Recurrence and progression in low grade papillary urothelial tumors

Non-invasive papillary urothelial neoplasms: the 2004 WHO/ISUP classification system

The classification and grading of papillary urothelial neoplasms has been a long-standing subject of controversy. Previously, numerous diverse grading schemes for bladder tumor, including the 1973 World Health Organization (WHO) classification, existed whereby one of the major limitations was poor inter-observer reproducibility among pathologists. The WHO/International Society of Urological Pathology (ISUP) consensus classification system of urothelial neoplasms of the urinary bladder was developed in 1998 and was revised most recently in 2003 (published in 2004). Importantly, the current classification system provides detailed histological criteria for papillary urothelial lesions and allows for designation of a lesion (papillary urothelial neoplasm of low malignant potential) with a negligible risk of progression. Thus, the latest system is designed to be a universally acceptable one for bladder tumors that not only could be effectively used by pathologists, urologists, and oncologists, but also stratifies the tumors into prognostically significant categories. This article outlines the 2004 WHO/ISUP classification system regarding the specific histological criteria for non-invasive papillary urothelial neoplasms and the clinical significance of each category.

Analysis of clinical characteristics, management and survival of patients with Ta T1 bladder tumours in Sweden between 1997 and 2001

OBJECTIVE

To analyse the management and outcome of patients with Ta T1 urinary bladder cancer in a population-based national database.

MATERIAL AND METHODS

Between 1997 and 2001, 94% of all newly diagnosed cases of urinary bladder cancer were registered in the Swedish National Bladder Cancer Register. Data were analysed regarding gender, healthcare region, stage and grade for patients with Ta T1 tumours. The choice of initial treatment in different regions was reviewed. Survival was analysed by calculating relative survival.

RESULTS

Out of 9859 registered patients, there were 4442 Ta tumours and 2139 T1 tumours. The median age at diagnosis was 72 and 73 years for patients with Ta and T1 tumours, respectively. Seventy-six percent of the patients were men. The choice of treatment varied between different healthcare regions. A significant trend towards an increased use of intravesical therapy was seen over time. Significantly fewer older than younger patients received such therapy. There was also a tendency towards more intensive therapy in men. The bladder cancer relative 5-year survival rate was 93% for Ta and 75% for T1 tumours. Survival was similar for men and women.

CONCLUSIONS

Our analysis revealed a regional variation in the treatment of bladder cancer. A large group of patients, even those at high risk, were still undertreated. However, the recent publication of guidelines may have contributed to an increased use of intravesical treatment. Urologists tended to treat TaG3 and T1G3 tumours more aggressively than T1G2 tumours. Therapeutic aggressiveness decreased as the age of the patients increased. The survival rate of patients with bladder cancer in Sweden seems to remain at the levels previously reported for the 1980s.

Provider treatment intensity and outcomes for patients with early-stage bladder cancer

BACKGROUND

Bladder cancer is among the most prevalent and expensive to treat cancers in the United States. In the absence of high-level evidence to guide the optimal management of bladder cancer, urologists may vary widely in how aggressively they treat early-stage disease. We examined associations between initial treatment intensity and subsequent outcomes.

METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients who were diagnosed with early-stage bladder cancer from January 1, 1992, through December 31, 2002 (n = 20 713), and the physician primarily responsible for providing care to each patient (n = 940). We ranked the providers according to the intensity of treatment they delivered to their patients (as measured by their average bladder cancer expenditures reported to Medicare in the first 2 years after a diagnosis) and then grouped them into quartiles that contained approximately equal numbers of patients. We assessed associations between treatment intensity and outcomes, including survival through December 31, 2005, and the need for subsequent major interventions by using Cox proportional hazards models. All statistical tests were two-sided.

RESULTS

The average Medicare expenditure per patient for providers in the highest quartile of treatment intensity was more than twice that for providers in the lowest quartile of treatment intensity ($7131 vs $2830, respectively). High-treatment intensity providers more commonly performed endoscopic surveillance and used more intravesical therapy and imaging studies than low-treatment intensity providers. However, the intensity of initial treatment was not associated with a lower risk of mortality (adjusted hazard ratio of death from any cause for patients of low- vs high-treatment intensity providers = 1.03, 95% confidence interval 0.97 to 1.09). Initial intensive management did not obviate the need for later interventions. In fact, a higher proportion of patients treated by high-treatment intensity providers than by low-treatment intensity providers subsequently underwent a major medical intervention (11.0% vs 6.4%, P = .02).

CONCLUSIONS

Providers vary widely in how aggressively they manage early-stage bladder cancer. Patients treated by high-treatment intensity providers do not appear to benefit in terms of survival or in avoidance of subsequent major medical interventions.

Utility of diagnostic and prognostic markers in urothelial carcinoma of the bladder

Urothelial carcinoma (UCC) of the bladder demonstrates diverse morphologic features, often leading to diagnostic challenges in the discrimination between UCC and benign mimickers of neoplasia, and between primary UCC and secondary neoplasms involving the bladder. In situ lesions also provide diagnostic difficulty in some instances, most prominently in the distinction between normal, reactive urothelium and flat urothelial carcinoma in situ. The use of ancillary techniques, including panels of immunohistochemical markers, in distinguishing these entities has aided not only in the diagnosis of UCC, but has also provided insight into the molecular pathogenesis and prognostic value of numerous molecular pathways in UCC. This review focuses on some of the more commonly encountered biomarkers in UCC and their role in addressing key diagnostic and prognostic issues in this disease process.

Phosphorylated H2AX in noninvasive low grade urothelial carcinoma of the bladder: correlation with tumor recurrence

PURPOSE

Histone modifications have been linked to DNA replication, transcription and repair. The phosphorylation of histone H2AX at serine 139 (gamma-H2AX) is associated with DNA breaks. gamma-H2AX has been shown to be expressed in bladder urothelial carcinoma. To our knowledge studies of the relationship of gamma-H2AX expression and the clinical outcome of urothelial carcinoma are lacking. Hence, we evaluated the rate of H2AX phosphorylation in low grade bladder urothelial carcinoma and assessed its potential role for predicting recurrence and/or progression.

MATERIALS AND METHODS

Immunohistochemical expression of gamma-H2AX using a polyclonal antibody was retrospectively assessed in 2 groups of patients from The Johns Hopkins Hospital with low grade bladder urothelial carcinoma. Group 1 consisted of transurethral resection biopsies from 18 patients from 2004 to 2006 that were retrieved from our surgical pathology files. Group 2 consisted of 42 archival transurethral biopsies obtained between 1971 and 1995 with longer followup that were used to construct a tissue microarray.

RESULTS

On univariate analysis recurrence in the entire cohort was more likely to develop in gamma-H2AX negative than in gamma-H2AX positive cases (24 of 32 or 81% vs 13 of 28 or 46%). The difference in recurrence was statistically significant (p = 0.02). The same was true in group 2 (16 of 21 cases or 76% vs 9 of 21 or 43%, p = 0.02). Female gender and intravesical therapy were also associated with a higher recurrence rate in our cohort. A higher progression rate was noted in group 2 patients and in the entire cohort in association with negative gamma-H2AX staining. However, the difference in progression between gamma-H2AX negative and positive tumors was not statistically significant. On multivariate analysis only patient gender and prior intravesical treatment remained predictive of recurrence (p <0.03).

CONCLUSIONS

Our data suggest that epigenetic alterations may have an important role in the mechanism of bladder tumor recurrence. Analysis in a larger cohort is needed to further assess our current preliminary findings of the role of gamma-H2AX expression for predicting outcome in low grade urothelial carcinoma cases.

Relationship of Ki67, TP53, MDM-2 and BCL-2 expressions with WHO 1973 and WHO/ISUP grades, tumor category and overall patient survival in urothelial tumors of the bladder

Using the 1998 World Health Organization/International Society of Urological Pathology (WHO/ISUP) (2004 WHO), 1999 WHO/ISUP, and 1973 WHO classifications, we examined Ki67, BCL-2, TP53, and MDM-2 expressions in invasive and noninvasive urothelial neoplasias of the bladder of 72 patients, and compared the results regarding tumor category and grade with clinical outcome to determine the clinicopathological relevance of these classifications. Ki67 and TP53 expressions were correlated with tumor grades of the 1973 WHO classification, and they also distinguished "papillary urothelial neoplasm with low malignant potential" from other WHO/ISUP grades (p < 0.05). No difference was observed for Ki67 and TP53 expressions between the other WHO/ISUP grades (p > 0.05). Neither tumor grade nor tumor category correlated with MDM-2 or BCL-2 expressions (p > 0.05). WHO/ISUP classifications are obviously not superior to the 1973 WHO classification for grading urothelial neoplasia of the bladder. However, if the "papillary urothelial neoplasm with low malignant potential" is distinguished from grade 1 tumors of the 1973 WHO classification, more precise prognostic information may be obtained.

Conservative management of low risk superficial bladder tumors

PURPOSE

The most common approach for nonmuscle invasive urothelial cancers of the bladder is transurethral resection of the bladder tumor, often under regional or general anesthesia. Due to the high rate of recurrence, many such patients experience the potential risks and morbidity of frequent surgical intervention, despite the often slow growth rate and low risk of progression of such tumors. Recent experiences have suggested that some patients with low grade superficial tumors may be treated expectantly. We report on our experience with expectant management of low risk superficial bladder tumors.

MATERIALS AND METHODS

We retrospectively evaluated 173 patients with superficial bladder cancer who are currently actively treated at our institution and who have complete clinical information. From this population we identified 22 cases (12.7%) under expectant management for bladder tumors in the last 12 months. Demographic and clinical information on this cohort are described as well as clinical and pathological outcomes, and disease interventions on followup.

RESULTS

All patients had a prior history of recurrent low risk (Ta, low grade) bladder tumors. The mean followup was 25 months. Of the 22 patients 8 had no growth, 9 had minimal growth and 5 had moderate growth of their tumors. Fifteen patients have required no intervention, 3 have undergone office fulguration and 4 have undergone repeat transurethral bladder tumor resection. Two men (9%) had evidence of grade progression on followup transurethral bladder tumor resection, and 1 of these men (4.5%) had stage progression (T1 disease). Both men had evidence of moderate tumor growth and suspicious/malignant cytology which resulted in the repeat transurethral bladder tumor resection. Interestingly, these 2 men had a 6 and 11 year history of recurrent Ta, low grade disease before progression and had been under expectant management for 18 and 12 months before progression. Interestingly all smokers had a recurrence during the surveillance period and this represented a 3.3-fold increased rate of recurrence over nonsmokers.

CONCLUSIONS

Expectant management of recurrent bladder tumors may be an appropriate option for some patients with a history of Ta, low grade tumors, especially those who are older and with significant medical comorbidities. Such a strategy may avoid potential risks and morbidities associated with frequent, repeat transurethral bladder tumor resection. However, under such an expectant management strategy, patients should remain under careful cystoscopic and cytologic surveillance as there remains some risk for grade and stage progression in this patient population.

Survival Following the Diagnosis of Noninvasive Bladder Cancer: WHO/International Society of Urological Pathology Versus WHO Classification Systems

PURPOSE

The WHO/International Society of Urological Pathology classification of bladder cancer, introduced in 1998, differs from the traditional 1973 WHO classification. Few studies have reported survival data based on the WHO/International Society of Urological Pathology classification and none has demonstrated clear superiority compared to the 1973 WHO system. In a large, nonselected population of patients with bladder cancer we rated all incident tumors using each system and compared long-term patient survival.

MATERIALS AND METHODS

New Hampshire residents with bladder cancer diagnosed between 1994 and 2000 were identified through the State Cancer Registry. Slides were retrieved from more than 90% of cases and reviewed by a single pathologist. Tumors were classified according to WHO and WHO/International Society of Urological Pathology criteria. Overall patient survival was determined for the cohort of 504 patients after an average of 7 years using a national mortality database.

RESULTS

For both grading systems there was a gradient of progressively lower survival times from the lowest grade to the highest grade tumors. Hazard ratios and 95% confidence intervals for the WHO/International Society of Urological Pathology system were 1.9 (1.0-3.4) for low grade papillary urothelial carcinoma and 3.0 (1.5-6.0) for high grade papillary urothelial carcinoma, compared to papillary urothelial neoplasms of low malignant potential. For the WHO (1973) system compared to grade 1 tumors the hazard ratio for grade 2 tumors was 1.8 (1.1-3.1) and for grade 3 was 2.4 (1.2-4.7).

CONCLUSIONS

Advantages of the WHO/International Society of Urological Pathology bladder tumor classification include more detailed diagnostic criteria, the ability to define a lesion with minimal malignant potential and the ability to identify a larger group of patients needing closer surveillance. However, we found that the WHO/International Society of Urological Pathology tumor categories did not detect a clear overall survival advantage compared to the WHO (1973) classification system.

Management of Low Grade Papillary Bladder Tumors

PURPOSE

We evaluated the management and treatment outcomes of low grade papillary bladder tumors.

MATERIALS AND METHODS

We evaluated 215 patients diagnosed with low grade and noninvasive papillary bladder tumors, and followed them every 6 months with flexible cystoscopy for 6 to 10 or more years. Tumor recurrence was treated with transurethral resection or outpatient cystoscopic fulguration.

RESULTS

Of the 215 patients 143 (67%) had at least 1 recurrence (positive cystoscopy). With a median followup of 8 years tumor recurrences averaged 6.2 (range 1 to 19) requiring 0.34 transurethral resections per year or 1 transurethral resection every 3 years, or 0.61 fulgurations or 1 fulguration approximately every 2 years. There were 17 patients (8%) who had progression in grade or stage and 1 patient (0.5%) died of bladder cancer. Patients most likely to have recurrence had multiple tumors, low grade (TaLG) carcinoma or tumor at first followup cystoscopy.

CONCLUSIONS

Surveillance cystoscopy at 6-month intervals coupled with outpatient fulguration controls recurrent tumors and reduces the therapeutic burden for patients diagnosed with low grade papillary bladder tumors.

Reproducibility and reliability of tumor grading in urological neoplasms

Histopathologic tumor grading reflects the degree of differentiation of a given tumor and for most urological tumors grading is an important factor in predicting their biological aggressiveness. Consequently, the clinical management of tumor patients is often strongly influenced by the tumor grade, provided by pathologists. This implicates that an ideal grading system should not only be of high prognostic relevance, but also of high reproducibility among different pathologists. To this end individual histological grading systems have been developed for different tumor entities and even for a given tumor type several grading systems have been proposed. All of these grading systems possess an inherent degree of subjectivity and consequently, both intra- and interobserver variability exist. In this review, grading systems for the most frequent urological tumors (i.e. prostate cancer, renal cell carcinoma, and urothelial tumors) are mentioned and data on the reproducibility and reliability of the most commonly used grading systems are summarized.

Early-stage bladder cancer surveillance does not improve survival if high-risk patients are permitted to progress to muscle invasion

OBJECTIVES

Surveillance of early-stage bladder cancer (cTis-T1) permits bladder preservation with conservative treatments, using cystectomy to salvage patients with refractory disease. Despite close observation, some tumors progress to muscle invasion during this period. Historically, some believed that cystectomy applied in this setting could provide a better outcome in patients with "early" cT2 disease compared with those with de novo cT2 disease. We compared the pathologic and survival outcomes of patients with high-risk early-stage disease with those of patients with muscle-invasive tumors at presentation.

METHODS

A cohort of 422 consecutive patients underwent primary cystectomy for high-risk, progressive, or muscle-invasive bladder cancer. A retrospective review of the demographics, surveillance time, clinical and pathologic parameters, and survival was undertaken. The variables were tested in univariate and multivariate analyses.

RESULTS

Before cystectomy, 182 high-risk patients (44%) had cTis-T1 cancer at diagnosis but did not progress to cT2 disease (group 1); 69 patients (17%) had cTis-T1 that progressed to cT2 during surveillance (group 2); and 167 patients (40%) presented with cT2 tumors (group 3). Groups 2 and 3 had similar patterns of pathologic staging (P = 0.9862), disease-specific survival (P = 0.469), and overall survival (P = 0.643). The rate of understaging was similar in groups 2 and 3 (59% to 60%).

CONCLUSIONS

Patients with disease progression to cT2 bladder cancer during surveillance have similar patterns of pathologic staging and survival after cystectomy as those with de novo cT2 disease, likely because of the similar rates of tumor understaging.

Comparison of 1998 WHO/ISUP and 1973 WHO classifications for interobserver variability in grading of papillary urothelial neoplasms of the bladder. Pathological evaluation of 258 cases

AIM

Our aim was to compare the interobserver variability between the 1998 WHO/ISUP and 1973 WHO classifications.

METHODS

258 consecutive papillary urothelial carcinomas were reviewed by two pathologists and assigned a tumor grade according to the 1973 WHO and 1998 WHO/ISUP without the knowledge of primary diagnosis and clinical follow-up. All cases were also histologically staged by the two pathologists separately as follows: pTa (noninvasive), pT1 (lamina propria invasion only), pT2 (muscularis propria invasion). Findings of both pathologists and degree of agreement were compared statistically by using Pearson's chi(2) test and kappa statistics respectively. A kappa value of 0.21-0.40 is accepted as fair, 0.41-0.60 moderate and 0.61-0.80 substantial agreement.

RESULTS

Regardless of the pathologist, tumor grades of two classifications correlated to each other and the pathological stage (p < 0.05). Overall degree of agreement between pathologists was higher in the 1998 WHO/ISUP (kappa 0.59) than the 1973 WHO (kappa 0.41), but both were still moderate. Papillary urothelial neoplasia with low malignant potential was the group of 1998 WHO/ISUP that showed the lowest degree of agreement and if excluded, interobserver variability of the 1998 WHO/ISUP decreased significantly (kappa 0.84).

CONCLUSION

The diagnosis of papillary urothelial neoplasia with low malignant potential and the criteria that differentiates it from low-grade carcinomas needs improvement in order to compare the different studies and therapies and to provide more accurate information for management.

Clinically Relevant Reduction in Risk of Recurrence of Superficial Bladder Cancer Using 5-Aminolevulinic Acid-Induced Fluorescence Diagnosis: 8-Year Results of Prospective Randomized Study

OBJECTIVES

Several studies have shown that 5-aminolevulinic acid (5-ALA)-induced fluorescence cystoscopy improves the detection of superficial bladder cancer. The results have suggested a reduced rate of recurrent tumors with the use of 5-ALA fluorescence before bladder tumor resection. We performed a prospective, randomized trial to investigate whether the long-term tumor recurrence and residual tumor rates can be decreased using 5-ALA fluorescence diagnosis (FD).

METHODS

A total of 301 patients with suspected superficial bladder carcinoma were randomized to transurethral resection (TUR) using conventional white light (WL) or FD. TUR was repeated to evaluate the residual tumor rate. In addition, patients were followed up for a median of 83 (WL) and 86 (FD) months to evaluate recurrence-free survival (RFS).

RESULTS

Of the 301 patients, 191 were available for the efficacy analysis. The residual tumor rate was 25.2% in the WL arm versus 4.5% in the FD arm (P <0.0001). The RFS rate after 2, 4, 6, and 8 years was 73%, 64%, 54%, and 45% in the WL group and 88%, 84%, 79%, and 71% in the FD group, respectively, revealing a statistically significant difference in favor of fluorescent TUR (P = 0.0003).

CONCLUSIONS

5-ALA-induced FD is significantly superior statistically to conventional WL TUR with respect to the residual tumor rate and RFS. This advantage of decreased bladder tumor recurrence risk was maintained with high statistical significance for at least 8 years. The differences in RFS imply that FD offers a clinically relevant procedure to reduce the incidence of tumor recurrence.

Histologic Grading of Noninvasive Papillary Urothelial Neoplasms

OBJECTIVES

In 1998, a revised system of classifying noninvasive papillary urothelial neoplasms of the urinary bladder was proposed and subsequently formally adopted by the World Health Organization (WHO). The introduction of this new system was justified as being potentially superior on a number of levels to the 1973 WHO classification system that it replaced. Specifically, a new category of neoplasms, designated papillary urothelial neoplasm of low malignant potential (PUNLMP), was considered advantageous for several reasons. The new system was expected to gain widespread acceptance, improve reproducibility of diagnoses among pathologists, and enhance the correlation between urine cytology and tumor histology. We examine the history of the changes in terminology for these lesions, the relative merits of PUNLMP terminology, the extent to which the expectations accompanying the new grading system have been met, and the extent to which the new system has enhanced the management of patients with noninvasive papillary urothelial neoplasms of the bladder.

METHODS

A PubMed literature search after the introduction of this new classification was performed and relevant papers reviewed.

RESULTS AND CONCLUSIONS

The 2004 WHO classification is a positive initiative in attempting to standardize urothelial tumor grading by expanding and clearly defining the morphologic characteristics of noninvasive papillary urothelial neoplasms. The new terminology used in this system is of questionable validity and utility. Full-genome searches for prognostic and predictive molecular gene expression signatures, GeneChip technology and proteomics techniques, and several new biomarkers and molecular tests may be useful in future grading schemes after their clinical utility is better established.

Superficial bladder cancer: part 1. Update on etiology, classification and natural history

Superficial 'nonmuscle-invasive' bladder tumors represent a heterogeneous group of cancers, which include those that are papillary in nature and limited to the mucosa (Ta), high grade, flat and confined to the epithelium (Tis) and those that invade the submucosa or lamina propria (T1). The natural history of these bladder cancers is that of disease recurrence and progression to higher grade and stage. Furthermore, recurrence and progression rates of superficial bladder cancer vary according to several tumor characteristics. The goal in the treatment of superficial bladder cancer is twofold: reducing tumor recurrence and the subsequent need for additional therapies, such as cystoscopy, transurethral resections, intravesical therapy and the morbidity associated with these treatments; and preventing tumor progression and the subsequent need for more aggressive therapy, such as radical cystectomy. The administration of intravesical chemotherapy and immunotherapy has become an important component in accomplishing these goals. This update is the first part of two articles reviewing important contemporary concepts in the etiology, classification and natural history of superficial bladder cancer, while part II of the series will review and highlight important aspects in management of superficial bladder cancer.

Gene Expression Analysis for the Prediction of Recurrence in Patients with Primary Ta Urothelial Cell Carcinoma

OBJECTIVES

The individual recurrence-free period after primary surgery of patients with Ta urothelial cell carcinoma (UCC) cannot be predicted accurately. This study aims at discriminating between patients with primary Ta UCC and long or short recurrence-free periods.

METHODS

We investigated mRNA expression of 23 genes in 44 primary Ta tumours (23 and 21 tumours were from patients with long [>or=4 yr] or short [<or=2 yr] recurrence-free periods, respectively), using real-time quantitative polymerase chain reaction. The genes were selected from previously published studies and showed a relationship with tumour recurrence in patients with UCC.

RESULTS

Differential mRNA expression between the two patient groups indicated statistical significance only for the gene survivin (p=0.0011). Its recurrence predictive value could not be increased by a combination with any of the other genes. Comparison of the receiver operating characteristic curves for survivin expression between patients with long or short recurrence-free intervals revealed an area under the curve of 0.79 (95%CI, 0.65-0.92). Using the median expression (0.84) as cut-off level, survivin identified 71.4% (95%CI, 47.8-88.7) and 69.6% (95%CI, 47.1-86.8) of the patients with long or short recurrence-free periods, respectively.

CONCLUSIONS

Our study identifies survivin as the most promising candidate to distinguish between patients with primary Ta UCC and long or short recurrence-free intervals. Therefore, survivin mRNA expression analysis might help the urologist to individualise patient treatment and prevent unnecessary cystoscopies in a subgroup of these patients.

Seven Years’ Experience with 5-Aminolevulinic Acid in Detection of Transitional Cell Carcinoma of the Bladder

OBJECTIVES

Photodynamic diagnosis (PDD) using 5-aminolevulinic acid has proved to be a procedure with an outstanding sensitivity for the detection of transitional cell carcinoma of the bladder, in particular in the detection of flat urothelial lesions. We report on our clinical results with 875 patients (1713 PDD procedures) between March 1995 and March 2002.

METHODS

A total of 1713 PDD procedures were done in 875 patients. Fluorescence imaging was performed 2 to 3 hours after instillation of 50 mL of a 3% solution of 5-aminolevulinic acid into the bladder by an incoherent light source. In total, specimens from 4630 lesions (2.7 lesions/PDD) were taken.

RESULTS

In 34.8% of all biopsies, the histologic finding was malignant; 23.7% of these biopsies had been taken only because of positive fluorescence. In 28.5% of the positive biopsies, flat lesions had been identified. Also, 43.4% of carcinoma in situ and 30.7% of dysplasia II degrees were detected only by positive fluorescence. Of all tumor lesions, 92.0% were detected by PDD compared with 76.3% detected by white light endoscopy.

CONCLUSIONS

PDD has proved to be an effective detection device for superficial bladder cancer.

Superficial and Muscle-Invasive Bladder Cancer: Principles of Management for Outcomes Assessments

Bladder cancer is a heterogeneous disease. Non–muscle-invasive bladder cancer embraces a spectrum of tumors with varying degrees of clinical behavior. Transurethral resection remains the surgical mainstay for the treatment of non–muscle-invasive bladder cancer. In an attempt to decrease the recurrence or progression rate, intravesical chemotherapy or immunotherapy is also used. Radical cystectomy with bilateral pelvic lymph node dissection remains the gold standard for treating muscle-invasive bladder cancer. Over the last decade, the orthotopic neobladder has gained widespread popularity as the preferred mode of urinary diversion in both males and females with similar oncologic and functional outcomes. Well-designed trials with effective chemotherapy have shown a beneficial role for neoadjuvant chemotherapy.

Prediction of recurrence in Ta urothelial cell carcinoma by real-time quantitative PCR analysis: a microarray validation study

Accurate prediction of tumor recurrence in patients with superficial urothelial cell carcinoma (UCC) might result in a significant reduction of invasive follow-up cystoscopies. A recent study identified a panel of 26 genes from a large cDNA microarray analysis of bladder tumors that discriminated between early- and late-recurring patients with superficial Ta tumors (Dyrskjøt et al., Nat Genet 2003;33:90-6). We aimed to validate this panel of genes in 44 primary Ta UCCs (23 and 21 tumors from patients with short or prolonged recurrence-free periods, respectively), by real-time quantitative PCR. Statistical analysis showed marginal significant different mRNA expression levels between the 2 patient groups. To evaluate a supplementary effect of genes for the identification of patients with short or prolonged recurrence-free intervals, forward logistic regression analysis was applied. This revealed that a combination of the expression profiles of the genes HNRPK, LTB4DH and ANP32B resulted in the best performance, although the combination only marginally increased the predictive value of HNRPK alone. Comparing the receiver-operating-characteristic curves for HNRPK expression among patients with short or prolonged recurrence-free periods, revealed an area under the curve of 0.696 (95% CI, 0.537-0.855). Using the median HNRPK expression level as cut-off, a sensitivity of 69.6% and a specificity of 71.4% were obtained for the identification of patients with short or prolonged recurrence-free periods, respectively. In conclusion, we were not able to confirm the microarray gene expression pattern of the 26 genes shown by Dyrskjøt et al. The discovery of accurate recurrence predictive markers, therefore, remains a challenge.

Combination analysis of hypermethylated Wnt-antagonist family genes as a novel epigenetic biomarker panel for bladder cancer detection

PURPOSE

Aberrant promoter hypermethylation of Wnt-antagonist genes contributes to the pathogenesis of several cancers. We hypothesized that combined methylation analysis of Wnt-antagonist genes could improve their use as a panel of biomarkers for diagnosing and staging of bladder cancers.

EXPERIMENTAL DESIGN

Samples (54 total) of bladder tumor and corresponding normal bladder mucosa were analyzed for the methylation and expression levels of six Wnt-antagonist genes (sFRP-1, sFRP-2, sFRP-4, and sFRP-5, Wif-1, and Dkk-3). To increase the sensitivity/specificity of bladder tumor detection, the methylation score (M score), a new method for multigene methylation analysis, was developed. The M score of each sample was calculated as the sum of the corresponding log hazard ratio coefficients derived from multivariate logistic regression analysis of the methylation status for each Wnt-antagonist gene. Receiver operator characteristic (ROC) curve analysis was used to determine the optimal sensitivity/specificity of the M score. Urine DNA from 24 matched patients with bladder tumor and 20 cancer-free volunteers was also used to investigate the methylation status of Wnt-antagonist genes.

RESULTS

The methylation levels of Wnt-antagonists were significantly higher and mRNA levels were significantly lower in bladder tumor than in bladder mucosa. Each methylation level was inversely correlated with the corresponding mRNA level. In multivariate regression analysis, the methylation levels of sFRP-2 and Dkk-3 were significant independent predictors of bladder tumor (P < 0.05 and P < 0.01, respectively), whereas with sFRP-1, sFRP-5, and Wif-1 there was a trend towards significance as independent predictors. The M score of Wnt-antagonist genes was significantly higher in bladder tumor than in bladder mucosa (P < 0.05). Overall, the M score had a sensitivity of 77.2% and a specificity of 66.7% as a diagnostic biomarker (areas under the curve, 0.763). The M score could distinguish superficial from invasive bladder tumors with a sensitivity of 72.2% and a specificity of 61.1% as a staging biomarker (areas under the curve, 0.671). In patients with bladder tumor, 80.6% of the methylation-specific PCR results had identical methylation in samples of tumor- and urine-derived DNA. Most urine DNA in normal controls showed no aberrant methylation of the Wnt-antagonist genes.

CONCLUSIONS

Hypermethylation of Wnt-antagonist genes plays an important role in the pathogenesis of bladder tumor and can be detected using cellular DNA extracted from urine samples. This is the first report demonstrating that M score analysis of Wnt-antagonist genes could serve as an excellent epigenetic biomarker panel for bladder tumors.

Papillary Urothelial Neoplasm of Low Malignant Potential: Evolving Terminology and Concepts

PURPOSE

The most controversial aspect of the new WHO 2004/ISUP classification system is the creation of the PUNLMP diagnostic category. We discuss PUNLMP tumors and the WHO 2004/ISUP classification system with an emphasis on tumor morphology and heterogeneity, recurrence and progression rates, tumor genetics, interobserver variability and the usefulness of biomarkers and molecular diagnostic techniques for grading bladder tumors.

MATERIALS AND METHODS

A literature search using PubMed was performed. All relevant literature concerning PUNLMP and the WHO 2004/ISUP grading system for urothelial neoplasms was reviewed.

RESULTS

The new WHO 2004/ISUP classification reflects work in progress. Low malignant potential terminology may not reflect the true biological behavior of these tumors. Additionally, interobserver variability in making a diagnosis of PUNLMP is high despite detailed histological criteria. Urine cytopathology in the context of the WHO 2004/ISUP classification does not appear to effectively discriminate PUNLMP from low grade carcinoma.

CONCLUSIONS

For practical purposes patients with PUNLMP should be treated similarly to patients with low grade, noninvasive urothelial carcinoma. It is our hope that recent advances in the molecular grading of these tumors may eventually supplant traditional morphological classification, allowing a more precise and objective assessment of the biological potential of these tumors.

Bladder cancer diagnosis and recurrence prognosis: Comparison of markers with emphasis on survivin

Expression of the anti-apoptotic protein survivin is hardly detectable or even absent in many differentiated adult tissues, but is upregulated in almost any type of cancer. Furthermore, high survivin mRNA or protein expression generally correlates with an adverse disease course. Both these important features of survivin expression have been investigated for diagnostic and prognostic purposes in many human cancers, including bladder cancer. In this review, the role of survivin in the detection of bladder tumors and the prediction of tumor recurrence in patients with superficial bladder cancer will be discussed and compared to that of other markers/tests. The most promising marker(s) will be outlined. Also, important requirements for a successful implementation of such markers in a hospital setting are discussed. Finally, future directions for the discovery of new diagnostic or prognostic candidate markers will be mentioned.

Raf1, Aurora-A/STK15 and E-cadherin biomarkers expression in patients with pTa/pT1 urothelial bladder carcinoma; a retrospective TMA study of 246 patients with long-term follow-up

AIMS

The study was designed to evaluate Raf1, Aurora-A/STK15 and E-cadherin (E-CD) protein expression and their prognostic value in patients with pTa/pT1 tumours.

MATERIALS AND METHODS

A tissue microarray of 105 pTa, and 141 pT1 tumours was constructed and sections were immunostained with these three antibodies.

RESULTS

There were significant associations between Raf1 overexpression and tumour grade (p = 0.03), between Aurora-A overexpression/alterations of E-CD and tumour grade and stage (p < 0.001 and p < 0.001). In multiple Cox regression analysis, moderate/strong expression of E-CD seemed to be an independent factor in predicting slower tumour progression (p = 0.003) and Aurora-A overexpression (p = 0.022) displays an independent value in predicting tumour recurrences.

CONCLUSION

Evaluation of E-CD and Aurora-A expressions in tissue of patients with pTa/pT1 UC have been proven to be useful in predicting tumours behavior and Raf1 protein expression seemed to have no potential use in this regard.

Sustained prophylactic effect of intravesical bacille Calmette-Guérin for superficial bladder cancer: A smoothed hazard analysis in a randomized prospective study

OBJECTIVES

A previous meta-analysis had revealed that intravesical chemotherapy was effective in reducing the recurrence of superficial bladder cancer only in the early phase, the phase thought to be caused by tumor cell implantation and/or residual tumor cells. To ascertain the sustained prophylactic effect of intravesical bacille Calmette-Guérin (BCG) after transurethral resection of bladder tumor (TURBT), we compared the estimation of the duration of the effect with that of doxorubicin.

METHODS

Eighty eligible patients with superficial bladder cancer (Stage Ta or T1, grade 1 or 2) were included. Patients were randomly allocated into two groups: the BCG group (six weekly instillations of 80 mg BCG [Tokyo 172 strain]) and the doxorubicin group (17 instillations of 20 mg doxorubicin). A comparison between the smoothed hazards of tumor recurrence was performed using a kernel function method.

RESULTS

All 80 patients (40 each in the BCG and doxorubicin groups) were compared. The median follow-up period was 667 days (range 64 to 1607). The risk of recurrence was significantly lower in the BCG group than in the doxorubicin group (P = 0.017, log-rank test). A smoothed hazard curve depicting the reduced risk of recurrence in the BCG group suggested that BCG is not only efficacious in the early phase of recurrence (up to 500 days after TURBT), but also in the late phase, and the latter is thought to include second primary tumors (new tumors).

CONCLUSIONS

BCG instillation may prevent tumor recurrence caused by both tumor cell implantation and second primary tumors.

The pathology of bladder cancer

Pathologists play an important role in the management of urinary bladder cancer by making a careful morphologic assessment of the primary tumor and its relation to adjacent structures. Ideally, evaluation of the primary site will segregate patients into groups with distinct clinical features, biologic behavior, and response to therapy. Traditionally, to accomplish this goal, pathologists have relied on factors such as histologic tumor type, grade, depth of invasion, and presence or absence of vascular invasion. Recently, in an effort to enhance our ability to subclassify these patients, we have introduced new modalities, such as flow cytometry, monoclonal antibodies, assessment of proliferative rate, and cytogenetics and molecular genetics. Without question we are advancing into an era in which tumors will be classified based on their molecular "fingerprint." Nevertheless, at this time, morphology remains the "gold standard" and, consequently, the best tool to assess the biologic potential of early bladder cancer. Despite this undeniable fact, there are many problems with the pathologic evaluation of these tumors, mostly because of the inherent subjectivity of the field and the lack of universal, standardized criteria for the evaluation of the above-mentioned morphologic parameters. Publications in peer-reviewed journals and the proliferation of educational opportunities by way of seminars, conferences, and web-based tutorials play an important role in keeping the practicing pathologist informed and up to date. As novel concepts and modern techniques are reported, their clinical value must be validated prospectively. Expert pathology review and establishment of exportable practice standards play an important role in the process.

FGFR3 and p53 protein expressions in patients with pTa and pT1 urothelial bladder cancer

AIMS

This study is designed to evaluate the expression and prognostic value of FGFR3 protein expression in patients with pTa/pT1 tumours and to determine the significance of the combinations of FGFR3 and p53 protein expressions in bladder pathogenesis.

MATERIALS AND METHODS

A tissue microarray (TMA) of 107 pTa, and 147 pT1 tumours was constructed. The TMA sections were immunostained with FGFR3 and p53 monoclonal antibodies.

RESULTS

There were significant associations between loss of FGFR3 and tumour stage (p<0.001) and grade (p<0.001) and between p53 overexpression and tumour stage and grade (p<0.001 and p<0.001, respectively). There was no association between FGFR3 and p53 proteins (p=0.107). In addition, tumours with FGFR3+/p53- phenotype have slower recurrence rate than other (FGFR3+/p53+, FGFR3-/p53- and FGFR3-/p53+).

CONCLUSION

1-FGFR3 expression is significantly associated with two important prognostic factors; stage and grade. 2-FGFR3 protein expression is not an independent predictive factor for pTa/pT1 tumour recurrence and progression. 3-Tumours with FGFR3+/p53- phenotype seem to have a distinctive pathway in bladder tumorigenesis.

Ki-67 MIB1 labelling index and the prognosis of primary TaT1 urothelial cell carcinoma of the bladder

AIMS

To evaluate whether ki-67 labelling index (LI) has independent prognostic value for survival of patients with bladder urothelial tumours graded according to the 2004 World Health Organisation classification.

METHODS

Ki-67 LI was evaluated in 164 cases using the grid counting method. Non-invasive (stage Ta) tumours were: papilloma (n = 5), papillary urothelial neoplasia of low malignant potential (PUNLMP; n = 26), and low (LG; n = 34) or high grade (HG; n = 15) papillary urothelial carcinoma. Early invasive (stage T1) tumours were: LG (n = 58) and HG (n = 26) carcinoma. Statistical analysis included Fisher and chi2 tests, and mean comparisons by ANOVA and t test. Univariate and multivariate survival analyses were performed according to the Kaplan-Meier method with log rank test and Cox's proportional hazard method.

RESULTS

Mean ki-67 LI increased from papilloma to PUNLMP, LG, and HG in stage Ta (p<0.0001) and from LG to HG in stage T1 (p = 0.013) tumours. High tumour proliferation (>13%) was related to greater tumour size (p = 0.036), recurrence (p = 0.036), progression (p = 0.035), survival (p = 0.054), and high p53 accumulation (p = 0.015). Ki-67 LI and tumour size were independent predictors of disease free survival (DFS), but only ki-67 LI was related to progression free survival (PFS). Cancer specific overall survival (OS) was related to ki-67 LI, tumour size, and p27kip1 downregulation. Ki-67 LI was the main independent predictor of DFS (p = 0.0005), PFS (p = 0.0162), and cancer specific OS (p = 00195).

CONCLUSION

Tumour proliferation measured by Ki-67 LI is related to tumour recurrence, stage progression, and is an independent predictor of DFS, PFS, and cancer specific OS in TaT1 bladder urothelial cell carcinoma.

Predictive Value of N -Acetylglucosaminyltransferase-V for Superficial Bladder Cancer Recurrence

PURPOSE

GnT-V is an enzyme that catalyzes beta1-6 branching of N-acetylglucosamine on asparagine (N)-linked oligosaccharides of cell proteins. GnT-V expression has been closely related to malignant potentials in colon cancer, brain cancer and hepatocellular carcinoma. We determined whether GnT-V expression is predictive of superficial bladder cancer recurrence.

MATERIALS AND METHODS

The cohort comprised 60 consecutive patients with first time superficial bladder cancer treated with transurethral resection. None of the patients received prophylactic intravesical therapy until recurrence. Paraffin embedded tumor specimens were immunohistochemically examined by the avidin-biotin peroxidase method using monoclonal antibody against GnT-V. Kaplan-Meier survival curves were generated to determine disease-free survival. Univariate and multivariate analyses were done to compare GnT-V expression to other clinical and pathological variables.

RESULTS

GnT-V expression correlated inversely with tumor grade and stage. The positive incidence of GnT-V in G1 to G3 tumors was 7 of 9 (78%), 21 of 43 (49%) and 3 of 8 (38%), respectively. GnT-V was positive in 26 of 44 cases of pTa (60%) and in 5 of 16 of pT1 (31%) disease. The 31 patients with positive GnT-V expression had significantly higher disease-free survival than the 29 with negative GnT-V expression (log rank test p = 0.0034). Multivariate analysis revealed that patient age, pT, grade and negative GnT-V expression were independent predictors of recurrence (p = 0.015, 0.001, 0.019 and 0.011, respectively).

CONCLUSIONS

Immunohistochemical detection of GnT-V is an independent predictor of superficial bladder cancer recurrence.

Prognostic relevance of methylation markers in patients with non-muscle invasive bladder carcinoma

There is increasing evidence for the role of epigenetic gene silencing in superficial bladder cancer. The aim of the current study was to investigate the prognostic value of epigenetic alterations in patients with non-muscle invasive bladder carcinoma. We checked the methylation status of 20 cancer associated genes (p14ARF, p16 CDKN2A, STAT-1, SOCS-1, DR-3, DR-6, PIG-7, BCL-2, H-TERT, BAX, EDNRB, DAPK, RASSF-1A, FADD, TMS-1, E-Cadherin, ICAM-1, TIMP-3, MLH-1, COX-2) for DNA methylation. We analysed microdissected tumour samples from 105 consecutive patients with primary non-muscle invasive bladder carcinoma. Quantitative methylation analysis of CpG sites in the promoter region of the genes was performed with methylation sensitive quantitative real time PCR ('Methylight'). Univariate analysis for association with tumour recurrence was carried out with the Kaplan-Meier analysis and the log-rank test. Follow-up data were available in 95/105 patients (91.4%). A tumour recurrence was observed in 26 patients (27.3%). We could identify six genes (SOCS-1, STAT-1, BCL-2, DAPK, TIMP-3, E-Cadherin), where methylation was associated with tumour recurrence. In Kaplan-Meier analysis, TIMP-3 showed a significant association with recurrence free survival. Methylation of TIMP-3 predicted prolonged disease free interval. In this study, we report a comprehensive analysis on prognostic relevance of gene methylation in non-muscle invasive bladder cancer. We identified one gene (TIMP-3) where methylation was associated with a more favourable outcome. Our data strongly support the usefulness of gene methylation as a prognostic marker in patients with non-muscle invasive bladder cancer.

Urothelial carcinoma of the upper urinary tract: Comparison between the WHO/ISUP 1998 consensus classification and WHO 1999 classification system

OBJECTIVES

To compare the usefulness of World Health Organization (WHO)/International Society of Urological Pathologists 1998 consensus classification with the WHO 1999 classification in a large series of urothelial tumors of the upper urinary tract. Only a few bladder tumor studies have compared these systems.

METHODS

A clinical and histopathologic review was performed of all patients diagnosed in western Sweden between 1971 and 1998 with renal pelvic or ureteral carcinoma. We selected 555 surgically treated patients who all had a urothelial tumor on review of the pathologic findings and no bladder tumor before diagnosis of the upper tract tumor. The median follow-up was 52 months. Disease-specific survival was calculated using Kaplan-Meier estimates.

RESULTS

A total of 349 patients had Stage pTa, pT1, or pT2 tumor, with a 5-year disease-specific survival rate of 95%, 80%, and 79%, respectively. No significant difference was found in the prognosis among papillary urothelial neoplasm of low malignant potential and low-grade and high-grade tumors of the same stage. Nor was a difference found among papillary urothelial neoplasm of low malignant potential and grade 1, 2, and 3 tumors. Of the 349 patients, 171, all with high-grade Stage pT3 tumors, had a 35% disease-specific survival rate. Of these tumors, 38 were grade 2 and 133 were grade 3, with a survival rate of 49% and 25%, respectively (P <0.0037). All 35 pT4 tumors were high grade, and no patient survived past 30 months.

CONCLUSIONS

Tumor stage was a very strong predictor of prognosis in this series of patients treated with open surgery. The tumor grade had little additional prognostic value, although a small advantage was found for the WHO 1999 classification, but only for high-grade, Stage pT3 tumors.

Detection of methylated apoptosis-associated genes in urine sediments of bladder cancer patients

PURPOSE

There is increasing evidence for a fundamental role for epigenetic silencing of apoptotic pathways in cancer. Changes in DNA methylation can be detected with a high degree of sensitivity, so we used the MethyLight assay to determine how methylation patterns of apoptosis-associated genes change during bladder carcinogenesis and whether DNA methylation could be detected in urine sediments.

EXPERIMENTAL DESIGN

We analyzed the methylation status of the 5' regions of 12 apoptosis-associated genes (ARF, FADD, TNFRSF21, BAX, LITAF, DAPK, TMS-1, BCL2, RASSF1A, TERT, TNFRSF25, and EDNRB) in 18 bladder cancer cell lines, 127 bladder cancer samples, and 37 samples of adjacent normal bladder mucosa using the quantitative MethyLight assay. We also analyzed the methylation status in urine sediments of 20 cancer-free volunteers and 37 bladder cancer patients.

RESULTS

The 5' regions of DAPK, BCL2, TERT, RASSFIA, and TNFRSF25 showed significant increases in methylation levels when compared with nonmalignant adjacent tissue (P < or = 0.01). Methylation levels of BCL2 were significantly associated with tumor staging and grading (P < or = 0.01), whereas methylation levels of RASSF1A and ARF were only associated with tumor stage (P < or = 0.04), and TERT methylation and EDNRB methylation were predictors of tumor grade (P < or = 0.02). To investigate clinical usefulness for noninvasive bladder cancer detection, we further analyzed the methylation status of the markers in urine samples of patients with bladder cancer. Methylation of DAPK, BCL2, and TERT in urine sediment DNA from bladder cancer patients was detected in the majority of samples (78%), whereas they were unmethylated in the urine sediment DNA from age-matched cancer-free individuals.

CONCLUSIONS

Our results indicate that methylation of the 5' region of apoptosis-associated genes is a common finding in patients with bladder carcinoma. The ability to detect methylation not only in bladder tissue, but also in urine sediments, suggests that methylation markers are promising tools for noninvasive detection of bladder cancers. Our results also indicate that some methylation markers, such as those in regions of RASSF1A and TNFRSF25, might be of limited use for detection because they are also methylated in normal bladder tissues.

Karyometry detects subvisual differences in chromatin organisation state between non-recurrent and recurrent papillary urothelial neoplasms of low malignant potential

AIM

To analyse nuclear chromatin texture in non-recurrent and recurrent papillary urothelial neoplasms of low malignant potential (PUNLMPs).

MATERIALS

Ninety three karyometric features were analysed on haematoxylin and eosin stained sections from 20 PUNLMP cases: 10 from patients with a solitary PUNLMP lesion, who were disease free during at least eight years' follow up, and 10 from patients with unifocal PUNLMP, one or more recurrences being seen during follow up.

RESULTS

Kruskal-Wallis analysis was used to search for features showing significant differences between recurrent and non-recurrent cases. Significance was better than p<0.005 for more than 20 features. Based on significance, six texture features were selected for discriminant analysis. Stepwise linear discriminant analysis reduced Wilk's lambda to 0.87, indicating a highly significant difference between the two multivariate data sets, but only modest ability to discriminate (70% correct case classification). A box sequential classifier was used based on data derived from discriminant analysis. The classifier took three classification steps and classified 19 of the 20 cases correctly (95% correct case classification). To determine whether significant case grouping could also be obtained based on an objective criterion, the merged data sets of non-recurrent and recurrent cases were submitted to the unsupervised learning algorithm P-index. Two clusters were formed with significant differences. The subsequent application of a Cooley/Lohnes classifier resulted in an overall correct case classification rate of 85%.

CONCLUSIONS

Karyometry and multivariate analyses detect subvisual differences in chromatin organisation state between non-recurrent and recurrent PUNLMPs, thus allowing identification of lesions that do or do not recur.

Antineoplastic effect of gemcitabine in an animal model of superficial bladder cancer

OBJECTIVES

To evaluate the safety and efficacy of gemcitabine in an animal model of superficial bladder cancer because of the promising results for treatment of patients with advanced urothelial carcinoma using gemcitabine. The substantial failure rate and toxicity of currently available intravesical agents for treating superficial bladder cancer emphasize the need for alternative drugs.

METHODS

The mouse bladder tumor (MBT-2) model was used in female C3H/eb mice to evaluate gemcitabine toxicity (n = 45) and efficacy (n = 402).

RESULTS

Treatment with varying doses (0.5, 2.5, and 10 mg) of intravesical gemcitabine was well tolerated with no demonstrable side effects. No statistically significant differences in the histologic changes in the bladder wall were observed among the various treatment groups. The efficacy of the drug was tested in two sets of experiments and showed a statistically significant decrease in the bladder weight of the animals treated with gemcitabine compared with those treated with phosphate-buffered saline or untreated controls (61.4 +/- 24.1 mg versus 106.2 +/- 50 mg and 105.5 +/- 46 mg, respectively [P = 0.0001], for an aggressive tumor variant). In the second set of experiments, gemcitabine was given both intraperitoneally and intravesically and resulted in a lower bladder weight (44.5 +/- 15.75 mg and 59.71 +/- 22.5 mg, respectively) compared with the control groups (116.43 +/- 53.91 mg and 122.29 +/- 50 mg, respectively, P = 0.0004).

CONCLUSIONS

The results of the present study indicate that repeated doses of gemcitabine can be safely administered intravesically to C3H/eb mice. This drug displayed significant antineoplastic activity against superficial bladder cancer.

Expression of Maspin in non-muscle invasive bladder carcinoma: correlation with tumor angiogenesis and prognosis

OBJECTIVES

Maspin is a member of the serpin (serine protease inhibitor) family and has been shown to be a suppressor of tumor growth and an inhibitor of angiogenesis as well as metastasis in several types of tumors. We studied expression patterns of Maspin in pTa/pT1 urothelial carcinoma of the bladder and compared them with microvessel density (MVD) for two vascular markers (CD34 and CD105) and correlated the findings with clinical outcome.

MATERIAL AND METHODS

We investigated tumor samples of 110 patients undergoing transurethral resection for pTa/pT1 bladder carcinoma (pTa, n=84; pT1, n=26; grade 1, n= 22; grade 2, n= 81; grade 3, n=7). Immunohistochemical studies were performed using the monoclonal antibodies, anti-human Maspin (NCL Maspin), anti-CD34 Class II and anti-CD105. Maspin expression level was classified according to the staining intensity (- to +++). The blood vessels (CD34) and specifically proliferating blood vessels (CD105) were counted as vessels per field (microvessel density, MVD).

RESULTS

Of the 110 tumors, 27 showed a negative immunostaining for Maspin, 46 tumors stained +, 29 stained ++, and 8 stained +++. Maspin expression correlated inversely with CD34 reactivity. In tumors with loss of or only weak Maspin expression, the MVD for CD34 was 21.7 vessels per field, and 4.2 vessels per field for proliferating vessels (CD105), whereas Maspin-positive tumors had an MVD of 17.7 vessels per field (CD34), and of 6.0 vessels per field (CD105). Complete follow-up data are available in 92 patients. After a median follow-up of 25 months, 18 of the 92 patients (19.6%) had tumor recurrences. Tumors with decreased Maspin expression (-/+) had a shorter disease-free interval (23 months) than patients with stronger Maspin (++/+++) expression (29 months), whereas a Kaplan-Meier analysis and the log-rank test showed no significant difference in disease-free survival between the patients.

CONCLUSION

The clinical importance of Maspin has been mainly investigated regarding tumor progression or metastasis. We found a decreased Maspin expression in a large portion of pTa/pT1 bladder tumors. Even if patients with decreased Maspin expression have a slightly shorter disease-free survival Maspin does not appear to be a promising prognostic marker.

Histopathological aspects of transitional cell carcinoma of the bladder: Analysis of 20 years experience

BACKGROUND

In this study we used histopathological examinations performed over a 20-year period to describe the characteristics of newly diagnosed transitional cell carcinoma (TCC) of the bladder in relation to patient age, and to verify changes in the TCC over different periods of observation or in relation to patient age.

METHODS

We reviewed all histopathological examinations performed from January 1979 to December 1998 in patients undergoing surgery who were newly diagnosed with TCC of the bladder. All examinations were performed by the same pathologist and reviewed by two pathologists. In each case analyzed, we evaluated T classification of the tumor, histological grade, size, localization, growth type, multiplicity and carcinoma in situ (CIS).

RESULTS

The study population included 3113 men and 620 women. The mean patient age was 66.31 +/- 10.84 years. A high percentage of Ta (52.2%) and T1 (27.7%) tumors were found. The number of cases observed and, in particular, the percentage of Ta tumors increased significantly and progressively from the first (1979-1983 = 376 cases; Ta = 37.8%) to the last (1994-1998 = 1732 cases; Ta = 56.3%) period of observation (P < 0.001). A significant difference in the distribution of histological grade and T classification in the different age decades was apparent (P < 0.001); in particular, for G1 and Ta tumors there was a trend to decrease, whereas for G3, T1 and T2 tumors there was a tendency to increase with age decades.

CONCLUSION

In our analysis, age of patient and the period of examination significantly influenced different pathological characteristics of newly diagnosed TCC of the bladder.

Papillary urothelial neoplasm of low malignant potential: reliability of diagnosis and outcome

OBJECTIVE

To determine the ability of pathologists to reproducibly diagnose a newly defined lesion, i.e. the papillary urothelial neoplasm of low malignant potential (PUNLMP) using the published criteria, defined by the 1998 World Health Organisation/International Society of Urological Pathology (WHO/ISUP) classification system; in addition, debate remains about the clinical behaviour of these lesions, thus the rates of recurrence and progression of PUNLMP lesions were assessed and compared with low-grade papillary urothelial carcinomas (LG-PUC) and high-grade (HG-PUC) over a 10-year follow-up.

PATIENTS AND METHODS

Forty-nine cases of superficial bladder cancer (G1-3 pTa) representing an initial diagnosis of transitional cell carcinoma made in 1990 were identified and re-graded using the 1998 WHO/ISUP classification by two pathologists. Inter-observer agreement was assessed using Cohen weighted kappa statistics. After re-classification the clinical follow-up was reviewed retrospectively, and episodes of recurrence and progression recorded.

RESULTS

The inter-observer agreement was moderate, regardless of whether one (kappa 0.45) or two (kappa 0.60) pathologists were used to grade these lesions. Re-classification identified 12 PUNLMP, 28 LG-PUC and nine HG-PUC. PUNLMP lesions recurred in 25% (3/12) of cases; no progression was documented. Recurrence rates were 75% (21/28) and 67% (6/9) for LG- and HG-PUC, respectively, and progression rates were 4% (1/28) and 22% (2/9).

CONCLUSION

The 1998 WHO/ISUP classification of urothelial neoplasms can be reproducibly applied by pathologists, with a moderate level of agreement. There is evidence that PUNLMP lesions have a more indolent clinical behaviour than urothelial carcinomas. However, the risk of recurrence and progression remains, and clinical monitoring of these patients is important.

Efficacy of Office Fulguration for Recurrent Low Grade Papillary Bladder Tumors Less Than 0.5 cm

PURPOSE

Recurrent superficial papillary bladder tumors are most commonly treated with transurethral resection with the patient under anesthesia. We report our experience with office fulguration of small, recurrent, low grade papillary tumors using flexible cystodiathermy.

MATERIALS AND METHODS

We conducted a prospective single institution analysis of 267 consecutive patients with superficial bladder cancer undergoing routine bladder cancer surveillance between January 1998 and December 2001. Cytological and histological recurrences were recorded. Selection criteria for office fulguration were less than 5 low grade appearing papillary tumors, tumor size less than 0.5 cm, negative urine cytology and patient desire. All patients completed initial treatment (transurethral resection, partial cystectomy and/or intravesical therapy) and a minimum of 6 months on surveillance without recurrence (median 11.57 months).

RESULTS

Flexible cystodiathermy for small, low grade, recurrent papillary tumors was efficacious and well tolerated. Of the 123 patients 46% experienced 1 or more tumor recurrences (range 1 to 11) in a median followup of 2.6 years. Of these 123, 74 (60%) underwent office cystodiathermy. No difference was seen in disease specific survival (p = 0.1633) or disease progression (p = 0.860). When stratified by risk of recurrence 202 of 267 patients at high risk (76%) with low grade papillary recurrence had similar rates of progression to patients at low risk (p = 0.9025). Median time from diagnosis was 6.84 years, and time from last tumor was 20.4 months.

CONCLUSIONS

Office cystodiathermy of small, low grade papillary recurrence is safe and efficacious in properly selected patients. This change in practice can potentially improve patient quality of life and have a major economic impact on health care.