Association of cyclin D1 and E1 expression with disease progression and biomarkers in patients with nonmuscle-invasive urothelial cell carcinoma of the bladder

PURPOSE

To determine the association of cyclin D1 and E1 expression with bladder cancer presence, clinical and molecular characteristics, and disease progression in patients with nonmuscle-invasive urothelial cell carcinoma of the bladder.

METHODS

Immunohistochemical staining for cyclin D1, cyclin E1, p53, p21, p27, pRB, KI-67, and survivin was performed on a tissue microarray containing specimens from 9 normal controls and 74 patients with Ta, Tis, and/or T1 urothelial cell carcinoma of the bladder. Cyclin D1 and E1 immunoreactivity were considered low when samples showed less than 10% and 30% nuclear reactivity, respectively.

RESULTS

Normal bladder urothelium from all 9 control patients showed uniformly intense expression of cyclin D1 and cyclin E1. Cyclin D1 and E1 expression were low in 23 of 74 (31.1%) and 27 of 74 (36.5%) specimens. Kaplan-Meier analyses showed that low expression of cyclin E1 was significantly associated with an increased probability of tumor recurrence and progression in univariate, but not multivariate analysis. Cyclin D1 immunoreactivity was not associated with any pathologic characteristics or clinical outcomes. Low cyclin E1 expression was significantly associated with altered expression of p53, pRB, KI-67, and survivin.

CONCLUSIONS

Tissue expression of cyclin D1 or E1 seems not to add independent prognostic value to standard features in patients with nonmuscle -invasive urothelial cell carcinoma of the bladder.

Multiple biomarkers improve prediction of bladder cancer recurrence and mortality in patients undergoing cystectomy

BACKGROUND

Tested was whether the assessment of 5 established bladder cancer biomarkers (p53, pRB, p21, p27, and cyclin E1) could improve the ability to predict disease recurrence and cancer-specific survival after radical cystectomy in patients with pTa-3N0M0 urothelial carcinoma of the bladder (UCB).

METHODS

The study comprised 191 patients with pTa-3N0M0 UCB treated with radical cystectomy and bilateral lymphadenectomy (median follow-up, 3.1 years). Biomarker expression was assayed on serial tissue microarray slides using quantitative immunohistochemistry using advanced cell imaging and color detection software. Predictive accuracy was quantified using the concordance index and 200-bootstrap resamples were used to reduce overfit bias. Bootstrap-adjusted predictive accuracy estimates were compared using the Mantel-Haenszel test.

RESULTS

UCB recurred in 36 (18.8%) patients and 30 (15.7%) died of bladder cancer; 157 (82.2%) patients had altered expression of at least 1 biomarker. In univariate analyses the number of altered biomarkers had the highest predictive accuracy for both disease recurrence (76.8%, P< .001) and cancer-specific mortality (78.3%, P< .001). Addition of the number of altered biomarkers increased the predictive accuracy of nomograms based on the TNM staging system for disease recurrence and cancer-specific mortality by 10.9% (83.4% vs 72.5%, P< .001) and 8.6% (86.9% vs 78.3, P< .001), respectively.

CONCLUSIONS

Assessment of the number of altered biomarkers in the cystectomy specimen improves the prediction of bladder cancer recurrence and survival in patients with pTa-3N0M0 disease. Prospective evaluation of alteration in these biomarkers can help identify patients who would benefit from adjuvant treatment after radical cystectomy.

Pseudosarcomatous fibromyxoid tumor of the bladder

Pseudosarcomatous fibromyxoid tumors are uncommon lesions with uncertain pathogenesis. We present the case of a 36-year-old healthy patient who was evaluated for painless gross hematuria. Work-up revealed a bladder mass that was initially treated with transurethral resection that showed pseudosarcomatous fibromyxoid tumors. However, the mass recurred and was subsequently treated definitively with partial cystectomy with no recurrence at last follow-up. Partial cystectomy is a viable option in the treatment of recurrent symptomatic pseudosarcomatous fibromyxoid tumors of the bladder, when performed selectively.

Survivin expression in patients with non-muscle-invasive urothelial cell carcinoma of the bladder

OBJECTIVES

Survivin is a member of the inhibitor of apoptosis gene family that controls mitotic progression and induces tumor cell invasion. Our objectives were to evaluate the association of survivin expression with the presence of urothelial cell carcinoma of the bladder and clinical outcomes in patients with non-muscle-invasive urothelial cell carcinoma of the bladder.

METHODS

Immunohistochemical staining for survivin was performed on archival bladder tissue microarray specimens from 9 normal controls and 74 consecutive patients who had Stage Ta, Tis, and/or T1 disease on transurethral resection (TUR). Staining was also performed on cystectomy specimens from 22 of these patients who had undergone radical cystectomy for disease progression. Survivin was considered overexpressed when more than 10% of the cells expressed survivin.

RESULTS

Survivin was not expressed in normal bladder urothelium. Survivin was overexpressed in 53% of non-muscle-invasive bladder tumors. Overexpression of survivin was associated with greater tumor grade (P <0.001). On multivariate analyses adjusted for the effects of TUR stage, grade, and intravesical therapy, survivin overexpression was independently associated with cancer recurrence (hazard ratio 2.50, 95% confidence interval 1.09 to 5.69, P = 0.02) and progression (hazard ratio 3.87, 95% confidence interval 1.13 to 13.24, P = 0.03), but not disease-specific survival (hazard ratio 1.88, 95% confidence interval 0.90 to 6.46, P = 0.07). A high concordance rate for survivin expression was found between the 22 matched TUR and cystectomy specimens (86%).

CONCLUSIONS

Survivin expression analysis performed on TUR specimens might help identify patients with non-muscle-invasive urothelial cell carcinoma of the bladder at high risk of disease recurrence and progression who would benefit from closer follow-up or more aggressive therapy.

Intermediate comparison of partial nephrectomy and radiofrequency ablation for clinical T1a renal tumours

OBJECTIVE

To compare the intermediate-term outcomes of patients with clinical T1a renal tumours who were treated with nephron-sparing surgery by partial nephrectomy (PN), the preferred approach for small (cT1a) renal tumours, or radiofrequency ablation (RFA), recently offered to selected patients as an alternative, less morbid technique.

PATIENTS AND METHODS

We identified patients with stage T1a renal masses who had > or = 2 years of follow-up; those with bilateral synchronous or metachronous tumours, metastatic disease at presentation, or a family history of renal cell carcinoma were excluded. From July 1996 to January 2004 110 PNs were identified in our database; 37 patients who fulfilled the inclusion criteria had either open (30) or laparoscopic PN (seven) and 40 had either percutaneous (26) or laparoscopic (14) RFA.

RESULTS

The mean (range) follow-up for the RFA and PN groups was 30 (18-42) and 47 (24-93) months, respectively; the respective mean tumour size was 2.41 and 2.43 cm. There was one incomplete ablation and two local recurrences in the RFA group, and two recurrences in the PN group (one local and one in the contralateral kidney). There were no disease-specific deaths. The overall actuarial disease-free probability for the PN and RFA groups, respectively, was 95.8% and 93.4% (P = 0.67).

CONCLUSIONS

This initial 3-year actuarial analysis showed that RFA for cT1a renal tumours has comparable oncological outcomes to PN; however, longer term data are still needed.

Macroscopic, but not microscopic, perivesical fat invasion at radical cystectomy is an adverse predictor of recurrence and survival

OBJECTIVE

To examine whether the presence of microscopic (pT3a) or macroscopic (pT3b) disease worsens the prognosis relative to pT2 disease at radical cystectomy, as the prognostic significance of pT3a vs pT3b perivesical fat invasion (pT3) is controversial.

PATIENTS AND METHODS

In all, 242 patients with pT3 disease (pT3a in 88, pT3b in 121) had radical cystectomy and bilateral pelvic lymphadenectomy for transitional cell carcinoma of the urinary bladder; they were compared with 172 who had organ-confined muscle-invasive disease (pT2). For the analyses we used univariable and multivariable Cox regression models of recurrence and cancer-specific survival, adjusted for age, tumour grade, lymphovascular invasion and the presence of lymph node metastases.

RESULTS

In multivariable analyses, microscopic perivesical fat extension (pT3a) was not associated with higher recurrence (P = 0.3) or the mortality rate (P = 0.06) vs pT2 disease. Conversely, the presence of deep perivesical fat extension (pT3b) was associated with 1.8 times the rate of recurrence (P = 0.002) and with twice the rate of death (P = 0.001) vs pT2 disease.

CONCLUSION

These findings imply that a detailed assessment of the cystectomy specimen for the presence of microscopic perivesical fat invasion might not be necessary, as the presence of pT3a disease has no strong effect on recurrence or mortality. Moreover, patients with pT3a disease might not require more aggressive therapy than their counterparts with pT2 disease. However, further validation of our data is required.

A delay in radical cystectomy of >3 months is not associated with a worse clinical outcome

OBJECTIVE

To examine the association between the interval from the last transurethral resection (TUR) to radical cystectomy (RC) and bladder cancer-specific outcome, as the decision to proceed to RC for an individual patient is complex, and recent reports suggest an interval from diagnosis to RC of >3 months is associated with adverse outcomes.

PATIENTS AND METHODS

The records of 592 patients who had RC were reviewed; the interval from the last TUR was analysed as both a continuous and categorical variable (<3 vs >/=3 months). Logistic regression and survival analyses were used to evaluate the association between the interval to RC with pathological characteristics and clinical outcomes.

RESULTS

The mean (sd) actuarial cancer-specific survival was 70.5 (2.3)% and 60.7 (3.2)% at 3 and 7 years, respectively. Overall, the median (range) time from TUR to RC was 1.8 (0.3-11.6) months. The interval to RC analysed as a continuous or categorical variable was not associated with extravesical or nodal disease, lymph node metastases, disease recurrence, overall or cancer-specific survival. The results were similar in the subgroup of 320 patients (54%) with clinically muscle-invasive disease.

CONCLUSIONS

These results suggest that a reasonable delay from the last TUR to RC is not independently associated with stage progression or with decreased recurrence-free or disease-specific survival. These findings might have important implications for trial design in the ongoing evaluation of neoadjuvant regimens. Nevertheless, we see no reason to advocate anything less than the timely consideration of definitive treatment for patients with high-risk bladder cancer.

Decreased DOC-2/DAB2 Expression in Urothelial Carcinoma of the Bladder

PURPOSE

DOC-2/DAB2 (differentially expressed in ovarian carcinoma-2/disabled-2), a potential tumor suppressor gene, is underexpressed in several cancers. Little is known about the expression of this gene in urothelial carcinoma of the bladder (UCB). We profiled DOC-2/DAB2 expression in mouse and human normal and neoplastic urothelia.

EXPERIMENTAL DESIGN

Immunohistochemical staining for DOC-2/DAB2 was carried out on tissue specimens from two transgenic mouse models with urothelium-specific molecular alterations and on a tissue microarray containing cores from 9 normal controls, 44 patients who underwent transurethral resection of the bladder tumor (TURBT), 195 patients who underwent radical cystectomy for UCB, and 39 lymph nodes with metastatic UCB.

RESULTS

Normal mouse urothelium stained uniformly with DOC-2/DAB2. Weaker staining was observed in low-grade, superficial papillary bladder tumors from transgenic mice harboring constitutively active Ha-Ras, whereas carcinoma in situ-like lesions and high-grade bladder tumors from transgenic mice expressing a SV40 T antigen completely lacked DOC-2/DAB2 expression. In human tissues, DOC-2/DAB2 expression was decreased in 11% of normal bladder specimens, 59% of TURBT specimens, 65% of radical cystectomy specimens, and 77% of the metastatic lymph node specimens. Decreased DOC-2/DAB2 expression was associated with advanced pathologic stage (P = 0.023), lymph node metastases (P = 0.050), and lymphovascular invasion (P < 0.001). In univariable, but not in multivariable analysis, decreased DOC-2/DAB2 was associated with an increased probability of bladder cancer recurrence (log-rank test, P = 0.020) and bladder cancer-specific mortality (log-rank test, P = 0.023).

CONCLUSIONS

Decreased DOC-2/DAB2 expression seems to occur early in bladder tumorigenesis and becomes more prominent in advanced stages of UCB.

Prostate cancer disease-free survival after radical retropubic prostatectomy in patients older than 70 years compared to younger cohorts

OBJECTIVES

To evaluate the feasibility of radical retropubic prostatectomy (RRP) as an option for treating men older than 70 years with organ confined prostate cancer and to compare biochemical progression-free survival with younger cohorts.

MATERIALS AND METHODS

A total of 689 consecutive patients who were treated with RRP from 1994 to 2002 for clinically localized prostate cancer were categorized into 3 different age groups: younger than 50 years (n = 49), 50-70 years (n = 601), and older than 70 years (n = 39). Patients older than 70 years were healthy individuals for their age. Preoperative and postoperative cancer-specific characteristics were compared among these 3 groups.

RESULTS

There was no statistical significant difference among the 3 age strata in terms of clinical parameters (prostate-specific antigen, Gleason score, clinical stage, percent and number of positive biopsy cores) and pathologic findings (surgical margin, lymph node status, extracapsular extension, lymphovascular invasion, and pathologic Gleason score). The rate of seminal vesicle invasion and prostate volume increased with advancing age (P = 0.034 and P < 0.001). In multivariate logistic regression analysis, age was not associated with seminal vesicle invasion. The 5-year prostate-specific antigen progression-free estimates for patients younger than 50, 50-70, and older than 70 years were 82% (95% confidence interval [CI] 69% to 96%), 82% (95% CI 78% to 86%), and 65% (95% CI 43% to 86%), respectively (P = 0.349). The overall and cause-specific mortalities were not different.

CONCLUSIONS

RRP could be considered a standard treatment option in men older than 70 years with localized prostate cancer. Further studies are necessary to assess the survival benefit and health-related quality of life after radical prostatectomy versus watchful waiting in patients older than 70 years.

Survivin expression is associated with bladder cancer presence, stage, progression, and mortality

BACKGROUND

The purpose was to compare the differential expression of Survivin in normal bladder tissue, bladder transitional cell carcinoma (TCC) of different stages, and to determine whether expression of Survivin is associated with TCC clinical outcomes.

METHODS

Immunohistochemical staining for Survivin was carried out on archival bladder specimens from 9 normal controls and 222 consecutive patients who underwent radical cystectomy and bilateral lymphadenectomy. Lymph node tissue involved with TCC from 50 of the 222 cystectomy patients was also evaluated.

RESULTS

Survivin was expressed in none of the normal bladder specimens, 64% of the cystectomy specimens, and 94% of the malignant lymph nodes. Multivariable analyses performed in the cystectomy patients revealed that Survivin expression was associated with disease recurrence (P = .040), disease-specific mortality (P = .037), and all-cause mortality (P = .044).

CONCLUSIONS

The findings of the study provide a rationale for further evaluation of Survivin and its downstream signaling pathways in bladder cancer and raise the potential for Survivin-targeted therapy for bladder cancer.

The use of histone deacetylase inhibitor FK228 and DNA hypomethylation agent 5-azacytidine in human bladder cancer therapy

The long-term disease-free survival in patients with metastatic transitional cell carcinoma (TCC) is still considerably low. Novel chemotherapeutic agents are needed to decrease the morbidity and mortality of TCC. In this study, we have evaluated several epigenetic modifiers for their therapeutic application in bladder cancer. Both histone deacetylase inhibitors (FK228, TSA) and DNA hypomethylating agent (5-Azacytidine) were tested using in vitro assays such as cell viability, cell cycle analysis and western blot to determine their mechanisms of action. Drug combination experiments were also designed to study any additive or synergistic effects of these agents. In addition, two bladder cancer xenograft models (one subcutaneous and one orthotopic) were employed to assess the therapeutic efficacy of these agents in vivo. Three agents exhibited various growth inhibitory effects on 5 different TCC cell lines in a dose- and time-dependent manner. In addition to G2/M cell cycle arrest, FK228 is more potent in inducting apoptosis than the two other single agents, and combination of both FK228 and 5-Aza further enhances this effect. p21 induction is closely associated with FK228 or TSA but not 5-Aza, which is mediated via p53-independent pathway. Consistent with in vitro results, FK228 exhibited a significant in vivo growth inhibition of TCC tumor in both subcutaneous and orthotopic xenograft models. FK228 is a potent chemotherapeutic agent for TCC in vivo with minimal undesirable side effects. The elevated p21 level mediated via p53 independent pathway is a hallmark of FK228 mechanism of action.

Cooperative effect of cell-cycle regulators expression on bladder cancer development and biologic aggressiveness

The aim of this study was to evaluate the association between p53, p21, p27 and Rb expression, alone or in combination, with pathological features and clinical outcomes of urothelial carcinoma of the bladder. Immunohistochemical staining for p53, p21, p27 and pRB was performed on tissue microarrays comprising normal urothelium from nine controls, transurethral resection specimens from 74 patients with Ta, Tis and/or T1 bladder urothelial carcinoma, radical cystectomy specimens from 226 consecutive urothelial carcinoma patients, and lymph nodes with tumor invasion from 50 of the 226 cystectomy patients. All nine controls had normal status of biomarkers. The proportion of biomarkers alterations was highest in lymph node metastases. p53, pRB and p27 were associated with pathologic stage, lymphovascular invasion and lymph node metastases (P-values<or=0.050). Each biomarker alone, each combination of two biomarkers and the number of altered biomarkers were all independently associated with disease recurrence and bladder cancer-specific death (P-values<or=0.046). In patients with organ-confined disease, p53, p21 and p27 were independently associated with disease recurrence and bladder cancer-specific death (P-values<or=0.046). There was a good but not perfect concordance in the expression of biomarkers between matched transurethral resection and cystectomy specimens (n=22; concordance rates: 77-86%) and between matched lymph node and cystectomy specimens (n=50, 70-92%). In conclusion, p53, p21, p27 and pRB have a cooperative/synergistic role in the biologic behavior of bladder urothelial carcinoma. In contrast to the use of single biological markers, evaluation of their combined status may improve prognostic models and help identify patients who might benefit from adjuvant therapies and in decision-making.

Ki-67 is an independent predictor of bladder cancer outcome in patients treated with radical cystectomy for organ-confined disease

PURPOSE

To determine the association of the cell proliferative marker Ki-67 with pathologic features and disease prognosis in patients with transitional cell carcinoma (TCC) of the urinary bladder.

METHODS

Immunohistochemical staining for Ki-67 was done on serial cuts from tissue microarrays containing cystectomy specimens from 9 patients without bladder cancer and 226 consecutive patients with bladder TCC. We also assessed malignant lymph nodes from 50 of the 226 cystectomy patients.

RESULTS

Ki-67 expression was increased in 42.5% cystectomy specimens and in 54% metastatic lymph nodes. In contrast, it was absent in all nine benign cystectomy specimens. Ki-67 overexpression was associated with advanced pathologic stage, higher grade, lymphovascular invasion, and metastases to lymph nodes (P = 0.001, 0.040, 0.031, and 0.036, respectively). In multivariate analyses, pathologic stage and lymph node metastases were independent predictors of disease recurrence and bladder cancer-specific mortality. In the subgroup of patients with organ-confined disease (<pT(3) N(0); n = 91), excluding patients who received neoadjuvant or adjuvant chemotherapy, Ki-67 status was an independent predictor of both disease recurrence (risk ratio, 7.591; P = 0.001) and bladder cancer-specific mortality (risk ratio, 4.045; P = 0.041).

CONCLUSIONS

Ki-67 overexpression is associated with features of aggressive bladder TCC and adds independent prognostic information to standard pathologic features for prediction of clinical outcome after radical cystectomy.

Expression of Cyclooxygenase-2 in Normal Urothelium, and Superficial and Advanced Transitional Cell Carcinoma of Bladder

PURPOSE

We compared the differential expression of cyclooxygenase-2 in normal bladder tissue, primary bladder transitional cell carcinoma and transitional cell carcinoma metastases to lymph nodes, and determined whether cyclooxygenase-2 expression is associated with molecular alterations commonly found in bladder transitional cell carcinoma and clinical outcomes after radical cystectomy.

MATERIALS AND METHODS

Immunohistochemical staining for cyclooxygenase-2, survivin (Novus Biologicals, Littleton, Colorado), p21, p27, pRB, p53, MIB-1, Bax, Bcl-2, cyclin D(1) (Dakotrade mark), cyclin E (Oncogene, Cambridge, Massachusetts) and caspase-3 (Cell Signaling, Beverley, Massachusetts) was performed on archival bladder specimens from 9 subjects who underwent cystectomy for benign causes, 21 patients who underwent transurethral resection and 157 consecutive patients after radical cystectomy, and on 41 positive lymph nodes.

RESULTS

Cyclooxygenase-2 was expressed in none of the 9 normal bladder specimens (0%), 52% of transurethral resection specimens, 62% of cystectomy specimens and 80% of lymph nodes involved with transitional cell carcinoma. Cyclooxygenase-2 expression was associated with higher pathological stage, lymphovascular invasion and metastases to lymph nodes (p=0.001, 0.045 and 0.002, respectively). Cyclooxygenase-2 expression was associated with altered expression of p53 (p=0.039), pRB (p=0.025), cyclin D1 (p=0.034) and caspase-3 (p=0.014). On univariate analysis cyclooxygenase-2 expression was associated with an increased risk of disease recurrence and bladder cancer specific mortality (p=0.0189 and 0.0472, respectively). However, on multivariate analysis only pathological stage and metastases to lymph nodes were associated with disease recurrence (p<0.001 and <0.001) and survival (p<0.001 and 0.015, respectively).

CONCLUSIONS

Cyclooxygenase-2 is not expressed in normal bladder urothelium. Cyclooxygenase-2 over expression is associated with pathological and molecular features of biologically aggressive disease, suggesting a role for cyclooxygenase-2 in bladder cancer development and invasion.

Use of combined apoptosis biomarkers for prediction of bladder cancer recurrence and mortality after radical cystectomy

BACKGROUND

Deregulation of apoptosis is a characteristic of human carcinogenesis. We aimed to investigate expression of the apoptosis markers Bcl-2, caspase-3, P53, and survivin and the association with oncological outcomes of patients treated by radical cystectomy and bilateral lymphadenectomy for urothelial-cell carcinoma of the bladder.

METHODS

Bcl-2, caspase-3, P53, and survivin immunostaining was undertaken on serial tissue microarrays containing cores from 226 consecutive patients (median follow-up 36.9 months [IQR 13.3-79.0]). 200 bootstrap resamples with replacement were done to reduce overfit bias and for internal validation.

FINDINGS

Expression of Bcl-2, caspase-3, P53, and survivin was altered in 73 (32%), 111 (49%), 120 (53%), and 141 (64%) patients, respectively. By univariate analysis, altered expression of Bcl-2, caspase-3, P53, and survivin were all associated with high probability of disease recurrence (hazard ratio 2.24 [95% CI 1.51-3.32], p<0.001; 1.73 [1.16-2.59], p=0.007; 2.70 [1.77-4.12], p<0.001; and 2.32 [1.48-3.63], p<0.001) and disease-specific mortality (2.06 [1.33-3.18], p=0.001; 2.35 [1.48-3.73], p<0.001; 3.23 [1.98-5.28], p<0.001; and 2.64 [1.57-4.44], p<0.001; respectively). Risk of recurrence and disease-specific mortality progressively grew with increasing number of altered biomarkers. By multivariate analysis, alteration of four markers was independently associated with high rates of disease recurrence (4.03 [1.23-13.16], p=0.021) and disease-specific mortality (6.84 [1.43-32.63], p=0.016). Addition of the number of altered markers to a model that included standard predictors significantly enhanced its predictive accuracy for disease recurrence and disease-specific survival.

INTERPRETATION

Bcl-2, caspase-3, P53, and survivin have a cooperative effect on progression of bladder cancer. Assessment of combined apoptosis marker status and number of altered markers in patients treated by radical cystectomy provides prognostic information that could help to identify those at high risk for disease recurrence and mortality, who could benefit from early adjuvant treatment.

Predictive Value of Cell Cycle Biomarkers in Nonmuscle Invasive Bladder Transitional Cell Carcinoma

PURPOSE

We determined whether the combined expression of p53, p21, p27 and pRB is associated with outcomes of patients with nonmuscle invasive bladder transitional cell carcinoma.

MATERIALS AND METHODS

Immunohistochemical staining for p53, p21, p27 and pRB was performed on archival bladder specimens from 9 normal controls and 74 patients who underwent transurethral bladder tumor resection for Ta, Tis and/or T1 transitional cell carcinoma.

RESULTS

Normal urothelium had wild type status of p53, pRB, p21 and p27. p53 expression was altered in 34% of patients with transitional cell carcinoma, pRB in 39%, p21 in 35% and p27 in 47%. When analyzed separately, p53, pRB and p21 were each independently associated with tumor progression. Combination of biomarkers stratified patients into statistically significantly different risk groups for disease recurrence and progression. When tumor stage and grade were modeled with all 4 biomarkers, p53 and p27 were the sole independent predictors of disease recurrence and progression. After controlling for the effects of tumor grade and stage, the incremental number of altered biomarkers was associated with an increased risk of bladder cancer recurrence (p for trend = 0.011) and progression (p for trend = 0.005). The risk ratio for disease recurrence and progression increased incrementally with the number of biomarkers altered.

CONCLUSIONS

Combinations of p53, pRB, p21 and p27 had cooperative/synergistic effects stratifying patients into different risk groups. Higher total numbers of altered biomarkers were independently associated with an increased risk of disease progression and death. Prospective trials are necessary to usher bladder cancer management into the age of molecular biomarkers.

Discrepancy between Clinical and Pathologic Stage: Impact on Prognosis after Radical Cystectomy

OBJECTIVES

We compared clinical and pathologic staging in a large, contemporary, consecutive series of patients who were treated with radical cystectomy and pelvic lymphadenectomy, and determined the effect of stage discrepancy on outcomes.

METHODS

We collected retrospective data from 778 consecutive patients with bladder transitional cell carcinoma who were treated with radical cystectomy and pelvic lymphadenectomy, and for whom the clinical and pathologic stage were available.

RESULTS

Pathologic upstaging occurred in 42% of patients, and pathologic downstaging occurred in 22%. Forty percent of patients with non-muscle-invasive clinical stage had muscle-invasive pathologic stage. Thirty-six percent of patients with organ-confined clinical stage had non-organ-confined pathologic stage (> or =pT3N0 or pTanyN-positive). Patients with higher clinical stage were more likely to be upstaged to non-organ-confined disease (p<0.001). Patients were stratified into three groups: pathologically upstaged, same clinical and pathologic stage, and pathologically downstaged. When adjusted for the effects of standard postoperative features, upstaged patients were at a significantly higher risk of disease recurrence and bladder cancer-specific death than patients who had the same pathologic and clinical stage, who in turn were at significantly higher risk than downstaged patients. This observation remained true within each clinical stage strata. Within each pathologic stage strata, clinical stage did not substratify into different risk groups.

CONCLUSIONS

Clinical to pathologic stage discrepancy is a relatively common finding after extirpative surgery for bladder cancer. Clinical outcomes after radical cystectomy are largely driven by pathologic stage. Better clinical staging is necessary to improve patient evaluation and management.