Lymphovascular Invasion Is Independently Associated With Overall Survival, Cause-Specific Survival, and Local and Distant Recurrence in Patients With Negative Lymph Nodes at Radical Cystectomy

The prognostic value of lymphovascular invasion in radical prostatectomy: a systematic review and meta-analysis

To systematically evaluate the prognostic value of lymphovascular invasion (LVI) in radical prostatectomy (RP) by a meta-analysis based on the published literature. To identify relevant studies, PubMed, Cochrane Library, and Web of Science database were searched from 1966 to May 2014. Finally, 25 studies (9503 patients) were included. LVI was found in 12.2% (1156/9503) of the RP specimens. LVI was found to be correlated with higher pathological tumor stages (greater than pT3 stage) (risk ratio [RR] 1.90, 95% confidence interval [CI] 1.73–2.08, P < 0.00001), higher Gleason scores (greater than GS = 7) (RR 1.30, 95% CI 1.23–1.38, P < 0.00001), positive pathological node (pN) status (RR 5.67, 95% CI 3.14–10.24, P < 0.00001), extracapsular extension (RR 1.72, 95% CI 1.46–2.02, P < 0.00001), and seminal vesicle involvement (RR 3.36, 95% CI 2.41–4.70, P < 0.00001). The pooled hazard ratio (HR) was statistically significant for Biochemical Recurrence-Free (BCR-free) probability (HR 2.05, 95% CI 1.64–2.56; Z = 6.30, P < 0.00001). Sensitivity analysis showed that the pooled HR and 95% CI were not significantly altered by the omission of any single study. Begg's Funnel plots showed no significant publication bias (P = 0.112). In conclusion, LVI exhibited a detrimental effect on the BCR-Free probability and clinicopathological features in RP specimens, and may prove to be an independent prognostic factor of BCR.

Recurrence of Urothelial Bladder Carcinoma in the Colon Presenting as Hematochezia

Patients with superficial bladder cancers remain clinically indolent after treatment with even a modicum of urologic intervention. However, with more invasive disease, the majority of patients experience recurrence. The conventional route of metastasis and recurrence in primary urothelial cell carcinoma is through lymphatic system, with regional lymph nodes, lungs, liver, brain, and bone being the most common sites. Isolated intraluminal colonic recurrence in the absence of local invasion is extremely rare. We report a unique case of urothelial cell carcinoma presenting with an isolated colonic mass, which unexpectedly, on immunohistostaining, proved to be primarily of urothelial rather than colonic origin.

The prognostic role of lymphovascular invasion in urothelial carcinoma of the bladder

Outcome prediction in patients with bladder cancer has improved through the development of nomograms and predictive models. However, integration of further characteristics such as lymphovascular invasion (LVI) might increase the accuracy and clinical utility of these instruments. Assessment and reporting of LVI in specimens from transurethral resection of the bladder tumour (TURBT) or biopsy in patients with non-muscle-invasive bladder cancer (NMIBC) or muscle-invasive bladder cancer (MIBC) might enable improved staging, prognostication and clinical decision-making. In NMIBC, presence of LVI in TURBT and biopsy samples seems to be associated with understaging and increased risks of disease recurrence and progression. In MIBC, presence of LVI is associated with features of aggressive disease and predicts recurrence and survival. Integration of LVI status into predictive models might aid clinical decision-making regarding intravesical instillation schedules and regimens, early radical cystectomy in patients with high-grade T1 disease and perioperative chemotherapy. However, LVI assessment is hampered by insufficient reproducibility and reliability, lack of routine evaluation and limited concordance between findings in TURBT and radical cystectomy specimens. Standardization of the pathological criteria defining LVI is warranted to improve its reporting in routine clinical practice and its utility as a care-changing prognostic marker.

Lymphovascular invasion is associated with survival for papillary thyroid cancer

Data are limited regarding the association between tumor lymphovascular invasion and survival for patients with papillary thyroid cancer (PTC). This study sought to examine lymphovascular invasion as an independent prognostic factor for patients with PTC undergoing thyroid resection. The National Cancer Data Base (2010-2011) was queried for patients with PTC who underwent total thyroidectomy or lobectomy. Patients were classified into two groups based on the presence/absence of lymphovascular invasion. Demographic, clinical and pathological features were evaluated for all patients. A Cox proportional hazards model was utilized to identify factors associated with survival. Results show that 45,415 patients met inclusion criteria; 11.6% had lymphovascular invasion. Patients with lymphovascular invasion were more likely to have larger tumors (2.8cm vs 1.5cm, P<0.01), metastatic lymph nodes (74.1% vs 32.5%, P<0.01), and distant metastases (3.0% vs 0.5%, P<0.01). They were also more likely to receive radioactive iodine (69.3% vs 44.9%, P<0.01). Unadjusted overall 5-year survival was lower for patients who had tumors with lymphovascular invasion (86.6% vs 94.5%) (log-rank P<0.01). After adjustment, increasing patient age (HR=1.06, P<0.01), male gender (HR=1.68, P<0.01), presence of metastatic lymph nodes (HR=1.77, P<0.01), distant metastases (HR=3.49, P<0.01), and lymphovascular invasion (HR=1.88, P<0.01) were associated with compromised survival. For patients with lymphovascular invasion, treatment with RAI was associated with reduced mortality (HR=0.43, P<0.01). The presence of lymphovascular invasion among patients with PTC is independently associated with compromised survival. Patients who have PTC with lymphovascular invasion should be considered higher risk, and adjuvant RAI should be more strongly considered.

Apparent diffusion coefficient value for estimating clinicohistological factors in bladder cancer including infiltration style and lymphatic invasion

Objective

To evaluate a role of apparent diffusion coefficient (ADC) values measured from diffusion-weighted imaging we investigated its association with clinicopathological tumor characteristics of bladder cancer.

Materials and methods

Diffusion-weighted MRI at 1.5 Tesla using b-values of 0, 1000 s/mm² was taken before transurethral resection by 114 bladder urothelial tumor patients. ADC value was measured and its relationship with pathological factors including T stage, tumor grade, infiltration style (INF) and lymphatic invasion (ly) was analyzed.

Results

Median ADC value was significantly lower in Grade 3 than in Grade 1 (P < 0.001) or in Grade 2 (P = 0.002), in INFb than in INFa (P = 0.004), in INFc than in INFa (P < 0.001), in ly1 than in ly0 (P < 0.001) and lower in T2≦ than in T1≧ (P < 0.001), respectively. Receiver operating curve demonstrated the accuracy of detecting muscle invasive bladder cancer or ly+ by using area under curve (AUC), showing 0.758 and 0.748.

Conclusion

ADC value is likely to serve as a useful biomarker showing clinicopathological characterictics of bladder cancer.

Poor prognostic value of lymphovascular invasion for pT1 urothelial carcinoma with squamous differentiation in bladder cancer

Lymphovascular invasion (LVI) is the primary and essential step in the systemic dissemination of cancer cells. The aim of our study was to assess the independent prognostic role of LVI for pT1 urothelial carcinoma with squamous differentiation in bladder cancer. We retrospectively analyzed the clinical and pathological information of 206 patients diagnosed pT1 urothelial carcinoma with squamous differentiation. Of the 206 patients, LVI was detected in 57 (27.6%) patients. The 5 year cancer specific survival (CSS) rates were 87.2% in LVI (−) and 52.4% in LVI (+) (p < 0.001). According to univariate analysis, tumor multiplicity, tumor size, recurrence and LVI were the prognostic factors associated with CSS. Additionally, tumor size and LVI significantly influenced the CSS in multivariate analysis. TURBT had shorter median CSS than RC in recurred patients with LVI (+). Our study suggested that LVI is an important predictor for survival of pT1 urothelial carcinoma with squamous differentiation. LVI positive status and tumor size ≥3 cm led to a higher risk of death. RC should be routinely performed in recurred LVI (+) bladder cancer patients of pT1 urothelial carcinoma with squamous differentiation.

Comparative analysis of the effect of prostatic invasion patterns on cancer-specific mortality after radical cystectomy in pT4a urothelial carcinoma of the bladder

PURPOSE

To evaluate the prognostic relevance of different prostatic invasion patterns in pT4a urothelial carcinoma of the bladder (UCB) after radical cystectomy.

MATERIALS AND METHODS

Our study comprised a total of 358 men with pT4a UCB. Patients were divided in 2 groups-group A with stromal infiltration of the prostate via the prostatic urethra with additional muscle-invasive UCB (n = 121, 33.8%) and group B with continuous infiltration of the prostate through the entire bladder wall (n = 237, 66.2%). The effect of age, tumor grade, carcinoma in situ, lymphovascular invasion, soft tissue surgical margin, lymph node metastases, administration of adjuvant chemotherapy, and prostatic invasion patterns on cancer-specific mortality (CSM) was evaluated using competing-risk regression analysis. Decision curve analysis was used to evaluate the net benefit of including the variable invasion pattern within our model.

RESULTS

The estimated 5-year CSM-rates for group A and B were 50.1% and 66.0%, respectively. In multivariable competing-risk analysis, lymph node metastases (hazard ratio [HR] = 1.73, P<0.001), lymphovascular invasion (HR = 1.62, P = 0.0023), soft tissue surgical margin (HR = 1.49, P = 0.026), absence of adjuvant chemotherapy (HR = 2.11, P<0.001), and tumor infiltration of the prostate by continuous infiltration of the entire bladder wall (HR = 1.37, P = 0.044) were significantly associated with a higher risk for CSM. Decision curve analysis showed a net benefit of our model including the variable invasion pattern.

CONCLUSIONS

Continuous infiltration of the prostate through the entire bladder wall showed an adverse effect on CSM. Besides including these patients into clinical trials for an adjuvant therapy, we recommend including prostatic invasion patterns in predictive models in pT4a UCB in men.

Short and Long-Term Outcomes of Epidural or Intravenous Analgesia after Esophagectomy: A Propensity-Matched Cohort Study

BACKGROUND AND OBJECTIVES

As a well-established technique for postoperative pain relief, the benefits of epidural analgesia (EDA) have been under debate recently. This study aimed to determine whether EDA could improve perioperative outcomes and survival in patients undergoing esophagectomy.

METHODS

From January 2010 to December 2012, 587 consecutive cases undergoing McKeown-type esohpageactomy were retrospectively identified from a prospectively maintained database.

RESULTS

After propensity-matching, incorporating baseline characteristics, 178 cases were included in each group, and patients characteristics distributions were well-balanced between two groups. Compared with intravenous analgesia, the use of EDA significantly decreased the incidence of pneumonia from 32% to 19.7% (P = 0.008), and anastomotic leakage from 23.0% to 14.0% (P = 0.029). The change in CRP level of EDA group was significantly decreased (preoperative, 6.2 vs. 6.2; POD 1, 108.1 vs. 121.3; POD 3, 131.5 vs. 137.8; POD 7, 69.3 vs. 82.1 mg/L; P = 0.044). EDA patients had a significantly longer duration of indwelling urinary catheter (P<0.001), and lower levels in both systolic (P = 0.001) and diastolic blood pressure (P<0.001). There weren't significant differences in overall survival (log-rank P = 0.47) and recurrence (Gray-test P = 0.46) between two groups.

CONCLUSIONS

These findings revealed that EDA could attenuate inflammatory response and reduce the incidence of pneumonia and anastomotic leakage after esophagectomy, at the price of delayed urinary catheter removal and lower blood pressure. EDA remains an important component of multimodal perioperative management after esophagectomy.

Identification and Validation of Lymphovascular Invasion as a Prognostic and Staging Factor in Node-Negative Esophageal Squamous Cell Carcinoma

INTRODUCTION

Lymphovascular invasion (LVI) is a histopathological feature that is associated with an increased risk for micrometastasis. The aim of this study was to determine the prognostic and staging value of LVI among patients with esophageal squamous cell carcinoma (ESCC) undergoing esophagectomy.

METHODS

A prospective database of patients with ESCC was used to retrospectively analyze 666 cases to identify the relationship between LVI and survival, and to evaluate predictive accuracy of prognosis after combining LVI and the tumor, node, and metastasis (TNM) system. Pathological slides were reassessed by gastrointestinal pathologists according to the strict criteria; 1000-bootstrap resampling was used for internal validation, and 222 cases from an independent multicenter database were used for external validation.

RESULTS

LVI was present in 33.8% of patients, and the proportion increased with advancing T and N classification. LVI was an independent predictor of unfavorable disease-specific survival (DSS) (hazard ratio = 1.59, 95% confidence interval: 1.30-1.94) and disease-free survival (DFS) (hazard ratio = 1.62, 95% confidence interval: 1.32-1.98) after T classification. Among node-negative patients, LVI and T classification were two independent predictors of DSS and DFS (p < 0.001). The risk score model combing LVI and T classification improved the predictive accuracy of the TNM system for DSS and DFS by 3.5% and 4.8%, respectively (p < 0.001). The external validation showed congruent results. The DSS of TxN0MO disease with LVI was similar to the DSS of TxN1M0 (both p > 0.05). In contrast, LVI was not associated with DSS or DFS among node-positive patients.

CONCLUSIONS

The independent prognostic significance of LVI existed only in node-negative patients with ESCC, and the combination of LVI and the TNM system enhanced the predictive accuracy of prognosis. After confirmation, node-negative patients with LVI might be considered for upstaging in pathological staging.

Prognostic significance of lymphovascular invasion in bladder cancer after surgical resection: A meta-analysis

Bladder cancer remains a commonly diagnosed malignancy worldwide, bringing huge economic burden and high morbidity for patients. Assessment of prognostic significance of lymphovascular invasion (LVI) is a critical issue in the surgical management of bladder cancer after transurethral resection or radical cystectomy. A systematic search of PubMed, Embase and Cochrane Library was performed up to Oct 10, 2014 to identify eligible studies. Outcomes of interest were collected from studies comparing overall survival (OS), cancer specific survival (CSS) and recurrence free survival (RFS) in patients with the LVI. Results of studies were pooled, and combined hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) for survival were used as the effect size estimation. Funnel plots were done to show the publication bias, while the forest plots and subgroup analyses were used to limit the heterogeneity. A total of 20 studies (10 663 patients) met the eligibility criteria and were included for this meta-analysis. Our pooled results showed that there were significant differences in OS (pooled HR, 1.71; 95%CI, 1.52-1.92; P<0.00001), CSS (pooled HR, 2.25; 95% CI, 1.80-2.81; P<0.00001) and RFS (pooled HR, 1.91; 95% CI, 1.57-2.32; P<0.00001) between the patients with LVI and the patients without LVI. There were significant heterogeneities observed in the studies concerning the relationship between LVI and CSS, RFS. There was no clear evidence of publication bias. When tumor stage was beyond T3, LVI lost its predictive value for CSS and RFS. For the patients who had negative lymph nodes, LVI was still an adverse predictor. Our pooled results demonstrate that LVI indicates poor prognosis of patients with bladder cancer after surgical procedures, and it can be of particular importance in clinical practice. However, these results need to be further confirmed by more adequately designed prospective studies.

Clinical and therapeutic factors associated with adverse pathological outcomes in clinically node-negative patients treated with neoadjuvant cisplatin-based chemotherapy and radical cystectomy

PURPOSE

Several disease characteristics have been identified as potential predictors for pathological node involvement (pN+) following radical cystectomy (RC). However, these have not been assessed in patients treated with neoadjuvant chemotherapy (NAC). We endeavored to assess factors predicting adverse pathology in clinically node-negative patients treated with NAC and RC.

METHODS

Patients from four North American institutions with cT2-4aN0M0 UC who received three or four cycles of NAC followed by RC were selected. Logistic regression was used to predict pN+, <pT2 and pT4 disease.

RESULTS

One hundred and ninety-six patients were included. The clinical stage was cT2 in 115 (61 %), cT3 in 62 (33 %) and cT4 in 12 (6 %) cases. NAC regiments were gemcitabine-cisplatin (GC)-4 cycles 57 (29 %), GC-3 cycles 77 (39 %), methotrexate, vinblastine, adriamycin, cisplatin (MVAC)-3 cycle 22 (11 %) and MVAC-4 cycles 40 (21 %). pN+ was seen in 35 (18 %) patients. In the logistic regression analysis, cT4 stage (OR 7.50; 95 % CI 1.58-33.3) and three compared to four cycles of GC (OR 3.44; 95 % CI 1.09-10.9) were significant predictors of pN+ status. Additionally, when controlling for clinical stage, three cycles of GC, compared to four, were significantly associated with higher rates of pT4 disease and lower rates of downstaging to non-muscle-invasive disease.

CONCLUSIONS

The results suggest that four cycles of neoadjuvant GC may be superior to three cycles, and the latter regimen may be associated with adverse pathological findings. Although this would require validation in a prospective trial, it does encourage the completion of the conventional four cycles GC whenever possible.

High VEGF-D and Low MMP-2 Serum Levels Predict Nodal-Positive Disease in Invasive Bladder Cancer

Background

To investigate stromal variables including angiogenesis, lymphangiogenesis, and matrix metalloproteinase (MMP) in the serum of patients with urothelial carcinoma of the bladder (UCB) and to evaluate their association with histopathological characteristics and clinical outcome.

Material/Methods

Protein levels of vascular endothelial growth factors-A, -C, -D (VEGF-A/-C/-D), their receptors- VEGF-R2 and -R3 (VEGF-R2/-R3), and matrix metalloproteinases 2, -3, and -7 (MMP-2, MMP-3, MMP-7) were quantified in the blood serum samples of 71 patients with UCB before radical cystectomy (RC). Samples of patients with non-invasive UCB or no history of UCB were investigated as controls (n=20). Protein levels in the serum were measured using a flow cytometric cytokine assay.

Results

A positive association for VEGF-D (p<0.001) and an inverse association for MMP-2 (p=0.017) were observed in patients with positive lymph node (LN) status at the time of RC. VEGF-A (p<0.001), VEGF-C (p<0.001), MMP-2 (p<0.001), and MMP-7 (p=0.005) serum levels were different in serum of patients with invasive UCB compared with non-invasive UCB or healthy individuals. None of the serum markers were associated with disease progression.

Conclusions

High VEGF-D and low MMP-2 serum levels predict LN metastasis in patients with UCB at the time of RC. VEGF-A, VEGF-C, MMP-2, and MMP-7 serum levels varied significantly between invasive and non-invasive disease as well as in comparison with healthy individuals. Clinical implementation of these marker serum measurements may be valuable to select high-risk patients with more invasive or nodal-positive disease.

Optimal treatment of non-muscle invasive urothelial carcinoma including perioperative management revisited

Non-muscle invasive urothelial carcinoma is a heterogeneous disease that requires the practicing urologist to implement a variety of surgical and non-surgical treatment strategies. The disease course can range from recurrent low grade papillary disease to aggressive disease concerning for progression from initial presentation. Depending on the particular patient and goals of care, treatments similarly span the range from minimally invasive fulgurations to immediate radical cystectomy. For most patients some form of intravesical therapy will bridge the gap between transurethral resections (TUR) and radical surgery. Recent advances in the field continue to emphasize the importance of quality TUR and its strong impact on outcomes. In addition, continued research to optimize intravesical therapies has provided more information about how, when, and in whom these agents should be utilized to enhance their efficacy. This review covers the current state of NMIBC and the standards of care for the management of this disease.

Risk based neoadjuvant chemotherapy in muscle invasive bladder cancer

Muscle invasive bladder cancer (MIBC) is an aggressive disease that frequently requires radical cystectomy (RC) to achieve durable cure rates. Surgery is most effective when performed in organ-confined disease, with the best outcomes for those patients with a pT0 result. The goals of neoadjuvant chemotherapy (NC) are to optimize surgical outcomes for a malignancy with limited adjuvant therapies and a lack of effective salvage treatments. Despite level 1 evidence demonstrating a survival benefit, the utilization of NC has been hampered by several issues, including, the inability to predict responders and the perception that NC may delay curative surgery. In this article, we review the current efforts to identify patients that are most likely to derive a benefit from NC, in order to create a risk-adapted paradigm that reserves NC for those who need it.

Histological variant as the significant predictor of survival in patients with lymph node positive urothelial carcinoma of the bladder

The aim of this study was to evaluate the impact of histological variants of urothelial carcinoma (UC) on survival outcomes in patients with lymph node (LN) positive UC of the bladder. We reviewed and analyzed the clinical data from 424 patients who underwent radical cystectomy (RC) with pelvic lymph node dissection (PLND) for UC of the bladder and who did not receive neoadjuvant chemotherapy in our institution between 1991 and 2012. In total, 92 patients (21.7%) had histologically confirmed LN positive disease. In the LN negative group (332 patients), histological variants of UC were not a significant predictor in univariate analysis. However, in the LN positive group, histological variants of UC were a significant independent prognostic factor of overall survival (hazard ratio (HR) 3.54; 95% confidence interval (CI) 1.77–7.08, p < 0.001) and cancer specific survival (HR 3.66; 95% CI 1.69–7.90, p = 0.001) in both uni-variate and multivariate Cox regression analyses. The presence of histological variants of UC may indicate a worse prognosis in LN positive patients after RC with PLND for UC of the bladder and more aggressive adjuvant therapy may be required for the improvement of postoperative survival.

Significance of lymphovascular invasion in organ-confined, node-negative urothelial cancer of the bladder: data from the prospective p53-MVAC trial

OBJECTIVES

To investigate the association between lymphovascular invasion (LVI) and clinical outcome in organ-confined, node-negative urothelial cancer of the bladder (UCB) in a post hoc analysis of a prospective clinical trial. To explore the effect of adjuvant chemotherapy with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) on outcome in the subset of patients whose tumours exhibited LVI.

PATIENTS AND METHODS

Surgical and tumour factors were extracted from the operative and pathology reports of 499 patients who had undergone radical cystectomy (RC) for pT1-T2 N0 UCB in the p53-MVAC trial (Southwest Oncology Group 4B951/NCT00005047). The presence or absence of LVI was determined by pathological examination of transurethral resection or RC specimens. Variables were examined in univariate and multivariate Cox proportional hazards models for associations with time to recurrence (TTR) and overall survival (OS).

RESULTS

Among 499 patients with a median follow-up of 4.9 years, a subset of 102 (20%) had LVI-positive tumours. Of these, 34 patients had pT1 and 68 had pT2 disease. LVI was significantly associated with TTR with a hazard ratio (HR) of 1.78 [95% confidence interval (CI) 1.15-2.77; number of events (EV) 95; P = 0.01) and with OS with a HR of 2.02 (95% CI 1.31-3.11; EV 98; P = 0.001) after adjustment for pathological stage. Among 27 patients with LVI-positive tumours who were randomised to receive adjuvant chemotherapy, receiving MVAC was not significantly associated with TTR (HR 0.70, 95% CI 0.16-3.17; EV 7; P = 0.65) or with OS (HR 0.45, 95% CI 0.11-1.83; EV 9; P = 0.26).

CONCLUSIONS

Our post hoc analysis of the p53-MVAC trial revealed an association between LVI and shorter TTR and OS in patients with pT1-T2N0 disease. The analysis did not show a statistically significant benefit of adjuvant MVAC chemotherapy in patients with LVI, although a possible benefit was not excluded.

Clinical, demographic and histopathological prognostic factors for urothelial carcinoma of the bladder

INTRODUCTION

Our aim is to evaluate the influence of clinical and histopathological parameters, including age, gender, tumor stage, grade, tumor differentiation, necrosis, lymphovascular/perineural invasion (LVI/PNI) and concomitant carcinoma in situ (CIS), on outcomes of patients with urothelial carcinoma of the bladder (UCB).

MATERIAL AND METHODS

A total of 84 patients who underwent radical cystectomy (RC) (n = 11) and radical cystoprostatectomy (n = 73) for muscle-invasive bladder cancer at our hospital between 2007-2013, were included in the study.

RESULTS

The mean age of patients at diagnosis was 66.1, of whom 75 were males and 9 were females. Of the 84 patients, 38 were ≤65 years and 46 were >65 years. Mean tumor diameter was 3.66 cm. There were 38 cases which showed divergent differentiations. Concomitant CIS was observed in 30 tumors, 41 cases showed tumor necrosis, 44 PNI and 61 LVI. The rate of overall survival (OS) in patients aged ≤65 years was statistically significantly higher than in those aged >65 years. A negative statistical relationship was found between OS with lymph node metastasis (LNM) and tumor differentiation. On the other hand, necrosis did not remain significant on multivariate analysis. No statistically significant relationship was found between smoking, tumor stage, PNI, LVI and concomitant CIS and OS.

CONCLUSIONS

In this study, advanced age, LNM, tumor differentiation were found to be independent prognostic risk factors associated with OS after RC. These additional factors, which may explain the different clinical course in patients with similar tumor stage and lymph node status, should be taken into consideration in treatment planning.

In cystectomy specimens with bladder cancer whole organ embedding increases the detection rate of histopathological parameters, but not of those with prognostic significance

Histological tumor subtyping, staging, and grading are of utmost importance to stratify patients with bladder cancer for treatment and should be as precise as possible. In the presented study, we investigated the prognostic impact of standard clinicopathological parameters in cystectomy patients and compared embedding of the entire bladder with standard partial embedding via a virtual superimposed approach. The study included 121 cystectomy specimens, which were completely embedded. Clinical and histopathological data of patients were obtained (median follow-up 21.5 months; range 1-67 months). For 88 patients two-dimensional tumor maps (macrophotographs and histology-based maps) were prepared, and embedding of the entire bladder was compared with a virtual standard partial embedding, created by a virtual overlay and data extraction of the tumor maps. Kaplan-Meier plots, Cox regression estimators, Chi-square, and McNemar tests were used. In a multivariate Cox regression model for overall survival, only venous invasion (p = 0.008, HR = 3.35, 95 % CI 1.375-8.161) and organ-confined (pTis-pT2) versus non-organ-confined diseases (pT3-pT4; p = 0.021, HR 2.669, 95 % CI 1.157-6.159) were found significant. Advanced versus standard embedding revealed significant improvement in the detection of carcinoma in situ (50 versus 61, p = 0.003) and lymphatic invasion (18 versus 24, p = 0.041), but no significant advantage in the detection of tumor stage, tumor multifocality, or venous invasion (all p > 0.05). TNM classification, including lymphatic and venous invasion, is of utmost importance to stratify patients with advanced invasive bladder cancer. Histopathological details are detected more reliably by whole organ embedding, but this approach showed no significant benefit in terms of outcome-related parameters (max. tumor stage, venous invasion) in our cohort.

Neutrophil-Lymphocyte Ratio and Pathological Response to Neoadjuvant Chemotherapy in Patients With Muscle-Invasive Bladder Cancer

BACKGROUND

Cisplatin-based neoadjuvant chemotherapy (NC) improves overall survival in muscle-invasive bladder cancer (MIBC), but there are currently no predictive biomarkers of response to NC in MIBC. An increased peripheral blood neutrophil to lymphocyte ratio (NLR) is a marker of systemic inflammation and is linked to poor prognosis in some solid tumors. We evaluated whether NLR is associated with pathological response (pathR) in MIBC patients who receive NC.

PATIENTS AND METHODS

MIBC patients treated with NC and radical cystectomy (RC) between July 2006 and April 2013 were retrospectively reviewed. The primary end point was to find variables associated with pathR in the RC specimen after NC. Potential predictive markers were analyzed using logistic regression. NLR values before NC, midway through NC, and before RC were collected and compared between patients who achieved pathR ('responders') and those who did not ('nonresponders').

RESULTS

In 26 evaluable patients, age, sex, performance status, smoking status, stage, hydronephrosis, NLR before NC, midway through NC, and before RC were not significantly associated with pathR, but the pattern of NLR change between responders and nonresponders was significantly different (P = .038). Responders exhibited a sustained decrease in NLR during NC until RC, and nonresponders exhibited a transient decrease in NLR which then increased to above its baseline before RC.

CONCLUSION

The pattern of change in NLR during NC varied significantly between responders and nonresponders. We hypothesize that a sustained decrease in inflammatory burden during NC is associated with pathR. Despite limitations of a small retrospective study, our observations might have clinical implications and warrant further basic and clinical research.

Intravesical tumor involvement of the trigone is associated with nodal metastasis in patients undergoing radical cystectomy

OBJECTIVE

To evaluate the influence of intravesical tumor location on nodal metastasis and mortality after cystectomy. The microvascular anatomy of the urinary bladder is variable in distinct regions of the bladder and thus tumor location may influence the tumors' ability to access lymphatic and vascular structures.

MATERIALS AND METHODS

An observational cohort study was conducted of all patients undergoing radical cystectomy at a single institution between January 2000 and July 2008. Tumor location was classified into the following 6 locations: lateral wall, posterior wall, anterior wall, trigone, dome, and bladder neck. The association between tumor location with nodal metastasis and cancer-specific mortality was assessed.

RESULTS

A total of 545 patients were identified in this cohort. Location of tumor at the bladder trigone was associated with an increased likelihood of nodal metastasis on univariate (odds ratio, 1.63; 95% confidence interval [CI], 1.01-2.62) and multivariate (odds ratio, 1.83; 95% CI 1.11-2.99) analysis. In addition, trigone location was associated with a decreased cancer-specific survival on univariate (hazard ratio, 1.49; 95% CI, 1.03-2.16) and multivariate (hazard ratio, 1.68; 95% CI, 1.11-2.55) analysis.

CONCLUSION

Patients with bladder tumor in the trigone have a greater risk of lymph node metastasis at cystectomy and decreased cancer-specific survival. Tumor location may be a useful prognostic factor in risk stratification of patients with invasive bladder cancer.

Prognostic significance of lymphovascular invasion in upper urinary tract urothelial carcinoma is influenced by tumor location

BACKGROUND

To examine the prognostic value of lymphovascular invasion (LVI) in different tumor locations (i.e., renal pelvis and ureter) of upper urinary tract urothelial carcinoma (UTUC).

METHODS

Data from a total of 250 patients with nonmetastatic UTUC who received radical nephroureterectomy between 2004 and 2010 at our institution were analyzed retrospectively. The significance of LVI and other relevant factors on cancer-specific survival (CSS), metastasis-free survival (MFS), and intraluminal recurrence-free survival (IRFS) were evaluated.

RESULTS

Lymphovascular invasion was present in 60 patients (24 %) and was related to advanced pathological T stage (P < 0.001), higher tumor grade (P < 0.001), lymph node metastasis (P = 0.005), and pyelocaliceal tumor location (P = 0.002). By Kaplan-Meier analysis, LVI was found to be significantly correlated with worse CSS and MFS but not with IRFS. Multivariate analysis showed that high pathological T stage and regional lymph node involvement were significant prognostic factors for CSS and MFS, and LVI was an independent predictor for MFS (hazard ratio 1.71, 95 % confidence interval 1.00-2.93, P = 0.049). In patients with ureteral tumors, LVI represented the only significant prognosticator for both CSS and MFS in multivariate analysis. The prognostic value of LVI was not observed in pyelocaliceal tumors.

CONCLUSIONS

The implication of LVI on prognosis, particularly in ureteral tumors but not in pyelocaliceal tumors, may imply diverse disease characteristics between different tumor locations among UTUC. LVI is essential to identify patients at high risk for metastasis/mortality and can facilitate treatment planning and surveillance strategies, especially in patients with ureteral tumors.

Outcome of patients with pathological tumor stage T3 urothelial carcinoma of the bladder following radical cystectomy in a single-center series with 116 patients

OBJECTIVE

Outcome prediction of pT3 urothelial carcinoma of the bladder (UCB) after radical cystectomy (RC) remains challenging. The objective of our study was to determine high-risk patients with poor survival outcome in a heterogeneous group substaged pT3 who might profit from early adjuvant chemotherapy.

MATERIALS AND METHODS

We compiled clinicopathological and immunohistochemical data of E-cadherin (E-cad) expression in 116 patients with pT3 UCB after RC in our single-center series. Multivariable Cox regression models including substaged pT3 established clinicopathological features, and the expression of the predictive immunohistochemical feature E-cad was used to identify independent predictors on progression-free (PFS), cancer-specific (CSS) and overall survival (OS), respectively.

RESULTS

No significant differences were found addressing clinicopathological data and substaged pT3. In multivariable Cox regression models, lymph node involvement was an independent predictor for PFS (p < 0.001), CSS (p < 0.001) and OS (p = 0.002), respectively. Lymphovascular invasion (LVI) significantly influenced PFS (p = 0.016). ASA score 3/4 independently predicted CSS (p = 0.049) and OS (p = 0.032). Neither pT3 substages nor E-cad expression were significant prognosticators for survival.

CONCLUSIONS

In pT3 UCB patients with ASA 3/4, positive lymph node status and/or presence of LVI, administration of chemotherapy should be considered due to the high risk of poor oncological outcome. The immunohistochemical marker E-cad was not an independent predictor.

Reporting trends and prognostic significance of lymphovascular invasion in muscle-invasive urothelial carcinoma: a population-based study

OBJECTIVES

To investigate reporting patterns and outcomes associated with lymphovascular invasion in a general population setting.

METHODS

We identified all cystectomy patients with muscle-invasive urothelial cancer in Ontario, Canada, 1994-2008. Surgical pathology reports were analyzed for pathological variables including lymphovascular invasion. Lymphovascular invasion reporting patterns were described over time. A Cox proportional hazards model was used to evaluate the association of lymphovascular invasion with survival.

RESULTS

Of the 2802 cases identified, lymphovascular invasion status was reported in 75%. Lymphovascular invasion reporting significantly improved over the study period and was correlated with poor prognostic pathological features (T stage and N stage). Comprehensive cancer center status was not consistently associated with lymphovascular invasion reporting. Patients with lymphovascular invasion had substantially lower survival than patients who were lymphovascular invasion-negative or whose lymphovascular invasion status was unstated (P < 0.001). Lymphovascular invasion was independently associated with survival in patients regardless of lymph node metastasis. After adjusting for age, stage, comorbidity, margin status and adjuvant chemotherapy, lymphovascular invasion remained strongly associated with reduced survival (hazard ratio 1.98, 95% confidence interval 1.71-2.29).

CONCLUSIONS

Although routine reporting of lymphovascular invasion has improved over the years, pathologists appear to be biased towards evaluating lymphovascular invasion in patients with high-stage disease. Despite this bias, lymphovascular invasion remains an important prognostic factor among patients treated by cystectomy. Pathologists in general practice should report lymphovascular invasion status more consistently and urologists should hold their pathology colleagues to a higher standard.

Squamous cell carcinoma of the tonsil managed by conventional surgery and postoperative radiation

BACKGROUND

The purpose of this study was to report the long-term outcome of patients with squamous cell cancer (SCC) of the tonsil managed by surgery followed by postoperative radiotherapy (PORT).

METHODS

Eighty-eight patients treated between 1985 and 2005 were analyzed. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were determined by the Kaplan-Meier method. Factors predictive of outcome were determined by univariate and multivariate analysis.

RESULTS

Forty-eight percent of patients had T3 to T4 disease and 75% had a positive neck. Five-year OS, DSS, and RFS were 66%, 82%, and 80%, respectively. The status of the neck was not predictive of outcome (DSS 80% for N0 vs 82% for N+; p = .97). Lymphovascular invasion was an independent predictor of OS, DSS, and RFS on multivariate analysis.

CONCLUSION

Lymphovascular invasion but not pathological stage of the neck is an independent predictor of outcome in patients with tonsillar SCC.

Nestin is an independent predictor of cancer-specific survival after radical cystectomy in patients with urothelial carcinoma of the bladder

OBJECTIVES

To investigate the association between the expression of nestin, a class VI intermediate filament protein, and pathologic features or survival in patients with urothelial carcinoma of the bladder (UCB).

METHODS

Nestin expression in tumor cells was immunohistochemically studied in 93 patients with UCB who underwent radical cystectomy with pelvic lymphadenectomy. The associations with clinicopathologic parameters were evaluated. Kaplan-Meier survival analysis and Cox proportional hazards models were used to estimate the effect of nestin expression on survival.

RESULTS

Nestin expression in cystectomy specimens was observed in 13 of 93 patients (14.0%). Nestin expression was associated with pathologic tumor stage (p = 0.006). Nestin-negative patients had better overall survival compared with nestin-positive patients (log-rank p = 0.0148). Univariable analysis indicated that nestin expression, lymphovascular invasion, and lymph node status were significantly associated with cancer-specific survival (hazard ratios, 2.78, 2.15, and 2.80, respectively). On multivariable analysis, nestin expression and lymph node status were independent prognostic factors in cancer-specific survival (hazard ratios, 2.45 and 2.65, respectively).

CONCLUSIONS

The results suggest that nestin expression is a novel independent prognostic indicator for patients with UCB and a potentially useful marker to select patients who may be candidates for adjuvant chemotherapy.

Can statistically determined prognostic factors predict the long-term survival of patients with pancreatic ductal adenocarcinoma following surgical resection?: Clinicopathological analysis of 82 long-term survivors

OBJECTIVE

The objective of this study were to analyze and describe the clinicopathological characteristics of long-term pancreatic ductal adenocarcinoma survivors and to determine if statistically identified prognostic factors can be used to predict the actual survival.

METHODS

Between January 2000 and December 2007, 537 patients with resectable pancreatic ductal adenocarcinoma underwent surgical resection at a single institute. Medical records were retrospectively reviewed, and 9 patients were excluded. Of the remaining 528, patients who survived for more than 5 years were classified as long-term survivors.

RESULTS

The actual 5-year survival rate of all 528 included patients was 15.5% (82 patients; median follow-up period, 82.7 months). Fifty-eight patients (70.7%) were diagnosed with cancers located in the head of pancreas, and the median size was 2.5 cm (range, 0.8-12.0 cm). Three patients had focal involvement noted on the resected surfaces. Poorly differentiated carcinoma (9.8%), lymph node metastasis (32.9%), lymphovascular invasion (25.6%), and perineural invasion (48.8%) were detected. Fifty-five of the 82 long-term survivors whose clinicopathological characteristics included several dismal predictors survived for more than 5 years without recurrence.

CONCLUSIONS

The long-term survivors identified in this study did not meet the appropriate prognostic criteria. Therefore, there are limitations in the use of statistically determined prognostic factors for estimating in the long term.

Altered expression of transmembrane mucins, MUC1 and MUC4, in bladder cancer: pathological implications in diagnosis

PURPOSE

Radical changes in both expression and glycosylation pattern of transmembrane mucins have been observed in various malignancies. We and others have shown that MUC1 and MUC4, two transmembrane mucins, play a sentinel role in cell signaling events that drive several epithelial malignancies. In the present study, we investigated the expression profile of MUC1 and MUC4 in the non-neoplastic bladder urothelium, in various malignant neoplasms of bladder and in bladder carcinoma cell lines.

MATERIAL AND METHODS

Immunohistochemistry was performed on tissue sections from the urinary bladder biopsies, resection samples and tissue microarrays (TMAs) with monoclonal antibodies specific for MUC1 and MUC4. We also investigated their expression in bladder carcinoma cell lines by RT-PCR and immunoblotting.

RESULTS

MUC1 is expressed on the apical surface or in umbrella cells of the normal non-neoplastic bladder urothelium. Strong expression of MUC1 was also observed in urothelial carcinoma (UC). MUC1 staining increased from normal urothelium (n = 27, 0.35±0.12) to urothelial carcinoma (UC, n = 323, H-score, 2.4±0.22, p≤0.0001). In contrast to MUC1, MUC4 was expressed in all the layers of non-neoplastic bladder urothelium (n = 14, 2.5±0.28), both in the cell membrane and cytoplasm. In comparison to non-neoplastic urothelium, the loss of MUC4 expression was observed during urothelial carcinoma (n = 211, 0.56±0.06). However, re-expression of MUC4 was observed in a subset of metastatic cases of urothelial carcinoma (mean H-score 0.734±0.9).

CONCLUSION

The expression of MUC1 is increased while that of MUC4 decreased in UC compared to the normal non-neoplastic urothelium. Expression of both MUC1 and MUC4, however, are significantly higher in urothelial carcinoma metastatic cases compared to localized UC. These results suggest differential expression of MUC1 and MUC4 during development and progression of bladder carcinoma.

Robotic-assisted radical cystectomy with extracorporeal urinary diversion for urothelial carcinoma of the bladder: analysis of complications and oncologic outcomes in 175 patients with a median follow-up of 3 years

OBJECTIVE

To report oncologic outcomes and complications after robotic-assisted radical cystectomy (RARC).

MATERIALS AND METHODS

From March 2004 to August 2011, 175 consecutive patients underwent RARC with extracorporeal urinary diversion at our institution by a single surgeon. The study design was prospective. Perioperative parameters and postoperative complications were prospectively collected using the modified Clavien system. Recurrence-free survival and cancer-specific survival curves were generated using the Kaplan-Meier method.

RESULTS

A total of 145 men and 30 women with a median age of 73 years and a median body mass index of 27 kg/m(2) underwent RARC. Four patients (2.3%) required conversion to open surgery because of difficulty to progress. One hundred nine patients (62%) underwent a transcutaneous ileal conduit, 40 patients (23%) an orthotopic neobladder, and 26 (15%) a continent cutaneous conduit. The median operating time was 360 minutes (interquartile range [IQR]: 300-420). The median estimated blood loss was 400 mL (IQR: 250-612), with a transfusion rate of 17.0%. The median postoperative length of stay was 7.0 days (IQR: 5.2-10). Early (<30 days) and late surgery-related complications (30-90 days) occurred in 74 (42%) and 59 (34%) patients, respectively. The perioperative mortality rate was 2.8%. The positive soft tissue surgical margins rate was 5%. The median number of lymph nodes removed was 19 (IQR: 12-28). The median follow-up was 37 months (IQR: 21.5-53.5). Actuarial recurrence-free survival and cancer-specific survival at 2, 3, and 5 years after RARC were 67%, 63%, 63% and 73%, 68%, 66%, respectively.

CONCLUSION

RARC achieved mid-term oncologic efficacy. Moreover, the complication rates were comparable with open radical cystectomy series.

Radical cystectomy and the implications of comorbidity

Radical cystectomy (RC) with pelvic lymph node dissection constitutes the gold standard treatment for muscle-invasive urothelial carcinoma of the bladder and high-risk nonmuscle-invasive disease refractory to instillation therapy. Although RC is performed with curative intent, the overall 5-year survival has been reported to be as low as 62% in the current literature. Various clinicopathological parameters determine post-RC outcome, but besides these, the role of comorbidity has gained increasing attention. In the current clinical practice, comorbidity information is quantified using various evaluated comorbidity indices. In this paper, we discuss the most recent data on comorbidity and performance indices assessed in patients undergoing RC and highlight their clinical implications.