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Abstract
PURPOSE OF REVIEW A bladder-preserving approach for high-grade nonmuscle invasive bladder cancer that has invaded the lamina propria (T1HG) may result in increased recurrence, progression, and even death from bladder cancer in some patients. Initial radical cystectomy does have increased cancer-specific survival (CSS), but represents significant overtreatment for many patients. An evidence-based, risk-stratified approach is required to select patients for immediate radical cystectomy in order to improve CSS. RECENT FINDINGS A restaging transurethral resection aids in optimal staging and treatment of T1HG. Intravesical Bacillus Calmette-Guerin induction followed by 3 years of maintenance is the standard adjuvant management. However, when very high-risk (hydronephrosis, abnormal bimanual examination, variant histology, lymphovascular invasion, or residual disease on re-resection, and Bacillus Calmette-Guerin failure or early recurrence) or multiple high-risk factors (concomitant CIS, size >3 cm, multifocality, unfavorable tumor location, extensive lamina propria invasion, and elderly) are present, the risk of progression often outweighs the risk associated with radical cystectomy. In these cases, an immediate radical cystectomy likely provides an improved opportunity for cure compared to a bladder-preserving strategy. SUMMARY In order to increase the CSS of patients diagnosed with T1HG bladder cancer, an aggressive approach may benefit those with increased risk of progression.
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Jallad S, Thomas P, Newport MJ, Kern F. Baseline Cytokine Profiles of Tuberculin-Specific CD4 + T Cells in Non-Muscle-Invasive Bladder Cancer May Predict Outcomes of BCG Immunotherapy. Cancer Immunol Res 2018; 6:1212-1219. [PMID: 30120103 DOI: 10.1158/2326-6066.cir-18-0046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/08/2018] [Accepted: 08/08/2018] [Indexed: 11/16/2022]
Abstract
Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy preserves the bladder after resection of high-risk non-muscle-invasive bladder cancer (NMIBC). About 30% of patients experience treatment failure, which cannot be predicted a priori and carries a high risk of disease progression. We examined the in vitro tuberculin responsiveness of CD4+ T cells before BCG immunotherapy in 42 patients with high-risk NMIBC. The frequencies and functionalities of cytokine-expressing CD4+ T cells immediately before and after BCG immunotherapy induction were assessed by flow cytometry after overnight tuberculin stimulation. Tuberculin-induced secreted mediators were measured by electrochemiluminescence. We correlated the results with recurrence-free patient survival 6 months after induction. A tuberculin-induced, secreted, IL2 concentration > 250 pg/mL was the best predictor of recurrence-free survival, providing 79% sensitivity, 86% specificity (AUC = 0.852, P = 0.000), and overall correct classification in 78.6% of cases. In 50% of patients later experiencing recurrence, but not in any of the recurrence-free survivors, IL2 secretion was < 120 pg/mL. Other parameters predicting recurrence-free survival included secreted IFNγ (AUC = 0.796, P = 0.002) and the frequencies of TNF-producing (TNF+) CD4+ T cells (AUC = 0.745, P = 0.010). "Polyfunctional" CD4+ T cells (IFNγ+/IL2+/TNF+) were significantly associated with recurrence-free survival (AUC = 0.801, P = 0.002). Thus, the amount of IL2 secretion from CD4+ T cells after overnight in vitro incubation with tuberculin predicted the outcome of BCG immunotherapy. As many as half of potential BCG failures could be identified before induction therapy is begun, enabling better choices regarding treatment. Cancer Immunol Res; 6(10); 1212-9. ©2018 AACR.
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Affiliation(s)
- Samer Jallad
- Department of Urology, Imperial College Healthcare NHS Trust, London, United Kingdom.,Department of Urology, Brighton and Sussex University Hospital Trust (BSUH), Brighton, United Kingdom
| | - Philip Thomas
- Department of Urology, Brighton and Sussex University Hospital Trust (BSUH), Brighton, United Kingdom
| | - Melanie J Newport
- Department of Global Health and Infectious Diseases, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Florian Kern
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, United Kingdom.
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Wang G, McKenney JK. Urinary Bladder Pathology: World Health Organization Classification and American Joint Committee on Cancer Staging Update. Arch Pathol Lab Med 2018; 143:571-577. [DOI: 10.5858/arpa.2017-0539-ra] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Since the publication of the previous World Health Organization (WHO) Classification of Tumours on the Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs in 2004, significant new knowledge has been generated regarding the pathology and genetics of bladder neoplasia. Publication of the 2016 WHO “Blue Book” has codified that new data into updated recommendations for classification and prognostication. Similarly, the recent release of the 8th edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, which was implemented in January 2018, has also addressed staging criteria for bladder cancer in several unique settings to clarify their application.
Objective.—
To highlight subtle changes within the recent WHO and AJCC publications that may affect daily surgical pathology practice.
Data Sources.—
Peer-reviewed published literature, the 2016 WHO Classification of Tumours of the Urinary System and Male Genital Organs, and the 8th edition of the AJCC Cancer Staging Manual were reviewed.
Conclusions.—
Selected changes and/or clarifications are discussed and include classification of flat and papillary urothelial neoplasia, select variant patterns of invasive urothelial carcinoma, staging of invasive carcinoma in bladder diverticula, and staging of carcinomas involving the prostate gland.
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Affiliation(s)
- Gang Wang
- From the Department of Pathology, University of Texas MD Anderson Cancer Center, Houston (Dr Wang); and the Robert J. Tomsich Pathology and Laboratory Medicine Institute, Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio (Dr McKenney)
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2 - Epidemiologia E Classificazione Istopatologica. TUMORI JOURNAL 2018; 104:S8-S13. [PMID: 29893175 DOI: 10.1177/0300891618766105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Metric substage according to micro and extensive lamina propria invasion improves prognostics in T1 bladder cancer. Urol Oncol 2018; 36:361.e7-361.e13. [PMID: 29880460 DOI: 10.1016/j.urolonc.2018.05.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 05/05/2018] [Accepted: 05/08/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Reliable prognosticators for T1 bladder cancer (T1BC) are urgently needed. OBJECTIVE To compare the prognostic value of 2 substage systems for T1BC in patients treated by transurethral resection (TUR) and adjuvant bacillus Calmette-Guérin therapy. DESIGN, SETTING, AND PARTICIPANTS The slides of 601 primary T1BCs from four institutes were reviewed by 2 uropathologists and substaged according to 2 classifications: metric substage according to T1 microinvasive (T1m-lamina propria invasion <0.5mm) and T1 extensive invasive (pT1e-invasion ≥ 0.5mm), and according to invasion of the muscularis mucosae (MM) (T1a-invasion above or into MM/T1b). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariable analyses for progression-free (PFS) and cancer-specific survival (CSS) were performed including substage, size, multiplicity, carcinoma in situ, sex, age, WHO-grade 1973, and WHO-grade 2004 as variables. RESULTS Median follow-up was 5.9 years (interquartile range: 3.3-9.0). Progression to T2BC was observed in 148 (25%) patients and 94 (16%) died of BC. The MM was not present at the invasion front in 135 (22%) of tumors. Slides were substaged as follows: 213 T1m and 388 T1e and 281 T1a and 320 T1b. On multivariable analysis, T1m/e substage and WHO 1973 grade were the strongest prognosticators for PFS (hazard ratio [HR] = 3.8 and HR = 1.8) and CSS (HR = 2.7 and HR = 2.6), respectively. Other prognostic factors for CSS were age (HR = 1.03), and tumor size (HR = 1.8). Substage according to MM-invasion was not significant. Our study was limited by its retrospective design and that standard re-TUR was not performed if TUR was macroscopically complete and muscularis propria was present in resected specimens. CONCLUSIONS Metric substaging of T1BC was possible in all cases of 601 T1BC patients and it was a strong independent prognosticator of both PFS and CSS.
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Turan T, Efiloğlu Ö, Günaydin B, Özkanli Ş, Nikerel E, Atiş G, Çaşkurlu T, Yildirim A. Comparative differences between T1a/b and T1e/m as substages in T1 urothelial carcinoma of the bladder. Int Braz J Urol 2018; 44:267-272. [PMID: 29219283 PMCID: PMC6050560 DOI: 10.1590/s1677-5538.ibju.2017.0424] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/23/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the prognostic value of the depth of lamina propria invasion in patients with T1 bladder cancer and to display comparative differences between the T1a/b and T1e/m substaging systems. Patients and Methods This study included 106 patients with primary stage T1 urothelial bladder tumours who underwent surgery between January 2009 and December 2014. Pathologic specimens were re-evaluated to confirm the diagnosis of T1 and substaging by the same pathologist using two systems: T1a and T1b, and T1m and T1e. Age, tumour size, multiplicity, associated carcinoma in situ, tumour grade, and T1 substaging system were investigated to detect the relation between disease progression and recurrence. Results The recurrence rate was 52% for T1a (n=42) vs. 76% for T1b (n=20) (p=0.028) and 55% for T1m (n=32) vs. 62% for T1e (n=30), respectively (p=0.446). There was no significant difference between the substaging groups for disease progression: T1a (n=12, 15%) vs. T1b (n=7, 27%), and T1m (n=8, 13.8%) vs. T1e (n=11, 23%) (p>0.05). In the multivariate analysis, tumour size >3 cm (p=0.008), multiplicity (p=0.049), and substaging T1b (p=0.043) were independent predictive factors for tumour recurrence. According to the Kaplan-Meier actuarial method, recurrence-free survival was significantly different in patients with pT1a tumours compared with those with pT1b tumours (p=0.033). Conclusions Substaging T1 provides a prediction of disease recurrence. Regarding recurrence, T1a/b substaging can provide better knowledge of disease behaviour because it is predicted as more superior than T1 m/e, and it can help in determining the requirement for early cystectomy.
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Affiliation(s)
- Turgay Turan
- Department of Urology, Istanbul Medeniyet University, Faculty of Medicine, Istanbul, Turkey
| | - Özgür Efiloğlu
- Department of Urology, Istanbul Medeniyet University, Faculty of Medicine, Istanbul, Turkey
| | - Bilal Günaydin
- Department of Urology, Istanbul Medeniyet University, Faculty of Medicine, Istanbul, Turkey
| | - Şeyma Özkanli
- Istanbul Medeniyet University, Faculty of Medicine, Department of Pathology, Istanbul, Turkey
| | - Emrah Nikerel
- Yeditepe Universitesi, Genetics and Bioengineering Istanbul, Turkey
| | - Gökhan Atiş
- Department of Urology, Istanbul Medeniyet University, Faculty of Medicine, Istanbul, Turkey
| | - Turhan Çaşkurlu
- Department of Urology, Istanbul Medeniyet University, Faculty of Medicine, Istanbul, Turkey
| | - Asif Yildirim
- Department of Urology, Istanbul Medeniyet University, Faculty of Medicine, Istanbul, Turkey
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van de Putte EEF, Bosschieter J, van der Kwast TH, Bertz S, Denzinger S, Manach Q, Compérat EM, Boormans JL, Jewett MAS, Stoehr R, van Leenders GJLH, Nieuwenhuijzen JA, Zlotta AR, Hendricksen K, Rouprêt M, Otto W, Burger M, Hartmann A, van Rhijn BWG. The World Health Organization 1973 classification system for grade is an important prognosticator in T1 non-muscle-invasive bladder cancer. BJU Int 2018; 122:978-985. [PMID: 29637669 DOI: 10.1111/bju.14238] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To compare the prognostic value of the World Health Organization (WHO) 1973 and 2004 classification systems for grade in T1 bladder cancer (T1-BC), as both are currently recommended in international guidelines. PATIENTS AND METHODS Three uro-pathologists re-revised slides of 601 primary (first diagnosis) T1-BCs, initially managed conservatively (bacille Calmette-Guérin) in four hospitals. Grade was defined according to WHO1973 (Grade 1-3) and WHO2004 (low-grade [LG] and high-grade [HG]). This resulted in a lack of Grade 1 tumours, 188 (31%) Grade 2, and 413 (69%) Grade 3 tumours. There were 47 LG (8%) vs 554 (92%) HG tumours. We determined the prognostic value for progression-free survival (PFS) and cancer-specific survival (CSS) in Cox-regression models and corrected for age, sex, multiplicity, size and concomitant carcinoma in situ. RESULTS At a median follow-up of 5.9 years, 148 patients showed progression and 94 died from BC. The WHO1973 Grade 3 was negatively associated with PFS (hazard ratio [HR] 2.1) and CSS (HR 3.4), whilst WHO2004 grade was not prognostic. On multivariable analysis, WHO1973 grade was the only prognostic factor for progression (HR 2.0). Grade 3 tumours (HR 3.0), older age (HR 1.03) and tumour size >3 cm (HR 1.8) were all independently associated with worse CSS. CONCLUSION The WHO1973 classification system for grade has strong prognostic value in T1-BC, compared to the WHO2004 system. Our present results suggest that WHO1973 grade cannot be replaced by the WHO2004 classification in non-muscle-invasive BC guidelines.
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Affiliation(s)
- Elisabeth E Fransen van de Putte
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Judith Bosschieter
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.,Department of Urology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Theo H van der Kwast
- Department of Pathology, Erasmus MC Cancer Institute, Erasmus MC, Rotterdam, The Netherlands.,Department of Pathology, Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Simone Bertz
- Department of Pathology, University of Erlangen, Erlangen, Germany
| | - Stefan Denzinger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Quentin Manach
- Academic Department of Urology, Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris, Pierre et Marie Curie Medical School, University Paris, Paris, France
| | - Eva M Compérat
- Department of Pathology, Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris, Pierre et Marie Curie Medical School, University Paris, Paris, France
| | - Joost L Boormans
- Department of Urology, Erasmus MC Cancer Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Michael A S Jewett
- Department of Surgical Oncology (Urology), Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Robert Stoehr
- Department of Pathology, University of Erlangen, Erlangen, Germany
| | | | | | - Alexandre R Zlotta
- Department of Surgical Oncology (Urology), Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada.,Department of Urology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Kees Hendricksen
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Morgan Rouprêt
- Academic Department of Urology, Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris, Pierre et Marie Curie Medical School, University Paris, Paris, France
| | - Wolfgang Otto
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Arndt Hartmann
- Department of Pathology, University of Erlangen, Erlangen, Germany
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.,Department of Urology, Erasmus MC Cancer Institute, Erasmus MC, Rotterdam, The Netherlands.,Department of Surgical Oncology (Urology), Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada.,Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
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Paner GP, Stadler WM, Hansel DE, Montironi R, Lin DW, Amin MB. Updates in the Eighth Edition of the Tumor-Node-Metastasis Staging Classification for Urologic Cancers. Eur Urol 2018; 73:560-569. [DOI: 10.1016/j.eururo.2017.12.018] [Citation(s) in RCA: 285] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 12/14/2017] [Indexed: 12/23/2022]
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Otto W, van Rhijn BWG, Breyer J, Bertz S, Eckstein M, Mayr R, Lausenmeyer EM, Denzinger S, Burger M, Hartmann A. Infiltrative lamina propria invasion pattern as an independent predictor for cancer-specific and overall survival of instillation treatment-naïve stage T1 high-grade urothelial bladder cancer. Int J Urol 2018; 25:442-449. [DOI: 10.1111/iju.13532] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 12/22/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Wolfgang Otto
- Department of Urology; Caritas St. Josef Medical Center; Regensburg University; Regensburg Germany
- Member of the BRIDGE Consortium; Mannheim Germany
| | - Bas WG van Rhijn
- Department of Urology; Caritas St. Josef Medical Center; Regensburg University; Regensburg Germany
- Department of Surgical Oncology (Urology); Netherlands Cancer Institute; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Johannes Breyer
- Department of Urology; Caritas St. Josef Medical Center; Regensburg University; Regensburg Germany
- Member of the BRIDGE Consortium; Mannheim Germany
| | - Simone Bertz
- Institute of Pathology; Nuremberg-Erlangen University; Erlangen Germany
| | - Markus Eckstein
- Member of the BRIDGE Consortium; Mannheim Germany
- Institute of Pathology; Nuremberg-Erlangen University; Erlangen Germany
| | - Roman Mayr
- Department of Urology; Caritas St. Josef Medical Center; Regensburg University; Regensburg Germany
| | - Eva M Lausenmeyer
- Department of Urology; Caritas St. Josef Medical Center; Regensburg University; Regensburg Germany
| | - Stefan Denzinger
- Department of Urology; Caritas St. Josef Medical Center; Regensburg University; Regensburg Germany
| | - Maximilian Burger
- Department of Urology; Caritas St. Josef Medical Center; Regensburg University; Regensburg Germany
- Member of the BRIDGE Consortium; Mannheim Germany
| | - Arndt Hartmann
- Member of the BRIDGE Consortium; Mannheim Germany
- Institute of Pathology; Nuremberg-Erlangen University; Erlangen Germany
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Compérat E, Varinot J, Moroch J, Eymerit-Morin C, Brimo F. A practical guide to bladder cancer pathology. Nat Rev Urol 2018; 15:143-154. [PMID: 29384523 DOI: 10.1038/nrurol.2018.2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pathological assessment of bladder cancer is becoming an increasingly complex task owing to the growing availability of molecular data for different histological subtypes and the appreciation of their importance in determining outcomes of neoadjuvant chemotherapy. Urologists are aware of the need to closely collaborate with pathologists, and comprehensive sharing of information is crucial to achieve optimal patient management. Numerous steps towards this goal have been made during the past years. Important advances in the assessment and reporting of grading and staging, especially substaging of pT1 urothelial carcinomas, have been made. As part of the International Collaboration on Cancer Reporting (ICCR), an international expert group has suggested worldwide reporting standards for urothelial lesions. Nevertheless, several issues remain unresolved, for example, regarding the reporting of heterogeneous lesions and substaging as well as the gross handling and the reporting for lymphadenectomy specimens. During the past few years, major insights have been gained into the molecular changes that occur during bladder cancer development, but a consensus on how to integrate these data into daily practice has not been achieved.
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Affiliation(s)
- Eva Compérat
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Tenon, HUEP, 4 rue de la Chine, 75020 Paris, UPMC Paris VI, Sorbonne Universities, France
| | - Justine Varinot
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Tenon, HUEP, 4 rue de la Chine, 75020 Paris, UPMC Paris VI, Sorbonne Universities, France
| | - Julien Moroch
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Tenon, HUEP, 4 rue de la Chine, 75020 Paris, UPMC Paris VI, Sorbonne Universities, France
| | - Caroline Eymerit-Morin
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Tenon, HUEP, 4 rue de la Chine, 75020 Paris, UPMC Paris VI, Sorbonne Universities, France
| | - Fadi Brimo
- McGill University Health Center, Glen Site, Office E4-4188, 1001 Decarie Blvd, Montréal, Quebec H4A 3J1, Canada
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Cogorno Wasylkowski L, Ríos-González E, Linares Espinós E, Leibar Tamayo A, Martínez-Piñeiro Lorenzo L. Indication for early cystectomy in nonmuscle-invasive bladder cancer. Literature review. Actas Urol Esp 2018; 42:17-24. [PMID: 28238343 DOI: 10.1016/j.acuro.2016.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 10/20/2022]
Abstract
CONTEXT High-risk nonmuscle-invasive bladder cancer is a disease that includes a heterogeneous group of patients, for whom close follow-up is recommended due to the risk of progression to a muscle-invasive tumour. The treatment of choice for these tumours is transurethral resection of the bladder tumour followed by a programme of bacillus Calmette-Guerin instillations. There is a subgroup of patients who have a greater risk of progression and who benefit from early radical treatment. OBJECTIVE To identify which patient group with nonmuscle-invasive bladder cancer will benefit from early radical treatment. SEARCHING THE EVIDENCE We performed a literature review to identify the risk factors for progression for these patients and thereby recommend a treatment that improves their survival rate. SYNTHESIS OF THE EVIDENCE We identified the various prognostic factors associated with tumour progression: the persistence of T1 tumour in re-resection of the bladder tumour, the presence of carcinoma in situ, patients refractory to bacillus Calmette-Guerin treatment, patients older than 70 years, tumours larger than 3cm, the substaging of T1 tumours, the presence of lymphovascular invasion and the presence of a tumour in the prostatic urethra. Similarly, we comment on the advantages of radical versus conservative treatment, considering that the performance of an early cystectomy due to a high-risk noninvasive vesical tumour has a better cancer prognosis than those in which the operation is deferred until the progression. CONCLUSIONS In this disease, it is important to individualise the patients to provide them personalized treatment. For patients with the previously mentioned characteristics, it is recommended that early cystectomy not be delayed.
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Single, Immediate, Postoperative Intravesical Chemotherapy. Bladder Cancer 2018. [DOI: 10.1016/b978-0-12-809939-1.00017-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Park JY. Risk Factors for Recurrence and Progression of Nonmuscle Invasive Bladder Cancer. Bladder Cancer 2018. [DOI: 10.1016/b978-0-12-809939-1.00013-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Colombo R, Hurle R, Moschini M, Freschi M, Colombo P, Colecchia M, Ferrari L, Lucianò R, Conti G, Magnani T, Capogrosso P, Conti A, Pasini L, Burgio G, Guazzoni G, Patriarca C. Feasibility and Clinical Roles of Different Substaging Systems at First and Second Transurethral Resection in Patients with T1 High-Grade Bladder Cancer. Eur Urol Focus 2018; 4:87-93. [DOI: 10.1016/j.euf.2016.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/13/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
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van de Putte EEF, Burger M, van Rhijn BWG. Risk Stratification and Prognostication of Bladder Cancer. Urol Oncol 2018. [DOI: 10.1007/978-3-319-42603-7_28-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Latest Novelties on the World Health Organization Morphological Classifications of Genitourinary Cancers. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.eursup.2017.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Vetterlein MW, Roschinski J, Gild P, Marks P, Soave A, Doh O, Isbarn H, Höppner W, Wagner W, Shariat SF, Brausi M, Büscheck F, Sauter G, Fisch M, Rink M. Impact of the Ki-67 labeling index and p53 expression status on disease-free survival in pT1 urothelial carcinoma of the bladder. Transl Androl Urol 2017; 6:1018-1026. [PMID: 29354488 PMCID: PMC5760387 DOI: 10.21037/tau.2017.11.10] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background The identification of protein biomarkers to guide treatment decisions regarding adjuvant therapies for high-risk non-muscle-invasive bladder cancer (NMIBC) has been of increasing interest. Evidence of the impact of tumor suppressor gene product p53 and cell proliferation marker Ki-67 on oncologic outcomes in bladder cancer patients at highest risk of recurrence and progression is partially contradictory. We sought to mirror contemporary expression patterns of p53 and Ki-67 in a select cohort of patients with pT1 bladder cancer. Methods Patients from four Northern German institutions with a primary diagnosis of pT1 bladder cancer between 2009 and 2016 and complete data regarding p53 or Ki-67 expression status were included for final analyses. Baseline patient characteristics (age, gender, age-adjusted Charlson comorbidity index) and tumor characteristics [diagnostic sequence, tumor focality, concomitant carcinoma in situ, 1973 World Health Organization (WHO) grading, lymphovascular invasion, adjuvant instillation therapy] were abstracted by retrospective chart review. Immunohistochemistry for detection of p53 and Ki-67 expression was performed according to standardized protocols. Microscopic analyses were performed by central pathologic review. First, we compared patients with positive vs. negative p53 expression and Ki-67 labeling index [>40% vs. ≤40%; cutoffs based on best discriminative ability in univariable Cox regression analysis with disease-free survival (DFS) as endpoint] with regard to baseline and tumor characteristics. Second, we evaluated the effect of biomarker positivity on DFS by plotting univariable Kaplan-Meier curves and performing uni- and multivariable Cox regression analyses. Results Of 102 patients with complete information on p53 status, 44 (43.1%) were p53 positive, and they more often harbored concomitant carcinoma in situ (50.0% vs. 27.6%; P=0.032) and 1973 WHO grade 3 (97.7% vs. 69.0%; P=0.001) compared to their p53 negative counterparts. Of 79 patients with complete information on Ki-67 expression status, 30 (38.0%) had a labeling index >40%. Mean Ki-67 labeling index was higher in WHO grade 3 vs. grade 2 tumors (45.8 vs. 29.7; P=0.004). At a median follow-up of 51.0 months, 31/91 patients with complete follow-up information (34.1%) suffered from disease recurrence or progression. In univariable Kaplan-Meier analyses, no difference regarding DFS was found in p53 positive vs. negative (P=0.8) or Ki-67 labeling index >40% vs. ≤40% (P=0.078) patients. In multivariable analyses, Ki-67 labeling index >40% remained an independent predictor of DFS [hazard ratio (HR), 2.66; 95% confidence interval (CI), 1.02–6.95; P=0.046], after adjusting for p53 expression and lymphovascular invasion. However, p53 status was not associated with our endpoint (P=0.8). Conclusions While we found an association of a Ki-67 labeling index >40% and shorter DFS in pT1 bladder cancer patients, this did not hold true for p53 positivity. Future research is needed to identify additional microscopic and molecular risk factors and biomarker panels to improve risk stratification and guide adjuvant therapies in those patients.
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Affiliation(s)
- Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Roschinski
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Gild
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Phillip Marks
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Armin Soave
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ousman Doh
- Department of Urology, Regio Medical Center Elmshorn, Elmshorn, Germany
| | - Hendrik Isbarn
- Department of Urology, Regio Medical Center Elmshorn, Elmshorn, Germany
| | | | - Walter Wagner
- Department of Urology, Federal Armed Forces Hospital, Hamburg, Germany
| | | | - Maurizio Brausi
- Department of Urology, Azienda Unità Sanitaria Locale di Modena, Modena, Italy
| | - Franziska Büscheck
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Sauter
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Holz S, Albisinni S, Gilsoul J, Pirson M, Duthie V, Quackels T, Vanden Bossche M, Roumeguère T. Risk factor assessment in high-risk, bacillus Calmette-Guérin-treated, non-muscle-invasive bladder cancer. Res Rep Urol 2017; 9:195-202. [PMID: 29034222 PMCID: PMC5628686 DOI: 10.2147/rru.s143865] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective To assess the risk factors associated with recurrence, progression and survival in high-risk non-muscle-invasive bladder cancer (NMIBC) patients treated with bacillus Calmette–Guérin (BCG) and validate the European Organization for Research and Treatment of Cancer (EORTC) and Spanish Urological Club for Oncological Treatment (CUETO) scores. Patients and methods We retrospectively analyzed all BCG-treated NMIBC patients from 1998 to 2012. Multiple variables were tested as risk factors for recurrence-free survival and progression-free survival (PFS). Variables included age, sex, grade, stage, tumor size, number of tumors, carcinoma in situ (CIS), recurrence status, BCG strain used, smoking status, use of re-staging transurethral resection and use of single immediate postoperative instillation. We also tested the accuracy of EORTC and CUETO scores in predicting recurrence and progression. Results Overall, 123 patients were analyzed. Median (interquartile range) follow-up was 49 months. The 5-year overall survival, cancer-specific survival, recurrence-free survival and PFS were 75.0%, 89.3%, 59.4% and 79.2%, respectively. On univariate analysis, multiple tumors (≥3), concomitant CIS and smoking influenced recurrence. Regarding progression, multiple tumors, concomitant CIS and Connaught strain (vs Tice) negatively influenced PFS on univariate and multivariate analyses were independent prognostic factors. CUETO scores were accurate, with a slight overestimation, while EORTC score was not predictive of recurrence or progression. Conclusion In this study, CIS and tumor multiplicity were unfavorable predictors of recurrence and progression in patients with NMIBC receiving BCG. CUETO model was superior to EORTC risk tables in predicting recurrence and progression in our BCG-treated patient population. Nonetheless, both scores overestimated recurrence and progression rates. Prospective trials are needed to validate our findings.
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Affiliation(s)
- Serge Holz
- Department of Urology, Erasme Hospital, Université libre de Bruxelles, Belgium
| | - Simone Albisinni
- Department of Urology, Erasme Hospital, Université libre de Bruxelles, Belgium
| | - Jacques Gilsoul
- Department of Urology, Erasme Hospital, Université libre de Bruxelles, Belgium
| | - Michel Pirson
- Department of Urology, Erasme Hospital, Université libre de Bruxelles, Belgium
| | - Véronique Duthie
- Department of Urology, Erasme Hospital, Université libre de Bruxelles, Belgium
| | - Thierry Quackels
- Department of Urology, Erasme Hospital, Université libre de Bruxelles, Belgium
| | - Marc Vanden Bossche
- Department of Urology, Erasme Hospital, Université libre de Bruxelles, Belgium
| | - Thierry Roumeguère
- Department of Urology, Erasme Hospital, Université libre de Bruxelles, Belgium
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Patriarca C, Hurle R, Colombo P, Colecchia M, Freschi M, Conti G, Petracco G, Colombo R. In reply to: Lawless et al. Stalk versus base invasion in pT1 papillary cancers of the bladder: improved substaging system predicting the risk of progression. Histopathology 2017; 72:361-362. [PMID: 28851130 DOI: 10.1111/his.13374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Carlo Patriarca
- Department of Pathology, Azienda Ospedaliera Sant'Anna, Como, Italy
| | - Rodolfo Hurle
- Department of Urology, Humanitas Research Hospital, Rozzano (MI), Italy
| | | | - Maurizio Colecchia
- Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Massimo Freschi
- Department of Pathology, Ospedale San Raffaele, Milan, Italy
| | - Giario Conti
- Department of Urology, Azienda Ospedaliera Sant'Anna, Como, Italy
| | - Guido Petracco
- Department of Pathology, Azienda Ospedaliera Sant'Anna, Como, Italy
| | - Renzo Colombo
- Department of Urology, Ospedale San Raffaele, Milan, Italy
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Metcalfe MJ, Ferguson JE, Li R, Xiao L, Guo CC, Czerniak BA, Siefker-Radtke A, Pretzsch SM, Navai N, McConkey DJ, Kamat AM, Campbell M, Dinney C. Impact of High-risk Features and Effect of Neoadjuvant Chemotherapy in Urothelial Cancer Patients with Invasion into the Lamina Propria on Transurethral Resection in the Absence of Deep Muscle Invasion. Eur Urol Focus 2017; 3:577-583. [PMID: 28753816 DOI: 10.1016/j.euf.2017.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/23/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND High-risk non-muscle-invasive bladder cancer (NMIBC) that invades into the lamina propria is frequently understaged and is associated with a risk of lymph node metastasis and death. OBJECTIVE To identify high-risk features (HRFs) for NMIBC that may identify patients with poorer prognosis who may benefit from neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC). DESIGN, SETTING, AND PARTICIPANTS We performed a single-center retrospective review of patients who underwent RC for NMIBC with invasion into the lamina propria between 1995 and 2013. HRFs included hydronephrosis, abnormal examination under anesthesia, lymphovascular invasion, or variant histology. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Pathology at RC, and overall (OS) and disease-specific (DSS) survival were evaluated and analyzed by Fisher's exact test, Student t test, Cox proportional hazards regression analysis, and the Kaplan-Meier method. RESULTS AND LIMITATIONS We identified 336 patients with a median follow-up of 130 mo. Of these, 159 (47%) had no HRF, 140 (41.5%) had one HRF, and 37 (11%) had ≥2 HRFs. At RC, patients with ≥2 HRFs had a significantly higher rate of pathologic T stage upstaging and lymph node metastasis (p<0.05). Median OS was 139 mo for those with no HRF, 127 mo for those with one HRF, and 56 mo for those with ≥2 HRF (p=0.0057). HRFs are also associated with a decreased DSS (p=0.0009). Patients with ≥2 HRFs (11/37) who received NAC showed improved OS (21% vs 55% 5-yr OS, p=0.0353) and trended toward an improvement in DSS (25% vs 56% 5-yr OS, p=0.0716) compared with RC alone. CONCLUSIONS The presence of ≥2 HRFs in NMIBC invading the lamina propria is associated with worse pathology at RC and a significant decrease in OS and DSS. NAC appears to provide benefit for these patients. Limitations include retrospective design and limited sample size. PATIENT SUMMARY The presence of high-risk features in urothelial cancer with invasion into the lamina propria has a worse prognosis that may be mitigated by neoadjuvant chemotherapy.
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Affiliation(s)
- Michael J Metcalfe
- Departments of Urology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - James E Ferguson
- Departments of Urology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Roger Li
- Departments of Urology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lianchun Xiao
- Department of Biostatistics at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Charles C Guo
- Department of Pathology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bogdan A Czerniak
- Department of Pathology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Arlene Siefker-Radtke
- Department of Genitourinary Medical Oncology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shanna M Pretzsch
- Departments of Urology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Neema Navai
- Departments of Urology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David J McConkey
- Department of Urology at Johns Hopkins, Baltimore, Maryland, USA
| | - Ashish M Kamat
- Departments of Urology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mathew Campbell
- Department of Genitourinary Medical Oncology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Colin Dinney
- Departments of Urology at the University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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72
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Challenges in Pathologic Staging of Bladder Cancer: Proposals for Fresh Approaches of Assessing Pathologic Stage in Light of Recent Studies and Observations Pertaining to Bladder Histoanatomic Variances. Adv Anat Pathol 2017; 24:113-127. [PMID: 28398951 DOI: 10.1097/pap.0000000000000152] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The paradigm of pathologic stage (pT) categorization in bladder cancer remains the depth of invasion into the different histologic layers of the bladder wall. However, the approaches to assigning pT stage category toward an enhanced outcome stratification have been marked by challenges and innovations, due in part to our growing appreciation of the surprisingly perplexing bladder histoanatomy. Upstaging of pT1 tumors after radical cystectomy is substantial and underscores the potential value of pT1 substaging in transurethral resection (TUR) specimens. The 2017 American Joint Committee on Cancer tumor-node-metastasis system recommends pT1 substaging but recognizes the need to optimize the approach. Over the years, the cut-off for microinvasion has been significantly lowered to 0.5 mm and is now a promising scheme for pT1 (micrometric) substaging. Unlike the micrometric approach, histoanatomic substaging using muscularis mucosae (MM) and vascular plexus as landmarks is less feasible in TUR specimens and inconsistent in stratifying the outcome of pT1 tumors. The lamina propria possesses inherent variations in depth, MM, and vascular plexus dispositions that should be factored in future pT1 substaging proposals. Histoanatomic variations among the bladder regions also occur, and studies suggest that trigone and bladder neck cancers may have more adverse outcomes. The muscularis propria (MP), besides being the essential histologic landmark for assigning pT2 stage category, is also considered a surrogate for the adequacy of TUR, furthering the importance of identifying its presence in TUR specimens. MP, however, may be mimicked by hyperplastic or isolated MP-like MM muscle bundles in the lamina propria with overstaging implications, and caution should be exercised in distinguishing these 2 muscle types morphologically and immunohistochemically. Presence of additional superficial MP unique from the detrusor muscle proper may also complicate staging at the trigone and ureter insertion sites. With regard to the depth of MP invasion, large and multicenter studies have reaffirmed the prognostic significance of pT2a/b subcategories. It is revealed that there are at least 3 ways used to demarcate the irregular MP to perivesical soft tissue junction, and use of a common criterion indicates improvement in pT2b/pT3a staging reproducibility. Although studies have shown significantly poorer outcome in pT3b compared with pT3a tumors, this designation has a substantial reliance on the prosector's gross assessment of perivesical soft tissue invasion which if performed incorrectly may lead to staging inaccuracy of pT3 tumors. The 8th edition of the American Joint Committee on Cancer has updated the staging schema for bladder cancers with concomitant prostatic stromal invasion and cancers within bladder diverticula. Because of 2 possible pT designations, prostatic stromal invasion in TUR specimens should not be automatically staged as either pT4a or pT2 (urethral). Recent data support that bladder cancer invading into the seminal vesicle has comparable outcome to pT4b tumors. Interestingly, several studies in pT4a tumors, which are staged based on sex-specific organs, have shown poorer outcome in females than males after radical cystectomy, and while there are possibly several reasons, they may also include anatomic factors. Despite the progress has been made, work remains to be done to inform future bladder cancer pT category definitions and their reproducibility in application and prognostication.
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Patschan O, Holmäng S, Hosseini A, Jancke G, Liedberg F, Ljungberg B, Malmström PU, Rosell J, Jahnson S. Second-look resection for primary stage T1 bladder cancer: a population-based study. Scand J Urol 2017; 51:301-307. [DOI: 10.1080/21681805.2017.1303846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Oliver Patschan
- Department of Translational Medicine, Lund University and Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Sten Holmäng
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Abolfazl Hosseini
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Georg Jancke
- Department of Translational Medicine, Lund University and Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Fredrik Liedberg
- Department of Translational Medicine, Lund University and Department of Urology, Skåne University Hospital, Malmö, Sweden
| | - Börje Ljungberg
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Per-Uno Malmström
- Department of Urology, Akademiska University Hospital, Uppsala, Sweden
| | - Johan Rosell
- Regional Cancer Center Southeast Sweden and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Staffan Jahnson
- Department of Urology, University Hospital and IKE, Linköping University, Linköping, Sweden
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Nonmuscle-invasive bladder cancer: what's changing and what has changed. Urologia 2017; 84:1-8. [PMID: 28165132 DOI: 10.5301/uro.5000213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE Nonmuscle-invasive bladder cancer (NMIBC) is a challenging disease to manage primarily due to its varied clinical course. The management of NMIBC has witnessed a widespread change with respect to its diagnosis and treatment. Although transurethral resection (TUR) and adjuvant bacillus Calmette-Guerin (BCG) stills remain the cornerstone, newer protocols has come into vogue to achieve optimal care. On the basis of a literature review, we aimed to establish 'what changes has already occurred and what is expected in the future' in NMIBC. METHODS A Medline search was performed to identify the published literature with respect to diagnosis, treatment and future perspectives on NMIBC. Particular emphasis was directed to determinants such as the quality of TUR and the newer modifications, Re-TUR, current status of newer macroscopic and microscopic imaging, role of urinary biomarkers, clinical, histologic and molecular predictors of high-risk disease, administration of intravesical agents, salvage therapy in BCG recurrence and the current best practice guidelines were analyzed. RESULTS AND CONCLUSIONS Optimal TUR, restaging in select group, incorporation of newer endoscopic imaging and judicious administration of intravesical chemo-immunotherapeutic agents can contribute to better patient care. Although there is a plethora of urinary markers, there is insufficient evidence for their use in isolation. The future probably lies in identification of genetic markers to determine disease recurrence, nonresponders to standard treatment and early institution of alternative/targeted therapy.
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WHO 1973 grade 3 and infiltrative growth pattern proved, aberrant E-cadherin expression tends to be of predictive value for progression in a series of stage T1 high-grade bladder cancer after organ-sparing approach. Int Urol Nephrol 2016; 49:431-437. [PMID: 28035618 DOI: 10.1007/s11255-016-1491-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Stage pT1 urothelial bladder cancer (UBC) is characterized as a challenging subentity of urothelial carcinoma with an unforeseeable clinical course. In addition to more or less established clinical and histopathological features, we evaluated the role of epithelial-mesenchymal transition (EMT) marker E-cadherin, shown to be of prognostic value in muscle-invasive disease, regarding the prognosis of stage pT1 high-grade (hg) UBC. METHODS Tissue of 226 stage pT1 hg UBC patients from transurethral resection could be immunostained for E-cadherin. Kaplan-Meier analysis and univariate and multivariate Cox regression analyses regarding progression-free (PFS) and cancer-specific survival (CSS) were performed. RESULTS Aberrant expression of E-cadherin was recognized in 74% of patients. Kaplan-Meier analysis showed that aberrant E-cadherin expression was associated with worse 10-year PFS (62 vs. 90%, p = 0.045). In univariate analysis, aberrant E-cadherin staining, associated carcinoma in situ, grading 3 after WHO classification 1973 and infiltrative growth pattern at the invasion front were the statistically significant predictive factors for worse PFS, only infiltrative growth pattern for CSS. With regard to progression, grading 3 after WHO classification of 1973 (HR 6.49; CI 1.54-27.28, p = 0.011) and infiltrative tumor invasion pattern (HR 2.06; CI 1.10-3.86, p = 0.024) revealed as independent factors for PFS, and there was a trend also for E-cadherin expression (HR 0.45; CI 0.19-1.06; p = 0.068). Regarding CSS, infiltrative tumor growth pattern (HR 3.79; CI 1.67-8.60, p = 0.001) was the only statistically significantly independent predictive factor in multivariate Cox regression analysis. CONCLUSIONS Beside invasion growth pattern and WHO grading 1973 that achieved to be independent prognostic factors, there was a trend for the parameter E-cadherin expression to be of predictive value for PFS in stage pT1 hg urothelial bladder carcinoma after organ-sparing approach. Further studies on genetic level are warranted to define the distinct role of EMT in early-invasive UBC.
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76
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Sibony M. [Bladder tumor histo-seminar - case 1: Invasive urothelial carcinoma, high grade and stage T1 extensive]. Ann Pathol 2016; 36:375-378. [PMID: 27838078 DOI: 10.1016/j.annpat.2016.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 09/26/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Mathilde Sibony
- Service d'anatomie et cytologie pathologiques, hôpital Cochin, université Paris Descartes, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
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77
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Clinical outcomes of second transurethral resection in non-muscle invasive high-grade bladder cancer: a retrospective, multi-institutional, collaborative study. Int J Clin Oncol 2016; 22:353-358. [DOI: 10.1007/s10147-016-1048-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 09/30/2016] [Indexed: 11/25/2022]
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Abstract
Bladder cancer is the fourth most common cancer in men, and is associated with significant morbidity and mortality. Pathologic evaluation of urothelial cancers relies predominantly on histomorphologic features but can be aided in a small subset of cases by immunohistochemical analyses. Distinction of papillary versus flat lesions, low-grade versus high-grade cytology, and histologic variants and the presence or absence of invasive tumor is important for proper clinical management. Advances in the molecular alterations associated with the various subtypes of urothelial carcinoma have been made but such studies are ongoing.
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79
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Harshman LC, Preston MA, Bellmunt J, Beard C. Diagnosis of Bladder Carcinoma: A Clinician's Perspective. Surg Pathol Clin 2016; 8:677-85. [PMID: 26612221 DOI: 10.1016/j.path.2015.07.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In 2014, more than 74,000 new cases and 15,000 deaths from bladder cancer were estimated to occur. The most reliable prognostic factors for survival are pathologic stage and histologic grade. Accordingly, a good understanding of the pathologic features of these cancers is essential to guide optimal clinical treatment, which requires a multidisciplinary team of pathologists, urologists, radiation oncologists, and medical oncologists. This review highlights several clinical scenarios in which detailed pathologic evaluation and accurate reporting impact clinical management.
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Affiliation(s)
- Lauren C Harshman
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 1230 DANA, 450 Brookline Ave, Boston, MA 02215, USA.
| | - Mark A Preston
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, 45, Francis street, Boston, MA 02115, USA
| | - Joaquim Bellmunt
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 1230 DANA, 450 Brookline Ave, Boston, MA 02215, USA
| | - Clair Beard
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Fukumoto K, Kikuchi E, Mikami S, Ogihara K, Matsumoto K, Miyajima A, Oya M. Tumor budding, a novel prognostic indicator for predicting stage progression in T1 bladder cancers. Cancer Sci 2016; 107:1338-44. [PMID: 27317460 PMCID: PMC5021027 DOI: 10.1111/cas.12990] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/07/2016] [Accepted: 06/16/2016] [Indexed: 12/17/2022] Open
Abstract
Tumor budding has been defined as an isolated single cancer cell or a cluster composed of fewer than five cancer cells scattered in the stroma. It is a strong predictor for lymph node metastasis in T1 colorectal cancer. We introduced this concept to T1 non‐muscle invasive bladder cancer and evaluated whether tumor budding could have a prognostic impact on the clinical outcome. We identified 121 consecutive patients with newly diagnosed T1 bladder cancer between 1994 and 2014 at Keio University Hospital. All slides were re‐reviewed by a dedicated uropathologist. Budding foci were counted under ×200 magnification. When the number of budding foci was 10 or more, tumor budding was defined as positive. The relationship between tumor budding and clinical outcomes was assessed using a multivariate analysis. The median follow‐up was 52 months. Tumor budding was positive in 21 patients (17.4%). Tumor budding was significantly associated with T1 substaging, tumor architecture and lymphovascular invasion. The 5‐year progression‐free survival rate in T1 bladder cancer patients with tumor budding was 53.8%, which was significantly lower than that in patients without tumor budding (88.4%, P = 0.001). A multivariate Cox regression analysis revealed that tumor budding was independently associated with stage progression (P = 0.002, hazard ratio = 4.90). In a subgroup of patients treated with bacillus Calmette‐Guérin instillation (n = 88), tumor budding was also independently associated with stage progression (P = 0.003, hazard ratio = 5.65). Tumor budding may be a novel indicator for predicting stage progression in T1 bladder cancer, and would likely be easily introduced in clinical practice.
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Affiliation(s)
- Keishiro Fukumoto
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Eiji Kikuchi
- Department of Urology, Keio University School of Medicine, Tokyo, Japan.
| | - Shuji Mikami
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Koichiro Ogihara
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | | | - Akira Miyajima
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
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Compérat E, Furudoï A, Varinot J, Rioux-Leclerq N. [From new genetic and histological classifications to direct treatment]. Ann Pathol 2016; 36:275-8. [PMID: 27474530 DOI: 10.1016/j.annpat.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/31/2016] [Accepted: 06/12/2016] [Indexed: 10/21/2022]
Abstract
The most important criterion for optimal cancer treatment is a correct classification of the tumour. During the last three years, several very important progresses have been made with a better definition of urothelial carcinoma (UC), especially from a molecular point of view. We start having a global understanding of UC, although many details are still not completely understood.
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Affiliation(s)
- Eva Compérat
- Service d'anatomie et cytologie pathologiques, hôpital Pitié Salpêtrière, UPMC Paris VI, 91, boulevard de l'Hôpital, 75013 Paris, France.
| | - Adeline Furudoï
- Service d'anatomie et cytologie pathologiques, hôpital Pitié Salpêtrière, UPMC Paris VI, 91, boulevard de l'Hôpital, 75013 Paris, France
| | - Justine Varinot
- Service d'anatomie et cytologie pathologiques, hôpital Pitié Salpêtrière, UPMC Paris VI, 91, boulevard de l'Hôpital, 75013 Paris, France
| | - Nathalie Rioux-Leclerq
- Service d'anatomie et cytologie pathologiques, faculté de médecine, CHU Pontchaillou, 2, avenue du Professeur-Léon-Bernard, 35033 Rennes cedex, France
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82
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Yun SJ, Kim SK, Kim WJ. How do we manage high-grade T1 bladder cancer? Conservative or aggressive therapy? Investig Clin Urol 2016; 57 Suppl 1:S44-51. [PMID: 27326407 PMCID: PMC4910762 DOI: 10.4111/icu.2016.57.s1.s44] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 05/06/2016] [Indexed: 11/24/2022] Open
Abstract
High-grade T1 bladder cancer has a poor prognosis due to a higher incidence of recurrence and progression than other nonmuscle invasive bladder cancer; thus patients with high-grade T1 have to be carefully monitored and managed. If patients are diagnosed with high-grade T1 at initial transurethral resection (TUR), a second TUR is strongly recommended regardless of whether muscle layer is present in the specimen because of the possibility of understating due to incomplete resection. Since high-grade T1 disease shows diverse clinical courses, individual approaches are recommended for treatment. In cases with low risk of progression, cystectomy could represent overtreatment and deteriorate quality of life irreversibly, while, in those with high risk, bacillus Calmette-Guérin (BCG) therapy may worsen survival by delaying definitive therapy. Therefore, a strategy for predicting prognosis based on the risk of progression is needed for managing high-grade T1 disease. Molecular risk classifiers predicting the risk of progression and response to BCG may help identify the optimal management of high-grade T1 disease for each individual.
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Affiliation(s)
- Seok Joong Yun
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seon-Kyu Kim
- Medical Genomics Research Center, Research Institute of Bioscience and Biotechnology, Daejeon, Korea.; Korean Bioinformation Center, Research Institute of Bioscience and Biotechnology, Daejeon, Korea
| | - Wun-Jae Kim
- Department of Urology, Chungbuk National University College of Medicine, Cheongju, Korea
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83
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Patriarca C, Hurle R, Moschini M, Freschi M, Colombo P, Colecchia M, Ferrari L, Guazzoni G, Conti A, Conti G, Lucianò R, Magnani T, Colombo R. Usefulness of pT1 substaging in papillary urothelial bladder carcinoma. Diagn Pathol 2016; 11:6. [PMID: 26791567 PMCID: PMC4721190 DOI: 10.1186/s13000-016-0466-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 01/14/2016] [Indexed: 12/24/2022] Open
Abstract
Background When treating bladder cancer patients, the most significant problems usually concern cases with high-grade non-muscle-invasive carcinoma, and a better understanding of which patients would benefit from early radical cystectomy is urgently needed. The uropathology community is seeking more user-friendly approaches to distinguishing between T1 cancers exhibiting different types of clinical behavior. Methods After a retrospective review, we selected a group of 314 patients who underwent transurethral resection of the bladder (TURB) and were diagnosed with high-grade urothelial carcinoma staged as T1. Three different substaging systems were applied: one was the anatomy-based T1 a/b; and two involved micrometric thresholds of either 0.5 mm of invasion (as proposed by van Rhijn et al.), or 1 mm of invasion (as proposed in the present study). Early reTUR (repeated transurethral resection) was performed in 250 patients, and the same substaging approaches were applied to cases of T1. Results It proved feasible to apply the 1 mm substaging system in 100 % of cases, the van Rhijn system in 100 %, and the anatomy-based method (T1 a/b) in 72.3 % of cases. At a mean follow-up of 46 months, the recurrence-free survival rate was significantly better (p < 0.001) in the group that underwent reTUR, while none of the three substaging systems reliably predicted recurrences. The 1 mm did seem promising, however, as a threshold for predicting progression, reaching statistical significance in the Kaplan Meier estimates (p < 0.04). Conclusion Our study shows that micrometric substaging is feasible in this setting and should be extended to include any early reTUR to complete the substaging done after the first TURB. It can also provide helpful prognostic information.
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Affiliation(s)
- Carlo Patriarca
- Department of Pathology, Azienda Ospedaliera Sant'Anna, 22020, Como, Italy.
| | - Rodolfo Hurle
- Department of Urology, Humanitas Research Hospital, Rozzano (MI), Italy.
| | - Marco Moschini
- Department of Urology, Ospedale San Raffaele, Milan, Italy.
| | - Massimo Freschi
- Department of Pathology, Ospedale San Raffaele, Milan, Italy.
| | | | - Maurizio Colecchia
- Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Lucia Ferrari
- Department of Pathology, Azienda Ospedaliera Sant'Anna, 22020, Como, Italy.
| | - Giorgio Guazzoni
- Department of Urology, Humanitas Research Hospital, Rozzano (MI), Italy.
| | - Andrea Conti
- Department of Urology, Azienda Ospedaliera Sant'Anna, Como, Italy.
| | - Giario Conti
- Department of Urology, Azienda Ospedaliera Sant'Anna, Como, Italy.
| | - Roberta Lucianò
- Department of Pathology, Ospedale San Raffaele, Milan, Italy.
| | - Tiziana Magnani
- Department of Urology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Renzo Colombo
- Department of Urology, Ospedale San Raffaele, Milan, Italy.
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84
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Patschan O, Sjödahl G, Chebil G, Lövgren K, Lauss M, Gudjonsson S, Kollberg P, Eriksson P, Aine M, Månsson W, Fernö M, Liedberg F, Höglund M. A Molecular Pathologic Framework for Risk Stratification of Stage T1 Urothelial Carcinoma. Eur Urol 2015; 68:824-32; discussion 835-6. [DOI: 10.1016/j.eururo.2015.02.021] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/18/2015] [Indexed: 01/01/2023]
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85
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Patschan O, Sjödahl G, Chebil G, Lövgren K, Lauss M, Gudjonsson S, Kollberg P, Eriksson P, Aine M, Fernö M, Liedberg F, Höglund M. Reply from Authors re: Bas W.G. van Rhijn, Mark A. Behrendt, Kees Hendricksen, Theo H. van der Kwast. Toward Optimal Prediction of Prognosis in T1 Urothelial Carcinoma of the Bladder. Eur Urol 2015;68:833–4. Eur Urol 2015. [DOI: 10.1016/j.eururo.2015.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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86
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Gershman B, Boorjian SA, Hautmann RE. Management of T1 Urothelial Carcinoma of the Bladder: What Do We Know and What Do We Need To Know? Bladder Cancer 2015; 2:1-14. [PMID: 27376120 PMCID: PMC4927848 DOI: 10.3233/blc-150022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
T1 bladder cancer constitutes approximately 25% of incident bladder cancers, and as such carries an important public health impact. Notably, it has a heterogeneous natural history, with large variation in reported oncologic outcomes. Optimal risk-stratification is essential to individualize patient management, targeting those at greatest risk of progression for aggressive therapies such as early cystectomy, while allowing others to safely pursue bladder-preserving approaches including intravesical bacillus Calmette-Guerrin (BCG). Current strategies for diagnosis, risk-stratification, and treatment are imperfect, but emerging technologies and molecular approaches represent exciting opportunities to advance clinical paradigms in management of this disease entity.
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87
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Prognostic significance of substage and WHO classification systems in T1 urothelial carcinoma of the bladder. Curr Opin Urol 2015; 25:427-35. [DOI: 10.1097/mou.0000000000000202] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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88
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Lim SD, Cho YM, Choi GS, Park HK, Paick SH, Kim WY, Kim SN, Yoon G. Clinical Significance of Substaging and HER2 Expression in Papillary Nonmuscle Invasive Urothelial Cancers of the Urinary Bladder. J Korean Med Sci 2015; 30:1068-77. [PMID: 26240484 PMCID: PMC4520937 DOI: 10.3346/jkms.2015.30.8.1068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 06/23/2015] [Indexed: 12/30/2022] Open
Abstract
The study aimed to verify the prognostic utility, therapeutic application and clinical benefits of tumor substaging and HER2 status in papillary non-muscle invasive bladder cancer (NMIBC). Select NMIBC transurethral resection specimens from 141 patients were used to construct tissue microarrays for assessing the substaging, HER2 protein expression by immunohistochemistry (HER2-IHC) and gene amplification by dual-color silver in situ hybridization (HER2-SISH). Substages were identified by the differing depth of tumor invasion (pTa / pT1a / pT1b / pT1c). HER2 protein expression was semiquantitatively analyzed and grouped into negative (score 0, 1+) and positive (score 2+, 3+). Other clinicopathological variables were also investigated. For NMIBC, HER2-IHC and HER2-SISH showed positive results in 6/141 (4.3%) and 4/141 (2.8%) respectively, which correlated well with tumor substaging. In multivariate analysis, substaging, HER2-IHC, and HER2-SISH were found to be independent predictors of progression-free survival (P < 0.001, P < 0.001, P = 0.031). HER2-IHC was the sole independent predictor of recurrent free survival in NMIBC (P = 0.017). It is suggested that tumor substaging and HER2 status are independent predictive markers for tumor progression or recurrence, and thus could be included in diagnostic and therapeutic management for NMIBC.
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Affiliation(s)
- So Dug Lim
- Department of Pathology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Yong Mee Cho
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyung Kyu Park
- Department of Pathology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sung Hyun Paick
- Department of Urology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Wook Youn Kim
- Department of Pathology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Soo-Nyung Kim
- Department of Obstetrics and Gynecology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Ghilsuk Yoon
- Department of Pathology, Kyungpook National University Medical Center, Kyungpook National University School of Medicine, Daegu, Korea
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89
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Orsola A, Palou J, Solsona E. High-risk nonmuscle invasive bladder cancer. Hematol Oncol Clin North Am 2015; 29:227-36, viii. [PMID: 25836931 DOI: 10.1016/j.hoc.2014.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Please also verify that the expansion of HGT1 is OK as set: The risk of progression for high-grade T1 (HGT1) cancer has been recently established at 21% using updated information on large series and a meta-analysis. These outcomes are better than those classically expected supporting the rule of thirds for HGT1. The main limitation of this subgroup is that most studies are retrospective observational studies, which, compared with randomized controlled trials, are subject to various selection biases, carrying a higher risk of uncontrolled confounding factors, with potential preferential reporting of positive findings.
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Affiliation(s)
- Anna Orsola
- Bladder Cancer Center, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02115, USA.
| | - Joan Palou
- Urology Department, Fundacio Puigvert, Cartagena 340-350, Barcelona 08025, Spain
| | - Eduardo Solsona
- Urology Department, Instituto Valenciano de Oncologia, Calle del Profesor Beltrán Bàguena, 8, València 46009, Spain
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90
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[Non-muscle-invasive high-grade bladder cancer]. Urologe A 2015; 54:491-8. [PMID: 25802103 DOI: 10.1007/s00120-015-3774-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Non-muscle-invasive bladder cancer with a low-grade differentiation represents a special challenge. METHOD Although urine cytology is still the most reliable and effective urine-based marker and there are no substantial novel aspects in this field, photodynamic diagnostics have the most important value in transurethral resection of the bladder (TURB) of high-grade T1 tumors and new techniques, such as hybrid knife TURB are coming up. The histopathological assessment of T1 tumors can be supplemented by a description of the exact penetration depth, so-called substaging and the invasion pattern. RESULTS Intravesicle therapy with Bacillus Calmette-Guèrin (BCG) represents the gold standard and a pillar of bladder-preserving therapy and should be planned as maintenance therapy for at least 1 year. With the right risk constellation cystectomy is a safe and proven concept for high-grade bladder cancer, even without proof of muscle invasion.
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91
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[Clinical practice and adherence to the diagnosis and treatment of NMIBC guidelines: a report of a recognition based clinical cases study]. Urologia 2015; 82:58-70. [PMID: 25744706 DOI: 10.5301/uro.5000107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 11/20/2022]
Abstract
For non-muscle invasive bladder cancer, a disease with a considerable epidemiological and socio-economic impact, the introduction of the Guidelines has always evoked as a tool for the resolution of long-standing disputes in terms of diagnosis and therapy. Check the degree of routine clinical practice adherence to the Recommendations is for this disease, more than for other uro-oncology pathology, an urgent need felt by the urological community. To assess the level of Guidelines adherence's, and study issues related to the paths of diagnosis and treatment of non-muscle invasive bladder cancer, and identifying the processes actually implemented in daily clinical practice, a series of case studies has submitted to a group of experts. The acknowledgement study allowed testing the impact of the current Evidence Based Medicine Recommendations in the everyday clinical practice identifying strengths and weaknesses. Questions Responses Analysis' of 5 clinical cases (Ta low grade, T1 low grade, T1 high grade, T1 high grade + CIS, Ta low-grade multiple recurrence) showed a moderate amendment to the European Association of Urology (EAU)-Guidelines. On the other hand, it was emphasized that there are clear discrepancies between what should be done, in accordance with the Evidence Based Medicine Recommendations, and what is actually do in everyday clinical practice. The most common reason for the low Recommendations adherences are structural and organizational practical limitations.
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92
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Prognostic factors in urothelial carcinoma of the bladder: histologic and molecular correlates. Adv Anat Pathol 2015; 22:102-12. [PMID: 25664945 DOI: 10.1097/pap.0000000000000050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Histologic characterization of urothelial carcinoma remains the most important factor for determining a patient's prognosis and treatment regimen. However, challenges remain in accurately staging and grading many tumors, and substaging remains controversial. Recently, significant insight has been gained into the molecular pathogenesis of bladder cancer that may aid in further characterizing urothelial carcinoma. Many molecular biomarkers have been clinically validated, and some have been shown to provide more prognostic information than histology alone. In addition, a subset of these markers may even represent targets for molecular therapy. Here, we review histologic staging and grading of urothelial carcinoma, as well as discuss many of the clinically relevant molecular markers. As each urothelial carcinoma likely represents a unique biological entity, the need for complete histologic and molecular characterization of these tumors is necessary as we enter the age of personalized medicine.
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93
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Martin-Doyle W, Leow JJ, Orsola A, Chang SL, Bellmunt J. Improving Selection Criteria for Early Cystectomy in High-Grade T1 Bladder Cancer: A Meta-Analysis of 15,215 Patients. J Clin Oncol 2015; 33:643-50. [DOI: 10.1200/jco.2014.57.6967] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Purpose High-grade T1 (HGT1) bladder cancer is the highest risk subtype of non–muscle-invasive bladder cancer, with highly variable prognosis, poorly understood risk factors, and considerable debate about the role of early cystectomy. We aimed to address these questions through a meta-analysis of outcomes and prognostic factors. Methods PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and American Society of Clinical Oncology abstracts were searched for cohort studies in HGT1. We pooled data on recurrence, progression, and cancer-specific survival from 73 studies. Results Five-year rates of recurrence, progression, and cancer-specific survival were 42% (95% CI, 39% to 45%), 21% (95% CI, 18% to 23%), and 87% (95% CI, 85% to 89%), respectively (56 studies, n = 15,215). In the prognostic factor meta-analysis (33 studies, n = 8,880), the highest impact risk factor was depth of invasion (T1b/c) into lamina propria (progression: hazard ratio [HR], 3.34; P < .001; cancer-specific survival: HR, 2.02; P = .001). Several other previously proposed factors also predicted progression and cancer-specific survival (lymphovascular invasion, associated carcinoma in situ, nonuse of bacillus Calmette-Guérin, tumor size > 3 cm, and older age; HRs for progression between 1.32 and 2.88, P ≤ .002; HRs for cancer-specific survival between 1.28 and 2.08, P ≤ .02). Conclusion In this large analysis of outcomes and prognostic factors in HGT1 bladder cancer, deep lamina propria invasion had the largest negative impact, and other previously proposed prognostic factors were also confirmed. These factors should be used for prognostication and patient stratification in future clinical trials, and depth of invasion should be considered for inclusion in TNM staging criteria. This meta-analysis can also help define selection criteria for early cystectomy in HGT1 bladder cancer, particularly for patients with deep lamina propria invasion combined with other risk factors.
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Affiliation(s)
- William Martin-Doyle
- William Martin-Doyle, University of Massachusetts Medical School, Worcester; Jeffrey J. Leow, Steven L. Chang, and Joaquim Bellmunt, Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School; Jeffrey J. Leow and Steven L. Chang, Brigham and Women's Hospital, Harvard Medical School; Anna Orsola, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and Joaquim Bellmunt, University Hospital del Mar d'Investigacions Médiques, IMIM, Barcelona, Spain
| | - Jeffrey J. Leow
- William Martin-Doyle, University of Massachusetts Medical School, Worcester; Jeffrey J. Leow, Steven L. Chang, and Joaquim Bellmunt, Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School; Jeffrey J. Leow and Steven L. Chang, Brigham and Women's Hospital, Harvard Medical School; Anna Orsola, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and Joaquim Bellmunt, University Hospital del Mar d'Investigacions Médiques, IMIM, Barcelona, Spain
| | - Anna Orsola
- William Martin-Doyle, University of Massachusetts Medical School, Worcester; Jeffrey J. Leow, Steven L. Chang, and Joaquim Bellmunt, Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School; Jeffrey J. Leow and Steven L. Chang, Brigham and Women's Hospital, Harvard Medical School; Anna Orsola, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and Joaquim Bellmunt, University Hospital del Mar d'Investigacions Médiques, IMIM, Barcelona, Spain
| | - Steven L. Chang
- William Martin-Doyle, University of Massachusetts Medical School, Worcester; Jeffrey J. Leow, Steven L. Chang, and Joaquim Bellmunt, Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School; Jeffrey J. Leow and Steven L. Chang, Brigham and Women's Hospital, Harvard Medical School; Anna Orsola, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and Joaquim Bellmunt, University Hospital del Mar d'Investigacions Médiques, IMIM, Barcelona, Spain
| | - Joaquim Bellmunt
- William Martin-Doyle, University of Massachusetts Medical School, Worcester; Jeffrey J. Leow, Steven L. Chang, and Joaquim Bellmunt, Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School; Jeffrey J. Leow and Steven L. Chang, Brigham and Women's Hospital, Harvard Medical School; Anna Orsola, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; and Joaquim Bellmunt, University Hospital del Mar d'Investigacions Médiques, IMIM, Barcelona, Spain
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Orsola A, Werner L, de Torres I, Martin-Doyle W, Raventos CX, Lozano F, Mullane SA, Leow JJ, Barletta JA, Bellmunt J, Morote J. Reexamining treatment of high-grade T1 bladder cancer according to depth of lamina propria invasion: a prospective trial of 200 patients. Br J Cancer 2015; 112:468-74. [PMID: 25535728 PMCID: PMC4453654 DOI: 10.1038/bjc.2014.633] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 11/21/2014] [Accepted: 11/30/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Management of high-grade T1 (HGT1) bladder cancer represents a major challenge. We studied a treatment strategy according to substaging by depth of lamina propria invasion. METHODS In this prospective observational cohort study, patients received initial transurethral resection (TUR), mitomycin-C, and BCG. Subjects with shallower lamina propria invasion (HGT1a) were followed without further surgery, whereas subjects with HGT1b received a second TUR. Association of clinical and histological features with outcomes (primary: progression; secondary: recurrence and cancer-specific survival) was assessed using Cox regression. RESULTS Median age was 71 years; 89.5% were males, with 89 (44.5%) cases T1a and 111 (55.5%) T1b. At median follow-up of 71 months, disease progression was observed in 31 (15.5%) and in univariate analysis, substaging, carcinoma in situ, tumour size, and tumour pattern predicted progression. On multivariate analysis only substaging, associated carcinoma in situ, and tumour size remained significant for progression. CONCLUSIONS In HGT1 bladder cancer, the strategy of performing a second TUR only in T1b cases results in a global low progression rate of 15.5%. Tumours deeply invading the lamina propria (HGT1b) showed a three-fold increase in risk of progression. Substaging should be routinely evaluated, with HGT1b cases being thoroughly evaluated for cystectomy. Inclusion in the TNM system should also be carefully considered.
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Affiliation(s)
- A Orsola
- Department of Oncology, Dana-Farber/Brigham and Women's Hospital Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - L Werner
- Departments of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
| | - I de Torres
- Department of Pathology, Vall d'Hebron Hospital, Barcelona 08035, Spain
| | - W Martin-Doyle
- University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - C X Raventos
- Department of Urology, Vall d'Hebron Hospital, Barcelona 08035, Spain
| | - F Lozano
- Department of Urology, Vall d'Hebron Hospital, Barcelona 08035, Spain
| | - S A Mullane
- Department of Oncology, Dana-Farber/Brigham and Women's Hospital Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - J J Leow
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA 02215, USA
- Division of Urology, Brigham and Women's Hospital, Boston, MA 02215, USA
| | - J A Barletta
- Department of Pathology, Dana-Farber/Brigham and Women's Hospital Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - J Bellmunt
- Department of Oncology, Dana-Farber/Brigham and Women's Hospital Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - J Morote
- Department of Oncology, Dana-Farber/Brigham and Women's Hospital Cancer Center, Harvard Medical School, Boston, MA 02215, USA
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Kitamura H, Kakehi Y. Treatment and management of high-grade T1 bladder cancer: what should we do after second TUR? Jpn J Clin Oncol 2015; 45:315-22. [PMID: 25583419 DOI: 10.1093/jjco/hyu219] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Most T1 bladder cancers are high grade and have the potential to progress to muscle invasion and extravesical dissemination. Many studies reported that ∼50% of patients displayed residual tumors when a second transurethral resection was performed 2-6 weeks after the initial resection for patients who were diagnosed with T1 bladder cancer. Furthermore, muscle-invasive disease was detected by the second transurethral resection in 10-25% of those patients. Therefore, a second transurethral resection is strongly recommended for patients newly diagnosed with high-grade T1 bladder cancer in various guidelines. T1 bladder cancers are heterogeneous in terms of progression and prognosis after the second transurethral resection. Optimal management and treatment should be considered for patients with T1 bladder cancer based on the pathological findings for the second transurethral resection specimen. If the second transurethral resection reveals residual tumors, aggressive treatments based on the pathological findings should be performed. Conversely, overtreatment with respect to the tumor status should be avoided. Since the evidence of pathological diagnosis at the second transurethral resection is insufficient and many retrospective studies were carried out before the second transurethral resection era, prospective randomized studies should be conducted.
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Affiliation(s)
- Hiroshi Kitamura
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo
| | - Yoshiyuki Kakehi
- Department of Urology, Kagawa University Faculty of Medicine, Kagawa, Japan
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Fransen van de Putte EE, van Rhijn BWG. Word of wisdom. Re: prognostic interest in discriminating muscularis mucosa invasion (T1a vs T1b) in nonmuscle invasive bladder carcinoma: French national multicenter study with central pathology review. Eur Urol 2014; 66:787-8. [PMID: 25218075 DOI: 10.1016/j.eururo.2014.07.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Elisabeth E Fransen van de Putte
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Bas W G van Rhijn
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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97
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Pellucchi F, Freschi M, Moschini M, Rocchini L, Maccagnano C, Nazareno S, Bergamaschi F, Montorsi F, Colombo R. Oncological predictive value of the 2004 World Health Organisation grading classification in primary T1 non-muscle-invasive bladder cancer. A step forward or back? BJU Int 2014; 115:267-73. [DOI: 10.1111/bju.12666] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Federico Pellucchi
- Department of Urology; Scientific Institute San Raffaele; ‘Vita-Salute University’ and Urological Research Institute; Milan Italy
| | - Massimo Freschi
- Department of Pathology; Scientific Institute San Raffaele; ‘Vita-Salute University’ and Urological Research Institute; Milan Italy
| | - Marco Moschini
- Department of Urology; IRCCS Arcispedale Santa Maria Nuova; Reggio Emilia Italy
| | - Lorenzo Rocchini
- Department of Urology; IRCCS Arcispedale Santa Maria Nuova; Reggio Emilia Italy
| | - Carmen Maccagnano
- Department of Urology; IRCCS Arcispedale Santa Maria Nuova; Reggio Emilia Italy
| | - Suardi Nazareno
- Department of Urology; IRCCS Arcispedale Santa Maria Nuova; Reggio Emilia Italy
| | - Franco Bergamaschi
- Department of Urology; Scientific Institute San Raffaele; ‘Vita-Salute University’ and Urological Research Institute; Milan Italy
| | - Francesco Montorsi
- Department of Urology; IRCCS Arcispedale Santa Maria Nuova; Reggio Emilia Italy
| | - Renzo Colombo
- Department of Urology; IRCCS Arcispedale Santa Maria Nuova; Reggio Emilia Italy
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98
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DE Marco V, Cerruto MA, D'Elia C, Brunelli M, Otte O, Minja A, Luchini C, Novella G, Cavalleri S, Martignoni G, Artibani W. Prognostic role of substaging in T1G3 transitional cell carcinoma of the urinary bladder. Mol Clin Oncol 2014; 2:575-580. [PMID: 24940498 DOI: 10.3892/mco.2014.290] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 04/08/2014] [Indexed: 11/05/2022] Open
Abstract
This study was conducted to test a new substaging system in a population of patients with stage T1 bladder cancer (BC) at diagnosis and assess its prognostic role in terms of disease progression and disease-specific survival (DSS). Patients with primary stage T1G3 urothelial carcinoma of the bladder were stratified according to the following models: i) T1a [the tumour does not infiltrate the muscularis mucosae-vascular plexus, (MM-VP)]; T1b (the tumour partially infiltrates the MM-VP); and T1c (the tumour infiltrates and invades the MM-VP). ii) T1m (diameter of tumour infiltrating the lamina propria ≤0.5 mm under a high-resolution microscope; and T1e (diameter of tumour infiltrating the lamina propria >0.5 mm). Age, gender, tumour size and multifocality were not found to be of statistical significance. Using the T1a/T1b/T1c system, patients with stage T1a disease exhibited a 5- and 10-year progression rate of 13.3 and 20%, respectively, without reaching statistical significance. Moreover, patients with stage T1a disease exhibited a 5- and 10-year DSS of 93.3 and 73.3%, respectively, which was higher compared to T1b and T1c but not statistically significant. Using the T1m/T1e system, patients with stage T1m disease exhibited a disease progression rate of 8.3 and 16.7% at 5 and 10 years, respectively, which was not statistically significant. Moreover, patients in group T1m presented with DSS rates of 91.7 and 83.3% at 5 and 10 years, respectively, which were higher compared to those in the T1e group (71.4 and 60.7%), although not reaching statistical significance. In conclusion, in our study, neither of the two substaging systems of stage T1 BC reached the prognostic conventional significance level for tumour progression or DSS.
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Affiliation(s)
| | | | | | - Matteo Brunelli
- Department of Pathology, University of Verona, I-37126 Verona, Italy
| | - Oscar Otte
- Urology Clinic, University of Verona, I-37126 Verona, Italy
| | - Anila Minja
- Urology Clinic, University of Verona, I-37126 Verona, Italy
| | - Claudio Luchini
- Department of Pathology, University of Verona, I-37126 Verona, Italy
| | | | | | - Guido Martignoni
- Department of Pathology, University of Verona, I-37126 Verona, Italy
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99
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Pan CC, Yu HJ, Chang YH. The prognostic value of combined clinicopathological and biomarker modelling for non-muscle-invasive bladder cancer. Histopathology 2014. [DOI: 10.1111/his.12385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Chin-Chen Pan
- Department of Pathology; Taipei Veterans General Hospital and National Yang-Ming University; Taipei Taiwan
| | - Hui-Jung Yu
- Department of Pathology; Cardinal Tien Hospital and School of Medicine; Fu-Jen Catholic University; New Taipei City Taiwan
| | - Yen-Hwa Chang
- Department of Urology; Taipei Veterans General Hospital; Taipei Taiwan
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100
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Soukup V, Duková J, Pel M, Capoun O, Feherová Z, Zámecník L, Hanu T, Babjuk M. The Prognostic Value of T1 Bladder Cancer Substaging: A Single Institution Retrospective Study. Urol Int 2014; 92:150-6. [DOI: 10.1159/000355358] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/28/2013] [Indexed: 11/19/2022]
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