transurethral resection of the bladder with or without adjuvant therapy at 8 institutions between 1996 and 2007. Multivariable Cox-regression analyses addressed factors associated with disease recurrence and progression. The net reclassification index was used to compare the performance of the EAU categories with the EORTC scoring system.

RESULTS

Of 5,122 patients, 632 (12.3%), 2,302 (45.0%), and 2,188 (42.7%) were assigned to the low-, intermediate-, and high-risk EAU category, respectively. Within a median follow-up of 62 months (interquartile range: 27-97), 2,365 (46.2%) and 516 (10.1%) patients experienced disease recurrence and progression, respectively. In multivariable Cox-regression analyses, EAU intermediate- and high-risk categories were associated with a higher risk of disease recurrence (P<0.001) and progression (P<0.001) compared to low-risk patients. Application of the EAU categories reclassified 1,940 (37.9%) patients into a higher risk group for recurrence. Likewise, 602 (11.8%) patients were reclassified to a higher and 278 (5.4%) to a lower risk group for progression. The net reclassification index of the EAU risk stratification was 0.1% (95% CI: -3.1% to 3.2%) for recurrence and 10.1% (95% CI: -8.0% to 12.0%) for progression, respectively.

CONCLUSIONS

Compared to EORTC risk stratification, the EAU categories reclassifies 37.9% patients into a higher risk group of recurrence and 11.8% into a higher risk of progression. However, the novel risk stratification assigns most patients to the same treatment as the more complex EORTC tables and can be regarded as an alternative tool for treatment decision-making.

External Validation of the Pathologic Nodal Staging Score for Prostate Cancer: A Population-based Study

BACKGROUND

We sought to externally validate our pathologic nodal staging score (pNSS) model, which allows for quantification of the likelihood that a pathologically node-negative patient will not have lymph node (LN) metastasis after radical prostatectomy for prostate cancer (PCa) in a population-based cohort.

PATIENTS AND METHODS

We analyzed data from 50,598 patients treated with radical prostatectomy and pelvic LN dissection using the Surveillance, Epidemiology, and End Results database. We estimated the sensitivity of pathologic nodal staging using a β-binomial model and developed a novel pNSS model, which represents the probability that a patient's PCa has been correctly staged as node negative as a function of the number of examined LNs. These findings were compared against those from the original cohort of 7135 patients.

RESULTS

The mean and median number of LNs removed was 6.5 and 5, respectively (range, 1-89; interquartile range, 2-8), and 96.9% of the patients (n = 49,020) had stage pN0. Similar to the original cohort, the probability of missing a positive LN decreased with the increasing number of LNs examined. In both the validation and the original cohort, the number of LNs needed to correctly stage a patient's disease as node negative increased with more advanced tumor stage, higher Gleason sum, positive surgical margins, and higher preoperative prostate-specific antigen levels.

CONCLUSION

We have confirmed that the number of examined LNs needed for adequate nodal staging in PCa depends on the pathologic tumor stage, Gleason sum, surgical margins status, and preoperative prostate-specific antigen. We externally validated our pNSS in a population-based cohort, which could help to refine decision-making regarding the administration of adjuvant therapy.

Prognostic Role of N-cadherin Expression in Patients With Invasive Bladder Cancer

BACKGROUND

We assessed the role of N-cadherin as a prognostic biomarker in patients with invasive bladder cancer (BCa) who had undergone radical cystectomy (RC).

PATIENTS AND METHODS

The present retrospective single-center study included 433 BCa patients who had undergone RC and bilateral lymph node dissection. Formalin-fixed paraffin tissue microarrays were stained with an anti-N-cadherin monoclonal mouse antibody. N-cadherin expression was considered positive if any immunoreactivity was detected. Multivariable Cox regression models were created to evaluate the prognostic effect of N-cadherin on survival.

RESULTS

N-cadherin expression was observed in 189 patients (43.7%). It was associated with advanced pathologic stage (P = .001) and lymph node metastasis (P < .001). During a median follow-up period of 10.6 years, N-cadherin expression was associated with worse recurrence-free survival, overall survival, and cancer-specific survival (P < .001, P = .001, and P < .001, respectively). On multivariable analysis adjusted for the effects of standard clinicopathologic features, N-cadherin expression retained its association with worse recurrence-free survival (hazard ratio, 1.41; 95% confidence interval, 1.02-1.92; P = .032) but not cancer-specific survival (P = .07) and overall survival (P = .3).

CONCLUSION

N-cadherin was expressed in approximately 40% of patients with invasive BCa. Its expression was associated with features of biologically and pathologically adverse disease and worse recurrence-free survival. N-cadherin could be a part of a marker panel to help clinical decision-making and therapy for BCa.

Is transurethral resection alone enough for the diagnosis of histological variants? A single-center study

INTRODUCTION

To evaluate incidence of histological variants and grade agreement between transurethral resection (TUR) and radical cystectomy (RC) in patients with bladder cancer.

METHODS

A total of 779 patients treated with TUR and subsequently with RC between 1990 and 2013 at a single center were analyzed retrospectively. Variant histology classifications used in our analyses were sarcomatoid, small cell, squamous, or micropapillary. Grade agreement was calculated using the Cohen kappa coefficient. Logistic regression analyses were built to predict adverse pathologic features from histological variants at TUR.

RESULTS

Considering TUR, 213 (27.3%) patients were diagnosed with histological variants. Of these, 2.1% (n = 16) were found with sarcomatoid variant, 1.7% (n = 13) with small cell, 7.1% (n = 55) with squamous, 12.5% (n = 97) with micropapillary. Considering RC, 212 (27.2%) patients were diagnosed with histological variants. Poor agreement was found considering micropapillary variant and the presence of a histological variant in general (0.11 and 0.27, respectively). Intermediate agreement was found analyzing the presence of sarcomatoid, small cell, and squamous variants (0.43, 0.61, and 0.61, respectively). Small cell carcinoma at TUR was found associated with an increased risk of harboring positive soft tissue surgical margin (odds ratio = 2.08; CI: 1.27-3.41; P = 0.03).

CONCLUSIONS

One out of our patients with bladder cancer was diagnosed with a histological variant either at TUR and RC. We found poor agreement between TUR and RC. Our findings highlight that TUR alone is not sufficient to accurately evaluate the presence of histological variants that may have an effect on treatment and survival outcomes.

Prognostic role of N-cadherin expression in patients with non-muscle-invasive bladder cancer

PURPOSE

To assess the role of N-cadherin as a prognostic biomarker in patients with non-muscle-invasive bladder cancer (NMIBC) treated with transurethral resection with or without adjuvant intravesical therapy.

PATIENTS AND METHODS

Immunohistochemistry using monoclonal mouse antibody was used to evaluate the expression status of N-cadherin in 827 patients with NMIBC. N-cadherin was considered positive if any immunoreactivity with membranous staining was detected. Multivariable Cox regression models were performed to evaluate the prognostic effect of N-cadherin on survival outcomes.

RESULTS

N-cadherin expression was observed in 333 patients (40.3%); it was associated with pT1 stage and high tumor grade (both were P<0.001). Median follow-up was 55 months (interquartile range: 18-106). On multivariable Cox regression analyses that adjusted for the effect of the standard clinicopathologic features, N-cadherin expression remained associated with recurrence-free survival (P = 0.007) but not progression-free survival (P = 0.3), cancer-specific survival (P = 0.2), or overall survival (P = 0.9). Adding N-cadherin to a model for prediction of disease recurrence modestly improved its discrimination from 72.8% to 73.4%.

CONCLUSION

N-cadherin is expressed in approximately 2/5 patients with NMIBC. Its expression is associated with adverse pathological features and higher risk of disease recurrence but not progression. N-cadherin could be incorporated in predictive tools to assist in recurrence prediction helping thereby in patient selection regarding adjuvant therapies and follow-up planning.

Lymphocyte-to-monocyte ratio and neutrophil-to-lymphocyte ratio as biomarkers for predicting lymph node metastasis and survival in patients treated with radical cystectomy

PURPOSE

To evaluate the role of lymphocyte-to-monocyte ratio (LMR) and neutrophil-to-lymphocyte ratio (NLR) as pre-operative markers for predicting extravesical disease and survival outcomes in patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB).

MATERIALS AND METHODS

Data from 4335 patients undergoing RC for clinically non-metastatic UCB were analyzed. Multivariable logistic regression models were used to predict lymph node involvement and extravesical disease (defined as ≥pT3 and N0). Recurrence-free (RFS), cancer-specific (CSS), and overall survival (OS) were evaluated using multivariable Cox models. The accuracy of the models was assessed with receiver operating characteristics (ROC) curves and concordance-index.

RESULTS

Median LMR was 3.5 and median NLR was 2.7. Addition of LMR and NLR to a standard preoperative model improved its discrimination for prediction of lymph node metastasis by 4.5%. On multivariable analysis LMR and NLR independently predicted RFS, CSS, and OS. The discrimination of this model increased by adding LMR and NLR but was not significant.

CONCLUSIONS

LMR and NLR independently improved the preoperative prediction of lymph node metastasis and survival outcomes. As they are readily available, they could be integrated in a panel of preoperative markers helping selecting patients who have extravesical lymph node involvement and more aggressive disease.

Impact of Intra- and Postoperative Blood Transfusion on the Incidence, Timing, and Pattern of Disease Recurrence After Radical Cystectomy

BACKGROUND

The administration of blood transfusion (BT) has been associated with a decrease in survival expectancies in patients treated with radical cystectomy (RC), as a consequence of the immunosuppressive effect mediated by BT. We sought therefore to evaluate if the usage of BT may influence the risk and pattern location of distant recurrences after RC, which may be influenced by this effect.

METHODS

Data from 2 independent cohorts of consecutive patients with bladder cancer treated with RC were analyzed. Distant recurrence included all recurrence locations outside of the true pelvis, such as lung, liver, bone, extra pelvic lymph nodes, peritoneal, or brain recurrences. Cox regression analyses evaluating the risk of developing distant recurrence after RC were built.

RESULTS

In the testing cohort, composed of 1081 patients, 41.2% received a perioperative BT. Within a median follow-up of 52 months (interquartile range, 44-61 months), 277 (25.6%) patients experienced a distant recurrence. In the validation cohort, composed of 433 patients, 42.3% received perioperative BT within a median follow-up of 83 months, and 127 (28.3%) patients experienced distant recurrence. On multivariable analyses predicting distant recurrences, BT was not associated with the risk of distant recurrence stratified by location and time (within first year or later after RC; all P ≥ .2) in both cohorts.

CONCLUSIONS

BT administration was not associated with a different pattern, timing, or rate of distant recurrences in patients when compared with those who did not receive BT. New data are needed to investigate the mechanisms behind the association between BT and survival in RC patients.

The presence of carcinoma in situ at radical cystectomy increases the risk of urothelial recurrence: Implications for follow-up schemes

INTRODUCTION

To evaluate the incidence of carcinoma in situ (CIS) in patients treated with radical cystectomy (RC) due to bladder cancer and to assess its effect on recurrence and survival rates.

METHODS

The study focused on 1,128 consecutive nonmetastatic patients with bladder cancer treated with RC at a single tertiary care referral center from 1994 to 2014. The Kaplan-Meier method was used to compare recurrence, cancer-specific mortality (CSM), and overall mortality-free rates in the overall population and in pT0-pT2 and pT3-pT4 patients after stratifying according to the presence of CIS. Multivariable (MVA) Cox regression analyses tested the effect of the presence of CIS on survival outcomes. MVA competing risk analyses were performed to assess the effect of CIS on urothelial recurrence.

RESULTS

The presence of CIS was reported in 277 (24.6%) patients. During a median follow-up of 6 years, 355 recurrences, 377 CSM, and 468 overall mortality were reported. At MVA Cox regression analyses, the presence of concomitant CIS was not associated with any survival effect when the overall population was considered (all P≥0.3). At MVA Cox regression analyses, there was no effect of CIS on survival outcomes in pT3-pT4 patients (all P>0.2); on the contrary, the presence of CIS was associated with worse CSM in pT0-pT2 patients only (hazard ratio [HR] = 1.82; CI: 1.01-3.29; P = 0.04). At MVA competing risk analyses predicting urothelial recurrence only, the presence of CIS was associated to an increased risk of urothelial recurrence in pT0-pT2 patients (HR = 2.99; CI: 1.05-8.53; P = 0.04), pT3-pT4 patients (HR = 10.29; CI: 1.40-75.75; P = 0.02), and in the overall population (HR = 4.47; CI: 1.81-11.07; P = 0.001).

CONCLUSION

An increased risk of developing urothelial recurrence only was recorded in patients diagnosed with CIS at RC. Physicians should consider this aspect ensuring a more severe follow-up schemes in patients who harbored this pathological feature.